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165 Cards in this Set
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An older patient diagnosed with bacterial gastroenteritis is complaining of abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment?
A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown |
Answer: A
Rationale: In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool. |
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How do Anticholinergics and Antihistamines work as antiemetics?
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block brain from being stimulated by nauseous stimuli
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What is an example of an Anticholinergic antiemetic?
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Scopolamine, works against motion sickness
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What are two examples of Antihistamine anti emetics?
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Antivert, Bonine, works against motion sickness and as h1 blockers
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What is an example of a Neuroleptic antiemetic?
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Compazine for psychotic disorders
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What is an example of a Serotonin blocker as an antiemetic?
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Zofran, used mostly postop and for N/V with chemotherapy
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What are 3 acute bowel disorders?
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Appendicitis
Gastroenteritis Peritonitis |
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What are 3 chronic bowel disorders?
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Colitis
Crohn’s Diverticulitis |
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Inflammatory Bowel Disease (IBD)
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Inflammation of Large or Small Bowel
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What is appendicitis?
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Vermiform Appendix in cecum becomes blocked
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Where is the appendix?
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extends off the proximal cecum of the colon just below the ileocecal valve.
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Causes of appendicitis?
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obstruction d/t fecaliths (hard pieces of feces)
other causes are tumors, and worms |
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Life threatening complications of appendicitis?
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occur rapidly (24-48 hrs.) including peritonitis, and perforation of the appendix.
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Appendicitis peaks at what ages?
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20-30 years
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S/S appendicitis?
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Pain in epigastric or periumbilical area shifting to RLQ (McBurney’s) N/V, temp. 99-100.5, WBC’s 10,00-18,99/mm, Rigidity
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What is abd rigidity a sign of?
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perforation & peritonitis
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Treatment for appendicitis?
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NPO, IV fluids, no enema (May cause perforation), no heating pad (increase in circulation and inflammation and perforation), Pain meds, appendectomy
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What is McBurney's point?
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Area of appendicitis pain RLQ between anterior iliac crest and unbilicus
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Abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests...
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perforation and peritonitis
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Are all complications of peritonitis serious?
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Yes gangrene can occur w/in 24-36 hrs, life threatening. Need emergency surgery. Perforation can develop 24-48 hrs
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What is laparoscopy?
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minimally invasive surgical procedure with several small incisions near the umbilicus through which a small endoscope is placed
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What is a laparotomy?
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an open approach with larger abdominal incision for complicated or atypical appendicitis or peritonitis
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What is gastroenteritis?
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Acute diarrhea, Increase in frequency and watery stools with or without vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract
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What are causes of gastroenteritis?
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Viral, bacterial, or parasite
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s/s gastroenteritis
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Nausea, vomiting, diarrhea, abd.pain and cramping
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What is the Most common cause of morbidity and mortality in children and older adults in Asia, Africa, and Latin America?
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gastroenteritis
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Parasitic gastroenteritis most common causes by
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Giardia and Cryptosporidium
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How do we get Giardia and Cryptosporidium?
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Contaminated water and human contact
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Bacterial gastroenteritis is due to
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poor sanitation, contaminated food or drinking water.
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There are three main bacteria that
cause gastroenteritis:
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Escherichia coli (E. coli)
Shigella Campylobacter |
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How does E.Coli work to make us sick?
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Traveler's diarrhea- They release
non-inflammatory toxic substances
called enterotoxins which result in diarrhea.
Fecal/food/water |
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How does Shigella work to make us sick?
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Dysentery- Mostly humans under 10- attach to the epithelial lining and destroy the intestinal villi and cause malabsorption.
Fecal/Oral route |
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How does Campylobacter work to make us sick?
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Reservoirs domestic or wild animals and birds, foul smelling stools- attach to the epithelial lining and destroy the intestinal villi and cause malabsorption.
Fecal/Oral route |
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The bacterial toxins interfere with the _______ in the distal small bowel as well as the proximal colon
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absorption
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Viral gastroenteritis is usually acquired by...
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eating or drinking contaminated food or water, or sharing utensils, towels, or food with someone that is infected.
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Viruses that can cause gastroenteritis include:
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Norovirus
Rotavirus |
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Norovirus
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Affects children and adults and spreads quickly among people in confined spaces, such as on cruise ships. Can be transmitted person-person, but most often picked up from infected food or water.
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Rotavirus
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spread fecal-oral route, incubation 48 hours, seen most often in infants and young children
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What do Norovirus and Rotavirus cause?
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Causes watery diarrhea as well as vomiting, and is often called “the stomach flu”.
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1kg (2.2lbs) wt. gain or loss =
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1 liter of fluid
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Treatment for gastroenteritis
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No formal treatment, the key to a more rapid and safe recovery is good hydration. Recommended fluids are
clear fluids but not fruit juices or milk. |
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Meds for gastroenteritis?
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promethazine (Phenergan),
prochlorperazine (Compazine) or ondansetron (Zofran) may be prescribed to reduce vomiting, diphenoxylate and atropine (Lomotil) or loperamide (Imodium) to slow diarrhea. |
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Should gastroenteritis always be treated with meds?
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Many clinicians simply suggest no treatment for gastroenteritis symptoms as all of the drugs
have side effects, and the clinicians figure that if the patient stays well hydrated, the symptoms will soon stop anyway. |
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What diet to help once gastroenteritis symptoms abate?
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BRAT diet (bananas, rice, apples and toast) for a day or two before beginning a regular diet.
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Major problems with gastroeneritis?
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Dehydration (especially in elderly), Na, K loss
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Skin care with gastroenteritis?
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Skin care gentle cleansing with warm h2o, hydrocortisone creams, barriers, sitz baths.
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An older patient diagnosed with bacterial gastroenteritis is complaining of abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment?
A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown |
Answer: A
Rationale: In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool. |
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Peritonitis
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Acute, life threatening, inflammation (irritation) of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs
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Peritonitis is caused by
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Contamination of the peritoneal cavity by bacteria or chemicals.
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Bacteria enter the peritoneum by:
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perforation (appendicitis, diverticulitis, peptic ulcer disease), external penetrating wounds, gangrenous gallbladder, bowel obstruction, or infections coming from the genital tract.
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A less common cause of peritonitis includes
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perforating tumors, leakage or contamination during surgery, infections by skin pathogens ,and an undergoing continuous ambulatory peritoneal dialysis (CAPD).
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Common bacteria that cause peritonitis are:
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Escherichia coli, Streptococcus, Staphylococcus, Pneumococcus, and Gonococcus.
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Chemical peritonitis results from the leakage of:
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bile, pancreatic enzymes, and gastric acid.
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the bacteria or toxins responsible for the peritonitis can enter the blood steam from the peritoneal area and lead to ...
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bacteremia or Septicemia.
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Respiratory problems with peritonitis occur due...
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increase abdominal pressure to the diaphragm r/t abdominal distention.
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* S/S peritonitis
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Abdominal Pain and Distention
RIGID and elevated temp High WBC/neut count decreased urinary output Diarrhea Fever Lack of Appetite Nausea and Vomiting |
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Does peritonitis start out widespread pain?
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No, first localized, and if the body cannot contain or wall off the infection, it sill spread/diffuse and eventually can cause septicemia
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What is the problem with fluid in peritonitis?
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Fluid is shifted from the extracellular fluid compartment into the peritoneal cavity, connective tisses, and GI tract. The fluid that normally flows to the small bowel and colon for reabsorption, accumulates in the intestines in volumes of 7 to 8 Liters a day!
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Cardinal sign of peritonitis
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pain and abdominal tenderness
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With generalized peritonitis, pain is...
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widespread
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Abdominal wall ____ is a classic finding with peritonitis, sometimes referred to as...
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rigidity
"boardlike" abdomen |
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Anytime something leaks into the abdominal cavity, bursts into the cavity, or perforates into the abdominal cavity....
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Peritonitis can occur- infection! localized or generalized
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Key features of peritonitis
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Rigid, board-like, distended abdomen
Pain Diminished bowel sounds Inability to pass flatus or feces High fever Tachycardia Dehydration Decreased urine output Hiccups Respiratory issues Nausea, anorexia, vomiting |
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Tx for peritonitis
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-ABX!!!
-IV fluids (to replace fluids collected in the peritoneum) -NG tube (to decompress the stomach and the intestine, and for Pt’s on NPO status) -O2 I&Os, Weights -Pain control -Surgery- if needed |
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What kind of surgery for peritonitis?
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exploratory laparotomy- Cavity opened surgically, explored for inflammation and abnormalities, inflamed or perforated organs removed or repaired, cavity irrigated w/ Abx, drains inserted,
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Goal of exploratory laparotomy for peritonitis?
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This surgery controls the contamination, drains collected fluid, and removes foreign material from the peritoneal cavity
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If untreated, generalised peritonitis is almost always...
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Fatal
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Pts with peritonitis ALWAYS need..
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Abx- they are already infected!
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What is inflammatory bowel disease?
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disorders of the GI tract with no known etiology; Idiopathic (unknown cause) bowel disease, Includes Ulcerative colitiis and crohn’s diease
2 million people in us, 20-40 & 55-65 women more often, men more so in older years |
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Ulcerative Colitis
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Inflammation of colon
Chronic inflammatory disease-Mainly the rectum and rectosigmoid colon with exacerbation and remission. |
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What is the cause of ulcerative colitis
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unknown
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More severe ulcerative colitis causes
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Intestinal lining can bleed
Small erosions or ulcers form → abscess→ tissue necrosis Edema and mucosal thickening → narrowed colon→ partial bowel obstruction |
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COMPLICATIONS OF UC
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ower GI bleed
Abscess formation Toxic megacolon Obstruction may result from megacolon or cancer ↑ risk of colorectal cancer Extraintestinal complications |
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Toxic megacolon
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paralysis of the colon causes dilation and colonic ileus, possibly perforation
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____ ______ accounts for 1/3 of deaths related to UC
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Colorectal cancer
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Location of UC
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Colon and or rectum
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# and character of daily stools with UC
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10 -20 blood and mucous stools per day
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Complications of UC
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Hemorrhage, nutritional deficiencies
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Rosk factor for UC?
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Jewish heritage (Ashkenazi Jews)
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S/S UC
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Loose stools (10-20/day) with blood and mucus, Tenesmus (uncontrollable straining), Ulceration and edema in epitheuium of colon and rectum, Abd. Tenderness, Low-grade fever
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How to diagnose UC
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colonoscopy
CT Barium enema with contrast |
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Indications of surgical management for UC?
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bowel perforation, toxic megacolon, hemorrhage, colon cancer, etc.
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Surgical management for UC?
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colectomy – surgically remove diseased part of colon
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Ileostomy
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procedure in which a loop of the ileum if placed through the abdominal wall (stoma) for drainage of fecal material into a pouching system worn on the abdomen.
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Total colectomy with permanent ileostomy
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– involves surgical closure of anus- patient must wear pouch system at all times
- Proper skin care of stoma is most important! |
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Total colectomy with continent ileostomy
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– involves internal pouch system
- pt drains pouch several times a day using a catheter - need for surgical adjustments and leakage problems |
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Total colectomy with ileoanal anastomosis
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– removal of colon & rectum; ilium is sutured into anal canal
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Pts receiving a permanent ileostomy will need teaching on...
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how to adjust to and care for stoma and ostomy; collaborate with ostomy nurse
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Peak age of UC is between __ and __ years old.
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20 and 40
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True or False? Ulcerative Colitis is a disease with periodic remissions and exacerbations?
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True
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True or False? Ulcerative Colitis is most often seen in the terminal ileum involving all layers of the bowel?
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False- it most often is seen in the rectum and proceeds toward the cecum
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True or False? The colonoscopy is the most definitive test for diagnosing UC.
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True
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True or False? Lomotil is a drug used to treat diarrhea in UC patients.
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True
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What is a psychosocial problem with ulcerative colitis?
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The inability to control the disease symptoms, particularly diarrhea, can be disruptive and stress producing
Many feel "tied to the toilet" and become home bound |
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What labs to look for with UC?
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An increased WBC count, Plt count, C-reactive protein, or erythrocyte sedimentation rate (ESR) is consistent with inflammatory disease
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What is an ostomate?
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a visit from another person with an ostomy to share feelings with
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stoma aka
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ostomy
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What should a stome look like?
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pinkish to cherry red because it should be receiving adequate blood supply. If it looks pale, bluish, or dark, report these findings to the health care provider immediately
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what is a priority for pts with ostomies?
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Skin care around the stoma! And, they must wear their pouch system at all times with a skin barrier
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After GI surgery, the primary nursing responsibility is...
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to closely monitor the patient for s/s of of GI bleeding resulting from the disease or it's complications
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Drugs used to treat UC?
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Sulfasalazine (Azulfidine)
Mesalamine (Pentasa) Corticosteroids, Prednisone, Antidiarrheal drugs |
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How does Sulfasalazine (Azulfidine) work to treat UC?
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inhibits prostaglandin, give after meals with h2o
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*****How does Mesalamine (Pentasa) work to treat UC?*****
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an anti-inflammatory med, decreases production of protstaglandins
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**What form does Mesalamine come in?
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Oral or rectal
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**What are s/e of Mesalamine?
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headache and GI upset
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Ulcerative colitis is most commonly seen in individuals
belonging to which ethnic group? |
Ashkenazi Jews
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What is Crohn's disease?
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An inflammatory disease
Affects small intestine (terminal ileum most often). Can also affect colon Involves multiple regions of the intestines |
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What is significant about inflammtion with Crohn's disease?
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Inflammation may span the whole depth of intestinal wall (transmural inflammation)
Leads to thickened bowel wall |
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Is Crohn's disease aggressive?
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No, Progresses slowly and is Unpredictable and recurrent
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Crohn's disease is special for its...
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strictures, fissures, fistulas, and deep ulcerations
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Deep ulcerations gives Crohn's a _______ appearance
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cobblestone
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What are fistulas?
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An abnormal or surgically made passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs.
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What are the symptoms that arise from Crohn's?
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Severe Diarrhea
Malabsorption of nutrients Anemia due to iron deficiency or malabsorption wt loss fever abd pain Rectal bleeding |
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Crohn's complications?
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Hemorrhage
Severe malnourishment and debilitation due to malabsorption Fistulas and abscesses Deep intestinal obstruction, secondary to inflammation and edema Fibrosis and scar tissue |
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Does Crohn's cause cancer?
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Cancer is rare
Occurs after 15-20 years of disease |
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What is the cause of Crohn's
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Exact cause unknown
Genetic Immune Environmental links |
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What population has greatest risk of developing Crohn's?
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Eastern European especially Jewish descent has
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Name 3 risk factors of Crohn’s disease.
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Jewish decent
genetic predisposition age- 15-35 |
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True or False. Crohn’s disease has a higher prevalence among Asians, Native Americans, and Hispanics.
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False
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List 3 signs and symptoms of Crohn’s disease.
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severe diarrhea
weight loss fatigue |
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What will confirm the diagnosis of Crohn’s disease?
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Biopsy: only disease specific test available to confirm diagnosis. Done by colonoscopy
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What diet to recommend for Crohn's?
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Low-residue (low-fiber), high-caloric diet: Refined breads, cereals, crackers, and pasta, white rice, vegetable/fruit juices, cooked or canned fruit/vegetable without skin or seeds, ripe bananas, soft cantaloupe/honeydew, Milk, yogurt, pudding,
Avoid GI stimulants- coffee, caffeinated beverages, alcohol |
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True or False. Low-residue diet consists of raw fruits and vegetables, whole wheat bread, and nuts.
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False
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Name 3 reasons that indicate the need for surgery with Crohn's
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Perforation, massive hemorrhage, intestinal obstruction, strictures, abscesses, or cancer require surgery
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The patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor his laboratory results for evidence of:
Hypernatremia Hypercalcemia Hyperglycemia Hyperkalemia |
Hyperglycemia
Rationale: Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection. |
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steatorrhea is a complication of Crohn's... what is steatorrhea?
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fatty diarrheal stools
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Why is sever malnourishment a complication of Crohn's and not UC?
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Because it involves malabsorption by the small intestine, and UC does not involve the small bowel
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What is one of the #1 signs of crohn's?
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weight loss
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What are priorities of taking care of patients with fistulas?
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adequate nutrition and fluid and electrolyte balance.
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How many cals a day does a pt with a fistula require for healing?
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3000
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WHat type of management for fistulas?
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If fistula goes to outside of body, a pouch and skin care is necessary
If pouch is not possible, a VAC (vacuum assisted closure) can be used |
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What surgical managements for Crohn's?
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small bowel resection or stricturoplasty
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What is Diverticular Disease?
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Diverticulosis- Congenital or acquired pouchlike herniations of the mucosa through the muscular wall of the small or large intestine.
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Where are diverticulum most common?
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Most common in the sigmoid colon
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What can cause diverticulum?
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This bulging sac may be due to weakness of colon wall muscles and pressure inside the colon
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Diverticulitis
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The condition when the diverticula (small sacs) become inflamed or infected
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What causes Diverticulitis?
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Caused by retained undigested food and bacteria in diverticula (reduces blood flow)
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Complications of Diverticulitis?
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Perforation, infection, hemorrhage, pelvic abcess formation, bowel obstruction.
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What labs are common with diverticulitis?
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elevated WBC count. Decreased H & H if chronic or severe bleeding occurs
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What is diverticulitis r/t?
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Related to aging and lack of fiber in diet Undiagested food gets caught in diverticui 50% of people over 60
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What to avoid with diverticular disease?
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Avoid enemas, laxatives, straining, coughing or lifting heavy objects.
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Diet for diverticular disease?
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Metamucil, high fiber
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Diet to avoid with diverticular disease?
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avoid seeds, nuts, corn, popcorn, strawberries, cucumbers, tomatoes
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Diet to avoid when diverticulitis is inflamed?
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avoid all fiber! They are irritating and can make inflammation worse
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Anorectal Abscess is...
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a localized area of induration and pus caused by inflammation of the soft tissue near the rectum or anus
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How to manage an Anorectal Abscess
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abx therapy and
I & D- Incision and drainage |
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What is the most important education for a pt after and I & D?
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Stress the importance of good perineal hygiene after all BM and maintain a high fiber diet
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With any anal problem remember to
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provide privacy and dignity
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What is an anal fissure?
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a tear in the anal lining.
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Management of an anal fissure?
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superficial and usually heals on its own
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Anal fistula is
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an abnormal tract leading from the anal canal to the perianal skin
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How do most anal fistulas occur?
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mostly caused from anal abscesses, from blocked anal glands.
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How are anal fistulas treated?
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Surgery- fistulotomy
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How do people get parasitic infections?
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Fecal-oral contamination of food, h2o, oral-anal sexual practices, contact with feces from infected person
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Examples of parasites that infect humans?
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Entamoeba histolytica;Poor sanatation, areas where human feces is used for fertilizer
Giardia lamblia: most common in U.S. Cryptosporidium (HIV) |
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Treatment for parasitic infections?
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Amebicide drugs. Metronidazole (Flagyl)
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Examples of helminths that infect humans
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wormlike animals: Trichinosis (Roundworms) rare meat, pork, Enterobiasis (Pinworms) perianal pruritus , Tapeworms, uncooked beef, fish
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S/S of food poisoning
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N/V/D
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Types of agents that cause food poisoning
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Gram-negative Salmonella, Staphylococcal aureus, Escherichia coli, Botulism (discard punctured food cans)
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Treatments for food poisoning
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Control N/V, and drink fluids
parenteral fluids in cases of dehydration Sometimes antidiarrheals For botulism= trivalent botulism antitoxin given, stomach lavage, intubation and mechanical ventilation |
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How is food poisoning different from gastroenteritis?
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It cannot be contracted from person to person
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How many people are infected with Salmonella organism each year in the United States?
10,000 20,000 40,000 50,000 |
40,000
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Complications of fistulas with Crohn's
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systemic infections
skin problems malnutrition F&E embalances |
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Diet for fistulas
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3000 cal/day
High cal, High protein, High vitamin, low fiber foods enteral supplements may be necessary |
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What is the miracle drug for pts with severe UC exacerbations?
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Remecaid, given once q8wks via infusion
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