NURS 220 - Lower GI Conditions

Small Intestine - Components and What it is

Duodenum, Jejunum, Ileum, Ileocecal Valve; Absorbs nutrients and largest organ

Small Intestine - Duodenum

approx 12“ long, fixed shape and position

Small Intestine - Jejunum

approx 2.5m long, digestion

Small Intestine - Ileum

approx 3.5m long, absorption

Small Intestine - Ileocecal Valve

Opens into large intestine

Small Intestine - Mucosa components

intestinal villi, microvilli, Crypts of Lieberkuhn

Small Intestine - Intestinal Villi

finger-like projections contained in the lining, increase surface are for digestion and absorption of nutrients

Small Intestine - Microvilli

microscopic projection covered with a fuzzy coat called brush border, contains many digestive enzymes

Small Intestine - Crypts of Lieberkuhn

intestinal glands. that secrete about 2 L of fluid/day into lumen of intestine, fluid reabsorbed by villi; provide bath to help breakdown solid material to continue moving forward

Large Intestine - Component and What is it

Cecum, Colon, Rectum; Last processing of material to get to defecation, submucosal layer is the most important here

Large Intestine - Cecum

pocket at entry, appendix is located here adjacent to small intestine

Large Intestine - Colon

Ascending right, transverse, descending left, sigmoid

Large Intestine - Rectum

rectal vaults, anal canal, anal sphincter- internal is involuntary and external is voluntary

Microbiome - What is it?

all body surfaces in contact with the environment are colonized by microorganisms, collectively called “microbiome”

Microbiome - What is Biome?

environment characterized by climate and dominant flora and fauna

Microbiome - By how much does it outnumber our bodies cells?

outnumbers our own body cell by a factor of 10, microbial cell = 10¹³

Microbiome - What organisms are part of the human microbiome?

variety of organisms including bacteria, fungi, viruses, and more

Microbiome - What influence does the habitat have on microbiome residing?

depending on the habitata, composition of the microbiome differs significantly, ex: the gut is mainnly populate by various bacterial species, over 99%

Microbiome - Diversity is key to healthy microbiome

diversity is key to have a healthy environment as it creates healthy competition so theres’s lower risk of invasive organisms to attack cell

Microbiome - Complex ecosystem

complex ecosystem is unique to each individual; >400 species per person

Microbiome - Proper organ function

an integral part of the body, essential for proper organ function: protection from invasive pathogens, contributie to metabolic process

Appendix - What was historically believed of it?

historically believed to be a useless vestigal tissue/organ

Appendix - What does evidence suggest it’s function is?

evidence suggest it is likely a storage reservoir for microbiome

Appendix - What is the working theory?

serves as GI “seed bank” for microorganisms needed to populate digestive microbiome as needed (prn); seed bank refers to stored bacteria thats released for later use when needed

Appendix - Appendicitis: What is it caused by?

typically caused by blockage

Appendix - Appendicitis: S/Sx

preumbilical pain and nausea/vomiting; RLQ rebound tenderness (pain when release pressure), ferver, abd, cramping, dysuria, elevated WBCs

Appendix - Appendicitis: Dx method

CT scan or US

Appendix - Appendicitis: Tx options

antibiotic (profelactic), appendectomy (removal)

Appendix - Appendicitis: Early appendicitis

bacteria, mucus, stool, parasites or a foreign body block the appendix, resulting in a cramping type pain around the navel area

Appendix - Appendicitis: Appendiceal distention

pressure builds up in the appendix behind the obstruction and the appendix will swell, resulting in a loss of appetite, discomfort and vomiting. Pain begins to migrate form the navel to the lower right abdomen

Appendix - Appendicitis: Irritation of the lining of the abdominal and pelvic cavities

as the appendix swells, it irritates the surrounding tissues, causing constant pain or pain with coughing or being bumped

Appendix - Appendicitis: Perforation

as pressure cuts off blood flow to the wall of the appendix, tissues start to die and become weka. the appendix can then rupture, leaking mucus, stool and bacteria into the abdomen

Liver - What it is?

largest gland of the body; very vascular organ containing portal vein and hepatic artery

Liver - Functions

glucose metabolism, ammonia conversion, protein metabolism, fat metabolism, vitamin and iron storage, bile formation, bilirubin excretion, drug metabolism

Gallbladder - What is it?

storage container for bule produced by hepatocytes; communicate with duodenum via common bile duct and sphincter of oddi

Gallbladder - Bile

emulsifies fat → promotes intestinal absorption of fatty acids, cholesterol, lipids

Gallbladder - Cholangitis: what is it?

inflamation of the bile duct system

Gallbladder - Cholangitis: What is it d/t?

gallstone obstruction, can lead to infection

Gallbladder - Cholangitis: S/Sx

fever, RUQ, pain, jaundice, AMS, SIRS

Gallbladder - Cholangitis: Tx

hydration, Abx, ERCP - fold standar for biliary decompression if needed

What is ERCP?

Endoscopic Retrograde Cholandropancreatography; a camera-equipped endoscope goes through the mouth to the intestines to clear blockages or place stents

Pancreas - Exocrine Function

digestive enzyme from pancrease enter the duodenum via biliary tract, enzymes include of amylase, trypsin, lipase, secretin.

Pancreas - Exocrine Function: What happens it enzymes cannot leave the pancreas?

if enzymes cannot leave the pacreas into duodenum, auto-digestion will occur d/t back up causing inflmmation → pancreatitis

Pancreas - Endocrine Function

hormones release into bloodstream; Insulin promoting CHO metabolism, Glucagon stimulation hepatic glycogenesis

Pancreatitis - Acute

pancreatic duct become obstructed, enzymes back up causing autodigestiona nd inflammation of the pancreas

Pancreatitis - Chronic

progressive inflammatory disorder with destruction of the pancrease, cells are replace by fibour tissues; pressure withint eh pancrease increases, obstrucitng the pancreatic and common bile duct

Pancreatitis - Common causes

ETOH use DO, biliary tract obstruction, neoplasms, trauma, medications

Pancreatitis - Clinical Findings

pain, nausea and vomiting, abd distention, decrease BS, abnormal VS (ferver, tachycardia), abnormal labs (elevated amylase and lipase and WBCs)

Pancreatitis - What is the best treatment for these patients

NPO, IV fluids, antibiotics

Pancreatitis - Tx options

IV fluids, strict NPO, pain management, Abx, insulin, invasive procedures - Acute: ERCP, Chronic: Whipple

Pancreatitis - What is the Whipple procedure for chronic invasive procedure?

surgically removed portion of pancreas and pancreatic ducts, rerouting tail of pancreas to SI

Pancreatitis - Nursing Considerations

ABCs, IV access, positioning for comfort, many need NGT for decompression, monitor VS and labs

Lower GI Dysfunction: Clinical Manifestations

abd discomfort (pain, pressure, cramping, distention), diarrhea, constipation, melena, hematochezia

Constipation - Why does it occur?

poor motility causing greater absorption, harder feces

Constipation - Frequency of defecation

<3x/week, infrequent

Constipation - What is it?

difficult passage of feces through the lower GI tract

Constipation - Non surgical Tx options

dietary, behavioral, pharmacologic

Constipation - Surginal Tx Options

bowel resection

Laxatives - Bulk Forming Agents

high fiber to absorb water to increase bulk, keep soft and bulky to keep moving; distend bowel to initiate bowel activity; psyllium (metamucil), methylcellulose (citrucel)

Laxatives - Emollients

stool softeners and lubricantsl lubricates fecal material and intestinal walls, promotes water and fat excretion; docusate salts (colace), lubricants (mineral oils)

Laxatives - Hyperosmotics

increase fecal water content, pulling fluid into gut washing things forwards, very potent for severe constipation; increases bower distention and peristalsis; polyethylene glycol (PEG), sorbitol, glycerin, lactulose (for liver failure pt, reduces elevated serum ammonia levels)

Laxatives - Intestinal Stimulants

increase peristalsis via intestinal nerve stimulation; senna (senokot), bisacodyl (dulcolax), PO naloxone (narcan)

Laxatives - Nursing Considerations: Caution

all laxative cause electrolyte imbalance, assess fluid and electrolyte before giving

Laxatives - Nursing Considerations: Avoid long-term use

cause decreased bowel down and lead to dependency; encourage healthy high-fiber diet and increased fluid intake as an alternative

Laxatives - Nursing Considerations: Take table with 6 to 8 oz of water

should be swallow whole, give bisacodyl with water because of interaction with milk, juice, antacids

Laxatives - Nursing Considerations: Monitor for therapeutic effects

contact presciber is severe abdominal pain, muscle weakness, cramps, or dizziness; indicat possible fluid or electrolyte loss

Diarrhea - Why does it occur?

excess motility causes less absorption = loose feces, no time to absorb

Diarrhea - Frequency of defecation

abnormal frequent BMs, >3x/day

Diarrhea - What is it?

loose or liquid stool, d/t not absorption being done; acute or chronic

Diarrhea - Non surgical Tx options

dietary, behavioral, pharmacologic

Diarrhea - Surgical Tx options

bowel resection

Antidiarrheals - Adsorbents

coat the wall of GI tracts, absorbing what’s causing diarrhea and move quick to action; bind to causative bacteria or toxin, which is then eliminated through the stool; Bismuth subsalicylate (pepto-bismol), activacted charcoal

Antidiarrheals - Anticholinergics

decrease intestinal muscle tone and peristalsis of GI tract, slows moveemnt of fecal matter through GI tract, but will cause dry up of fluids all over the body CAUTION; belladonna alkaloids

Antidiarrheals - Opiates

decrease motilities and reduce pain by relief of rectal spasms; allow more time for water and electrolytes to be absorbed; paregoric, opium tincture, codeine, OTC loperamide, diphenoxylate

Antidiarrheals - Probiotics

supply missing bacteria to GI tract and suppress growth of diarreha-causing bacteria; lactobacillus acidophilus (bacid)

Antidiarrheals - Nursing Considerations: Caution

Older patients, bleeding risk, recent bowel surgery, or confusion - May cause urinary retention, HA, AMS, dry skin/mucous membranes, and/or blurred vision; Pepto inhibits platelets, adsorbents inhibit vit K absorption

Antidiarrheals - Nursing Considerations: Contraindications

Hx of narrow-angle glaucoma, GI obstruction, myasthenia gravis, or toxic megacolon

Antidiarrheals - Nursing Considerations: Assessment

fluid status, Input and Outpus, electrolytes, and mucus membranes before, during, and after starting Tx

Antidiarrheals - Nursing Considerations: monitor for therapeutic effect

notify prescriber immediately is sx persists, may indicate condition requiring invasive intervention

What agent would be administered to a patient experiencing diarrhe while completing a course of antibiotic therapy?

L. acidophilus (Bacid) - probiotic antidiarrheal

Which antidiarrheal does the nurse associate with the development of adverse effects of urinary retention, headache, confusion, dry skin, and blurred vision?

Anticholinergics; slows fluid exchange through entire body and retention

A patient who takes Coumadin has been prescribed an adsorbent for diarrhea. It is important for the nurse to monitor the patient for s/s bleeding and elevated INR (supratherapeutic) due to interference with _____ absorption. (its a vitamin)

Vitamin K - found in the intestinal flora, electrolyte that can set everything off balance

Motility Disorders - What are they?

intestinal obstruction and Irritable Bowel Syndrome

Intestinal Obstruction - What is it?

partial or complete blockage of intestinal tract

Intestinal Obstruction - What is the most common site?

small intestine

Intestinal Obstruction - Mechanical Obstruction

Physical: adhesions, hernia, tumors, impacted feces, volvulus, intussusception

Intestinal Obstruction - Functional Obstruction

Peristalsis Inhibitors: medications, ischemia, nervous system impairment

Intestinal Obstruction - Contributing factors

previous abdominal surgery with adhesions (scar tissue); congenital abnormalities of the bowel, metastasis carcinoma - cancer of intestinal tract or female reproductive organs; decreased muscle tone and /or activity - associated with medications or neurological impairment

Intestinal Obstruction - Clinical Manifestation

constipation, dehydration, eloctrolyte depletion, abd pain, N/V; Mechanical obrstuction - BS initially hyperactive; Functional obstruction - BS hypoactive or absent

Intestinal Obstruction - Tx

NPO; fluid/electrolyte replacement, remove mechanical blockage, decompression (NG tube), surgical intervention

Intestinal Obstruction - What happens if left unattended?

if left uncorrected, may cause toxic megacolon, perforation, or ischemia and necrosis leading to peritonitis, bowel gangrene, sepsis, and shock; megacolon in extreme cases

Intestinal Obstruction - Bowel Perforation

intestinal wall ruptures leading to release of intestinal contents into the peritoneal space = acute surgical emergency

Intestinal Obstruction - Toxic Megacolon: What is it?

massive dilation of colon

Intestinal Obstruction - Toxic Megacolon: What causes it?

prolonged constipations; complication of IBD, intestinal obstruction or bowel infection (c. diff); pseudomembranouse colitis may result in acute megacolon: surgical emergency

Intestinal Obstruction - Toxic Megacolon: Visibility of

huge dilated loops of large bowel visible on KUB; may resolve within the first 24 hours with decompression, but many patients will require a colectomy; fatal is untreated

IBS - What is it?

alternating diarrhea and constipation accompanied by abdominal cramping pain with no identifiable pathologic process in the GI tract

IBS - Other names

spastic colitis or irritable colon syndrome

IBS - Cause of

idiopathic; normal peristalsis wave is interrupted by irregular spasms

IBS - Clinical Presentation

diarrhea, constipation or alternating pattern of both; abdominal cramping pain; mucus in stool

IBS - Tx options

Rx, dietary, Alternative therapies, support groups