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

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’s point: In accute appendicitis tenderness situated between the unbilicus and the right anteriosuperior iliac crest Perforation: Puncuture or holes Rebound tenderness

McBurney’s Point

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

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

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

Peritonitis (Cont.)

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

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

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

Interventions Fluid replacement Nutrition therapy Drug therapy Skin care Health teaching

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

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

Assessment Physical assessment Clinical manifestations Psychosocial assessment Laboratory assessment Other diagnostic tests

Drug Therapy Aminosalicylates Glucocorticoids Immunomodulators Antidiarrheal drugs Other drugs

Other Therapies Nutrition therapy Rest Complementary and alternative therapies

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

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

Kock’s Ileostomy

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

Ileoanal Reservoir

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!

Fistulas

Assessment Physical assessment Clinical manifestations Psychosocial assessment Diagnostic assessment

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

Skin Barriers

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

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.

Diverticula

Assessments History Physical assessment Clinical manifestations Diagnostic assessment

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

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

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

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

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

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

Anal Fistula

Parasitic Infection Pathophysiology Entamoeba histolytica Giardia lamblia Cryptosporidium Assessment Interventions

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?

Food Poisoning Salmonellosis Staphylococcal infection Escherichia coli infection Botulism

NCLEX TIME

Question 1 Ulcerative colitis is most commonly seen in individuals belonging to which ethnic group? A.Hispanic B.Sephardic Jews C.Portuguese Romani D.Ashkenazi Jews

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? A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

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

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: A. Hypernatremia B. Hypercalcemia C. Hyperglycemia D. Hyperkalemia

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