week 6 Flashcards
1
Q
_________ WITH _________
Can visualize oropharynx, esophagus, stomach, and small intestine via fluoroscopy and x-ray (upper GI and small intestines)
procedure
- Patient swallows contrast/medium (Barium or Gastrograffin)
- positioned various ways
- with SBFT – take pics every 30 mins until contrast/medium reaches terminal ileum (the end of the small intestine)
- movement of contrast/medium is observed with fluoroscopy and x-rays
A
Upper GI/barium swallow WITH Small bowel series/small bowel follow through(SBFT)
2
Q
Upper GI/barium swallow WITH Small bowel series/small bowel follow through(SBFT)
nursing care
pre-procedure
- diet?
- smoking?
Post-procedure
- Prevent?
- white stool - expected or unexpected?
A
nursing care
pre-procedure
- NPO 8 hours
- No smoking after midnight
Post-procedure
- Prevent constipation
- Teach expected s/e – white stool
3
Q
_________ or _________
Both procedures involve drinking a liquid contrast material (barium) and taking X-rays to more thoroughly exam esophagus (compared to the upper GI tract)
which one specifically designed to evaluate swallowing function. This may involve using a modified barium mixture with different consistency or observing the patient’s swallowing mechanics more closely during the procedure.
A
Upper GI/barium swallow or modified barium swallow
modified barium swallow
4
Q
pt with:
-Dysphagia – maybe stroke pt
-Non-cardiac chest pain – rule out GI pain
-Painful swallowing
-GERD
indicated for which radiology test - Upper GI/barium swallow and modified barium swallow
OR
- Upper GI/barium swallow WITH Small bowel series/small bowel follow through(SBFT)
A
Upper GI/barium swallow and modified barium swallow
5
Q
Upper GI/barium swallow and modified barium swallow
nursing care
pre-procedure
- diet?
- smoking?
Post-procedure
- Prevent _________
- white stool expected or unexpected?
- when can they start eating again?
A
nursing care
pre-procedure
- NPO 8 hours
- No smoking after midnight
Post-procedure
- Prevent constipation
- Teach expected s/e – white stool
- If test is passed = can start eating again
6
Q
which test?
________________
X-ray examination used to visualize the large intestine.
Procedure
- Contrast/medium (barium)
- X-rays are taken to examine the colon and rectum (lower GI)
A
Lower GI/barium enema
7
Q
Lower GI/barium enema
Nursing care
Pre-procedure
- Enemas until _______
- diet? (2)
Post-procedure
- Cathartics (bowel cleanse) PRN
- white stool - expected or unexpected?
A
Nursing care
Pre-procedure
- Enemas until bowels are clear
- Clear liquids night before procedure
- NPO 8 hours
Post-procedure
- Cathartics PRN
- Teach expected s/e – white stool
8
Q
upper or lower GI
1. barium swallow
2. small bowel series/small bowel follow through
3. modified barium swallow
4. barium enema
5. EGD (Esophagogastroduodenoscopy)
6. Colonoscopy
A
upper - 1,2,3, 5
lower - 4, 6
9
Q
which test?
Patient eats a cooked egg containing radioactive metal
Images are taken at 0, 1, 2 and 4 hours later
A
Gastric emptying studies
10
Q
which test?
Indicated for
- Want to assess ability of stomach to empty solids
- PUD
- Ulcer surgery
- Diabetes
- Gastric malignancies or functional disorders – gastroparesis
A
Gastric emptying studies
Patient eats a cooked egg containing radioactive metal
Images are taken at 0, 1, 2 and 4 hours later
11
Q
Gastric emptying studies
Patient eats a cooked egg containing radioactive metal
Images are taken at 0, 1, 2 and 4 hours later
Nursing care
- Only _______ amounts of radioactive substances – little to no danger
- position during scanning?
A
Nursing care
- Only trace amounts of radioactive substances – little to no danger
- Must lie flat during scanning
12
Q
MRI vs CT
__________
- Radiologic exam
- Noninvasive
- Allows for exposure at different depths
- With or without contrast
-Contrast accentuates density differences
-Must assess for iodine/shellfish allergy
____________
- Radiofrequency and magnetic field used
- Noninvasive
- Contraindicated for metal implants and pregnancy
A
- CT
- MRI
13
Q
MRI vs CT?
Contraindicated for
1. metal implants
2. pregnancy
A
both MRI
14
Q
This procedure uses a flexible tube with a camera to examine the esophagus, stomach, and duodenum. UPPER GI
A
EGD (Esophagogastroduodenoscopy)
15
Q
Indications for which procedure?
- To directly visualize upper GI tract
- Looking for:
- upper GI bleed
- tumors
- varices
- mucosal inflammation
- hiatal hernia
- polyps
- ulcers
- obstructions
A
EGD (Esophagogastroduodenoscopy)
This procedure uses a flexible tube with a camera to examine the esophagus, stomach, and duodenum. UPPER GI
16
Q
which procedure
therapeutic/treatment purposes
- cauterize bleeding
- open strictures
- band esophageal varices
A
EGD (Esophagogastroduodenoscopy)
This procedure uses a flexible tube with a camera to examine the esophagus, stomach, and duodenum. UPPER GI
17
Q
EGD (Esophagogastroduodenoscopy)
This procedure uses a flexible tube with a camera to examine the esophagus, stomach, and duodenum. UPPER GI
nursing care
pre-procedure
- diet?
- Consent form?
Post-procedure
- NPO until _______
- Assess for _____
A
nursing care
pre-procedure
- NPO 8 hours
- Consent form
Post-procedure
- NPO until gag reflex returns 2-4 hours
- Assess for signs of internal bleeding – vitals
18
Q
This procedure uses a flexible tube with a camera to examine the colon (lower GI)
A
Colonoscopy
19
Q
Colonoscopy
This procedure uses a flexible tube with a camera to examine the colon (lower GI)
nursing care
pre-procedure
- bowel prep?
during procedure
- sedated?
- _________ - introducing air or gas into a body cavity or organ to distend it and improve visibility during an examination or surgery
Post-procedure
- Assess for signs of internal bleeding and perforation
o _______
o _______
o _________
A
nursing care
pre-procedure
- bowel prep
during procedure
- sedated
- air insufflation - introducing air or gas into a body cavity or organ to distend it and improve visibility during an examination or surgery
Post-procedure
- Assess for signs of internal bleeding and perforation
o vitals
o bleeding through colon
o tender abdomen
20
Q
fecal tests:
This test examines a stool sample for abnormalities such as blood, parasites, or inflammation.
This test is used to identify bacteria or other microorganisms that may be causing infection, including c.diff
A
Fecal analysis
Stool culture
Fecal tests can also check stool for ova and parasites
21
Q
Fecal analysis - This test examines a stool sample for abnormalities such as blood, parasites, or inflammation.
Keep diet free of _______ for 24-48 hours pre-test – could give false positive
A
red meat
22
Q
Weight reduction surgery, Surgery on stomach or intestines to help a person with extreme obesity lose weight
A
Bariatric surgery
23
Q
Criteria for bariatric surgery
- BMI __
- BMI __ with 1 or more severe obesity related medical complications – HTN, DM, HF, OSA
- Requires psychological, physical and behavior screening
A
Criteria
- BMI 40
- BMI 35 with 1+ severe obesity related medical complications – HTN, DM, HF, OSA
- Requires psychological, physical and behavior screening
24
Q
Bariatric surgery Types
1. __________ = less food is eaten (Sleeve gastrectomy and Intragastric balloon)
2. ___________ = less food absorbed b/c length of small intestine is decreased
3. Combination _________ and ____________ (Roux-en-Y procedure – most common)
Malabsorption, Restrictive, malabsorptive and restrictive
A
Types
1. Restrictive = less food is eaten
a. Sleeve gastrectomy
b. Intragastric balloon – minimally invasive, temporary
2. Malabsorption = less food absorbed b/c length of small intestine is decreased
3. Combination restrictive and malabsorptive
a. Roux-en-Y procedure – most common
25
restrictive, malabsorption, or combination?
Sleeve gastrectomy
Roux-en-Y procedure
Intragastric balloon
restrictive =
sleeve and intragastric ballon
combination =
Roux-en-Y procedure
26
which bariatric surgery?
- Most of the greater curvature of the stomach is removed
- A tubular stomach remains (creates a smaller food reservoir)
- Permanent
Restrictive = less food is eaten
Sleeve gastrectomy
27
which bariatric surgery?
Soft saline filled balloon inserted in stomach, makes person feel satiated
- 400-700 mL
- Temporary - Max 6 months, longer = risk for leakage
- minimally invasive
Restrictive = less food is eaten
Intragastric balloon
28
Intestines are not taken out, just rerouted so the stomach and parts of the small intestine are no longer used in digestion
- Restricts intake and lessens absorption
- “Stomach” is now a 15 ml pouch – serves purpose of food reservoir
- Gold standard
- Most common
- Avg hospital stay – 2-3 days
- Permanent
combination malabsorptive and restrictive
Roux-en-Y procedure
29
Bariatric surgery outcomes
Good outcomes
- __creased glucose tolerance
- __creased DM, BP, cholesterol/triglycerides, GERD, sleep apnea
Adverse outcomes
- Absorption issues
- __creased absorption of iron, vitamin b12, folic acid, calcium
- ____________ – concentrated sugary foods cause fluid shift out of the body and diarrhea, temporary hypovolemic s/s
Bariatric surgery outcomes
Good outcomes
- Increased glucose tolerance
- Decreased DM, BP, cholesterol/triglycerides, GERD, sleep apnea
Adverse outcomes
- Absorption issues
- Decreased absorption of iron, vitamin b12, folic acid, calcium
- Dumping syndrome – concentrated sugary foods cause fluid shift out of the body and diarrhea, temporary hypovolemic s/s
30
what causes dumping syndomre?
what procedure is it associated with?
what happens?
concentrated sugary foods cause fluid shift out of the body
adverse outcome of bariatric surgery
causes diarrhea and temporary hypovolemic s/s
hypotension
palpitations
diaphoresis
borborygmi - hyper active bowel sounds
31
Bariatric surgery
Post-op nursing care
- mobility?
- Pain?
- Risk for wound ________ and _____________– esp in obese patients
- Resumption of liquids and foods gradually – pt and family teaching
- Decompress (empty) stomach and rest stomach
1. NG to LWS
2. ____ or _____ liquids
3. High ______ liquids
4. Pureed diet 2 weeks
5. Solid foods 4-6 weeks
Bariatric surgery
Post-op nursing care
- Enhance mobility
- Pain management
- Risk for wound infection and dehiscence – esp in obese patients
- Resumption of liquids and foods – pt and family teaching
- Decompress (empty) stomach and rest stomach
o NG to LWS
o Water or sugar free liquids
o High protein liquids
o Pureed diet 2 weeks
o Solid foods 4-6 weeks
32
Long term recommended diet for post op bariatric surgery patients
DASH diet = Dietary approach to stop HTN
33
Drug therapy for upper GI problems
____________
o Decrease acid
o Not a solution, just treats symptoms short term
o take before meals and at bedtime
____________
o Decrease acid
o OTC or prescription
________________
o Coats the stomach for protection
o Sucralfate
____________- – for GERD
o Enhances gastric emptying
o Metoclopramide
Cytoprotective agent, Antacids, H2blockers, Prokinetic agent
Antacids
o Decrease acid
o Not a solution, just treats
symptoms short term
o take before meals and at
bedtime
H2blockers
o Decrease acid
o OTC or prescription
Cytoprotective agent
o Coats the stomach for
protection
o Sucralfate
Prokinetic agent – for GERD
o Enhances gastric emptying
o Metoclopramid
34
GERD
Backward flow “reflux” or very acidic stomach contents into esophagus
happens b/c ______ is loose
LES -Lower esophagus sphincter is loose
35
s/s
- heartburn
- regurgitation – burp up stomach contents
- respiratory symptoms
GERD
- respiratory symptoms – stomach contents goes into lungs
hiatal hernia presents similar to GERD
36
complications of GERD
- esophagitis – inflammation
- barrett’s esophagus (esophageal metaplasia) – long period of time, cellular level changes
- hemorrhage/internal bleed
- respiratory s/s – cough, bronchitis
- esophagitis – inflammation
- barrett’s esophagus (esophageal metaplasia) – long period of time, cellular level changes
X - hemorrhage/internal bleed
- respiratory s/s – cough, bronchitis
37
diagnostic studies
- barium swallow
- EGD
- barium enema
- Small bowel series/small bowel follow through(SBFT)
- barium swallow – checking for reflux when swallow contrast
- EGD – scopy
- (but often we just give anyone with symptomatic GERD dose of PPI, to avoid the cost/discomfort of the diagnostic study tests, if the PPIs work/help than they just stay on it and we skip the diagnostic tests)
38
Upper GI/barium swallow
- Patient swallows contrast/medium
o Barium
o Gastrograffin
which is used if we suspect perforation has occurred?
Gastrograffin
39
GERD and HH Treatment
Lifestyle modifications
- Avoid _________
- Quit smoking – improves ____ function
Treatment:
Lifestyle modifications
- Avoid triggers
- Quit smoking – improves LES function
40
GERD and HH treatment:
Nutritional therapy
- Avoid _______ foods
- Small frequent meals
- when to drink fluid?
- Avoid ________ snacks
- _______ 2-3 hours after meals
- Weight loss – decreased intra-abdominal pressure
Nutritional therapy
- Avoid fatty foods
- Small frequent meals
- with no fluid (only fluid between meals, not during meals) helps reduce distention
- Avoid late night snacks
- Elevate HOB 2-3 hours after meals
- Weight loss – decreased intra-abdominal pressure
41
GERD and HH treatment
Procedure options – if the lifestyle modifications and nutritional therapy doesn’t help
_______________
o Endoscopic procedure
o Augments the LES with a ring made of magnets
o Strengthens the LES closure
_______________
o Endoscopic (no incision) or open procedure (requires incision)
o Suture a collar around the LES which strengthens it
Fundoplication, LINX device insertion
42
- Fundoplication
- LINX device insertion
for what issues?
GERD and HH
- LINX device insertion
o Endoscopic procedure
o Augments the LES with a ring made of magnets
o Strengthens the LES closure
- Fundoplication
o Endoscopic (no incision) or open procedure (requires incision)
o Suture a collar around the LES which strengthens it
43
Herniation of a portion of the stomach into the esophagus, through an opening in the diaphragm
Hiatal hernia
“diaphragmatic hernia” or “esophageal hernia”
44
what Causes HH
- Structural pressure on LES – maybe from Pregnancy or obesity
45
s/s
- Asymptomatic
- Similar to GERD:
- heartburn
- regurgitation – burp up stomach contents
- respiratory symptoms – stomach contents goes into lungs
HH
46
Barrett’s Esophagus
T/F
1. Everyone with HH has or will get Barrett’s Esophagus
2. Confirm BE with biopsy
3. BE seriously increases chance of esophageal cancer
X 1. Not everyone with HH has Barrett’s Esophagus
2. Confirm BE with biopsy
3. BE seriously increases chance of esophageal cancer
47
barretts esophagus - condition in which the lining of the esophagus becomes damaged.
associated with what issues?
GERD and HH
48
The digestive action of HCl acid and pepsin causes erosion of GI mucosa, and sores or ulcers in the lining of the stomach or duodenum (the first part of the small intestine).
Peptic ulcer disease (PUD)
49
Causes
- H. pylori = triggers inflammation
- Drugs = NSAIDS
- H. pylori and NSAID use = double risk
- Alcohol
- Smoking
- Family hx
- Stress (aggravates exisiting issue, doesnt cause it)
PUD
50
Gastric ulcer vs Duodenal ulcer 1. in Stomach
2. Associated with H. pylori
3. in First part of the small intestine
4. Most common
Gastric ulcer
- Stomach
Duodenal ulcer
- First part of the small intestine
- Most common
- Associated with H. pylori
51
Acute ulcers vs Chronic ulcers
- Short duration ?
- More common ?
- Resolves quickly ?
- Deeper ?
Acute ulcers
- Short duration
- Resolves quickly
Chronic ulcers
- Deeper
- More common
52
PUD
Diagnostic studies
- EDG
- colonoscopy
- Tests to confirm H pylori
o Noninvasive – urea breath testing and stool testing
o Invasive – biopsy of antral mucosa and testing for urease
- CBC
- Stool for occult blood
- gastric emptying
- barium enema
- EDG
X- colonoscopy
- Tests to confirm H pylori
o Noninvasive – urea breath testing and stool testing
o Invasive – biopsy of antral mucosa and testing for urease
- CBC
- Stool for occult blood
X- gastric emptying
X- barium enema
- EDG – most accurate diagnostic procedure
- Tests to confirm H pylori
o Noninvasive – urea breath testing and stool testing (urea is a byproduct of metabolism of H pylori bacteria)
o Invasive – biopsy of antral mucosa and testing for urease – gold standard for diagnosis
- CBC – checking for anemia r/t PUD internal bleeding
- Stool for occult blood – invisible blood
53
PUD
1. most accurate diagnostic procedure
2. gold standard for diagnostic test that confirms H pylori
3. why check CBC
4. why is urea a way to confirm H pylori?
1. EDG
2. invasive – biopsy of antral mucosa and testing for urease
3. checking for anemia r/t PUD internal bleeding
4. (urea is a byproduct of metabolism of H pylori bacteria)
54
PUD complications
- Most common
- Assess/investigate changes in vital signs
- Change in amount and/or redness of gastric aspirate
- Pain may decrease with this complication
- NG tube to LWS – decompresses stomach
PUD
H - Hemorrhage
55
____complications
H -
O -
P -
PUD
hemorrhage
obstruction
perforation
56
PUD complications
- Can happen at anytime
- Most likely occurs if ulcer is located close to pylorus sphincter
- Gradual onset of symptoms
- NG to LWS until resolved, irrigate per protocol
O - Obstruction
57
PUD complications
- most lethal complication
- Sudden and dramatic onset
- Pain
o Sudden
o Severe
o Abdominal pain – radiates to back
o Not relived by food or antacids
- Rigid board like abdomen
- Respiration – shallow and weak
- Pulse – weak and tachy
- Bowel sounds – absent
P - Perforation
ulcer goes through all layers of stomach into peritoneum,
- Peritonitis can occur within 6-12 hours
58
Treatment PUD
- Adequate rest – helps decrease stress response
- Stop smoking
- Dietary modification – individualized
- Drug therapy
o Stop ____ and ____ for 4-6 weeks
o If ASA and/or NSAIDS are indicated – give with ____
o If h pylori – ___
o PPI
o Cytoproctive – sucralfate
- Surgical option
o Billroth – decreases secretion of acid
Treatment
- Adequate rest – helps decrease stress response
- Stop smoking
- Dietary modification – individualized
- Drug therapy
o Stop ASA and NSAIDS for 4-6 weeks
o If ASA and/or NSAIDS are indicated – give with PPI
o If h pylori – abx
o PPI
o Cytoproctive – sucralfate
- Surgical option
o Billroth – decreases secretion of acid
59
Bolus of hypertonic foods dump into small intestines
Fluid quickly shifts from plasma to GI tract
Dumping syndrome
60
s/s
- Weakness
- Sweating
- Palpitations
- Dizzy
- Abd cramping
- Borborygmi - rumbling or gurgling sounds that you hear in your abdomen.
- Urge to BM
- Diarrhea
- 15 mins of eating hyperosmolar meal
- hypotension
dumping syndrome - Bolus of hypertonic foods dump into small intestines
Fluid quickly shifts from plasma to GI tract
can be associated with tube feeds, bariatric surgery, GI things
61
Complication
- After meal (postprandial) hypoglycemia
- 2 hours after eating
Dumping syndrome
Bolus of hypertonic foods dump into small intestines
Fluid quickly shifts from plasma to GI tract
62
Treatment for dumping syndrome
- small or large meals?
- Fluids when?
- Avoid ?
- Proteins and fats encouraged or avoided?
- Rest period after eating ?
- s/s self-limiting or requires further treatment?
Treatment
- 6 small meals/day
- Fluids between meals, not during meals
- Avoid concentrated sweets
- Proteins and fats encouraged to promote rebuilding tissue post-op
- Rest period after eating
- s/s self-limiting (go away on their own) – months to a year
63
upper GI bleed
Hematemesis - _______
o Bright red color - “frank” or “gross” = indicates _____ or _____
o Coffee ground color/look = indicates _________
- Hematemesis – bloody vomit
o Bright red color - “frank” or “gross” = indicates recent or ongoing GI bleed
o Coffee ground color/look = indicates a significant bleed has stopped
64
Upper GI bleed
Bloody stool
o Black, tarry, malodorous stools – “melena” = indicates bleeding is coming from higher or lower in the GI tract?
o “occult blood” = ________
- Bloody stool
o Black, tarry, malodorous stools – “melena” = indicates transit time > 8 hours (it means that the blood has been in the digestive tract for more than 8 hours before being passed out of the body as a stool. This suggests that the bleeding is likely coming from a higher part of the digestive tract, such as the stomach or duodenum, where the blood has more time to be digested and darkened before being excreted)
o Not visible by the naked eye – “occult blood” = we would only know there is blood in stool by doing a guaiac test and results would be positive
65
melena
o Black, tarry, malodorous stools – comes from higher in the GI tract, been digested
66
what Causes upper GI bleeds
__________
___________
- Esophageal varices
- stomach or duodenal ulcers (50% of Upper GI bleeds are from ulcers)
67
GI bleeds
can be caused by
stomach or duodenal ulcers
related to (5)
- H pylori!!!
- NSAIDS, ASA (salicylates) and steroids!!!
- stress related mucosal disorders/SRMD
68
protrusions in esophagus, like hemorrhoids but in esophagus
occurs with severe portal hypertension/cirrhosis
esophageal varices
69
esophageal varices complications
- if the varices opened pt could have uncontrollable bleeding and die
70
esophageal varices active bleeding - emergency treatment
- emergency/ICU thing to treat a bleeding esophageal varices = sengstaken-blakemore tube – catheter that goes down their esophagus and when the balloon is blown up it applies pressure to the site of bleeding to stop it
71
upper GI bleed nursing interventions
1. monitor vitals
2. assess for s/s of _____volemia
3. Assess for what in abdomen that could indicate perforation/peritonitis?
4. Monitor labs – ____ and _____
5. Anticipate giving ______– start large bore IV access
6. NG ___avage (wash out) to rid stomach of blood
7. Assess emesis and stool for?
8. Admin meds
9. Prep for procedures like endoscopy/endotherapy/hemostasis – all first line management of UGI bleed
- 1. monitor vitals
- 2. assess for s/s of hypovolemia
- 3. Assess for tense, rigid, board like abdomen, distention, guarding – could be perforation/peritonitis
- 4. Monitor labs – H&H and BUN (GI bleeding is a reason for high BUN)
- 5. Anticipate giving PRBCs – start large bore IV access
- 6. NG lavage (wash out) to rid stomach of blood
- 7. Assess emesis and stool for blood – check for occult blood
- 8. Admin meds
- 9. Prep for endoscopy/endotherapy/hemostasis – all first line management of UGI bleed1.
72
s/s of hypovolemia
o HR __crease
o __creased thirst – r/t hyperosmolar and low blood volume
o hot or cold skin?
o Restlessness
- assess for s/s of hypovolemia
o rapid loss in blood volume could lead to hypovolemic shock
o HR increase
o Increased thirst – r/t hyperosmolar and low blood volume
o Cold clammy skin
o Restlessness – r/t hypoxia, or others
73
Inflammatory bowel diseases:
crohn’s and UC
74
Both, crohn’s, or UC?
- chronic inflammation of intestine
- periods of remission/exacerbation
- unknown cause/autoimmune
- no cure (except just removing organ)
- s/s – diarrhea, weight loss, abdominal pain, fever and fatigue
- hospitalization is indicated if no response to drug therapy or complications arise
both
75
treatment for IBD
includes meds?
includes surgery?
o sulfasalazine (aminosalicylates) – decrease _______
o corticosteroids – decrease ________
o antimicrobials – prevent/treat secondary _________
o immunosuppressants – suppress immune_______
o biologic and targeted therapy (immunodulators) – inhibit cytokine tumor necrosis factor (TNF) and prevent migration of leukocytes from blood stream to inflamed tissue
treatment includes meds and/or surgery
o sulfasalazine (aminosalicylates) – decrease inflammation
o corticosteroids – decrease inflmmation
o antimicrobials – prevent/treat secondary infection
o immunosuppressants – suppress immune response
o biologic and targeted therapy (immunodulators) – inhibit cytokine tumor necrosis factor (TNF) and prevent migration of leukocytes from blood stream to inflamed tissue
76
goals of treatment: IBD
- control inflammation and maintain remission
- combat infection
- correct malnutrition
- alleviate stress
- provide symptomatic relief using drug therapy
- improve quality of life
when flare up occurs = _____
NPO - rest bowel
fluids
77
- complications
o hemorrhage
o strictures
o perforation
IBD
78
- patient teaching
o rest and diet management
o perianal care
o drug action and s/e
o symptoms of recurrence of disease
o when to seek medical care
o use of diversional activities to reduce stress
IBD
79
UC vs Crohn's
Pattern of progression – uniform and continuous
Thickness of inflammation – submucosa or mucosa (superficial)
Rectal bleeding – common
Malabsorption and nutritional deficiencies – not common
Complications – perforation (b/c of toxic megacolon rupture)
Risk for colon cancer – colorectal cancer
Surgery – curative (total removal of colon)
80% of the time drug therapy induces remission
20% require surgery
Ulcerative colitis
Site of origin – rectum/colon
Bottom up
80
Surgery for UC or crohn's?
- total proctocolectomy (remove colon) AND illeal anal reservoir (IPAA)
- total proctocolectomy (remove colon) AND permanent ileostomy (stool bag)
- total proctocolectomy (remove colon) AND continent ileostomy/kock pouch (pt catheterizes them self, liquid stool)
UC
81
Surgery UC
1. which one is a 2 stage surgery, Most common?
2. which one is a one stage surgery with a permanent ileostomy?
3. which one has continent ileostomy?
total proctocolectomy AND illeal anal reservoir (IPAA)
total proctocolectomy AND kock pouch
total proctocolectomy AND permanent ileostomy
- total proctocolectomy (remove colon) AND illeal anal reservoir (IPAA)
o 2 stage surgery
o Most common
- total proctocolectomy (remove colon) AND permanent ileostomy (stool bag)
o one stage surgery
- total proctocolectomy (remove colon) AND continent ileostomy/kock pouch (pt catheterizes them self, liquid stool)
82
T/F
post colon surgery patient teaching is important b/c there is a high rate of post op complications
T
UC surgery
83
post colon surgery
patient education
call HCP if
T/F
- wound drainage
- wound opening
- wound redness
- wound changes in the appearance of the surrounding skin or around the ostomy
- no bowel movement for more than 24 hours
- lack of gas/stool from the rectum for more than 24 hours
- increased abdominal pain
- vomiting
- abdominal swelling
- high ostomy output
- dark urine
- no urine
- fever > 101.5
- patient is not able to take anything by mouth for > 24 hours
all
84
post colon surgery
patient education
call HCP if
- 4 wound
- 5 output
- 2 pain
- 1 temp
- 1 intake
- wound drainage
- wound opening
- wound redness
- wound changes in the appearance of the surrounding skin or around the ostomy
- high ostomy output
- dark urine or no urine
- vomiting
- no bowel movement for more than 24 hours
- or lack of gas/stool from the rectum for more than 24 hours
- abdominal pain and swelling
- fever > 101.5
- patient is not able to take anything by mouth for > 24 hours
85
uc or crohn's
- Pattern of progression – “skip” lesions, irregular
- Thickness of inflammation – transmural (deep)
- Rectal bleeding – not common
- Malabsorption and nutritional deficiencies – common
- Complications – perianal abscesses, fistula fissures, perforation (b/c inflammation involves entire bowel wall)
- Risk for colon cancer – small intestines cancer
- Surgery – for complications such as strictures, most need surgery at some point
“cobblestone appearance”
Site of origin – mouth to anus
Top down
86
Surgery uc or Crohn’s
- not curable by surgery
- surgery r/t complications like fistulas, strictures, obstructions and bleeding
- recurrence after surgery very high
- intestinal resection with anastomosis of healthy bowel
crohn's
87
Why nutrition is compromised (both but mainly, crohn’s)
- __creased food intake
- n/v
- malabsorption
- __creased metabolic rate (increased energy consumption at rest) b/c of chronic disease process
Why nutrition is compromised (both but mainly, crohn’s)
- decreased food intake
- n/v
- malabsorption
- increased metabolic rate (increased energy consumption at rest) b/c of chronic disease process
88
nutritional therapy
- during flare up (acute phase) =
- Consider ________ feedings when very malnourished, can’t use GI tract, or resting gut
- When the gut works use it EXCEPT if resting gut ____ may be indicated
- Diet – ____ calorie, ____ protein, ____ residue (ruffage/fiber), vitamin and iron supplements
- Food triggers are individualized or universal?
- Avoid smoking
nutritional therapy
- NPO during flare up (acute phase)
o Consider enteral/parenteral feedings when very malnourished, can’t use GI tract, or resting gut
o When the gut works use it EXCEPT if resting gut TPN may be indicated
- Diet – high calorie, high protein, low residue (ruffage/fiber), vitamin and iron supplements
- Food triggers are individualized (not universal) – food diary can help identify triggers
o Ex: Cold food, high residue, lactose
- Avoid smoking
89
TPN – total parenteral nutrition
T/F
- Allows for positive nitrogen balance while resting the bowels
- contains All comprehensive diet – vitamins, minerals, electrolytes, glucose, amino acids, etc. can be added
- Lipid emulsion usually infused as a separate solution
- Highly hypertonic
- HIGH dextrose – may require insulin coverage
- TPN uses dedicated central venous line/access device – via peripheral line would eat up the vein
- Not using the gut will cause intestinal mucosal atrophy – bacteremia and infections
- Start TPN slowly and end TPN slowly – pancreatic cells need time to adapt to increasing/decreasing insulin output
- PPN – partial parenteral nutrition
- aseptic technique
all true
90
Intestinal obstruction:
non-mechanical vs Mechanical
_______ - caused by a physical blockage within the intestines.
_________ – cause by a functional impairment of the intestinal muscles.
Mechanical - caused by a physical blockage within the intestines.
Non-mechanical – cause by a functional impairment of the intestinal muscles.
91
Intestinal obstruction:
non-mechanical vs Mechanical
1. Most common
2. Most often in small intestine
3. Surgical adhesions days to years post op – most common
4. Hernias
5. Strictures – from crohn’s
6. Paralytic ileus
1. M
2. M
3. M
4. M
5. M
6. NM
Mechanical - caused by a physical blockage within the intestines.
Non-mechanical – cause by a functional impairment of the intestinal muscles.
92
Care for ___________
-Decompress intestine - NG to LWS = keep intestines empty
- Correction/maintenance of fluid and electrolytes
- Pain control
- Removal of obstruction (mechanical)
- rest gut and wait until peristalsis starts back up (non-mechanical)
Intestinal obstruction
93
surgical procedure in which a portion of the intestine is removed and the remaining ends are reconnected.
Bowel resection with an end-to-end anastomosis
94
cancer that begins in the colon (large intestine) or rectum (final part of large intestine)
Colorectal cancer
95
colorectal cancer
risk factors
- Diet high in ____ meat or ______ meat
- Obesity
- Physical inactivity
- Alcohol
- Long term smoking
- ____ intake fruits and veg
- Genetic/familial and history of IBD
risk factors
- Diet high in red meat or processed meat
- Obesity
- Physical inactivity
- Alcohol
- Long term smoking
- Low intake fruits and veg
- Genetic/familial and history of IBD
96
s/s - Varies by location of primary lesion (beginning of colon vs end of colon)
- Insidious – doesn’t appear until disease is advanced
- Iron deficiency anemia
- Rectal bleeding
- Blood in stool
- Abdominal pain
- Rectal pain
- Change in bowel habits
- Intestinal obstruction/perforation
- Mass
colorectal cancer
97
colorectal cancer Diagnostic
1. Regular screening
2. Regular removal of pre-cancerous polyps
3. _________ – gold standard for CRC screening
4. colonoscopy for Average risk patient – age 50, 60, 70, 80 etc.
5. colonoscopy for _______ – age 45, 55, 65, 75 etc.
6. colonoscopy for risk patient – earlier and more frequent
7. ______________ – less favorable but acceptable if patient is unwilling to do the colonoscopy, once yearly
colonoscopy
black people
Fecal occult blood test
98
Care for colorectal cancer
-Surgery for_______ cancer - resection and maybe ostomy
- surgery for ______ cancer - Local excision, Abdominal-perineal resection (APR) w/ permanent colostomy, Low anterior resection (LAR)
-Radiation and chemo
rectal, bowel (colon)
bowel/colon
rectal
99
rectal cancer surgery
- ___________– small area of tissue is removed
- ____________ w/ permanent colostomy - removing the rectum, anus, and part of the colon. A permanent colostomy is created, diverting stool out of the body through an opening in the abdomen.
- _____________ – removing the lower part of the rectum and part of the colon. The remaining colon is then connected to the anus, preserving sphincter function and maintaining normal control over defecation
Abdominal-perineal resection (APR),
Local excision,
Low anterior resection (LAR)
Local excision – small area of tissue is removed
Abdominal-perineal resection (APR) w/ permanent colostomy - removing the rectum, anus, and part of the colon. A permanent colostomy is created, diverting stool out of the body through an opening in the abdomen.
Low anterior resection (LAR) – removing the lower part of the rectum and part of the colon. The remaining colon is then connected to the anus, preserving sphincter function and maintaining normal control over defecation
100
Ostomies -
Can be temporary or permanent
-________ : A surgical opening in the small intestine.
- __________: A surgical opening in the large intestine (colon).
-__________: A surgical opening in the urinary tract, usually created to divert urine away from the bladder.
- Ileostomy: A surgical opening in the small intestine.
- Colostomy: A surgical opening in the large intestine (colon).
- Urostomy: A surgical opening in the urinary tract, usually created to divert urine away from the bladder.
101
consistency of the ostomy output?
depends on location
- can be anywhere along large intestine/colon – ascending, transverse, descending
- ileostomy which is in the ileum (small intestine)
102
- ostomies at beginning of GI tract =
- ostomies at end of GI tract =
liquid
almost normal
103
ostomy at the descending colon
T/F
- located at the beginning of the GI tract
- will be liquid
- might need irrigation for descending or sigmoid ostomies
- irrigate q 1-2 days whatever normal bowel pattern was
- similar to enema, except it’s through the stoma
- large bag placed to gather contents
X- located at the end of the GI tract
-X will be almost normal
- might need irrigation for descending or sigmoid ostomies
- irrigate q 1-2 days whatever normal bowel pattern was
- similar to enema, except it’s through the stoma
- large bag placed to gather contents
104
which one?
- slices the intestine
- brings out the proximal end as a single stoma (part of the intestine is closer to the stomach.)
- distal portion (part of the intestine is closer to the anus.)
o surgically removed – permanent
o oversewn and left in mesentery – “hartmann’s pouch” – temporary, it is possible for the bowel to be re-anastomosed in the future “take down”
3 types of ostomies
- end stoma
- loop stoma
- double barrel stoma
end stoma
105
which one?
- bringing a loop of bowel to the skin surface
- sliced open, not completely (enterotomy)
- folded back over its self
- held in place by plastic rod and sutures
- 2 stomas
o Proximal opening (part of the intestine is closer to the stomach.) – stool
o Distal opening (part of the intestine is closer to the anus.) – mucus
- Posterior wall separates the 2 openings
- Usually temporary
3 types of ostomies
- end stoma
- loop stoma
- double barrel stoma
loop stoma
106
which one?
- Slices the intestine
- Both the proximal and distal ends are brought through the abdominal wall as 2 separate stomas
o Proximal opening (part of the intestine is closer to the stomach.) – functioning, stool
o Distal opening (part of the intestine is closer to the anus.) – non-functioning, mucus
- Usually temporary
3 types of ostomies
- end stoma
- loop stoma
- double barrel stoma
Double barrel stoma
107
Post op ____ care
- Assess color, edema, and bleeding
- Wash skin with mild soap, rinse with warm water, apply skin barrier
- Pouch – snug fit, use measuring card
- WOC nurse
stoma
108
ostomy care
T/F
- ________ stoma – may still pass stool/mucus through anus
- Empty bag frequently
- ostomy bag contains stool and gas
- No sphincter
- Plenty of towels on hand
- Control facial expressions – odor
- Food doesn't effects stoma output
- Patient teaching – go slow, may be complicated by emotional response
Care
- Double barrel stoma – may still pass stool/mucus through anus
- Empty bag frequently
- stool and gas
- No sphincter
- Plenty of towels on hand
- Control facial expressions – odor
X - Food effects stoma output – odor producing, gas producing, diarrhea causing, potential for obstructions
- Patient teaching – go slow, may be complicated by emotional response
109
_______ – the presence of out-pouching of the intestinal mucosa
_________ – flare up, one or more pouches become inflamed or infected
Diverticulosis
Diverticulitis
110
___________
- Asymptomatic
- Abdominal pain
- Bloating
- Flatulence
- Change in bowel habits
___________
- Acute pain LLQ
- Palpable abdominal mass
- s/s of infection
- Older adult may be afebrile, no change in WBC, little pain
Diverticulosis
Diverticulitis
111
Diverticulosis/diverticulitis
Education
Prevention
- _____ fiber
- ___ fat
- ____ red meat
- ____ levels of physical activity
- High fiber
- Low fat
- Low red meat
- High levels of physical activity
112
Diverticulosis/diverticulitis
Once disease is present
- ______ fiber
- avoid nuts or seeds?
- Weight reduction
- Avoid factors that _____ like constipation
Once disease is present
- High fiber
- Don’t need to avoid nuts or seeds
- Weight reduction
- Avoid factors that increase abdominal pressure like constipation
113
Acute diverticulitis
- Goal = rest bowel with ____ and decrease inflammation
- If severe = hospitalization, _____ and _____
- Monitor for abscess, bleeding, and peritonitis r/t rupture
- Surgery if complications – may involve resection/temporary ostomy
Acute diverticulitis
- Goal = rest bowel with NPO and decrease inflammation
- If severe = hospitalization, IVF, and abx
- Monitor for abscess, bleeding, and peritonitis r/t rupture
- Surgery if complications – may involve resection/temporary ostomy
