Block II: Learning Objectives Week 1 & 2
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. What would you like to do?
Describe the scope of
promote health and prevent illness or injury in patients from 18 to older than 100 years of age.
meet the biologic, psychosocial, cultural, and spiritual needs of the adult patient in a mutually trusting, respectful, and caring relationship.
Explain the recent increased focus on
patient safety and quality of care.
In 2000, the Institute of Medicine (IOM) stated in its To Err is Human: Building a Safer Health Care System publication that between 44,000 and 98,000 patient deaths result each year from preventable errors in acute care hospitals.
Institute for Healthcare Improvement (IHI) estimates that there are nearly 15 million health care errors in U.S. hospitals each year, or 40,000 per day.
100,000 Lives Campaign
Protect patients from five million incidents of medical harm over a 2-year period
Identify the purpose of the Rapid
Response Team (RRT).
Rapid Response Teams save lives and decrease the risk for harm by providing care to patients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team who responds to patient arrests, it intervenes rapidly when needed for those who are beginning to clinically decline.
Explain when to call the RRT.
early intervention for patients who are clinically changing. They require each health care organization to establish criteria for patients, families, or staff to call for additional assistance in response to an actual or perceived change in the patient's condition.
Differentiate the six core competencies that health care professionals need to provide safe, quality health care.
- Provide patient-centered care.
- Collaborate with the interdisciplinary health care team.
- Implement evidence-based practice
- Use quality improvement in patient care.
- Use informatics in patient care.
Identify three ethical principles that help guide clinical decision making.
- Self-determination or self-management
- Social Justice
Explain the importance of communication when collaborating with the interdisciplinary team.
Poor communication between professional caregivers and health care agencies causes many medical errors and patient safety risks.
Outline the five rights of the delegation and
- Right task: The task is within the UAP's scope of practice and competence.
- Right circumstances: The patient care setting and resources are appropriate for the delegation.
- Right person: The UAP is competent to perform the delegated task or activity.
- Right communication: The nurse provides a clear and concise explanation of the task or activity, including limits and expectations.
- Right supervision: The nurse appropriately monitors, evaluates, intervenes, and provides feedback on the delegation process as needed.
Describe the SBAR procedure for successful communication in health care agencies.
- Situation: Describe what is happening at the time to require this communication.
- Background: Explain any relevant background information that relates to the situation.
- Assessment: Provide an analysis of the problem or patient need based on assessment data.
- Recommendation: State what is needed or what the desired outcome is.
Describe the nurse's role in the systematic quality improvement process.
- Identify indicators to monitor quality and effectiveness of health care.
- Access and evaluate data to monitor the quality and effectiveness of health care.
- Recommend ways to improve care processes.
- Implement activities to improve care processes.
Identify three ways that informatics and technology are used in health care.
- 1) Documentation
- 2) Electronic data access
- 3) Data utilization
Explain how emerging technology related to infusion therapy can enhance patient safety.
Advances in medicine and technology have made it possible for people with chronic diseases such as diabetes mellitus, chronic kidney disease, and malabsorption syndromes to live long and productive lives. These patients are often dependent on long-term infusion therapy of some kind. They often have very poor vascular integrity and, therefore, accessing their peripheral veins takes a high level of skill.
Teach the patient and family about the type and care related to the patient's infusion therapy.
- Before catheter insertion, educate the patient and family about:
- The type of catheter to be used
- Hand hygiene and aseptic technique for care of the catheter
- The therapy required
- Alternatives to the catheter and therapy
- Activity limitations
- Any signs or symptoms of complications that should be reported to a health care professional
Identify the evidence-based recommendations for prevention of intravenous (IV) catheter–related bloodstream infection (CR-BSI).
- Perform hand hygiene before palpating the insertion site.
- Clip hair—do not shave.
- Ensure that skin is clean.
- Wear clean gloves for peripheral IV insertion; do not touch the access site after application of antiseptics.
- Prepare clean skin with 70% alcohol (or chlorhexidine) before peripheral venous catheter insertion.
- Apply povidone-iodine to the skin, and allow it to dry for at least 2 minutes.
Describe the special needs and care for older adults receiving IV therapy.
Because of changes in cardiac and renal status, the accuracy of infusion volume and flow rate measurements is very important in the older adult. The health care provider's prescription for infusion therapy should be assessed for appropriateness for the patient's condition. Older adults are very prone to fluid overload and resulting congestive heart failure. Electronic controlling devices may be required to ensure the necessary accuracy.
Identify the appropriate veins for peripheral IV catheter insertion.
Differentiate types of vascular access devices (VADs) used for peripheral and central IV therapy.
- Short peripheral catheters
- Midline catheters
- Peripherally inserted central catheters (PICC)
- Nontunneled percutaneous central venous catheters (CVCs)
- Tunneled catheters
- Implanted ports
- Hemodialysis catheters
Use best practice for inserting peripheral vascular access devices (VADs).
- Verify that the prescription for infusion therapy is complete and appropriate for infusion through a short peripheral catheter.
- For adults, choose a site for placement in the upper extremity. DO NOT USE THE WRIST.
- Choose the patient's nondominant arm when possible.
- Choose a distal site, and make all subsequent venipunctures proximal to previous sites.
- Do not use the arm on the side of a mastectomy, lymph node dissection, arteriovenous shunt or fistula, or paralysis.
- Avoid choosing a site in an area of joint flexion.
- Avoid choosing a site in a vein that feels hard or cordlike.
- Avoid choosing a site close to areas of cellulitis, dermatitis, or complications from previous catheter sites.
- Choose a vein of appropriate length and width to fit the size of the catheter required for infusion.
Assess the patient's infusion site frequently for local complications, such as phlebitis and infiltration.
Phlebitis is the inflammation of a vein caused by mechanical, chemical, or bacterial irritation.
Infiltration occurs when IV solution leaks into the tissues around the vein.
Prioritize nursing interventions for maintaining an infusion system.
- Hand Hygeine
- Maximal barrier precautions
- Chlorhexidine for skin disinfection
- Appropproate sites
- Post placement care
- Daily review of the site
Assess, prevent, and manage systemic complications related to infusion therapy and VADs.
See Table 15-2 and 15-3
Identify nursing care associated with intra-arterial, intraperitoneal, subcutaneous, intraosseous, and intraspinal infusion therapy.
When changing the dressing, remove it by pulling laterally from side to side. It can also be removed by holding the external catheter and pulling it off toward the insertion site. Never pull it off by pulling away from the insertion site because this could dislodge the catheter!After removing the dressing from a midline catheter or any central venous catheter, note the external catheter length. Compare this length with the original length at insertion. If the length has changed, the catheter tip location has also changed and may no longer be in a vein appropriate for infusion. Follow agency policy or notify the health care provider about the length change. A repeat chest x-ray may be needed, and careful assessment of the type of therapy and remaining length of therapy will likely be required.Protect the external catheter, dressing, and all attached tubing from water because it is a source of contamination. While bathing, be sure that the unlicensed assistive personnel (UAP) cover the extremity. Plastic trash bags can be taped over the extremity; however, devices specially designed for this purpose are more convenient for the patient to use.
Assess the patient with a fluid or electrolyte imbalance for falls, especially older adults.
The patient with dehydration is at risk for falls because of the accompanying orthostatic hypotension, dysrhythmia, muscle weakness, and possible confusion
Use safety precautions to prevent injury or death when administering parenteral potassium-containing solutions.
- Never push potassium.
- Second check med?
Teach healthy adults and patients how to prevent dehydration.
- Teach all patients to drink more fluids, especially water, whenever they engage in heavy physical activity or live in dry climates or at higher altitudes.
- Beverages with caffeine can increase fluid loss, alcohol too
- Always offer fluids
Assess patients for factors that increase the risk for fluid and electrolyte imbalances, especially for older adults.
Ask specific questions about food and liquid intake, and guide the patient in reporting accurately the amount of fluid ingested because he or she may not understand the connection between dietary intake and the onset of fluid imbalances. Also assess the types of fluids and foods ingested to determine amount and osmolarity. Many patients do not know that solid foods contain liquid.
Teach patients at risk for fluid or electrolyte
imbalances as a result of drug therapy about the manifestations of the imbalance.
Severe electrolyte imbalances with actual losses or retention of specific electrolytes are life threatening and can occur in any setting. People at greatest risk for severe imbalances are older patients, patients with chronic kidney or endocrine disorders, patients who are mentally impaired, and patients who are taking drugs that alter fluid and electrolyte levels. All ill people are at some risk for electrolyte imbalances.
See individual imbalance symptoms
Explain the relationship between weight gain or loss and fluid imbalances.
Because 1 L of water weighs 2.2 pounds (1 kg), changes in daily weights are the best indicators of fluid losses or gains.
Apply knowledge of the anatomic and physiologic responses to aging when assessing hydration status of an older adult.
Older adults often use diuretics and laxatives, which can disturb fluid balance. Misuse and overuse of these drugs can lead to dehydration and electrolyte imbalances. An important issue for many older adults is that they may depend on other people to provide assistance in meeting fluid needs.
Interpret blood chemistry laboratory results to determine whether the patient has a fluid or electrolyte imbalance and to determine effectiveness of interventions.
- Normal Values
Assess the breathing effectiveness of any patient with skeletal muscle weakness from an electrolyte imbalance.
Respiratory monitoring is performed at least hourly for severe hypokalemia and includes rate and depth, especially checking for increasing rate and decreasing depth. Also check oxygen saturation by pulse oximetry to determine breathing effectiveness. Assess respiratory muscle effectiveness by checking the patient's ability to cough.
Prioritize interventions for patients who have dehydration or fluid overload.
- patient safety
- fluid replacement
- drug therapy
Prioritize interventions for patients who have
specific electrolyte imbalances.
The priorities for nursing care of the patient with hyponatremia are monitoring the patient's response to therapy and preventing hypernatremia and fluid overload.
Drug and nutritional therapy
Identify patients at risk for falls as a result of acid-base imbalances, especially older adults.
Assess the patient's level of consciousness and mental status, because changes in mental status occur with fluid imbalance and electrolyte imbalances.
Describe the relationship between free hydrogen ion level and pH.
- Acid-base balance is the result of processes that carefully regulate hydrogen ion (H+) production and elimination. Body fluid pH is a measure of the body fluid's free hydrogen ion level.
- This value has the narrowest range of normal and the tightest control mechanisms of all the electrolytes.
Explain the concept of compensation.
- The body adapts to attempt to correct changes in blood pH. A pH below 6.9 or above 7.8 is usually fatal
- Both the kidneys and the lungs can compensate for acid-base imbalances, but they are not equal in their final responses.
Compare the roles of the respiratory system and the kidneys in maintaining acid-base balance.
Respiratory compensation occurs through the lungs, usually to correct for acid-base imbalances from metabolic problems. For example, when prolonged running causes buildup of lactic acid, hydrogen ion levels in the ECF increase and the pH drops. To bring the pH back to normal, breathing is triggered in response to increased carbon dioxide levels. Both the rate and depth of respiration increase. These respiratory efforts cause the blood to lose carbon dioxide with each exhalation, so ECF levels of carbon dioxide and free hydrogen ions gradually decrease. When the lungs can fully compensate, the pH returns to normal.
Kidney compensation results when a healthy kidney works to correct for changes in blood pH that occur when the respiratory system either is overwhelmed or is not healthy. For example, in a person with chronic obstructive pulmonary disease (COPD), the respiratory system cannot exchange gases adequately. Carbon dioxide is retained continuously, hydrogen ion levels increase, and the blood pH falls (becomes more acidic). To oppose this process, the kidney excretes more hydrogen ions and increases the reabsorption of bicarbonate back into the blood. As a result, the blood pH remains either within or closer to the normal range. When these backup actions are completely effective, acid-base problems are fully compensated and the pH of the blood returns to normal even though the levels of oxygen and bicarbonate may be abnormal.
Use laboratory data and clinical manifestations to determine the presence of acid-base imbalances.
Interpret arterial blood gases to determine whether acidosis is respiratory or metabolic in origin.
- R espiratory
- O pposite
- M etabolic
- E qual
Prioritize nursing care for the patient with an
- Monitor to prevent complications
- Ensure safety
- Monitor response to complications
- Monitor response
Assess patients for complications of diagnostic tests.
- Check vital signs every 15 minutes until the patient is stable. Keep the siderails up until the patient is fully alert, and maintain NPO status. Observe for signs of perforation (causes severe pain) and hemorrhage, such as a rapid drop in blood pressure. Reassure the patient that a feeling of fullness, cramping, and passage of flatus are expected for several hours after the test. Fluids are permitted after the patient passes flatus to indicate that peristalsis has returned.
- report excessive bleeding or severe pain to the health care provider immediately
Identify factors that place patients at risk for GI problems.
- older adults are more at risk for stomach cancer than are younger adults. Younger adults are more at risk for inflammatory bowel disease (IBD). The exact reasons for these differences continue to be studied.
- Ask about prescription medications being taken, including how much, when the drugs are taken, and why they have been prescribed. Inquire if the patient takes over-the-counter (OTC) drugs, herbs, and/or supplements. In particular, ask whether aspirin, NSAIDs (e.g., ibuprofen), laxatives, herbal preparations, or enemas are routinely taken.
- Smoking is a major risk factor for most GI cancers.
Teach pre-test and post-test care for diagnostic GI testing to patients and families.
- Clear liquid diet
- Avoid red, orange, or purple beverages. Drink lots of gatorade to replace electrolytes loss
- NPO except water 4-6 hours before
- Remind them to avoid anticoags several days before
- Diabetics check with doctor because of NPO
- Golytely or sodium phospate
- Check vitals every 15 min until stable
- Keep siderails up until fully alert
- NPO until flatus return
- Observe for signs of perferation and hemorrhage such as rapid drop in BP
- Reassure client fullness and cramping is normal
Identify general psychological responses to GI health problems.
- patients are often reluctant to discuss elimination problems, which may be very personal and embarrassing. The interview focus is on whether usual activities have been interrupted or disturbed, including employment.
- Emotional stress has been associated with the development or exacerbation (flare-up) of irritable bowel syndrome (IBS) and other GI disorders. If the patient is diagnosed with cancer, he or she is expected to experience the phases of the grieving process. Patients may be depressed, angry, or in denial.
Describe GI system changes associated with aging.
- Stomach - Atrophy of the gastric mucosa is characterized by a decrease in the ratio of gastrin-secreting cells to somatostatin secreting cells. This change leads to decreased hydrochloric acid levels (hypochlorhydria).
- Large Intestine - Peristalsis decreases, and nerve impulses are dulled.
- Pancreas - Distention and dilation of pancreatic ducts change. Calcification of pancreatic vessels occurs with a decrease in lipase production.
- Liver - A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. This change and an increase in fibrous tissue lead to decreased protein synthesis and changes in liver enzymes. Enzyme activity and cholesterol synthesis are diminished.
Perform a GI history using selected Gordon's Functional Health Patterns.
- Chart 55-2
- Nutritional-Metabolic Pattern
- Elimination Pattern
Perform focused physical assessment for patients with suspected or actual GI health problems.
Explain and interpret common laboratory tests for a patient with a GI health problem.
- Serum tests - anemia caused by GI bleeding. associated with GI cancer, peptic ulcer disease, and inflammatory bowel disease. Bilirubin, lipase, ammonia level to evaluate hepatic function.
- Urine tests - presence of amylase --> acute pancreatitis, renal clearance of amylase is increased.
- Stool Tests - fecal occult blood test or bacterial tests
- Imaging Assessment - GI series, plain film, upper Gi radiographic series --> visualization from the mouth to the duodenojejunal junction. PCT, CT, Endoscopy, EGD, ERCP, Small Bowel Capsule Endoscopy
Explain the importance of collaborating with the health care team when providing care to patients with esophageal health problems that impair swallowing or limit nutrition.
- Prevent choking or asperation
- Meet nutritional needs
- Ongoing efforts are made to preserve the ability to swallow, but enteral feedings (tube feedings) may be needed temporarily when dysphagia is severe.
- Collaborate with the speech-language pathologist (SLP) to assist the patient with oral exercises to improve swallowing
Teach the patient and family about lifestyle changes to decrease gastroesophageal reflux disease (GERD) and the discomfort of hiatal hernias.
- Gerd - Teach the patient to elevate the head by 6 to 12 inches for sleep to prevent nighttime reflux. This can be done by placing blocks under the head of the bed or by using a large, wedge-style pillow instead of a standard pillow.
- Hiatal Hernia - The health care provider typically prescribes antacids and histamine receptor antagonists, such as ranitidine (Zantac), in an attempt to control reflux and its symptoms. Nutrition therapy is also important and follows the guidelines discussed earlier for GERD.
Describe special considerations for the older adult with GERD.
In the older adult, the incidence of heartburn decreases in those with gastroesophageal reflux (GERD). Instead, the more severe complications of the disease are more frequent in this population, including atypical chest pain; ear, nose, and throat infections; and pulmonary problems, such as aspiration pneumonia, sleep apnea, and asthma. Barrett's esophagus and esophageal erosions are also more common in older adults. The cause for these differences is not known
Identify the need for psychosocial support to patients and their families through diagnosis and treatment of esophageal cancer.
Determine the availability of support systems and the potential financial impact of the disease and its treatment. Refer the patient and family members to psychological counseling, pastoral care, and/or the social worker or case manager as needed.Determine the availability of support systems and the potential financial impact of the disease and its treatment. Refer the patient and family members to psychological counseling, pastoral care, and/or the social worker or case manager as needed.
Evaluate the impact of esophageal cancer on the patient's nutritional status, including the risk for aspiration.
Decreased nutritional intake related to impaired swallowing and possible metastasis.
Perform focused assessments for patients with esophageal health problems.
Ask the patient about a history of heartburn or atypical chest pain associated with the reflux of GI contents. Ask whether he or she has been newly diagnosed with asthma or has experienced morning hoarseness or pneumonia. These symptoms are suggestive of severe reflux reaching the pharynx or mouth or pulmonary aspiration.
Apply knowledge of pathophysiology to anticipate complications of GERD.
- Gerd causes damage to the esophagus. The body may for Barrett's epithelium instead of the normal squamous cell epithelium of the lower esophagus = more resistant to acid and supports esophagus healing. It is also premalignant
- Esophageal stricture --> narrowing of esophageal opening caused by the healing process
Plan how to teach patients with GERD about drug therapy.
- Inhibit gastric acid secretion
- Accelerate gastric emptying
- Protect the gastric mucosa
Develop a teaching plan for the patient and family about postoperative care after esophageal surgery.
- Oral hygiene
- Nutritional Management
- Position patient
- Teach the patient and/or family the importance of the patient eating six to eight small meals per day. Fluids should be taken between, rather than with, meals to prevent diarrhea.
- Wash hands
- Look for increased temp and signs of respiratory or swollen, painful neck incision
Apply knowledge of pathophysiology to recognize complications of esophageal surgical procedures.
- Increased pain
Plan community-based care for patients diagnosed with esophageal cancer.
Referrals to community or home care organizations assist the family in providing care in the home. The patient may need transportation to the radiation treatment center five times per week for up to 6 weeks. Oncology nursing care may be needed to monitor and evaluate the patient who is receiving chemotherapy at home through venous access devices or portable infusion pumps. Inform the patient and family about the services available through the American Cancer Society (www.cancer.org), including support groups and transportation. Familiarize the family with area hospice services for future planning. Coordinate resource referrals with the case manager or home care agency.
Describe the importance of collaborating with members of the health care team when caring for patients with stomach disorders.
The initial treatment for these disorders may be one thing, but over time shift focus. There are some drugs that they should not remain on too long.
Teach patients to tell their health care provider if they are taking clopidogrel. H2-receptor antagonists are drugs that block histamine-stimulated gastric secretions. These drugs may also be used for indigestion and gastritis. Lower-dose forms are available in over-the-counter (OTC) products. H2-receptor antagonists block the action of the H2 receptors of the parietal cells, thus inhibiting gastric acid secretion.
Identify community resources for patients with gastric disorders.
- American Cancer society
- Social workers
- Other community programs
Develop a teaching plan for patients about
complementary and alternative therapies that have been used to help manage gastritis and peptic ulcer disease (PUD).
Teach patients about complementary and alternative therapies that can reduce stress, including hypnosis and imagery. For example, the use of yoga and meditation techniques has demonstrated a beneficial effect on anxiety disorders. Many have suggested that GI disorders result from the dysfunction of both the GI tract itself and the brain. This means that emotional stress is thought to worsen GI disorders such as peptic ulcer disease. Yoga is thought to alter the activities of the central and autonomic nervous systems.
Plan interventions to promote GI health and prevent gastritis.
- Avoid NSAIDs
- Avoid foods spicy foods
- Small meals
- No smoking or alcohol
- Balanced diet
- Reduce stress
Identify the need for end-of-life care for patients with advanced gastric cancer.
If the prognosis is poor, they need continued professional support from case managers, social workers, and/or nurses to cope with death and dying.
Compare etiologies and assessment findings of acute and chronic gastritis.
- acute gastritis - The early pathologic manifestation of gastritis is a thickened, reddened mucous membrane with prominent rugae, or folds. Various degrees of mucosal necrosis and inflammatory reaction occur in acute disease. The diagnosis cannot be based solely on clinical symptoms. Complete regeneration and healing usually occur within a few days. If the stomach muscle is not involved, complete recovery usually occurs with no residual evidence of gastric inflammatory reaction. If the muscle is affected, hemorrhage may occur during an episode of acute gastritis.
- Chronic gastritis appears as a patchy, diffuse (spread out) inflammation of the mucosal lining of the stomach. As the disease progresses, the walls and lining of the stomach thin and atrophy. With progressive gastric atrophy from chronic mucosal injury, the function of the parietal (acid-secreting) cells decreases and the source of intrinsic factor is lost. The intrinsic factor is critical for absorption of vitamin B12. When body stores of vitamin B12 are eventually depleted, pernicious anemia results. The amount and concentration of acid in stomach secretions gradually decrease until the secretions consist of only mucus and water.
Identify risk factors for gastritis.
- H. pylori infection
- staphylococci, streptococci, Escherichia coli, or salmonella
- Long term NSAID use
Compare and contrast assessment findings associated with gastric and duodenal ulcers.
Identify the most common medical complications that can result from PUD.
- Pyloric obstruction
- intractable disease
Describe the purpose and adverse effects of drug therapy for gastritis and PUD.
- (1) provide pain relief
- (2) eliminate H. pylori infection
- (3) heal ulcerations
- (4) prevent recurrence.
Monitor patients with PUD and gastric cancer for signs of upper GI bleeding.
The first priority for care of the patient with upper GI bleeding is to maintain airway, breathing, and circulation (ABCs). Provide oxygen and other ventilatory support as needed. Start two large-bore IV lines for replacing fluids and blood. Monitor vital signs, hematocrit, and oxygen saturation.
Prioritize interventions for patients with upper GI bleeding.
- The patient who is actively bleeding has a life-threatening emergency. He or she needs supportive therapy to prevent hypovolemic shock and possible death.
- The first priority for care of the patient with upper GI bleeding is to maintain airway, breathing, and circulation (ABCs). Provide oxygen and other ventilatory support as needed. Start two large-bore IV lines for replacing fluids and blood. Monitor vital signs, hematocrit, and oxygen saturation.
Plan individualized care for the patient having gastric surgery.
- NGT inserted
- Nutritional therapy before and after
- Other nursing measures same as other abdominal surgery and general anesthesia
- Monitor vitals after anesthesia
- Monitor for wound infection
- Auscultate the lungs for adventitious sounds
- Monitor for bowel sounds
- Aggressive pulmonary exercises
- Elevate head of bed
Explain the purpose and procedure for gastric lavage.
Procedure of irrigating the stomach in which a large-bore nasogastric tube is inserted into the stomach and room-temperature solution is instilled in volumes of 200 to 300 mL. The solution and blood are repeatedly withdrawn manually until returns are clear or light pink and without clots.
Evaluate the impact of gastric disorders on the nutrition status of the patient.
Can reduce nutritional intake and/or absorption of nutrients
Develop a preoperative and postoperative plan of care for the patient undergoing gastric surgery.
- Nutritional therapy before and after
- Other nursing measures same as other abdominal surgery and general anesthesiaMonitor vitals after anesthesia Monitor for wound infectionAuscultate the lungs for adventitious soundsMonitor for bowel soundsAggressive pulmonary exercises Elevate head of bed
Identify risk factors for gastric cancer.
- Chronic gastritis
- The persistent inflammation extends deep into the mucosa, causing destruction of the gastric glands and cellular changes.
Prioritize nursing care for the patient with abdominal trauma.
- Assess for abdominal or referred pain and nausea. Every 15 to 30 minutes in the early postinjury period and then hourly
- Mental status
- Vital signs
- Clinical findings, such as vomiting, guarding, rigidity, or rebound tenderness
- Bowel sounds
- Urine output
- Report any changes to the health care provider!!
Identify community-based resources for patients with colorectal cancer (CRC).
The patient with colorectal cancer faces a serious illness with long-term consequences of the disease and treatment. A case manager or social worker can be very helpful in identifying patient and family needs, as well as ensuring continuity of care and support.
Describe the importance of collaborating with health care team members to provide care for patients with CRC.
Teach patients health promotion practices to prevent CRC.
- Genetic testing for family members of people who have had CRC
- Teach about the diagnostic screenings
- Modify their diets as needed to decrease fat, refined carbohydrates, and low-fiber foods.
- Teach about hazards of smoking, drinking and low physical activity
Plan health teaching for patients to promote self-management when caring for a colostomy.
- Keep care supplies where temperature isnt too hot or cold (I.E bathroom)
- Home care nurse nurse after patient is discharged to ensure continuity of care
- Moisture proof mattress padding
Assess patient and family response to a diagnosis of CRC.
Patients must cope with a diagnosis that instills fear and anxiety about treatment, feelings that life has been disrupted, a need to search for ways to deal with the diagnosis, and concern about family. They also have questions about why colon cancer affected them, as well as concerns about pain, possible disfigurement, and possible death. In addition, if the cancer is believed to have a genetic origin, there is anxiety concerning implications for immediate family members.
Develop a teaching-learning plan for patients with irritable bowel syndrome (IBS).
The patient with IBS is usually cared for in an ambulatory care setting and learns self-management strategies. Interventions include health teaching, drug therapy, and stress reduction. Some patients also use complementary and alternative therapies. A holistic approach to patient care is essential for positive outcomes.
Differentiate the most common types of hernias.
- indirect - sac formed from the peritoneum that contains a portion of the intestine or omentum. The hernia pushes downward at an angle into the inguinal canal. In males, indirect inguinal hernias can become large and often descend into the scrotum
- direct - pass through a weak point in the abdominal wall
- femoral - protrude through the femoral ring. A plug of fat in the femoral canal enlarges and eventually pulls the peritoneum and often the urinary bladder into the sac.
- umbilical - congenital or acquired. Congenital umbilical hernias appear in infancy. Acquired umbilical hernias directly result from increased intra-abdominal pressure. They are most commonly seen in obese people.
- incisional - occur at the site of a previous surgical incision. These hernias result from inadequate healing of the incision, which is usually caused by postoperative wound infections, inadequate nutrition, and obesity.
Develop a plan of care for a patient undergoing a minimally invasive inguinal hernia repair.
- rest for a few days
- inspection of incisions for signs of infection.
Identify risk factors for CRC.
- Older than 50 years
- genetic predisposition
- personal or family history of cancer
- and/or diseases that predispose the patient to cancer such as familial adenomatous polyposis (FAP)
- Crohn's disease
- ulcerative colitis
Interpret assessment findings for patients with CRC.
- rectal bleeding
- change in stool consistency or shape
- gas pain
- dull pain
Explain the role of the nurse in managing the patient with CRC.
- Pre and post op care
- Connect patient with resources
- Monitor for complications
Develop a perioperative plan of care for a patient undergoing a colon resection and colostomy.
- Monitor vitals
- Monitor NGT
Explain the differences between small-bowel and large-bowel obstructions.
Develop a plan of care for a patient with an
intestinal obstruction to promote elimination.
- Teach the patient to eat high-fiber foods, including plenty of raw fruits and vegetables and whole-grain products.
- Encourage the patient to drink adequate amounts of fluids, especially water.
- Do not routinely administer a laxative; teach the patient that laxative abuse decreases abdominal muscle tone and contributes to an atonic colon.
- Encourage the patient to exercise regularly, if possible. Walking every day is an excellent exercise for promoting intestinal motility.
- Use natural foods to stimulate peristalsis, such as warm beverages and prune juice.
- Take bulk-forming products, such as Metamucil, to provide fiber.
- Check the patient's stool for amount and frequency; oozing of soft or diarrheal stool often indicates a fecal impaction.
- Have the patient sit on a toilet or bedside commode, rather than on a bedpan, for elimination.
Describe the postoperative care for a patient having a hemorrhoid surgical procedure.
- Teach patients with hemorrhoids about the need to eat high-fiber, high-fluid diets to promote regular bowel patterns before and after surgery.
- Advise them to avoid stimulant laxatives, which can be habit forming.For patients who undergo any type of surgical intervention, monitor for bleeding and pain postoperatively and teach them to report these problems to their health care provider. Using moist heat (e.g., sitz baths) three or four times per day can help promote comfort.
Explain the pathophysiology of malabsorption syndrome.
- Associated with a variety of disorders and intestinal surgical procedures. It interferes with the ability to absorb nutrients and is a result of a generalized flattening of the mucosa of the small intestine. With various disorders, physiologic mechanisms limit absorption of nutrients because of one or more of these abnormalities:
- Bile salt deficiencies
- Enzyme deficiencies
- Presence of bacteria
- Disruption of the mucosal lining of the small intestine
- Altered lymphatic and vascular circulation
- Decrease in the gastric or intestinal surface area
Describe the importance of
collaborating with health care team members to provide care for patients with
chronic inflammatory bowel disease (IBD).
Collect data on family history of IBD, previous and current therapy for the illness, and dates and types of surgery. Obtain a nutrition history, including intolerance of milk and milk products and fried, spicy, or hot foods. Ask about usual bowel elimination pattern (color, number, consistency, and character of stools), abdominal pain, tenesmus, anorexia, and fatigue. Note any relationship between diarrhea, timing of meals, emotional distress, and activity. Inquire about recent (past 2 to 3 month) exposure to antibiotics suggesting Clostridium difficile infection. Has the patient traveled to or emigrated from tropical areas? Ask about recent use of NSAIDs that can either present with the initial diagnosis or cause a flare-up of the disease. Ask about any extraintestinal symptoms such as arthritis, mouth sores, vision problems, and skin disorders.
Differentiate care for older adults with acute and chronic inflammatory bowel disorders.
Chronic inflammatory bowel disease (IBD) affects about 1.4 million people in the United States and is split about equally between ulcerative colitis (UC) and Crohn's disease (discussed later). Peak age for being diagnosed with UC is between 30 and 40 years and again at 55 to 65 years. Women are more often affected than men in their younger years, but men have the disease more often as middle-aged and older adults
Develop a health teaching plan for patients to promote self-management when caring for ileostomy or other surgical diversion.
- Skin Protection
- Pouch care
- Nutrition Therapy
- Drug Therapy
- Symptoms to watch for
Identify community resources for patients and families regarding chronic IBD.
If the patient needs assistance with self-management at home, collaborate with the case manager or social worker to arrange the services of a home care aide or nurse. A home care nurse can provide assessment and guidance in integrating ostomy care into the patient's lifestyle. The nurse may also teach about wound care, including the monitoring of wound healing, if needed (Chart 60-5). The patient and family need to know where to purchase ostomy supplies, along with the name, size, and manufacturer's order number.For patients with a permanent ileostomy, locate a community ostomy support group by contacting the United Ostomy Associations of America (www.uoaa.org). The United Ostomy Association of Canada serves the needs of Canadian patients (www.ostomycanada.ca). A local support group or the Crohn's and Colitis Foundation of America (www.ccfa.org) may be helpful in obtaining supplies and providing education for ostomates. Inform the patient and family of available ostomy ambulatory care clinics and ostomy specialists. If the patient agrees, a visit from an ostomate can be continued after discharge to home.
Discuss ways that food poisoning can be prevented.
- Wash hands
- Handle food properly
- Cook properly
- Avoid high risk foods
Identify expected body image changes associated with having an ileostomy or other surgical diversion.
A patient with an ileostomy may have many concerns about management at home and about sexual and social adjustments. Considering possible sexual issues helps the patient identify and discuss these concerns with the sex partner. For example, a change in positioning during intercourse may alleviate apprehension. Social situations may cause anxiety related to decreased self-esteem and a disturbance in body image. Encourage the patient to discuss possible concerns in addressing and resolving these potentially stressful events. Clinical depression is common among patients with ulcerative colitis. Refer patients to appropriate mental health resources if depression is suspected.
Describe patient and family response to chronic IBD.
- Many patients are very concerned about the frequency of stools and the presence of blood. The inability to control the disease symptoms, particularly diarrhea, can be disruptive and stress producing. Severe illness may limit the patient's activities outside the home with fear of fecal incontinence resulting in feeling “tied to the toilet.” Severe anxiety and depression may result. Eating may be associated with pain and cramping and an increased frequency of stools. Mealtimes may become unpleasant experiences. Frequent visits to health care providers and close monitoring of the colon mucosa for abnormal cell changes can be anxiety provoking.
- Assess the patient's understanding of the illness and its impact on his or her lifestyle. Encourage and support the patient while exploring:
- • The relationship of life events to disease exacerbations
- • Stress factors that produce symptoms
- • Family and social support systems
- • Concerns regarding the possible genetic basis and associated cancer risks of the disease
- • Internet access for reliable education information
Differentiate common types of acute inflammatory bowel disease.
- Ulcerative Colitis
- Location: Begins in the rectum and proceeds in a continuous manner toward the cecum
- Etiology: Unknown
- Peak incidence: 15-25 yr and 55-65 yr
- Number of stools: 10-20 liquid, bloody stools per day
- Complications: Hemorrhage and Nutritional deficiencies
- Need for Surgery: Infrequent
- Crohn's Disease
- Location: Most often in the terminal ileum, with patchy involvement through all layers of the bowel
- Etiology: Unknown
- Peak incidence: 15-40 year
- Number of stools: 5-6 soft, loose stools per day, non-bloody
- Complications: Fistulas (common) and Nutritional deficiencies.
- Need for surgery: Frequent
Develop a collaborative plan of care for the patient who has appendicitis and peritonitis.
- 1. Ask about risk factors such as age, familial tendency, and intra-abdominal tumors.
- 2. History taking and tracking the sequence of symptoms: Abdominal pain followed by nausea and vomiting can indicate appendicitis.
- 2. Classically, patients with appendicitis have cramplike pain in the epigastric or periumbilical area.
- 3. Anorexia is a frequent symptom with nausea and vomiting occurring in many cases.
- 4. Perform a complete pain assessment. Initially, pain can present anywhere in the abdomen or flank area. As the inflammation and infection progress, the pain becomes more severe and steady and shifts to the RLQ between the anterior iliac crest and the umbilicus. (Referred to as McBurney's point)
- 5. Abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis.
- 6. Assess for muscle rigidity and guarding on palpation of the abdomen. The patient may report pain after release of pressure. This is referred to as “rebound” tenderness.
- 7. Laboratory findings do not establish the diagnosis, but often there is a moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000/mm3 with a “shift to the left” (an increased number of immature WBCs). A WBC elevation to greater than 20,000/mm3 may indicate a perforated appendix.
- 8. An ultrasound study may show the presence of an enlarged appendix.
- 9. Ask about risk factors such as age, familial tendency, and intra-abdominal tumors.
- All patients with suspected or confirmed appendicitis are hospitalized and examined by a surgeon. When the diagnosis is not clear, the health care team observes the patient before surgical exploration.
- Nonsurgical Management
- Keep the patient with suspected or known appendicitis on NPO to prepare for the possibility of emergency surgery and to avoid making the inflammation worse.
- Surgical Management
- Surgery is required as soon as possible. An appendectomy is the removal of the inflamed appendix by one of several surgical approaches.
- 1. Uncomplicated appendectomy procedures are usually done via laparoscopy. A laparoscopy is a minimally invasive surgical (MIS) procedure with one or more small incisions near the umbilicus through which a small endoscope is placed. Patients have few postoperative complications.
- 2. A newer procedure known as natural orifice transluminal endoscopic surgery (NOTES) (e.g., transvaginal endoscopic appendectomy) does not require an external skin incision. In this procedure, the surgeon places the endoscope into the vagina or other orifice and makes a small incision to enter the peritoneal space.
- 3. Patients having any type of laparoscopic procedures are typically discharged the same day of surgery with less pain and few complications after discharge. Most patients can return to usual activities in 1 to 2 weeks.
- 4. Preoperative teaching is often limited because the patient is in pain or may be transferred quickly to the operating suite for emergency surgery.
- 5. The patient is prepared for general anesthesia and surgery.
- 6. After surgery, care of the patient who has undergone an appendectomy is the same as that required for anyone who has received general anesthesia.
- 7. If peritonitis or abscesses are found, wound drains are inserted and a nasogastric tube may be placed to decompress the stomach and prevent abdominal distention.
- 8. Administer IV antibiotics and opioid analgesics as prescribed.
- 9. Help the patient out of bed on the evening of surgery to help prevent respiratory complications, such as atelectasis.
- 10. He or she may be hospitalized for as long as 3 to 5 days and return to normal activity in 4 to 6 weeks.
- Peritonitis is a life-threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity. Primary peritonitis is rare and indicates the peritoneum is infected via the bloodstream. This problem is not discussed here.
Discuss the common causes of gastroenteritis.
- • Gastroenteritis is an increase in frequency and water content of stools or vomiting related to infection and inflammation of the mucous membranes of the stomach and intestinal tract, usually self-limiting unless complications occur.
- • Some clinicians classify infectious disease of the intestine as bacterial, viral, or parasitic, without using the term gastroenteritis.
- • Treatment with antibiotics may be needed if bacterial gastroenteritis.
- • Weakness and cardiac dysrhythmias may be the result of loss of potassium (hypokalemia) from diarrhea.
Compare and contrast the pathophysiology and clinical manifestations of ulcerative colitis and Crohn's disease.
- 1. Ulcerative colitis (UC) creates widespread inflammation of mainly the rectum and rectosigmoid colon but can extend to the entire colon when the disease is extensive. Distribution of the disease can remain constant for years. UC is a disease that is associated with periodic remissions and exacerbations (flare-ups) (McCance et al., 2010). Many factors can cause exacerbations, including intestinal infections.
- The intestinal mucosa becomes hyperemic (has increased blood flow), edematous, and reddened. In more severe inflammation, the lining can bleed and small erosions, or ulcers, occur. Abscesses can form in these ulcerative areas and result in tissue necrosis (cell death). Continued edema and mucosal thickening can lead to a narrowed colon and possibly a partial bowel obstruction. Table 60-3 lists the categories of the severity of UC.
- The patient's stool typically contains blood and mucus. Patients report tenesmus (an unpleasant and urgent sensation to defecate) and lower abdominal colicky pain relieved with defecation. Malaise, anorexia, anemia, dehydration, fever, and weight loss are common. Extraintestinal manifestations such as migratory polyarthritis, ankylosing spondylitis, and erythema nodosum are present in a large number of patients. The common complications of UC, including extraintestinal manifestations, are listed in Table 60-4.
- 2. Crohn's disease (CD) is an inflammatory disease of the small intestine (most often), the colon, or both. It can affect the GI tract from the mouth to the anus but most commonly affects the terminal ileum. CD is a slowly progressive and unpredictable disease with involvement of multiple regions of the intestine with normal sections in between (called “skip lesions” on x-rays). Like ulcerative colitis (UC), this disease is recurrent with remissions and exacerbations.
- Unlike UC, Crohn's disease presents as transmural inflammation that causes a thickened bowel wall. Strictures and deep ulcerations (cobblestone appearance) also occur, which put the patient at risk for developing bowel fistulas. The result is severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption issues.
- The complications associated with Crohn's disease are similar to those of ulcerative colitis (see Table 60-4). Hemorrhage is more common in ulcerative colitis, but it can occur in CD as well. Severe malabsorption by the small intestine is more common in patients with CD because UC does not involve the small bowel to any significant extent. Therefore patients with CD can become very malnourished and debilitated.
- Rarely, cancer of the small bowel and colon develop but can occur after the disease has been present for 15 to 20 years. Fistula formation is a common complication of CD but is rare in UC. Fistulas can occur between segments of the intestine or manifest as cutaneous fistulas (opening to the skin) or perirectal abscesses. They can also extend from the bowel to other organs and body cavities, such as the bladder or vagina (Fig. 60-4). Some patients develop intestinal obstruction, which, at first, is secondary to inflammation and edema. Over time, fibrosis and scar tissue develop and obstruction results from a narrowing of the bowel. Most patients with CD require surgery at some time.
- The exact cause of CD is not known, but it seems to include a combination of genetic, immune, and environmental factors. About 10% to 20% of patients have a positive family history for the disease, but no predominant inheritance pattern is present (Nussbaum et al., 2007). The discovery of a mutation in the NOD2/CARD15 gene on chromosome 16 seems to be associated with some patients who have CD. This gene is found in monocytes that normally recognize and destroy bacteria. Other gene mutations that may contribute to the pathogenesis of CD are IBD3, IBD5, and IBD10.
Identify priority problems for patients with ulcerative colitis.
- COMPLICATIONS OF UC AND CD:
- 1) Hemorrhage/perforation 2) Abscess formation 3) Toxic megacolon 4) Malabsorption 5) Nonmechanical bowel obstruction 6) Fistulas 7) Colorectal cancer 8) Extraintestinal complications 9) Osteoporosis
Explain the purpose of and nursing implications related to drug therapy for patients with IBD.
- 1. Common drug therapy for UC includes aminosalicylates, glucocorticoids, antidiarrheal drugs, and immunomodulators. Teach patients about side effects and adverse drug events (ADEs) and when to call their health care provider.
- The aminosalicylates are drugs commonly used to treat mild to moderate UC and/or maintain remission. Several aminosalicylic acid compounds are available. These drugs, also called 5-ASAs, are thought to have an anti-inflammatory effect by inhibiting prostaglandins and are usually effective in 2 to 4 weeks.
- 1) Sulfasalazine (Azulfidine, Azulfidine EN-tabs), the first aminosalicylate approved for UC, is metabolized by the intestinal bacteria into 5-ASA, which delivers the beneficial effects of the drug, and sulfapyridine, which is responsible for unwanted side effects.
- 2) Mesalamine (Asacol, Pentasa, Rowasa, Apriso, Canasa) is better tolerated than sulfasalazine because none of its preparations contain sulfapyridine. Asacol is an enteric-coated drug and is released in the terminal ileum and right side of the colon. Pentasa and Apriso are delayed- and extended-release drugs that work throughout the colon and rectum. Rowasa can be given as an enema, and Canasa can be given as a suppository. These preparations have minimal systemic absorption and therefore have fewer side effects. Table 60-5 lists commonly used 5-ASA drugs.
- Glucocorticoids, such as prednisone and prednisolone, are corticosteroid therapies prescribed during exacerbations of the disease.
- 1) Prednisone (Deltasone, Winpred) 40 to 65 mg daily is typically prescribed, but the dose may be increased as acute flare-ups occur. Once clinical improvement occurs, the corticosteroids are tapered because of the adverse effects that commonly occur with long-term steroid therapy (e.g., hyperglycemia, osteoporosis, peptic ulcer disease, increased risk for infection). For patients with rectal symptoms, topical steroids in the form of small retention enemas may be prescribed.
- To provide symptomatic management of diarrhea, antidiarrheal drugs may be prescribed. These drugs are given very cautiously, however, because they can cause colon dilation and toxic megacolon. Common antidiarrheal drugs include 1) diphenoxylate hydrochloride and 2) atropine sulfate (Lomotil) and 3) loperamide (Imodium).
- Immunomodulators are drugs that alter a person's immune response. Alone, they are often not effective in the treatment of ulcerative colitis. However, in combination with steroids, they may offer a synergistic effect to a quicker response, thereby decreasing the amount of steroids needed. Immunosuppressants used with UC (and Crohn's disease, discussed later in this chapter) include:
- 1) infliximab (Remicade) Although not approved as a first-line therapy for ulcerative colitis, infliximab (Remicade) may be used for refractory disease or for severe complications, such as toxic megacolon (massive dilation of the colon that can lead to gangrene and peritonitis) and extraintestinal manifestations. Remicade is an immunoglobulin G (IgG) monoclonal antibody that reduces the activity of tumor necrosis factor (TNF) to decrease inflammation.
- 2) Adalimumab (Humira) is another monoclonal antibody approved for refractory (not responsive to other therapies) cases. They are used more commonly in management of Crohn's disease. These drugs cause immunosuppression and should be used with caution. Teach the patient to report any signs of a beginning infection, including a cold, and to avoid large crowds or others who are sick.
- NURSE SAFETY for UC drugs: Teach patients taking sulfasalazine to report nausea, vomiting, anorexia, rash, and headache to the health care provider. With higher doses, hemolytic anemia, hepatitis, male infertility, or agranulocytosis can occur. This drug is in the same family as sulfonamide antibiotics. Therefore assess the patient for an allergy to sulfonamide or other drugs that contain sulfur before the patient takes the drug. The use of a thiazide diuretic is also a contraindication for sulfasalazine.
- 2. Common drug therapy for CD
- Drugs used to manage Crohn's disease (CD) are similar to those used in the treatment of ulcerative colitis (UC). For mild to moderate disease, 5-ASA drugs may be very effective (see p. 1274 in the Drug Therapy discussion in the Ulcerative Colitis section).
- Most patients have moderate to severe disease and need stronger drug therapy to control their symptoms. Two agents that may be prescribed for CD are:
- 1) azathioprine (Imuran) and
- 2) mercaptopurine (Purinethol) These drugs suppress the immune system but can lead to serious infections.
- 3) Methotrexate (MTX) may also be given to suppress immune activity of the disease.
- More recently, a group of monoclonal antibody drugs has been approved for use in Crohn's disease when other drugs have been ineffective. These drugs inhibit tumor necrosis factor (TNF)–alpha, which decreases the inflammatory response. Examples of commonly used drugs for patients with CD include:
- 1) infliximab (Remicade),
- 2) adalimumab (Humira),
- 3) natalizumab (Tysabri), and
- 4) certolizumab pegol (Cimzia). These agents are not given to patients with a history of cancer, heart disease, or multiple sclerosis.
- NURSE SAFETY for the CD drugs: Both infliximab and certolizumab pegol must be given in a health care setting, such as a physician's office via parenteral routes. Adalimumab (Humira) is self-administered by subcutaneous injection every other week. If needed, instruct patients on how to give themselves a subcutaneous injection. Teach patients to report injection site reactions, including redness and swelling. Remind them that headache, abdominal pain, and nausea and vomiting are common side effects. Teach them to avoid crowds, such as malls and large shopping centers, and people with infection. Reinforce the need to report any infection, including a cold or sore throat, to the health care provider immediately.
- Natalizumab is given IV under medical supervision every 4 weeks for moderate to severe CD and is given when other drugs are not effective. Although the use of this drug has decreased the length of hospital stays (Dudley-Brown et al., 2009), natalizumab can cause progressive multifocal leukoencephalopathy (PML), a deadly infection that affects the brain. Before giving the drug, be sure that patient is free of all infections. Teach patients the importance of reporting any cognitive, motor, or sensory changes immediately to the health care provider.
Plan priority postoperative care for a patient undergoing surgery for IBD.
- 1. Postoperative Care for UC:
- Provide general postoperative care after surgery, as described in Chapter 18. All patients requiring open approach surgery for ulcerative colitis have a large abdominal incision. At first, most patients are NPO and a nasogastric tube (NGT) is used for suction. The tube is removed in 1 to 2 days as the drainage decreases, and fluids and food are slowly introduced. The patient having minimally invasive surgery (MIS) usually does not have an NGT.
- In collaboration with the ostomy nurse, help the patient adjust and learn the required care. The ileostomy begins to drain within 24 hours after surgery at more than 1 L per day. Be sure that fluids are replaced by adding an additional 500 mL or more each day to prevent dehydration. After about a week of high-volume output, the drainage slows and becomes thicker. During this period, some patients need antidiarrheal drugs.
- The hospital stay is usually from 2 to 5 days, depending on whether the patient has laparoscopic or conventional open surgery. Patients having MIS have less pain from surgery and faster restoration of bowel function when compared with other surgical patients, but the incidence of complications is about the same (Fajardo et al., 2010).
- For those who have the RPC-IPAA procedure, remind them that the internal pouch can become inflamed. This problem is usually effectively treated with metronidazole (Flagyl) for 7 to 10 days. Teach patients that after the second stage of surgery, they might have burning during bowel elimination because gastric acid cannot be well absorbed by the ileum. Also instruct them to omit foods that can cause odors or gas, such as cabbage, asparagus, and beans. Teach patients to eliminate foods that cannot be well digested, such as nuts and corn. Each patient differs in which foods he or she can tolerate.
- Surgery for UC may result in altered body image. However, it may be viewed as positive because the patient will have fewer symptoms and feel more comfortable than before the procedure. Patients have to adjust to having an ostomy before they can resume their presurgery activities.
- 2. Postoperative Care for CD:
- Care before and after each of these surgical procedures is similar to care for patients undergoing other types of abdominal surgery (see Chapters 16 and 18).
Develop a hospital discharge teaching
plan for patients having surgery for IBD.
- Patient And Family Education: Preparing For Self-Management with UC
- Ileostomy Care
- Skin Protection
- • Use a skin barrier to protect your skin from contact with contents from the ostomy.
- • Use skin care products, such as skin sealants and ostomy skin creams. If your skin continues to come into contact with ostomy contents, select a product to fill in problem areas and provide an even skin surface.
- • Watch your skin for any irritation or redness.
- Pouch Care
- • Empty your pouch when it is one-third to one-half full.
- • Change the pouch during inactive times, such as before meals, before retiring at night, on waking in the morning, and 2 to 4 hours after eating.
- • Change the entire pouch system every 3 to 7 days.
- • Chew food thoroughly.
- • Be cautious of high-fiber and high-cellulose foods. You may need to eliminate these from the diet if they cause severe problems (diarrhea, constipation, or blockage). Examples include corn, peanuts, coconut, Chinese vegetables, string beans, tough-fiber meats, shrimp and lobster, rice, bran, and vegetables with skins (tomatoes, corn, and peas).
- Drug Therapy
- • Avoid taking enteric-coated and capsule medications.
- • Inform any health care provider who is prescribing medications for you that you have an ostomy. Before having prescriptions filled, inform your pharmacist that you have an ostomy.
- • Do not take any laxative or enemas. You should usually have loose stool and should contact a physician if no stool has passed in 6 to 12 hours.
- Symptoms to Watch for
- • Report any drastic increase or decrease in drainage to your health care provider.
- • If stomal swelling, abdominal cramping, or distention occurs or if ileostomy contents stop draining:
- • Remove the pouch with faceplate.
- • Lie down, assuming a knee-chest position.
- • Begin abdominal massage.
- • Apply moist towels to the abdomen.
- • Drink hot tea.
- • If none of these maneuvers is effective in resuming ileostomy flow or if abdominal pain is severe, call your health care provider right away.
- Patient And Family Education: Preparing For Self-Management with CD
- The teaching plan for Crohn's disease is similar to that for the patient with ulcerative colitis: 1) Teach the patient about the usual course of the disease, symptoms of complications, and when to notify the health care provider. Provide health teaching for drug therapy, including purpose, dose, and side effects. In addition to other drugs, vitamin supplements, including monthly vitamin B12 injections, may be needed because of the inability of the ileum to absorb these nutrients. In collaboration with the dietitian, instruct the patient to follow a low-residue, high-calorie diet and to avoid foods that cause discomfort, such as milk, gluten, and other GI stimulants like caffeine.
- 2) Remind the patient to take rest periods, especially during exacerbations of the disease. If stress appears to increase symptoms of the disease, recommend stress management techniques, counseling, and/or physical activity to improve quality of life (Crumbock et al., 2009). For long-term follow-up, teach the patient about the increased risk for bowel cancer and the importance of having frequent colonoscopies.
- 3) If a patient has a fistula, explain and demonstrate fistula care. Provide the opportunity for the patient to practice this care in the hospital. Ideally, he or she should be independent in fistula care before leaving the hospital. However, because of location of the fistula (perirectal or vaginal) or a large abdomen, assistance may be needed. If this is the case, teach a family member or other caregiver how to manage the fistula. Patients may be transferred to a transitional or skilled nursing unit for collaborative care.
Explain the role of nutrition therapy in managing the patient with diverticular disease.
Teach the patient to avoid all fiber when symptoms of diverticulitis are present, because high-fiber foods are then irritating. As inflammation resolves, fiber can gradually be added until progression to a high-fiber diet is established. The patient who has undergone surgery is usually taking solid food by the time of discharge from the hospital.
Describe the comfort measures that the nurse can use for the patient with anal disorders.
For patients with an anorectal abscess, nursing interventions are focused on comfort and helping the patient maintain optimal perineal hygiene (Chart 60-7). Encourage the use of warm sitz baths, analgesics, bulk-producing agents, and stool softeners after the surgery until healing occurs. Stress the importance of good perineal hygiene after all bowel movements and the maintenance of a regular bowel pattern with a high-fiber diet.
Collaborate with health care team members to provide care for patients with pancreatic disorders.
- The priorities for patient care are to provide supportive care by relieving symptoms, to decrease inflammation, and to anticipate or treat complications. As for any patient, continually assess for and support the ABCs (airway, breathing, and circulation). In collaboration with the respiratory therapist, if available, provide oxygen and other respiratory support as needed. The collaborative plan of care depends on the severity of the illness.
- Abdominal pain is the most common symptom of pancreatitis. The main focus of nursing care is aimed at controlling pain by interventions that decrease GI tract activity, thus decreasing pancreatic stimulation. Pain assessment to measure the effectiveness of these interventions is an essential part of nursing care.
- Nonsurgical Management
- Mild pancreatitis requires hydration with IV fluids, pain control, and drug therapy. The health care team initially attempts to relieve pain with nonsurgical interventions, which include fasting and rest, drug therapy, and comfort measures. If the patient has a life-threatening complication or requires frequent assessment, he or she is admitted to a critical care unit for invasive hemodynamic monitoring.
- To rest the pancreas and reduce pancreatic enzyme secretion, withhold food and fluids during the acute period. The health care provider prescribes IV isotonic fluid administration to maintain hydration. IV replacement of calcium and magnesium may also be needed. Measure and document intake and output. Some patients have an indwelling urinary catheter to obtain accurate measurements.
- Nasogastric drainage and suction are reserved for more severely ill patients who have continuous vomiting or biliary obstruction. Gastric decompression using a nasogastric tube (NGT) prevents gastric juices from flowing into the duodenum.
- To decrease pain, the primary drug class used is opioid. Other drugs may also be prescribed. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia (PCA). Drugs such as morphine or hydromorphone (Dilaudid) are typically used because meperidine (Demerol) can cause seizures, especially in older adults. Other options that have been used successfully to manage acute pain include IV or transdermal fentanyl and epidural analgesia.In mild pancreatitis, the pain usually subsides in 2 to 3 days. However, with severe acute pancreatitis, the abdominal pain and tenderness may persist for up to 2 weeks. The dosages and intervals of drug administration are individualized according to the severity of the disease and the symptoms.
- Histamine receptor antagonists (e.g., ranitidine [Zantac]) and proton pump inhibitors (e.g., omeprazole [Prilosec]) help decrease gastric acid secretion. Antibiotics may be used, but they are indicated primarily for patients with acute necrotizing pancreatitis. Common drugs used include cefuroxime (Zinacef) and ceftazidime (Ceptaz).
- Helping the patient assume a side-lying position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis. Sitting with the knees flexed toward the chest is also helpful.
- If the patient is NPO or has an NGT, remind assistive nursing personnel to implement frequent oral hygiene measures to keep mucous membranes moist and free of inflammation or crusting. Because of the drying effect of drugs and the absence of oral fluids, the mouth and oral cavity may be extremely dry, resulting in considerable discomfort and possibly parotitis (inflammation of the parotid [salivary] glands).
- Lowering the patient's anxiety level may also substantially reduce pain. Explain all procedures and other aspects of patient care thoroughly. Provide reassurance, offer diversional activities such as music and reading material, and encourage visitors to direct attention away from the pain.
- If pancreatitis was caused by gallstones, an ERCP with a sphincterotomy (opening of the sphincter of Oddi) may be performed on an urgent or emergent basis. If this procedure is not successful, surgery is required. ERCP is described in detail in Chapter 55.
- Surgical Management
- Surgical intervention for acute pancreatitis is usually not indicated. However, if an ERCP is not successful in removing gallstones, a laparoscopic cholecystectomy may be performed as described on p. 1319 in the discussion of Surgical Management in the Cholecystitis section.
- Complications of pancreatitis, such as pancreatic pseudocyst and abscess, may also require surgical intervention. Laparoscopy (minimally invasive surgery [MIS]) may be done to drain an abscess or pseudocyst. For patients who are high surgical risks, pseudocysts or abscesses can be treated by percutaneous drainage under CT guidance.
Teach people about health promotion practices to prevent gallbladder disease.
- Etiology and Genetic Risk
- A familial or genetic tendency appears to play a role in the development of cholelithiasis, but this may be partially related to familial nutrition habits (excessive dietary cholesterol intake) and sedentary lifestyles. Genetic-environment interactions may contribute to gallstone production (Attasaranya et al., 2008).
- Cholelithiasis is seen more frequently in obese patients, probably as a result of impaired fat metabolism or increased cholesterol. The risk for developing gallstones increases as people age. Patients with diabetes mellitus are also at increased risk because they usually have higher levels of fatty acids (triglycerides). American Indians have a higher incidence of the disease than other groups, which may be due to the higher incidence of diabetes mellitus and obesity in this population (McCance et al., 2010). Risk factors for cholecystitis are listed in Table 62-1.
- Women's Health Considerations
- Women who are between 20 and 60 years of age are twice as likely to develop gallstones as are men. Obesity is a major risk factor for gallstone formation, especially in women. Pregnancy and drugs such as hormone replacements and birth control pills (especially the older oral contraceptives) alter hormone levels and delay muscular contraction of the gallbladder, decreasing the rate of bile emptying. The incidence of gallstones is higher in women who have had multiple pregnancies. Combinations of causative factors increase the incidence of stone formation, especially in women. Therefore some clinicians refer to the patient most at risk for cholecystitis and gallstones by the four Fs:
- • Female
- • Forty
- • Fat
- • Fertile
Teach people about health promotion practices to prevent pancreatitis.
Identify community-based resources for patients with pancreatic disorders.
Describe the psychosocial needs of patients with pancreatic cancer and their families.
Assess patient and family response to a diagnosis of pancreatic cancer.
Identify risk factors for gallbladder disease.
Interpret diagnostic test results associated with gallbladder disease.
Compare postoperative care of patients undergoing a traditional cholecystectomy with that of patients having laparoscopic cholecystectomy.
Compare and contrast the pathophysiology of acute and chronic pancreatitis.
Interpret laboratory test results associated with acute pancreatitis.
Interpret common assessment findings associated with acute and chronic pancreatitis.
Prioritize nursing care for patients with acute
pancreatitis and patients with chronic pancreatitis.
Explain the use and precautions associated with enzyme replacement for chronic pancreatitis.
Develop a postoperative plan of care for patients having a Whipple procedure.
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