Chapter 60

1. Chapter 60 Care of Patients with Inflammatory Intestinal Disorders Mrs. Kreisel MSN, RN NU130 Adult Health Summer 2011

2. Appendicitis • Acute inflammation of the vermiform appendix—the blind pouch attached to the cecum of the colon • Abdominal pain in the epigastric or periumbilical area is the initial symptom of classic appendicitis • McBurney’spoint: In accute appendicitis tenderness situated between the unbilicus and the right anteriosuperior iliac crest • Perforation: Puncuture or holes • Rebound tenderness

3. McBurney’sPoint

4. Interventions • Nonsurgical management includes: • NPO • IV fluids • Semi-Fowler’s position • Analgesics • No laxatives or enemas • No heat • PROVIDE COMFORT TOUCH AND REASSURANCE!

5. Surgical Management • Laparoscopy or laparotomy to rule out appendicitis • Preoperative care as for general anesthesia surgeries • Operative procedure—appendectomy • Postoperative care

6. Peritonitis • Life-threatening acute inflammation of visceral/parietal peritoneum and endothelial lining of abdominal cavity, or peritoneum • Primary or secondary peritonitis • Rigid, boardlike abdomen, abdominal pain, distended abdomen, high fever, tachycardia, dehydration, low urine output, hiccups, compromised respiratory status, nausea and vomiting • ASSESS FOR BOWEL SOUNDS FREQUENTLY

7. Peritonitis(Cont.)

8. Nonsurgical Management • IV fluids • Broad-spectrum antibiotics • Daily weight monitored • Fluid volume assessed • Nasogastric suctioning • NPO status • Oxygen • Pain management

9. Surgical Management • Exploratory laparotomy • Semi-Fowler's position • Wound care: • Care of the incisions and drains • Peritoneal irrigation • IV fluid replacement

10. Gastroenteritis • Increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract • Differs from food poisoning • Bacterial form—Campylobacter, Shigella, Escherichia coli • Viral form—Norwalk virus

11. Interventions • Fluid replacement • Nutrition therapy • Drug therapy • Skin care • Health teaching

12. Inflammatory Bowel Disease (IBD) • Several disorders of the GI tract with no known etiology • Ulcerative colitis • Crohn’s disease

13. Ulcerative Colitis • Widespread inflammation of mainly the rectum and rectosigmoid colon; can extend to the entire colon • Associated with periodic remissions and exacerbations • Tenesmus • Loose stools containing blood and mucus, poor absorption of vital nutrients, and thickening of the colon wall can result • Increased risk for colon cancer

14. Assessment • Physical assessment • Clinical manifestations • Psychosocial assessment • Laboratory assessment • Other diagnostic tests

15. Drug Therapy • Aminosalicylates • Glucocorticoids • Immunomodulators • Antidiarrheal drugs • Other drugs

16. Other Therapies • Nutrition therapy • Rest • Complementary and alternative therapies

17. Surgical Management • Colectomy • Total proctocolectomy with a permanent ileostomy • Preoperative care • Operative procedure • Postoperative care: • Loose, dark green liquid, with some blood in stool • Pouch system worn at all times • Skin care

18. Total Colectomy with a Continent (Kock’s) Ileostomy • Internal ileal reservoir • Intra-abdominal pouch created from the terminal ileum by the surgeon • Stool stored in the pouch drained by catheter • Care of pouch • Effluent, or drainage, monitored

19. Kock’sIleostomy

20. Total Colectomy with Ileoanal Anastomosis (J Pouch) • Removal of the colon and the rectum with the ileum sutured into the anal canal • Spares the rectal sphincter and need for an ostomy • Preoperative care • Operative procedure • Postoperative care

21. Ileoanal Reservoir

22. Crohn’s Disease • Inflammatory disease of the small intestine and the colon, or both. • It can affect the GI tract from mouth to anus but mostly the terminal ileum. • Transmural inflammation causing thickening of the bowel wall with strictures and deep ulcerations with bowel fistulas commonly developing. • Rarely, cancer of the small bowel and colon develop. • Malabsorption of vitamins and nutrients due to diarrhea. It can lead to signs and symptoms of anemia!

23. Fistulas

24. Assessment • Physical assessment • Clinical manifestations • Psychosocial assessment • Diagnostic assessment

25. Nonsurgical Management • Drug therapy • Nutritional therapy • Fistula management • Complication management • Fluid and electrolyte therapy • Skin care • Prevention of infection • Complementary and alternative therapies

26. Skin Barriers

27. Surgical Management • Laparoscopy • Small bowel resection and ileocecal resections • Stricturoplasty • Preoperative care • Operative procedure • Postoperative care

28. Diverticular Disease • Diverticulosis is the presence of many abnormal pouchlike herniations in the wall of the intestine. • Diverticulitis is inflammation of one or more of the diverticula.

29. Diverticula

30. Assessments • History • Physical assessment • Clinical manifestations • Diagnostic assessment

31. Nonsurgical Management • Drug therapy • Nutrition therapy • Rest • IV fluids to correct dehydration • IV antibiotics • Anticholinergics • Analgesics

32. Nonsurgical Management (Cont’d) • Avoid laxatives and enemas • Rest • NPO in the hospital

33. Surgical Management • Preoperative care • Operative procedure • Postoperative care: • Drain care • Care of the ostomy • NPO followed by clear liquids

34. Anorectal Abscess • Localized induration and pus caused by inflammation of the soft tissue near the rectum or anus • Rectal pain first symptom • Surgical incision and drainage • Nursing interventions focused on helping the patient maintain comfort and optimal perineal hygiene • High-fiber diet

35. Anal Fissure • Tear in the anal lining • Acute and chronic forms • Assessment • Management • Patient teaching

36. Anal Fistula • Abnormal tract leading from the anal canal to the perianal skin • Most anal fistulas result from anorectal abscesses • Proctoscopy • Surgery

37. Anal Fistula

38. Parasitic Infection • Pathophysiology • Entamoeba histolytica • Giardia lamblia • Cryptosporidium • Assessment • Interventions

39. Helminthic (worms) Infestation • ROUND WORMS: cause the most infections worldwide • Enterobiasis: pinworm most common in the USA. Oral intake • Trichinosis: very low in the USA roundworm. Get from under cooked meat • Hookworms: roundworm enter body through the skin • Tapeworms: From undercooked meat, eating bugs, contaminated water • WHAT NURSING CONSIDERATIONS ARE IMPORTANT?

40. Food Poisoning • Salmonellosis • Staphylococcal infection • Escherichia coli infection • Botulism

41. NCLEX TIME

42. Question 1 Ulcerative colitis is most commonly seen in individuals belonging to which ethnic group? • Hispanic • Sephardic Jews • Portuguese Romani • Ashkenazi Jews

43. Question 2 An older patient diagnosed with bacterial gastroenteritis is complaining of abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment? • Dehydration • Hypokalemia • Hypernatremia • Perineal skin breakdown

44. Question 3 What is an expected outcome of a patient taking sulfasalazine (Azulfidine) for treatment of ulcerative colitis? • Anorexia • Anemia • Diarrhea • Dermatitis

45. Question 4 The patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor his laboratory results for evidence of: • Hypernatremia • Hypercalcemia • Hyperglycemia • Hyperkalemia

46. Question 5 How many people are infected with Salmonella organism each year in the United States? • 10,000 • 20,000 • 40,000 • 50,000