Lower GI: Study Guide Final

LOWER GASTROINTESTINAL PROBLEMS Nursing Exam Study Guide Chapter 47 | Adults 1 | Dr. Keegan 💉 Blue = NCLEX Tips 🧠 Gold = Exam Tips 🎙 Pink = Prof Said 🚨 Red = Emergency SECTION 1: DIARRHEA & C. DIFFICILE (CDI) Causes of Diarrhea • • • • Drugs (laxatives), food intolerances (lactose, undigested carbs → water pulled into bowel → rapid transit) Osmotic: rapid GI transit/dumping syndrome Malabsorption: celiac disease, short bowel syndrome Foodborne illness, infections (viral, bacterial) 🎙 PROF SAID: "We talked about foodborne illness & dumping syndrome — the way it affects the body, that rapid GI transit causes loose stool. Food intolerances, laxatives, and malabsorption issues like celiac disease or short bowel syndrome —like dumping syndrome but it's your small bowel that's the problem. You end up with very loose stool as a result." Clinical Manifestations Diarrhea by Origin Location Feature Upper GI Origin Lower GI Origin Volume Large-volume, watery stools Small-volume stools Pain Periumbilical (around belly button) Lower abdominal Blood/Mucus Rarely Bloody; leukocytes + mucus in stool Fever Low-grade or none Fever more common 🎙 PROF SAID: "Clinical manifestations depend on where we're talking. In the upper GI tract you get large volumes of watery stools, cramping — periumbilical pain — you may have nausea, vomiting, may or may not have a fever. In the lower GI tract you get smaller volume, you can notice bloody diarrhea, and the stool may contain leukocytes, blood, or mucus." 🧠 EXAM TIP: Severe diarrhea #1 danger = DEHYDRATION + low K+ (potassium). Always check electrolytes! Metabolic ACIDOSIS results from fluid/electrolyte loss. Dangers of Prolonged Diarrhea • • • • • Dehydration — life-threatening if prolonged Electrolyte imbalances → dysrhythmias (low K+ is the big one) Metabolic acidosis from fluid and electrolyte loss C. diff → colitis and intestinal perforation Dehydration + blood in stool → elevated BUN/creatinine → risk for ACUTE KIDNEY INJURY 🎙 PROF SAID: "Our concern is dehydration. Too much, too long can be life threatening. You can have electrolyte imbalances which could lead to dysrhythmias, and metabolic acidosis. And then there's C. diff. If there's any bleeding or if we've got dehydration, we can end up with acute kidney disease. So we have to be careful, make sure this doesn't go on for too long and they get hydrated." Diagnostic Studies • • • • • • Stool cultures: blood, mucus, WBCs, infectious pathogens Blood cultures: if sepsis suspected or immunocompromised CBC: check for anemia (iron + folate deficiencies if blood in stool) BUN, creatinine, electrolytes, pH, osmolality — dehydration + AKI risk Stool fat, protein — malabsorption workup (NOT done in emergent setting) GI hormones (gastrin) — elevated = increased motility 🎙 PROF SAID: "Stool can be sent off looking for fat or protein — we're concerned about malabsorption disorders. And GI hormones — if there's an extra amount of gastrin in the gut that can increase motility. The fat and protein are things that are NOT done in an emergent setting. If we're worried about anemia — iron or folate — that can get sent off right from an emergency room." Interprofessional Management • • • • • • Treatment depends on the CAUSE — always find and treat the cause first Prevent transmission — especially if viral or bacterial Replace fluids and electrolytes — oral OR IV Protect the skin from acidic stool — risk of breakdown, fissures, infection Antidiarrheals: coat mucosa, slow motility, decrease secretions (use with caution) Antibiotics (fluoroquinolones, azithromycin) if bacterial 🎙 PROF SAID: "The treatment depends on the cause. You want to prevent transmission, especially if this diarrhea is because of a virus or bacteria. Replacing fluid and electrolytes — that can be oral or IV. Some people have diarrhea but there's no reason they can't have oral intake if they're not vomiting. And imagine the area of skin getting irritated — diarrhea can be acidic and that will burn that area. If you have a burned mucosa in the rectum, now you've got a potential for a fissure or an ulcerous area where bacteria can get in." 🚨 EMERGENCY: NEVER give antidiarrheals if infection is SUSPECTED — traps bacteria in the gut, worsens the illness, and can cause TOXIC MEGACOLON in IBD patients! C. Difficile (CDI) • Healthcare-Associated Infection (HAI) • • • • • • High risk: patients on antimicrobials, chemotherapy, gastric acid-suppressing, or immunosuppressive drugs C. diff spores survive UP TO 70 DAYS on surfaces — everywhere in healthcare settings Isolation: contact precautions — GOWN AND GLOVES for everyone entering the room Alcohol-based sanitizers are INEFFECTIVE — SOAP AND WATER ONLY ◦ Treatment #1: Oral vancomycin OR fidaxomicin × 10 days PO (orally) ◦ Alternate: metronidazole ◦ Complicated: vancomycin + IV metronidazole ◦ Ileus (bowel stopped moving): vancomycin via ENEMA — can't take oral if bowel isn't working Stop nonessential antibiotics, stool softeners, laxatives, antidiarrheals Recurrent C. diff: FMT (Fecal Microbiota Transplantation) — donor feces restores healthy gut bacteria 🧠 EXAM TIP: C. diff = contact precautions + SOAP AND WATER only (alcohol sanitizer does NOT kill C. diff spores). This is the #1 tested C. diff nursing action. FMT = used for recurrent C. diff that doesn't respond to antibiotics. 💉 NCLEX TIP: Probiotics (lactobacillus) may be used as prophylaxis or adjunct therapy to restore normal gut flora alongside C. diff treatment. SECTION 2: CONSTIPATION & FECAL INCONTINENCE Constipation • • Fewer than 3 stools per week — with straining, incomplete evacuation, bloating, hard/lumpy stools It is a SYMPTOM, not a disease; Acute < 1 week; Chronic > 3 months Key Risk Factors • • • • Low-fiber diet, decreased physical activity Ignoring the urge to defecate → muscles desensitize, stool dries → harder to pass Emotions, anxiety, depression → slow GI motility Opioids = #1 DRUG CAUSE of constipation ◦ Cathartic colon syndrome: chronic laxative overuse → the colon becomes dilated and atonic (stretched and weak) → it can no longer function normally. 🧠 EXAM TIP: Opioids = #1 drug cause of constipation. Any patient started on opioids should ALSO get a stool softener/bowel regimen — ALWAYS. Nutrition Therapy • • • Dietary fiber: vegetables, fruits, grains Adequate fluid: 2 L/day — caution with cardiac/renal disease patients Probiotics to restore normal bowel function 🚨 EMERGENCY: ALWAYS increase FLUID alongside fiber — fiber alone WITHOUT enough water = WORSENS constipation and can cause IMPACTION! Implementation — Bowel Training • • Best time to attempt bowel movement: 30 minutes AFTER breakfast — gastrocolic reflex is strongest If ineffective: bisacodyl/glycerin suppository, small enema, digital stimulation, tap water irrigation ◦ Peripherally acting opioid receptor antagonists (e.g., methylnaltrexone): Opioidinduced constipation drug: 🧠 EXAM TIP: Peripherally acting opioid antagonists (methylnaltrexone) = block constipation effect only in the GUT — do NOT reverse pain control. Classic NCLEX pharmacology distinction! Fecal Incontinence • • • • • • Involuntary loss of stool from motor and/or sensory dysfunction Chronic constipation → fecal impaction → straining weakens pelvic floor → incontinence Diagnosis: H&P, rectal examination always, anorectal manometry, ultrasound, EMG Management: bowel training (30 min after breakfast), high-fiber diet + fluids Reduce triggers: caffeine, artificial sweeteners, dairy, gas-producing vegetables Skin integrity: prompt cleansing, moisturizing, protection; absorbent pads SECTION 3: INFLAMMATORY BOWEL DISEASE (IBD) IBD Overview • • • • Chronic inflammation of GI tract — periods of REMISSION alternating with EXACERBATIONS Autoimmune: the immune system attacks own GI tract in a genetically susceptible person Begins in teens/early adulthood; second peak in 60s Two types: Ulcerative Colitis (UC) and Crohn's Disease Crohn's vs. Ulcerative Colitis — MOST TESTED Crohn's Disease vs. Ulcerative Colitis Feature Crohn's Disease Ulcerative Colitis (UC) Location Anywhere mouth to anus; most common: distal ileum + proximal colon Colon and rectum ONLY; starts in RECTUM, spreads to cecum Layers affected ALL layers of bowel wall Mucosal layer ONLY (innermost) Pattern Skip lesions (patches of inflammation, normal tissue between) Continuous — NO skip lesions Appearance Cobblestone (deep ulcers = uneven surface) Pseudopolyps (tongue-like projections) Hallmark symptom Diarrhea, cramping, weight loss from malabsorption Bloody diarrhea — HALLMARK Fistulas COMMON — abnormal tunnels to other organs/skin Less common Strictures YES — scar tissue → bowel obstruction Less common Major complication Short bowel syndrome (repeated surgeries) Toxic megacolon (colon dangerously dilates) Curable by surgery? NO — disease RECURS at reconnection site YES — total proctocolectomy is CURATIVE B12 absorption ↓ if terminal ileum inflamed → lifelong B12 injections needed Not typically affected 🧠 EXAM TIP: UC = colon only + mucosal layer + continuous + CURABLE by surgery. Crohn's = anywhere + all layers + skip lesions + fistulas + NOT curable. Tested constantly! 💉 NCLEX TIP: UC = bloody diarrhea + starts in rectum + mucosal layer only. Crohn's = all layers + skip lesions + fistulas. Know every distinction. UC Severity — Know the Numbers! UC Severity Classification Severity Stools/Day Signs Action Mild < 4 semi-formed Little blood Outpatient Moderate Up to 10/day Increased bleeding, fever, malaise, anemia, anorexia Close monitoring Severe 10-20/day Bloody with mucus, fever, tachycardia, dehydration HOSPITALIZATION required Complications of IBD 🚨 EMERGENCY: TOXIC MEGACOLON = UC complication = SURGICAL EMERGENCY. SUDDEN IMPROVEMENT in diarrhea + abdominal DISTENTION + fever = colon STOPPED MOVING. Call HCP IMMEDIATELY! • • • • • Local: hemorrhage, strictures, perforation → peritonitis, abscesses, fistulas CDI (C. diff) is more severe and frequent in IBD patients High risk for COLORECTAL CANCER → regular colonoscopy screening essential Systemic: ankylosing spondylitis (spinal bone fusion), liver disease, osteoporosis, anemia Bone density scan at BASELINE + every 2 years (steroids weaken bones) Drug Therapy — Know Each Class 5-ASA Aminosalicylates (Colazal, Mesalamine) • • • Anti-inflammatory for bowel lining; much MORE effective for UC than Crohn's Given oral OR rectal (enema, foam, suppository) DEPLETES folic acid → supplement folic acid DAILY Corticosteroids (Prednisone, Budesonide) • • • • Reduce inflammation; use for SHORTEST time possible NEVER stop abruptly — must TAPER to prevent adrenal crisis Side effects: osteoporosis, hyperglycemia, infection risk, adrenal suppression, K+ depletion Deplete calcium AND potassium → supplement both 💉 NCLEX TIP: Corticosteroids = NEVER stop abruptly (must taper). Long-term: monitor blood sugar, bone density, infection signs, and potassium! Immunomodulators (Azathioprine, 6-MP, Methotrexate) • Maintain remission AFTER corticosteroid therapy — DELAYED onset (weeks) • • • NOT useful for acute flares Monitor CBC regularly — bone marrow suppression → infection + bleeding risk NO methotrexate in pregnancy 🧠 EXAM TIP: Immunomodulators = DELAYED onset — USELESS for acute flares. Used only for MAINTAINING remission long-term. Biologic Therapies ◦ ◦ ◦ ◦ Anti-TNF (Infliximab/Remicade IV; Adalimumab/Humira SQ): block TNF (tumor necrosis factor), an inflammatory protein; used to induce and maintain remission and treat draining fistulas; can reactivate TB and hepatitis. Alpha 4-integrin inhibitors (Vedolizumab): block white blood cells from entering and sticking to the inflamed gut lining; used for patients who don't respond to other therapies; risk of liver damage (hepatotoxicity). IL-12/23 antagonists (Ustekinumab): block interleukins (immune signaling proteins) that drive inflammation; used for severe UC and Crohn's. JAK Inhibitors: (NEWEST for UC): the newest drug class for UC; block the JAK enzyme inside immune cells to suppress the immune response; must screen for TB before starting; cannot combine with other biologics. 🧠 EXAM TIP: Screen for TB AND hepatitis BEFORE starting ANY biologic therapy — all biologics suppress immunity and can reactivate dormant infections. Applies to ALL biologic classes. Surgical Therapy Ulcerative Colitis — SURGERY IS CURATIVE • • • Total proctocolectomy = removal of colon AND rectum = CURE for UC ◦ IPAA (J-pouch): (Ileal Pouch-Anal Anastomosis) = surgical procedure where the colon and rectum are removed and an internal pouch is created from the small intestine, then connected to the anus — allowing the patient to pass stool normally without a permanent external bag. Results in approximately 4-6 stools/day; anal sphincter controls defecation. Post-IPAA: transient mucus incontinence = NORMAL; Kegel exercises after 4 weeks; perianal skin care Phantom rectal pain after rectum removed = NORMAL, expected 🧠 EXAM TIP: Total proctocolectomy = CURE for UC ONLY — not for Crohn's (disease affects areas beyond colon). Crohn's Disease — Surgery Does NOT Cure • • • Done for complications only: obstruction, fistulas, abscesses, non-responders Resection with reanastomosis: disease RECURS at reconnection site Repeated surgeries → SHORT BOWEL SYNDROME (SBS) ◦ Strictureplasty: a surgical procedure that widens narrowed areas of bowel without removing intestine — preserving bowel length and reducing the risk of Short Bowel Syndrome. Used in Crohn's disease. 🧠 EXAM TIP: Surgery does NOT cure Crohn's. Goal = preserve as much bowel as possible to prevent Short Bowel Syndrome! Nutrition Therapy for IBD • • • • Goals: adequate nutrition without worsening symptoms; correct malnutrition; replace fluid/electrolytes; prevent weight loss ◦ During flare-up: liquid enteral feedings preferred — high calorie, lactose-free, and easily absorbed; promotes healing and remission. ◦ Crohn's (terminal ileum inflamed): cannot absorb B12 or bile acids → requires lifelong B12 injections. Sulfasalazine/methotrexate → deplete folic acid → daily folic acid supplement Corticosteroids → deplete calcium + potassium → supplement both Keep food diary; reintroduce regular foods gradually; stress reduction (stress triggers flares) 💉 NCLEX TIP: IBD flare-up → switch to liquid enteral feedings (NOT parenteral unless gut completely non-functional). Gut rest + nutrition = promotes healing! SECTION 4: APPENDICITIS & PERITONITIS Appendicitis • • Most common EMERGENT abdominal surgery; most common age 10-30 Luminal obstruction → swelling + mucus + bacteria → gangrene → PERFORATION → peritonitis Classic Signs — Know ALL FOUR Appendicitis Physical Signs Sign How to Test Positive Means McBurney's Point Palpate 2/3 from belly button to R hip bone Maximum pain at that specific spot in RLQ Rovsing's Sign Press LEFT side of abdomen Pain felt on the RIGHT side Psoas Sign Patient straightens RIGHT leg Pain (inflamed appendix touching psoas muscle) Obturator Sign Rotate RIGHT leg inward Pain (inflamed appendix touching obturator muscle) Rebound Tenderness Press abdomen then SUDDENLY release Pain WORSENS on release → peritonitis sign 🧠 EXAM TIP: RLQ pain + rebound tenderness + McBurney's point = CLASSIC appendicitis. Know ALL FOUR signs: Rovsing's, psoas, obturator, rebound. Pain that suddenly IMPROVES then returns WORSE = PERFORATION occurred! Diagnosis & Management • • • • • CT scan preferred over ultrasound or MRI Labs: WBC elevated; urinalysis always (rules out kidney/bladder cause) Treatment: appendectomy IMMEDIATELY to avoid rupture Pre-op: IV fluids + antibiotics Post-op: early ambulation, advance diet as tolerated, IV antibiotics if ruptured 🚨 EMERGENCY: Suspected appendicitis: NPO, NO HEAT to abdomen (heat increases blood flow → speeds rupture!), NO laxatives or enemas. Classic NCLEX trap! Peritonitis • Inflammation/infection of the peritoneum — most commonly from organ PERFORATION (secondary) • Chemical peritonitis (initial spillage) progresses to bacterial peritonitis → fluid shifts → adhesions Clinical Manifestations 🚨 EMERGENCY: RIGID board-like abdomen + rebound tenderness + fever + tachycardia = PERITONITIS = SURGICAL EMERGENCY! Notify HCP immediately. • • • • Severe, continuous abdominal pain — most common symptom Rigid/board-like abdomen, rebound tenderness, muscle guarding Fever, tachycardia, N/V, abdominal distention, altered bowel habits Complications: hypovolemic shock, sepsis, intra-abdominal abscess, PARALYTIC ILEUS, ARDS Management • • • • Two large-bore IVs for fluids + antibiotics Pre-op/mild: NPO, NG suction, IV fluids, antibiotics, analgesia, antiemetics Positioning: knees FLEXED — reduces abdominal wall tension, relieves pain Post-op: NPO, IV fluids, NG suction, parenteral nutrition, antibiotics, opioids, antiemetics; drain care 💉 NCLEX TIP: Always rule out cardiac cause of abdominal pain with an ECG — heart attacks CAN present as upper abdominal pain! Always do a pregnancy test too (rule out ectopic). SECTION 5: INTESTINAL OBSTRUCTION Types & Causes Bowel Obstruction Reference Type #1 Cause Other Causes Key Danger SBO (Small Bowel) Surgical ADHESIONS (scar tissue from prior surgery) Hernias, cancer, Crohn's strictures, intussusception Rapid dehydration LBO (Large Bowel) COLORECTAL CANCER Diverticular disease, volvulus, adhesions Slower dehydration; more distention Paralytic Ileus Abdominal SURGERY (most common nonmechanical) Peritonitis, electrolyte imbalances, spinal fractures No bowel sounds; NPO Strangulated Blood supply cut off — any obstruction can strangulate — BOWEL DEATH = emergency NOW Volvulus Bowel TWISTS on itself Sigmoid colon most common Can strangulate quickly 🚨 EMERGENCY: STRANGULATED obstruction = no blood supply = bowel death = IMMEDIATE SURGICAL EMERGENCY. Suspect when pain suddenly becomes constant or dramatically worsens. 🧠 EXAM TIP: SBO #1 cause = ADHESIONS from prior surgery. LBO #1 cause = COLORECTAL CANCER. Post-op patient + no bowel sounds + distention = PARALYTIC ILEUS → NPO, notify HCP. Four Hallmark Signs of Obstruction • • • • 1. Abdominal PAIN 2. Nausea and VOMITING 3. Abdominal DISTENTION (more prominent in LBO) 4. CONSTIPATION / inability to pass flatus 💡 QUICK LOGIC: Passing gas (flatus) = bowel IS working. ABSENT bowel sounds = obstruction or ileus. Always auscultate BEFORE palpating! Acid-Base Implications — HIGH YIELD Obstruction Location & Acid-Base Location What's Lost Result High / Upper duodenum HCl (stomach acid) Metabolic ALKALOSIS Small intestine Rapid fluid/electrolyte loss Dehydration occurs QUICKLY Large intestine Slower loss Dehydration + imbalances develop LATER Prolonged vomiting (any level) HCl Metabolic ALKALOSIS 🧠 EXAM TIP: HIGH obstruction = metabolic ALKALOSIS from HCl loss. LOW obstruction = metabolic ACIDOSIS. Classic exam distinction — know it! Management • • • • Emergency surgery: strangulation or perforation → IMMEDIATE NGT for decompression — relieve pressure, reduce vomiting IV fluids, electrolyte replacement, strict I&O + hourly urine with catheter Surgical: resection with anastomosis; colostomy or ileostomy if needed 💉 NCLEX TIP: Post-op patient — no bowel sounds + abdominal distention = paralytic ileus → keep NPO, notify HCP. Do NOT advance diet without return of bowel sounds or passage of flatus! SECTION 6: POLYPS & COLORECTAL CANCER (CRC) Colon Polyps • • • Sessile: flat, broad-based, attached directly to wall Pedunculated: attached by thin stalk Most ASYMPTOMATIC — found during routine screening; most common sign = rectal or occult bleeding Polyp Types • Hyperplastic: non-cancerous, < 5mm — benign ◦ Adenomatous: precancerous polyps — can be cancerous or non-cancerous; three subtypes: tubular, tubulovillous, and villous (villous = highest cancer risk). ◦ FAP (Familial Adenomatous Polyposis): an inherited condition where hundreds or thousands of polyps develop and will ALL become cancerous by age 40 — requires removal of the colon and rectum by age 25. 🏙 PROF SAID: "I really want you guys to remember what FAP means. When we have a lot, a lot of polyps — by the age of 25, you are now ending up with some sort of colostomy or reservoir because it WILL lead to cancer." 🧠 EXAM TIP: Adenomatous polyps = PRECANCEROUS → must be removed. VILLOUS type = highest cancer risk. FAP = remove colon by age 25 before polyps turn cancerous. DNA testing available for family members. 💉 NCLEX TIP: After polypectomy → monitor for BLEEDING + PERFORATION. Fever + severe abdominal pain = PERFORATION = call HCP immediately! Colorectal Cancer (CRC) • • • • #2 LEADING cause of cancer-related deaths in men and women combined Usually starts from a polyp → grows over 10-20 years before becoming invasive ◦ Metastasis path: colon → portal vein → liver first → then lungs, bones, brain. Highest risk: first-degree relative with CRC, IBD, FAP, KRAS gene mutation Other risks: obesity, smoking, >7 red meat servings/week, >4 alcohol drinks/week, diabetes 🏙 PROF SAID: "CRC is the second leading cause of cancer death — first is lung cancer. Symptoms develop slowly and often do not appear until the disease is advanced. Sometimes the FIRST time we find out someone has cancer is when they come in for a bowel obstruction and a tumor is the reason for it. These are the patients where when they say they're losing weight, we ask: is it intentional? Because typically it was not — and unexplained weight loss is a concern for cancer. As things progress, it can affect the liver, and then from there we can develop ascites." 🧠 EXAM TIP: CRC spreads to LIVER FIRST via portal vein — classic path. Liver metastasis = poor prognosis. Manifestations by Location CRC Symptoms by Side Feature Right-Sided CRC Left-Sided CRC Bleeding Occult (hidden) → slowly causes ANEMIA Hematochezia (bright red blood in stool) Bowel changes Diarrhea Obstruction; change in bowel habits Recognition Often silent / unrecognized early More obvious symptoms Late signs Fatigue, weight loss, palpable mass Same + enlarged liver, ascites 🧠 EXAM TIP: Right side = ANEMIA + hidden bleeding. Left side = BRIGHT RED blood + obstruction. CRC is often SILENT until advanced! 🏙 PROF SAID: "Right-sided colorectal cancer is the ascending colon and the cecum — you may see more bleeding there, and unexplained anemia is a sign of cancer. Left-sided is the descending and sigmoid colon — you can see fresh blood in the stool. And sometimes the first time we find they have cancer is they come in for a bowel obstruction and a tumor is the reason for it." Screening Guidelines • • • Average risk: colonoscopy every 10 years starting at AGE 45 Annual: high sensitivity FOBT or FIT (fecal immunochemical test) ◦ Higher risk (1st degree relative with CRC): colonoscopy every 5 years starting at age 40, OR 10 years earlier than the youngest relative's diagnosis age. ◦ CEA (Carcinoembryonic Antigen): monitors treatment response only — NOT used for diagnosis due to too many false positives. Colonoscopy = GOLD STANDARD — entire colon viewed, biopsies taken, polyps removed 🧠 EXAM TIP: CEA = monitors TREATMENT response, NOT diagnosis. Standard screening = colonoscopy every 10 years starting at age 45. Incomplete bowel prep = procedure must be repeated! Surgery Types — APR vs. LAR APR vs. LAR Feature APR (Abdominal-Perineal Resection) LAR (Low Anterior Resection) Tumor location Distal rectum (bottom portion) Upper rectum Sphincters REMOVED — cannot preserve PRESERVED Ostomy PERMANENT colostomy TEMPORARY ostomy End result Permanent bag for life Bowel reconnected to anal canal 🧠 EXAM TIP: APR = PERMANENT colostomy (sphincters REMOVED). LAR = TEMPORARY ostomy (sphincters PRESERVED, bowel reconnected). Know the difference — constantly tested! • • Stage I & II: remove tumor + surrounding tissue + lymph nodes; anastomosis when possible Stage III: surgery + chemotherapy ± pre-op radiation to shrink tumor ◦ Well-differentiated cancer: cells still look more normal = less aggressive = better prognosis. SECTION 7: OSTOMIES — CARE & COMPLICATIONS Ostomy Output — Core Rule • More DISTAL the ostomy = more NORMAL the output (more functioning bowel remains) Ostomy Output Guide Ostomy Type Output Control Ileostomy (small intestine) Liquid or thin paste — never entered colon NO voluntary control; drains frequently; ALWAYS needs pouch Ascending colostomy Liquid to semi-liquid No control Transverse colostomy Semi-liquid to semi-formed No control Sigmoid colostomy (end of large intestine) FORMED stool — most like normal POSSIBLE regulation of emptying time 🧠 EXAM TIP: Ileostomy = liquid output, NO control. Sigmoid colostomy = formed stool, POSSIBLE regulation. Most tested ostomy distinction! Stoma Assessment • • Normal stoma: pink/red, moist, mild swelling — assess and document every 4 hours post-op Abnormal: purple/black/dry stoma = compromised blood supply = CALL HCP IMMEDIATELY Ileostomy Special Nursing Care • • • • • Output Day 1-2: minimal; returns to 1500-1800 mL/day as peristalsis resumes; adapts to ~500 mL/day Fluid intake: at least 2-3 L/day — high output = high fluid replacement needed Stool is CAUSTIC to skin — secure pouch at ALL times Chew food VERY WELL — undigested chunks can BLOCK the stoma Monitor Na+ and K+ closely — high output = major electrolyte loss 🚨 EMERGENCY: Ileostomy patient with DECREASED OUTPUT + CRAMPING = possible stoma obstruction → check for food blockage, notify HCP immediately! 💉 NCLEX TIP: HIGH ileostomy output (1500-1800 mL/day early) = major risk of DEHYDRATION + electrolyte loss (Na+ and K+). Monitor closely! Pouching & Daily Ostomy Care • • • • • Empty pouch when 1/3 FULL — prevents pulling and leaking WOCN (Wound, Ostomy & Continence Nurse) = specialist — consult before AND after surgery Stoma site selected preoperatively: within the rectus muscle (↓ hernia risk), flat surface (↓ leaks), patient can see it Bath, shower, swimming: SAFE with ostomy — stoma has no nerve endings Resume normal ADLs in 4-6 weeks post-op Loop vs. Double-Barrel vs. End Stoma ◦ ◦ ◦ End stoma (usually permanent): distal bowel is either removed (permanent stoma) or oversewn inside the body (Hartmann's pouch) — possible future reanastomosis. Loop stoma (usually temporary): a loop of bowel is brought to the surface with two openings in one loop — proximal opening = stool, distal opening = mucus; a plastic rod stays in place 7-10 days. Double-barrel stoma: bowel is completely divided creating two separate stomas — proximal = stool, distal = mucus fistula; usually temporary. 💉 NCLEX TIP: Two stomas = Double-barrel. Two openings in ONE loop of bowel = Loop stoma. Distal opening drains MUCUS not stool. Classic NCLEX trap! IPAA (J-Pouch) Post-Op Care • • • • • Expect 4-6 stools/day; adaptation takes 3-6 months; anal sphincter controls defecation — no external bag Transient mucus incontinence = NORMAL early post-op Kegel exercises begin at 4 weeks post-op Perianal skin care — frequent stools = skin breakdown risk Phantom rectal pain = NORMAL — feeling pain/urge after rectum removed SECTION 8: DIVERTICULOSIS & DIVERTICULITIS Overview ◦ • • Diverticulosis: multiple small sac-like pouches (diverticula) in the colon wall with no inflammation — usually asymptomatic. ◦ Diverticulitis: one or more of those pouches become inflamed or infected. Most common in the LEFT (sigmoid) colon Main risk factors: low-fiber diet, inactivity, obesity, NSAIDs, excess alcohol, smoking Clinical Manifestations • • Diverticulitis: acute LLQ PAIN, fever, elevated WBC, N/V, distention, decreased/absent bowel sounds ◦ Older adults: ATYPICAL in the elderly: Complications: perforation, abscess, peritonitis, fistula, bleeding 🧠 EXAM TIP: LLQ pain + fever + elevated WBC = DIVERTICULITIS until proven otherwise. Older adults may be afebrile with normal WBC — don't rule it out! Diagnosis • • Preferred test: CT scan with oral contrast — most accurate AVOID colonoscopy during ACUTE diverticulitis — RISK OF PERFORATION Treatment — The Classic Diet FLIP Diverticulitis Diet Phase Diet Rationale Acute diverticulitis LOW-fiber / clear liquids / bowel REST Reduce irritation; let inflammation settle After healing / Prevention HIGH-fiber diet + 2 L fluids/day Prevent recurrence; keep stool soft 🚨 EMERGENCY: DIET FLIP: Acute phase = LOW-fiber (bowel rest). After healing = HIGHfiber. This is the OPPOSITE of what you'd expect — classic exam trick! 💉 NCLEX TIP: Avoid increased intraabdominal pressure during recovery: no straining, no heavy lifting. Hospitalize if: severe symptoms, can't tolerate PO fluids, signs of systemic infection. SECTION 9: IBS · MALABSORPTION · CELIAC · SHORT BOWEL SYNDROME Irritable Bowel Syndrome (IBS) • • • Chronic abdominal pain + altered bowel patterns; NO known cause; NO structural damage or inflammation Triggers: psychologic stress, dietary intolerances, GI infections, family history IBS-C = constipation predominant; IBS-D = diarrhea predominant; IBS-Mixed = both Diagnosis — Rome IV Criteria • • • Abdominal pain ≥ 1 day/week × 3 months + ≥ 2 of: change in stool frequency OR change in stool form No definitive lab or imaging test — diagnosis based SOLELY on symptoms Must RULE OUT first: CRC, IBD, endometriosis, malabsorption disorders 🧠 EXAM TIP: IBS diagnosis = symptoms ONLY + Rome IV criteria. No lab or imaging confirms it. Rule out everything else first! 💡 QUICK LOGIC: KEY DIFFERENCE: IBS = no inflammation, no structural damage. IBD = actual inflammation visible on endoscopy. These are completely different conditions! FODMAP Diet & Treatment • • • • • FODMAPs: Fermentable Oligo-, Di-, Mono-saccharides And Polyols — poorly absorbed sugars that ferment in gut → gas, bloating, diarrhea Low FODMAP diet eliminates: wheat, rye, onions, garlic, lactose (dairy), fructose (honey, apples, pears), sorbitol (artificial sweeteners) Antispasmodics: reduce intestinal muscle spasms/cramping Antidepressants: help with pain signaling Cognitive behavioral therapy + stress management ◦ Alosetron (Lotronex): a drug used for diarrhea-predominant IBS with serious risks — can cause ischemic colitis (reduced blood flow to intestines) and severe constipation. Report bloody diarrhea, sudden worsening pain, or severe constipation immediately. 🚨 EMERGENCY: ALOSETRON (Lotronex): Report IMMEDIATELY — bloody diarrhea, sudden worsening pain, or severe constipation = ISCHEMIC COLITIS. Stop the drug and call HCP! Malabsorption Syndrome • • Most common cause: LACTOSE INTOLERANCE Other: IBD, celiac disease, tropical sprue, cystic fibrosis ◦ Steatorrhea: fatty, greasy, foul-smelling stools — the classic sign of fat malabsorption. 🧠 EXAM TIP: Steatorrhea = fatty, greasy stools = classic sign of MALABSORPTION. Fat is NOT being absorbed properly! Celiac Disease • • • • • • • Autoimmune disease triggered by GLUTEN (wheat, barley, rye) → damages small intestine mucosa → malabsorption More common in women; associated with RA and Type 1 diabetes Classic symptoms: foul-smelling diarrhea, abdominal pain, flatulence, distention Atypical: joint pain, dermatitis herpetiformis (itchy blistering rash), peripheral neuropathy, reproductive problems Other: weight loss, anemia, lactose intolerance, OSTEOPOROSIS ◦ Diagnosis: blood test (tTG-IgA antibody) first → biopsy to confirm = gold standard. Treatment: strict GLUTEN-FREE diet for LIFE — even SMALL amounts cause intestinal damage Check MEDICATION labels too — gluten can hide in medications, not just food 🧠 EXAM TIP: Celiac diagnosis = blood test (tTG-IgA) FIRST → biopsy to CONFIRM. Treatment = lifelong gluten-free diet. 💉 NCLEX TIP: Celiac = LIFELONG gluten-free diet. Even small amounts cause damage. Check MEDICATION labels too, not just food! Short Bowel Syndrome (SBS) • • • • Not enough functional small intestine to absorb nutrients Caused by surgical removal of 50-75% of the small intestine, congenital defects, and intestinal damage SBS = #1 CAUSE of INTESTINAL FAILURE Symptoms: dehydration, weight loss, diarrhea, malnutrition, vitamin deficiencies, electrolyte imbalances, steatorrhea ◦ Intestinal transplantation: the only long-term treatment option for severe SBS with intestinal failure. SECTION 10: ANORECTAL PROBLEMS Hemorrhoids Internal vs. External Hemorrhoids Feature Internal External Location ABOVE internal sphincter OUTSIDE external sphincter Pain Usually PAINLESS PAINFUL Bleeding Bright red blood — most common symptom Seldom bleed Appearance May prolapse (protrude) through anus Reddish-blue; itching, burning, edema Thrombosed Less common Bluish-purple, SEVERELY painful; hard clot • • • • Risk factors: pregnancy, constipation, straining, heavy lifting, prolonged sitting/standing, obesity Conservative (first line): high-fiber diet, fluids, avoid straining, sitz baths, OTC ointments/stool softeners Rubber band ligation: band cuts off blood supply → hemorrhoid falls off Hemorrhoidectomy: for prolapsed, excessive bleeding, large/multiple thrombosed hemorrhoids 💉 NCLEX TIP: Post-hemorrhoidectomy → SITZ BATHS for comfort + healing; monitor for URINARY RETENTION (very common post-op!). Supervise sitz baths initially. Other Anorectal Conditions Anal Fissure • • • Linear tear in anal mucosa — from hard stool, trauma, infection Signs: SEVERE anal pain with defecation, bright red bleeding, pain with sitting Treatment: fiber, fluids, sitz baths, topical analgesia, stool softeners; surgery = lateral internal sphincterotomy Anorectal Abscess • • Pus from blocked/infected anal glands — severe pain, swelling, drainage, fever, possible SEPSIS Treatment: SURGICAL DRAINAGE (priority) + antibiotics Anal Fistula • • • Abnormal tunnel from anus/rectum to skin — 80% from anorectal abscess Signs: persistent bloody, purulent, or fecal drainage Treatment: fistulotomy or LIFT procedure Anal Cancer • • • 90% associated with HPV — HPV vaccination is KEY prevention Risk factors: smoking, homosexual HIV+ men, immunocompromised, cervical/vulvar cancer history Treatment: low-dose radiation + chemotherapy; surgery with ostomy if needed 🧠 EXAM TIP: Anal cancer = 90% linked to HPV. HPV vaccination = key prevention strategy. Tested on exams! Pilonidal Sinus • • Tract under skin between buttocks at tailbone — irritation → cyst or abscess → pain/swelling Treatment: irrigation and drainage; warm moist heat, positioning, hygiene education SECTION 11: HERNIAS, FISTULAS & ABDOMINAL TRAUMA Hernias Hernia Types Type Location Key Risk Inguinal (MOST COMMON) Groin (inguinal canal) Can strangulate; more common in men Femoral (HIGH RISK) Upper thigh / femoral canal Strangulates EASILY — emergency risk Umbilical Belly button Weakened rectus muscle; common in newborns ◦ ◦ ◦ Reducible: easily returns to the abdominal cavity — not urgent. Incarcerated: contents are trapped and cannot be returned to the abdominal cavity — emergency risk. Strangulated: blood supply is compromised → gangrene and necrosis = emergency surgery NOW. 🚨 EMERGENCY: Strangulated hernia = NO BLOOD SUPPLY = EMERGENCY SURGERY NOW. Signs: sudden severe pain + firm/hard lump that cannot be reduced. Call HCP immediately! • • Herniorrhaphy: surgical repair (laparoscopic preferred) Hernioplasty: Reinforce the weakened area with wire, fascia, or mesh 💉 NCLEX TIP: Post-hernia repair → NO heavy lifting > 10 pounds for 6-8 WEEKS. Cough/sneeze with OPEN MOUTH to reduce intraabdominal pressure. Fistulas • • • • An abnormal tract connecting two hollow organs or an organ to the skin High output > 500 mL/day = major fluid + electrolyte loss — highest risk for dehydration + malnutrition Early signs: FEVER + abdominal pain Treatment: IV fluids + electrolytes, control infection, WOCN consult, high-calorie + high-protein nutrition 🧠 EXAM TIP: HIGH output fistula (>500 mL/day) = major fluid + electrolyte loss = immediate nutritional support with high-calorie, high-protein enteral or parenteral nutrition! Abdominal Trauma • • • Blunt (MVA, falls): may NOT be obvious immediately — patients may think they're fine Penetrating (knife/gunshot): DO NOT REMOVE IMPALED OBJECT — stabilize in place ◦ Cullen's sign: bruising around the belly button = internal bleeding. ◦ Grey Turner's sign: bruising on the flank (side) = retroperitoneal bleeding. Complications: hypovolemic shock, peritonitis, abdominal compartment syndrome 🚨 EMERGENCY: IMPALED OBJECT = NEVER REMOVE IT. Stabilize in place and call the surgeon. Removing it causes MASSIVE bleeding. Classic NCLEX safety question! 🧠 EXAM TIP: Cullen's sign = belly button bruising. Grey Turner's sign = flank bruising. Both = internal bleeding = EMERGENCY. Abdominal compartment syndrome = rising pressure → ↓ breathing + ↓ urine output = life-threatening. QUICK REFERENCE: MUST-KNOW EXAM LIST Top Priority Topics — High Yield for Exam • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Treat ALL diarrhea as infectious until cause known NEVER give antidiarrheals if infection suspected C. diff = contact precautions + SOAP AND WATER only (not hand sanitizer) C. diff treatment = oral vancomycin or fidaxomicin × 10 days; FMT for recurrent Opioids = #1 drug cause of constipation → always start bowel regimen Fiber + FLUID together — fiber alone = impaction Best bowel attempt = 30 min after breakfast (gastrocolic reflex) UC = colon only + mucosal + continuous + CURABLE by surgery Crohn's = anywhere + all layers + skip lesions + fistulas + NOT curable Toxic megacolon = UC complication = sudden diarrhea improvement + distention + fever = EMERGENCY Screen for TB + hepatitis BEFORE ANY biologic therapy Corticosteroids = NEVER stop abruptly; always taper; deplete K+ and calcium Immunomodulators = delayed onset; NOT for acute flares; monitor CBC Appendicitis: CT preferred; NO heat, NO laxatives, NO enemas; NPO Pain suddenly improves then worsens = PERFORATION occurred Know ALL 4 appendicitis signs: McBurney's, Rovsing's, Psoas, Obturator Rigid board-like abdomen + fever + rebound tenderness = peritonitis = emergency SBO #1 = adhesions; LBO #1 = colorectal cancer; strangulated = emergency High obstruction = metabolic ALKALOSIS; Low = metabolic ACIDOSIS FAP = remove colon by age 25; polyps cancerous by 40; DNA testing available Villous polyps = highest cancer risk; adenomatous = precancerous CEA = monitors treatment response ONLY — NOT for diagnosis APR = permanent colostomy; LAR = temporary ostomy More distal ostomy = more normal output; ileostomy = liquid; sigmoid = formed Stoma: pink/red/moist = normal; purple/black/dry = call HCP NOW Ileostomy: 2-3 L fluids/day; chew food thoroughly; stool caustic to skin Diverticulitis DIET FLIP: Acute = low-fiber; After healing = high-fiber IBS = symptoms only (Rome IV); no inflammation; rule out everything else first IBS vs IBD: IBS = no damage, no test; IBD = inflammation visible on scope Celiac = lifelong gluten-free; check medication labels; tTG-IgA first, biopsy confirms SBS = #1 cause of intestinal failure; intestinal transplant = only long-term option Anal cancer = 90% HPV; HPV vaccination = prevention Strangulated hernia = no blood supply = emergency surgery NOW Impaled object = NEVER remove; Cullen's = belly button bruise; Grey Turner's = flank bruise Good luck on your exam! You've got this! 💪 Study Guide compiled from lecture transcript & course notes — Chapter 47, Adults 1