Chapter 57 Care of Patients with inflammatory intestinal disorders/ GUARANTEED PASS/ Download To Score An A

Chapter 57 Care of Patients with inflammatory intestinal disorders Vocabulary • Immunomodulators o -alter a person's immune response. o Alone, they are often not effective o -In combination with steroids, they may offer a synergistic effect to a quicker response, decreasing the amount of steroids needed. o -Biologic response modifiers (BRMs) used for UC include infliximab (Remicade) and adalimumab (Humira). o -report any signs of a beginning infection, including a cold, and to avoid large crowds or others who are sick! • Glucocorticoids o -alter a person's immune response. o Alone, they are often not effective o -In combination with steroids, they may offer a synergistic effect to a quicker response, decreasing the amount of steroids needed. o -Biologic response modifiers (BRMs) used for UC include infliximab (Remicade) and adalimumab (Humira). o -report any signs of a beginning infection, including a cold, and to avoid large crowds or others who are sick! • Sulfasalazine o (Azulfidine, Azulfidine EN-tabs), aminosalicylate o -metabolized by the intestinal bacteria into 5-ASA, which delivers the beneficial effects of the drug, and sulfapyridine, which is responsible for unwanted side effects. • Norwalk or noro-virus o - resistant to low temperatures - fecal to oral route - person to person - contaminated food and water; surfaces - Vomiting causes the the virus to become airborne - incubation time is 1-2 days -older adults can become hypovolemic and experience electrolyte balances • Lomotil o Can contribute to habit forming falls and drowsiness • Fulminant o Greater than 10 bloody stools; severe anemia, colonic distention on xray • Aminosalicylates o - to treat mild to moderate UC and for maintenance -What are the first line treatments for remission maintenace of IBS -sulfasalazine (Azulfadine) - BLISTERS, PEELING FROM HEAD TO TOE • Remicade o -Biologic Response Modifier used with steroids for UC and Crohns teach patients any sign of a cold, prone to illness, be careful of mental status change • Fistulas o -an abnormal passage from one organ or cavity to another. Need dietary consult, patient will need 2-4000 more calories, risk for electrolyte loss like potassium - Flagyll, high risk for abscesses Inflammatory disorders • Intestinal o Appendicitis ▪ -Can fill with seeds and become enflamed, anybody and any age, useless piece) ▪ -Pain in McBurneys point ▪ -Pain relieved by lying down in fetal position ▪ -WBC> 10,000 ▪ -Removed Lacroscopically very quickly o Peritonitis ▪ -Ruptured appendix ▪ -UC perforation ▪ -Ruptured Gallbladder ▪ -Surgical procedure ▪ -Can kill if not attended • Bowel o Gastroenteritis (acute) ▪ Contaminated food and H2O ▪ -Ulcerations ▪ -Bloody diarrhea o Crohn’s disease ( chronic) ▪ Most often in the terminal ileum, with patchy involvement through all layers of the bowel ▪ -15-40 yr ▪ -5-6 soft, loose stools per day, non-bloody ▪ -Fistulas (common) ▪ -Nutritional deficiencies ▪ -Frequent o Ulcerative colitis (chronic) ▪ -Higher risk for passing blood and perforation ▪ -Bloody diarrhea and constipation ▪ -Anemia r/t blood loss (check Hb and HCT) ▪ -Electrolytes and nutritional status. ▪ -Fistula • -Abnormal opening from one cavity to another • -urine in stool • -stool in urine • -Chrohn's or UC • Anal o Anorectal abscess ▪ prevent infections, add ointments with zinc base to heal tissues o Anal fissure ▪ -Priority concern Infection AEB inflammation r/t contamination from stool -Uncommon • Parasitic infections o giardia, amoeba o -Rest bowel o -Suction GI acids • Food poisoning o Salmonellosis o Staph o Escherichia coli o Botulism Group activity for inflammatory disorders 1. priority concerns 2. common manifestations 3. treatment options 4. include collaborative health care team 5. potential complications 6. implications for older adults • individualized questions o appendicitis ▪ signs/symptoms before and after rupture o peritonitis ▪ teaching plan for surgical patient o gastroenteritis ▪ medications used o ulcerative colitis ▪ profile of typical patient; dietary teaching plan o Crohn’s disease ▪ Teaching plan o Diverticulosis vs. diverticulitis ▪ Compare/contrast o Anorectal abscess, and fissure, anal fistula ▪ Key differentiations o Food poisoning ▪ Teaching plan regarding organisms Appendicitis: • Appendicitis is an acute inflammation of the vermiform appendix that occurs most often among young adults. It is the most common cause of right lower quadrant (RLQ) pain. Inflammation occurs when the lumen (opening) of the appendix is obstructed (blocked), leading to infection as bacteria invade the wall of the appendix. The initial obstruction is usually a result of fecaliths (very hard pieces of feces) composed of calcium phosphate-rich mucus and inorganic salts. All complications of peritonitis are serious. Gangrene and sepsis can occur within 24 to 36 hours, are life threatening, and are some of the most common indications for emergency surgery. Perforation may develop within 24 hours, but the risk rises rapidly after 48 hours. Perforation of the appendix also results in peritonitis with a temperature of greater than 101° F (38.3° C) and a rise in pulse rate. o Considerations for older adults ▪ Appendicitis is relatively rare at extremes in age. However, perforation is more common in older people, causing a higher mortality rate. The diagnosis of appendicitis is difficult to establish in older adults because symptoms of pain and tenderness may not be as pronounced in this age-group. This difference results in treatment delay and an increased risk for perforation, peritonitis, and death. • Assessment o History taking and tracking the sequence of symptoms are important because nausea or vomiting before abdominal pain can indicate gastroenteritis. Abdominal pain followed by nausea and vomiting can indicate appendicitis. Ask about risk factors such as age, familial tendency, and intra-abdominal tumors. Classically, patients with appendicitis have cramplike pain in the epigastric or periumbilical area. Anorexia is a frequent symptom with nausea and vomiting. Perform a complete pain assessment. he pain becomes more severe and steady and shifts to the RLQ between the anterior iliac crest and the umbilicus. This area is referred to as McBurney's point (Fig. 57-1). Abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis. Often there is a moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000/mm3 with a "shift to the left" (an increased number of immature WBCs). A WBC elevation to greater than 20,000/mm3 may indicate a perforated appendix. An ultrasound study may show the presence of an enlarged appendix. If symptoms are recurrent or prolonged, a CT scan can be used. • Nonsurgical management o Keep the patient with suspected or known appendicitis on NPO to prepare for the possibility of surgery and to avoid making the inflammation worse. o Action alert ▪ For the patient with suspected appendicitis, administer IV fluids as prescribed to maintain fluid and electrolyte balance and to replace fluid volume. If tolerated, advise the patient to maintain a semi-Fowler's position so that abdominal drainage, if any, can be contained in the lower abdomen. Once the diagnosis of appendicitis is confirmed and surgery is scheduled, administer opioid analgesics and antibiotics as prescribed. The patient with suspected or confirmed appendicitis should not receive laxatives or enemas, which can cause perforation of the appendix. Do not apply heat to the abdomen because this may increase circulation to the appendix and result in increased inflammation and perforation! • Surgical management o An appendectomy is the removal of the inflamed appendix by one of several surgical approaches. Uncomplicated appendectomy procedures are done via laparoscopy. o A newer procedure known as natural orifice transluminal endoscopic surgery (NOTES) (e.g., transvaginal endoscopic appendectomy) does not require an external skin incision. In this procedure the surgeon places the endoscope into the vagina or other orifice and makes a small incision to enter the peritoneal space. o The surgeon may perform an exploratory laparotomy to rule out appendicitis. A laparotomy is an open surgical approach with a large abdominal incision for complicated or atypical appendicitis or peritonitis. o The patient is prepared for general anesthesia and surgery as described in Chapter 14. After surgery, care of the patient who has undergone an appendectomy is the same as that required for anyone who has received general anesthesia. o If complications such as peritonitis or abscesses are found during open traditional surgery, wound drains are inserted and a nasogastric tube may be placed to decompress the stomach and prevent abdominal distention. Administer IV antibiotics and opioid analgesics as prescribed. Help the patient out of bed on the evening of surgery to help prevent respiratory complications. • Laparoscopy o MIS procedure for appendicitis , PT can return after 1-2 weeks - can either go through umbilicus or vagina • Laparotomy o - exploratory if diagnosis not defined - general anesthesia ( follow post guidelines) o Complications ▪ - Peritonitis or abscesses - The NG tube provides a way to decompress the stomach and prevent abdominal distention -NOTE: if showing signs of distention with NG tube, first priority is to confirm placement - Administer iv opioids and antibiotics -Hospitalized for 3-5 days - Return to normal activity for 4-6 weeks Peritonitis • result of the "walling off" of fluid failing and bacteria and inflammation spread - can be caused by perforation, diverticultis, PUD, ecoli, streptococcus, staphylococcus, pneumococcosis- 50 ml of fluid o Third spacing ▪ when diagnosis and treatment of peritonitis are delayed, the body responds by shunting blood ( hyperemia) Fluid is then shifted into peritoneal cavity - leads to hypovolemic shock or decrease in circulating volume ( pallor, diaphoresis, tachycardia, hypotension) ▪ clinical manifestations • -hypovolemic shock or decrease in circulating volume ( pallor, diaphoresis, tachycardia, hypotension) peristalsis stops - respiratory problems as a result of increased abdominal pressure • Peritonitis is a life-threatening, acute inflammation and infection of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity. Normally the peritoneal cavity contains about 50 mL of sterile fluid (transudate), which prevents friction. A local reaction involves vascular dilation and increased capillary permeability, allowing transport of leukocytes and subsequent phagocytosis of the offending organisms. If this walling-off process fails, the inflammation spreads and contamination becomes massive, resulting in diffuse (widespread) peritonitis. When diagnosis and treatment of peritonitis are delayed, blood vessel dilation continues. The body responds to the continuing infectious process by shunting extra blood to the area of inflammation (hyperemia). Fluid is shifted from the extracellular fluid compartment into the peritoneal cavity, connective tissues, and GI tract ("third spacing"). This shift of fluid can result in a significant decrease in circulatory volume and hypovolemic shock. Severely decreased circulatory volume can result in insufficient perfusion of the kidneys, leading to acute kidney injury. Peristalsis slows or stops in response to severe peritoneal inflammation. Respiratory problems can occur as a result of increased abdominal pressure. • Assessment o - guardlike abdomen o - abdominal pain ( localized or sometimes referred to the shoulder or chest) o - distended abdomen o - nausea, anorexia, vomiting o - diminishing bowel sounds o - rebound tenderness o - tachycardia o - dehydration from high fever o - decreased urine output o -hiccups o Ask the patient about abdominal pain, and determine the character of the pain (e.g., cramping, sharp, aching), location of the pain, and whether the pain is localized or generalized. Ask about a history of a low-grade fever or recent spikes in temperature. Several factors: the stage of the disease, the ability of the body to localize the process by walling off the infection, and whether the inflammation has progressed to generalized peritonitis. The patient most often appears acutely ill, lying still, possibly with the knees flexed. Movement is guarded, and he or she may report and show signs of pain (e.g., facial grimacing) with coughing or movement of any type. During inspection, observe for progressive abdominal distention, often seen when the inflammation markedly reduces intestinal motility. Auscultate for bowel sounds, which usually disappear with progression. The cardinal signs of peritonitis are abdominal pain, tenderness, and distention. White blood cell (WBC) counts are often elevated to 20,000/mm3 with a high neutrophil count. Blood culture studies may be done. Abdominal x-rays can assess for free air or fluid in the abdominal cavity, indicating perforation. An abdominal ultrasound may also be performed. • Nonsurgical management o Hypertonic iv fluids - broad spectrum antibiotics - IV fluids to replace those collected in peritoneum and bowel - Monitor daily weight - Monitor input and output ( hourly) - NPO and Ngtube to decompress stomach -respiratory and oxygen o The health care provider prescribes hypertonic IV fluids and broad-spectrum antibiotics immediately after establishing the diagnosis of peritonitis. Monitor daily weight and intake and output carefully. A nasogastric tube (NGT) decompresses the stomach and the intestine, and the patient is NPO. Apply oxygen as prescribed. Administer analgesics, and monitor for pain control • Surgical management o Surgery focuses on controlling the contamination, removing foreign material from the peritoneal cavity, and draining collected fluid. Exploratory laparotomy (surgical opening into the abdomen) or laparoscopy is used to remove or repair the inflamed or perforated organ (e.g., appendectomy for an inflamed appendix; a colon resection, with or without a colostomy, for a perforated diverticulum). Before the incision(s) is closed, the surgeon irrigates the peritoneum with antibiotic solutions. Several catheters may be inserted to drain. Multi-system complications can occur with peritonitis. Loss of fluids and electrolytes from the extracellular space to the peritoneal cavity, NGT suctioning, and NPO status require that the patient receives IV fluid replacement. If the surgeon requests peritoneal irrigation through a drain, maintain sterile technique during manual irrigation. Assess whether the patient retains the fluid used for irrigation by comparing the amount of fluid returned with the amount of fluid instilled. o Action Alert ▪ Monitor the patient's level of consciousness, vital signs, respiratory status (respiratory rate and breath sounds), and intake and output at least hourly immediately after abdominal surgery. Maintain the patient in a semi- Fowler's position to promote drainage of peritoneal contents into the lower region of the abdominal cavity. This position helps increase lung expansion. • Diagnostic o CT scan, ultrasound, abdominal x-ray o Blood culture is done to rule out septicemia with peritonitis o Lab values ▪ Bandemia, 20,000 wbc - fluid and electrolyte - BUN, Creatine, H and H - Pao2 and Paco2 • Community based care o When discharged home, assess the patient's ability for self-management at home with the added task of incision care and a reduced activity tolerance. Provide the patient and family with written and oral instructions to report these problems to the health care provider immediately: o • Unusual or foul-smelling drainage o • Swelling, redness, or warmth or bleeding from the incision site o • A temperature higher than 101° F (38.3° C) o • Abdominal pain o • Signs of wound dehiscence or ileus o Patients with large incisions heal by second or third intention and may require dressings, solution, and catheter-tipped syringes to irrigate the wound. A home care nurse may be needed to assess, irrigate, or pack the wound and change the dressing as needed until the patient and family feel comfortable with the procedure. If the patient needs assistance with ADLs, a home care aide or temporary placement in a skilled care facility may be indicated. Review information about antibiotics and analgesics. Teach patients to refrain from any lifting for at least 6 weeks after an open surgical procedure. Gastroenteritis • Gastroenteritis is a very common health problem worldwide that causes diarrhea and/or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract. Norovirus (also known as Norwalk-like viruses) is the leading foodborne disease that causes gastroenteritis. It occurs most often between November and April because it is resistant to low temperatures. The incubation time is 1 to 2 days. • In most cases of gastroenteritis, the illness is self-limiting and lasts about 3 days • Assessment o Ask about recent travel. Also inquire if the patient has eaten at any restaurant in the past 24 to 36 hours. Large outbreaks have resulted from contaminated spinach and lettuce in the United States. The patient who has gastroenteritis usually looks ill. Nausea and vomiting typically occur first, followed by abdominal cramping and diarrhea. For patients who are older or for those who have inadequate immune systems, weakness and cardiac dysrhythmias may occur from loss of potassium (hypokalemia) from diarrhea. Monitor for and document manifestations of hypokalemia and hypovolemia (dehydration). o Action alert ▪ For patients with gastroenteritis, note any abdominal distention and listen for hyperactive bowel sounds. Depending on the amount of fluids and electrolytes lost through diarrhea and vomiting, patients may have varying degrees of dehydration manifested by: • Poor skin turgor • Fever (not common in older adults) • Dry mucous membranes • Orthostatic blood pressure changes (which can cause falls, especially for older adults) • Hypotension • Oliguria (scant urinary output) In some cases, dehydration may be severe. Dehydration occurs rapidly in older adults. Monitor mental status changes, such as acute confusion, that result from hypoxia in the older adult. These changes may be the only clinical manifestation of dehydration in older adults. • Interventions o For any type of gastroenteritis, encourage fluid replacement. Teach patients to drink extra fluids to replace fluid lost through vomiting and diarrhea. Oral rehydration therapy (ORT) may be needed. Examples of ORT solutions include Gatorade, Pedialyte, and Powerade. Drugs that suppress intestinal motility may not be given for bacterial or viral gastroenteritis. Use of these drugs can prevent the infecting organisms from being eliminated from the body. o Treatment with antibiotics may be needed if the gastroenteritis is due to bacterial infection. Examples of drugs that may be prescribed include ciprofloxacin (Cipro), levofloxacin (Levaquin), or azithromycin (Zithromax). If the gastroenteritis is due to shigellosis, anti-infective agents such as trimethoprim/sulfamethoxazole (Septra DS, Bactrim DS, Roubac image) or ciprofloxacin (Cipro) are prescribed. Teach the patient to avoid toilet paper and harsh soaps. Ideally, he or she can gently clean the area with warm water or an absorbent material, followed by thorough but gentle drying. Cream, oil, or gel can be applied to a damp, warm washcloth to remove stool that sticks to open skin. Special prepared skin wipes can also be used. Protective barrier cream can be applied to the skin between stools. Sitz baths for 10 minutes 2 or 3 times daily can also relieve discomfort. If leakage of stool is a problem, the patient can use an absorbent cotton or panty liner. eep the perineal and buttock areas clean and dry. The use of incontinent pads at night instead of briefs allows air to circulate to the skin and prevents irritation. o During the acute phase of the illness, teach the patient and family about the importance of fluid replacement. o Drug alert ▪ Diphenoxylate hydrochloride with atropine sulfate (Lomotil, Lomanate) reduces GI motility but is used sparingly because of its habit-forming ability. The drug should not be used for older adults because it also causes drowsiness and could contribute to falls. • Epidemic viral gastroenteritis o caused by many parvo-type organisms - transmitted by fecal-oral route in food and water - incubation period is 10-51 hours - communicable during acute illness • Bacterial GAstroenteritis: Campylobacter enteritis o - transmitted by fecal-oral route or by contact with infected animals or infants - incubation period: 1-10 days - communicable for 2-7 weeks - Azithromycin • Shigellios o - transmitted by direct and indirect fecal oral routes - incubation period 1-7 days - communicable during acute illness to 4 weeks - humans possible carriers for months - use Cipro Chronic Inflammatory bowel disease • Ulcerative colitis and Crohn's disease are the two most common inflammatory bowel diseases (IBDs) that affect adults. Ulcerative colitis • chronic - begins in the rectum and proceeds in a continuous manner toward the cecum - etiology is unknown - peak incidence of age: 15-25 and 55-65 years - 10-20 liquid bloody stools a day - complications are hemorrhage and nutritional deficiencies -need for surgery in infrequent • • Ulcerative colitis (UC) creates widespread inflammation of mainly the rectum and rectosigmoid colon but can extend to the entire colon when the disease is extensive. Associated with periodic remissions and exacerbations (flare-ups). The intestinal mucosa becomes hyperemic (has increased blood flow), edematous, and reddened. In more severe inflammation, the lining can bleed and small erosions, or ulcers, occur. Abscesses can form in these ulcerative areas and result in tissue necrosis (cell death). Continued edema and mucosal thickening can lead to a narrowed colon and possibly a partial bowel obstruction. • The patient's stool typically contains blood and mucus. Patients report tenesmus (an unpleasant and urgent sensation to defecate) and lower abdominal colicky pain relieved with defecation. Malaise, anorexia, anemia, dehydration, fever, and weight loss are common. Extraintestinal manifestations such as migratory polyarthritis, ankylosing spondylitis, and erythema nodosum are present in a large number of patients. • Pathophysiology o Intestinal mucosa becomes HYPEREMIC, REDDENED AND EDAMATOUS. Lining can bleed and cause erosion or ULCERS. Abscesses can lead to necrosis. Continued edema and mucosal thickening lead to NARROWING OF THE COLON • Etiology and genetic risk o The exact cause of UC is unknown, but a combination of genetic, immunologic, and environmental factors likely contributes to disease development. With long-term disease, cellular changes can occur that increase the risk for colon cancer. • Cultural considerations o Ulcerative colitis is more common among Jewish persons than among those who are not Jewish and among whites more than non-whites. • History o collect data on family history of IBD, previous and current therapy for the illness, and dates and types of surgery. Obtain a nutrition history, including intolerances. Ask about usual bowel elimination pattern (color, number, consistency, and character of stools), abdominal pain, tenesmus, anorexia, and fatigue. Note any relationship between diarrhea, timing of meals, emotional distress, and activity. Inquire about recent (past 2 to 3 month) exposure to antibiotics suggesting C. diff. Has the patient traveled? Ask about recent use of NSAIDs that can cause a flare-up of the disease. Ask about any extraintestinal symptoms such as arthritis, mouth sores, vision problems, and skin disorders • Assessment o Family history -milk products -fried spicy foods -ask about usual bowel elimination patter - ask about recent exposure to antibiotics -triggers - alleviates o Symptoms ▪ malaise, anorexia, anemia, dehydration, fever and weight loss, inflamed joints, sores around mouth o Vital signs are usually within normal limits in mild disease. In more severe cases, the patient may have a low-grade fever (99° to 100° F [37.2° to 37.8° C]). The physical assessment findings are usually nonspecific, and in milder cases the physical examination may be normal. Viral and bacterial infections cause symptoms similar to those of UC. Note any abdominal distention. Fever associated with tachycardia may indicate peritonitis, dehydration, and bowel perforation. Assess for clinical manifestations associated with extraintestinal complications, such as inflamed joints and lesions inside the mouth. o Psychosocial assessment ▪ The inability to control the disease symptoms, particularly diarrhea, can be disruptive and stress producing. Severe illness may limit the patient's activities outside the home with fear of fecal incontinence resulting in feeling "tied to the toilet." Severe anxiety and depression may result. Mealtimes may become unpleasant experiences. Encourage and support the patient while exploring: • The relationship of life events to disease exacerbations • Stress factors that produce symptoms • Family and social support systems • Concerns regarding the possible genetic basis and associated cancer risks of the disease • Internet access for reliable education information • Laboratory o As a result of chronic blood loss, hematocrit and hemoglobin levels may be low. An increased WBC count, C-reactive protein, or erythrocyte sedimentation rate (ESR) is consistent with inflammatory disease. Blood levels of sodium, potassium, and chloride may be low. Hypoalbuminemia (decreased serum albumin) is found in patients with extensive disease from losing protein in the stool. o Other diagnostic assessment ▪ Magnetic resonance enterography (MRE) is the major examination used to study the bowel in patients who have IBD. Teach the patient that he or she will need to fast for 4 to 6 hours prior. The patient drinks a contrast medium, which can cause diarrhea. A colonoscopy may be done to aid in diagnosis, but the bowel prep can be especially uncomfortable for patients with inflammatory bowel disease (IBD). Frequent colonoscopies are recommended when patients have longer than a 10-year history of UC involving the entire colon because they are at high risk for colorectal cancer. In some cases, a CT scan may be done to confirm the disease or its complications. Barium enemas with air contrast can show differences between UC and Crohn's disease. • Nonsurgical management o Nonsurgical management includes drug and nutrition therapy. The use of physical and emotional rest is also an important consideration. Teach the patient to record color, volume, frequency, and consistency of stools to determine severity of the problem. o Monitor the skin in the perianal area for irritation and ulceration. Stool cultures may be sent. Have the patient weigh himself or herself 1 or 2 times per week. If the patient is hospitalized, remind unlicensed assistive personnel to weigh him or her on admission and daily in the morning before breakfast. • Drug therapy o Includes aminosalicylates, glucocorticoids, antidiarrheal drugs, and immunomodulators. Teach patients about side effects and adverse drug events (ADEs). The aminosalicylates are drugs commonly used to treat mild to moderate UC and/or maintain remission. These drugs, also called 5-ASAs, are thought to have an anti-inflammatory effect by inhibiting prostaglandins. o Glucocorticoids, such as prednisone and prednisolone, are corticosteroid therapies prescribed during exacerbations of the disease. Once clinical improvement occurs, the corticosteroids are tapered because of the adverse effects that commonly occur with long-term steroid therapy (e.g., hyperglycemia, osteoporosis, peptic ulcer disease, increased risk for infection). For patients with rectal inflammation, topical steroids in the form of small retention enemas may be prescribed. o Antidiarrheal drugs may be prescribed. These drugs are given very cautiously, however, because they can cause colon dilation and toxic megacolon. Common antidiarrheal drugs include diphenoxylate hydrochloride and atropine sulfate (Lomotil) and loperamide (Imodium). o Immunomodulators are drugs that alter a person's immune response. Alone, they are often not effective in the treatment of ulcerative colitis. However, in combination with steroids, they may offer a synergistic effect. Biologic response modifiers (BRMs) used for UC (and Crohn's disease, discussed later in this chapter) include infliximab (Remicade) and adalimumab (Humira). BRMs are used more commonly in management 1177of Crohn's disease. These drugs cause immunosuppression and should be used with caution. Teach the patient to report any signs of a beginning infection, including a cold, and to avoid large crowds or others who are sick! • Nutrition Therapy and rest: o -Low fiber -Low or no dairy -F &E balance (dehydration and hypokalemia) -Iron because bleeding -.8-1 g protein for ea. Kilo of body weight o Are kept NPO to ensure bowel rest. The physician may prescribe total parenteral nutrition (TPN). Patients with less severe symptoms may drink elemental formulas such as Vivonex PLUS or Vivonex T.E.N, which are absorbed in the small bowel and reduce bowel stimulation. Diet is not a major factor in the inflammatory process, but some patients with ulcerative colitis (UC) find that caffeine and alcohol increase diarrhea and cramping. For some patients, raw vegetables and other high-fiber foods can cause GI symptoms. Lactose- containing foods may be poorly tolerated. Teach patients that carbonated beverages, pepper, nuts and corn, dried fruits, and smoking are common GI stimulants. Patient activity is generally restricted because rest can reduce intestinal activity, provide comfort, and promote healing. Ensure that the patient has easy access to a bedpan, bedside commode, or bathroom o Complementary and alternative therapies ▪ Examples include herbs (e.g., flaxseed), selenium, and vitamin C. Biofeedback, hypnosis, yoga, acupuncture, and ayurveda (a combination of diet, yoga, herbs, and breathing exercises) may also be helpful. These therapies need further study. • Interventions o -Adequate nutrients -Daily weights -I & O -Tissue breakdown -Correct amount of exercise -Monitor results of meds • Operative procedures o Laparoscopic surgery usually involves one or several small incisions but often takes longer to perform than the open surgical approach. A newer procedure, natural orifice transluminal endoscopic surgery (NOTES), can be performed via the anus or vagina. Patients who are obese, have had previous abdominal surgeries, or have dense scar tissue (adhesions) may not be candidates for laparoscopic procedures. The conventional open surgical approach involves an abdominal incision and is done under general anesthesia. • Restorative Proctocolectomy with Ileo Pouch-Anal Anastomosis (RPC-IPAA) o This procedure has become the gold standard for patients with UC. In some centers, the surgery is performed via laparoscopy (laparoscopic RPC-IPAA). It is usually a two-stage procedure that includes the removal of the colon and most of the rectum. The anus and anal sphincter remain intact. The surgeon then surgically creates an internal pouch (reservoir). The pouch, sometimes called a J-pouch, S-pouch, or pelvic pouch, is then connected to the anus. A temporary ileostomy through the abdominal skin is created. In the second surgical stage, the loop ileostomy is closed. Usually bowel continence is excellent after this procedure, but some patients have leakage of stool during sleep. They may take antidiarrheal drugs to help. • Total Proctocolectomy with a Permanent Ileostomy o The procedure involves the removal of the colon, rectum, and anus with surgical closure of the anus. The surgeon brings the end of the ileum out through the abdominal wall and forms a stoma, or ostomy. With an ileostomy, initially after surgery the output is a loose, dark green liquid that may contain some blood. Over time, a process called "ileostomy adaptation" occurs. The small intestine begins to perform some of the functions that had 1178previously been done by the colon, including the absorption of increased amounts of sodium and water. Stool volume decreases, becomes thicker (pastelike), and turns yellow-green or yellow-brown. The effluent (fluid material) usually has little odor or a sweet odor. Any foul or unpleasant odor may be a symptom of a problem such as blockage or infection. The ostomy drains frequently, and the stool is irritating. The patient must wear a pouch system at all times. Skin care around the stoma is a priority! A pouch system with a skin barrier (gelatin or pectin) provides sufficient protection. • 3 Stages o Mild UC ▪ less than 4 stools a day with or without blood; asymptomatic labs normal o Moderate UC ▪ Greater that 4 stools a day with or without blood ▪ Mild abdominal pain, mile intermittent nausea, possible increased C reactive protein and ESR o Severe UC ▪ Greater 6 bloody stool; fever, tachycardia, anemia, abdominal pain, elevated c reactive and ESR • C reactive protein values o Very reliable in first 6 hours of inflammation <0.1 normal • Complications from UC o - malabsorption, - hemorrhage, -abscess formation, -bowel obstruction, -fistulas, -colon cancer, ( Uc for more than 10 years have risk) -osteoporosis Crohn’s Disease • How it presents o - thickened bowel wall -strictures and deep ulcerations -cobble stone appearance - FISTULAS very common -Patients with CD become more malnourished than UC - cancer of the colon can happen after 15-20 years - potential intestinal obstruction • Crohn's disease (CD) is a chronic inflammatory disease of the small intestine (most often), the colon, or both. It can affect the 1182GI tract from the mouth to the anus but most commonly affects the terminal ileum. CD is a slowly progressive and unpredictable disease with involvement of multiple regions of the intestine with normal sections in between (called "skip lesions" on x-rays). Like ulcerative colitis (UC), this disease is recurrent with remissions and exacerbations. Crohn's disease presents as inflammation that causes a thickened bowel wall. Strictures and deep ulcerations (cobblestone appearance) also occur, which put the patient at risk for developing bowel fistulas (abnormal openings between two organs or structures). The result is severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption. Severe malabsorption by the small intestine is more common in patients with CD because UC may not involve the small bowel to any significant extent. Therefore patients with CD can become very malnourished and debilitated. Fistula formation is a common complication of CD. Some patients develop intestinal obstruction, which at first is secondary to inflammation and edema. Over time, fibrosis and scar tissue develop and obstruction results from a narrowing of the bowel. • Genetic considerations o The exact cause of CD is unknown. A combination of genetic, immune, and environmental factors may contribute to its development. About 10% to 20% of patients have a positive family history for the disease. The discovery of a mutation in the NOD2/CARD15 gene on chromosome 16 seems to be associated with some patients who have CD. This gene is found in monocytes that normally recognize and destroy bacteria. Pro-inflammatory cytokines, such as tumor necrosis factor-alpha (TNF-alpha) and interleukins (ILs) (e.g., IL-6 and IL-8), are immunologic factors that contribute to the etiology of CD. Many of the drugs used for the disease inhibit or block one or more of these factors. Other risk factors include tobacco use, Jewish ethnicity, and living in urban areas. CD is more common in people of Ashkenazi Jewish background than in any other group. The reasons for these factors have not been established. It was once thought that stress and nutrition play a role in the development of CD, but these factors have not been proven. However, inadequate nutrition can worsen the patient's symptoms. • Asessement o - Inspection: distention, masses or visible peristalsis o - Bowel sounds may be decreased or absent OR o High pitched or rushing sounds over narrowed bowel loops o - Guarding, masses, rigidity, tenderness o -Low grade fever o - Steatorrhea o - Pain in RLQ or pain around umbilicus before and after bowel movement o Crohn's disease is made worse by bacterial infection. Ask about recent unintentional weight loss, the frequency and consistency of stools, the presence of blood in the stool, fever, and abdominal pain. o Perform a thorough abdominal assessment. Assess for distention, masses, or visible peristalsis. Inspection of the perianal area may reveal ulcerations, fissures, or fistulas. During auscultation, bowel sounds may be decreased or absent with severe inflammation or obstruction. An increase in high-pitched or rushing sounds may be present over areas of narrowed bowel loops. Muscle guarding, masses, rigidity, or tenderness may be noted on palpation. o Most patients report diarrhea, abdominal pain, and low-grade fever. Fever is common with fistulas, abscesses, and severe inflammation. If the disease occurs in only the ileum, diarrhea occurs 5 or 6 times per day, often with a soft, loose stool. Steatorrhea (fatty diarrheal stools) is common. Rarely, stools may contain bright red blood. Abdominal pain from the inflammatory process is usually constant and often located in the right lower quadrant. If the lower colon is diseased, pain is common in both lower abdominal quadrants. Most patients with Crohn's disease have weight loss. Nutritional problems are the result of increased catabolism from chronic inflammation, anorexia, malabsorption, or self-imposed dietary restrictions. The patient who has Crohn's disease (CD) needs a complete psychosocial assessment. Anemia is common as a result of slow bleeding and poor nutrition. Serum levels of folic acid and vitamin B12 are generally low because of malabsorption. Amino acid malabsorption and protein-losing enteropathy may result in decreased albumin levels. C-reactive protein and ESR may be elevated to indicate inflammation. White blood cells (WBCs) in the urine may show infection (pyuria). May have fluid and electrolyte losses, particularly potassium and magnesium. X-rays show the narrowing, ulcerations, strictures, and fistulas common with Crohn's disease. Magnetic resonance enterography (MRE) is performed to determine bowel activity and motility. An abdominal ultrasound or CT scan may also be performed. In acute illness, these tests may be deferred until the risk for perforation lessens. If the patient has lower GI bleeding of more than 0.5 mL per minute, a GI bleeding scan may be useful. o Action alert ▪ For the patient with Crohn's disease, be especially alert for manifestations of peritonitis (discussed earlier in this chapter), small-bowel obstruction, and nutritional and fluid imbalances. Early detection of a change in the patient's status helps reduce these life-threatening complications. • Drug therapy o same as UC - Methotextrate -Crohns patients do not take glucocorticoids because they can mask symptoms of infection - Flagyl better o For mild to moderate disease, 5-ASA drugs may be very effective. Two agents that may be prescribed for CD are azathioprine (Imuran) and mercaptopurine (Purinethol). These drugs suppress the immune system and can lead to serious infections. Methotrexate (MTX) may also be given to suppress immune activity of the disease. o A group of biologic response modifiers (BRMs), also known as monoclonal antibody drugs, have been approved for use in Crohn's disease when other drugs have been ineffective. These drugs inhibit tumor necrosis factor (TNF)-alpha, which decreases the inflammatory response. Examples of commonly used drugs for patients with CD include infliximab (Remicade), adalimumab (Humira), natalizumab (Tysabri), and certolizumab pegol (Cimzia). Although glucocorticoids can be effective for patients with Crohn's disease, sepsis can result from abscesses or fistulas that may be present. These drugs mask the symptoms of infection. Therefore they must be used with caution. Monitor the patient closely for signs of infection. Metronidazole (Flagyl, Novonidazol image) has been helpful in patients with fistulas. • Nutrition therapy o Poor nutrition can lead to inadequate fistula and wound healing, loss of lean muscle mass, decreased immune responses, and increased morbidity and mortality. The patient may be hospitalized to provide bowel rest and nutritional support with total parenteral 1184nutrition (TPN). For less severe exacerbations, an elemental or semi-elemental product such as Vivonex PLUS may be prescribed. Nutritional supplements such as Ensure or Sustacal can be added then to provide nutrients and more calories. Teach the patient to avoid GI stimulants, such as caffeinated beverages and alcohol. • Fistula management: Crohn’s disease o They can be between the bowel and bladder (enterovesical), between two segments of bowel (enteroenteric), between the skin and bowel (enterocutaneous), or between the bowel and vagina (enterovaginal). Treatment of the patient with a fistula is complicated and includes nutrition and electrolyte therapy, skin care, and prevention of infection. The patient requires at least 3000 calories daily to promote healing of the fistula. If he or she cannot take adequate oral fluids and nutrients, total enteral nutrition (TEN) or TPN may be prescribed. For patients who do not require TEN or TPN, collaborate with the dietitian to: o • Carefully monitor the patient's tolerance to the prescribed diet. o • Assist the patient in selecting high-calorie, high-protein, high-vitamin, low-fiber meals. o • Offer enteral supplements, such as Ensure and Vivonex PLUS. o • Record food intake for accurate calorie counts. o Providing enteral supplements, recording intake and output, and taking daily weights may be delegated to unlicensed assistive personnel (UAP). o Skin irritation needs to be prevented. This may be accomplished through the use of skin barriers, pouching systems, and insertion of drains. Skin barriers or dressings are used when the fistula drainage is less than 100 mL in 24 hours. A pouch is used for heavily draining fistulas. Drainage may need to be managed using regulated wall suction or a negative-pressure wound therapy device. Patients with fistulas are also at high risk for intra-abdominal abscesses and sepsis. Antibiotic therapy is commonly prescribed. Observe for signs of sepsis (systemic infection). Therapies may include naturopathy, herbs (e.g., ginger), acupuncture, hypnotherapy, and ayurveda (a combination of diet, herbs, yoga, breathing exercises). o Action alert ▪ Adequate nutrition and fluid and electrolyte balance are priorities in the care of the patient with a fistula. GI secretions are high in volume and rich in electrolytes and enzymes. The patient is at high risk for malnutrition, dehydration, and hypokalemia (decreased serum potassium). Assess for these complications, and collaborate with the health care team to manage them. Monitor urinary output and daily weights. A decrease indicates possible dehydration, which should be treated immediately by providing additional fluids. ▪ For patients with fistulas, preserving and protecting the skin is the nursing priority. Be sure that wound drainage is not in direct contact with skin because intestinal fluid enzymes are caustic! Clean the skin promptly to prevent skin breakdown or fungal infection, which can cause major discomfort for the patient. • Surgical management o The patient with a fistula may undergo resection of the diseased area. Other indications for surgical treatment include perforation, massive hemorrhage, intestinal obstruction or strictures, abscesses, or cancer. In some cases, a resection (removal of part of the small bowel) can be performed as minimally invasive surgery (MIS) via laparoscopy. Both small-bowel resection (usually the ileum) and ileocecal resection can be done using this procedure. Stricturoplasty may be performed for bowel strictures related to Crohn's disease. This procedure increases the bowel diameter • Community based care o The interventions that were started to manage the disease are continued. Reinforce measures to control the disease and related symptoms and manage nutrition. Teach the patient and family to make arrangements for the patient to have easy access to the bathroom, as well as privacy to perform fistula care, if needed. Teach the patient about the usual course of the disease, symptoms of complications, and when to notify the HCP. . Provide health teaching for drug therapy. In addition to other drugs, vitamin supplements, including monthly vitamin B12 injections, may be needed because of the inability of the ileum to absorb these nutrients. In collaboration with the dietitian, instruct the patient to follow a low-residue, high-calorie diet and to avoid foods that cause discomfort, such as milk, gluten (wheat products), and other GI stimulants like caffeine. Remind the patient to take rest periods, especially during exacerbations of the disease. Teach the patient about the increased risk for bowel cancer and the importance of having frequent colonoscopies. If a patient has a fistula, explain and demonstrate wound care. Assess the patient's and family's ability to monitor the progress of fistula healing and to watch for indications of infection and sepsis. A home care aide or other service might be helpful. Diverticula • - pouch like herniations of the mucosa through the muscular wall ( mostly colon) - occur in points of weakness in intestinal wall - colon hypertrophies, thickens and becomes rigid Diverticulosis • - many abnormal pouchlike herniations in the wall of the intestine -- most commonly diagnosed during ROUTINE colonoscopies - no symptoms • Acute Diverticulitis o - inflammation of the Diverticula when undigested foods or bacteria get trapped in the diverticulum - can perforate and develop local abscess - periotonitis and lower GI bleed a problem • Assessment o - ab pain, localized to LLQ o - pain intermittent then persistent o -nausea and vomiting o -fever of 101 F o -chills o -tachycardia o -observe for distention • Lab o Elevated WBC o Low H and H o Occult blood test • Treatment o - NPO for bowel rest and Hydration - blood pressure checks ( orthostatic) to rule out sepsis and hypovolemic shock • Diverticular disease • -Anywhere from esophagus to colon -Inflammation or rupture (diverticulitis) -Sediment accumulates in pouch -Avoid berries with tiny seeds • Diverticula can occur in any part of the small or large intestine but usually occur in the sigmoid colon. The muscle of the colon hypertrophies, thickens, and becomes rigid, and herniation of the mucosa and submucosa through the colon wall is seen. Muscle weakness develops as part of the aging process or as a result of a lack of fiber in the diet. Without inflammation, diverticula cause few problems. If undigested food or bacteria become trapped in a diverticulum, however, blood supply to that area is reduced. Bacteria invade the diverticulum, resulting in diverticulitis, which then can perforate and develop a local abscess. A perforated diverticulum can progress to an intra-abdominal perforation with peritonitis (inflammation of the peritoneum). Lower GI bleeding also. Retained undigested food in diverticula is suggested to be one cause of diverticulitis. The retained food reduces blood flow to that area and makes bacterial invasion of the sac easier. • Assessment o The patient with diverticulosis usually has no symptoms. Diverticula are most often diagnosed during routine colonoscopy. For the patient with uncomplicated diverticulosis, ask about intermittent pain in the left lower quadrant and a history of constipation. If diverticulitis is suspected, ask about a history of low-grade fever, nausea, and abdominal pain. Inquire about recent bowel elimination patterns because constipation may develop as a result of intestinal inflammation. Also ask about any bleeding from the rectum. o The patient with diverticulitis may have abdominal pain, most often localized to the left lower quadrant. It is intermittent at first but becomes progressively steady. Occasionally, pain may be just above the pubic bone or may occur on one side. Abdominal pain is generalized if peritonitis. Nausea and vomiting are common. The patient's temperature is elevated, ranging from a low-grade fever to 101° F (38.3° C). Chills may be present. Often an increased heart rate (tachycardia) occurs with fever. Observe for distention. The patient may report tenderness. Localized muscle spasm, guarded movement, and rebound tenderness may be present. If generalized peritonitis is present, profound guarding occurs; rebound tenderness 1187is more widespread; and sepsis, hypotension, or hypovolemic shock can occur. Blood pressure checks may show orthostatic changes. If bleeding is massive, the patient may have hypotension and dehydration that result in shock. The patient with diverticulitis, however, has an elevated white blood cell (WBC) count. Decreased hematocrit and hemoglobin values are common if chronic or severe bleeding occurs. Stool tests for occult blood, if requested, are sometimes positive. Abdominal x-rays may be done to evaluate for free air and fluid indicating perforation. A CT scan may be performed to diagnose an abscess or thickening of the bowel. Abdominal ultrasonography, a noninvasive test, may also reveal bowel thickening or an abscess. The health care provider may recommend a colonoscopy 4 to 8 weeks after the acute phase of the illness to rule out a tumor in the large intestine. • Nonsurgical management o Broad-spectrum antimicrobial drugs, such as metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS, Septra) or ciprofloxacin (Cipro), are often prescribed. A mild analgesic may be given for pain. The patient with more severe pain may be admitted to the hospital for IV fluids to correct dehydration and IV drug. Laxatives and enemas are avoided because they increase intestinal motility. Assess the patient on an ongoing basis for manifestations of impaired fluid and electrolyte balance. Teach the patient to rest during the acute phase of illness. Remind him or her to refrain from lifting, straining, coughing, or bending to avoid an increase in intra-abdominal pressure, which can result in perforation. Nutrition therapy should be restricted to low fiber or clear liquids based on symptoms. The patient with more severe symptoms is NPO. A nasogastric tube (NGT) is inserted if nausea, vomiting, or abdominal distention is severe. Infuse IV fluids as prescribed for hydration. • Surgical management o The surgeon performs emergency surgery if peritonitis, bowel obstruction, or pelvic abscess is present. Colon resection, with or without a colostomy, is the most common surgical procedure for patients with diverticular disease. • Community based care o Patients with diverticular disease need education regarding a high-fiber diet. Encourage the patient with diverticulosis to eat a diet high in cellulose and hemicellulose types of fiber. These substances can be found in wheat bran, whole-grain breads, and cereals. Teach the patient to eat at least 25 to 35 g of fiber per day. Fresh fruits and vegetables with high fiber content are added to provide bulk to stools. Teach the patient to add them to the diet gradually to avoid flatulence and abdominal cramping. If he or she cannot tolerate the recommended fiber requirement, a bulk-forming laxative, such as psyllium hydrophilic mucilloid (Metamucil), can be taken. Teach the patient to drink plenty of fluids to help prevent bloating that may occur with a high-fiber diet. Alcohol should be avoided. Foods containing seeds or indigestible material that may block a diverticulum, such as nuts, corn, popcorn, cucumbers, tomatoes, figs, and strawberries, may be eliminated. Teach the patient that dietary fat intake should not exceed 30%. Teach the patient to avoid all fiber when symptoms of diverticulitis are present, because high-fiber foods are then irritating. Teach the patient to avoid all fiber when symptoms of diverticulitis are present, because high-fiber foods are then irritating. Teach about the manifestations of acute diverticulitis, including fever, abdominal pain, and bloody, mahogany, or tarry stools. Advise patients to avoid the use of laxatives (other than bulk- forming types) and enemas. Celiac Disease • CD is a chronic inflammation of the small intestinal mucosa that can cause bowel wall atrophy and malabsorption. Like many inflammatory disorders, it is thought to be caused by a combination of genetic, immunologic, and environmental factors. The primary complication of CD is cancer, specifically non-Hodgkin's lymphoma or GI cancers. • Patients with CD have varying clinical manifestations with cycles of remission and exacerbation (flare-up). Classic symptoms include anorexia, diarrhea and/or constipation, steatorrhea (fatty stools), abdominal pain, abdominal bloating and distention, and weight loss. Dietary management is the only available treatment for achieving disease remission. In most cases, a gluten-free diet (GFD) results in healing the intestinal mucosa after about 2 years. Gluten is the primary substance in wheat and wheat-based products. Teach patients to carefully check for hidden sources of gluten that are in foods, food additives, drugs, and cosmetics. Patients often take vitamin and mineral supplements to replace those lost in avoiding gluten foods. • Assessment: Anorectal abcess • - familial • - pus caused by inflammation • - i and d to drain • - there is a risk with crohns • - encourage warm sitz baths, bulk producing agents, stool softeners • - good perineal hygiene • Anorectal abscess is a localized area of induration and pus caused by inflammation of the soft tissue near the rectum or anus. It is most often the result of obstruction of the ducts of glands in the anorectal region. Rectal pain is often the first symptom. There may be no other manifestations at first, but local swelling, redness, and tenderness are present within a few days. If the abscess becomes chronic, discharge, bleeding, and pruritus (itching) may exist. Fever occurs if larger abscesses are present. Anorectal abscesses are managed by surgical incision and drainage (I&D). The physician can often excise (surgically remove) simple perianal and ischiorectal abscesses using a local anesthetic. For patients with more extensive abscesses, a regional or general anesthetic may be needed. Systemic antibiotics are given only for patients who are immunocompromised, are diabetic, have valvular disease or a prosthetic valve, or are obese. Anal fissure • - large deeper fissures in anal lining - happens with crohns - acute one resolves on own - chronic fissures require surgery • An anal fissure is a tear in the anal lining, which can be very painful. Smaller fissures occur with straining to have a stool, such as with diarrhea or constipation. Larger, deeper fissures may occur as a result of another disorder (e.g., Crohn's disease, tuberculosis, leukemia, neoplasm) or from trauma (e.g., from a foreign body, anal intercourse, perirectal surgery). • An acute anal fissure is superficial and usually resolves on its own or heals quickly. Chronic fissures recur, and surgical treatment may be needed. Pain during and after defecation and bright red blood in the stool are the most common symptoms. Other manifestations include pruritus, urinary frequency or retention, dysuria, and dyspareunia (painful intercourse). • The diagnosis is made by stretching and inspecting the perianal skin. If he or she is not in severe pain, a digital examination and possibly a sigmoidoscopy are performed. When painless or multiple fissures are present, a colonoscopy may be performed to rule out any IBDs. Management of an acute fissure is usually aimed at local pain relief and softening of stools to reduce trauma to the area. Teach the patient to use warm sitz baths, analgesics, and bulk- producing agents (e.g., psyllium hydrophilic mucilloid [Metamucil]) to help minimize the pain from defecation. Topical anti-inflammatory agents (hydrocortisone creams and suppositories) may be helpful for some patients. • Explain pain control measures to the patient. Remind him or her to notify the health care provider if pain is not relieved within a few days. If fissures do not respond to management within several days to weeks, surgical repair under a local anesthetic may be needed. Teach the patient to report any drainage or bleeding from the rectum. • Symptoms o - pain during and after defecation - bright red blood in the stool - pruritus, urinary frequency or retention, dysuria or dyspareunia ( painful intercourse) - use sitz baths, etc and hydrocortisone Anal fistula • - abnormal tract leading from the anal cancal to perineal skin - caused by anal abscesses which are caused by obstruction - can occur with tuberculosis, Crohns Disease, cancer - surgery and then healing by secondary intention • An anal fistula, or fistula in ano, is an abnormal tract leading from the anal canal to the perianal skin. Most anal fistulas result from anorectal abscesses, which are caused by obstruction of anal glands. • The patient with an anal fistula has pruritus (itching), purulent discharge, and tenderness or pain that is worsened by bowel movements. A proctoscope may be used to identify the source of symptoms and to locate the fistula. Because fistulas do not heal spontaneously, surgery is necessary. To perform a fistulotomy, the surgeon opens the tissue over the tract and scrapes the base. The incision site then heals by secondary intention. For a fistula higher in the anus, a special surgical technique is used to preserve important sphincters. After surgery, instruct the patient about sitz baths, analgesics, and the use of bulk-producing agents or stool softeners to reduce pain. Parasitic infections • Common parasites that cause infection in humans are Giardia lamblia, which causes giardiasis; Entamoeba histolytica, which causes amebiasis (amebic dysentery); and Cryptosporidium. Handwashing is the best way to prevent the spread of parasitic infections. Humans who eliminate cysts are infectious. Flies can spread the cysts. Humans are hosts to this organism, but beavers and dogs may be reservoirs for infection. • Giardiasis is a well-recognized problem in international travelers, campers, and immunosuppressed patients. This disorder affects only the intestinal system, causing acute diarrhea, chronic diarrhea, or malabsorption syndrome. The acute phase usually is self-limiting, lasting days or weeks. The chronic phase can last for years. Diarrhea is usually mild in both forms, but it can be severe. As stools increase in frequency, they become more watery, greasy, frothy, and malodorous with mucus. Weight loss and weakness are also common. Malabsorption can occur. Manifestations result from malabsorption of fat, protein, and vitamin B12 and lactase deficiency. • Humans are the only known hosts for E. histolytica (also known as amebiasis). Amebiasis causes tens of thousands of deaths annually worldwide. The disease causes less severe symptoms and often goes undiagnosed in temperate climates. E. histolytica either feeds on bacteria in the intestine or invades and ulcerates the mucosa of the large intestine. • Cryptosporidium is manifested by diarrhea. This infection occurs most commonly in immunosuppressed patients, particularly those with human immune deficiency virus (HIV). It can also occur in children and older adults from contaminated swimming pools. • Chagas disease is caused by the Trypanosoma cruzi parasite by the triatomine (kissing) bug. Patients first develop an acute infection, followed by an intermediate asymptomatic period and a chronic infection. Patients with chronic Chagas disease often develop cardiac dysrhythmias or heart failure, as well as colon or esophagus dilation causing impaired digestion and bowel elimination. • Assessment o A history of travel. GI symptoms related to travel may be delayed as long as 1 to 2 weeks after the return home. Immigrants (newcomers) may have the infection upon entering. A nutrition history is especially helpful if several people in a group become ill. Common water supplies or bodies of water may be infected with Giardia or Cryptosporidium. Trichinosis should be considered if the patient has eaten pork products. o Mild to moderate E. histolytica infestation causes the daily passage of several strongly foul-smelling stools, possibly with mucus but without blood, accompanied by abdominal cramping, flatulence (gas), fatigue, and weight loss. Severe amebic dysentery is manifested by frequent, more liquid, and foul-smelling stools with mucus and blood. Fever up to 104° F (40° C), tenesmus (feeling the urge to defecate), generalized abdominal tenderness, and vomiting can also occur. The ulcerations of invading amebiasis that occur in the colon can cause pain, bleeding, and obstruction. Ulcerations can also occur in the rectum, resulting in formed stool with blood. Complications are rare but include appendicitis and bowel perforation. The most common form of extraintestinal is amebic liver abscess, which causes symptoms of fever, pain, and an enlarged liver. The abscess can rupture, and death can result. The most common form is amebic liver abscess, which causes symptoms of fever, pain, and an enlarged liver. The abscess can rupture, and death can result. The use of sigmoidoscopy may detect ulcerations in the rectum or colon. Exudate obtained during sigmoidoscopic examination is studied for the parasite. The white blood cell (WBC) count can be very high when severe dysentery is present. o The diagnosis of giardiasis is also confirmed by the presence of parasites in the stool. Because organisms may not be detected for at least 1 week after symptoms appear, multiple stool samples should be examined. • Intervention o Treatment for all types of amebiasis involves the use of amebicide drugs. Metronidazole (Flagyl, Novonidazol image) and diloxanide furoate (Entamide) or diloxanide furoate and tetracycline hydrochloride (Sumycin) followed by chloroquine are commonly prescribed. The patient with severe dysentery requires IV fluid replacement and possibly opiates, such as diphenoxylate hydrochloride and atropine sulfate (Lomotil), to control bowel motility. The patient with extraintestinal amebiasis or severe dehydration is hospitalized. Teach patients the importance of keeping their follow-up appointments and taking all drugs as prescribed. Treatment for giardiasis is drug therapy. Metronidazole is the drug of choice, 250 mg orally 3 times daily for 5 days. Tinidazole (Fasigyn) can be used as an alternative. Stools are examined 2 weeks after treatment to assess for drug effectiveness. Infection with Cryptosporidium is usually self-limiting in people who have normal immune function. Drug therapy for patients who are immunosuppressed may include paromomycin (Paromycin), an aminoglycoside antibiotic. Teach patients that this drug can cause dizziness. MULTIPLE CHOICE 1. A nurse assesses a client who has appendicitis. Which clinical manifestation should the nurse expect to find? a. Severe, steady right lower quadrant pain b. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee flexion ANS: A Right lower quadrant pain, specifically at McBurney’s point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the client has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion. 2. A nurse cares for an older adult client who has Salmonella food poisoning. The client’s vital signs are heart rate: 102 beats/min, blood pressure: 98/55 mm Hg, respiratory rate: 22 breaths/min, and oxygen saturation: 92%. Which action should the nurse complete first? a. Apply oxygen via nasal cannula. b. Administer intravenous fluids. c. Provide perineal care with a premedicated wipe. d. Teach proper food preparation to prevent contamination. ANS: B Dehydration caused by diarrhea can occur quickly in older clients with Salmonella food poisoning, so maintenance of fluid balance is a high priority. Monitoring vital signs and providing perineal care are important nursing actions but are of low