Acute GI Lower Conditions PDF

https://www.toonzone.net/best-episode-ever-toonzone-talks-joe/ ACUTE GASTROINTESTINAL CONDITIONS – LOWER GI HLTENN043 Implement and monitor care for a person with acute health conditions By the end of this lesson, students should be able to: Discuss disorders of the lower GI tract Explore different...

https://www.toonzone.net/best-episode-ever-toonzone-talks-joe/ ACUTE GASTROINTESTINAL CONDITIONS – LOWER GI HLTENN043 Implement and monitor care for a person with acute health conditions By the end of this lesson, students should be able to: Discuss disorders of the lower GI tract Explore different surgeries Differentiate difference between stomas of GI and urinary systems Discuss pre and postop care of the client undergoing surgery Acute Abdomen Acute abdomen – emergency conditions  Bowel obstruction  Appendicitis  Peritonitis  Pancreatitis  Strangulated hernias  Abdominal trauma  Wound dehiscence / evisceration 3 https://www.mja.com.au/podcast/207/11/mja-podcasts-2017-episode-71-fast-tracking-acute-abdomen-dr-katherine-broughton S&S ACUTE ABDOMEN  Severe abdominal pain, tenderness at the site, temperature, nausea and vomiting  Can be caused by infections, trauma, rupture  Treatment depends on the condition  Analgesia may be required depends on the condition 4 http://drangiehealth.com/wp-content/uploads/2015/06/colonoscopy.jpg 5 Diverticulitis Polyps Cancer ACUTE GASTROINTESTINAL DISORDERS COLONOSCOPY 6 COLONOSOCPY  The examination of the Lower GIT (colon to distal end of small intestine)  Performed using a ‘twilight’ anaesthetic in day surgery  NBM @ 6 hours prior to procedure  Patient will need to have completed a bowel prep prior to procedure to totally evacuate the bowel. 7 Swinburne https://www.youtube.com/watch?v=kcenBy18nIc 8 APPENDICITIS  Inflammation of the appendix  Causes:  Mucosal ulceration → inflammation → obstruction → distension and increased pressure → increased bacteria, inflammation and pressure →blood supply impeded → severe pain → perforation → peritonitis http://www.andhrawishesh.com/health/621-disorders-care/58756-appendicitis-a-digestive-disorder.html 9 APPENDICITIS  Presentation:  Right lower quadrant      tenderness Pyrexia Nausea / vomiting Anorexia Increased WCC with serology Rebound tenderness on palpation 10 APPENDICITIS  Management:  Monitor vital signs  Pain assessment  IV fluid replacement  Antibiotics  Nil orally  Prep for OT  Post op care 11 PERITONITIS  Inflammation of the peritoneum  Causes:   S&S:   Trauma, ischaemia, perforation of abdominal organ Nausea and vomiting, abdominal pain, rebound tenderness and abdominal rigidity, pyrexia Nursing considerations:  NBM / ?NGT insertion  IV therapy and antibiotics  Surgery to correct cause (ie organ rupture)  Pre / post operative care 12 HERNIA  An abnormal protrusion of an organ or structure through a weakened area in the abdominal wall.  A hernia sac is formed by the peritoneum protruding through muscle wall  May be caused by coughing, straining, heavy lifting or at a surgical site  Umbilical  Inguinal  Femoral  Surgical  Strangulated  Incarcerated (not able to be reduced manually) 13 INGUINAL HERNIA  Locations:  Inguinal  located in the groin where the spermatic cord (males) or round ligament (females) emerges from the abdominal wall.  Most common in males. May become strangulated or incarcerated. 14 / http://www.paediatricsurgeondubai.com/2017/10/09/inguinal-hernia-repair-in-children Swinburne https://www.nejm.org/doi/full/10.1056/NEJMicm1208699 15 FEMORAL  occurs where the femoral artery enters into the femoral canal. UMBILICAL  May contain part of the peritoneum and bladder. results from abnormal muscle structures around the umbilicus. Common in neonates and obese women who have had multiple pregnancies. Abdominal viscera protrude outside the body.  May become strangulated or incarcerated. 16 https://www.momjunction.com/articles/umbilical-hernia-after-pregnancy_00387566/ INCISIONAL HERNIA  Locations:  Incisional  also called ventral. Develops at site of previous surgery. Usually a mid-line incision.  Also caused by abdominal weakness from https://www.webmd.com/digestive-disorders/ss/slideshow-hernia-guide infection or impaired wound healing. 17 MANAGEMENT Post op care: Surgical intervention - mesh may be used to strengthen the abdominal wall prior to closure. Routine post anaesthetic observations (RPAO’s) Deep breathing and coughing exercises Ice packs to elevate scrotum and reduce swelling (if inguinal) Avoid activities which raise intra-abdominal pressure Observe for S&S of infection Avoid lifting, driving, sexual intercourse for 2-6 weeks May return to work after 2 weeks 18 INFLAMMATORY BOWEL DISEASE Crohns disease (small intestine and/or the colon.)  GI tract from the mouth to the anus  strictures (intestinal obstruction or narrowing of the intestinal wall)  abscesses (boils) and skin tags (swollen lumps or ‘flaps’ of thickened skin occurring just outside the anus)  fistulae (abnormal channels connecting different loops of intestine to itself or to other body organs)  fissures (ulcerated tears or cracks in the lining of the anal canal) malabsorption and malnutrition Ulcerative colitis (large intestine or colon.) inflamed lining = larger than normal amount of intestinal lubricant / mucus which sometimes contain pus.  profuse bleeding from deep ulcers  perforation (rupture) of the colon  toxic megacolon  https://www.crohnsandcolitis.com.au/about-crohns-colitis/ 19 INFLAMMATORY BOWEL DISEASE Crohns disease  https://www.quora.com/How-do-I-know-if-I-have-Crohns-disease Crohns disease Ulcerative colitis https://www.quora.com/How-do-I-know-if-I-have-Crohns-disease https://www.crohnsandcolitis.com.au/about-crohns-colitis/ 20 https://www.inxmedical.com/blog/crohns-disease-recognizing-the-signs-and-symptoms/ 21 INFLAMMATORY BOWEL DISEASE 22 BOWEL CANCER MOST BOWEL CANCERS START AS BENIGN, NON-THREATENING GROWTHS – CALLED POLYPS – ON THE WALL OR LINING OF THE BOWEL. 23 LOWER GI SURGERY  Colonoscopy  Colectomy +/- rectum & anus  Haemorrhoidectomy  Rectopexy  Proctectomy Brady, A.-M., McCabe, C., & McCann, M. (2014). Fundamentals of medical-surgical nursing : a systems approach. John Wiley & Sons. 24 BOWEL RESECTION A bowel resection is done to:  treat cancer in the small intestine, colon, rectum or anus  treat or relieve symptoms of cancer that has spread to the intestine  remove a blockage in the intestine (called a bowel obstruction)  remove as much cancer as possible (called debulking)  remove precancerous conditions before they become cancer (called prophylactic surgery)  remove parts of the colon that are damaged by an inflammatory bowel disease or diverticulitis  fix a tear or hole in the intestine (called a bowel perforation) HTTPS://WWW.CANCER.CA/EN/CANCER-INFORMATION/DIAGNOSIS-AND-TREATMENT/TESTS-AND-PROCEDURES/BOWELRESECTION/?REGION=SK 25 POSTOPERATIVE  IVT  +/- NGT  IDC  WOUND +/- DRAIN  +/-STOMA  Vital signs  FBC  Pain management  NBM 26 WHAT IS A STOMA?  ‘Stoma’ = ‘opening’  ‘Ostomy’ = a surgical created opening  A stoma is a surgically created opening of the bowel or urinary system onto the abdomen, to facilitate drainage of faeces or urine. 27 http://www.slhd.nsw.gov.au/concord/gastro/Stomas/ilostomy.html Stomas are covered by a bag/pouch that collects excretions! Stomas can be temporary or permanent. Anastomosis = join the ends back together 28 http://www.webmd.com/digestive-disorders/colostomy-stoma Bowel stomas Colostomies - formed from a piece of colon/large intestine Ileostomies - formed from the ileum or small intestine Urinary stomas (Urostomy) TYPES OF STOMAS Ileal conduits - formed in the urinary tract using a section of ileum 29 INDICATIONS FOR A STOMA  to divert faeces away from a bowel anastamosis to facilitate healing, (temporary measure). https://www.healthline.com/health/anastomosis permanent alternatives for clients with debilitating bowel or bladder diseases. i.e cancer / crohn’s disease / trauma 30 WHAT IS A COLOSTOMY? The colon is brought through a surgical opening in abdominal wall to form a stoma. Location of the stoma depends on the part of the colon used. 31 INDICATIONS FOR A COLOSTOMY Bowel carcinoma (most common reason in adults) Diverticulitis Diverticulosis  Crohn's Disease Congenital abnormalities Trauma Bowel ischaemia Crohn’s Disease Faecal incontinence 32 http://thediverticulitisblog.blogspot.com.au/ http://easypediatrics.com/pediatric-crohns-disease LOCATION OF COLOSTOMIES Colostomies are named after the area of the colon that forms the stoma 33 http://info.cancer.ca/cce-ecc/default.aspx?cceid=8312 http://colonicirrigationwirral.com/ TYPES OF COLOSTOMIES End Colostomy only one end of the colon is brought out through the abdominal wall; the other end is either removed or sewn shut. 34 http://www.ostomy.or.kr/html/jangru_shape.php http://www.dansac.com/Default.asp?Action=glossary&search_letter=e typically. temporary protect a surgical join (further down) in the bowel. faecal diversion Plastic rod placed in the middle of the proximal and distal openings to prevent it from going back into the abdomen. Distal end also know as mucous fistula as mucous still produced by bowel and can exit there – also can have occasional stool and/or mucous output through anus. Loop Colostomy 35 http://www.ostomy.or.kr/html/jangru_shape.php http://www.dansac.com/Default.asp?Action=glossary&search_letter=e A LOOP ILEOSTOMY OR COLOSTOMY  securicaremedical.co.uk 3/11/10 1900  http://qwickstep.com/search/loop-ileostomy.html?p=7 3/11/10 1900 36 LOOP STOMA SUPPORT DEVICE  coloplast.com 3/11/10 1900 37 TYPES OF COLOSTOMIES Double barrel is similar to loop except there are 2 separate ends, one will excrete faeces the other mucous. Some bowel diseases will produce mucous. Can be temporary and allow the bowel to rest. Double-barrel Colostomy 38 http://www.zanecohencentre.com/logon/45-ibd/patients/ostomy-details http://www.coloplast.com/ostomycare/topics/basicinfo/howostomyiscreated/ WHAT IS AN ILEOSTOMY? A stoma created by a surgical procedure in which a part of the ileum (small intestine) is attached to the abdominal wall in order to bypass the large intestine. Crohns or ulcerative colitis 39 http://reachingforfringe.blogspot.com.au/2012/10/nation-ostomy-day-and-ryans-ileostomy.html http://www.upstate.edu/surgery/healthcare/colorectal/ileostomy.php ASSESSING THE STOMA  Site – what type of stoma is this and what type and volume of effluent should be expected.  Colour - should appear beefy and red,  Size – oedema is to be expected  Spout – how far does the stoma protrude from the skin?  Output – volume depends on the type of stoma. bile, gas, mucous, faecal fluid / matter or blood.  Peristomal skin –redness, tenderness, rashes or weeping. 40 COMPLICATIONS OF STOMAS: SKIN EXCORIATION Caused by: exposure to bowel/urinary waste products Irritation from wafer removal Irritants; humidity; pressure Skin irritation from effluent Manage with: 41 Appliance change Skin protectants Skin irritation from adhesive removal http://www.dansac.com/Default.asp?Action=glossary&search_letter=m COMPLICATIONS OF STOMAS: STOMA RETRACTION Occurs when the stoma is “pulled” down to or below the skin level.  Caused by: Colon remains inactive after surgery Weight gain  Manage with: Change pouch system to match stoma shape Surgery may be required 42 http://images.wocn.org/photos/4 COMPLICATIONS OF STOMAS: PERISTOMAL HERNIA Occur when part of the bowel (colon) bulges into the area around the stoma (under the skin).  Caused by: Pressure on the abdomen  Manage with: Use of a hernia belt. Changes to the pouch system to create a proper seal. 43 Surgery may be required http://stoma_mgt_phil.tripod.com/complicationsavoid.htm COMPLICATIONS OF STOMAS: PROLAPSE the bowel protrudes out of the stoma and above the abdomen surface.  Caused by: increased abdominal pressure.  Manage with: Surgery may be required Pouch system needs to be changed to match the stoma shape 44 COMPLICATIONS OF STOMAS: STENOSIS a narrowing or tightening of the stoma at or below the skin level, can cause obstruction.  Caused by: Swelling Inappropriate sized opening in the COMPLICATIONS OF STOMAS: STENOSIS skin  Manage with: If the stoma is mild, a qualified person may enlarge it by stretching it with his finger. If the stenosis is severe, surgery is 45 usually needed. http://stoma_mgt_phil.tripod.com/complicationsavoid.htm Swinburne POST OPERATIVE - mild to moderate oedema of the stoma in the first 5-7 days post-op. - Blood oozing from the stomal mucosa when touched is normal because it is so vascular. - The stoma will generally not function for first 3-4 days – as peristalsis returns the discharge will be mucous and serosanguinous fluid. 46 FAECAL OUTPUT FROM A STOMA  ileostomy is usually semi-liquid or a “toothpaste” consistency.  ascending colon stoma can also be runny to thick in consistency.  transverse colon output is thick to semi formed,  descending or sigmoid colon faeces ranges from semi formed to formed.  descending colon or sigmoid colon stool is near formed, it may only work 1 – 2 times a day. 47 OSTOMY APPLIANCES  tradeget.com 3/11/10 1930  diytrade.com 3/11/10 1947 48 ONE PIECE APPLIANCE  One piece units 49 TWO PIECE APPLIANCE Two parts: A flange (with adhesive backing) – also called wafer or baseplate An attachable pouch. The flange stays in place while the pouch is removed New pouch is attached to the same flange. The pouch does not need to be reattached to the skin each time – good for sensitive skin. 50 SKIN PROTECTION  Skin barrier/sealant wipes  Pectin-based paste or paste strips/rings:  Paste or powder that protects skin against output that contains digestive enzymes Particularly for ascending or transverse colostomies  Other pastes are used to fill in skin creases and create a flat surface to apply the pouch 51 EMPTYING A STOMA BAG Empty a drainable pouch or replace the colostomy bag as needed or when it is no more than 1/3 full – too much weight can cause leakage! Drain contents of pouch into a receptacle or toilet. Clean pouch opening. 52 http://myflexicare.com/us/ostomy/emptying.php http://colorkiddos.net/2010/04/cleaning-the-colostomy-bag/ CHANGING A STOMA BAG  Remove old pouch gently so as not to put tension on the skin. Patient removing stoma pouch 53 http://www.eakin.eu/userguides/professionals.aspx CHANGING A STOMA BAG  Clean stoma and surrounding skin.  Observe stoma colour, size and output and document.  Observe any changes in peristomal skin integrity. 54 http://monroeplan.kramesonline.com/HealthSheets/3,S,82172 CHANGING A STOMA BAG 1. Cut hole to stoma size using the template – little or no skin (13mm) should be exposed. 2. Apply paste, barrier wipes as needed 1. 2. 3. 3. Apply prepared pouch over stoma – remove adhesive cover; press firmly. 55 http://www.allegromedical.com/ostomy-supplies http://www.mountnittany.org/articles/healthsheets/863 URINARY DIVERSIONS  Cystectomy  Neurogenic bladder, congenital anomalies, strictures, trauma to the bladder, and chronic infections with deterioration of renal function  Types:  Ileal conduit  Cutaneous ureterostomy  Nephrostomy 56 ILEAL CONDUIT  A small portion of small intestine is resected  One end is closed and the other end is brought through the abdominal wall to form a stoma  The ureters are implanted into the portion of intestine.  urine drains into the conduit and out through the stoma into a urostomy appliance.  indicated for cancer of the bladder, neurogenic bladder and severe incontinence. 57  mercksource.com 3/11/10 1910  gastrointestinalatlas.com 3/11/10 1910 58 Cutaneous ureterostomy 59 NEPHROSTOMY - Swinburne Catheter is inserted into the pelvis of the kidney may be temporary or permanent. Advantage: No need for major surgery Disadvantage: High risk of renal infection / calculus formation. May have to be changed every month. Catheter should not be clamped, should remain open 60 Swinburne KOCK POUCH -loops of intestine are anastomosed together and then connected to the abdomen via the stomal segment. Ureters are attached to the pouch above a valve, which prevents reflux of urine to the kidney. A second valve is placed in the intestinal segment leading to the stoma -Patient will need to self-catheterise every 4-6 hours 61 Swinburne COMPLICATIONS - Breakdown of the anastomoses in the GI tract. - Leakage from the ureteroileal or ureterosigmoid anastomosis - Wound infection - Stomal necrosis 62 POST OP CARE – URINARY DIVERSION  Stents placed in ileal conduit for 7-10 days to promote urinary drainage. If continent urostomy, will have catheter or stent in stoma (sutured in place) to allow drainage from reservoir.  Drain tube in pelvic area for drainage of blood and surgical fluids.  May have NGT until effective intestinal peristalsis returned. May then start on clear liquids to advance as tolerated.  With ileal conduit, clear pouch placed over stoma so that it can be easily assessed.  Careful visualisation of stoma in contact with catheter.  Monitor urine output carefully. 63 POST OP CARE  Blood in urine is expected in immediate postop period with gradual clearing.  Mucus is present in urine because it is secreted by the intestines as a result of the irritating effect of the urine.  Ileal conduit stoma oedema will begin to subside within 7 days after surgery and continue to decrease in size gradually for the next 6 to 8 weeks. 64 REINTRODUCING FLUIDS https://meded.ucsd.edu/clinicalmed/abdomen.htm Postoperative Ileus = temporary impairment of bowel motility after abdominal surgery. POI usually 48-72 hours post surgery Presents as intolerance of oral feeding, distended abdomen, absent bowel sounds, N&V, failure of passage of flatus &/or bowel movement. FESHARAKIZADEH, M. ET AL. (2013) POSTOPERATIVE ILEUS IN COLORECTAL SURGERY: IS THERE ANY DIFFERENCE BETWEEN LAPAROSCOPIC AND OPEN SURGERY? HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC3938009/ 65 REINTRODUCING FLUIDS UNTIL S&S of bowel motility return, patient NBM! Then slow introduction of … Water Clear fluids Light diet Full diet As tolerated 66 REFERENCES  Khair , J 2005, ‘Guidelines for testing the placing of nasogastric tubes’, Nursing times. Net, vol.101, no.20, p.26  Koutoukidis. G, Stainton. K, Hughson. J (2013) Tabbners Nursing Care;Theory and Practice 6th Ed; Elsevier  Lemone, P et al. 2011, Medical-Surgical Nursing: Critical Thinking in Client Care (First Australian Edition), Pearson Australia, Frenchs Forest.  Marieb. E, (2012) Essentials of Human Anatomy and Physiology; 10th Ed, Pearson Benjamin Cummings  Memmler’s The Human Body in Health & Disease; (2012) 10th Ed ;Lippincott Williams & Wilkins  https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Enteral_feeding_and_medication_administration/  https://www.crohnsandcolitis.com.au/about-crohns-colitis/ accessed 07/09/18 1401  Wimpenny, P & Royal District Nursing Society, 2011, Nasogastric/Nasoenteric Tube care and Management, accessed March 8th, 2013 from Joanna Briggs Institute http://connect.jbiconnectplus.org.ezproxy.holmesglen.vic.edu.au/ViewPdf.aspx?0=3520&1=2