Main drug therapy for ulcerative colitis is sulfa for one year

Key concept this client will be sulfa for at least a year after the diagnosis is made corticosteroids they made be on or off depending on exacerbation, If they have anorexia may have to give the IV fluids

Chrons Di ease

Effects any part of the GI tract not just the move from the rectum through the sigmoid like ulcerative colitis

Cause is unknown, periods of exacerbation and remissions just like ulcerative, however incidence is more rare than ulcerative

Inflammation that effects different segments of the GI tract, most commonly in the small intestine, fistulas and abscesses will occur, the esophagus, stomach, duodenum involvement rare.

Inflammation result in thicken and narrowing of lumen (stricture may develop) which then diminish the blood flow in the colon which causes fistulas, inflammation is not continuous so normal bowel between the inflammation are normal. What will happen with this client?

Clinical symptoms diarrhea that is not bloody biggest difference in chrons and ulcerative, abdominal pain and severe cramping and they also pain around the umbilicus, fistulas because of the narrowing, and the obstructions, they can be perianal or vaginal, impaired absorption of fat so they have malnutrition systemic complications include arthritis, liver disease, kidney stones, renal disease

Key concept fistula formation between the bowel and bladder is very common in chrons disease, and is evident when a patient develops a fever and symptoms of a UTI and foul smelling urine. Often time when we test test the urine we find feces in the urine that tells you they have a fistula.

INTESTINAL OBSTRUCTION

Intestinal obstructions may be partial or complete. There are mechanical and non mechanical obstructions

Chrons disease is actually an obstruction too because of the strictures.

Mechanical:

Caused by an occlusion of the lumen any kind of occlusion is mechanical Occurs mostly in the ileum and the small intestine90% of all obstructionspain comes and goes in waves (cramping)

Non mechanical

nuerovascular or vascular disordermost common is paralytic ileusKey concept: Paralytic ileus is a lack of intestinal peristalsis and the presence of no bowel sounds, this is your assessment findings. Typically occurs after abdominal surgery, high risk after surgery for paralytic also caused by peritonitis, chrons, ulcerative colitis, and electrolyte abnormal especially hypokalemia, also after lumbar or thoracic injury or fractures its a nerve issue.

Pathofluids, gas and contents accumulate proximal to the obstruction (distension), this causes decreased fluid absorption, and further dilates the intestines, diminishes blood flow, causing edema, congestion and necrosis which can rupture the bowel, hypo tension can also happen

s/s abdominal distension, n & v, abdominal pain, inability to pass flatus, constipation, proximal to the obstruction you will hear borborgymi(hyperactive, high pitched bowel sounds you dont need a stethoscope that loud)

SMALL BOWEL OBSTRUCTION

Rapid onset, projectile vomiting which can relieve the abdominal pain, but fecal movement only for short time, abd distension (non or minimal) and crampy pain

LARGE BOWEL OBSTRUCTION
Vomiting is rare, because impact lower, but if they do vomit it will be fecal matter, patient has suction in stomach and you will see feces in the container, very dangerous lack of bowel sounds, and pain, constipation and distension(check girth)

Therapeutic management for both

decompress small intestines (NG)decompress large intestinal (enemas, rectal tubes, sigmiodscopy, colonscopy, NG tube)IV tpn because they are NPO Surgery: Colectomy, colostomy ilostomy (most common txt is surgery)

MALIGNANCIES OF LARGE INTESTINE

Second most common cancer of cancer deathsHighest in cecum, ascending colon and sigmoid colon

commonly spreads to the liver via the portal vein

Key concept: the early sign of cancer is change in bowel habits.

Clinical manifestation:

Left side (sigmoid)Rectal bleedingalternating constipation.diarrheanarrow ribbon like stoolsKey concept: Patient with a lesion on the sigmoid side (left) will have alternating diarrhea, constipation and rectal bleeding and narrow ribbon like stools. Usually with right sided lesions usually asymptomatic, stools can be liquid, they have vague abdominal pain, can be anemic because of occult blood and start to have bleeding in stool, this stool will look darker than left sided. If the tumor is large enough you can palpate it

Therapy:Endoscopic polyectomy laser therapy (can be palliative if the cancer has spread)Irrigate the peritoneum with anti neoplastic agents

Surgery(most common)Right hemicolectomyif the cancer is in the cecum, ascending colon, hepatic fixture or transverse colon

Left sidedLeft transverse colon, splenic fixture, descending colon, sigmoid, upper rectum are resectedIf cancer is within 5 cm of anus, abdominal perineal resection is done

abdominal perineal resectionremoval of distal rectum an anus thru perineal incision; then the proximal sigmoid becomes permanent colostomy

The areas of colostomy: ascending, descending, ileostomy, and sigmoid.

Care for the colostomyperineal wounds: drains or left open to drain

drain left in place until drainage less than 50cc/24hrs

side to side positioning, sitz bath

Ostomy care and patient teachingExplain what it is

home care instruction (wash with soap and water change bag when 1/3 or full)

financial aspects (equipment) (case management)

diet (no spicy foods, decrease gassy foods, hold fiber then add as tolerated

sexual activity and social life

Because liquid stools we need to prevent dehydration by drinking 3000ml day at least because large intestine is not there to absorb the fluid.

ABDOMINAL TRAUMA

Blunt traumapenetration (gun shot, stabbings) these have higher mortality rate due to gross contamination Key concept: if the patient has been stabbed in the abdomen priority nursing care includes assessing the airway and assessing s/s of hypovalemic shock (hypo-tension, tachycardia, anxiety, agitation, cool and clammy skin, confusion, decreased urine output) also the nurse does remove the object or palpate, listen carefully with stethoscope to hear bowel sounds can be important, then notify doctor of hypovalemic shock if present.CIRRHOSIS OF THE LIVER

Chronic progressive degeneration of the liver cells as they regenerate they become fibrotic, this interferes with normal activity and impeded vascular flow

ALCOHOLIC CIRRHOSIS

Most commonExcess alcohol formationscar formation throughout the liverKey concept: usually associated with alcohol abuse, first change of liver is an accumulation of uncomplicated fat cells in the liver are potentially reversible if the person stops drinking alcohol early. All these fat deposits in the liver cells can be reversible. If alcohol continues large scar formations happen throughout the liver and it is irreversible.

POST NECROTIC CIRRHOSIS Complication of viral, toxic, or autoimmune hepscar tissue is throughout the liver.

BILIARY CIRRHOSISAssociated with chronic biliary obstruction and infectionliver is fibrotic with presenting jaundice

CARDIAC CIRRHOSISCaused by rt sided heart failureCor pulmonale (enlargement of rt vent)constrictive pericarditis (fiber thicken of pericardium caused by gradual scarring or fibrosis of the membrane) heart becomes very rigid tricuspid insufficiency

Clinical manifestationsGI disturbances (anorexia, dyspepsia, flatulence, n&v, change in bowel habits)abdominal pain RUQ or epigastriumEnlargement of spleen and liverOthers:Feverlassitude (weakness; low energy)weight lossKey concept: as a result of the livers altered metabolism of carbs and proteins or fats, dull ache in the stomach and very heavy feeling in RUQ due to stretching o swelling

Late s/sJaundiceperipheral edemaascitesskin lesion hematologic disordersendocrine disturbancesperipheral neuropathiesKey concepts: s/s of sever liver dysfunction with accompanying jaundice include clay stools, peritis and dark urine. Later stages may result in portal hypertension. Skin lesions include spider angiomas which are small dilate blood vessels, due to an increase circulation of estrogen as a result of the damaged liver inability to metabolize steroid hormones.

HEPATIC ENCELAPATHYRisk for a comas/s of impending coma esticsis (flapping tremors)ask the patient to extend there arms out in front of them if the client is unable to hold this position they are at risk

Increase ammonia causes Slow deep respirations and hyperactive reflexes mental changes.

Treatment includes lactolos which detracts the ammonia in the gut and causes diarrhea, explosive diarrhea which expels the ammonia thereby decreases the levels. This help improve the nervous system.

PORTAL HYPERTENSION

Increased central venous pressuresplenomegalylarge collateral veinsascitessystemic hypertensionesophageal varices

Key concept: structural damage in the liver cause this due to cirrhosis which compresses and destroys hepatic veins Changes result in obstruction of the normal flow of blood to the portal system which is what supplies the liver with blood results in portal hypertension. The goal is to reduce the risk for bleeding associated with portal hypertension, therefore the patients are often given stool softeners

Key concept: Esophageal varices are complexed veins at the end f the esophagus and they are enlarged and swollen as a result of portal hypertension. Common in cirrhosis. Die within 6 weeks. The nurse must assess the client for hemorrhage. The patient will be txt with balloon tapanode to reduce bleeding in the esophagus, 250ml of air inflate, x-ray confirm placement. NURSING: Deflate the balloon every 8-12 hrs to avoid necrosis. The most common complication of balloon tampanode is aspiration pneumonia, therefore suction and frequent oral hygiene must be performed.

ASCITESDue to decreased albumin and increase portal hypertensionperipheral edemaabdominal distension due to water and proteins in the abdominal areaaccumulation of serous fluid in the abd, the lymp are unable to carry away excess proteins and water causing them to leak through the liver and into the peritoneal cavity. Retention of sodium as well as increased antiduertic hormone causes additional water in the abd. Because of increase edema there is decreased invascular volume and decreased renal blood flow, and decreased glumaular activity

Key concept: clients with severe ascites must be evaluated for respiratory changes, such as decreased lung expansion bc of diaphragm pressure place the client in the fowler's position to relieve pressure on the diaphragm. Patients with ascites should never be in a flat position, the patient might also be more comfortable in the tripod position. There number on issue is breathing.

S/s in ascites that accompanying: peritoneal distension, umbilical (cullens) stria, dry cough, sunken eyeballs, decreased urine and hypokalemia which may b due to the diuretics they are placed on,

TREATMENT FOR ASCITESparacentitis can not take to much because will have hypo tension.

PANCREATITISInflammation of the pancreasKey concepts: Some patients recover completely, some clients still have reoccurring attacks, and other chronic complications. IN the us the most common cause is alcoholism followed by gallbladder issues.

Client may assume may positions to relieve the pain. Pain is due to the distension of the pancreas, peritoneal irritation and obstruction of the biliary tract.

S/sn/vlow grade feverleukocytoshypotensiontachycardiajaundiceabd tendernessguardingGrey turners (bruising of the flanks)Cullens electrolyte imbalancehypocalemia which is associated with pacreatitis and includes muscle twitching, digit numbness, seizure and mental confusion.

The nurse should plan to administer calcium gluconate.

SURGICAL INTERVENTIONSNecessary for acute pancreatisis r/t gallstones. And also an abscess, Percutaneous drainage of a pseudocyst usually necessitates a drainage tube left in placement

Nursing managementNPOSmall feeds beginning to introduce carbs slowlybland diet no stimulants-coffee or alcoholneed fat soluble vitaminsTPN may be needed