*Appendicitis - PowerPoint Presentation

Slide1

*Appendicitis*Gastroenteritis*Peritonitis*Ulcerative Colitis*Crohn’s Disease*Diverticular Disease*Gallbladder Disease

Acute and Chronic Inflammatory Bowel Disorders and Bowel DiseasesSlide2

AppendicitisAcute inflammation of vermiform appendixMost common cause of RLQ painLumen (opening) of appendix is blocked by fecaliths (hard feces, composed of calcium phosphate rich mucus and inorganic salts)Slide3

Appendicitis Cont.Other causes:malignant tumorsHelminthesOther infectionsSlide4

Appendicitis Cont.The lumen gets blocked  the mucosa secretes fluid  internal pressure increases  causing painSlow process may develop abscessRapid process may result in peritonitis Gangrene can occur in 24-36 hoursLife threating

Emergency surgery

Perforation may develop Slide5

AssessmentAbdominal pain followed by N/VCramp like pain in in epigastric or periumbilical areaAnorexiaInitally pain can be anywhere in the abdomen or flank areaPain becomes severe and shifts to the RJQ (McBurney’s point)Between anterior iliac crest and umbilicusSlide6

Assessment Cont.Pain that increases with cough or movement suggest perforation and peritonitisObserve for:Muscle rigidityGuarding on palpationRebound tendernessLab findings:Incresed WBC’s with a shift to the leftSlide7

Assessment Cont.Other tests:Ultrasound-may show enlarged appendixCT scan- may reveal a fecalithSlide8

Nonsurgical ManagementIV fluidsNPOSemi-fowlers position to facilitate abdominal drainageAnalgesics AntibioticsDO NOT:Apply heat-increases inflammation and perforationGive laxatives or enemas-may cause perforationSlide9

Surgical managementAppendectomy-removal of appendixLaparoscopy-minimally invasiveNatural orifice transluminal endoscopic surgery (NOTES)-endoscope is placed in vagina or other orifice and makes small incision into peritoneal spaceLaparotomy- open surgical approachSlide10

GastroenteritisDiarrhea and/or vomiting caused by inflammation of the mucous membranes of stomach and intestinal tractSmall bowel affectedViral or bacterial Slide11

GastroenteritisViral:Epidemic viral:parvovirus-type organism transmitted fecal-oral in food and water. Incubation period 10-51 hours. Communicable during acute illness.Rotavirus and Norwalk virus:transmitted fecal-oral and possibly resp. route. Incubation 48 hours. Common in infants and young children.

Norwalk virus affects young children and adultsSlide12

Gastroenteritis Cont.Bactreial:Campylobactor enteritis:Transmitted fecal-oral or contact with infected animals or infants Incubation period 1-10 daysCommunicable 2-7 weeksEscherichia coli diarrhea:Transmitted by fecal contamination of food or waterShigellosis:Transmitted by direct or indirect fecal-oral routes

Incubation period 1-7 days

Communicable during acute illness and up to 4 weeks after

Humans possibly carries for monthsSlide13

AssessmentObtain history of recent travel especially tropical regionsN/VDiarrheaMyalgiaHAMalaiseWeaknessCardiac dysrhythmias due to hypokalemiaHyrotension

Dry mucous membranes

Poor skin

turgorSlide14

Assessment Cont.Lab assessment:Gram stain stool:Many WBC’s suggest shigellosisWBC’s and RBC’s indicate Campylobacter gasteroenteritisSlide15

InterventionsFluid replacement: OralIV- may need potassium added if excessive diarrheaDrug therapy:Imodium if deemed necessaryAntibiotics if bacterial infectionCiproLevaquinZithromaxSeptra

DS

Skin care

Avoid toilet paper and harsh soap

Gently clean with warm water or absorbent material followed by gentle drying

Apply cream, oils, gel or barrier cream

sitz

baths for 10 minutes 2-3 times a daySlide16

Peritonitisacute inflammation of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity. LIFE THREATENINGBody begins an inflammatory reaction to create a “wall” to stop the spread of bacteriaWhen the wall fails the bacteria spreads resulting in peritonitis.Slide17

PeritonitisCauses:Bacteria or chemicals contaminating the peritoneal cavity Escherichia coliStreptococcusStaphylococcusPneumococcusGonococcusBilePancreatic enzymesGastric acidSlide18

Peritonitis Cont.How bacteria get in: perforation (appendicitis, diverticulitis, PUD),an external perforating wound a gangrenous gallbladder bowel obstructionascending infection through the genital tract.Slide19

Peritonitis Cont.Hypovolemic shock results from a decrease in ECF and circulatory volume (this fluid migrates to the peritoneal cavity). Hypovolemic shock insufficient perfusion to kidneys kidney failure with electrolyte imbalancePeritoneal inflammation peristalsis slows or stops

lumen of bowel becomes distended



fluid accumulates in intestine (7-8 L DAILY)Slide20

AssessmentRespiratory problems caused by abdominal pressure on diaphragm Rigid, board like abd. (classic)PainDistentionrebound tendernessN/VAnorexiadiminished bowel soundsinability to “pass flatus” or poopHigh feverTachycardia

Dehydration

decreased UO

Hiccups

possible compromised respiratory statusSlide21

Assessment Cont.Lab assessmentElevated WBC with high neutrophil countBlood culture studies to check for septicemia (bacterial invasion of blood)ElectrolytesBUN,CRTH&H O2X-rays may be ordered to assess for air or fluid

 Slide22

Nonsurgical ManagementAdminister IV fluidsbroad spectrum antibioticsMonitor daily weightI&OPlace NG tube NPOO2SPO2 and respiratory status checksPain medications Slide23

Surgical ManagementLaparotomy or Laparoscopy to remove or repair the inflamed or perforated organThe focus is to control contamination and drain fluidCatheters may be placed to drain the cavity and provide irrigation routeAfter surgeryMaintain sterile technique during manual irrigation of peritoneal wounds through a drainAssess for fluid retention during irrigationPlace in semi-fowlers to promote drainage and increase lung expansionSlide24

Surgical Management Cont.After surgeryMaintain sterile technique during manual irrigation of peritoneal wounds through a drainAssess for fluid retention during irrigationPlace in semi-fowlers to promote drainage and increase lung expansionAssess ability of self-managementTeachingProvide written and oral instructionsDiscuss when to immediately call provider ( unusual/ foul-smelling drainage, swelling, redness, warmth, bleeding from incision site, temperature higher than 101,

abd

pain)

Collaborate with case manager to ensure care will be provided at home if needed

Review medications

Refrain from

ANY

lifting for

AT LEAST

6 weeksSlide25

Ulcerative ColitisWidespread inflammation of rectum and rectosigmoid colon, but may extend to entire colon when the disease is extensiveAssociated with periodic remissions and exacerbationsDisease may remain constant for yearsSlide26

Ulcerative Colitis Cont.Intestinal mucosa becomes hyperemic (increased blood flow), edematous, and reddenedIn severe cases, the lining may bleed, causing small erosions, or ulcers, to occurAbscesses form in ulcerative areas, resulting in tissue necrosisContinued edema leads to narrowed colon, and possibly a bowel obstructionSlide27

Ulcerative Colitis Cont.Patient’s stool contains blood and mucusPatient reports tenesmus (unpleasant, urgent sensation to defecate), and lower abdominal pain which is relieved with defecationAdditional s/sx: malaise, anorexia, anemia, dehydration, fever, weight lossSlide28

Ulcerative Colitis Etiology/RiskAffects about 1.4 million in U.S.Peak age of Dx: 30-40 y/oWomen affected more than men in younger years; men affected more in middle-older ageCause is unknownMore prevalent among Jewish persons, and among whites more than non-whites (Reason for this is unknown)Genetic/immunologic factors suspectedOften found in families and twinsAutoimmune dysfunction: epithelial antibodies IgG

have been found in the blood of some patients with Ulcerative Colitis

With long-term disease, risk for developing colon cancer increasesSlide29

Ulcerative Colitis: Classification of SeverityMild: <4 stools/day with/without bloodAsymptomaticLab values usually normalModerate: >4 stools/day with/without bloodMinimal symptomsMild abd pain

Mild intermittent nausea

Possible increased C-reactive protein or ESR (erythrocyte sedimentation rate)

Severe: >6 bloody stools/day

Fever

Tachycardia

Anemia

Abd

pain

Elevated C-reactive protein and/or ESR

Fulminant

: >10 bloody stools/day

Increasing symptoms

Anemia may require transfusion

Colonic distention on x-raySlide30

AssessmentHistoryCollect family hx data, nutrition hx, usual bowel patterns (color, characteristic, consistency of stools)Inquire about recent antibiotic use (may suggest C-diff infection)Inquire about travel to tropical areasAsk about use of NSAIDs (may cause flare-up)Physical Asessment

Symptoms vary, VS are usually WNL in mild cases

In severe cases, fever (99-100 F or 37.2-37.8 C)

Note any

abd

distention

Fever with tachycardia may indicate peritonitis, dehydration, and bowel perforation

Assess for complications such as inflamed joints and lesions in the mouthSlide31

Assessment con’tPsychosocial AssessmentInability to control bowel, specifically presence of diarrhea, can be disruptive and stress-producingExplore: stress factors which cause flare-ups, family and social support systems, genetic concernsLab AssessmentH&H low due to blood loss (indicates anemia and a chronic disease state)Elevated WBC, C-reactive protein, and/or ESRSerum Na, K, and Cl may be low due to diarrhea and

malabsorption

from diseased bowel

Decreased serum albumin due to loss of protein through stool

Other Diagnostic Assessment

Colonoscopy is the most definitive test for diagnosing UCSlide32

Planning/ImplementationPriority problems:Diarrhea/incontinence r/t inflammation of bowel mucosaPain r/t inflammation and ulceration of bowel mucosa and skin irritationPotential for lower GI bleeding and resulting anemiaNonsurgical management (Drug therapy)Aminosalicylates (anti-inflammatory effect by inhibiting prostaglandins; effective in 2-4 wks)Sulfasalizine, Mesalamine

Glucocorticoids

(prescribed during exacerbations)

Prednisone – tapered dosing once improvement occurs

Immunomodulators

(synergistic effect with prednisone)

Remicade

,

HumiraSlide33

Planning/Implementation Cont.Nutrition therapyPatients are kept NPO when symptoms are severe, to ensure bowel restTPN for severely ill/malnourished patientsDiet is not a major factor, but ETOH and caffeine may increase diarrhea and crampingFor some patients, lactose and high-fiber foods cause GI symptomsRestActivity is generally restricted to slow peristalsisEnsure access to bedpan, bedside commode, or bathroom in case of

tenesmus

(urgency)Slide34

Planning/Implementation Cont.CAM therapiesHerbs (flaxseed), selenium, Vit. C, biofeedback, hypnosis, acupuncture, and ayurveda (a combination of diet, yoga, herbs, and breathing exercises)Surgical managementTemporary or permanent ileostomyLaparoscopic surgeryNatural orifice transluminal

endoscopic surgery (NOTES) performed through anus or vagina

Total

proctolectomy

with permanent

ileostomy

(removal of anus, rectum, and colon)Slide35

EvaluationExpected outcomes:Verbalizes decrease in painGain of control over bowel eliminationNo GI bleedingSelf-management of ileostomyMaintains peristomal skin integrityDemonstrates behaviors that integrate ostomy care into his or her lifestyle if a permanent

ileostomy

is performedSlide36

Crohn’s DiseaseInflammatory disease of the small intestine, colon, or bothCan affect GI tract from mouth to anus, but most commonly affects the terminal ileumProgressive, unpredictable diseaseLike UC, this is recurrent with remissions and exacerbationsUnlike UC, Crohn’s causes a thickened bowel wall with strictures and deep ulcerations that have a cobblestone appearance (these put the patient at risk for bowel fistulas)Malabsorption of vital nutrients; anemia resultsSlide37

Horses and ZebrasHorses (Similarities between UC and CD)Inflammatory diseasePeriodic remissions and exacerbationsWeight loss, frequent, bloody stools, fever, abd pain, abd distention, diarrheaNo known cause; familial patterns; Jewish ethnicityAnemia Elevated WBCs, C-reactive protein, and ESR

Decreased albumin

Decreased electrolytes

Complications: hemorrhage/perforation, abscess formation, toxic

megacolon

,

malabsorption

,

nonmechanical

bowel obstruction, fistulas, colorectal cancer,

extraintestinal

complications (arthritis, oral and skin lesions), osteoporosis

Interventions are the same

Drugs:

Aminosalicylates

,

Remicade

,

Humira

,

glucocorticoids

(contraindication: fistulas)

Need for TPN in malnourished patientsSlide38

Horses and ZebrasZebras: (Differences between UC and CD)Unlike UC, CD causes thickened bowel wall with necrosis, strictures, and deep ulcerationsHemorrhage is more common in UCFistula formation is common in CD (rare in UC)Malabsorption by small intestine is common in CD because UC doesn’t significantly involve the small bowelTherefore, patients with CD tend to be more malnourishedPatients with CD at increased risk for sepsisSurgical management for CD: laparoscopic bowel resection, or

stricturoplasty

(increasing the diameter of the bowel)Slide39

Diverticular DiseaseDiverticula: pouchlike herniations of the mucosa through the muscular wall of any portion of the gut, usually the colonDiverticulosis: presence of many abnormal diverticula in the wall of the intestine (without inflammation, this causes few problems)Diverticulitis

: inflammation of one or more

diverticula

(caused by trapping of undigested food or bacteria in

diverticulum

, resulting in reduced blood supply to that area)Slide40

Diverticular Disease Cont.Diverticulitis: low-grade fever, N&V, abd pain (may be localized to LLQ), bleeding from rectum, chills, tachycardiaIf pain is generalized, peritonitis has occurredElevated WBCs, decreased H&HStool test for occult bloodPossible RBCs present in UAMost often diagnosed with colonoscopyCT to diagnose abscess or thickeningTreated with wide-spectrum antimicrobials (

Flagyl

, sulfa,

cipro

)

Avoid laxatives and enemas which increase motilitySlide41

Gallbladder Disease (GBD)The gallbladder is a small pear-shaped digestive organ located under the liver.Bile is released from liver and stored in gallbladder.Slide42

Gallbladder DiseaseISMore common in women than menInflammationInfectionStonesObstruction of the gallbladder. Most common cause is gallstonesSymptoms vary widely from discomfort to severe pain Begins after eatingSevere Cases

Jaundice

nausea

feverSlide43

Risk FactorsHeredity. More frequently in Mexican Americans and Native Americans but are also common in people of northern European stock. Age. Gallbladder disease often strikes people over sixty years of age.Gender. Excess estrogen may be implicated, since hormone replacement after menopause increases the likelihood of stones. Diet. Most people know that there is an established link between fat intake and gallbladder disease, but many don't realize that there is also a significant correlation with high sugar intake as well. (Diabetes mellitus)

Obesity.

In comparison with people of normal weight, the bile of obese people is supersaturated with cholesterol, predisposing them to the development of gallbladder illness.

Slow intestinal transit

. Medical professionals have long known that constipation is common in patients who have gallbladder disease. Studies confirm that slow intestinal transit contributes to the formation of gallstones in women of normal weight. Slide44

GallstonesFormed by crystallized bile substances :Excess cholesterolBile saltscalciumVary in size:Can be as small as a grain of sand. Slide45

SymptomsN/VA bloated sensation in the abdomenGassiness, with belching and passing of intestinal gasIndigestionClay-colored stoolsJaundiceChillsSweatingFeverSlide46

CholecystitisAcuteInflammation of the gall bladder from:Irritation and inflammation from gallstonesstone blocking a passageway (cholelithiasis)ChronicRepeated episodes of duct obstructionSlide47

SymptomsIntense and sudden pain in the upper right part of the abdomen recurrent painful attacks for several hours after meals N/VRigid abdominal muscles on right side Slight fever Chills JaundiceItching Loose, light-colored bowel movements Abdominal bloating Slide48

Nonsurgical ManagementPain medicationDilaudidMorphine ToradolAntiemetics for N/VIV antibioticsExtracorporeal shock wave lithotripsy (ESWL)Biliary catheters to open blocked ductsSlide49

Surgical ManagementCholecystectomy --surgical removal of the gallbladderLaparoscopic minimally invasive surgery (MIS)Complications are not commonThe death rate is very lowBile duct injuries are rarePatient recovery is quickerPostoperative pain is less severeSlide50

Surgical ManagementCont.Traditional CholecystectomyOpen surgical approachUsed for severe biliary obstructionT-tube drain may be inserted into duct for drainageJP drains my be placed in gallbladder bed to prevent fluid accumulationSlide51

Post-0p CarePCACough and deep breathAntiemeticsWound careKeep NPO until fully awake then advance clear liquids red dietV/SLOCAssess surgical site for redness and purulent drainage

AmbulationSlide52

Patient TeachingTeach signs of postcholecystectomy syndrome (PCS)Repeat abdominal painEpigastric pain with vomiting that may occur weeks to months after surgerySlide53

PCSCausesPseudocystCommon bile duct (CBD) leakCBD or pancreatic duct obstructionSphincter dysfunctionRetained or new gallstonePancreatic or liver massDiverticular compressionSlide54

Presented byLaura HendersonLindsey KinchIvette NunezRonald PattersonDonna WadeSlide55

ReferencesIgnatavicius, M. R., & Workman, P. R. (2013). Medical Surgical Nursing: Patient-Centered Collaborative Care. St. Louis: Elsevier Saunders.