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medsurg exam 3
Management of the Patient with a Lower GI Disorder
| Question | Answer |
|---|---|
| layers of intestinal lumen: outer most to inner most | serosa, longitudinal muscle layer, circular muscle layer, submucosa, mucosa |
| IBD: 2 types | chron's disease (regional enteritis) ulcerative colitis (UC) |
| IBD can be | debilitating |
| IBD is characterized by | chronic, recurrent inflammation of the intestinal tract |
| IBD has periods of | remission and exacerbation |
| how many people currently have IBD | 1 mil |
| possible causes of IBD | Infectious agents (viral, bacterial) Auto-immune diseases Food allergies Smoking Familial-Genetic Predisposition Oral contraceptives |
| management of IBD is aimed at | decreasing or eliminating symptoms and improving patient’s quality of life |
| Therapeutic agents will be selected based on | symptom severity and drug side effects |
| ulcerative colitis affects | large intestine |
| ulcerative colitis involves | mucosa and submucosa |
| ulcerative colitis exacerbations | mild to severe at unpredictable intervals |
| ulcerative colitis manifestations | bloody diarrhea with mucus, LLQ pain, Tenesmus |
| Tenesmus | need to pass still even though the bowels are empty, causes straining |
| people with ulcerative colitis at risk for | higher risk of colon cancer, hypovolemia, decreased albumin, weight loss and anemia |
| complications of ulcerative colitis | hemorrhage, perforation, toxic megacolon |
| chrons disease (regional enteritis) affects | anywhere along the GIT, ileum and colon mostly |
| chrons disease involves | all layers |
| chrons disease exacerbations | symptoms aren't specific but there is abdominal pain, fatigue, non bloody diarrhea, fissures, RUQ pain, weight loss, anemia |
| chrons disease is 2x likely in | smokers |
| chrons disease on xray | cobblestone effect of GIT |
| main comparison between UC and CD | UC: involves mucosa and submucosa, affects colon and ileum, has bloody d CD: involves all layers, affects anywhere in GIT and had non bloody d |
| dx of IBD | History Clinical evaluation Radiographic studies: CT, MRI Endoscopy, colonoscopy Lab Tests: Fecal occult blood test, CBC |
| Endoscopy to make sure | pt still has a gag reflex |
| management of IBD | Nutritional treatment (TPN) Bowel Rest (Severe) Medications Surgery |
| Medications for IBD | Antibiotics Immunosuppressants Aminosalicylates Anti-Tumor Necrosis Factor Janus Kinase Inhibitors Interleukin-23 antagonists Anti-diarrheal |
| IBD nursing care | Pain relief Maintain hydration Maintain optimal nutrition Promote rest Reduce anxiety Prevent skin breakdown Medication education Fewer, firmer stools |
| surgery of large intestine with anastomosis | removes a diseased portion of the bowel and rejoins the healthy ends, allowing for normal bowel movements |
| ascending colostomy stool will be | more liquidy |
| descending colostomy stool will be | soft, almost firm |
| ileostomy stool will be | completely liquid which causes risk for fluid and electrolye imbalances |
| ileostomy is | complete removal of colon |
| sigmoid colostomy single barreled stool will be | pretty normal |
| transverse colostomy double barreled stool will be | more firm |
| Colon Surgery with Colostomy: Pre-op Preparation | Physical preparation of the patient Education on surgical procedure, post-op care and stoma care Emotional support for the patient and family |
| Physical preparation before surgery | Diet Cleansing the bowel: Antibiotics- keflex, neomycin… NG placement Pain and antiemetic therapy I/O Electrolyte balance |
| Cleansing the bowel using Antibiotics like keflex, neomycin in case | there is any stool in the peritoneal cavity |
| diet before colon surgery | liquid the day before |
| Preoperative psychological/sociological | Health perception Fear/anxiety Role change Alteration in body image Coping |
| education of colon surgery | Pain control Diet Tubes to expect DVT/ pneumonia prophylaxis Incision /wound care Ostomy care |
| ostomy care education | stoma appearance and output |
| Role of the Enterostomal Therapist | Identify ability to perform self care Identify support systems Identify potential adverse factors Begin education on ostomy Mark site of stoma before surgery Monitor self-care ability Identify how to obtain additional supplies |
| post op assessment of | observe and record!!! |
| what to observe and record | wound, skin integrity, stoma characteristics drainage from the stoma flatus, fecal drainage, increase abd distention |
| drainage from the stoma | mucus and serosanguinous |
| flatus should occur | 24-72 hrs after |
| fecal drainage should occur | 72 hrs after |
| color of stomas should be | rose to brick red (means viable stoma) !beefy red |
| pale stoma | may indicate anemia |
| blanching, dark red, purple to black stoma | indicates ** inadequate blood supply ** to the stoma or bowel from adhesions, low flow, or excessive tension on the bowel at the time of construction |
| blanching, dark red, purple to black stomas are | emergency situations needing immediate attention |
| mild to moderate edema in stomas | normal in the initial postoperative period |
| moderate to severe edema in stomas | obstruction of the stoma an allergic reaction or gastroenteritis |
| you should report | any trauma or increasing edema to the stoma |
| small amount of bleeding at the stoma | oozing from the stomal mucosa when touched is normal because of its high vascularity |
| moderate to large amounts of bleeding at the stoma | could indicate coagulation deficiency, stomal varicies secondary to portal hypertension or lower GI bleed |
| most important thing to do after nursing assessment | RECORD!! |
| what to assess in post op pt | Abdomen I & O – NG output, urine output, other drains Pain Electrolytes H/H Infection Psychological response Diet tolerance |
| diet tolerance when pt is post op | NPO until flatus is present and there are bowel sounds |
| interventions of IBD | Clear liquid diet once ordered (+flatus, +BS) Pain management Activity IS SCD use to prevent DVT !Provide private time for patient to discuss self image and sexual concerns Aseptic technique for dressing changes Ostomy care |
| colostomy irrigation is like | an enema |
| colostomy irrigation for ascending colostomies | mainly used for transverse and descending colostomies |
| colostomy irrigation for transverse colostomies | allows the pt to go up to 24–48 hours without needing a pouch |
| colostomy irrigation for descending colostomies | often eliminates the need for a continuous pouch |
| prolapsed stoma | when the bowel protrudes further than normal through abdominal wall |
| retracted stoma | occurs when the bowel pulls back below skin level |
| discharge planning for pts with new stomas | Wound care (wound not healed by d/c) Involve home health nurse and ET nurse Avoid heavy lifting Involve ostomy society Diet/hydration Discuss potential adjuvant therapies and follow up care |
| Ileostomy and Colostomy Diet | May start out with low-fiber/low residue diet until intestinal swelling resolves Advance to regular diet with balanced dietary fiber Take vitamin supplements as directed by physician Eat at regular intervals |
| ileostomy and colostomy pts should not | skip meals |
| ileostomy and colostomy pts commonly are | lactose intolerant |
| when trying new foods with ileostomy or colostomy, you should | Add new foods gradually to determine tolerance Try foods several times before eliminating them |
| ileostomy and colostomy pts may benefit from | more frequent and smaller meals |
Created by:
leh195