GI Adult Health 2

Crohn's Disease

• Inflammatory bowel disorder affecting all layers of the GI tract in segments from mouth to anus.
• Cause is unknown but associated with altered immunity and genetics.
• Chronic and progressive condition.
• Commonly found in the terminal ileum and proximal colon.
• Inside the GI tract it has a cobblestone appearance due to ulcers.
• The disease has periods of remission and exacerbation.
• Seen in both young and older adults.

Complications of Crohn's Disease

• Bowel obstruction prevents contents from passing through.
• Fistula is an abnormal connection between two body parts.
• Fissure is a tear in the intestinal wall.
• Abscess is an infection.

Absorption and Malabsorption

• Small intestines are where absorption takes place.
• If the small intestine is involved, it can cause malabsorption.
• Pernicious anemia can occur due to decreased absorption of B12.
• Fluid and electrolyte imbalances might occur.
• Sodium and/or potassium depletion can be caused by diarrhea or fistula drainage.

Onset and Symptoms

• Onset is insidious, with symptoms gradually increasing.
• Pain is usually in the right lower quadrant.
• Diarrhea and flatulence may occur.
• Stools may be soft or semi-liquid with mucus and pus.
• Blood in the stool is not typical.
• Urgency with defecation is common.
• Fever may be exhibited.
• Stool may be pale at times.
• Anorexia and weight loss occur.
• Malnutrition and dehydration result.
• Electrolyte imbalances happen.
• Increased peristalsis is present.
• Fatigue can develop.
• Strictures can form, leading to obstructions.
• Fistulas can form to other body parts, including the vagina or urinary tract.

Treatment for Crohn's Disease

• For mild to moderate cases, anti-inflammatory meds like azulfidine are used (sulfa drug).
• Anti-diarrheals such as Imodium can be administered
• Corticosteroids are potent anti-inflammatory medications.
• Flagyl might be used.
• Multivitamins and B12 shots help address deficiencies.
• If these don't work, second-line immunosuppressant drugs like cyclosporin can be tried.
• Biological response modifiers like infliximab or Remicade are another option.
• Surgery is reserved for emergency situations like excessive bleeding, obstruction, or peritonitis.
• Resection is a preferred surgical treatment.

Nursing Interventions

• Normal post-GI surgery nursing care applies.
• TPN or tube feedings may be required.
• Oral intake may be low residue, high protein, and high calorie, gradually introduced.
• Oral diets should be at least 2500 mL per day to replace fluids and electrolytes.
• B12 and iron dextran may be needed (iron given via Z-track injection).
• Monitor weight gain/loss and urinary output (at least 30 cc's/hour).
• Maintain at least 1500 mL per day of urine.
• Bedpans and bedside commodes should be available and emptied quickly.
• Monitor anal excoriation and provide appropriate treatment.
• Provide emotional support and education about the disease.

Diet Recommendations

• Avoid lactose, gas-containing foods (certain vegetables), caffeine, beer, MSG, sugarless gum/mints, highly seasoned foods, concentrated fruit juices, carbonated beverages, and fatty foods.
• Have a diet high in protein.
• Eat small, frequent meals.
• Increase liquid intake.
• Bowel rest may be prescribed with NPO and TPN.

Appendicitis

• Inflammation of the veriform appendix, often obstructed by feces, a foreign body, or a tumor.
• It's an acute condition that can rupture, leading to peritonitis.

Signs and Symptoms

• Rebound pain is felt in the right lower quadrant (McBurney's point).
• There might be a rigid abdomen, especially if ruptured.
• Clients will guard the affected area.
• Fever, nausea, and vomiting are common.
• Anorexia is present.
• Bowel sounds will be decreased or absent.
• WBC count will be higher than 10,000.

Treatment and Interventions

• Treatment includes a surgical appendectomy.
• Antibiotics will be given if there's a perforation.
• No enemas or cathartics should be given.
• Apply ice, not heat.
• Keep the patient NPO.
• Administer IV fluids.
• Monitor vital signs every hour.
• Provide pain relief.
• Provide usual post-op care after abdominal surgery.

Diverticulosis and Diverticulitis

• Usually seen after 40 years of age.
• Lack of exercise, obesity, smoking, and low-fiber diet contribute to the development of these.
• Commonly found in the sigmoid colon.

Diverticulosis

• The presence of pouchlike herniations through the circular smooth muscle of the colon.

Diverticulitis

• Inflammation or infection of one or more diverticula.
• Repeated inflammation can narrow the lumen, causing obstruction.

Complications

• Perforation and abscess formation.
• Peritonitis and obstruction.
• Hemorrhage.

Signs and Symptoms

• Diverticulosis: Usually asymptomatic, but can cause diarrhea or constipation, distension, flatulence, anorexia, nausea, mild cramping, and pain in the left lower abdomen.
• Diverticulitis: Severe pain in the left lower quadrant, fever, elevated WBC, elevated sed rate.
• Untreated diverticulitis can lead to septicemia and septic shock.
• Abdominal distension and nausea/vomiting might also be manifestations.

Septic Shock Symptoms

• Heart rate goes up
• Blood pressure comes down
• Respirations are also going up

Treatment

• Diverticulosis: High fiber diet (fruits and vegetables), bulk-forming laxatives, weight reduction, avoid straining, decrease fat and red meat, exercise.
• Diverticulitis: Low fiber, antibiotics, IV fluids, NG tube (if obstruction or perforation), pain management.
• Monitor labs, focusing on rest and decreasing inflammation.
• After an attack: Advance diet gradually, monitor for peritonitis.
• If bowel rest and antibiotics are unsuccessful, surgical intervention may be necessary.

Surgical Intervention

• Bowel prep pre-op and prophylactic antibiotics, perforation, abscess, peritonitis, or fistula may require resection of the bowel and temporary colostomy.
• Reversal of colostomy is typically in about six weeks to three months.

Peritonitis

• Inflammation of the abdominal peritoneum after fecal matter seeps through a ruptured site.
• Can be caused by a variety of gastrointestinal issues.
• An inflammatory response is triggered, leading to a massive fluid shift and perioneal edema.
• Adhesions may form as the body tries to wall off the infection.
• Septicemia can result if not treated quickly.

Signs and Symptoms

• Severe abdominal pain
• Lying on back or side with flexed knees
• Nausea and vomiting
• Absent peristalsis due to paralytic ileus
• Explosive vomiting is possible.
• Fever and chills
• Weakness and abdominal tenderness
• Rebound tenderness may be reported or observed.
• Muscular rigidity and spasms
• Constipation or diarrhea may occur in early stages.
• Distended, rigid, and tender abdomen
• Signs of shock (increased pulse and respiration, decreased blood pressure)

Treatment and Interventions

• Remove the chemical irritant through surgery.
• Administer parenteral IV antibiotics.
• Replace fluids and electrolytes.
• Provide pain management.
• Use an NG tube to decompress the abdomen, typically set to low continuous or intermittent suction.
• Consider TPN.
• Bed rest in semi-Fowler's position.
• Encourage oral hygiene.
• Monitor I&O and labs.
• Administer prescribed antibiotics and pain medicine.
• Monitor bowel sounds (listen for 5 minutes to confirm absence).
• Encourage deep breathing exercises with incentive spirometry.
• Promote leg exercises to prevent clots.
• Decrease anxiety.
• Ensure meticulous aseptic wound care.
• Provide a nutritious diet if appropriate.
• Avoid lifting anything greater than 10 pounds until cleared by the provider.

Hernias

• Protrusion of the viscera through an abnormal opening or weakened area in a wall of a cavity where it should be contained.

Types of Hernias

• Reducible: Can be manually returned to the original position (by provider).
• Irreducible (Incarcerated): Cannot be returned to the cavity; may cause obstruction.
• Strangulated: Blood supply is occluded, requiring immediate surgery.

Signs and Symptoms

• Palpation reveals a soft, nodular sac.
• Inguinal hernias may cause pain, urgency, and a palpable mass.
• Incarcerated or strangulated hernias can cause obstruction, abdominal distention, and vomiting.

Different Types

• Ventral (Incisional): Weakness at a previous incision site. Common in obese clients or those with multiple procedures in the same area.
• Femoral: Weakness in the lower abdominal wall causing bulges in the groin.
• Inguinal: Weakness in the lower abdominal wall opening; where the spermatic cord comes through in men, and where the round ligament of the uterus emerges in women.
• Umbilical: Protrusion through the umbilicus due to a weakened abdominal lining.

Treatment

• If no discomfort, strangulation, or obstruction, hernias are often left alone.
• Teach the client to recognize signs of complications.
• Manual reduction by the provider and abdominal binder may be used
• Surgical repair (laparoscopically or open incision)

Nursing Interventions

• May require NG tube, IV antibiotics, electrolyte replacement, and analgesics.
• Watch for urinary retention and wound infections
• With inguinal hernia repair, monitor scrotal edema; elevate the scrotum, apply ice, and provide support with a jock strap or briefs.
• Encourage deep breathing, splinting of the incision, and analgesics.
• Limit activities and avoid heavy lifting for 5-6 weeks.

Hiatal Hernia

• Protrusion of part of the stomach or abdominal viscera through a weakness in the diaphragm.

Risk Factors

• Obesity and trauma
• The primary sign and symptom is heartburn, often following overeating.

Complications

• Strangulation, leading to infarction and ulceration, requiring surgery.

Treatment

• Small, frequent meals
• Lose weight as needed
• Use antacids.
• Avoid smoking, tight clothing, and straining with bowel movements.
• Sleep with the head elevated.
• Surgery is a last resort: gastropexy (suturing the stomach in place) or laparoscopic Nissen fundoplication (wrapping the fundus of the stomach around the lower esophagus).

Intestinal Obstruction

• Intestinal contents cannot pass through the GI tract.

Mechanical Obstruction

• Most occur in the ileum of the small intestine.
• Causes include adhesions, incarcerated hernias, impaction, diverticular disease, tumors, intussusception, and volvulus.

Non-Mechanical Obstruction

• Due to a neuromuscular or vascular disorder, or related to general anesthesia during surgery.
• Decreased muscle action to move feces results in paralytic ileus.

Mechanical Issues

• Interrupts secretion and reabsorption of fluid in the small intestine.
• Fluid, bacteria, and swallowed air build up.
• Pressure increases, causing edema, congestion, and necrosis.
• Bowel may rupture, leading to hypovolemic shock.

Signs and Symptoms

• Depend on location and extent of the obstruction.
• Hyperactive bowel sounds above the obstruction; absent bowel sounds below it
• Abdominal pain, distension, and guarding.
• Nausea and vomiting, Constipation, and inability to pass flatus
• Vomiting may lead to alkalosis.
• Decreased blood pressure and dehydration.

Treatment and Interventions

• NG tube for decompression, check for patency, and irrigate with normal saline.
• Restore fluids and electrolytes.
• Non opioid analgesics are preferrable as opioid analgesics interfere with peristalsis.
• Elevate the head of the bed 30-40 degrees.
• Monitor I&O and bowel sounds in each quadrant.
• Ensure NG tube is functioning.
• Administer analgesics, monitor for hypovolemic shock, labs, and fluid and electrolytes.
• Post-op: Fowler's position, breathe through the nose, deep breathing and coughing
• NG tube will be in place until bowel activity returns (document bowel sounds, girth, and expulsion of flatus).
• A temporary bowel diversion may be necessary.

Colorectal Cancer

• Signs and symptoms depend on the site of the tumor.

Signs and Symptoms

• Rectal bleeding
• Alternating constipation and diarrhea
• Gas
• Cramping pain in the lower abdomen or distension, abdominal pain, nausea and vomiting
• Cachexia is also possible. This indicated there are lack of nutrients due to lack of appetite, which results in weight loss and general ill health.
• The most common clinical manifestation is chronic blood loss and anemia.

Diagnosis

• Through fecal occult blood test, early screening, and colonoscopy to screen for colorectal cancer (every 10 years), and also remove polyps during colonoscopy.
• Should have a baseline at 50 years of age.
• CA will be elevated.
• Cologuard is also good

Treatment

• Radiation, chemotherapy, and surgical.

Radiation

• Can be used prior to surgery to decrease the chance of cancer cell implantation.
• Decrease the size of the tumor and decrease the rate of lymphatic involvement so that it will lead to metastasis.

Chemotherapy

• Typically when there is systemic disease that is incurable by radiation or surgery alone
• Maybe be used for palliative therapy to decrease the tumor size and relieve symptoms

Surgical

• Surgery is can be curative.
• The surgery removes the cancer and it performs an end-to-end anatomosis
• An extensive surgery that's also possible is an abdomino perineal resection.
• This requires a permanent colostomy, because the distal sigmoid, rectum, and anus are all removed.
• The surgeon may pack the wounds with drain.
• Expect a lot of drainage from the wound in the first 24 hours.
• It can occur after to decrease reocurrence

Pre-Op Interventions

• They will get a bowel prep
• Follow a two-three day liquid diet
• Laxatives
• Enemas
• Oral antibiotics to sterilize the bow
• Remember to provide post-op instructions, because post-op they will not understand what the surgery is to follow.

Post-Op Interventions

• Vital Signs
• Monitor that dressing
• Monitor NG tube
• Monitor the drains.

Complications

• Paralytic ileus
• A stoma that necrose or abscess could occur and should be observed carefully
• They should also be beafly red.
• Urinary retention is a potential problem and with it, there's potential also for sexual dysfunction.

Hemmorrhoids

• Dilated veins that occur inside or outside the anal sphincter.
• Straining and pregnancy are different causes.

Interal Hemmorrhoids

• On the inside, duh!

External Hemmorrhoids

• On the outside

Signs and Symptoms

• Constipation
• Occur from dirrhea
• Bleeding which cause bright red blood in stool.
• Severe pain
• Thrombosed which means it has become hard
• Itching can occur around in the anal area

Treatment

• High Fiber diet
• Increased fluid intake
• Warm compresses
• Analgesic ointment
• Tux are good also
• Sit baths are recommended to help increase circulation
• Rubber band litigation is perrformed
• Sclerotherapy is injected with a what to cause sclerosing of the hemmorhoid
• Crysurgery- Freezing of vessels
• It can be burnt also by infrared Photo Coagulation
• Hemmorhoid Excision is when they are removed- used if severe bleeding, prolaps

Nursing Interventions

• Ice pack, they can numb and local anesthetics
• Cushions can be helpful to those in pain
• Post op patients need vital signs to rule out bleeding
• Soft Diet
• Giveanalgesia before going to the bathroom.
• Encourage fluids and help with soft diet
• Make sure there is moderate exercise that is happening
• Report any signs of infection