Unit 10; Alterations In Intestinal Elimination

Front 1

An inflammation of the appendix, a narrow blind tube that extends from the inferior part of the cecum; can occur at any age but is more common in young adults:

Back 1

-Appendicitis

Front 2

Most common causes are obstruction of the lumen by a fecalith (accumulated feces), foreign bodes, tumor of the cecum or appendix, or intramural thickening caused by excessive growth of lymphoid tissue; results in distention, venous engorgement, and the accumulation of mucus and bacteria, which can lead to gangrene and perforation:

Back 2

-Etiology of Appendicitis

Front 3

Describe signs and symptoms of appendicitis:

Back 3

-Typically begins wit periumbilical pain, followed by anorexia, nausea, and vomiting
-Pain is persistent and continuous, localizing at McBurney's point (located halfway between the umbilicus and the right iliac crest)
-Localized tenderness, rebound tenderness, and muscle guarding, low-grade fever, coughing aggravates pain
-Complications of perforation, peritonitis, and abscesses

Front 4

Describe nursing measures for a patient with appendicitis:

Back 4

-Avoid self-treatment; laxatives and enemas are especially dangerous
-Patient should be NPO
-Apply ice bag may be applied to the right lower quadrant to decrease the flow of blood to the area and impede inflammatory process
-Heat is never used because it may cause the appendix to rupture
-Laparoscopy surgery
-Postop: observe for evidence of peritonitis; ambulation begins the day of surgery or the first postop day; diet is advanced as tolerated

Front 5

Two immunologically related disorders that are referred to as IBD; both diseases are characterized by chronic inflammation of the intestine with periods of remission interspersed with periods of exacerbation; cause is unknown and there is no cure:

Back 5

-Crohn's Disease
-Ulcerative Colitis

Front 6

-An autoimmune disease
-Actual tissue damage is due to an overactive, inappropriate, and sustained inflammatory response
-Commonly occur during the teenage years and early adulthood, but both have a second peak in the sixth decade

Back 6

-Etiology of IBD

Front 7

This form of IBD: the inflammation involves all layers of the bowel wall; can occur anywhere in the GI tract from the mouth to the anus, but occurs most commonly in the terminal ileum and colon; skip lesions can occur; typically ulcerations are deep and longitudinal and penetrate between islands of inflamed edematous mucosa, causing the classic cobblestone appearance; may cause bowel obstruction and fistulas; leaks can allow bowel contents to enter the peritoneal cavity and form abscesses or peritonitis:

Back 7

-Etiology of Crohn's Disease

Front 8

This form of IBD usually starts in the rectum and moves in a continual fashion toward the cecum; spreads in a continuous pattern; inflammation and ulceration occur in the mucosal layers, the innermost layer of the bowel wall; fistulas and abscesses are rare; H20 and electrolytes are absorbed when the mucosal epithelium is healthy, but cannot be absorbed through inflamed mucosa resulting in diarrhea with large fluid and electrolyte losses; breakdown of cells results in protein loss through the stool

Back 8

-Etiology of Ulcerative Colitis

Front 9

Describe signs and symptoms of Crohn's disease:

Back 9

-Localized: weight loss occurs from malabsorption if the small intestine occurs, rectal bleeding
-Systemic: fever

Front 10

Describe signs and symptoms of ulcerative colitis:

Back 10

-Bloody diarrhea and abdominal pain
-Mild disease: diarrhea may consist of 1-2 semiformed stools daily that contain small amounts of blood
-Moderate disease: 4-5 stools per day, increased bleeding, fever, malaise, and anorexia
-Severe disease: diarrhea is bloody, contains mucus, and occurs 10-20 stools per day, fever weight loss greater than 10%, anemia, tachycardia, and dehydration

Front 11

Describe nutritional therapy for a patients with IBD:

Back 11

-Essential that people with IBD eat a well balanced, healthy diet with sufficient calories, protein, and nutrients
-Cobalamin in injections monthly, or orally/nasal daily
-A food diary helps them identify problem foods to avoid
-Milk products are avoided
-High-fat foods also tend to trigger diarrhea
-Quit smoking
-May need parenteral nutrition or enteral feedings
-Supplemental iron

Front 12

Describe 5 categories of drugs used for the treatment of IBD:

Back 12

1.) aminosalicylates: suppresses proinflammatory cytokines and other inflammatory mediators (more effective for ulcerative colitis)
2.) antimicrobials: unknown mechanism of action (Metronidazole); successful against Crohn's disease
3.) Corticosteriods: used to achieve remission but not maintaining; helpful for acute flare ups; many side effects for long term use
4.) immunosuppressants: given orally and take 3-6 months to exhibit full effectiveness; effective with Crohn's disease
5.) biologic therapy: given IV to induce and maintain remission in pts with active Crohn's disease and in pts with draining fistulas

Front 13

Describe nursing actions for a patient with IBD:

Back 13

-During the acute phase: attention is focused on hemodynamic stability, pain control, fluid and electrolyte balance, and nutritional support; I & O; number and appearance of stools
-Teaching the patient strategies for managing stress
-Quit smoking
-Rest is important
-The pt must be kept clean, dry, and free of odor; a deodorizer should be placed in the room and have ready access to a toliet; meticulous perinanal skin care using plain water
-Dibucaine witch hazel, or other soothing compresses or prescribed ointment and sitz baths may reduce irritation and relieve discomfort of the anus

Front 14

A saccular dilation or outpouching of the mucosa through the circular smooth muscle of the intestinal wall:

Back 14

-Diverticulum

Front 15

An infection of the diverticular sacs that is thought to be caused by obstruction with fecal matter; inflammation of the diverticula occurs, which can result in perfortion of one or more diverticula; may occur at any point within the GI tract but are most commonly found in the sigmoid colon:

Back 15

-Diverticulitis

Front 16

Etiology of this disease occurs in the sigmoid colon and are thought to be associated with high luminal pressures from a deficiency in dietary fiber intake and perhaps combined with a loss of muscle mass and collagen with the aging process; results from retention of stool and bacteria in the diverticulum, forming a hardened mass called a fecalith and causes inflammation and small perforations and can spread to surrounding area in the intestines causing the tissue to become edematous:

Back 16

-Etiology of Diverticulitis

Front 17

Describe the signs and symptoms of diverticulitis:

Back 17

-Abdominal pain is localized over the involved area of the colon
-Left lower abdominal pain, fever, leukocytosis, and sometimes a palpable abdominal mass

Front 18

Describe complications of diverticulitis:

Back 18

-Perforation with peritonitis, abscess and fistula formation, bowel obstruction, ureteral obstruction, and bleeding

Front 19

The most common cause of lower GI hemorrhage is:

Back 19

-Diverticulitis

Front 20

Describe nursing actions for a patient with diverticulitis:

Back 20

-Encourage a high-fiber diet, mainly from fruits and veggies, and decreased intake of fat and red meat are recommended for prevention
-High-fiber diet
-Weight reduction (decreases intraabdominal pressure)
-Avoid straining at stool, vomiting, bending, lifting, and tight, restrictive clothing
-Acute diverticulitis: to allow the colon to rest and the inflammation to subside; kept NPO; bed rest and given parenteral fluids; observed for signs of peritonitis; broad spectrum antibiotic therapy; WBC count is monitored
-When acute attack subsides, oral fluids are given and progressed to semisolids; ambulation is permitted

Front 21

A protrusion of a viscus through an abdominal opening or a weakened area in the wall of the cavity in which it is normally contained:

Back 21

-Hernia

Front 22

Hernias that easily return to the abdominal cavity are called:

Back 22

-reducible

Front 23

Hernias that cannot be placed back into the abdominal cavity are called:

Back 23

-irreducible or incarcerated

Front 24

When the hernia is irreducible and the intestinal flow and blood supply are obstructed, the hernia is:

Back 24

-strangulated

Front 25

This hernia is the most common type and occurs at the point of weakness in the abdominal wall where the spermatic cord in men and the round ligament in women emerge; can be direct (posterior inguinal wall) or indirect (through inguinal ring):

Back 25

-Inguinal hernia

Front 26

This type of hernia occurs when there is a protrusion through the femoral ring into the femoral canal; occurs below the inguinal (Poupart's) ligament as a bulge; becomes strangulated easily and occurs more often in women:

Back 26

-Femoral hernia

Front 27

This type of hernia occurs when the rectus muscle is weak (as with obesity) or the umbilical opening fails to close after birth:

Back 27

-Umbilical hernia

Front 28

This type of hernia is due to weakness of the abdominal wall at the site of a previous incision:

Back 28

-Ventral or incisional hernias

Front 29

Describe signs and symptoms of hernias:

Back 29

-If the hernia becomes stragulated, the patient will experience severe pain and symptoms of a bowel obstruction, such as vomiting, cramping abdominal pain, and distention

Front 30

Describe nursing actions for a patient with a hernia:

Back 30

-If a patient wears a truss, check for skin irritation
-Observe for a distended bladder; I & O; apply ice bag; coughing is not encouraged, but deep breathing and turning should be done; the incision should be splinted during coughing and sneezing
-Restrict heavy lifting for 6-8 weeks

Front 31

The surgical repair of a hernia is known as a:

Back 31

-Herniorrhaphy

Front 32

The reinforcement of the weakened area with wire, fascia, or mesh is known as a:

Back 32

-Hernioplasty

Front 33

Dilated hemorrhoidal veins; may be internal (occurring above the internal sphincter) or external (occurring outside the external sphincter):

Back 33

-Hemorrhoids

Front 34

Are thought to develop as a result of shearing forces during defecation which damages supporting muscles resulting in venules becoming dilates; most common reason for bleeding with defecation; may be precipitated by many factors, including pregnancy, prolonged constipation, straining in effort to defecate, heavy lifting, prolonged standing and sitting, and portal hypertension:

Back 34

-Etiology of Hemorrhoids

Front 35

Describe signs and symptoms of having hemorrhoids:

Back 35

-Bleeding, anal pruritus, prolapse, and pain
-Internal: may be asymptomatic; can bleed resulting in blood on toilet paper after defecation or blood on the outside of stool
-External: blood clots cause pain and inflammation, and the hemorrhoids are described as thrombosed; cause intermittent pain, pain on palpation, itching, and burning

Front 36

Describe nursing actions for a patient experiencing hemorrhoids:

Back 36

-Teaching measures to prevent constipation, avoidance of prolonged standing or sitting, proper use of OTC drugs available for hemorrhoidal symptoms, and the need to seek medical care for severe symptoms
-Recommend sitz bath
-Privacy should be provided
-Pain meds may be given before BM to reduce discomfort
-If the pt does not have a BM within 2-3 days, an oil-retention enema is given
-Pt are taught the importance of diet, care of the anal area, symptoms of complications, and avoidance of constipation and straining

Front 37

Occurs when intestinal contents cannot pass through the GI tract; may occur in the small intestine or colon and can be partial or complete:

Back 37

-Intestinal Obstruction

Front 38

The obstruction is a detectable occlusion of the intestinal lumen; most occur in the small intestine:

Back 38

-Mechanical Obstruction

Front 39

What is the most common cause of a small bowel mechanical obstruction? Second?

Back 39

-1st: surgical adhesion
-2nd: hernias and tumors

Front 40

What is the most common cause of large bowel mechanical obstruction?

Back 40

-Carcinoma followed by volvulus and diverticular disease

Front 41

The obstruction that may result from a neuromuscular or vascular disorder:

Back 41

-Nonmechanical Obstruction

Front 42

Lack of intestinal peristalsis and the presence of no bowel sounds and is the most common form of nonmechanical obstruction; occurs to some degree after any abdominal surgery:

Back 42

-Paralytic (adynamic) Ileus

Front 43

How can you tell whether postoperative obstruction is due to paralytic ileus or adhesion?

Back 43

-Bowel sounds usually return before postoperative adhesions develop

Front 44

What are causes of paralytic ileus?

Back 44

-Peritonitis
-Inflammatory responses (acute peritonitis, acute appendicitis)
-Electrolyte abnormalities (especially hypokalemia)
-Thoracic or lumbar fractures

Front 45

An apparent mechanical obstruction of the intestine without demonstration of obstruction by radiologic:

Back 45

-Pseudo-obstruction

Front 46

Bacteria flourish when this occurs in the small bowel; proximal bowel fluid, gas, and intestinal contents accumulate, bowel becomes increasingly distended, and intraluminal bowel pressure rises which leads to an increase in capillary permeability and extravasation of fluids and electrolytes into the peritoneal cavity; distal bowel collapses; bowel tissue becomes ischemic, then necrotic, and then may rupture; location determines the extent of fluid, electrolyte, and acid-base imbalances; may be partial or complete:

Back 46

-Etiology of Intestinal Obstruction

Front 47

What is the most dangerous intestinal obstruction?

Back 47

-When the bowel becomes strangulated and the blood supply is cut off leading to massive infection and death

Front 48

A closed-loop obstruction occurs when the lumen is blocked in two different spots; results in an isolated segment of bowel and obstruction proximal to that segment; strangulation and gangrene are likely to develop if treatment is not immediate:

Back 48

-Volvulus

Front 49

Describe signs and symptoms of intestinal obstruction:

Back 49

-Vary depending on the location of the obstruction, and include nausea, vomiting, abdominal pain, distention, inability to pass flatus, and constipation
-Projectile vomit and contains bile and may be orange-brown and foul smelling like feces because of bacterial overgrowth
-Vomiting usually relieves pain in high intestinal obstructions
-Persistent, colicky abdominal pain is seen with lower intestinal obstruction; a characteristic sign of mechanical obstruction is pain that comes and goes in waves due to peristaltic waves trying to move bowel contents past the obstructed area
-Paralytic ileus produces a constant generalized discomfort
-Strangulation causes severe, constant pain that is rapid in onset
-Abdominal distention
-Abdominal tenderness and rigidity are usually absent unless strangulation or peritonitis has occurred
-Temp rarely rises above 100F unless strangulation or peritonitis has occured

Front 50

Describe what bowel sounds may occur for intestinal obstructions:

Back 50

-High-pitched sounds above the area of obstruction due to overworking of peristalsis
-Bowel sounds may also be absent as in paralytic ileus
-Borborygmi: audible abdominal sounds produced by hyperactive intestinal motility

Front 51

Describe nursing actions for a patient with an intestinal obstruction:

Back 51

-Preventing fluid and electrolyte deficiencies and early recognition of deteriorations in the patient's condition
-Determine the location, duration, intensity, and frequency of abdominal pain and whether abdominal tenderness or rigidity is present
-Onset, frequency, color, odor, and amount of vomitus should be recorded
-Nurse auscultates for bowel sounds and documents their character and location; inspects the abdomen for scars, visible masses, and distention; and perhaps for muscle guarding and tenderness
-A urinary catheter is usually ordered to monitor hourly urine outputs
-Mouth and nose care

Front 52

The third most common form of cancer and the second leading cause of cancer-related deaths in the US; has an insidious onset, and symptoms do not appear until the disease is quite advanced; regular screening is necessary; 1/2 occur in the rectosigmoid area:

Back 52

-Colorectal Cancer

Front 53

What is considered the gold standard for colorectal cancer screening and the distention and removal of precancerous polyps:

Back 53

-Colonoscopy

Front 54

More common in men than women, and mortality rates are highest among African American men and women:

Back 54

-Etiology of Colorectal Cancer

Front 55

Describe major risk factors for the development of colorectal cancer;

Back 55

Major risk factors include increasing age, family or personal history of colorectal cancer, colorectal polyps, and IBD, obesity, smoking, alcohol, and a large intake of red meat

Front 56

What can help decrease the risk of developing colorectal cancer?

Back 56

-Physical exercise, diet with large amounts of fruits, veggies, and grains

Front 57

Describe sigs and symptoms of colorectal cancer:

Back 57

-Hematochezia (passage of blood through rectum) or melena (black, tarry stools), abdominal pain, and/or changes in bowel habits
-Weakness, anemia, and weight loss
-Symptoms vary from right-side and left-side of the colon
-Right: usually asymptomatic
-Left: rectal bleeding (most common), alternating constipation and diarrhea, change in stool caliber (ribbonlike, narrow), and sensation of incomplete evacuation

Front 58

________ during colonoscopy can be used to resect colorectal cancer in situ and is considered successful when the resected margin of the polyp is free of cancer, the cancer is well differentiated, and there is no apparent lymphatic or blood vessel involvement:

Back 58

-Polypectomy

Front 59

_______ is recommended when a patient has positive lymph nodes at the time of surgery or has metastatic disease.

Back 59

-Chemotherapy

Front 60

_______ ______ may be used postoperatively as an adjuvant to surgery and chemotherapy or as a palliative measure for patients with metastatic cancer.

Back 60

-Radiation Therapy

Front 61

Describe nursing actions for a patient with colorectal cancer:

Back 61

-Encourage all pts over 50 to have regular colorectal cancer screening
-Teaching proper positioning, providing information regarding ostomy, surgical options, fears about life changes
-Perineal dressing is reinforced and changed frequently during the first several hours after surgery when drainage is likely to be most profuse
-All drainage is carefully assessed for amount, color, and consistently and is usually serosanguineous
-Nurse should examine the wound regularly and record bleeding, excessive drainage, and unusual odor
-Wound is usually irrigated with a normal saline solution when the dressings are changed, several times a day and aseptic technique is always used
-Partially closed wound and drains are in place, the nurse assesses the incision for suture integrity and signs and symptoms of wound inflammation and infection; drainage is examined for amount, color, and characteristics
-Nurse monitors for edema, erythema, and drainage around the suture line, fever, and elevated WBC count
-Sitz bath, antipruitic agents, and use of a pressure-reducing chair cushion provides comfort

Front 62

This diagnostic study directly visualizes entire colon up to ileocecal valve with flexible fiberoptic scope; pt's position is changed frequently during procedure to assist with advancement of scope to cecum; test is used to diagnose inflammatory bowel disease, detect tumors, diagnose diverticulosis, and dilate strictures; procedure allows for biopsy and removal of polyps without laparotomy:

Back 62

-Colonoscopy

Front 63

Describe nursing actions for a patient undergoing a colonscopy:

Back 63

-Before: a bowel prep is done; type of varies depending on physician (clear liquids for 1-2 days, enema given night b4, or drink 1 gallon of GoLYTELY the night b4); explain to pt that flexible scope will b inserted while pt is in side-lying position; sedation will be given
-After: be aware the pt may experience abdominal cramps caused by stimulation of peristalsis because the bowel is constantly inflated with air during procedure; observe for rectal bleeding and signs of perforation; check VS

Front 64

This diagnostic study directly visualize rectum and sigmoid colon with lighted flexible endoscope; sometimes special table is used to tilt patient into knee-chest position; may detect tumors, polyps, inflammatory and infectious diseases, fissures, and hemorrhoids:

Back 64

-Sigmoidoscopy

Front 65

Describe nursing actions for a patient undergoing a sigmoidoscopy:

Back 65

-Administer enemas evening before and morning of procedure; pt may have clear liquid day before, or no dietary restrictions may be necessary; explain to pt knee-chest position (unless pt is older or very ill), need to take deep breaths during insertion of scope, and possible urge to defecate as scope is passed; encourage pt to relax and let abdomen go limp; observe for rectal bleeding after polypectomy or biopsy

Front 66

This diagnostic study is a fluoroscopic x-ray examination of colon using contrast medium, which is administered rectally (enema); double-contrast or air-contrast barium enema is test of choice; air is infused after thick barium lows through the transverse colon:

Back 66

-Lower GI series

Front 67

Describe nursing actions for a patient undergoing a lower GI series:

Back 67

-Before: administer laxatives and enemas until colon is clear of stool evening before procedure; admin clear liquid diet evening before procedure; keep pt NPO for 8 hr before test; instruct pt about being given barium by enema; explain that cramping and urge to defecate may occur during procedure and that pt may be placed in various positions on tilt table
-After: give fluids, laxatives, or suppositories to assist in expelling barium; observe stool for passage of contrast medium

Front 68

In this diagnostic study; form, consistency, and color are noted; specimen examined for mucus. blood, pus, parasites, and fat content; test for occult blood (guaiac test, Hemoccult, Hematest) are done:

Back 68

-Fecal Analysis (guaiac, bile pigment, fat content, ova parasite)

Front 69

Describe nursing actions for a patient undergoing a fecal analysis:

Back 69

-Observe pt's stools; collect stool specimens; check stools for blod with Hemoccult or Hematest; keep diet free of red meat for 24-48 hr before guaiac test

Front 70

Describe nursing actions and rationale for testing stool for occult blood:

Back 70

-Explain purpose of the test
-Perform hand hygiene
-Obtain a small sample of stool and thinly smear stool in the first box of the guaiac paper
-Apply a second fecal specimen from a different portion of the stool to the slide's second box
-Close slide cover, and turn the packet over to the reverse side; after waiting 3-5 min, open cardboard flap and apply 2 drops of developing solution on each smear
-Interpret color within 60 seconds (blue positive for blood)
-After interpreting, apply 1 drop of developer to the quality control section and interpret within 10 sec

Front 71

Describe nursing actions and rationale for administering an enema:

Back 71

-Sterile technique is unnecessary
-Wear gloves
-Place client in left side-lying (Sims) position with right knee flexed
-Solution should always to be room temperature (never cold)
-Lube 2.5-3 inches and insert approximately 3-4 inches for adults
-Hold tubing until end of fluid instillation
-Raise solution about 12 inches above rectum
-Place layers of tp around tubing as it is withdrawn; explain feeling of distention is normal
-Encourage to retain solution as long as possible for approximately 10-15 minutes (differs depending on solution)
-Assist to toilet; observe character of feces; assist client as needed with washing anal area

Front 72

Describe action, use, route, side effects, and nursing implications for Dulcolax (bisacodyl) or castor oil:

Back 72

-Action: Agents irritate intestinal mucosa to increase motility; agents decrease absorption in small bowel and colon
-Indications: prepare bowel for diagnostic procedures
-Risks: cause severe cramping; not for long-term use; chronic use causes fluid and electrolyte imbalances; not for clients who are pregnant or breast-feeding
-Route: PO and rectally

Front 73

What classification is Dulcolax and castor oil a part of?

Back 73

-Stimulant laxatives

Front 74

Describe action, use, route, side effects, and nursing implications for Metamucil:

Back 74

-Action: High-fiber content absorbs water and increases solid intestinal bulk; agents stretch intestinal wall to stimulate peristalsis; absorbs water and increases solid intestinal bulk
-Indications: least irritating, most natural, and safest cathartics; drugs of choice for chronic constipation; relieves mild diarrhea, if treating diarrhea, admin less water
-Risks: cause obstruction if not mixed with at least 240 mL of water or juice and swallowed quickly; caution is necessary with bulk forming laxatives that also contain stimulants; not for whom large fluid intake is contraindicated; follow each dose with 8oz water
-Side effects: bronchospasm, cramps, intestinal or esophageal obstruction, nausea or vomiting
-Route: PO

Front 75

What classification is Metamucil a part of?

Back 75

-Bulk-forming agents

Front 76

Describe action, use, route, side effects, and nursing implications of Colace and mineral oil:

Back 76

-Action: stool softeners are detergents that lower surface tension of feces, allowing water and fat to penetrate; increase secretion of water by intestine
-Indications: for short-term therapy to relieve straining on defecation
-Risks: are of little value for treatment of chronic constipation
-Route: PO (prevention) and rectally (soften fecal impaction)
-Side effects: throat irritation, mild cramps, rashes
-Nursing: assess bowel sounds and for abdominal distention; assess for diarrhea b4 admin; admin with a full glass of water

Front 77

What classification is Colace or mineral oil a part of?

Back 77

-Stool-softeners

Front 78

Describe action, use, route, side effects, and nursing implications of Lomotil:

Back 78

-Action: inhibits excess GI motility with subsequent decrease in diarrhea
-Side effects: dizziness, constipation, dry eyes, dry mouth, urinary retention
-Route: PO
-Implications: assess frequency and consistency of stools and bowel sounds; assess fluid and electrolyte balance

Front 79

What classification is Lomotil a part of?

Back 79

-Anti-cholinergic

Front 80

Describe action, use, side effects, route, and nursing implications of Golytely and Colyte:

Back 80

-Action: acts as an osmotic agent, drawing water into the lumen of the GI tract for the evacuation of the GI tract without water or electrolyte imbalance
-Route: PO
-Side effects: abdominal fullness, diarrhea, bloating, cramps, nausea, vomiting
-Nursing implications: assess for abdominal distention, presence of bowel sounds, and usual pattern of bowel function; pt should fast 3-4 hr prior to admin and never have solid foods 2 hr prior

Front 81

What classification is Golytely a part of?

Back 81

-Osmotics