Vanessa Brown, SVN

1. S/S of Diarrhea:

Stools are watery and frequent

Some cases, blood and mucus in stool

Experiences urgency (tenesmus) and abdomen discomfort 

Bowel sounds are hyperactive

 Fever may be present

 Skin around anus may become excoriated

Management:

Rest the bowel by limiting intake to clear liquids for one or two meals and gradually advancing to a regular diet.

Administer antidiarrheal agent, such as Lomotil, Imodium, or a combination product such as Kaopectate

 Fluid and electrolyte replacement by either the oral or IV route

Dietary adjustments, may involve eliminating foods that cause diarrhea

TPN if diarrhea is severe and prolonged and if the introduction of oral fluid and food results in another episode of diarrhea

Ro re-colonize the bowel take or eat probiotics. Example eat yogurt Low residue diet to manage it

S/S of constipation

 Bowel elimination is infrequent or irregular. Feel “bloated”

 Bowel sounds may be hypoactive, abdomen May be distended or tympanic

Stool that is passed may be hard and dry

Rectal bleeding from stretching and tearing the tissue from hard, dry stools

Scybala (stool feels like small rocks) when having a rectal exam If constipated for a long time, client may pass liquid stool that goes around the obstructed mass of stool (encorpresis) This is the most common symptom of nursing home residents, school-aged children who have chronic constipation, and stool withholding behavior.

Management:

For quick symptomatic relief physician prescribes an enema or a laxative in oral or suppository form, followed by prophylactic administration of stool softener High fiber Diet

 Drugs such as Senokot, MOM, Metamucil, Colace

2. Appendicitis

Define: inflammation of a narrow, blind protrusion called the vermiform appendix located at the tip of the cecum in the right lower quadrant of the abdomen

Clinical signs:

v Positive Rovsing’s sign which is examiner does deep palpation in the left lower abdominal quadrant and the client feels pain in the right lower abdominal quadrant. This suggests acute appendicitis.

v Early s/s abdominal pain in epigastric or umbilical area, or associated with abdominal discomfort and accompanied by fever and N/V.

v Intermediate (acute) stage: over period of few hours pain shifts from mid-abdomen to RLQ, and is aggravated by walking, coughing, and movement. Pain may be accompanied by sensation of constipation.

v Anorexia, malaise, occasional diarrhea and diminished peristalsis can occur. Pain may come from urinating.

Pre and post-operative care:

Pre:

v An informed consent form must be signed acknowledging that the patient understands the procedure, the potential risks, and that they will receive certain medications.

v Preoperative tests vary according to the patient’s age and health, but a blood test, chest x-ray, and electrocardiogram (EKG) are standard.

v Antibiotics are given, client restricted from eating & drinking, including oral medications, while decision is being made about surgery if surgery is already known client needs to restrict eating and drinking after midnight the night before.

v IV fluids are prescribed to meet clients fluid needs

v If symptoms worsen the surgeon performs an appendectomy before the appendix ruptures.

v Prepare client quickly for surgery to avoid delaying surgical complications.

v know about any other medical conditions; if the patient is taking any medication (prescription or OTC); if any dietary supplements or herbal products are being used; if there has been recent illicit drug use; if the patient smokes cigarettes or drinks alcohol; if the patient has a history of allergies, especially to medications; or has had a previous reaction to anesthesia, or a family history of problems with anesthesia.

Post:

v Following surgery, the patient is taken to the postanesthesia care unit (PACU) until the anesthesia wears off.

v During this time, the nursing staff checks temperature, heart rate, and breathing at frequent intervals. When the anesthesia wears off and vital signs stabilize, the patient is transferred to their hospital room

v A healthy young patient may return to activities soon; age, general physical condition, and extent of complications depend on how fast client recovers.

v Avoid heavy lifting after surgery

3. Peritonitis

Causes:

v Perforation by a peptic ulcer, bowel, or the appendix

v Abdominal trauma (gun shot or knife wound)

v IBD

v Ruptured ectopic pregnancy

v Infection introduced during peritoneal dialysis

Nursing responsibilities:

v Administer analgesics

v Ng tube to connected to suction

v Urinary retention catherter

v V/S taken frequently and monitor central venous and pulmonary artery pressures

v Assess fluid balance, dressing drainage, pain level (1-10), frequent explanations and emotional support

v Monitor for continued abdominal infection

v Notify physician quickly if anything worsens (changes in level of conciousness, deviations in V/S)

Sources:

v Introductory Medical surgical nursing, by Barbara K. Timby & Nancy E. Smith

v http://www.surgerychannel.com/appendectomy/postop.shtml

4. HERNIAS

A hernia is a protrusion of any organ from the cavity that normally confines it; most commonly used to describe the protrusion of the intestine through a defect in the abdominal wall.

Five common types of hernia’s are;

1. Inguinal hernia: is a protrusion of the hernial sac and contains the intestine at the inguinal opening

2. Umbilical hernia: occurs in the umbilical region, through which the hernial sac protrudes. This type occurs in children when the umbilical orifice fails to close shortly after birth. It may occur in obese adults who have prolonged abdominal distention.

3. Femoral: intestines descent through the femoral ring where the femoral artery passes into the femoral canal, below the inguinal ligament. Incidence of strangulation is high.

4. Incisional: Occurs through the scar of a surgical incision when healing is impaired. Obese, older, or malnourished clients are prone to the development of incisional hernias.

5. Hiatus hernia: Occurs in the chest and afftects the digestive tract.

Common treatments: surgery is the only method of eliminating a hernia. If a pt does not want to have surgery or is not a candidate for surgery then they can wear a truss (an apparatus that press over the hernia and prevents protrusion). Another treatment is the pt can lie supine while manual pressure is applied over the protruding area to reduce the hernia periodically.

Surgery is called a herniorrhaphy and when performed the protruding intestine is repositioned in the abdominal cavity and the defect in the abdominal wall is repaired. It’s performed under local, spinal or general anesthesia or can be treated using laparoscopic approach.

If a person is prone to recurrence of the hernia ie: obese pt’s a hernioplasty may be performed. The procedure being performed is reinforcing with wire, fascia, or mesh, this is done so that the weak lining can help hold the herniated organ in place. Before being performed the obese pt is asked to loose some weight.

Nursing Care: Before surgery, obtain med history and drug history because of malnutrition and diabetes, or concurrent use of corticosteroids or antimetabolite cancer drugs which can affect wound healing, obtain pt allergy and smoking history because can cause sneezing and coughing which increases intra abdominal pressure after surgery, auscultate lungs to check for infection in respiratory and document pt’s weight and duration of hernia.

After surgery: (post-op) the nurse teaches the family and pt verbal and written instructions, and advise of signs and symptoms (ie: bleeding, infection) to cll healthcare provider asap, avoid constipation and straining to have a bowel movement, pt is to avoid strenuous exertion and heavy lifting

5. DIVERTICULOSIS (IT IS)

Diverticulosis is an asymptomatic diverticula

Diverticulitis is the inflammation of the diverticula

Diverticula are sacs/pouches caused by herniation of the mucosa through a weakened portion of the muscular intestine or other structures (can appear anywhere in the GI tract)

Diverticula are common in the colon and in the sigmoid area in people over 50yrs of age, and people with low fiber diet have more incidence of diverticula. Diverticula become inflamed when fecal material becomes trapped in one or more blind pouches. Inflammation causes swelling of the tissue, edema may be severe enough to cause intestinal obstruction.

Sources from timby pg 865-868

And www.hernia.org

c.fernandez svn

Austin Sherer

Thursday, August 14, 2008

GI Assignment – #6, 7, 8

6) “Define Crohn’s disease, and differentiate between care in Crohn’s and ulcerative colitis”

a. Crohn’s Disease: A chronic, inflammatory disease that can involve any part of the GI tract from the mouth to the anus. Typically, the disease occurs in segments, leaving portions of healthy bowel in between the diseased areas.

b. The difference between care of a client with Crohn’s Disease versus ulcerative colitis varies. Even though they both share a lot of the same medicinal treatments such as corticosteroids, Remicade is a primary medicine used for Crohn’s Disease, whereas it isn’t used in clients with ulcerative colitis. Surgically, portions of the bowel may be removed in Crohn’s disease since it affects portions of the bowel. In ulcerative colitis, the entire section of the colon is removed. Also, after a colectomy, several pouches can be made with portions of the small intestine. For a client with Crohn’s disease, these pouches are not recommended since Crohn’s can occur in the pouch.

7) “Discuss the incidence of cancer of the colon.”

a. Cancer of the colon develops from colorectal tumors that have derived from benign adenomas in the mucosal and submucosal intestinal layers. The benign polyps become malignant, which begin to attack the surrounding tissues. Colorectal cancer can be catalyzed by the presence of ulcerative colitis, chronic bowel inflammation such as Crohn’s Disease and a lifestyle of eating low-fiber, high-fat foods.

“Recognize specific nursing responsibilities for clients with a colostomy.”

a. Nursing responsibilities for clients with a colostomy would include inspecting the stoma for any changes in appearance, such as size and color. Other nursing responsibilities would include encouraging the client to eat a regular diet while avoiding gas-producing foods, eliminate food items from their diet that result in diarrhea, eat slowly with mouth closed and chew food well to decrease gas intake from swallowing additional air with the food. More nursing responsibilities would include checking the body weight regularly, irrigate the site of the stoma at the same time everyday (typically best after a meal since food in the digestive tract stimulates peristalsis and defecation).

Sources: “Introductory Medical-Surgical Nursing”, Timby.

Austin Sherer, SVN

INTESTINAL DISORDERS

9. Recognize the importance of wound hygiene, and carry out appropriate care to reduce infection and enhance client comfort
Wound healing is monitored, and complications that develop are managed. Possible post-op complications include: intestinal obstruction, bleeding, impaired blood supply to, stenosis of, or prolapse or excessive protrusion of the stoma.

Different ostomies include: a colostomy, temporary colostomy, permanent colostomy, sigmoid or descending colostomy, transverse colostomy, loop colostomy, ascending colostomy, ileostomy, ileoanal reservoir (J-Pouch), and continent ileostomy (Kock Pouch).

Before beginning wound care, the wound must be assessed for healthy or unhealthy characteristics by assessing the color, size, opening, surface, length, and sensation. Then the nurse begins the wound care:

· Perform hand hygiene and organize equipment, and prepare new stoma pouch.

· Explain procedure to patient, then provide privacy

· Position mirror to reveal stoma area to client.

· Put on gloves.

· Place waterproof pad on abdomen around and below stoma opening.

· Remove pouch (and place in a plastic waste bag) by gently lifting corner with fingers of dominant hand while pressing skin downward with fingers of nondominant hand at small sections at a time.

· Place 4×4 gauze over stoma opening.

· Empty pouch, measure waste in graduated container before discarding.

· Remove gloves and perform hand hygiene.

· Clean entire stoma and the skin surrounding the stoma with a washcloth soaked in warm, soapy water. Rinse and pat dry.

· Use measuring guide to trace opening on back of wafer.

· Leaving intact adhesive covering of skin-barrier wafer, cut out circle, allowing an extra 1/8 inch for placement over stoma.

· Remove gauze and apply stomal paste around stoma or to the edges of the opening in the wafer.

· Remove gloves and discard all necessary equipment.

· Spray room deodorizer if needed.

· Perform hand hygiene

[see Smith-Temple, Johnson: Nurse’s Guide to Clinical Procedures 5th edition, pg 535-537, 544-547]

10. List the types of ostomy equipment necessary for caring for colostomy, and perform necessary procedures to ensure good hygiene

· Two pairs of nonsterile gloves

· Graduated container

· Disposable waterproof bed pad

· Basin of warm, soapy water (soap should be mild without oils, perfumes, or creams)

· Washcloth and towel

· 4×4 gauze

· Scissors

· Pen or pencil

· New pouch appliance

· Peristomal skin paste and wafer

· Stoma measuring guide

· Mirror

· Room deodorizer

OTHER OSTOMY ACCESSORIES

· Convex Inserts- Convex shaped plastic discs that are inserted inside the flange of specific two-piece products.

· Ostomy Belts- Belts that wrap around the abdomen and attach to the loops found on certain pouches. Belts can also be used to help support the pouch or as an alternative to adhesives if skin problems develop. A belt may be helpful in maintaining an adequate seal when using a convex skin barrier.

· Pouch Covers- Made with a cotton or cotton blend backing, easily fit over the pouch and protect and comfort the skin. They are often used to cover the pouch during intimate occasions. Many pouches now include built-in cloth covers on one or both sides, reducing the need for separate pouch covers.

· Skin Barrier Liquid/Wipes/Powder- Wipes and powder help protect the skin under the wafer and around the stoma from irritation caused by digestive products or adhesives. They also aid in adhesion of the wafer.

· Skin Barrier Paste- Paste that can be used to fill in folds, crevices or other shape or surface irregularities of the abdominal wall behind the wafer, thereby creating a better seal. Paste is used as a “caulking” material; it is not an adhesive.

· Tapes- Tapes are sometimes used to help support the wafer or flange (faceplate) and for waterproofing. They are available in a wide range of materials to meet the needs of different skin sensitivities.

· Adhesive Remover- Adhesive remover may be helpful in cleaning the adhesive that might stick to the skin after removing the wafer or tape, or from other adhesives.

[see United Ostomy Associations of America, Inc. http://www.uoaa.org/ostomy_info/whatis.shtml]

—————————————————————————————F. Pada SVN-EC

11. Define intestinal obstruction. Discuss the implications for nursing care.

     Intestinal obstruction occurs when a blockage interferes with the normal progression of intestinal contents through the intestinal tract. The causes are classified as mechanical or functional and as partial or complete. The severity depends on the region of the bowel affected, degree to which the lumen is obstructed, and degree to which the blood circulation to the intestine is impeded. An intestinal obstruction is extremely dangerous and maybe fatal if not treated promptly.

     The care of a client with an intestinal obstruction involves managing pain, maintaining fluid balance to prevent deficits related to fluid shifts and losses from vomiting, and helping the client deal with fear related to severe, possibly life-threatening symptoms and an unstable condition. The nurse also manages pain by maintaining the patency of the decompression tube and administering a prescribed narcotic analgesic as long as blood pressure and respiratory rate indicate that doing so is safe. The nurse maintains uninterrupted infusion of IV fluids and shortens the siege of vomiting by maintaining intestinal decompression, even though intestinal fluid is lost in suctioning. It is crucial to monitor urinary output hourly and to report output below 50 mL/hour, a finding that may indicate that the client is going into shock.

12. List important nursing considerations for a client undergoing rectal surgery and assist in planning care and carrying out appropriate measures.

• Getting Ready for Surgery
  To prepare for rectal surgery—
  • Do not eat or drink anything after midnight the night before surgery; this includes water and chewing gum.
  • Continue to take medication as prescribed, but with only a sip of water. Do not take ibuprofen, aspirin or any medication containing aspirin for one week before surgery.
  • Do not smoke after midnight the night before surgery.
  • Do not wear artificial nails or nail polish. Patient’s nails are monitored during surgery to identify oxygen and blood circulation.
  • Bring a list of all medications and their dosages.

Most anorectal surgical procedures are done in same-day surgery. A few more extensive procedures require hospitalization for one to three days. Patient’s ability to tolerate the pain postoperatively and doctor’s concern about patient’s wounds determine the time of discharge.

Anorectal Nursing Care Plan after surgery:

Instruct client, unless contraindicated, to increase intake of water to 2 L/day.

Provide a list of high-fiber foods.

Instruct client in use of laxatives or stool softeners as ordered.

Teach the client to heed the urge to have a bowel movement.

Encourage client to rest in a comfortable position that removes pressure from surgical site, or to use a flotation device.

Administer pain medications as ordered.

Apply ice and analgesic ointments as indicated.

Instruct client to cleanse perianal area with warm water and to dry with cotton wipes.

Teach client how to do sitz baths at home, using warm water, and three to four times each day.

Encourage client to follow diet and medication instructions.

>Encourage moderate exercise.

Bowel Function
Bowel movements after anorectal surgery are usually associated with moderate to severe discomfort. Constipation and diarrhea make the pain much worse and must be avoided. The trauma to the anal wounds caused by hard bowel movements will slow down the healing process.

Constipation
Client should be sure to have a bowel movement at least every other day. If two days pass without one, take an ounce of milk of magnesia; if there is no result; repeat this dose in six hours. Client can also use an over-the-counter phosphate enema or tap water enema.

Diarrhea
Diarrhea, usually caused by overuse of laxatives, is also a concern if patient have more than three watery bowel movements during a 24-hour period. If diarrhea occurs, stop taking milk of magnesia or other laxatives. Continue the bulk-forming agents. If the diarrhea persists, call the physician.

Bathing
After bowel movements, use a wet wash cloth, toilet paper, cotton, or perianal pads (Tucks, Preparation H pads) to clean. If possible, take a sitz bath or tub bath immediately. Baths should last at least 10 to 15 minutes with the water as warm as client can comfortably tolerate. Try to take at least three baths (or showers with a hand-held sprayer) a day.

Discharge/Infection
Some bloody discharge after bowel movements is normal for at least two to four weeks after rectal surgery. If client have profuse, continuing bleeding, call the doctor immediately. Postoperative infection around the rectal opening is surprisingly uncommon despite the obvious contamination by stool. This is probably because of the very excellent blood supply to the area.

Urination
If client  have trouble urinating, do so while sitting in a warm tub of water, or run the water faucet while sitting on the toilet. If the problem is severe or persistent, the doctor may prescribe oral bladder stimulants.

Diet
Eat a high-fiber general diet, including plenty of fruits and vegetables. Try to drink at least six to eight glasses of water or juice per day to help keep the stool soft.

Activity
On discharge there are generally no restrictions on walking, climbing stairs, or riding in a car. After some procedures client will be asked to avoid strenuous activity or heavy lifting for 7 to 14 days.

 

Sources:

 Barbara K. Timby and Nancy E. Smith Book

 http://www.colonrectal.org/index.htm

Atlanta Colon & Rectal Surgery,P.A.