Lower GI-Lecture #2
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When does a person usually get an appendicitis?
Complication of appendicitis
Clinical Manifestations of Appendicitis
- Pain RLQ
- Rebound Tenderness
- Muscle Guarding
Common causes of Peritonitis
- ruptured appendix
- perforated gastric/duodenal ulcer
- severely inflamed gallbladder
- abdominal trauma-GSW/knife wound
Diseases that can cause peritonitis
- peritoneal dialysis
Clinical Manifestations of peritonitis
- abdominal pain
- rebound tenderness
- muscular rigidity
- abdominal distention
Why don't you give a person with an appendicitis laxatives or an enema?
increases peristalsis and can cause perforation
After a person has had surgery/been NPO when do you advance their diet?
Once you hear bowel sounds
How do you treat peritonitis?
- fluid & electrolyte replacement
- NG Tube with suction
- semi fowlers
- pain management
Name 2 inflammatory bowel diseases
Ulcerative Colitis and Crohn's
chronic recurrent inflammation of the intestinal tract
Who's most likely to get IBD's?
Jewish white people....who have it in their family. Inherited
Where do Ulcerative Colitis usually occur?
starts in the rectum and sigmoid colon and spreads up the colon in a CONITNUOUS pattern of inflammation and ulceration of the mucosal layer
Why are F&E lost with ulcerative colitis?
cuz there is a decreased mucosal area for absorption of F&E
Clinical Manifestations of Ulcerative Colitis
- bloody diarrhea (4/5xday)
- abdominal pain
Sever Ulcerative Colitis presents itself as....
- 10-20 stools per day
- mucous and blood in stools
- weight loss
- symptoms of dehydration
Complications of Ulcerative Colitis
- Toxic Megacolon
- Hemorrhage causing anemia
- Increased risk of colorectal cancer
Systemic complications from Ulcerative colitis
- eye inflammation
- skin lesions
- kidney stones
- sclerosing cholangitis
Lab studies for ulcerative colitis/Crohns and why you do those studies
- CBC-iron deficiency anemia
- WBC count-megacolon/perforation
- Serum Protein-hypoalbuminemia
- Stool testing-OB and C&S
Dx studies for ulcerative colitis and Crohns
- barium enema
Planning goals for a person with ulcerative colitis and Crohns
- decreased # of stools/day
- soft formed stools
- keep food in and maintain wt
- no anxiety
Interventions with ulcerative colitis/Crohns
- IV fluids and electrolytes
- monitor # stools and appearance
- meticulous peri care
Most effective exacerbation medications for ulcerative colitis/Crohns (2)...what does it do?
it's a retention enema that is an anti inflammatory
Severe anti inflammatory medications for ulcerative colitis/Crohns
- Prednisone PO
- Solumedrol IV
Maintenance medication for ulcerative colitis
Surgical procedure for Ulcerative Colitis
total l colectomy with rectal mucosal stripping and ileal reservoir
After colorectal surgery for ulcerative colitis...how much fluid may you see in the stoma bag?
change bag frequently
Foods to encourage and discourage with Ulcerative Colitis
Encourage-high calorie, high protein low residue diet w/vitamins and iron supplements
Discourage-cold foods, high residue foods (wheat bread, cereal with bran, nuts, raw fruit) smoking
Describe Crohn's disease
- discontinuous inflammation involving all layers of the bowel
- most common in the terminal ileum and colon
Clinical Manifestations of Crohn's
- abdominal pain
- wt loss/malnutrition
- v. deficiency
- electrolyte imbalance
Ultimate problem with Crohns disease
- will need surgery, but it wont cure the problem
- due to multiple surgeries...they will ultimately have short bowel syndrome
short bowel syndrome causes
Oral diet for a person with Crohns
- high calorie
- high nitrogen (replace protein loss)
- fat free
- no residue
With Crohns if there is malabsorption at the terminal ileum what will my patient need?
v. B12 shots monthly
Gerontologic considerations for Crohns and Ulcerative colitis
- Second peak occurs at 70
- riskier to have surgery
- hard to control F&E issues
Mechanical Neurogenic bowel obstruction
caused by an occlusion of the lumen of the intestinal tract (usually small) from adhesions post op
Most common mechanical obstruction of the large intestine
Nom mechanical neurogenic bowel obstruction
- paralytic ileus (lack of peristalsis)
- vascular obstruction (emboli/atherosclerosis)
What is a neurogenic bowel obstruction
when the bowel cant tell that brain that it is full, and the brain cant tell the bowel to empty completely or at an appropriate time
Patho of neurogenic bowel obstructions
- obstruction causes distention and stimulates intestinal secretions
- increased pressure causes capillary permeability and fluids shift in to the peritoneal cavity
Systemic problems from neurogenic bowel obstructions
- F&E imbalances
Clinical Manifestations of neurogenic bowel obstructions
- abdominal pain/distention
- NO FLATUS
DX studies for neurogenic bowel obstructions
- Abdominal X ray (gas/fluids)
- CBC/Serum Chesistries
- Stool for OB
- Sigmoidoscopy/Colonoscopy with biopsy
High intestinal obstructions vs. low intestinal obstructions you will see.....Metabolic
Nursing management for a person with a neurogenic bowel obstruction
- watch for fluid and electrolyte imbalances
- replace potassium?
- Manage NG tube
What are diverticula
saccular dilations or outpouching of the mucosa thru the smooth muscle of the intestinal wall
Where do diverticula mainly occur?
What is thought to be the cause of diverticula?
Who gets it the most?
lack of fiber and high carb diet
US Americans get it the most
What is the result of diverticula?
transit time slows and more water is absorbed from the stool making it more difficult to pass thru the lumen
What causes diverticulitis?
retention of stool and bacteria in the diverticula causing inflammation, abscesses and small perforations
Common symptoms of diverticulitis
- LLQ abdominal pain
Compolications of diverticulitis
- Perforation with peritonitis
- abscess and fistula formation
- bowel and ureteral obstruction
What kind of a diet does a person with diverticulitis eat?
- High fiber...fruits and vegetables
- increased fluids
Avoid bending, heavy lifting and tight clothes
go back in to place by manipulation or when the patient lies down
cant be placed back in to the abdominal cavity and may become strangulated.
Most common hernia and most common in men
Pushes through inguinal ring
Occurs most in women
pushes thru the femoral ring in to the femoral canal
occur when the rectus muscle is weak or the umbilical opening fails to close after birth
occur due to a weakness in the abdominal wall at the site of a previous incision
Hernias are most common in people who are.....
- have had multiple surgeries in the same area
- inadequate wound healing
Clinical Manifestations of Hernias
- Severe pain if strangulated
surgical repair of a hernia...done laparoscopically
reinforcement of a weakened area around a hernia
If strangulation of the intestines occur due to a hernia what will happen....
- bowel resection with temporary colostomy
After Herniorraphy or Hernioplasty....tell the patient
- don't sneeze/cough
- don't lift heavy things for 6-8 weeks
chronic, progressive degeneration and destruction of liver cells
With cirrhosis destroyed liver cells are replaced by scar tissue....what's the result?
- inadequate blood flow
- poor cellular nutrition/hypoxia
further decreases fxn of liver
What causes cirrhosis
- Chronic Hepatitis
- Biliary cirrhosis
- Cardiac problems
Which Hepatitis cause Cirrhosis?
How does heart disease cause cirrhosis?
caused by long standing Rt. sided heart failure causing venous flow to back up in to the liver
Early symptoms of cirrhosis
- GI Distress
Later symptoms of Cirrhosis
- Peripheral Edema
- Skin lesions
- Endocrine disturbances
- Peripheral Neuropathies
Hematologic problems seen with cirrhosis
Complications of Cirrhosis
- Portal HTN
- Esophageal Varices
- Peripheral Edema
- Hepatic Encephalopathy
- Hepatorenal Syndrome
What's esophageal Varices?
large torturous veins at the lower end of the esophagus as a result of portal hypertension causing high pressure and they are weak so they may hemorrhage.
Vericose veins of the esophagus
What causes Hepatic Encephalopathy?
the liver doesn't metabolize the ammonia in the body so it accumulates and crosses over the blood brain barrier causing neurologic changes
S/S of encephalopathy
lethargy to coma
occurs with cirrhosis....renal failure with azotemia and is a result of portal hypertension
Persons with Cirrhosis are at risk for....
- Excess fluid volume
- Imbalanced nutrition
- impaired skin integrity
- acute confusion
Interventions for a person with cirrhosis
- reduce/eliminate risk factors for alcoholism
- rest to decrease metabolic demand on liver
- Banana Bag-B complex vitamins
- Assess for F&E imbalances
- Address skin
Nutritional therapy for a person with cirrhosis
- High calories/carbs
- Low fat/protein
Person with ascites is treated with....
- sodium restrictions
- peritoneal shunt
How do you treat a patient with Esophageal Varices
- Goal is to reduce risk of bleeding....
- Give Beta Blockers to reduce BP
- TIPS-Transjugular Intrahepatic Portosystemic Shunt
- Vitamin K
Why is a person with Cirrhosis given V. K?
to correct clotting abnormalities
How is ammonia removed to prevent encephalopathy? (2)
- it is going to be removed via the intestines with Lactulose 3-4x/day
- Antibiotics impair bacterial action on protein in the feces to decrease ammonia production.
Clinical manifestation of pancreatitis
- LUQ abdominal pain
What aggravates pancreatitis
Greys Turner's Sign
- seen in pt. with pancreatitis
- bluish discoloration of the blank areas
- seen with Pancreatitis
- Bluish periumbilical discoloration resulting from seepage of blood stained exudates from the pancreas
Chronic pancreatitis will cause....
- weight loss
- mild jaundice
- dark urine
Systemic complications of pancreatitis
- pleural effusion
Key management issues for a person with Pancreatitis
- NGT with suction
- F&E balance
- PAIN MANAGEMENT (#1)
- Monitor infections
- Nutritional therapy
inflammation of the gallbladder
What causes cholelithiasis?
increased precipitation of cholesterol, bile salts and calcium. Infection and disturbances of cholesterol metabolism create an environment for gallstones to form
Gallstones are most commonly made from
How does cholelithiasis cause cholecystitis?
stones from the gallbladder migrate to the cystic/bile duct causing a blockage. There will be a blockage of bile from the gallbladder causing stasis and cholecystitis?
Clinical Manifestations of Cholecystitis
- RUQ pain
Patients with Cholecystitis will complain of....
- fat intolerance
How do you manage cholecystitis?
- pain management
- antibiotic for infections
- F&E balance per labs
- NGT tube with suction
How do you manage cholelithiasis?
After a cholecystectomy why may the person have should pain?
cuz carbon dioxide wasn't released or absorbed by the body
What is given to a person with cholecystitis to help with spasms?
Fat soluable vitamins given to a person with cholecystitis
What kind of diet should a person eat with cholecystitis?
What's toxic megacolon?
- a condition seen in people with UC and Crohns. Inflammation and infection cause a widening of the colon:
- abdominal pain/distention/tenderness
What would you like to do?
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