CONCEPTS IV WEEK 10

What are some causes of altered bowel elimination

insufficient dietary intake

inadequate fluid intake

meds (chronic laxative use)

lack of exercise

ignoring urge to defecate

infections/inflammation

neoplasms

change in routine

emotional factors

How does bowel elimination change in childhood

development of control over sphincters and mm for urination and bowel elimination occur in early childhood

How does bowel elimination change in pregnancy

increased pressure and bladder and intestines can cause urinary and bowel frequency

how does bowel elimination change in elderly

physiological changes include decreased renal blood flow, loss of nephrons, atrophy of smooth mm in colon and reduced mucous secretions all contribution to constipation or incontinence

signs of impaired bowel elimination

decreased frequency

difficulty passing stools

decreased stool volume

retention of feces in rectum

abdo pain

bloating

changes in bowel habits

Nursing interventions to optimize bowel elimination

promoting adequate fibre intake

encouraging fluid intake

promoting activity

health education on bowel habits

addressing emotional factors

collaborative interventions to optimize bowel elimination

adjust meds

conduct further ax to reveal underlying medical conditions

individualized care plans

subjective GI assessment

Dx hx

surgical hx

medication hx

abdo pain

N/V

food intolerance

changes in appetite or weight

dysphagia

last BM

constipation or diarrhea

Objective GI ax

inspection

auscultation

palpation

percussion

normal inspection findings in GI ax

symmetry of shape and color

flat or rounded contour

no visible lesions

intact skin

normal auscultation findings in GI ax

presence of normal bowel sounds

normal palpation findings in GI ax

absence of pain or tenderness

absence of masses

voluntary guarding

GI assessment in infants

breast or formula fed

infants have protuberant abdo contour

ax the umbilical cord

respirations observed in abdo

GI assessment in children

protuberant contour until age 4

often can't provide more subjective info than "my stomach hurts"

what is hematemesis

vomiting of red blood

what does hematemesis usually indicate and what is it due to

indicates upper GI bleed

typically d/t peptic ulcers, vascular lesion

Coffee ground emesis

Committing of dark brown, granular material

what is coffee ground emesis usually a result of

upper GI bleed that has slowed or stopped with conversion of red hemoglobin to brown hematin by gastric acid

what is hematochezia

passage of gross blood from the rectum

what does hematochezia usually indicate

lower GI bleed but can result from vigorous upper bleed

what is melena

black tarry stool

what is melena usually due to

typically upper GI bleed, but possibly from small bowel or R colon

Common etiologies of upper GI bleeds

Duodenal ulcer

Gastric or duodenal erosions

Varices

Gastric ulcer

Mallory-Weiss tear

Erosive esophagitis

Angioma

Arteriovenous malformations

GI stromal tumours

common etiologies of lower GI bleeds

Anal fissures

Angiodysplasia

Colitis

Colonic carcinoma

Colonic polyps

Diverticular disease

IBD: ulcerative colitis / Crohn's

Internal hemorrhoids

Common etiologies of GI bleeds in the elderly

Hemorrhoids and colorectal cancer most common causes of minor bleeding

Peptic ulcer, diverticular disease, and angiodysplasia most common causes of major bleeding

Important history in GI bleeding

Ascertain quantity and frequency of blood passage

Patients with hematemesis should be asked whether blood was passed with initial vomiting or only after several nonbloody emesis

Ask questions to distinguish b/w hematemis and hemoptysis cause pts get them confused

PMH to collect for GI blleds

inquire about previous GI blleding

known IBD

liver disease

meds

drugs and alcohol use

Meds that can contribute to GI bleeding

NSAIDS

anticoags

antiplatelets

bismuth

iron

common manifestations of GI bleeds

abdo pain

dysphagia

weight loss

easy bleeding or bruising

S/S of anemia (weakness, fatigue, dizziness(

Nausea / retching

change in bowel habits

Orthostatic changes seen w/ GI bleeding

>10bpm change in pulse

drop of ≥10mmHg in BP

both commonly develop after acute loss (≥2L) of blood

external stigmata of GI bleeding

petechiae

ecchymosis

chronic liver disease signs

portan HTN signs

chronic liver disease external signs

spider angiomas

ascites

palmar erythema

external signs of portal HTN

splenomegaly

dilated abdominal wall vessels

GI bleed H2T ax: CNS signs

decreased mentation

ALOC

lightheadedness

fainting

dizziness

GI bleed H2T ax: HEENT signs

pale eyes

pale mucosa and lips

GI bleed H2T ax: respiratory signs

decreased O2

SOB

GI bleed H2T ax: CV signs

chest pain

tachycardia

hypoTN

GI bleed H2T ax: GI signs

abdo pain

anal fissures

hemorrhoids

masses

hematemesis

melena

GI bleed H2T ax: hematologic signs

anemia

GI bleed H2T ax: integumentary signs

pallor

Red flags that suggest shock r/t GI bleeds

syncope

hypoTN

pallor

diaphoresis

tachycardia

oliguria

how are GI bleeds dx

CBC

coag profile

NGT

upper endoscopy (upper bleed)

colonoscopy (lower bleed(

angiography

Priority interventions for GI bleeds

maintain patent airway

fluid resuscitation / blood transfusion if indicated

medication

hemostasis

surgery

IV fluid resus protocol for GI bleeds

obtain IV access immediately (large bore in AC)

IV NS 500mL - 1L until signs improve

max 2L

pts who don't improve should get transfusion w packed RBCs until intravascular volume is restored

Medications used for upper GI bleeds

proton pump inhibitors

Meds used for variceal bleeds and dose

Octreotide (somatostatin)

50mcg bolus followed by continuous infusion of 50mcg/hr