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Acute and Chronic Inflammatory Bowel Disorders and Bowel Diseases. *Appendicitis *Gastroenteritis *Peritonitis *Ulcerative Colitis * Crohn’s Disease * Diverticular Disease *Gallbladder Disease. Appendicitis. Acute inflammation of vermiform appendix Most common cause of RLQ pain - PowerPoint PPT Presentation
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*Appendicitis*Gastroenteritis
*Peritonitis*Ulcerative Colitis*Crohn’s Disease
*Diverticular Disease*Gallbladder Disease
Acute and Chronic Inflammatory Bowel Disorders and Bowel
Diseases
Appendicitis
Acute inflammation of vermiform appendix
Most common cause of RLQ pain
Lumen (opening) of appendix is blocked by fecaliths (hard feces, composed of calcium phosphate rich mucus and inorganic salts)
Appendicitis Cont.
Other causes:malignant tumorsHelminthesOther infections
Appendicitis Cont.
The lumen gets blocked the mucosa secretes fluid internal pressure increases causing pain
Slow process may develop abscess Rapid process may result in
peritonitis Gangrene can occur in 24-36 hours Life threating Emergency surgery
Perforation may develop
Assessment
Abdominal pain followed by N/V Cramp like pain in in epigastric or
periumbilical area Anorexia Initally pain can be anywhere in the
abdomen or flank area Pain becomes severe and shifts to
the RJQ (McBurney’s point) Between anterior iliac crest and
umbilicus
Assessment Cont.
Pain that increases with cough or movement suggest perforation and peritonitis
Observe for: Muscle rigidity Guarding on palpation Rebound tenderness
Lab findings: Incresed WBC’s with a shift to the left
Assessment Cont.
Other tests: Ultrasound-may show enlarged appendix CT scan- may reveal a fecalith
Nonsurgical Management
IV fluids NPO Semi-fowlers position to facilitate
abdominal drainage Analgesics Antibiotics DO NOT:
Apply heat-increases inflammation and perforation
Give laxatives or enemas-may cause perforation
Surgical management
Appendectomy-removal of appendix Laparoscopy-minimally invasive Natural orifice transluminal endoscopic
surgery (NOTES)-endoscope is placed in vagina or other orifice and makes small incision into peritoneal space
Laparotomy- open surgical approach
Gastroenteritis
Diarrhea and/or vomiting caused by inflammation of the mucous membranes of stomach and intestinal tract
Small bowel affected
Viral or bacterial
Gastroenteritis
Viral: Epidemic viral:▪ parvovirus-type organism ▪ transmitted fecal-oral in food and water. ▪ Incubation period 10-51 hours. ▪ Communicable during acute illness.
Rotavirus and Norwalk virus:▪ transmitted fecal-oral and possibly resp. route.▪ Incubation 48 hours. ▪ Common in infants and young children.▪ Norwalk virus affects young children and adults
Gastroenteritis Cont. Bactreial:
Campylobactor enteritis:▪ Transmitted fecal-oral or contact with infected animals or
infants ▪ Incubation period 1-10 days▪ Communicable 2-7 weeks
Escherichia coli diarrhea:▪ Transmitted by fecal contamination of food or water
Shigellosis:▪ Transmitted by direct or indirect fecal-oral routes▪ Incubation period 1-7 days▪ Communicable during acute illness and up to 4 weeks after▪ Humans possibly carries for months
Assessment Obtain history of recent travel especially tropical
regions N/V Diarrhea Myalgia HA Malaise Weakness Cardiac dysrhythmias due to hypokalemia Hyrotension Dry mucous membranes Poor skin turgor
Assessment Cont.
Lab assessment: Gram stain stool:▪ Many WBC’s suggest shigellosis▪ WBC’s and RBC’s indicate Campylobacter
gasteroenteritis
Interventions Fluid replacement:
Oral IV- may need potassium added if excessive diarrhea
Drug therapy: Imodium if deemed necessary Antibiotics if bacterial infection
▪ Cipro▪ Levaquin▪ Zithromax▪ Septra DS
Skin care Avoid toilet paper and harsh soap Gently clean with warm water or absorbent material followed by
gentle drying Apply cream, oils, gel or barrier cream sitz baths for 10 minutes 2-3 times a day
Peritonitis acute inflammation of
the visceral/parietal peritoneum and endothelial lining of the abdominal cavity.
LIFE THREATENING Body begins an
inflammatory reaction to create a “wall” to stop the spread of bacteria
When the wall fails the bacteria spreads resulting in peritonitis.
Peritonitis
Causes: Bacteria or chemicals contaminating the
peritoneal cavity ▪ Escherichia coli▪ Streptococcus▪ Staphylococcus▪ Pneumococcus▪ Gonococcus▪ Bile▪ Pancreatic enzymes▪ Gastric acid
Peritonitis Cont.
How bacteria get in:▪ perforation (appendicitis, diverticulitis, PUD),▪ an external perforating wound▪ a gangrenous gallbladder▪ bowel obstruction▪ ascending infection through the genital tract.
Peritonitis Cont. Hypovolemic shock results from a decrease
in ECF and circulatory volume (this fluid migrates to the peritoneal cavity).
Hypovolemic shock insufficient perfusion to kidneys kidney failure with electrolyte imbalance
Peritoneal inflammation peristalsis slows or stops lumen of bowel becomes distended fluid accumulates in intestine (7-8 L DAILY)
Assessment Respiratory problems caused by abdominal pressure on
diaphragm Rigid, board like abd. (classic) Pain Distention rebound tenderness N/V Anorexia diminished bowel sounds inability to “pass flatus” or poop High fever Tachycardia Dehydration decreased UO Hiccups possible compromised respiratory status
Assessment Cont. Lab assessment
Elevated WBC with high neutrophil count Blood culture studies to check for septicemia
(bacterial invasion of blood) Electrolytes BUN, CRT H&H O2
X-rays may be ordered to assess for air or fluid
Nonsurgical Management
Administer IV fluids broad spectrum antibiotics Monitor daily weight I&O Place NG tube NPO O2 SPO2 and respiratory status checks Pain medications
Surgical Management Laparotomy or Laparoscopy to remove or repair
the inflamed or perforated organ The focus is to control contamination and drain
fluid Catheters may be placed to drain the cavity and
provide irrigation route After surgery
Maintain sterile technique during manual irrigation of peritoneal wounds through a drain
Assess for fluid retention during irrigation Place in semi-fowlers to promote drainage and
increase lung expansion
Surgical Management Cont.
After surgery Maintain sterile technique during manual irrigation of peritoneal
wounds through a drain Assess for fluid retention during irrigation Place in semi-fowlers to promote drainage and increase lung
expansion Assess ability of self-management
Teaching Provide written and oral instructions Discuss when to immediately call provider ( unusual/ foul-smelling
drainage, swelling, redness, warmth, bleeding from incision site, temperature higher than 101, abd pain)
Collaborate with case manager to ensure care will be provided at home if needed
Review medications Refrain from ANY lifting for AT LEAST 6 weeks
Ulcerative Colitis Widespread
inflammation of rectum and rectosigmoid colon, but may extend to entire colon when the disease is extensive
Associated with periodic remissions and exacerbations
Disease may remain constant for years
Ulcerative Colitis Cont.
Intestinal mucosa becomes hyperemic (increased blood flow), edematous, and reddened
In severe cases, the lining may bleed, causing small erosions, or ulcers, to occur
Abscesses form in ulcerative areas, resulting in tissue necrosis
Continued edema leads to narrowed colon, and possibly a bowel obstruction
Ulcerative Colitis Cont.
Patient’s stool contains blood and mucus
Patient reports tenesmus (unpleasant, urgent sensation to defecate), and lower abdominal pain which is relieved with defecation
Additional s/sx: malaise, anorexia, anemia, dehydration, fever, weight loss
Ulcerative Colitis Etiology/Risk
Affects about 1.4 million in U.S. Peak age of Dx: 30-40 y/o Women affected more than men in younger years; men
affected more in middle-older age Cause is unknown More prevalent among Jewish persons, and among whites
more than non-whites (Reason for this is unknown) Genetic/immunologic factors suspected Often found in families and twins Autoimmune dysfunction: epithelial antibodies IgG have
been found in the blood of some patients with Ulcerative Colitis
With long-term disease, risk for developing colon cancer increases
Ulcerative Colitis: Classification of Severity
Mild: <4 stools/day with/without blood Asymptomatic Lab values usually normal
Moderate: >4 stools/day with/without blood Minimal symptoms Mild abd pain Mild intermittent nausea Possible increased C-reactive protein or ESR (erythrocyte sedimentation rate)
Severe: >6 bloody stools/day Fever Tachycardia Anemia Abd pain Elevated C-reactive protein and/or ESR
Fulminant: >10 bloody stools/day Increasing symptoms Anemia may require transfusion Colonic distention on x-ray
Assessment History
Collect family hx data, nutrition hx, usual bowel patterns (color, characteristic, consistency of stools)
Inquire about recent antibiotic use (may suggest C-diff infection) Inquire about travel to tropical areas Ask about use of NSAIDs (may cause flare-up)
Physical Asessment Symptoms vary, VS are usually WNL in mild cases In severe cases, fever (99-100 F or 37.2-37.8 C) Note any abd distention Fever with tachycardia may indicate peritonitis, dehydration,
and bowel perforation Assess for complications such as inflamed joints and lesions in
the mouth
Assessment con’t Psychosocial Assessment
Inability to control bowel, specifically presence of diarrhea, can be disruptive and stress-producing
Explore: stress factors which cause flare-ups, family and social support systems, genetic concerns
Lab Assessment H&H low due to blood loss (indicates anemia and a chronic
disease state) Elevated WBC, C-reactive protein, and/or ESR Serum Na, K, and Cl may be low due to diarrhea and
malabsorption from diseased bowel Decreased serum albumin due to loss of protein through stool
Other Diagnostic Assessment Colonoscopy is the most definitive test for diagnosing UC
Planning/Implementation
Priority problems: Diarrhea/incontinence r/t inflammation of bowel mucosa Pain r/t inflammation and ulceration of bowel mucosa and
skin irritation Potential for lower GI bleeding and resulting anemia
Nonsurgical management (Drug therapy) Aminosalicylates (anti-inflammatory effect by inhibiting
prostaglandins; effective in 2-4 wks)▪ Sulfasalizine, Mesalamine
Glucocorticoids (prescribed during exacerbations)▪ Prednisone – tapered dosing once improvement occurs
Immunomodulators (synergistic effect with prednisone)▪ Remicade, Humira
Planning/Implementation Cont. Nutrition therapy
Patients are kept NPO when symptoms are severe, to ensure bowel rest
TPN for severely ill/malnourished patients Diet is not a major factor, but ETOH and caffeine
may increase diarrhea and cramping For some patients, lactose and high-fiber foods cause
GI symptoms Rest
Activity is generally restricted to slow peristalsis Ensure access to bedpan, bedside commode, or
bathroom in case of tenesmus (urgency)
Planning/Implementation Cont. CAM therapies
Herbs (flaxseed), selenium, Vit. C, biofeedback, hypnosis, acupuncture, and ayurveda (a combination of diet, yoga, herbs, and breathing exercises)
Surgical management Temporary or permanent ileostomy Laparoscopic surgery Natural orifice transluminal endoscopic surgery
(NOTES) performed through anus or vagina Total proctolectomy with permanent ileostomy
(removal of anus, rectum, and colon)
Evaluation
Expected outcomes: Verbalizes decrease in pain Gain of control over bowel elimination No GI bleeding Self-management of ileostomy Maintains peristomal skin integrity Demonstrates behaviors that integrate
ostomy care into his or her lifestyle if a permanent ileostomy is performed
Crohn’s Disease Inflammatory disease of the small
intestine, colon, or both Can affect GI tract from mouth to
anus, but most commonly affects the terminal ileum
Progressive, unpredictable disease Like UC, this is recurrent with
remissions and exacerbations Unlike UC, Crohn’s causes a
thickened bowel wall with strictures and deep ulcerations that have a cobblestone appearance (these put the patient at risk for bowel fistulas)
Malabsorption of vital nutrients; anemia results
Horses and Zebras Horses (Similarities between UC and CD)
Inflammatory disease Periodic remissions and exacerbations Weight loss, frequent, bloody stools, fever, abd pain, abd distention, diarrhea No known cause; familial patterns; Jewish ethnicity Anemia Elevated WBCs, C-reactive protein, and ESR Decreased albumin Decreased electrolytes Complications: hemorrhage/perforation, abscess formation, toxic
megacolon, malabsorption, nonmechanical bowel obstruction, fistulas, colorectal cancer, extraintestinal complications (arthritis, oral and skin lesions), osteoporosis
Interventions are the same Drugs: Aminosalicylates, Remicade, Humira, glucocorticoids
(contraindication: fistulas) Need for TPN in malnourished patients
Horses and Zebras Zebras: (Differences between UC and CD)
Unlike UC, CD causes thickened bowel wall with necrosis, strictures, and deep ulcerations
Hemorrhage is more common in UC Fistula formation is common in CD (rare in UC) Malabsorption by small intestine is common in CD because
UC doesn’t significantly involve the small bowel Therefore, patients with CD tend to be more malnourished Patients with CD at increased risk for sepsis Surgical management for CD: laparoscopic bowel
resection, or stricturoplasty (increasing the diameter of the bowel)
Diverticular Disease Diverticula: pouchlike
herniations of the mucosa through the muscular wall of any portion of the gut, usually the colon
Diverticulosis: presence of many abnormal diverticula in the wall of the intestine (without inflammation, this causes few problems)
Diverticulitis: inflammation of one or more diverticula (caused by trapping of undigested food or bacteria in diverticulum, resulting in reduced blood supply to that area)
Diverticular Disease Cont.
Diverticulitis: low-grade fever, N&V, abd pain (may be localized to LLQ), bleeding from rectum, chills, tachycardia
If pain is generalized, peritonitis has occurred Elevated WBCs, decreased H&H Stool test for occult blood Possible RBCs present in UA Most often diagnosed with colonoscopy CT to diagnose abscess or thickening Treated with wide-spectrum antimicrobials (Flagyl,
sulfa, cipro) Avoid laxatives and enemas which increase
motility
Gallbladder Disease (GBD)
The gallbladder is a small pear-shaped digestive organ located under the liver.
Bile is released from liver and stored in gallbladder.
Gallbladder Disease IS
More common in women than men Inflammation Infection Stones Obstruction of the gallbladder. Most common cause is gallstones
Symptoms vary widely from discomfort to severe pain Begins after eating
Severe Cases Jaundice nausea fever
Risk Factors Heredity. More frequently in Mexican Americans and Native Americans but are
also common in people of northern European stock.
Age. Gallbladder disease often strikes people over sixty years of age.
Gender. Excess estrogen may be implicated, since hormone replacement after menopause increases the likelihood of stones.
Diet. Most people know that there is an established link between fat intake and gallbladder disease, but many don't realize that there is also a significant correlation with high sugar intake as well. (Diabetes mellitus)
Obesity. In comparison with people of normal weight, the bile of obese people is supersaturated with cholesterol, predisposing them to the development of gallbladder illness.
Slow intestinal transit. Medical professionals have long known that constipation is common in patients who have gallbladder disease. Studies confirm that slow intestinal transit contributes to the formation of gallstones in women of normal weight.
Gallstones
Formed by crystallized bile substances : Excess cholesterol Bile salts calcium
Vary in size: Can be as small as a grain of sand.
Symptoms
N/V A bloated sensation in the abdomen Gassiness, with belching and passing of
intestinal gas Indigestion Clay-colored stools Jaundice Chills Sweating Fever
Cholecystitis
Acute Inflammation of the gall bladder from:▪ Irritation and inflammation from gallstones▪ stone blocking a passageway (cholelithiasis)
Chronic Repeated episodes of duct obstruction
Symptoms Intense and sudden pain in the upper right part
of the abdomen recurrent painful attacks for several hours after
meals N/V Rigid abdominal muscles on right side Slight fever Chills Jaundice Itching Loose, light-colored bowel movements Abdominal bloating
Nonsurgical Management
Pain medication Dilaudid Morphine Toradol
Antiemetics for N/V IV antibiotics Extracorporeal shock wave
lithotripsy (ESWL) Biliary catheters to open blocked
ducts
Surgical Management
Cholecystectomy --surgical removal of the gallbladder Laparoscopic ▪ minimally invasive surgery (MIS)▪ Complications are not common▪ The death rate is very low▪ Bile duct injuries are rare▪ Patient recovery is quicker▪ Postoperative pain is less severe
Surgical ManagementCont.
Traditional Cholecystectomy Open surgical approach Used for severe biliary obstruction T-tube drain may be inserted into duct
for drainage JP drains my be placed in gallbladder
bed to prevent fluid accumulation
Post-0p Care PCA Cough and deep breath Antiemetics Wound care Keep NPO until fully awake then advance
clear liquids red diet V/S LOC Assess surgical site for redness and purulent
drainage Ambulation
Patient Teaching
Teach signs of postcholecystectomy syndrome (PCS) Repeat abdominal pain Epigastric pain with vomiting that may
occur weeks to months after surgery
PCS
Causes Pseudocyst Common bile duct (CBD) leak CBD or pancreatic duct obstruction Sphincter dysfunction Retained or new gallstone Pancreatic or liver mass Diverticular compression
Presented by
Laura HendersonLindsey KinchIvette Nunez
Ronald PattersonDonna Wade
References
Ignatavicius, M. R., & Workman, P. R. (2013). Medical Surgical Nursing: Patient-Centered Collaborative Care. St. Louis: Elsevier Saunders.