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57 Cards in this Set
- Front
- Back
Bowel Elimination Problems
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-Irritable Bowel Syndrome
-Acute Intestinal Disorders -Inflammatory Bowel Disease -Intestinal Obstruction -Colorectal Cancer -Diseases of the Anorectum |
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Irritable Bowel Syndrome (IBS)
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-12% adults in US report symptoms
-More common in women than men -Cause unknown |
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Pathophysiology / Symptoms (IBS)
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-Functional disorder of motility with no evidence of inflammation
-Symptoms: -Alteration in bowel patterns (constipation, diarrhea, combination) -Pain -Bloating -Abdominal distention |
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Diagnostic Studies (IBS)
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-R/o with stool studies, xrays, proctoscopy
-Barium enemas & colonoscopy - spasms, distention |
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Medical Management (IBS)
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-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 |
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Acute Intestinal Disorders Appendicitis
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-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 |
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McBurney's point
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-in the right lower quadrant between the umbilicus and the anterior superior iliac spine
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Rovsing's sign
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-pain felt in the right lower quadrant after the left lower quadrant has been palpated
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Diagnostic Studies (Appendicitis)
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-CBC -elevated WBC
-Abdominal x-rays -ultrasound -CT scans |
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Complications (Appendicitis)
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-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 |
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Causes of Peritonitis
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-Gastric and duodenal ulcers
-Inflammatory bowel disease -Diverticulitis of sigmoid -Appendicitis |
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Nursing Management
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-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) |
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Diverticulosis/itis
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-Diverticulum
-Diverticulosis -Diverticulitis |
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Diverticulum
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Saclike herniation of lining of bowel extending through muscle layer resulting from high intraluminal pressure, 95% in sigmoid colon
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Diverticulosis
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multiple diverticula with no inflammation or symptoms
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Diverticulitis
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Inflammation/infection from retained food and bacteria
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Diverticulosis/itis Manifestations
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Bowel irregularities - diarrhea, nausea, bloating or abdomen distention - incidence increases with age
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Diagnosis / Diagnostic Tests(Diverticulosis/itis)
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-Colonoscopy
-CT Scan |
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Complications (Diverticulosis/itis)
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-peritonitis
-abscess -bleeding |
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Medical Management (Diverticulosis/itis)
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Medical: rest, analgesics, antispasmodics, high-fiber, low-fat diet
Surgical: necessitated by complications |
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Inflammatory Bowel Diseases
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-Regional enteritis (Crohn's)
-Ulcerative Colitis |
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Regional enteritis (Crohn's)
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-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. |
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Ulcerative Colitis
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-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 |
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Medical Management: Nutritional (Inflammatory Bowel Diseases)
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-Increase oral fluids
-Low residue, high protein, high calorie diet with supplemental vitamins & iron replacement -Avoid cold foods and smoking - increase intestinal motility |
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Medical Management: Pharmacologic (Inflammatory Bowel Diseases)
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-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 |
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Medical Management: Surgical (Inflammatory Bowel Diseases)
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-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 |
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Total colectomy with ileostomy
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Ileum to outside, drainage of fecal matter (effluent) is very mushy and occurs frequently
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Continent ileostomy
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Kock pouch - stoma with nipple and ileal reservoir internally eliminating need for external bag
-effluent collects in reservoir, catheter inserted to drain effluent |
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Restorative Protocolectomy with Ileal Pouch Anal Anastamosis
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establishes ileal reservoir and anal sphincter control of elimination is retained
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Nursing Management (Inflammatory Bowel Diseases)
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-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 |
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Intestinal Obstruction (Small Bowel and Large Bowel)
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-Mechanical obstruction
-Functional obstruction |
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Mechanical obstruction
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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. |
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Functional obstruction
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Musculature cannot propel contents along the bowel
-Amyloidosis, muscular dystrophy, DM, Parkinson's |
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Small Bowel Obstruction
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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
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Large Bowel Obstruction
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-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 |
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Colorectal Cancer
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-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 |
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Risk Factors (Colorectal Cancer)
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-Increasing age
-Family history -Previous colon cancer or adenomatous polyps -History of IBD -High fat, high protein, low fiber diet -genital or breast cancer |
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Clinical Manifestations (Colorectal Cancer)
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-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 |
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Diagnosis (Colorectal Cancer)
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-Physical exam
-Barium enema -Colonoscopy -occult blood -carcinoembryonic antigen studies |
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Duke's Classification Modified Staging System
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-Class A
-Class B1 -Class B2 -Class C1 -Class C2 -Class D |
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Class A
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Tumor limited to muscular mucosa and submucosa
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Class B1
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Tumor extends into mucosa
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Class B2
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Tumor extends through entire bowel wall into serosa or pericolic fat, no nodal involvement
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Class C1
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Positive nodes, tumor is limited to bowel wall
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Class C2
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Positive nodes, tumor extends through entire bowel wall
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Class D
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Advanced and metastasis to liver, lung, or bone
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TNM (tumor, nodal involvement, metastasis) Classification
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-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 |
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Medical Management (Colorectal Cancer)
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-Treatment depends on classification
-Surgery can be curative or palliative |
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Abdominoperineal Resection
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-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 |
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Colostomy Placements
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-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. |
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Nursing Management (Colorectal Cancer)
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-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 |
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Anorectal Diseases
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-Abscesses
-Fistulas -Fissures -Hemorrhoids |
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Abscesses
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Regional enteritis, AIDS
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Fistulas
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tiny, tubular, fibrous tract extending into anus from adjacent tissue
S&S: passage of flatus or feces from vagina or bladder |
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Fissures
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longitudinal tear or ulceration in lining of anal canal - trauma from stool, childbirth, overuse of laxatives (can heal with conservative treatment)
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Hemorrhoids
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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 |
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Nursing Management (Anorectal Diseases)
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-relieving constipation
-reducing anxiety -relieving pain -promoting urinary elimination -monitoring and managing complications -patient/family education |