Week 8: Bowel Issues, Appendicitis, IBS/IBD

appendicitis definition

inflammation of the appendix → may lead to rupture

appendicitis risk factors

fecalith/appendicolith (calcium) obstruction, foreign bodies, bacteria/toxins, low fiber diet, high intake of refined carbs

appendicitis clinical manifestations

constant dull pain in RLQ, McBurney’s point RLQ, Rosving Sign LLQ rebound pain in RLQ, Psoas sign upper thigh muscle pain bending knee. side lying, abdominal guarding with legs flexed. anorexia, n+, low grade fever, high wbc, constipation/diarrhea

appendicitis dx

wbc >10, neutrophil 75%, abdominal radiograph, US, CT → RLQ density or localized bowel distention

appendicitis complications

perforation - 24 hr after pain, manifests fever, abd distention + rigidity, constant pain, tenderness, guarding → peritonitis

peritonitis

inflammation of the peritoneum with bacteria, bile, or enzymes → sharp abd pain, rebound tenderness, guarding, fever, n+v, tachycardia, tachypnea, abd distention and rigidity, shallow respirations, movement causes pain → stillness. tx - ATBs

appendicitis collab care

open/laparoscopic appendectomy, rupture → ATBs + IV fluids 6-8 hr prior appendectomy.

appendicitis drug tx

NS/LR until urine output is 1ml/kg and electrolytes are replaced. broad spectrum ATBs, analgesics

preop appendectomy nursing interventions

NPO IV hydration, antipyretics, antibiotics, analgesics. Monitor for rupture/peritonitis → ATBs asap. right side lying or low-semi fowler for comfort. bowel sounds, ice packs, avovid head, laxatives, or enema

postop appendectomy nursing interventions

monitor temp, incision site. NPO until bowel function returns, advance diet graduatelly/as tolerated. rupture → penrose drain (profuse drainage for first 2 hr, change dressing) or incision left to heal inside out. patient ed - wound care/report complications, avoid heavy lifting. notify HCP of fever - infection.

colorectal CA risk factors

red meat, low fruit and veggie intake, alcohol, smoking, physical activity, family HX, IBD, obesity. >45 should be screened

colorectal CA dx studies

barium enema, sigmoidoscopy/colonoscopy w/biopsy, hemoccult stools, digital rectal exam. abd CT/xray. CBC, electrolytes.

colorectal CA manifestations

change in stool, ascites, fatigue, weight loss. hematochezia (fresh blood) - left side, diarrhea - right side. abd pain, palpable mass, hepatomegaly.

colorectal CA collab care

NPO, NG tube - bowel decompression, check q4 for patency, stabilize vs, electrolytes + IV fluids, pain mgmt, promote rest, measure abdominal girth, reposition frequently to relieve pain. surgical removal of obstruction/primary lesion, laser therapy to ablate non-resectable tumors, chemo, radiation

diverticulosis vs diverticulitis

multiple noninflamed diverticula vs. 1+ inflamed diverticula, resulting in perforation into the peritoneum

diverticulitis dx studies

sigmoidoscopy, colonoscopy, CBC

diverticulitis complications

perforation, abscess, fistula, bleeding

diverticulosis manifestations

asymptomatic - may have abd pain, bloating, flatulence, change in bowel habits

diverticulitis manifestations

LLQ pain, distention, decreased or absent bowel sounds, n+v, infection signs

diverticulitis collab care

NPO, IV fluids, NGT suctioning q/4. diet - high fiber/fiber supplements, smoking/alc cessation, avoid lifting/bending/tight clothes. vitals, labs, pain, bedrest, strict I+O, oral care.

diverticulitis drug therapy

ATBs - metronidazole, trimethoprim-sulfamethoxazole, ciprofloxacin. analgesics - acetaminophen, opioids

types of intestinal obstructions

small/large bowel, partial complete, simple - intact blood supply, strangulated - no blood supply. mechanical - physical blockage, nonmechanical - absent peristalsis, neuromuscular alteration, paralytic ileus

general bowel obstruction etiology

inadequate blood flow → intestinal strangulation/infarction, necrosis and perforation. requires immediate tx to prevent septic shock and death

small bowel obstruction etiology

no absorption of fluid or nutrients, causes VS changes.

large bowel obstruction etiology

bowel proximal (bottom left) colon, causes discomfort

bowel obstruction clinical manifestations

4 hallmark signs - abd pain, n+v, distention, constipation. also changes in VS, bowel sounds, decreased urine output, electrolyte imbalance

bowel obstruction dx studies

abd xray/CT, contrast enema, sigmoidoscopy/colonoscopy. cbc, blood chemistries - WBC = strangulation/perforation, increased Hct = hemoconcentration, increased waste products. vomiting → metabolic acidosis

bowel obstruction collab care

NPO, IV, parenteral nutrition, strict I+O, NGT, IV antiemetics, obtain cultures + IV ATBs, emergency surgery for strangulation/perforation, colonoscopy - remove polyps, dilate strictures, laser destruction, removal of tumors, partial or total colectomy/ileostomy, colostomy

stoma care/patient ed

should be red, soft, and moist. clean with soap and water. can eat anything, better to avoid gassy food. cover entire area around stoma to prevent skin breakdown. empty around ½ full. output may be 1500-200 mL/24 h. monitor for fluid volume deficit, encourage more fluids

short bowel syndrome

not enough nutrients absorbed through small intestine, usually resulting from removal. symptoms - dehydration, weight loss, diarrhea malnutrition, vitamin deficiencies, electrolyte imbalance, lifetime parenteral nutrition, oral supplements.

IBS definition

chronic abd pain or discomfort and alteration of bowel patterns - diarrhea/constipation, increased by stress, does not cause inflammation. can be w constipation or diarrhea.

IBS clinical manifestations

LLQ pain, nausea, flatulence, mucus in stool, feeling like you don’t empty your bowels fully, change in bowel sounds, anorexia. fatigue, headache, sleep problems

IBS collab care

symptom mgmt - no sign of disease or abnormality during colon exam. psychologic support, drugs to regulate stool and reduce pain - opioid agonists, antispasmotics, antidepressants, antidiarrheals, or laxatives. diet

IBS diet

limit FODMAP foods, 2-3 L water. constipation = eat insoluble fiber → wheat bran, veggies, whole grains. diarrhea = soluble fiber → oat bran, barley, nuts, seeds, beans, lentils, peas, fruits and veggies.

high FODMAP foods

aggravate the gut - diary, wheat, beans, lentils, artichokes, asparagus, onions, garlic, apples, cherries, pears, peaches

low FODMAP foods

eggs, meat, cheese - brie, camembert, cheddar, feta, almond milk, grains - rice, quinoa, oats, eggplant, potatoes, tomatoes, cucumbers, zucchini, grapes, oranges, strawberries, blueberries, pineapple

IBD definition

autoimmune disease causing chronic inflammation of the GI tract characterized by periods of remission, interspersed with periods of exacerbation. caused by diet, smoking, stress, high sugar intake, low raw fruit, veggies, omega 3s, and fiber. associated with nsaids, atbs, oral contraceptives. ulcerative colitis - colon. crohn’s - anywhere

crohn’s disease definition

autoimmune inflammation from mouth to anus - distal ileum, proximal colon. skip lesions, deep ulcercations make “cobblestone appearance.” strictures - bowel obstruction, fistulas common.

crohn’s disease manifestations

diarrhea 5-6x daily, cramping, weight loss, abd pain, fever, fatigue, slight rectal bleeding

ulcerative colitis definition

inflammation from the rectum to the cecum, affects the mucosal layer, protein loss in stool, precancerous pseudopolyps form

ulcerative colitis manifestations

bloody diarrhea. mild = <4, moderate = 4-10, severe 10-20 stools daily. weight loss, abd pain, fever, fatigue

CD/UC dx studies

h+p, CBC, chem, c-reactive protein. stool → blood, pus, mucus, infection, hemoccult stool. imagine - double contrast barium enema, small bowel series, transabdominal US, CT, MRI, colonoscopy

CD/UC collab care

rest bowels, meds, control inflammation, infection, nutrition, avoid smoking, surgery is curative - generally done for complications, colostomy, ileostomy

CD/UC nutritional therapy

liquid enteral feedings. diet - high protein, high cal. soluble fiber for diarrhea. avoid triggers - caffeine, alcohol, lactose intolerance, high fat foods, cold foods. small frequent meals, keep food diary,. check iron, cobalamin, folate, calcium, and zinc.

CD/UC drug therapy

5-aminosalicates, monoclonal antibodies, corticosteroids, immunomodulators, antimicrobials

5-aminosalicylates

mesalamine - decreases inflammation

anti tumor necrosis factor

adalimumab - decreases inflammation

immunomodulators

azathioprine, methotrexate - immunosuppressants

antimicrobials for CD/UC

ciprofloxacin, clarithromycin, metronidazole

CD/UC complications

hemorrhage, strictures (inflammation + scar tissue buildup), perforation, abscesses, fistulas, c. diff, colonic dilation (toxic megacolon), risk for colorectal CA

c. diff etiology

natural flora overgrowth, spores survive up to 70 days.

c. diff collab care/nursing interventions

hand wash with soap and water, contact precautions, probiotics used preventatively. hydrate, drug therapy - vanco/fidaxomixin/metronidazole, complicated uses both. do not give antidiarrheals