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Gastrointestinal System: Part vI Inflammatory Intestinal Disorders
Mrs. April Page, MSN ARNP FNPC Gulf Coast State College NUR1213C Intermediate Adult Care
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Lesson Objectives Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of appendicitis, inflammatory bowel disease Identify risk factors and prevention methods associated with appendicitis, inflammatory bowel disease Compare Crohn’s disease (regional enteritis) and ulcerative colitis with regard to their pathophysiology; clinical manifestations; diagnostic evaluation; and medical, surgical, and nursing management. Describe the nursing management of the patient with an anorectal condition. Illustrate the nursing process in providing care of the patient with inflammatory bowel disease.
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Care of Patients with Inflammatory Intestinal Disorders
Chapter 57 Care of Patients with Inflammatory Intestinal Disorders
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Introduction Inflammatory Disorders
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Inflammatory Disorders
Gastroenteritis Inflammation of stomach and intestinal tract Diarrhea, pain, cramping Fever, N/V, Anorexia, Distention, Tenesmus, Borborygmi Etiology Infected / contaminated food Salmonella (eggs) Campylobacter (chicken) Escherchia Coli (raw or undercooked meat) Clostridium difficile (pseudomembranous colitis) Bacterial dysentary (abx therapy > 7 days or lg dose, Hx blockers, bowel preps, chemo) Gastroenteritis Pathogens - fecal-oral route Intestinal flora disrupted or altered action Temp, self limiting, 1-5 days Population at risk, sick, elderly or young
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Parasitic Infections Protozoa Helminths
Replicate in intestines of hosts, excreted in feces Fecal oral transmission Giardiasis – most common Spoiled food, contamination with feces from infected persons/animals, contamined water Helminths Parasitic worms Ascaris (round), Enterobius (pin),Trichinella Spiralis (trichniosis) Cestoda (Tape)
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Restore fluid and electrolytes
Medical Management Rest bowel – NPO Decrease diarrhea Restore fluid and electrolytes
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Nursing Management Diarrhea Other SX Abdominal assessment
Number, onset, consistency, color Other SX Abdominal assessment Prevent spread of disease Wash hands Private room Spores from C dif live for MONTHS on surfaces
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Lesson objective one Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of appendicitis, inflammatory bowel disease
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Appendicitis
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Appendicitis Epidemiology Acute inflammation of the vermiform appendix
Common condition that occurs highest in year-old age group Affects males more than females
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Appendicitis Pathophysiology Clinical manifestations
A small hollow appendage Made of lymphatic tissue No known function Clinical manifestations Result of a fecalith or other foreign body blocking the opening Leads to inflammation and infection
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Appendicitis Causes No risk factors identified
Fecalith (Fecolith, faecoloma) Kinking of the appendix Swelling of bowel wall Fibrous condition of bowel wall External occlusion of bowel by adhesions No risk factors identified Early detection is important for best outcome
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Clinical Manifestations
Acute abdominal pain in waves / undulating, epigastrium, periumbilical; shifts to right lower quad Steady pain, guarding, fetal position to protect, relieve Vomiting after pain, loss of appetite, low grade fever, coated tongue Lab mild WBC elevation initially 10,000 – 15,000 Mc Burney’s point - pain
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McBurney’s Point (Appendicitis)
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Surgical Management Appendectomy 24 hrs – 48 hrs of sx.
Laparoscopic if possible, open procedure if not Rupture can cause peritonitis Bowel perforation – most common surgical problem D/C hours if laparoscopic and no rupture
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Nursing Management Pre OP Post OP NPO Assess abdomen Labs
IV for electrolytes and hydration Comfort – position of comfort for pt: fetal, knees to chest Post OP Infection, rupture? Surgical incision care; may leave incision open to drain
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Peritonitis Inflammation of peritoneal membrane
Sac covers all organs in abdominal cavity E Coli common Risk factors: None, this is result of another problem Systemic effects Inflammatory response Diverts blood to inflamed area of bowel to fight infection Peristalsis stops/slows Fluids and air retained in bowel Pain which reinforces less respiration d/t pain
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Peritonitis
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Peritonitis Inflammation of peritoneal membrane
Sac covers all organs in abdominal cavity E Coli common Risk factors: None, this is result of another problem Systemic effects Inflammatory response Diverts blood to inflamed area of bowel to fight infection Peristalsis stops/slows Fluids and air retained in bowel Pain which reinforces less respiration d/t pain
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Medical and Surgical Management
Maintain fluid and electrolytes Shock and Sepsis TX Abx NPO Surgery Removal of inflamed object (appendix, diverticulum….) I & D of abscess
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Medical and Surgical Management (cont’d)
No medical management for acute appendicitis Surgical consult should be obtained as soon as possible Patient prepared for the operating room for removal of the appendix (appendectomy) Laxatives and enemas should be avoided Surgeon may perform appendectomy with laparoscopy .
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Nursing Management Pre Op Abdominal assessment
Medical therapy management ABX Pain Vital signs Monitor for Sepsis, shock Drop in B/P Drop in temp; small increase
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Inflammatory bowel disease
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Inflammatory Bowel Disease
Epidemiology Umbrella term for 2 similar chronic GI tract diseases Crohn’s disease Ulcerative colitis 1.4 million Americans suffer from IBD
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Inflammatory Bowel Disease (cont.)
Pathophysiology and clinical manifestations Cause of IBD is unknown Linked to genetic predisposition, environmental conditions, and defects in immune regulation
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Inflammatory Bowel Disease: Crohn’s Disease
Affect gastrointestinal tract from mouth to anus More common in the terminal ileum and colon Transmural Not uniform in appearance and noted for having skip lesions with normal-appearing bowel between lesions Strictures and adhesions are common Diarrhea is less severe than in ulcerative colitis Pain is worse in the right lower quadrant
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Crohn’s Disease
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Inflammatory Bowel Disease: Ulcerative Colitis
Affects large intestine and involves only mucosa and submucosa Small intestine is rarely involved Diarrhea is common Blood, mucus, and pus are common with ulcerative colitis Abdominal pain and tenderness worse in left lower quadrant Tenesmus
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Ulcerative Colitis
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Inflammatory Bowel Disease: Management (cont’d)
Rest bowel and control inflammation Treatments include medications, surgery, correction of nutritional deficits, and psychosocial needs Medications to help control the disease and treat or prevent exacerbations Psychosocial assessment
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Inflammatory bowel disease: Complications
Fistulas more common with Crohn’s disease Short bowel syndrome Chronic abdominal pain Surgical management For Crohn’s if failed medical management and/or experience complications For ulcerative colitis if failed medical management or experienced complications
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Lesson objective two Identify risk factors and prevention methods associated with appendicitis, inflammatory bowel disease
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Appendicitis: Risk Factors
Age Familial Tendency Intra-abdominal tumors
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Appendicitis: Prevention
No prevention Reduce risk Nutritious diet High in Fiber Fresh vegetables Fresh fruit Sprinkling oat bran or wheat germ over breakfast cereals, yogurt, and salads Cooking or baking with whole-wheat flour whenever possible Swapping white rice for brown rice Adding kidney beans or other variations to salads
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Inflammatory Bowel Disease: Risk Factors
Ulcerative Colitis Age < 30 Race or ethnicity (Caucasians highest risk) Family History (close relative) Crohn’s Disease Positive family history Immunologic factors Tobacco use Jewish ethnicity (Ashkenazi) Those who live in urban areas
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Inflammatory Bowel Disease: Prevention
Ulcerative Colitis Cannot be prevented because etiology unknown Reduce or eliminate symptoms Dietary changes, including avoiding certain foods (e.g., dairy products, cabbage, broccoli, beans, spicy foods) Increasing dietary fiber, may help in some cases. Crohn’s Disease Reduce the severity of the disease No specific diet – practice good nutrition Dietary changes: reduce or remove bulky grains, hot spices, alcohol, and milk products may increase diarrhea and cramping. Smoking cessation
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LESSON OBJECTIVE THREE
Compare Crohn’s disease (regional enteritis) and ulcerative colitis with regard to their pathophysiology; clinical manifestations; diagnostic evaluation; and medical, surgical, and nursing management.
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Inflammatory Bowel Disease
Crohn’s disease (regional enteritis) Ulcerative colitis
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Inflammatory Bowel Disease
Crohn’s & Ulcerative Collitis Recurrent Young adult disease, 15-30 Surgery mimic other conditions Surgery common Bowel removal, diseased, necrotic Repair perforations
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Comparison of Crohns Disease and Ulcerative Colitis
Ulcerative Collitis Entire length of colon Mucosal and submucosa involvement only Contiguous disease process in bowel Inflammation, thickening, congestion, edema, and lacerations that bleed Higher in young adults, women and Jews. *Rectal bleeding common Toxic Megacolon – risk for obstruction (can occur in Crohn’s too) Diarrhea – 20+ stools, blood mucus Only known cure is surgery Crohns Discontinuous development disease of bowel Terminal ileum and colon, most common Entire bowel thickness involved Pts do well between flares Slowly progressive *Fistula and abscess formation; toxin release Urgency to expell stool at night Malabsorption, steatorrhea Stools soft or semi liquid, rare with gross blood, and pus Medical Management, surgery to control manifestations; no cure
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Clinical Manifestations
Similar Surgeries for both diseases Abdominal pain, diarrhea, fluid imbalance, weight loss Metabolic acidosis from diarrhea / vomiting Fever with acute disease H & H decreased Abdominal assessment – inflamed bowel is tender Hemorrhoids (Crohn’s – perianal abscesses, fistulas, and ulcers) BE used to differentiate between two diseases IBD’s get routine colonoscopy
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Medical Management Decrease diarrhea Pharmacologic therapy Nutrition
Anti inflammatory threrapy – steroids Crohn’s more chronic, longer therapy Fluid, electrolyte replacement Minimal physical activity Pharmacologic therapy Control diarrhea, reduce inflammation, and treat pain Nutrition Deficiencies of fat soluble vitamins A, D, E, & K, folate Dietary supplements – high protein & calories TPN if less than adequate response or pre surgical
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Surgical Management Proctocolectomy Kock Pouch
Colon and rectum removed; anus closed Terminal ileum to abdominal wall; permanent ileostomy Kock Pouch Reservoir (pouch) from distal ileum; stool stored until mechanically drained Flat stoma on right abdomen No external pouch No flatus or leakage of stool Drains several times / day Not with Crohn’s; recurrent disease Suture line leaks, peritonitis
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Nursing Process: The Care of the Patient With Inflammatory Bowel Disease—Assessment
Health history to identify onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history Discuss dietary patterns, alcohol, caffeine, and nicotine use Assess bowel elimination patterns and stool Abdominal assessment
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Nursing Process: The Care of the Patient With Inflammatory Bowel Disease — Diagnoses
Diarrhea Acute pain Deficient fluid Imbalanced nutrition Activity intolerance Anxiety Ineffective coping Risk for impaired skin integrity Risk for ineffective therapeutic regimen management
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Collaborative Problems and Potential Complications
Electrolyte imbalance Cardiac dysrhythmias GI bleeding with fluid loss Perforation of the bowel
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Nursing Process: The Care of the Patient With Inflammatory Bowel Disease— Planning
Major goals may include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, increased knowledge of disease process and therapeutic regimen, and avoidance of complications
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Maintaining Normal Elimination Pattern
Identify relationship between diarrhea and food, activities, or emotional stressors Provide ready access to bathroom or commode Encourage bed rest to reduce peristalsis Administer medications as prescribed Record frequency, consistency, character, and amounts of stools
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Other Interventions Assessment and treatment of pain or discomfort, anticholinergic medications before meals, analgesics, positioning, diversional activities, and prevention of fatigue Fluid deficit, I&O, daily weight, assessment of symptoms of dehydration or fluid loss, encourage oral intake, measures to decrease diarrhea Optimal nutrition; elemental feedings that are high in protein and low residue or PN may be needed Reduce anxiety, use a calm manner, allow patient to express feelings, listening, patient education
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Patient Education Understanding of disease process Nutrition and diet
Medications Information sources: National Foundation for Ileitis and Colitis Ileostomy care if applicable
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LESSON OBJECTIVE FOUR Describe the nursing management of the patient with an anorectal condition.
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Anorectal Conditions Anorectal abscess Anal fistula Anal fissure
Hemorrhoids Sexually transmitted anorectal diseases Pilonidal sinus or cyst
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Anorectal Fissure
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Fistulas
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Anal Fistula
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Anal Lesions
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Pilonidal Sinus
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LESSON OBJECTIVE Five Illustrate the nursing process in providing care of the patient with inflammatory bowel disease.
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Nursing Process: The Care of the Patient With an Anorectal Condition—Assessment
Health history Pruritus, pain, or burning Elimination patterns Diet Exercise and activity Occupation Inspection of the area
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Nursing Process: The Care of the Patient With an Anorectal Condition—Diagnoses
Constipation Anxiety Acute pain Urinary retention Risk for ineffective therapeutic regimen management
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Collaborative Problems and Potential Complications
Hemorrhage
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Nursing Process: The Care of the Patient With an Anorectal Condition—Planning
Major goals may include adequate elimination patterns, reduction of anxiety, pain relief, promotion of urinary elimination, management of the therapeutic regimen, and absence of complications
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Interventions Encourage intake of at least 2 L of water a day
Recommend high-fiber foods Bulk laxatives, stool softeners, and topical medications Promote urinary elimination Hygiene and sitz baths Monitor for complications Educate on self-care
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Lesson objective Six Illustrate the nursing process in providing care for patients with diverticular disease.
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Diverticula
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Diverticular Disease Diverticulosis and Diverticulitis Diverticulosis
Diverticulum – blind out-pouch or herniation of intestinal mucosa through muscular coat of the large intestine, usually sigmoid Diverticulosis Non inflamed diverticula Diverticulitis Inflammation of diverticulum Common in obese & > 45 years old Risk factors Low fiber diet
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Diverticulitis SX: Depends on inflammation and site
Dull, episodic pain Steady left quadrant or mid abdominal pain Bowel changes (constipation, diarrhea, or both) Increased flatus Anorexia Low – grade fever Localized tenderness If inflammation does not subside, can result in bladder or vaginal fistulas and peritonitis
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Medical Management Asymptomatic – diet modification Symptomatic
High fiber Bran and bulk laxitives Symptomatic Colon rest; NPO, NG, fluids, ABX Pain control Demerol (Meperidine) (MS causes colon spasm)
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Surgical Management Only 20% require surgery
Surgery for hemorrhage, obstruction, abscesses, and perforation Meckel’s diverticulum Embryonic development, outpouching of the bowel within 10 cm of cecum
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Diverticular Disease Diverticulum: sac-like herniation of the lining of the bowel that extends through a defect in the muscle layer May occur anywhere in the intestine but most common in the sigmoid colon Diverticulosis: multiple diverticula without inflammation Diverticulitis: infection and inflammation of diverticula Diverticular disease increases with age and is associated with a low-fiber diet Diagnosis is usually by colonoscopy
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Nursing Process: The Care of the Patient With Diverticulitis—Assessment
Patients may have chronic constipation preceding development of diverticulosis, frequently asymptomatic but may include bowel irregularities, nausea, anorexia, bloating, and abdominal distention. With diverticulitis, symptoms include mild or severe pain in lower left quadrant, nausea, vomiting, fever, chills, and leukocytosis. Ask regarding the onset and duration of pain and past and present elimination patterns. Nutrition and dietary patterns, including fiber intake. Inspect stool and monitor for symptoms potential complications.
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Nursing Process: The Care of the Patient With Diverticulitis—Diagnoses
Constipation Acute pain
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Collaborative Problems and Potential Complications
Perforation Peritonitis Abscess formation Bleeding
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Nursing Process: The Care of the Patient With Diverticulitis—Planning
Major goals may include attainment and maintenance of normal elimination patterns, pain, relief, and absence of complications
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Maintaining Normal Elimination Pattern
Encourage fluid intake of at least 2 L/d Soft foods with increased fiber, such as cooked vegetables Individualized exercise program Bulk laxatives (psyllium) and stool softeners
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Major Points Differences between Crohn’s and Ulcerative Colitis
Both surgeries are similar Diverticulitis is Diverticulosis with inflammation Management of patients with bowel disorders includes bowel rest Bowel obstructions are medical and surgical emergencies
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Major Points (cont.) Bowel elimination problems Intestinal disorders
Constipation Diarrhea Bowel Incontinence Intestinal disorders Slow Obstruct Accelerate Secretion Motility Absorption
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Major Points The most common acute inflammatory bowel problems are
Appendicitis Gastroenteritis Peritonitis These disorders are potentially life threatening and can have major systemic complications if not treated promptly.
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The End Chapter 57
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