Diverticulitis- Test 5

8/6/2019 Diverticulitis- Test 5

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Diverticulitis

Occurs when retained undigested food mixed with bacteria accumulates in the diverticulum, forming a

hard mass cutting off the blood supply to the diverticulums thin walls

Complications: Ruptured diverticula that causes abd abscesses or peritonitis, Intestinal obstruction,

rectal hemorrhage, portal pyemia, fistula

y Low fiber consumptiony Recent consumption of foods containing seeds or kernels or indigestible roughage, such as

celery and corn

y Complaints of moderate dull or steady pain/ Lf lower abd quad, aggravated by straining, lifting,or coughing

y Mild nausea, gas, diarrhea, or intermittent bouts of constipation, rectal bleedingy Distressed appearancey Low-grade fevery Palpable mass/tendernessy Muscle spasmsy Guarding and rebound tendernessy Decreased or exaggerated bowel soundsy Hallmark: change in bowel habits, w/ fever, tachycardia may occur

Barium studies arent performed for acute diverticulitis due to potential rupture

CT scanning with I.V. and oral contrast of the abd is the test of choice, evaluates the presence of

abscesses or acute perforation

Treatment: NG for decompression, bed rest, NPO w/progression to fluids and then high-fiber diet

Possible surgery and temp colostomy to drain abscesses or to rest the colon 6-8 wks

Interventions:

y Maintain bed rest, cluster carey Avoid morphine and other opioidsy Foods high in fibery Maintain NG patency

After colon resection:

y Meticulous wound carey TCDB and early ambulationy Maintain NG suction and irrigate as orderedy Provide colostomy carey Auscultate the abd for return of bowel sounds, advance diet

Monitor:

y Pain level and reliefy Abd status, distention and bowel soundsy Stool pattern and characteristics, color, consistency, and freqy NG tube


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Teaching:

y Need for stool softeners and bulk-forming agentsy Incisional or ostomy carey Need to remain active overall but restrict activity when diverticulitis occursy Need 25-35g of fiber dailyy F

resh fruits and veg with high-fiber content add bulk to stools, low faty Add foods slowly to avoid gas and abd crampingy Drink plenty of fluids to prevent bloatingy Alcohol should be avoid because it irritates the bowel

Monitor for confusion, urinary retention or failure, and orthostatic hypotension as S/E of meds

Do not give laxatives (senna lax) or enemas

Rest and avoid activities that cause straining or increase abd pressure

While diverticulitis is active, provide a low-fiber diet, then when resolved provide high-fiber

Watch for sudden change in mental status in older patients

Perform freq abd assessments to determine distention and tenderness on palpation

Check stools for occult or frank bleeding

Pt may have laxatives and enemas for one to two days andHELD if fever/abd pain are present

Post-op may have drain/monitor incision

For colostomy stoma can be covered w/ petroleum gauze for 2 days, NPO w/NG tube until peristalsis

returns, if performed laparscopic pt will NOT have NG tube

May need to be admitted to the hospital if: temp higher than 101, persistent and severe abd pain for

more than 3 days, and/or lower GI bleeding

No nuts, corn, popcorn, cucumbers, tomatoes, figs, strawberries


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Pancreatitis

Complications: DM, massive hemorrhage, diabetic acidosis, shock and coma, ARDS, atelectasis and

pleural effusion, pneumonia, paralytic ileus, GI bleeding; obstruction, pancreatic abscess and cancer,

renal failure

HX:

y Intense epigastric pain centered close to the umbilicus and radiating to the back (acute)y Intermittent severe pain in mid- to upper left abd, possible radiate to back for several hours

(chronic)

y Pain aggravated by fatty foods, alcohol consumption, or recumbent position (supine)y Weight loss with N/V and diarrheay HX of alcohol or med use

Physical Findings:

y Hypotensiony Tachycardiay F

every Dyspnea, orthopneay Pleural effusiony Steatorrheay Generalized jaundicey Hypoactive bowel soundsy Cullens sign (bluish periumbilical discoloration)y Turners sign (bluish flank discoloration)y Abdominal tenderness, rigidity, and guardingy Pancreatic ascites may create dull sound on percussiony Decreased BP

Lab:

y Serum amylase and lipase levels, WBC, serum bili, CRP, urine amylase all elevatedy Transient hyperglycemia and glycosuria are present

Abd and chest x-ray differentiate pancreatitis from other diseases; also detect pleural effusions

Treatment:

y Emergency treatment of shock; vigorous IV replacement of fluids, electrolytes, and protein(acute)

y Blood transfusions (hemorrhage)y NG suctioning

Diet:

y NPOy After crisis, oral feedings high in carb and low fat and protein (acute), low in fat and high protein

and calories for chronic

y No alcohol or caffeineChronic: need pancreatic enzyme supplements-Pancrelipase, and insulin is needed


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Interventions:

y Maintain NPO until pain and tenderness resolve andGI motility returnsy Assist with NG insertion, provide NG care, maintain suction, and observe drainagey Provide small, freq mealsy Daily wtsy H

ead of bed upright, TCD

B and incentive spirometryy Evaluate pancreatic enzyme levels, glucose levels, and F&Ey Pt may be on TPN (check blood sugars), may require insulin-FSBS

Monitor:

y NG function and drainagey Resp statusy Acid-base balancey Glucose levely F&Ey Daily wty Pain level and reliefy Renal functionTeach:y The need to take pancreatic enzymes before or with meals and snacksy Importance of abstaining from alcohol ingestion

Assess for tachycardia, elevated temp, and decreased BP

Pleural effusions, atelectasis, and pneumonia are common

Observe for changes in behavior or LOC may be r/t alcohol withdraw, hypoxia, or impending sepsis

w/shock

Morphine and dilaudid given for pain by PCA for severe pain

Bentyl to decrease vagal stimulation, motility, and pancreatic flow- contraindicated in pt w/ paralytic

ileus

Alcohol history is usually the cause so take full assessment of alcohol consumption

Pancrelipase contain pancreatic enzymes

Side-lying for comfort with legs drawn to chest

Monitor for fluid overload, crackles, edema

Monitor S/S of hypocalcemia by assessing Chvosteks and Trousseaus signs

GI stimulants should be avoided, caffeine containing foods (tea, coffee, cola, and chocolate) and alcohol

Teach to notify Dr if acute abd pain, jaundice, clay-colored stools, or darkened urine

Anticholinergics such as Bentyl which helps decrease vagal stimulation, motility, and pancreatic flow,

contraindicated in pts w/ paralytic ileous

Pancreatic Enzymes take before or w/ meals w/ a glass of water, admin after antacids/H2 blockersNo chewing/crushing tablets, if in powder form put in apple juice/fruit juice or mashed fruit/rice cearl to

decrease oral irritation

Do not mix with protein containing foods, wipe lips after taking, do not inhale while mixing powder form

Can cause increase in uric acid levels (F-2.8-6.8M-3.5-8.0)


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Cirrhosis

Blood and lymph flow are impaired

Risk Factors: Alcoholism, toxins, biliary, obstruction, hepatitis, met disorders

Complications: Ascites, muscle wasting, coagulopathy, portal hypertension, bleeding esophageal varices,

hepatic encephalopathy

HX:

y Chronic alcoholismy Malnutritiony Hepatitis-C leading causey Exposure to liver toxins such as arsenic and certain medsy Prolonged biliary tract obstruction or inflammation

Early Stage:

y Abd pain, diarrhea, constipation, fatigue, N/V, muscle crampsLater Stage:

y Chronic dyspepsia, constipation, pruritus, wt loss, bleeding tendency- nosebleeds, easy bruising,and bleeding gums

y Hepatic encephalopathyPhysical findings:

y Telangiectasis-small dilated blood vessels near surface of the skin- on the cheeksy Spider angiomas on the face, neck, arms, and trunky Gynecomastiay Umbilical herniay Distended abd blood vesselsy Ascitesy Testicular atrophyy Menstrual irregularitiesy Palmar erythemay Clubbed fingersy Thigh and leg edemay Ecchymosisy Anemiay Hematemesis, hematochezia- bright red blood in stool, or melenay Jaundicey Palpable, large, firm liver with a sharp edgey Enlarged spleeny Asterixis- tremor of the wristy Slurred speech, paranoia, hallucinations

Labs:

y Elevated liver enzymesy Decreased serum albumin, cholesterol, and protein levelsy Prolonged PT, INR, and PTTy Decreased H&H, platelet, electrolytes


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y Deficient vit A,C, & Ky Increased urine biliy Elevated ammonia levels

Liver biopsy definitive test

Esophagogastroduodenoscopy revels bleeding esophageal varices, stomach irritation or ulceration, andduodenal bleeding and irritation

Treatment:

y Paracentesisy Esophageal balloon tamponade

Diet:

y Restricted sodium consumption limited to 2g/dayy Restricted fluid intakey No alcohol intakey High-calorie, high-fiber diety Protein intake of 1-1.5g/kg of body weight

Frequent rest periods

Lactulose for encephalitis- to maintain 2-3 bowel movements a day, nonabsorable antibiotics may be

given if lactulose does not help or cannot tolerate the drug, these drugs should not be given together,

observe for response to lactulose, pt may report intestinal bloating and cramping, serum ammonia

levels may be monitored by do not always correlate with symptoms.

Interventions:

y Measure abd girth and wt dailyy Provide meticulous skin care, esp to dependent, edematous, and pruritic areasy Encourage turning freqy Obtain specimens, for testing, such as hepatic enzyme levels, electrolyte levels, ammonia levels,

and coagulation studies

y Institute bleeding precautions, and inspect emesis, stool, and urine for bloody Monitor for s/s of fluid retentiony Monitor neuro status, LOC, orientation, recent memory, attention span, past memory, mood,

affect, and behavior

Monitor:

y Hydration, nutritional statusy Abd girth and weighty Bleeding tendenciesy Neurologic status, esp changes in mentation and behaviory Bowel eliminationy Renal function

Teach:

y S/S of bleeding to report such as black, tarry stools and coffee-ground emesisy Use of small, freq meals; and diet high in caloriesy Avoid infections and abstain from alcoholy Need to avoid sedatives and acetaminopheny Importance of obtaining immunization for influenza, pneumococcal pneumonia, and hepA& B


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y Need for follow-up lab every 6-12 monthsBleeding esophageal varices is life-threatening, can be severe blood loss, resulting in shock from

hypovolemia, Loss of consciousness may occur before any observed bleeding, abd pressure may

increase the likelihood of a variceal bleed, including heavy lifting or physical exercise.

Splenomegaly, enlarged spleen destroys platelets, causing thrombocytopenia-commonly caused by

portal hypertension

Indirect bili is greater than 1.2 is indicative of cirrhosis


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Encephalopathy

A neurologic syndrome that develops as a complication of aggressive fulminant hepatitis or chronic

hepatic disease

Most common in pt w/ cirrhosis

PSE-Portal-systemic encephalopathy, pt report sleep disturbance, mood disturbance, mental changes,

and speech problems, later altered LOC, impaired thinking processes, and neuromuscular problems

Risk factors: Excessive protein intake, sepsis, bacterial action on protein and urea to form ammonia,

hepatitis, diuretic therapy, alcoholism, metabolic alkalosis, hypoxia, azotemia, infection, impaired

glucose metabolism, use of sedatives, opioids, and general anesthetics

HX: Erratic, questionable judgment: mental changes, including difficulty w/ memory, mild confusion,

agitation, and irritability, restlessness, sleeping during day, awake at night: lethargy, slowing of

mentation and speech, difficulty w/ orientation to time, loss of inhibition: marked confusion, aggressive

behavior: coma

Physical Findings:

y Jaundicey Ascitesy GI hemorrhage: hematemesis and melenay Systemic infection

Stage 1 Prodromal

y Personality & behavioral changes, emotional liability (euphoria, depression), impaired thinking,inability to concentrate, fatigue, drowsiness, slurred or slow speech, sleep pattern disturbances

Stage 2 Impending

y Mental confusion, disorientation to time, place, or person, Asterixis (hand flapping)Stage 3 Stuporous

y Progressive deterioration, marked mental confusion, stuporous, drowsy but arousable,abnormal electroencephalogram tracing, muscle twitching, hyperreflexia, asterixis

Stage 4 Comatose

y Unresponsiveness, leading to death in most pt, unarousable, response to painful stimulus, noasterixis, positiveBabinskis sign, muscle rigidity, fetor hepaticus (characteristic liver breath-

musty, sweet odor), seizures

Lab: Ammonia levels elevated and together w/ characteristic clinical features, strongly suggest hepatic

encephalopathy

y Bili elevatedy PT prolongedy Electrolyte levels may reveal hypokalemia, altered calcium levels, or hypomagnesemiay Ammonia levels elevated (15-45)y Elevated ALT (10-35) AST (5-40) LDH (100-190)y Elevated Total bili (0.1-1.2) Direct bilirubin (.1-.3), Protein (6-8), PT (10-30 secs/1.5-2.5x control),

INR (2.0-3.0) Platelets (150,000-400,000), WBC (4500-10,000) RBC (F-4.0-5.0M-4.6-6.0/


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Diet:

y Limited protein intakey Avoidance of alcoholy NPO w/ decreased responsivenessy Parenteral or enteric feedings

Bed rest until condition improves

Lactulose to promote ammonia excretion

Potassium supplements to treat hypokalemia

Liver transplant may be needed

Interventions:

y Promote rest, comfort, and a quiet atmospherey Institute emergency care measures to maintain airway and cardiopulmonary function and to

treat GI bleeding

y Admin lactulose syrup, 30-60ml of a 50% solution 4x daily, reducing to 15-30ml twice daily when3 or more bowel movements occur in a day

y Provide meticulous perianal skin care to prevent breakdown due to increased bowel movementsy Reorient the patient as needed, provide clear explanations about all carey Measure abd girth and wt dailyy Diet low in proteiny Provide skin care, esp to folds of skin and pressure areasy Passive ROM

Monitor:

y Neurologic status, LOC, motor function, and changes in handwriting to determine progressiony F&E and renal functiony WT & abd girthy Signs of anemia, alkalosis, GI bleeding, and infectiony Serum ammonia levely Emotional status, including coping ability

Teach:

y Monitor abd girth and weigh dailyy Low protein diet

PSE: 4 stages, Prodromal, impending, stuporous, and comatose.

PSE can occur after paracentesis or shunting procedures

Patients with cirrhosis and ascites may develop acute spontaneous bacterial peritonitis


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Sengstaken-Blakemore Tube

Not commonly used, uncomfortable for patient, and prone to dangerous complications.Maybe needed

if pt is not able to have an endoscopy or TIPS procedure

Similar to N

G, the tube is placed through the nose and into the stomach; an attached balloon is inflatedto apply pressure to the bleeding variceal area

Before this tamponade, the patient is usually intubated and placed on mechanical ventilator to protect

the airway; some patients may need liver transplantation to prevent further bleeding episodes

Check balloons by trial inflation to detect leaks, best done under water

Chill the tube, then lubricate

Check placement by irrigating with air, an obtain x-ray

Inflate with 200-250ml with air; gently pull tube back to seat balloon against gastroesophageal junction

Clamp gastric balloon, mark tube location at nares

Apply suction to gastric aspiration opening, irrigate at least hourly

If respiratory distress occurs cut the port and pull the tube!


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Paracentesis

Consent, note and report allergies, no dietary restrictions

Local anesthetic, blood sample may be taken

Test takes 45-60 minutes

Ask pt to void before procedure

Head of bed elevated

Weigh the pt after procedure

Obtain baseline VS, wt, and abd girth

Prepare and drape the puncture site

Needle or trocar and cannula are inserted 2.5-5 cm below the umbilicus, or in each quadrant of the abd

Post-op: observe puncture site and drainage for bleeding and infection

Observe the patient for hematuria, which may indicate bladder trauma

Monitor serum electrolyte esp sodium and protein levels

If large amount of fluid was removed, watch for signs of vascular collapse such as tachycardia,tachypnea, hypotension, dizziness, and changes in mental status

Watch for s/s of hemorrhage and shock and for increasing pain and abd tenderness

Observe the pt with severe hepatic disease for signs of hepatic coma, which may result from loss of

sodium and potassium accompanying hypovolemia


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Appendicitis

Fatal if left untreated, gangrene and perforation develop within 36 hours

Most common complication is peritonitis

HX: Abd periumbilical pain, generalized and then localizes in the rt lower abd (McBurneys point)

Anorexia, N/V

Physical Findings:

y Low-grade fever, tachycardiay Fetal positiony Guarding, rt lower quad tendernessy Normoactive bowel sounds, with possible constipation or diarrheay Rebound tenderness and spasm of the abdominal musclesy Rovsing sign (pain in rt lower quad that occurs with palpation of lt lower quad)y Psoas sign (abd pain that occurs when the pt flexes his hip when pressure applied to knee)y Obturator sign (abd pain that occurs when the hip is rotated)y Absent abd tenderness or flank tenderness in pt w/ a retrocele or pelvic appendix

Imaging:

y Barium enema revels nonfilling appendixIn suspected abscess, delay surgery until antibiotic therapy is initiated

Interventions:

y NPOy Avoid analgesicsy Avoid admin cathartics or enemas that may rupture the appendixy Place the pt in fowlers to decrease painy Never apply heat to the rt lower abd can cause rupture

After Surgery:

y Bowel sounds, passing of flatus, and bowel movementsy Wound healingy Pain controly TCDB and incentive spirometryy Activity limitations for 4-6 wksy Post-op follow up 2 and 6 wksy S/S to report: anorexia, N/V, abd pain, fever, and chills


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Ulcerative Colitis

Episodic inflammatory chronic disease that causes ulcerations of the mucosa in the colon

Begins in the rectum and sigmoid colon and may extend upward into the entire colon

Produces congestion, edema, and ulcerations

Risk Factors: Stress, Jewish ancestry

HX: Mild cramping and lower abd pain, recurrent bloody diarrhea as often as 10-25x daily, nocturnal

diarrhea, fatigue and weakness, anorexia and wt loss, N/V, arthralgia, rectal urgency, occasional fecal

incontinence

y Intolerance of milk and milk products and fried, spicy, or hot foodsy Ask about usual stool patterns

Physical findings:

y Liquid stools with visible pus, mucus, and bloody Possible abd distention and tendernessy Perianal irritation, hemorrhoids, and fissuresy Jaundicey Joint painy Wt lossy Tenesmus (unpleasant urge to defecate)

Lab:

y Stool specimen analysis reveals blood, pus, and mucous, but no pathogenic organismsy Decreased levels of potassium, magnesium, hemoglobin, and albuminy Leukocytosis and increased PTy Elevated ESR and CRP

Imaging: barium enema discloses the extent of disease and complications, such as strictures and

carcinoma

Warning! Pts w/ active s/s shouldnt undergo barium enemas!

Colonoscopy may help determine extent of disease. NOT performed when the pt has active s/s

Diet:

y NPO if severey Parenteral nutrition if severey Low fiber/high protein/high calorie, no lactose containing foods

Corticosteroids for severe exacerbations, and antidiarrheal agents

Surgery is last resort, total colectomy with ileostomy pouch (curative)

Interventions:

y Ensure the pt has ready access to bathroom or commodey Meticulous skin care, esp after a bowel movementy Schedule pt care to allow for rest throughout the day, cluster care


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y Auscultate bowel sounds and measure abd girth for changesy Provide comfort measures such as warm sitz bathsy Obtain daily wtsy Obtain specimens for CBC, liver function tests, and vitamin levelsy Enlist the aid of a certified wound ostomy nurse if an ileostomy is planned

Monitor:y Abd distentiony Bowel soundsy Stool, including amount, characteristics, and freq of diarrhea episodesy Daily wty Electrolyte levels, hemoglobin, and ESRy Stools for occult bloody S/S of infection or obstruction

After surgery:

y Wound sitey Pain level and managementy Bowel functiony Stool characteristicsy NG tube function and drainagey Skin integrity

Teaching:

y S/S of relapse and complications, increased abd discomfort, diarrhea, frank blood in stool, andabnormal drainage, fever greater than 101, tachycardia, palpitations, N/V, and to notifyPCP

y Possible adverse reactions associated with meds, including cushingoid syndrome withprednisone, and the need to taper steroids gradually

y Need for follow-up labs such as CBC to evaluate for anemia and evidence of inflammation andyearly liver function tests

y Skin care measures, including perianal hygiene measures and sitz baths

y Importance to adequate rest, physical and emotionaly Foods to avoid or include and the need to monitor weight for changesy Post-op care measures, including surgical site care and stomay Importance of follow-up care including regular visits and screening for colon cancer, such as

colonoscopy with biopsy every 1-2 years after the disease has been present for 7-8 years and

cholangiography to identify cholestasis

Mild- less than 4 stools/day

Moderate- greater than 4 stools/day, mild abd pain, mild intermittent nausea

Severe- greater than 6 bloody stools/day, fever, tachycardia, anemia, abd pain, elevated CRP and/or ESR

Fulminant- greater than 10 bloody stools/day, increasing symptoms, anemia may require transfusion,

colonic distention on x-ray

Common Complications: Hemorrhage/perforation, abscess formation, toxic megacolon, malabsorption,

nonmechanical bowel obstruction, fistulas, colorectal cancer, osteoporosis

Teach to record color, volume, freq, and consistency of stools to determine severity

Patient needs to weigh themselves 1-2x a week

May need low-fiber (low-residue) diet


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Warn the pt caffeinated beverages; pepper, alcohol, and smoking are common GI stimulants


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Crohns Disease

Inflammatory bowel disease that can affect any part of theGI tract from the mouth to the anus

Slow, progressive inflammation of the bowel or digestive tract

Edema, mucosal ulceration, fissures, and abscesses occur

Risk factors: History of smoking, use of oral contraceptives or NSAIDs

Occurs more often in females, ages 15-30

HX: Fatigue and weakness, fever, flatulence, nausea, colicky or cramping abd pain occurs rt lower quad,

diarrhea that may worsen after emotional upset or ingestion of poorly tolerated foods such as milk,

fatty foods, and spices, wt loss, anorexia

Physical findings:

y Soft or semiliquid stool, usually w/o gross bloody Rt lower abd quad tenderness or distentiony Possible abd massy Hyperactive bowel soundsy Bloody diarrheay Perianal and rectal abscessesy Cobble stone appearancey Malabsorption of vital nutrientsy Anemiay 5-6 loose stools per day non bloodyy Ulcerations in perianal areay Fissuresy Steatorrhea

Lab:

y Occult blood in stoolsy H&H may be decreasedy WBC, CPR, and ESR may be increasedy Potassium, calcium, and magnesium levels may be decreasedy Vit B12 and folate deficiency may occur

Imaging:

y X-ray, barium enema, and CT scanning usedy Diagnostic upper endoscopy, sigmoidoscopy, and colonoscopy show patchy areas of

inflammation

Treatment:

y Stress reductiony Sitz bath for perirectal disease

Diet:

y Avoidance of foods that worsen diarrheay Avoidance of raw fruits and vegetables if blockage occursy Adequate caloric, protein, and vitamin intakey Parenteral nutrition if necessaryy Decreased fat for fat malabsorption


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y No gas forming or spicy foods, no foods w/ lactoseActivity reduced, physical and emotion rest

Corticosteroids

Surgery indicated for acute intestinal obstruction, may need colectomy w/ ileostomy

Interventions:

y Meticulous skin care, esp after bowel movement, ensure the pt has ready access to bathroom ora commode

y Schedule patient care to include rest periods, cluster carey Provide comfort measures such as warm sitz bathsy Obtain daily wty Obtain specimens for lab testings such as CBC, liver function tests, and vit levelsy Prepare the patient for possible surgery, such as drainage of abscesses, repair of fistulae, or

colectomy with ostomy

Monitor:

y Fluid balancey Abd distention and bowel soundsy Stool, including amount, characteristics, episodes of diarrhea and freqy Daily wty Electrolyte levels,HB level, and ESRy Stools for occult blood

Teach:

y S/S such as an increase in abd discomfort, diarrhea, frank blood in stool, and abnormal drainage,and to notify PCP

y Need for follow-up lab testing, such as CBC to evaluate for anemia and evidence ofinflammation, yearly liver function tests, and folate and vitamin B12 levels

y Skin care measures, including perianal hygiene and sitz bathsy Importance of adequate rest, both physical and emotionaly Ways to identity and reduce sources of stressy Need to monitor weight for changes and foods to avoid or includey Follow-up , regular visits q 3-6 months if condition is stable, possible endoscopy for changes in

S/S, and surveillance colonoscopy beginning 8 years after initial diagnosis and then q 1-3 yrs

Abd pain Interventions:

y Assist with freq positioning, observe for s/s of peritonitisSkin irritation Interventions:

y Mild soap and water after bowel movements, gently pat area dry, apply a thin coat of vit A&D oraloe cream, use medicated wipes instead of tissues, observe for s/s r/t megacolon (fever,

leukocytosis, tachycardia, distended abd)

Common Complications: Hemorrhage/perforation, abscess formation, toxic megacolon, malabsorption,

nonmechanical bowel obstruction, fistulas, colorectal cancer, osteoporosis

Notify PCP: greater than 6 bloody stools a day, fever, tachycardia, anemia possibly requiring transfusion,

elevated CRP/ESR, increase/change of symptoms


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Promote healing of fistulas at least 3000 calories a day, if heavily draining fistula then a puch may be

used to reduce skin irritation, if pouch not possible use low continuous wall suction attached to wound

bed NOT fistula tract, preserving and protecting the skin is Priority, NEVER allow wound drainage to be

in contact w/ skin


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Ostomies

Home care: Assess dietary and fluid intake and habits, presence or absence of N/V, wt gain or loss,

bowel elimination pattern and characteristics and amount of effluent (stool), bowel sounds

Assess condition of stoma, location, size, protrusion, color, and integrity, signs of ischemia, such as dull

coloring or dark or purplish bruising

Assess peristomal skin for presence or absence of excoriated skin, leakage underneath drainage system,

fit of appliance and effectiveness of skin barrier and appliance

y Use pectin-based skin barrier to protect skin from contact with contentsy Skin sealants and ostomy skin creamsy Watch for any irritation or rednessy Empty pouch when its 1/3 to fully Change the entire pouch every 3-7 daysy Chew food thoroughlyy Be cautious of high-fiber foods and high-cellulose foods such as corn, peanuts, coconut, chinese

vegetables, string beans, tough-fiber meats, shrimp and lobster, rice, bran, and veg w/ skins like

tomatoes, corn, and peas

y Avoid taking enteric-coated and capsule medsy Do not take laxatives or enemas and contact doc if no stools in 6-12 hrs

Symptoms to watch for:

y Report any drastic increase or decrease in drainagey If stomal swelling, abd cramping, or distention occurs or if contents stop draining: Remove the

pouch with faceplate, lie down, assume knee-chest position, begin abd massage, apply moist

towels to abd, drink hot teaIf none of these works call PCP immediately

Report signs of ischemia and necrosis, unusual bleeding, mucocutaneous separation

A healthy stoma should protrude of an inch and should be reddish pink and moist

Gas producing foods: Broccoli, beans, spicy foods, onions, Brussels sprouts, cabbage, cauliflower,

cucumbers, mushrooms, peas, chewing gum, smoking, drinking beer, and skipping meals

Foods to prevent gas: crackers, toast, and yogurt, buttermilk, cranberry juice, parsley

Charcoal filters/pouch deodorizers/placement of breath mint in pouch will help eliminate odors from

pouch

Pt should be cautioned to not put aspirin tablets in pouch cause it may cause ulceration of the stoma


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Clostridium Difficle

A gram-positive anaerobic bacterium often resulting in antibiotic-related diarrhea

Complications include: Hypovolemic shock, toxic megacolon, colonic perforation, peritonitis, sepsis,

hemorrhage

HX: Recent antibiotic therapy or hospitalization, abd pain, cramping, anorexia, malaise, fever, N/V

Physical Findings: soft, unformed, or watery diarrhea more than 3 stools in a 24-hr period, may be foul

smelling or grossly bloody, abd tenderness, hypovolemia

Treatment:

y Withdrawal of causative antibioticy Good skin care

Diet:

y Well-balanced diety Increased fluid intake

Rest periods during acute phase

Interventions:

y Contact precautions, wash hands with soapy Make sure reusable equipment is disinfectedy Meticulous skin care to the perianal area

Teach:

y Need to avoid the intake of alcohol, including over the counter meds that may contain ity Proper hand-washingy Proper disinfection of contaminated clothing or household itemsy Importance of adequate of fluid intakey S/S of dehydrationy Measures for perianal skin care

Do not give antidiarrheal meds


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Abdominal Perineal Resection

The perineal wound is generally surgically closed and two bulb suction drains such as Jackson-Pratt

drains are placed in the wound or through stab wounds near the wound

The drains help prevent drainage from collecting within the wound and are usually left in place forseveral days, depending on the character and amount of drainage.

Monitoring drainage from the perineal wound and cavity is important because of the possibility of

infection and abscess formation

Serosanguineous drainage from the perineal wound may be observed for 1-2 months after surgery

Complete wound healing of the perineal wound may take 6-8 months

This wound can be a greater source of discomfort than the abdominal incision and ostomy, and more

care may be required.

The patient may experience phantom rectal sensations, rectal pain and itching occasionally occur after

healing. Interventions may include antipruritic drugs and sitz baths

Continually assess for signs of infection, abscess, or other complications

Teach to avoid lifting heavy objects, avoid straining on defecation to prevent tension, if open surgical

approach driving should be avoided for 4-6 wks while the incision heals

If laparoscopy, can usually return to all usual activities in 1-2 wks

Report cramping, abd pain, N/V

Avoid gas-producing foods and carbonated beverages

Ostomy nurse marks the abd for an optimal location

Pt needs to be taught risks for post-op sexual dysfunction and urinary incontinence due to nerve

damage

Post-op: Necrotizing Enterocolitis-Monitor for signs of sepsis (death of intestinal tissues characterized

by ischemia) Call PCP immediately


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Peritonitis

Commonly causes decreased intestinal motility and intestinal distention with gas

Three forms: Primary usually due to ascites from chronic liver disease called spontaneous bacterial

peritonitis; secondary usually do to a pathologic process in an organ, trauma, or surgery the most

common type; and tertiary recurrent or persistent infection after initial therapy.

Complications: abscess, fistula formation, septicemia, resp compromise, bowel obstruction, shock, liver

failure

HX: early phase: generalized abd pain

With progression, increasingly severe and constant abd pain that increases with movement and

respirations, possible referral of pain to the shoulder or thoracic area, anorexia, N/V, inability to pass

stools and flatus, hiccups

Physical Findings:

y Fevery Tachycardiay Hypotensiony Shallow breathingy Signs of dehydrationy Positive bowel sounds-early; absent bowel sounds-latery Abd rigidityy General abd tendernessy Rebound tendernessy Pt lying very still with knees flexedy Inability to have a bowel movement and flatus

Lab: CBC shows leukocytosis, blood may reveal dehydration and acidosis

Treatment:

y NG intubationy Hemodynamic monitoring

Diet:

y NPO until bowel function returnsy Total parenteral nutrition if necessary

Bed rest until condition improves, semi-fowlers, avoidance of lifting for at least 6 wks post-op

Interventions:

y Initiate IV accessy Institute cardiac monitoringy Provide NG care, ensure patency, and note color and characteristics of drainagey Maintain NPO status, auscultate bowel soundsy Elevate head of bed to assist in pain relief and promote maximum chest expansion

Monitor:

y Cardiopulmonary statusy Pain level and reliefy Fluid balance


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y NG Tube and drainagey Bowel functiony Incision site and dressing

Watch for S/S of abscess formation, including persistent abd tenderness and fever

Teaching:

y Possible side effects of meds such as N/V, gastric distress, and rashy TCDB, leg exercises, position changes, incentive spirometry, and monitoringy S/S of infectiony Incisional site care


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Colonoscopy

Consent form, insert IV and admin sedation

Maintain a clear liquid diet for 24-48 hours before the test and to take nothing by mouth after midnight

the night before the test

No alcohol for one week before test

Advise the pt he may feel the need to defecate

Test takes 30-60 minutes

Assist patient to left side with knees flexed

Baseline vitals, vs and electrocardiogram are monitored during the procedure

Post-op Care

y Observe closely for signs of bowel perforationy Report excessive bleeding immediately

Contraindicated in pregnant pt, pt who have had recent abd surgery, and in those with peritonitis,

colitis, or a perforated viscus

Monitor closely for adverse effects from the sedative, have emergency resuscitation equipment and an

opioid antagonist available

If pt reports abd pain/fever/or suspected bleeding-continue to monitor VS and notify PCP


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Bowel Obstruction

HX: Recent change in bowel habits,Hiccups, colicky pain, N/V, constipation, diffuse abd discomfort, freq

vomiting

Physical Findings: Distended abd, borborygmi and rushes, abd tenderness, rebound tenderness,

decreased bowel sounds early, absent late

Sodium, chloride, potassium, decreased due to vomiting

Treatment:

y Correction ofF&E imbalancesy Decompression of the bowel to relieve vomiting and distensiony Treatment of shock and peritonitis

Diet:

y NPO if surgery plannedy Parenteral nutrition until bowel is functioningy High-fiber, when obstruction is relieved

Bed rest during acute phase

Post-op avoidance of lifting and contact sports

Interventions:

y NG tube and attach to low-pressure, intermittent suctiony Inspect the abd for distention, measure abd girth, and auscultate bowel soundsy Maintain semi-fowlersy Provide mouth and nose carey Insert an indwelling urinary cathetery Institute measures to address shock or peritonitis

Monitor:

y S/S of shock and peritonitisy Bowel soundsy ABGy NG function and drainagey Abd girthy Stool samples for consistency and amount and for occult bloody Wound sitey S/S of post-op complications: increasing pain intensity; peritonitis, such as rigidity and

tenderness; metabolic alkalosis, such as slow, shallow respirations, and changes in

consciousness; and metabolic acidosis, such as weakness, disorientation, and rapid breathing

and shortness of breath with exertion; and shock including pallor, hypotension, and tachycardia

Report to PCP: Severe pain that stops and changes to tenderness on palpation, no flatus or bowel

movement, hiccups, suspected obstruction immediately place pt on NPO and contact PCP!

Abd distention, peristalsis waves, high pitched bowel sounds (borborygmi)

Do not put anything into the pig tail!

NG placement is checked by pH (Not greater than 4) pH of stomach 1-4


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NG tube when FIRST placed position is confirmed by x-ray

Auscultate bowel sounds but always turn OFF suction before listening to bowel sounds

Diverticulitis- Test 5

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