1020 Exam 3 / part 2
Gastric surgery (568)
- maintain NG tube patency
- doctor may order NS solution irrigation
- check q4h and medicate
- pt needs to be comfortable
- pre-op show how to splint stomach
- observe dressing, odor?
- monitor WBC
- 48 hrs post-op, early ambulation
Stomach Cancer
- rare under 30 yrs
- common over 60 yrs
- there’s no single cause
- some causes: smoked, spicy, salty (carcinogenic) foods
- genetic
- atrophic gastritis
- polyps
- achlorhydria (no stomach acid)
Dx
- endoscopy
- biopsy
Tx
- no medical Tx
- total or sub-total gastrectomy
- Bill Roth surgeries
- know complications!
Upper GI Bleeding
- serious loss of RBCs from GI tract
- can be sudden or insidious
- severity depends if venous, capillary, or arterial
- bright red = no HCL acid involved
- coffee ground = yes HCL acid, has been in stomach
- melena = slow bleed from upper GI source
- * the darker the Melena or hematomesis, the longer the passage thru the tract
- * massive hemorrhage: blood loss of >1500 mL OR 25 % intravascular volume
causes
- drug induced: aspirin, nsaids, corticosteroids
- esophagitis or esophageal varcies
- systemic diseases like leukemia
- stomach or duodenum: PUD, carcinoma, hem, gastritis, polyps
management
- most will stop spontaneously
- locate the cause and treat asap
- VS q 15 minutes
- ringers lactate
- pack RBCs or whole blood
- * fresh frozen plasma is preferred due to no clotting factors
- endoscopy is performed once stable
- re-assess for re-bleeding and shock
- ice lavage via NG tube
Ice Lavage (557)
- shivering is NL
- check for s+s of perforation (board-like abdomen)
- monitor for dysrythmias
Tubes
- decompression
- replacement
- salem sump (never clamp pigtail airway)
- lavine
- intestinal tubes: miller-abbot / cantor
- intestinal tubes have weighted tip, not taped, reposition q2h to allow advancement
- NG irrigation use NS
- always check patency
- if not draining, check to see if it’s in and connected appropriately
(remember: when pts NPO, only ice chips are allowed to be given)
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TPN (total parenteral nutrition) 533
- also known as hyperalimentation or “hyperal”
- used when GI can’t: ingest, digest, or absorb
- nutritional solution is hypertonic
- glucose, proteins, minerals, vitamins
- GOAL: to meet nutritional needs and new tissue growth
- regular IV fluids have no protein and 1L = 107-200 calories (i.e. ringers)
- NL adult requirements 1,200-1,500 calories/day
- TPN via central line / used for long-term
- PPN via peripheral line / used for short-term
- continuous pump
- provides 3-4,000 calories/day
- base is dextrose and protein
- pharmacy will add electrolytes, vitamins, zinc, copper, or manganese
indications
- severe burns
- abd surgery
- complicated surgery
- trauma
- chronic diarrhea
- malabsorption problems
- IBS, paralytic ilius, bowel resection
basic info
- 3 in 1 solution = total nutrient solution (dextrose, proteins, lipids)
- lipids and carbs meet pt energy requirements
- 10, 20, and 30 % lipid solutions
- 10% = 1 cal/mL, 20% = 2 cal/mL, …
- soybean or safflower triglyceride w/ eggphospholipid emulsifier
- maximum fat emulsion shouldn’t exceed 2.5g/kg per day
- given over 12-24 hours
- lipids are NOT filtered (filter should be above lipids)
- if given too fast: N+V and increased temp will present
- contraindicated in pts who can’t metabolize, egg allergies
- use cautiously high risk for fat emboli (fractures)
nursing implications
- check egg allergies
- catheter placement and x-ray confirmation
- strict aseptic technique
- catheter tip is in superior vena cava
- change dressing q3d
- change line and solution q24h
- location is a good bacteria medium
- if site is purulent, culture site for C+S
- weigh daily
- strict I+O
- baseline F+E, glucose
- NEVER increase IV rate
- insulin is in the initial solution
- perform regular fingersticks: due to increase in glucose
- give R insulin sq
- ONLY add R insulin to the bag
- solution is filtered because it is an excellent bacteria medium
- when bag gets to 3-400 mL, prepare new bag at room temp
- * IF new bag isn’t available, call pharmacy and temporarily run a 10% dextrose bag
until next new bag is ready. TPN must run continuously, never abruptly stopped.
- if abruptly d/c = hypovolemic shock could ensue
- slowly titrate off
MONITOR:
- hyperglycemia
- hypovolemic shock
- over/dehydration
- CHF
- pulmonary edema
- F+E imbalances
NDx
- risk for infection r/t catheter
- anxiety r/t not able to ingest
- F+E imbalance r/t hypo/hyper glycemia
IBS (Irritable Bowel Syndrome) 627
- also known as “spastic/nervous colon”
- chronic GI disorder
- exacerbation from causative agents
- starts and stops
- women have it 2-3 Xs more than men
causes
- exact cause unknown
- familial
- pts tend to have panic or anxiety disorders
- diverticular disease
- coffee
- lactose intolerance
- stress
- mental behavior
S+S
- usually start in young adulthood
- diarrhea
- constipation
- abd pain
- bloating
assessment
caffeine? stress? food intolerances? abd pain/distension? relieved by BM? sensation of
non-evacuated stool? mucous in stool?
Dx
- use complaints to make diagnosis
- colonic spasms usually seen
- routine labs
- CBC
- stool for occult blood
- barium enema
teaching
- stress management
- avoid exacerbations
- don’t hold stool
- avoid straining, alcohol, sorbitols (artificial sweetener)
- build good relationship w/ pt to allow them to confide in you, try to identify pt stress
- constipation and diarrhea are both treated with bulk forming Metamucil
- to prevent impaction, drink 3 L qd, unless pt has CHF or renal problems
- don’t add water to the Metamucil until you’re at the bedside
Diet
- fiber given to create routine bowels
- need 30-40 g/d
- eat regularly
- chew slow
Medication
- symptom oriented
- anti-anxieties
- bulk formers / constipation (Metamucil, Mitrolan)
- anti-diarrheas / diarrhea (Lomotil, Imodium)
- anti-spasmotics / pain (Bentyl) 30 min before meals
- anti-depressant / anxiety (Elivil)
- partial agonist / stimulates peristalsis (Zelnorm) not w/ food
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Hernias (677)
- weakness in abd muscle wall, a segment of the bowel or other structure protrudes
cause
obesity, pregnancy, heavy-lifting r/t increased intra-abd pressure
Indirect:
- sac formed from peritoneum
- contains portion of intestine or omentum
- pushes down into inguinal canal
- males: can descend into scrotum
Direct:
- passes thru a weak point in abd wall
Femoral:
- protrudes thru femoral ring
- plug of fat enlarges
- eventually pulls peritoneum and bladder into the sac
Umbilical:
- congenital: appear in infancy
- acquired: obese, pregnancy, heavy-lifting
Incisional/ventral:
- occur at site of previous surgical incision
- result form inadequate healing r/t infection, obesity, malnutrition
Reducible:
- can be put back into cavity without surgery
Irreducible/incarcerated:
- can’t be put back without surgery
Strangulated:
- blood supply cut of by hernia ring
- S+S bowel perforation, abd distention, N+V, pain, fever, tachycardia
Assessment
- pt will complain of the site
- if reducible, bulge will disappear when laying down
- pt does valsalva, look for bulge
- examine ring and contents
- pt coughs once inside inguinal canal
- never force a reduction
- a lump means strangulation
non surgical
- reduction performed
- apply truse and belt to area
- assess skin daily
- apply light powder
- encourage deep breathing
- NO coughing
Surgical
- most treated same day
- laparoscopic
- local anesthesia
- usual pre-op standards
- covered ice to scrotal area
- small pillow elevates scrotum
- void in NL position
- avoid lifting for 2 wks
- can shower in 48 hrs
- NO coughing
- #1 comp. is urinary retention
Hernia plasty:
Herniaorrhaphy:
Colorectal Cancer (669)
- colon, rectum and large bowel
- 95% is adenocarcinoma
- most in the rectosigmoidal region
- can metastasize thru blood and lymph
- can go to liver, lungs, brain, bone, and adrenal glands
genetic predisposition
- familial polyposis
- get colonoscopy every year
personal/dietary factors
- over 50 yrs
- decreased bowel transit time
- high animal fat diet
- fatty, fried food
- refined carbs
- processed foods
- *these foods are considered: chemical mutagens
IBD
- ulcerative colitis
- Crohn’s disease
- other diseases that have been long and severe
Teaching
- regardless of risk, eat low fat, low refined carbs
- eat boiled, baked foods high in fiber
- nsaids reduce cancer incidence
- regular exercise
- multi-vitamins
- female hormone therapy (good/bad?)
- regular screenings
- FOBT: every year
- colonoscopy: q 3-5 years
- sigmoidoscopy: q 5 years
- barium enema: q 5 years
- digital exam: every year after 40
Assessment
- any risk factors for cancer?
- changes in bowel? stool? color? fatigue? abd fullness? weight loss?
S+S
- depends on tumor location
- * rectal bleeding / anemia / changes in stool *
- NO blood = R colon
- YES blood = L colon and rectum
- dull pain
- mass in LRQ
- abd distention or masses
- no bowel sounds indicate complete bowel obstruction
Dx
- FOBT: 48 hrs before; stop nsaids, meats, beets, horseradish, vita C
- carcinoembryotic antigen is elevated
- barium enema
- CT scan
- sigmoidoscopy
- liver scan to locate metastasis
- * colonoscopy is definitive test *
NDx
- pain
- fatigue r/t anemia
- disturbed body image
- ineffective coping r/t uncertainty
- imbal. nutr. less t/r malabsorption or malinjestion
Non surgical mgmt
- based on staging and classifying
Radiation:
- improves overall survival, (don’t wash off markings), helps palliation
- se: diarrhea and fatigue
Chemotherapy:
- thru a central line, kills cancer cells (5FU, leukovorin)
- se: diarrhea, stomatitis, anemia, leuko/thrombocyto-penia, mylosuppression
Surgery
- is the treatment of choice
- remove tumor and small part of good bowel
Colon resection (colectomy):
1. colon removed
2. colostomy (673)
3. abd/peritoneal resection/ ‘A+P repair’
(4 types of colostomy)
R side tumor:
- R hemacolectomy if small tumor
- R ascending colostomy or ileostomy if wide-spread
- there will be a cecostomy for decompression
L side tumor:
- L hemacolectomy if small tumor
- L descending colostomy if wide-spread
Sigmoid tumor:
- sigmoid colectomy if small tumor
- sigmoid colonostomy if wide-spread
Rectal tumor:
- resection with anastamosis (reconnecting)
- permanent colostomy
- A+P repair with colostomy
*Double-barrel stoma:
proximal (upper) = feces / clear bag
distal (lower) = mucous / petroleum jelly dressing, keep moist
Pre-op
- ET (entrastomal therapist) nurse will select site w/o skin fold
- colostomy care
- A+P repair risks: sexual dysfunction, urinary incontinence
- clear diet for 2-3 days
- (golitely) day before
- NPO night before
- (neomycin) enema to reduce infection risk
- prophylactic oral and IV antibiotics to prevent post-op complication
Post-op
- NG tube on low intermittent suction; used for decompression
- check pH with Litmus strip
- if acidic, disconnect/clamp for 30 minutes to give pt antacid
- don’t remove NG tube unless BS are present
- PCA for 24-36 h
- VS q4h
- monitor stoma, should be beefy red, slightly bloody, mucous ok
- call doctor if: stoma dark/purple, lots of bleeding, suture-breakdown
- document skin appearance
- empty bag when 1/3 -1/2 full of stool
- stool will go from liquid to solid
- ascending = liquid
- transverse = pasty
- descending = solid
- know diet ! 673
- sigmoid ostomy is the ONLY one that can be regulated
Hemorrhoids 688
-un-naturally distended veins
- apart of NL structure of the anus
- internal: can’t be seen, above anal sphincter
- external: can be seen, below anal sphincter
- prolapse can become thrombosed or inflamed, or bleed
- pain or bleeding is significant
causes: increased abd pressure, straining at stool, portal HTN, obesity
S+S
- prolapse
- bleeding
- swelling
- itching
- mucous discharge
Prevention
- high fiber diet
- increase liquids
- avoid BM straining
- increase exercise
- maintain healthy weight
Dx
- procto
- digital exam
Hemorrhoidectomy
- veins are cut
- urinary retention possible
- sitz bath
- pain meds are given before first BM
Interventions
- know diet
- cold packs
- sitz bath 2-3 times qd
- don’t sit for long periods of time
- witchazel pads (tucks)
- keep peri area clean
- gently swab, don’t wipe
- avoid straining (docusate)
- avoid irritating laxatives
Peritonitis (634)
Causes
- perforation (appendicitis, endoscopy, trauma…)
- chemical or bacterial contamination of peritoneal cavity
- can lead to: organ failure, paralytic ilius, septicemia, hypovolemic shock
S+S
- * rigid, board-like abdomen *
- rebound tenderness
- tachy
- fever
- confusion
- oliguria
- temp over 101
Dx
- look at S+S
- H+P
- CBC
- F+E
- abd x-ray
- CT scan
- paracentisis (if fluid id present)
Tx
- NG tube for decompression, check drainage
- IV
- analgesic
- peritoneal lavage
- bed rest
- monitor severity of pain
- strict I+O
Appendicitis (631)
- most common reason for ER abd surgery
- common at 20-30 yrs
- appendix has no function in adults
- appendix lumen obstructed, l/t bacteria infection, blood restricted, hypoxia, perforation
- located in RLQ
Assessment
Early S+S
- * abd pain in epigastric or peri-umbilical area *
- N+V, cramping, anorexia
- pain gets worse then shifts to RLQ
- pain increases with activity, relieved by bending over or flexing R hip
Late S+S
- inflammation, tenderness
- Mc Burney’s point / btwn anterior iliac crest and umbilicus / RLQ
- tense muscles over area
- perforation S+S (WBC >20,000)
- temp 99-105
- temp and pulse increase
Dx
- lab findings don’t establish Dx
- moderate increase in WBC (leukocytosis)
- ‘shift to the left’: increase # of immature WBC
- CT shows fecalith impacted appendix
Interventions
- NPO
- IV fluids
- pain meds
- semi-fowler position
- surgery asap, high risk for perforation
- hospitalization 3-5 days
IBD Inflammatory Bowel Disease (648)
(Ulcerative Colitis and Crohn’s Disease)
Ulcerative Colitis
- unknown etiology
- starts and stops
- effects mucosal lining of colon and rectum
(UC vs CD 649)
- malabsorption
- colon wall thickens
- lifestyle disruption
- debilitating, multiple hospital stays
- inflammation and loss of epithelium
- ulcers and abscess formation
- starts in rectum  cecum
- familial
- autoimmune
- found in Jewish and white pts
S+S
- vary
- pain
- bloody diarrhea
- tenesmus
- VS WNL
- low grade temp
- abd distension
- rebound tenderness
- hemorrhage
- bowel obstruction
Assessment
- family history? stool pattern? weight loss? pain? fatigue? precipitating pain factors?
Labs
- H+H low = anemia
- WBC, ERS high = inflammation
- Na, K, Cl low = diarrhea and malabsorption
- hypoalbuminemia
Dx
- barium enema, but with air contrast
NDx
- diarrhea
- acute pain
- imbal. nutr: less than
- anxiety
- risk for decreased fluid vol
Interventions
- relieve S+S
- decrease intestinal motility
- decrease inflammation
- aid in mucosal healing
- monitor fecal volume, color, odor, frequency
- pay CLOSE attention to perianal skin care
- weigh daily
Medications 653
Corticosteroids
- mask s+s of infection
- take with food
- they increase glucose
- Cushing’s syndrome
- use with immunisuppressives
immunosuppressive
- allow decrease of steroid use, when used with steroids
- (cyclosporin)
- prevents colectomy
- monitor WBC, signs of infection
- monitor thrombocytopenia, leukopenia, renal failure, GI ulceration
Anti-diarrheas
- (lomotil)
- (immodium)
Anti-inflammatory
- (sulfasalazine) *
- check allergies to sulfas
- take with full glass of water after meals
h
Diet 657
- if severe; NPO, TPN or PPN
- (vivonex) (ensure) = elemental diet
- no milk or milk products
- low residue diet
- low fiber
- decrease caffeine, pepper, GI stimulants
- restricted activity or bed rest to promote healing
- easy commode access
- usually pts put in private room
- portable deodorizer
Surgery
- indications: bowel perforation, hem, colon cancer, failure of conventional Tx
- different types of colectomy
Total proctocolectomy w/ permanent ileostomy
- colon, rectum, anus removed
- ileum stoma RLQ below belt line
- perianal incision
- not regulated
Pre-op:
- ET visit
- ostomate visit
- (Neomycin)
- enema or laxative
Post-op:
- green/bloody liquid stool
- effluent will decrease, will turn yel-brn and pasty
- minute odor NL, but if bad odor = infection
- wear bag at all times to prevent excoriation of skin
Total colectomy w/ continent ileostomy
- kock
Post-op:
- one-way valve
- monitor effluent
- interior pouch
- small moist dressing
- pt is continent *
- pouch holds 50-75 mL initially
- pt will sense urge to defecate
- will eventually hold 500-700 mL normally