Med Surg Exam III week 8 Final Study Guide. Latest 2021

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Signs and symptoms (S/S) of intestinal obstruction Can be mechanical (adhesions, tumor, stool, herniation, intussession, involvus) or nonmechanical (neuromuscular or vascular eg paralytic ileus – ... no peristalsis/ bowel sounds). Most occur in small bowel, most adhesions (days or years after surgery) Paralytic ileus occurs to some degree after abdom surgery – can be hard to tell if PI or adhesions Distention leads to ↑intraluminal bowel pressure, = ↑ capilliary permeability, = fluid extravasation, = reduction in circulating blood vol/ hypovolemia + hypovolemix shock.If blood flow inadequate, bowel tissue becomes ischemia. Can lead to perforation, systemic infection, death. If obstruction is high (eg pylorus), metabolic alkalosis may result from loss of gastric HCl acid through vomiting or NG intubation. If located in small bowel, dehydration occurs rapidly. Dehydration and lyte imbalances do not occur if obstruction occurs in large bowel. General o Nausea/vomiting o Poorly localized abdominal pain o Abdominal distention o Inability to pass flatus o Obstipation (failure to pass stool or gas) o S/S of hypovolemia o High pitched bowel sounds above obstruction leading to absent bowel sounds Proximal small intestine obstructions o Rapidly developing nausea & projectile vomiting of bile o Vomiting usually relieves pain o Usually no abdominal distention Distal small intestine obstruction o Gradual onset o Vomitus may be orange-brown and smell like feces o Abdominal distention is common Lower intestinal obstruction Persistent colicky pain Mechanical obstruction o Pain that comes and goes in waves as peristalsis tries to push past obstruction (in contrast, PI produces more constant generalized discomfort) Strangulation (lack of blood flow to intestine)  Severe, constant pain with a rapid onset Abdominal distension is usually absent or minimally noticeable in proximal small intestine onstructions and markedly increased in lower intestinal obstructions. Abdominal tenderness and rigidity are usually absent unless strangulation or peritonitis has occurred. Ascultation reveals high pitched sounds above area of obstruction, bowel sounds may also be absent. Patient often notes borborygmi (audible sounds produced by hyperactive motility). Temp rarely rises above 100 F (37.8 C) unless strangulation or peritonitis has occurred. Intestinal Obstruction—complete or partial blockage of the small or large intestine; can be due to mechanical problems such as tumors, neurological difficulties such as paralytic ileus; increased pressure above blockage and decreased peristalsis below; higher the obstruction, the more severe the symptoms. 1. Assessment a. Small intestine obstruction (1) Vomiting—possibly fecal (2) Abdominal distention (3) Absence of stools (4) Dehydration b. Large bowel obstruction—slower progression of symptoms (1) Constipation (2) Abdominal distention (3) Cramplike pain in lower abdomen 2. Medical Diagnosis a. Patient history and physical exam b. Flat plate x-ray of abdomen c. Laboratory studies 3. Medical Treatment a. Surgery b. Miller-Abbott or Cantor tube for intestinal decompression c. IV hydration d. Prophylactic antibiotics e. I & O monitoring 4. Nursing Interventions a. Assess and document patient’s symptoms b. Record intake and output, including amount and character of drainage from decompression tube c. Maintain NPO d. Monitor hydration e. Routine postop care if surgery 2. Medical and surgical recommendation for patients with polyps: sessile, hyerplastic, adenomatous, and familial adenomatous polyposis All polyps are considered abnormal and should be removed o Colonoscopy with polypectomy is preferred method Sessile: Flat, broad based, small Pedunculated: large, attached by a small stalk Tend to start sessile and become pedunculated – commonly found in rectosigmoid area. Most asymptomatic, rectal bleeding and occult blood in stool most common signs. Hyperplastic: Benign, non-neoplastic. Usually <5mm. Never cause clinical symptoms Adenomatous: Precursor to cancer. Tubular, villous adenomas. Neoplastic; closely related to colorectal adenocarcinoma o Risk of CA increases with polyp size Familial adenomatous polyposis: thousands of polyps, 80% lifetime risk of colorectal cancer. o Autosomal dominant (so 50% of offspring will have – anyone with a family history of FAP should have genetic testing in childhood) disorder causing hundreds or thousands of polyps that will become cancerous (80% lifetime risk), usually before age 40. If gene is present colorectal screening begins at puberty, and annual colonoscory at age 16. o Tx: prophylactic removal of colon and rectum with ileostomy or ileo-anal anastomosis, usually by age 25. Pts with FAp also at risk for other cancers so lifetime surveillance essential. Polypectomy, colectomy Removing the adenomatous polyps decreases the occurrence of colorectal cancer. NB Colonoscopy, sigmoidoscopy, barium enema, and CT/MRI colonography (virtual colonoscopy) are used to discover polyps. All are considered abnormal and should be removed. Colonoscopy preferred becaue it allows evaluation of total colon and polyps can be removed immediately (polypectomy). Only polyps in the distal colon and rectum can be detected and removed during sigmoidoscopy. After polypectomy observe for rectal bleeding, fever, severe abdominal pain, and abdom distention – may indicate hemorrhage or performation. 3. Nursing management and D/C teaching for patients with diverticulosis and diverticulitis (TC) (slide 24 in lower GI lecture, p.1047) Diverticulosis = outpouching of mucosa through the intestinal wall, forming sacs Diverticulitis = inflammation, infection, perforation of sacs, peritonitis, GI bleed Dietary recommendation: high fiber, ↑ fluids, ↑ physical activity Conservative therapy: High fiber diet (fruits/ veg, decreased fat intake/ red meat). No evidence that nuts and seeds should be avoided – in fact, nuts and popcorn may have a protective effect. Dietary fiber supplements Stool softners Anticholinergics Mineral oil Bed rest Clear liquid diet Oral antibiotics Bulk laxatives Weight reduction (if overweight) Avoid increasing intra abdominal pressure – valsalva, straining to poo, vomiting, bending, lifting, and tight restrictive clothing. Acute care: Abx, NPO, IV fluids Possible resection of involved colon for obstruction or hemorrhage Possible temporary colostomy Bed rest NG suction For acute diverticulitis, goal of tx is to let colon rest and inflammation subside Pts at home can be managed with oral abx and clear liquid diet. Hospitalize if cannot tolerate oral fluids, severe symptoms, co-morbid conditions, immunosuppressed. Pts in hospital are kept on NPO status, bed rest, and fluids and IV abx are given Observe for signs of abscess, bleeding, peritonitis, and monitor WBC count When acute episode subsides, give oral fluids and then progress to semisolids diet. Pt can ambulate too. Surgery is reserved for patients with complications such as abcess or obstruction that cannot be managed medically. Usu resecation + anastome (temporary colostomy may be required). Provide patient will a full explanation of the condition to increase compliance to regimen. Diverticular Disease (Diverticulosis/Diverticulitis)—Diverticulosis is an outpouching of the mucosa of the colon; diverticulitis is an inflammation of the outpouching (diverticulum). 1. Assessment a. Abdominal cramps b. Lower-quadrant tenderness [Show More]

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