GI upper and lower MED SURG 2

defined by saclike outpouchings of bowel lining that extends through a defect in the muscle layer

95% occur in the sigmoid colon, but may occur anywhere in the intestines

multiple diverticula without inflammation in colon

inflammation and infection of diverticula in colon

increases with age and is associated with a low-fiber diet

diverticula are present but there are often no symptoms, common in developed countries, over half americans over 80 have these, and there is no known cause except diets low in fiber are predisposing

majority have no symptoms, preceded by chronic constipation by many years, abdominal pain, bloating/gas, bowel irregularity, intervals of diarrhea, nausea, anorexia

can progress to diverticulitis

acute onset of mild to severe LLQ pain and often radiates to back, nausea/vomiting, fever and chills, leukocytosis

anything with seeds/corn/broccoli

colonoscopy, abdominal xray, CT is preferred, barium swallow with small bowel series, barium enema (this is contraindicated if peritoneal irritation is present)

CBC: increased WBC

let colon rest and inflammation subside, some patients can be managed at home with oral antibiotics and a clear liquid diet

perforation, peritonitis, abcess formation-surgery required-resection of the involved colon or a temporary diverting colostomy. The colonostomy is reanastomosed after the colon heals, bleeding.

rest, analgesics, antispasmotics--30 minutes before meals and at bedime to relieve bowel spasms and discomfort-- antibiotics for 10 days, instruct to take the full course
clear liquid diet until inflammation and abd discomfort subsides
progress to a full liquid diet and if tolereated eat a high fiber diet balanced with 2 servings of protein rich foods each day
soft foods with high fiber such as cooked veggies and low fat recommended
bulk forming laxatives and stool softners-avoid constipation which would increase pressue on the bowel

*a high fiber diet: fruits and veggies, decreased fat intake and decreased intake of red meat, fiber supplements
weight reduction to decrease intra abdominal pressure as well as avoiding straining at stool, bedning, lifting and tight clothing
exercise will help improve the muscle tone of the bowels and peristalsis and bowel movements will be easier

a protrusion of a viscus through an abnormal opening or a weakened area in the wall of the cavity in which it is normally contained. usually occur in the abdominal cavity.

mostly increased intra-abdominal pressure and weakened muscles-- straining

hernia over the site of an old incision

hernia that occurs where the spermatic corn in med and the round ligament in women emerge (groin area)

a hernia protrudes through the femoral ring in to the femoral canal (also in the groin area but placed lower than an inguinal hernia)

hernia: protrusion at belly button

hernia can be easily returned to the abdominal cavity

hernia cannot be returned to abdominal cavity

hernia is not reducible, the intestinal flow and the blood supply are obstructed

incarcerated

strangulated hernia

herniorrhaphy
surgical reinforcement of weakend areas with wire/fascia/mesh is called a hernioplasty

a pad placed over the hernia and held in place with a belt

Observe for distended bladder
accurate i&o
scrotal support and applicatiopn of ice for scrotal edema and pain
deep breathing and turning-- these pts should NOT be taught to cough
teach splinting the incision and teach to cough and or sneeze WITH MOUTH OPEN to decrease thoracic and intra-abdominal pressure
pt is restricted from heavy lifting for 6-8 weeks

Pressure, Position, Pee, and Private parts

decrease intra-abdominal pressure

open mouth to cough/sneeze, no lifting, no tight clothing

decrease intra-abdominal pressure

Knees bent
Head of bed elevated

Risk for urine retention

check for distended bladder
accurate I&O

post-op scrotal edema

Scortal elevation
application of ice pack

inguinal hernia

femoral hernia

blockage prevents flow of intestinal contents through the GI tract, may be partial or complete

intraluminal obstruction from pressure on the intestinal wall (intussusception, tumors, stenosis, adhesions, hernias, abscesses)

musculature is unable to propel intestinal contents

(MD, endocrine disorders, neurologic disorders, temporary result of manipulation during surgery)

adhesions are the most common cause then hernias and neoplasms

most frequent in sigmoid section: Carcinoma is most common then diverticulitis, IBD, and benign tumors

Small: Rapid
Large: Gradual

Small: frequent and copious
Large: rare

Small: colicky and cramplike, intermittent
Large: Low grade, cramping, abdominal pain

Small: feces for a short time
Large: absolute constipation

small: greatly increased
large: increased

-NPO
-abdominal assessment: high pitched sounds above the area of obstruction, distention, tenderness, bowel function- flatus
-NG tube
-IV fluid resuscitation with LR or NSS
-Monitor I&O
-Analgesics
-if the obstruction does not improve surgery is indicated
-parental nutrition may be necessary in some cases to improve the nutrtion before surgery

-acute pain
-deficient fluid volume
-imbalanced nutrition
-paralytic ileus

patches of inflammation in large intestines, can affect ANY part of the GI tract from the mouth to the anus, most often see in the terminal ileus and colon

ALL OF THEM.
1) epithelium
2) lamina propria
3) muscularis musosa
4) submucosa
5) muscularis propria

mucosa
submucosa

segments of normal bowel occuring between diseased portions

lumen
bowel obstruction

bowel
peritoneal

*Watery Diarrhea-- NOT usually bloody
*Colicky/crampy abdominal pain
-fever, fatigue, weight loss can occur is small intestine is involved

CBC: decreases, become anemic, feel weak, low HH
WBC: decreased
K, Cl, Mg, Na- decreases due to diarrhea
Albumin- nutritional status results in protein loss
Stool- possibility of blood, mucus, and pus

variety of medication- prednisone
hospitalization is necessary if patient fails to respond to drug therapy

-food diary
-correct and provent malnutrtion
-provide TPN parentral through IV, replace fluid and electrolyte imbalances
-HIGH calorie, HIGH protein, LOW-residue diet
Avoid smoking because it stimulates GI track
Vitamin and Iron supplements-may need B12

PLACEMENT
always check placement
pull out, check pH, due an x-ray
elemental diet high in calories and are absorbed in the proximal small instesting, often preferred because of their effects on the colonic microflora
stress management
emotional issues such as anxiety, frustration, and depression due to 10-20 BMs per day with rectal discomfort
Rest is IMPORTANT

75% will require surgery
surgery produces remission but has a high reoccurence rate
strictureplasty to widen areas of narrowed bowel
sometimes necessary to resect the diseased bowel and anastamose the ends together

adequate absorption is available to maintain life unless TPN is issued

impaired skin integrity due to diarrhea
anxiety (unpredictable disease)
ineffective coping
ineffective self-health mgmt
imbalanced nutrtion: less than body requirements
decreased albumin
fluid imbalance

colon is to be removed

tube feed
example: ensure-undigested

form of enteral, liquid made of digested components

diffuse inflammation beginning in the rectum and spreading up the colon in a continuous pattern
inflammation and ulcerations occur in mucosa and submucosal layers
ulcerations destroy the mucosal epithelium, causing bleeding and diarrhea
protein loss
pseudopolyps develop

BLOODY DIARRHEA **main difference between ulcerative colitis and crohns
1-2 semi formed stools daily, in moderate 4-5 stools per day, and in severe cases 10-20 times a day
abdominal pain
tenesmus (urge to poop, ineffective painful straining)
rectal bleeding

25-40% wil need surgery at some time during their illness

-total colectomy with rectal mucosal stripping and ileoanal reservoir
-total protocolectomy with continent ileostomy (Kock pouch)
-total protocolectomy with permanent ilesostomy

combination of two procedures
8-12 weeks apart
adaption over 3-6 months
*Able to control defecation at anal sphinctor

rarely used today
pouch is a reservoir and is drained at regular intervals *by insertion of a catheter*
problems include: valve failure, leakage, pouchitis

one stage operation
removal of colon, rectum, and anus with closure. the end of the terminal ileum is brought out through the abdominal wall and forms a stoma or ostomy. The stoma is in the RLQ below the belt
continence is not possible

stoma viability- color, size, may be edematous
mucocutaneous juncture (area where the mucous membrane of the bowel interfaces with the skin)
peristomal skin integrity

not good, could indicate anemia

red, moist, size of a quarter

really bad, could mean dead tissue

-Selfcare instructions given and reviewed before discharge!
-output may be as high as 1500-2000 ml per 24 hours
-oberve for hemorrhage, abdominal abscess, small bowel obstruction, dehydration
-inital drainage will be liquid and mucus like
transient incontinence of mucus from manipulation of anal canal
-kegel exercises to strengthen pelvin floor
-perianal skin care to protect the skin from mucous drainage
-An NG tube may be used until bowel function returns to normal