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Gastrointestinal Med Surg 1 (Day 2)

Terms in this set (48)

Crohn's disease
-aka ganulomatous colitis, ileitis, regional enteritis.
-Chronic inflammatory disease of bowel
-occurs anywhere in gi tract but usu. in distal ileum
-Insidious onset
Characteristics of Crohn's disease
-Extends through all layers of bowel wall (transmural)
-Submucosal layer is most involved
•Hyperemia, edema, ulcerations in affected areas give 'cobblestone' appearance on endoscopy
•'skip lesions' random inflamed areas alternating with normal areas
•Chronic lesions cause scarring which leads to bowel obstruction
•Damage through the intestinal wall causes fistulas to form
-Enterocutaneous (bowel to skin)
Most common are perianal, perilabial
-Enterovaginal, vaginal rectal
-Enterovesicle
-Enteroenteric
Clinical manifestations of Crohn's disease
Abd pain, tenderness (esp. Rlq) & distention
Distension may be associated with eating
Chronic diarrhea which may lead to dehydration
Fever
Fatigue
Anorexia, wt. Loss
Poor growth in children & adolescents
Systemic effects
Systemic effects of Crohns
-Arthritis
-erthyema nodosum
-pyoderma gangrenosum
-uveitis
-conjunctivitis
-liver and gallbladder disorders
Diagnostic tests
•Stool
•Negative c&s
•Positive for blood & wbcs
Blood
•Anemia (r/t blood loss & malnutrition)
•Wbcs & sed rate elevated (r/t inflammation)
•Protein & albumin decreased (r/t malnutrition)
•Vitamin adek levels decreased
•Abnormal lytes & abgs (r/t diarrhea)
•New serum antibody tests (adjunctive test r/t may or may not be elevated & normal people may have
elevated levels)
-Asca (anti-saccaromyces antibody)
•X-rays
-Barium enema shows inflammation in large bowel
-Upper gi series with small bowel follow through if upper gi tract involvement suspected
•Endoscopy confirms dx.
Colonoscopy or sigmoidoscopy
•Shows skip lesions & cobblestones
•Allows bx. For chronic inflamation & granuloma
Granuloma = crohn's
No granuloma does not r/o crohn's
-Egd if upper gi tract involvement suspected
Med management of Crohns
Drugs -

(5 Acetylsalicylic acid and steroids)
Supplements - vitamins, fe+++
Antidiarrheals - lomotil, immodium (if infection present may cause toxic megacolon)
Steroids - during acute exacerbation
•Prednisone po
•Hydrocortisone enema or suppository
•5- acetylsalicylic acid (5-asa)
- Examples
•Sulfasalazine (azulfadine)
•Olsalazine (dipentum)
•Mesalamine (asacol, pentasa, rowasa [enema or suppository])
- Contraindicated if asa allergy
- Need high folate intake
- Take with food to decrease gi upset
- Report s/s bone marrow suppression
- Sunscreen
•Immune modulators - if 5-asa & steroids not effective in maintaining remission
-Examples
•Mercaptopurine (6-mp)
•Azathioprine (imuran)
•Cyclosporine (sandimmune)
•Tacrolimus (prograf)
•Methotrexate (mtx)
-Bone marrow suppression, liver damage, infection (s/s may not be obvious)
-Category x
•Biologic agents - new
- Example
•Infliximab (remicade)
- Antibody which interferes with inflammation - given iv
- For severe fistulizing crohn's
- Pre-med pt. With tylenol & benadryl to decrease side effects
- Pre-med pt. With prednisone if previous reaction
- Bone marrow suppression, infection (s/s may not be obvious)
•Antibiotics
-Metronidazole (flagyl)
-Ciprofloxan (cipro)
surgical treatment of Crohns
Surgical treatment (illeostomy)
-Not curative reoccurs in remaining bowel
-Done for complications
-Intestinal obstruction/ perforation
-Fistula formation
-May result in short bowel syndrome & tpn for life
Nursing teaching, pts reportable s/s
- Increased # bms, visible blood in stool
- Severe abd pain
- Extreme fatigue, wt. Loss
Nursing Assessment in Crohn's
•Diet hx. & allergies
•Clinical manifestations
•Bm pattern
•Medication side effects
•Response to treatment
•Complications
•Focus of care
-Assess as described
-Manage f&e & acid-base balance
-I&o, turgor, vs, wt.
-Emotional support
-Caution with bowel preps during acute attack
•Avoid laxatives for bowel prep during acute attack r/t may cause toxic megacolon & perforation
Diet for Crohn's disease
low-residue
low-fat
high-protein
high-calorie diet
with no dairy products
When do you avoid laxatives and bowel prep in crohns patients?
during an acute attack.
Ulcerative colitis
chronic inflammation of the colon with presence of ulcers
Ulcerative colitis patho
-Patho
Inflammation begins in rectum & extends proximally to cecum
Lesions are continuous without normal tissue in between
Ulcerations develop r/t inflammation & extend to but not into the muscular layer of the bowel wall so only mucosal lining is involved.
-Poor integrity of bowel wall can lead to toxic megacolon
Ulcerative colitis triggered by
-Infection, allergy, emotional stress, environmental toxins
Ulcerative Colitis Clinical manifestations
Abrupt onset
Exacerbations & remissions
Severe bloody & mucosy diarrhea (10-20/day) f&e imbalance
Abd cramps
Tenesmus
-straining r/t rectal spasms but no stool is passed, common in ulcerative colitis
Dietary management of ulcerative colitis
-NPO during acute attack to rest & heal bowel
-ID Irritatin foods & avoid them
-high calorie and high protein
-avoid very cold foods (increases motility
-decrease fiber during acute attack
-use tpn to rest bowel
Med management of ulcerative colitis
-Fe+++ r/t anemia
-Vitamins r/t absorption with diarrhea
-Steroids (po, iv, suppository, enema)
-Antidiarrheals (lomotil & imodium) decreases peristalsis & rest bowel
-Antibx. For secondary infections of lesions, abscesses, perforation, & peritonitis
-5-ASA drugs
-Immune modulating agents
Surgey for ulcerative colitis goal?
Curative
Kock continent pouch
Permanent illeostomy with pouch & nipple valve drained by a catheter 4 x/day
Nursing considerations for ulcerative colitis surgeries
-Usu. Post op gi care & observations
-Observe stoma - report if darkens r/t means it is poorly perfused
-Manage & teach pt. Ostomy care & refer to support group
Nursing care of ulcerative colitis pts
-Maintain & teach dietary modifications
-Manage tpn if used
-Anemia -
•Planned rest & safety (fall risk r/t orthostatic & fatigue)
•Manage transfusions
-Manage iv's & observe for dehydration & electrolyte disturbances
-I&o, teach & assist with smoking cessation
•Administer & teach about meds
•Teach pt. To report fever, sore throat
•Report any sudden onset of abd distention, severe pain or fever (may mean perforation)
•Id & report changes in s/s & onset of complications
-Toxic megacolon, perforation, peritonitis
•Observe for subtle s/s infection (malaise, low bp) r/t steroids
•Emotional support & refer to support group
GERD cause
-INCOMPETENT CARDIAC (LES) SPHINCTER DOES NOT CLOSE FULLY
-MAY BE R/T SPHINCTER ITSELF BEING INCOMPENTENT, ABNORMAL ANGLE AT
JUNCTION, ABNORMAL INNERVATION OF AREA
GERD
-ACIDIC GASTRIC CONTENTS RUN UP INTO ESOPHAGUS WHICH HAS NO PROTECTIVE
MUCOSA
•CAUSES GI PAIN
•CAUSES CHANGES IN TRACHEAL TISSUE
GERD Risk factors
-ANY CONDITION WHICH CAUSES INCREASED PRESSURE ON STOMACH (SQUEEZES
CONTENTS UPWARD)
-Obesity
-Pregnancy
-FOODS WHICH CHEMICALLY DECREASE LOWER ESOPHAGEAL SPHINCTER (LES)
TONE
•ETOH, PEPPERMINT, LICORICE, CAFFEINE, TOBACCO, CARBONATED BEVERAGES
GERD
GERD Clinical manifestations
-EPIGASTRIC PAIN & DISCOMFORT
-REGURGITATION
-HEARTBURN
-CHEST PAIN (must rule out MI)
GERD Complications
-ESOPHAGITIS - INFLAMMATION OF THE LINING OF THE ESOPHAGUS CAUSES
•PAINFUL OR DIFFICULT SWALLOWING
-ESOPHAGEAL ULCERATION CAUSES SLOW BLEEDING LEADING TO ANEMIA OVER
TIME
-ESOPHAGEAL STRICTURES & CANCER
Diagnostic tests of GERD
-barium swallow (shows esophagitis & stricture)
-endoscopy &biopsy (confirms esophagitis)
Medical Management
-H2 blockers to suppress acid formation to prevent injury to esophagus (pepcid, axid, zantac)
-Proton pump inhibitors to suppress last step of acid formation (prilosec, prevacid, protonix
-GI Motility agents
(Reglan)
-Antacids to decrease damage to esophagus by neutralizing acids (maalox, mylanta, tums)
Nursing management of GERD
-TEACHING MEDICATIONS
-DIETARY TEACHING
•SMALL FREQ. MEALS
•REMAIN UPRIGHT FOR 2 HRS. AFTER MEALS
•NO EATING AT BEDTIME
-AVOID FOODS, SUBSTANCES, & BEVERAGES WHICH DECREASE CARDIAC
SPHINCTER FUNCTION & CAUSE ESOPHAGEAL IRRITATION
»ETOH, PEPPERMINT, LICORICE, CAFFEINE, TOBACCO, CARBONATED BEVERAGES
-LOW FAT, HIGH FIBER
GERD
•SLEEP WITH HOB ON 3-4 INCH BLOCKS
•WT. LOSS IF OBESE
•AVOID BEHAVIORS WHICH INCREASE ABD. PRESSURE
-VALSALVA, LIFTING, STRAINING, TIGHT CLOTHES
Fundoplication
wrap stomach fundus around cardiac sphincter to keep it from opening & causing reflux
Fundoplication nursing consideration
-monitor for nausea & gastric distention post-op r/t pt. unable to vomit or belch post-op
angelchik antireflux prosthesis
-c-shaped gel filled synthetic ring applied around distal esophagus
-side effects-dysphagia achalasia
Small bowel obstruction causes
Anesthesia & handling of bowel during abd surgery (lasts 12-36 h)
Inflammation i.e. Peritonitis
Electrolyte disturbance i.e. k+ r/t smooth muscle ability to contract
Drugs i.e. Narcotics, cholinergic blockers
Ischemia to bowel r/t shock or embolus (esp. To mesenteric artery)
Clinical manifestations of Small bowel obstruction
-Nausea
-vomiting of bile or fecal material from obstruction
non mechanical small bowel obstruction
paralytic ileus, adynamic bowel.
No peristalsis = no bowel sounds
Mechanical small bowel obstruction
-Results from narrowing of the bowel lumen due to a mass i.e. Tumor, impacted feces, barium, adhesions, incarcerated or strangulated hernia, volvulus, intussusceptions high pitched sounds on auscultation
-Stagnant intestinal contents cause distention above obstruction
Bowel sounds (nonmechanical)
(paralytic ileus)= no bowel sounds r/t no peristalsis
Bowel sounds (mechanical)
-At 1
st high pitched bowel sounds above obstruction r/t "bowel rocking" to move obstruction
-bowel sounds stop if bowel dies
diagnosis of bowel obstruction
-X-ray (flat plate & decubitus)
-Barium enema shows obstruction
-Ct freq. Used for mechanical
-Labs
Management of SBO
-Npo, iv with electrolytes
-Freq. Vital signs & urine output (report changes & uo < 50 cc/h)
-Antibx if infection
-Analgesics
-Bowel decompression
•Ng suction for partial or obstruction high in small bowel
•For lower obstruction (Mercury or tungsten gel weighted tube)
•Placed by md
•Turn pt. Q2h (right-high fowlers-left)
•Monitor tube movement
•Leave untaped until reaches obstruction
• Monitor abd girth
• Decompression may relieve nonmechanical
• Occas. Mechanical can be fixed per endoscopy
Removal of masses i.e. Polyps
• Mechanical usu. Needs surgery - may have temporary or permanent ostomy
Peritonitis
Inflammation of the serous lining peritoneum of the abd. cavity
-Caused by perforation of gi tract (r/t pud, appendicitis, inflammatory bowel disease), trauma (gunshot, knife), ruptured ectopic pregnancy, or infection introduced during a procedure
Peritonitis Patho
-Chemicals & bacteria spill into peritoneal cavity -> inflammation of the peritoneum -> abscesses form &
fluid shifts (third spaces) from blood to peritoneal cavity -> hypovolemic shock -> death
Peritonitis Clinical manifestations
-Severe abd pain -> pt. Lays with knees drawn up & resists movement
-Shallow breathing r/t abd pain
-Abd tender to palpation
-Abd. Distention r/t decreased gi motility -> bowel distend with gas & fluid -> need ng tube
-N/v, fever develops as pt. Becomes more septic & shocky
-Absent bowel sounds
-abd ridgid & boardlike r/t accumulated gas & fluid in abd
s/s shock
decreased bp, increased pulse, as fluid shifts into peritoneal space as pt becomes more septic
Peritonitis Diagnostic tests
-WBC Markedly elevated (increased neutrophils, segs (mature neutrophil), granulocytes r/t bacteria.
-X-ray for free air (turn pt on side -> air rises so can see air & fluid in abd.
-CT/Ultrasound shows structural changes in organs
Peritonitis Nursing Management
-NG-> Suction
-IV - replace F& E lost into the abd. cavity, maintain bp & replace ng output
-Foley to monitor fluid status & renal perfusion during shock
-meds (antibx, analgesics, antipyretics
-pt will need surgery repair damage or abscess
-Monitor & maintain ng, iv & foley
-comfort measures for fever
-monitor peak & troughs on antibx
Peritonitis Nursing Management
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