Nutritional Patterns IIB

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Nutritional Patterns IIB

• Terry Moorman, RN, MSN

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Peritonitis

• Inflammation of the peritoneum
• Usually the result of a bacterial infection from
  the GI or reproductive tract
• Most common bacteria are E-coli and Klebsiella
• Can also result from external sources

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Pathophysiology Of Peritonitis

• Inflammatory process shunts extra blood to
  inflamed area
• Peristaltic activity of bowel ceases
• Fluid and air are retained
• Large amounts of protein filled fluid shifts into
  abdominal cavity
• Oxygen requirements increase but respiratory
  movement may cause pain

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Diagnostic Findings With Peritonitis

• WBC
• Electrolytes
• Flat plate of abdomen
• CT of abdomen

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Medical Management Of Peritonitis

• Identify and treat cause
• Maintain fluid and electrolyte balance
• Decrease abdominal distention
• Antiemetics for N/V
• Antibiotic therapy
• Analgesics
• Oxygen therapy

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Surgical Intervention For Peritonitis

• Excision
• Resection
• Repair
• Drainage

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Nursing Management For Client With Peritonitis

• Assess vital signs
• Assess respiratory status and administer oxygen
  as ordered
• Assess characteristics of abdominal pain
• Perform thorough abdominal assessment

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• Administer IV fluids and meds as ordered
• Monitor FE status
• Maintain patency of NG tube
• Place client in semi-Fowlers position

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Diverticular Disease

• Diverticulosis - presence of multiple
  non-inflamed diverticulum
• Diverticulitis - Inflammation of a diverticulum

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Clinical Manifestations

• Mild to severe pain in left quadrant
• Bloating and abdominal distention
• Low grade fever
• Nausea and anorexia
• Alteration in bowel habits
• Rectal bleeding
• Urinary frequency

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Diagnostic Tests For Diverticulitis

• BaE
• Abdominal x-ray
• Colonoscopy
• CT scan
• CBC
• Sedimentation rate

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Complications Of Diverticulitis

• Perforation
• Peritonitis
• Abscess formation
• Hemorrhage
• Obstruction

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Medical Management Of Diverticular Disease

• Asymptomatic diverticular disease
• High fiber, low fat diet
• Bulk laxatives
• Notify physician of fever, abdominal pain,
  change in bowel habits
• Diverticulitis
• Allow colon to rest
• Antibiotics
• Bulk laxatives

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• Acute diverticulitis
• NPO
• NG if vomiting present
• IV fluids and antibiotics
• Pain relief
• Antispasmodics - Probanthine, Daricon
• Bulk lax or stool softeners
• Surgical interventions
• Resection with anastomosis
• Remove inflamed area and create colostomy

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Nursing Interventions For The Client With
Diverticular Disease

• Encourage fluid intake of 2 liters if not
  contraindicated
• Instruct on diet
• Recommend bulk lax
• Stool softeners
• Administer analgesics, antibiotics,
  antispasmodics
• Monitor for complications

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Two Processes With Obstruction

• Mechanical - something blocking the inner lumen
• Adhesions,Intussusception
• Volvulus
• Hernis
• Functional - muscles do not propel contents
  forward

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Clinical Manifestations Of Obstruction

• Crampy abdominal pain
• Nausea and vomiting
• Blood and mucous passed rectally small bowel
  obstruction
• Constipation large bowel obstruction

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• Abdominal distention
• Bowel sounds increased at first then silent
• Dehydration
• Shock

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Treatment of Intestinal Obstruction

• Decompression of bowel
• Treat dehydration
• Surgery to treat cause

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• After our patient had abdominal surgery, we told
  him that we were unable to let him eat until he
  had passed gas. The next morning we were
  rounding on him and, lo and behold, we walked
  into the room to find he had a sign hanging
  around his neck that read Will Fart For Food!

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Inflammatory Bowel Disease (IBD)

• Consists of 2 chronic inflammatory disorders
• Crohns disease -Regional enteritis
• Ulcerative colitis
• Both have periods of remission and acute
  exacerbation

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Risk Factors For Inflammatory Bowel Disease

• Autoimmune or allergic response
• Enteric pathogens
• Environmental agents
• Genetic tendency

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Characteristics Of Crohns Disease (Regional
Enteritis)

• More often affects people 20-30 years old
• Terminal ileum, cecum and ascending colon most
  often affected
• Inflammation is transmural
• Granulomas frequently develop
• Bowel wall thickens and lumen narrows

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Clinical Manifestations Of Crohns

• Diarrhea and often steatorrhea
• Abdominal pain crampy after eating
• Low grade fever
• Weight loss, malnutrition
• Abscesses, fistulas, fissures are common
• Arthritis, conjunctivitis and erythema nodosum
  often seen

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Diagnostic Findings With Crohns

• Elevated WBC
• Elevated sedimentation rate
• Albumin and protein levels down
• HH decreased
• Colonoscopy with biopsy
• Upper GI and SB series - string sign
• BaE - cobblestone appearance, fistulas, fissures

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Complications Of Crohns

• Intestinal obstruction
• Fluid and electrolyte imbalance
• Malnutrition
• Fistula, fissure and abscess formation
• Increased risk of colon cancer

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Characteristics Of Ulcerative Colitis

• Occurs more in women, in the Jewish and Caucasian
  populations, peaks between 30-50 years of age
• Begins in rectum and may span entire colon
• Only the mucosa and submucosa are affected
• Diffuse inflammation and multiple ulcerations
  that bleed. Abscesses form
• Bowel narrows, thickens and shortens

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Clinical Manifestations Of Ulcerative
Colitis

• Diarrhea
• Abdominal pain
• Intermittent tenesmus
• Rectal bleeding
• Loss of appetite and weight loss
• Fever
• Arthritis, uveitis, erythema nodosum

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Diagnostic Findings With Ulcerative Colitis

• Stool - positive for blood
• BaE - shows mucosal irregularities, shortening of
  colon
• Colonoscopy - friable, inflamed mucosa and
  ulceration
• HH - decreased
• Albumin - decreased
• WBC - elevated
• ESR - elevated

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Complications Of Ulcerative Colitis

• Toxic megacolon
• Perforation
• Hemorrhage
• Obstruction

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Medical Management Of Inflammatory Bowel Disease

• Low residue, high protein, high CHO diet
• Medications
• Antidiarrheals (Immodium) and antispasmodics (
  Bentyl)
• Aminosalicylates - Azulfidine (sulfasalazine),
  Asacol (mesalamine) or Colazol (balsalazide) if
  sulfa allergy

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• Antibiotics - Flagyl (metronidazole), Cipro
  (ciprofloxacin)
• Corticosteroids - Prednisone
• Immunosuppressive agents - cyclosporine,
  Methotrexate, Imuran (azathioprine), Remicade
  (infliximab)

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Surgical Management Of Inflammatory Bowel Disease

• Total colectomy with ileostomy
• Total colectomy with continent ileostomy (Kock
  pouch)
• Colectomy with ileoanal anastomosis
• Small bowel resection with anastomosis
• Intestinal transplant

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Nursing Diagnoses For The Client With
Inflammatory Bowel Disease
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Nursing Interventions For the Client With Acute
Inflammatory Bowel Disease

• Maintain normal elimination pattern
• Determine if any relationship between food,
  activity, stress
• Administer anti-diarrheal medication
• Administer antispasmodics
• Record frequency and consistency of stools
• Encourage bedrest

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• Relieve pain
• Assess pain frequently
• Administer anticholinergics and antispasmodics

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• Maintain fluid intake
• Accurate IO
• Daily weights
• Assess for fluid deficit
• Assess labs
• Encourage at least 8 glasses of liquid/day

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• Maintain optimum nutrition
• Daily weights
• Feedings high in protein and CHO, low in fat and
  residue and no caffeine
• Frequent, small feedings
• Administer TPN if ordered

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• Reduce anxiety and enhance coping
• Prevent skin breakdown
• Assess skin frequently
• Perianal care with skin barrier after each BM

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• Monitor for potential complications
• Perforation
• Peritonitis
• Obstruction
• Hemorrhage

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Nursing Management Of The Client Requiring An
Ileostomy

• Provide pre-operative care
• Abdomen marked
• Teaching
• Provide post-operative care
• Monitor vital signs, dressings, drainage tubes
• Assess stoma
• Monitor for fecal drainage
• Monitor and maintain NG suction
• Monitor for complications

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• Manage skin and stoma care
• Ostomy bag should be emptied when 1/3 - 1/2 full
• Change pouch during times of low flow
• Cut pouch to fit stoma
• Face-plate usually changed every 5-7 days

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• Candida most common cause of skin infection
• Instruct on foods that cause odors
• Encourage foods that deodorize
• Kock pouch will need to be drained with a cath
  every 4-6 hours

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• Manage dietary and fluid needs
• Weigh daily
• Low residue, high protein, high CHO diet
• Supplemental vitamins
• Increase fluid intake
• Limit fibrous foods if effluent watery

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• Monitor for and prevent complications
• Peristomal skin irritation
• Diarrhea
• Stomal stenosis
• Renal calculi
• Cholelithiasis

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• Provide emotional support
• May go through grieving
• Refer to support groups
• Pregnancy and normal delivery are possible

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Risk Factors For Colorectal Cancer

• Dietary influence
• Genetic link
• Inflammatory bowel disease

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Clinical Manifestations Of Colorectal Cancer

• Change in bowel habits
• Blood in stools
• Anorexia, weight loss
• Anemia
• Pain
• Obstruction

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Diagnostic Tests For Colorectal Cancer

• BaE
• Colonoscopy or proctosigmoidoscopy
• Digital rectal exam (DRE)
• Stool for occult blood (FOBT)
• CEA
• CT scan

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Surgical Management Of Colorectal Cancer

• Segmental resection with anastomosis
• Abdominoperineal resection with colostomy
• Proctosigmoidectomy

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Pre-operative Nursing Care For Colorectal Surgery

• Diet high in calories, protein and CHO but low in
  residue
• Bowel cleaning
• Administration of antibiotics
• Provide emotional support
• Consult enterostomal therapist
• Teaching
• Provide emotional support

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Post-operative Nursing Care Following Colorectal
Surgery

• Monitor vital signs
• Monitor abdominal dressing
• Monitor stoma
• Monitor labs

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• Monitor and prevent pulmonary complications
• Monitor pain
• Monitor for and prevent thrombophlebitis

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• Teach ostomy care
• Opening in pouch cut 1/8 larger than stoma
• Change pouch every 5-7 days
• Teach irrigation
• Use approximately 500-1000 cc fluid
• Bag suspended at shoulder height
• Insert tip of irrigation tube only 3 or use
  cone
• Teach about foods that cause odor and gas and
  foods that decrease odor
• Drink 2 liters of fluids daily

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• Monitor for complications related to colostomy
• Leakage from anastomosis
• Prolapse of stoma
• Perforation
• Fecal impaction

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Diseases Of The Anorectum

• Anorectal abscess - an infection in the
  perirectal spaces
• SS - swelling, redness, tenderness, pain, fever
• Tx - incise and drain, antibiotics, sitz baths,
  packing

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• Anal fistula - tubular tract that extends from an
  opening beside the anus into the anal canal
• SS leakage of pus or stool from opening,
  vagina or bladder
• Tx - fistulectomy

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• Anal fissure - longitudinal tear or ulceration in
  mucosa of anal canal
• SS painful defecation with burning bleeding
• Tx stool softeners, bulk lax, sitz baths,
  increase fluids

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• Hemorrhoids - dilated portions of veins in anal
  canal
• SS itching, pain, bleeding with defecation
• Tx stool softeners, bulk lax, sitz bath,
  increase fluids