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192 Cards in this Set
- Front
- Back
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The lower GI system consists of
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The small intestines and large intestines
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The small intestines are made up of 3 parts
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-Duodenum
-Jejunum -Ileum (Extends from pylorus of stomach to ileocecal valve) |
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The main function of the small intestines
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absorption of nutrients
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Functions of the Lower GI tract
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-Digestive enzymes and bile in the duodenum come from the pancreas, liver, gall bladder, and glands within the intestines
-Intestinal glands secrete mucus, hormones, electrolytes, and enzymes |
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2 Types of contractions that occur in the Small Intestines
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-Segmentation contractions: mixing waves of contents, churning motion
-Intestinal peristalsis: propels the contents of the small intestine towards colon |
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Major function of Large Intestines
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Water reabsorption
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Structure of Large intestine
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-Extends from ileocecal junction to the anus
-Ascending, Transverse and Descending colon |
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________ makes up a major part of the contents of large intestine assisting in breakdown of material
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Bacteria
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2 Types of secretions occurring in the large intestines
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-Bicarbonate (Neutral)
-Mucus (protects colonic mucosa) |
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The environment in the colon is normally
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Neutral (due to bicarb)
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A patient with severe diarrhea is likely to develop
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metabolic acidosis
*Due to loss of bicarb |
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Slow weak peristaltic activity of the large intestine aids in
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moving contents along the colonic tract, allowing efficient reabsorption of H20 and electrolytes
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Significant lower GI Laboratory Tests
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-Electrolytes
-H&H -CBC -Stool samples -Liver enzymes (aspartate and alanine) -Pancreas function (serum amylase and lipase) -Bilirubin -Urine Tests |
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Vitamin ____ is synthesized in the liver
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K
* Aids in clotting factor |
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Common radiological study for lower GI
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(KUB)
Kidney, Ureter and Bladder abdominal film |
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Common endoscopic studies for lower GI
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-Colonoscopy
-Sigmoidoscopy |
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Urine tests involving the lower GI function test for
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-Amylase
-Urine urobilogen |
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Stool tests involving lower Gi function test for
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-Fecal occult blood
-Ova Parasites -Clostridium difficile |
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(True/False)
It is okay to use alcohol base cleaner after working with a pt with C. Diff |
False
* Soap and water must be used to kill C. Diff *C. Diff can live up to 70 days! |
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Oncofetal Antigens (cancer markers) involving the lower GI system
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-CA 19-9
-CEA (carcinoembryonic antigen) |
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Nursing implications for Barium Enema
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-Liquid diet 1 day prior to procedure
-NPO 8 hours before procedure -Informed consent -Administer laxatives if ordered -Laxative given after procedure |
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Stools may be white for how long following a barium enema
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1 to 2 days
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Barium enema
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Barium liquid is instilled into the large intestine through the anus
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Nursing implications for a colonoscopy
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-Liquid diet for 2 days prior to the procedure
-NPO 8 hours before procedure -Instruct the pt in bowel preparation |
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What type of sedation is typically used for colonoscopy
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conscious sedation
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Pt will lay on ________ side during a colonoscopy
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left
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Restricted food items prior to colonoscopy
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Anything containing Red dye
-Jello -Gatorade -Popsicles |
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(2) common cathartics used for bowel preparation
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1-Magnesium citrate
2-Polyethylene Glycol |
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Administration of Magnesium Citrate
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-Empty stomach followed by a full glass of h20
-Chill the solution -Give the medication early in the evening so it does not interfere with sleep |
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Administration of Polyethylene Glycol
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-No food or oral liquid 2 to 3 hours prior to nor within 2 hours of ingesting the solution
-Chill -Give early in the evening |
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True/False
Informed consent is required for a colonoscopy |
True
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Nursing implications following a colonoscopy
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-Report any abdominal pain, chills, fever, rectal bleeding or mucupurulent drainage
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Patient teachings following colonoscopy polyp removal
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-Avoid heavy lifting for 7 days
-Avoid high fiber diet for 1 to 2 days |
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Proctosigmoidoscopy
(def) |
Endoscopic examination of the rectum and sigmoid colon
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Nursing implications for a Proctosigmoidoscopy
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-Liquid diet 24 hours prior
-Cleansing enema, laxative |
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Patient teachings for a proctosigmoidoscopy
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-Inform them they may experience mild gas pain and flatulence during and after the procedure due to air being placed into the rectum
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True/False
A small amount of bleeding may occur as a result of a biopsy |
True
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What type of diet should a patient with GI inflammation be placed on
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Low residue diet
-Items typically white in color -Bland food that is easily digested |
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Sample Low Residue Breakfast
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-1/2 cup oj
-1 cup cornflakes -poached egg -1 slice white toast -1 tsp margarine -1 tbsp jelly -1 cup skim milk |
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Sample Low Residue Lunch
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-3 oz fish
-1/2 cup mashed potatoes -1/2 cup cooked green beans -1 slice white bread -1 tsp margarine -1 tbsp jelly -1/2 cup applesauce |
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Which diet is best to work the pt colon
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High Fiber diet
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Sample High Fiber Breakfast
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-1/2 grapefruit
-3/4 cup oatmeal -2 tbsp raisins -2 slices whole wheat toast -2 tsp margarine -2 tbsp jelly -1 cup skim milk -3/4 cup coffee |
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Sample High Fiber Lunch
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-1 cup vegetable soup
-3 oz lean hamburger patty -1 multigrain bun -2 tomato slices -lettuce -1/2 cup baked beans -1 medium apple -1 oatmeal cookie -1 cup skim milk |
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Indications for parenteral nutrition
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-Patients with an inability to absorb nutrients via GI tract
-Patients whose nutritional needs cannot be met within 7-10 days with an enteral feeding -Patients with severe malnutrition or catabolism where the GI tract is unusable within 3-5 days |
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Parenteral (TPN) nutrition often includes
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-High glucose (COH)
-High Amino Acids (PRO) -High lipids (FATS) -Electrolytes and Minerals -Vitamins -Trace elements |
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Common Trace Elements in TPN
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K+
Ca+ Po4 Zinc |
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True/False
TPN often includes iron |
False
*TPN does not include iron and pt's may require supplements |
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If a patient is unable to eat for ____ to _____ days, TPN will often be ordered
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7 to 10
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The (3) most important values significant to patients nutrition
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-Albumin
-Pre-albumin -Total protein |
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Health Hx and Clinical Manifestations with lower GI
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-Tobacco and Alcohol
-Medications -Surgeries -Unexplained wt. gain or loss -Pain -Indigestion -Intestinal gas -N/V -Changes in bowel habits and stool |
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Assessment for lower GI
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-Mouth, teeth, gums, tongue
note: ulcers, nodules, swelling -Abdomen: look, listen then feel note: bowel sounds, rebound tenderness -Anal and perineal area note: rash, fistula openings, external hemorrhoids |
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(IBD) Inflammatory Bowel Disease (Def)
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Chronic, recurrent inflammation of the intestinal tract
*Absorption is a big problem due to the inflammation |
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Characteristics of IBD
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-Periods of remission interspersed with periods of exacerbation
-Cause is unknown -No Cure |
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Treatment for IBD includes
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Medications to treat inflammation and maintain remission
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Additional characteristics of IBD
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-May occur at any age
-Peaks between 15-25 years -Equally effects both sexes -Genetic and environmental factors play a role |
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True/False
IBD is an autoimmune disease |
True
*An antigen initiates the inflammation; actual disease damage is fro inappropriate sustained immune response |
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IBD is a (chronic/Acute) disorder
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Chronic
*with mild to severe exacerbations *may occur at unpredictable intervals over the years |
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IBD has been shown to flare up in response to
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-Stress
-Specific foods |
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A pt with an IBD flare up may experience _____ to _____ stools
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10-14 stools daily!
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Clinical manifestations with IBD
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-Diarrhea
-Fatigue -Abdominal pain -Weight loss -Fever |
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Blood diagnostic studies for IBD
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-CBC
-Serum electrolyte balance -Serum protein levels |
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Stool cultures and exams for IBD
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-Pus
-Blood -Mucus |
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Additional IBD diagnostic studies
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-Sigmoidoscopy
-Colonoscopy -Double-contrast barium enema -Capsule endoscopy |
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Sigmoidoscopy and colonoscopies performed for IBD are often indicated for
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Biopsy specimens
*DO NOT scope pt during a flare up of inflammation |
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Treatment goals for IBD
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-Rest the bowel (NPO)
-Control inflammation -Combat infection -Correct malnutrition -Alleviate Stress -Symptomatic relief -Improve quality of life *IV Therapy almost always implemented for hydration and antibiotics |
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Drug Therapy for IBD
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-Aminosalicylates (5-ASA)
-Corticosteroids -Antimicrobials -Immunosuppressants -Biological Therapy (last line in therapy) |
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First line Rx for IBD Therapy
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1- Aminosalicylates (5-ASA)
2- Corticosteroids |
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Aminosalicylate (5-ASA) Drug used for IBD
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Sulfasalazide (Azulfidine)
*Principal Drug Used *May turn skin and urine orange |
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Sulfasalazide (Azulfidine) works by
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-Decreasing GI inflammation
-Effective in achieving and maintaining remission -For mild to moderately severe attacks |
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Sulfasalazide (Azulfidine) can be administered
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-Orally
-Rectally -Foam enema ( if inflammation in rectum and sigmoid colon area) |
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Corticosteroids work for IBD by
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-Decreasing inflammation
-Used to achieve remission -Helpful for acute flare ups |
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Effects of corticosteroid use
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-Hyperglycemia
-Hypernatremia -Hypokalemia *Taper dosage when d/c |
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Antimicrobial drug therapy for IBD
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-Flagyl
-Cipro *Prevent or treat secondary infection |
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Immunosuppressant Drugs used for IBD
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1-Azathioprine (Imuran)
2- Mercaptopurine (Purinethol) *ONLY given if patients are NOT responding to 5-ASA and corticosteroids |
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Results from Immunosuppressant therapy for IBD may take how long?
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3 to 6 months
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Immunosuppressants for IBD work by
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-Suppressing immune response
-Most useful when not responding to other therapies |
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What should be monitored when a pt is taking immunosuppressants for IBD
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Regular CBC due to bone marrow suppression
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Biologic Therapy Drugs administered for IBD
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Infliximab (Remicade)
*Given IV |
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Biologic Therapy Drugs work by
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-Inhibiting TNF (tumor necrosis factor)
-Induce and maintain remission |
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Other Rx therapies for IBD
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1.Antidiarrheals
-Decrease GI motility 2. Hematinics and Vitamins -Correct iron deficiency -Promote healing |
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Surgical Therapies for IBD may be used for patients with
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-Failure to respond to treatment
-Frequent/debilitating exacerbations -Massive bleeding and obstructions -Development of dysplasia or carcinoma -Perforation |
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IBD includes
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1- Ulcerative Colitis
2- Crohn's Disease |
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Surgical procedures for Chronic Ulcerative Colitis
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-Total colectomy with rectal mucosal stripping and ileoanal reservoir
-Total protocolectomy with continent ileostomy -Total protocolectomy with permanent ileostomy |
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Total Colectomy with Rectal Mucosal Stripping and Ileoanal Reservoir
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-Combination of 2 procedures
-8-12 weeks apart -Adaptation over 3-6 months -Able to control defecation at anal sphincter |
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_____% pt with Crohn's disease typically require surgery
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75%
-Surgery produces remission, but high recurrence rate |
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____ to ____% of Ulverative Colitis pt's typically require surgery
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25-40%
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RN's trained to work with GI therapy problems
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Enterostomal Therapy (ET) RN
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Role of ET RN prior to GI surgery
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Good for ET RN to work with pt to determine placement location for stoma
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Postoperative monitoring for Ileostomy includes
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Monitoring of:
-Stoma viability -Mucocutaneous Juncture -Peristomal skin integrity -Observe for hemorrhage, abdominal abscess, small bowel obstruction, dehydration |
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Output may be as high as _______ to ________ following an ileostomy
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1500-2000 ml
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Characteristics of stools following an ileostomy
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-Watery stools because of bypassing large intestines (h20 not reabsorbed)
-Pt may also experience mucus from the anal canal (colon and rectum will still produce mucus) |
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Self-care instructions for pt following illeostomy
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-Review before discharge
-Kegel exercises -Perianal skin care |
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Nutritional Therapy for IBD
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-Dietary consult
-Provide adequate nutrition without exacerbating symptoms -Correct and prevent malnutrition -Replace fluid and e- loses (replace what is lost in stool and not reabsorbed) -High Calorie -High PRO -Low-residue diet -Vitamin and Iron supplements -Elemental diet -Parenteral nutrition -prevent weight loss |
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Pt's with IBD also tend to suffer from
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Iron Deficiency Anemia
*Monitor CBC |
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Assessment for IBD
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-Autoimmune Disorders
-Use of Rx and OTC -Family history -Diarrhea (blood) -Weight loss -Anxiety, depression |
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Best indicator of fluid volume deficit with IBD
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Weight loss
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Possible RN Diagnoses with IBD
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1. Imbalanced Nutrition: Less than body requirements
2. Diarrhea 3. Anxiety 4. Ineffective coping 5. Ineffective therapeutic regimens |
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Overall goals for IBD
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-Experience a decrease in # and severity of acute exacerbations
-Maintain normal f&e balance -Free from pain and discomfort -Comply with medical regimen -Improve quality of life |
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Expected outcomes for IBD
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-F&E balance
-Fewer, firmer stools -Decreased anxiety -Use of effective coping strategies -Maintenance of body weight -No evidence of skin breakdown -Healthy coping behaviors |
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Teachings for IBD
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-Importance of rest and diet management
-Perianal care -Action of side effects of drugs -Symptoms of recurrence -When to seek medical care -Use of diversional activities to reduce stress |
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Ulcerative Colitis
(Patho) |
-Diffuse inflammation beginning in the rectum and spreading up the colon in a continuous pattern
-Multiple abscesses develop in the intestinal glands |
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Inflammation with ulcerative colitis occurs
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in the mucosa and submucosa
* the muscular layer is not damaged *damage is inside the colon |
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Ulcerations with ulcerative colitis are caused by
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abscesses breaking through the submucosa destroying the mucosal epithelium
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Mucosal ulcerations result in
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-Bleeding
-Diarrhea -F&E imbalance -Protein loss -Pseudopolyps |
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Major symptoms associated with Ulcerative Colitis
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-Bloody diarrhea
-Abdominal pain Also: -Tenesmus (spasmodic contraction of anus) -Rectal bleeding |
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Intestinal complications r/t Ulcerative Colitis
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-Hemorrhage
-Strictures (narrowing of intestines) -Perforation -Toxic Megacolon |
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Toxic Megacolon
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-Dilation and paralysis of the colon
-Associated with perforation (wearing out of the intestines leads to peristalsis stopping) |
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Crohn's Disease
(def) |
-Chronic non-specific inflammatory bowel disorder of unknown origin
-Can affect any part of the GI tract from the mouth to the anus |
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Crohn's Disease is most often seen in
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terminal ileum (end of the small intestines) and colon
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Inflammation with Crohn's disease involves
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ALL layers of the bowel wall
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Skip Lesions with Crohn's Disease refer to
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Segments of normal bowel occurring between diseased portions (cobblestone)
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Ulcerations occurring with Crohn's Disease
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-deep and longitudinal
-penetrate between islands of inflamed edematous mucosa, causing the classic cobblestone appearance |
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Bowel obstruction occuring with Crohn's disease may occur as a result of
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Narrowing of the lumen and stricture development
*Microscopic leaks can allow bowel contents into the peritoneal cavity |
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A major cause for concern with Crohn's Disease
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Development of Peritonitis
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Peritonitis
(def) |
Disease of the entire lumen causing leaking of bowel contents into peritoneal cavity
*May cause sepsis and death |
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S/S of Peritonitis
|
Abdomen:
Tight Tender Painful Hard as a board |
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Clinical Manifestations of Crohn's Disease
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-Diarrhea (possibly non-bloody)
-Colicky abdominal pain -malabsorption -nutritional deficiencies |
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Intestinal Complications of Crohn's Disease
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-Strictures and obstruction of scar tissue
-Fistulas -Peritonitis |
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Extraintestinal Complications of Crohn's Disease
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-Thromboembolism
-Arthritis -Ankylosing spondytitis (Spinal pressure) -Osteoporosis -Liver Disease -Eye inflammation -Kidney/Gall stones -Skin lesions |
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Bloody diarrhea can occur with both Crohn's and Ulcerative Colitis, but is more likely to occur with
|
Ulcerative Colitis
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Ulcerative Colitis complications typically occur
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Inside the GI tract
|
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Crohn's Disease Complications Typically occur
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Systemically
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Types of Intestinal Obstructions
|
1. Mechanical (Twisting)
2. Non-mechanical (electrolyte imbalance) 3. Partial vs complete |
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Intestinal Obstruction
(Patho) |
-Fluid and air proximal to obstruction
-Increased peristalsis -Proximal intestinal dilation causing peristalsis to cease -Edema/Distended bowel causing abdominal distension -Hypovolemia causing shock -Decreased blood flow causing intestinal gangrene |
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Compensation for Intestinal Obstruction
|
The body will increase peristalsis to compensate causing pain
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Patients at risk for intestinal obstruction
|
Diabetes
*Due to decreased blood flow to the intestines |
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Types of Mechanical Intestinal Obstruction
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-Adhesions: (LOA) Lysis of Adhesions from scar tissue
-Hernias -Tumors -Volvulus (Twisting) -Intussusception: telescoping of the bowel= once section moves into another one |
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Types of Non-Mechanical Intestinal Obstruction
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-Paralytic Ileus: slowing or absence of peristalsis
-Mesenteric Vascular Obstruction Infarction |
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A major cause of decreased peristalsis
|
Hypokalemia
|
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Symptoms of Small Intestinal Obstruction
|
-Abdominal pain
-Vomiting (may have foul feces smell) -Loud, frequent, high pitched bowel sounds leading to absent bowel sounds (intestines become worn out) -Abdominal distention -Dehydration -Shock |
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Treatment for Intestinal Obstruction
|
-Decompression
-NPO -F&E |
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Decompression for Intestinal Obstruction is performed by
|
putting in NG tube to suck out fluid collecting in the stomach
*IV therapy will also be administered to replace electrolytes lost from suction |
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Surgical treatment for Intestinal Obstruction
|
-Release of adhesion (LOA)
-Resection -Colostomy |
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Diverticular Disease
(Def) |
Small outpouchings or herniations of the mucosal lining of the GI tract
|
|
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Diverticular Disease causes
|
-Increased intraluminal pressure
-Decreased strength in colon wall -Decreased fecal volume |
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Types of Diverticular Disease
|
1-Diverticulosis
2-Diverticulitis 3-Meckles |
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Diverticulosis
(def) |
Multiple asymptomatic diverticula
|
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Diverticulitis
(def) |
Trapped feces and bacteria combine to product acute inflammation and infection
|
|
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Meckles
(def) |
Congenital, similar to appendix, open into distal ileum
|
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|
Diverticular disease if often caused by
|
-Decrease in fiber
-Increase in processed foods |
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Clinical manifestations for Diverticulitis
|
-LLQ abdominal pain
-Low grade fever -N/V -Bowel irregularity -Diarrhea/constipation -Abdominal tenderness/distention -Complications |
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Diagnosis of Diverticulitis
|
-Hx of presenting symptoms
-CT scan (will show inflammations) -Barium enema -Sigmoid/colonoscopy |
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Treatment for Diverticulosis
|
-High fiber diet
-Bulk laxatives *These both aide in prevention |
|
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Treatment for Diverticulitis
|
-Bowel rest
-IV therapy -Analgesics -Stool softener -NPO or clear liquids -Antibiotics -Anticholinergics -Bulk Laxatives -Gradual diet plan |
|
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Gradual Diet Plan for Diverticulitis
|
Bland diet when inflammation is occurring then move to high fiber diet
|
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|
Bulk Laxative mechanism of action
|
-Absorbs water
-Increases Bulk -Stimulates peristalsis |
|
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Examples of Bulk Laxatives
|
-Fiberall
-Metamucil -Konsyl *All Must be given with 8oz h20 -Mirilax may be given on a daily basis |
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Diverticulitis Complications
|
-Perforation and peritonitis
-Abscess and fistula formation -Bowel obstruction -Bleeding |
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Types of colostomies
|
-Transverse colostomy
-Ascending colostomy -Descending colostomy -Ileostomy -Cecostomy -Sigmoid ostomy *Take the name for which portion they are created in |
|
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Stool from a Transverse Colostomy may appear
|
Pasty
|
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Stool from an Ascending colostomy may appear
|
liquid
|
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Stool from a descending colostomy may appear
|
normal
|
|
|
The most common permanent Colostomy
|
Sigmoid
|
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Sigmoid Colostomy
|
-Sigmoid colon, rectum and anus are removed through abdominal and perineal incisions
-The anal canal is closed and a stoma is formed from the proximal sigmoid colon -The stoma is located in the lower left quadrant of the abdomen |
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Ostomy Post op care
|
-Pain
-Wound (stoma) management |
|
|
Post-op stoma management
|
-should be pink and moist
-dark red and black indicates ischemic necrosis -look for excessive bleeding -Observe for suture separation from stoma to abdominal wall |
|
|
True/False
The colostomy pouch should be cut 1/8" larger than the stoma |
True
*To allow for stoma swelling |
|
|
Evaluation of stool post-op should last for
|
2-4 days
|
|
|
Colorectal cancer is more common in
|
men
|
|
|
Risk factors for colorectal cancer
|
-Family or personal history (adenomatous polyps)
-Increased age -Colorectal polyps -IBD -Obesity -Smoking -Alcohol -Large amounts of red meat |
|
|
85% of colorectal caners arise from
|
adenomatous polyps
|
|
|
Most common sites for colorectal cancer metastasis
|
-Regional lymph nodes
-Liver -Lungs -Peritoneum *Liver biopsy often performed because colorectal cancer often travels to the liver |
|
|
Symptoms of colorectal cancer are more common
|
in the descending colon rather than the ascending colon
|
|
|
S/S of colorectal cancer are usually nonspecific and typically do not appear until
|
the disease is advanced
|
|
|
S/S of colorectal cancer
|
-Hematochezia
-Melena -Abdominal pain -Anemia -Weight loss -Rectal bleeding -Changes in bowel habits -Weakness |
|
|
The most common s/s of colorectal cancer
|
rectal bleeding
|
|
|
Hematochezia
(def) |
passage of blood through the rectum
|
|
|
Diagnostic studies for colorectal cancer
|
-Family hx (screen early)
-Physical exam -Digital exam -Colonoscopy |
|
|
Colonoscopies should be performed
|
around age 50 then every 7-10 years
|
|
|
Colonoscopy procedure
|
-Gold standard for colorectal detection
-Should be performed by a colorectal md -entire colon is examined -biposies can be obtained -Polyps can be removed and sent for examination |
|
|
______ and ______ are used to confirm colorectal cancer
|
colonoscopy and biopsy
|
|
|
Laboratory studies for colorectal cancer
|
-CBC
-Coagulation studies -Liver function test -Fecal occult blood tests |
|
|
(CEA) Carcinoembryonic Antigen
|
Tumor marker for colorectal cancer
*may show up in laboratory tests |
|
|
Fecal occult blood test
|
Guaiac- based test (FOBT)
|
|
|
Items to avoid before FOBT
|
-NSAIDS
-Vitamin C -Citrus juices -red meat for 3 days |
|
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FOBT is taken how often
|
6 samples from 3 consecutive bowel movements
|
|
|
________ is often a problem with FOBT
|
compliance
|
|
|
CT Scan and MRI's for colorectal cancer are used for detecting
|
-Liver metastases
-Retroperitoneal and pelvic disease -Depth of penetration of tumor in bowel wall |
|
|
Surgical therapy for colorectal cancer
|
-Polypectomy during colonoscopy
-If cancer is localized, can be resected (healthy tissue sewn together) -Lymph nodes removed |
|
|
Surgical goals for colorectal cancer
|
-Complete resection of the tumor
-Thorough exploration of the abdomen -Restoration of bowel continuity -Prevention of surgical complications |
|
|
Tumor resection surgery
|
Surgeon will make sure the margins (edges) are clear of cancer cells
|
|
|
Chemo and Radiation may be utilized for colorectal cancer if
|
cancer is spread to lymph nodes or nearby tissue
|
|
|
Once cancer has spread to distant sites, surgery is considered
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palliative
|
|
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_______ is used as the primary treatment of nonrescetable colorectal cancer
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Chemotherapy
|
|
|
First line treatment for metastatic colorectal cancer
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5-Fluorouracil (5-FU) plus
-leucovorin -iriotecan |
|
|
Radiation therapy for colorectal cancer is often used as
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-adjuvant to surgery and chemotherapy
-palliative for metastasis |
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|
Overall goals for lower GI problems
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-Normal bowel elimination problems
-Quality of live appropriate to disease progression -Relief of pain -feelings of comfort and well-being |
|
|
American Cancer Society recommends starting at age 50
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-Yearly fecal occult test
-Double contrast enema every 5 years -Sigmoidoscopy every 5 years -Colonoscopy every 10 years (more often if polyps removed) |
|
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Colonoscopies only detect polyps when the bowel has been
|
adequately prepared
|
|
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It is required to do what before a colonoscopy
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-Only drink clear liquids for 24 hours before procedure
-Use of an oral preparation before |
|
|
Teachings for pt's with lower gi problems
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-Diet
-Medications -Disease process -S/S -Health maintenance |
|
|
Community Resources for GI
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-Home care
-American Cancer Society -Support groups |
