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57 Cards in this Set

  • Front
  • Back
Bowel Elimination Problems
-Irritable Bowel Syndrome
-Acute Intestinal Disorders
-Inflammatory Bowel Disease
-Intestinal Obstruction
-Colorectal Cancer
-Diseases of the Anorectum
Irritable Bowel Syndrome (IBS)
-12% adults in US report symptoms
-More common in women than men
-Cause unknown
Pathophysiology / Symptoms (IBS)
-Functional disorder of motility with no evidence of inflammation

-Symptoms:
-Alteration in bowel patterns
(constipation, diarrhea, combination)
-Pain
-Bloating
-Abdominal distention
Diagnostic Studies (IBS)
-R/o with stool studies, xrays, proctoscopy
-Barium enemas & colonoscopy - spasms, distention
Medical Management (IBS)
-high fiber diet - elimination of problem foods
-Reduction in stress to decrease intestinal motility
-Bulk colloids and antidiarrheal agents

Medications:
-anti-depressants
-anticholinergics - decrease spasms
-Zelnorm - treats chronic constipation - monitor adverse effect of diarrhea for hypovolemia
Acute Intestinal Disorders Appendicitis
-Most common cause of acute abdomen in US - 10-30 y/o
-Inflammatory response as result of occlusion with hardened fecal matter
-S/S - epigastric or periumbilical pain progressing to RLQ pain, low grade fever, nausea, local tenderness at McBurney's point, may have Rovsing's sign
McBurney's point
-in the right lower quadrant between the umbilicus and the anterior superior iliac spine
Rovsing's sign
-pain felt in the right lower quadrant after the left lower quadrant has been palpated
Diagnostic Studies (Appendicitis)
-CBC -elevated WBC
-Abdominal x-rays
-ultrasound
-CT scans
Complications (Appendicitis)
-rupture - 24 hrs after onset of pain - incidence higher in elderly
-Peritonitis
-Abscess formation
-Septic thrombosis of portal vein from vegetative emboli from septic intestines
Causes of Peritonitis
-Gastric and duodenal ulcers
-Inflammatory bowel disease
-Diverticulitis of sigmoid
-Appendicitis
Nursing Management
-Pre-Op - avoid enemas and laxatives -may cause perforation

Post-Op
- High Fowler's position
-Replacement of fluids & electrolytes
-Pain management
-Antibiotics - prophylactically or therapeutic
-wound care
-patient/family education: medications, wound care, general Postop instructions, pain management (pharmacologic and non-pharmacologic)
Diverticulosis/itis
-Diverticulum
-Diverticulosis
-Diverticulitis
Diverticulum
Saclike herniation of lining of bowel extending through muscle layer resulting from high intraluminal pressure, 95% in sigmoid colon
Diverticulosis
multiple diverticula with no inflammation or symptoms
Diverticulitis
Inflammation/infection from retained food and bacteria
Diverticulosis/itis Manifestations
Bowel irregularities - diarrhea, nausea, bloating or abdomen distention - incidence increases with age
Diagnosis / Diagnostic Tests(Diverticulosis/itis)
-Colonoscopy
-CT Scan
Complications (Diverticulosis/itis)
-peritonitis
-abscess
-bleeding
Medical Management (Diverticulosis/itis)
Medical: rest, analgesics, antispasmodics, high-fiber, low-fat diet
Surgical: necessitated by complications
Inflammatory Bowel Diseases
-Regional enteritis (Crohn's)
-Ulcerative Colitis
Regional enteritis (Crohn's)
-First diagnosed in adolescence - incidence rising
-Ileum - discontinuous lesions, narrowing of colon, mucosal edema, stenosis, fistulas
-Sub-acute chronic inflammation - granulomas in 50% of pts
-Usually no bleeding, diarrhea not severe
-Diagnostic tests: proctosigmoidoscopy, stool studies for blood and fat, Upper GI - string sign

*The most conclusive diagnostic aid for regional enteritis is a barium study of the upper GI tract that shows the classic “string sign” on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.
Ulcerative Colitis
-Prevalence highest in Caucasians and Jewish heritage
-High mortality rate
-Begins in rectum, spreads proximally up descending colon - diffuse contiguous lesions
-bleeding can be severe
-severe diarrhea
-bowel shortens, no edema, stenosis rare
-Diagnostic tests: sigmoidoscopy, colonoscopy, lower GI, low H&H, high WBC, low albumin, electrolyte imbalance
Medical Management: Nutritional (Inflammatory Bowel Diseases)
-Increase oral fluids
-Low residue, high protein, high calorie diet with supplemental vitamins & iron replacement
-Avoid cold foods and smoking - increase intestinal motility
Medical Management: Pharmacologic (Inflammatory Bowel Diseases)
-Sedatives, antidiarrheal, antiperistaltic meds
-Aminosalicylate (Azulfidine), sulfa-free aminosalycilates (Asacol, Pentasa) prevent and treat recurrences
-Antibiotics (Flagyl)
-Corticosteroids - Prednisone (outpatient), Solu-Cortef (inpatient)
-Immunomodulators (Methotrexate, Cyclosporine) alter immune response - used for pts with severe disease not responding to other meds
Medical Management: Surgical (Inflammatory Bowel Diseases)
-More than 50% of pts with Crohn's requires surgery within 5 years
-25% of pts with Ulcerative colitis eventually have total colectomies

Procedures: laparoscopic strictureplasty, small bowel resection, total colectomy with ileostomy, intestinal transplant
Total colectomy with ileostomy
Ileum to outside, drainage of fecal matter (effluent) is very mushy and occurs frequently
Continent ileostomy
Kock pouch - stoma with nipple and ileal reservoir internally eliminating need for external bag
-effluent collects in reservoir, catheter inserted to drain effluent
Restorative Protocolectomy with Ileal Pouch Anal Anastamosis
establishes ileal reservoir and anal sphincter control of elimination is retained
Nursing Management (Inflammatory Bowel Diseases)
-Routine postoperative care
-Alteration in body image r/t surgery
-Preventing skin breakdown
(Skin barrier - many products available)
(Protect skin around stoma)

Patient/family education
-Stoma care and appliance change
-Diet and medication management
-S&S to report
-Community resources
-Support groups
Intestinal Obstruction (Small Bowel and Large Bowel)
-Mechanical obstruction
-Functional obstruction
Mechanical obstruction
Intraluminal
-intussusception,tumors, stenosis, structure, adhesions, hernias, abscesses

-Intussusception: One part of the intestine slips into another part located below it (like a telescope shortening).
Result: The intestinal lumen becomes narrowed.

-Volvulus: Bowel twists and turns on itself.
Result: Intestinal lumen becomes obstructed. Gas and fluid accumulate in the trapped bowel.

-Inguinal Hernia: Protrusion of intestine through a weakened area in the abdominal muscle or wall.
Result: Intestinal flow may be completely obstructed. Blood flow to the area may be obstructed as well.
Functional obstruction
Musculature cannot propel contents along the bowel
-Amyloidosis, muscular dystrophy, DM, Parkinson's
Small Bowel Obstruction
Contents accumulate above obstruction with distention, retention of fluid, eventually decrease in venous and arteriolar capillary pressure resulting in edema, congestion, necrosis and eventual rupture and peritonitis
Large Bowel Obstruction
-Contents accumulate above obstruction with distention and eventual rupture and peritonitis
-Large bowel able to absorb fluid and can distend more
-Adenocarcinoid tumors are majority of large bowel obstruction
Colorectal Cancer
-Third most common site for cancer and deaths in the US (56,000/yr)
-Incidences increase with age (highest in people above 85 y/o)
-Higher in people with IBD, family history, or polyps
-Of the 150,000 diagnosed annually, less than half die
-Survival rates after late diagnosis low
-Predominately adenocarcinoma (arising from epithelial lining of colon)
-Liver most common site of metastasis
Risk Factors (Colorectal Cancer)
-Increasing age
-Family history
-Previous colon cancer or adenomatous polyps
-History of IBD
-High fat, high protein, low fiber diet
-genital or breast cancer
Clinical Manifestations (Colorectal Cancer)
-Dependent on location
-Most common presenting symptom is change in bowel habits
-Second most common is bloody stools
-Unexplained anemia, anorexia, weight loss and fatigue
-Right sided lesions - dull abdominal pain, melena (ie, black, tarry stools).
-Left sided lesions - abdominal pain, cramping, narrowing stools, constipation, distention, bright red blood
-Rectal lesions - rectal pain, feeling of incomplete evacuation, alternating constipation/diarrhea, bloody stool
Diagnosis (Colorectal Cancer)
-Physical exam
-Barium enema
-Colonoscopy
-occult blood
-carcinoembryonic antigen studies
Duke's Classification Modified Staging System
-Class A
-Class B1
-Class B2
-Class C1
-Class C2
-Class D
Class A
Tumor limited to muscular mucosa and submucosa
Class B1
Tumor extends into mucosa
Class B2
Tumor extends through entire bowel wall into serosa or pericolic fat, no nodal involvement
Class C1
Positive nodes, tumor is limited to bowel wall
Class C2
Positive nodes, tumor extends through entire bowel wall
Class D
Advanced and metastasis to liver, lung, or bone
TNM (tumor, nodal involvement, metastasis) Classification
-Another staging system
-May be used to describe anatomic extent of the primary tumor, depending on:
-Size, invasion depth, and surface spread
-Extent of nodal involvement
-Presence or absence of metastasis
Medical Management (Colorectal Cancer)
-Treatment depends on classification
-Surgery can be curative or palliative
Abdominoperineal Resection
-Pre-Op: Prior to surgery, note tumor in rectum.
-Intra-Op: Sigmoid removed and colostomy established
-perianal resection: removal of the rectum and free portion of the sigmoid from below. A perineal drain is inserted
-Result: Healed perineal wound with a permanent colostomy
Colostomy Placements
-The nature of the discharge varies with the site.
-With a sigmoid colostomy, the feces are solid.
-With a descending colostomy, the feces are semimushy.
-With a transverse colostomy, the feces are mushy.
-With an ascending colostomy, the feces are fluid.
Nursing Management (Colorectal Cancer)
-Routine pre-op care
-Routine post-op care
-Monitor and change appliance PRN
-Special attention to skin around stoma and appliance
-Support positive body image & sexuality - How?

Patient/family education
-ostomy care
-skin care
-resources
-support groups
Anorectal Diseases
-Abscesses
-Fistulas
-Fissures
-Hemorrhoids
Abscesses
Regional enteritis, AIDS
Fistulas
tiny, tubular, fibrous tract extending into anus from adjacent tissue

S&S: passage of flatus or feces from vagina or bladder
Fissures
longitudinal tear or ulceration in lining of anal canal - trauma from stool, childbirth, overuse of laxatives (can heal with conservative treatment)
Hemorrhoids
Dilated veins in anal canal.

Internal: above internal sphincter
External: outside external sphincter

S&S - itching, pain, bleeding with defecation

Conservative treatment usually successful.

Non-surgical: infrared photocoagulation, bipolar diathermy, laser therapy, sclerosing agents

Surgery: banding, cryosurgical hemorrhoidectomy, hemorrhoidectomy
Nursing Management (Anorectal Diseases)
-relieving constipation
-reducing anxiety
-relieving pain
-promoting urinary elimination
-monitoring and managing complications
-patient/family education