Assessment

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 occurring in many cases.

Perform a complete pain assessment. Initially, pain can present anywhere in the abdomen or flank area. As the inflammation and infection progress, the 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. 60-1). Abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis. An advanced practice nurse or other health care provider assesses for muscle rigidity and guarding on palpation of the abdomen. The patient may report pain after release of pressure. This is referred to as “rebound” tenderness.

FIG. 60-1 McBurney’s point is located midway between the anterior iliac crest and the umbilicus in the right lower quadrant. This is the classic area for localized tenderness during the later stages of appendicitis.

Laboratory findings do not establish the diagnosis, but 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 computed tomography (CT) scan can be used for diagnosis and may reveal the presence of a fecalith.

Interventions

All patients with suspected or confirmed appendicitis are hospitalized and examined by a surgeon. When the diagnosis is not clear, the health care team observes the patient before surgical exploration.

Nonsurgical Management

Keep the patient with suspected or known appendicitis on NPO to prepare for the possibility of emergency surgery and to avoid making the inflammation worse.

Surgical Management

Surgery is required as soon as possible. An appendectomy is the removal of the inflamed appendix by one of several surgical approaches. Uncomplicated appendectomy procedures are usually done via laparoscopy. A laparoscopy is a minimally invasive surgical (MIS) procedure with one or more small incisions near the umbilicus through which a small endoscope is placed. Patients having this type of surgery for appendix removal have few postoperative complications. 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. Patients having any type of laparoscopic procedures are typically discharged the same day of surgery with less pain and few complications after discharge. Most patients can return to usual activities in 1 to 2 weeks.

If the diagnosis is not definitive but the patient is at high risk for complications from suspected appendicitis, the surgeon may perform an exploratory laparotomy to rule out appendicitis. A laparotomy is an open surgical approach with a larger abdominal incision for complicated or atypical appendicitis or peritonitis.

Preoperative teaching is often limited because the patient is in pain or may be transferred quickly to the operating suite for emergency surgery. The patient is prepared for general anesthesia and surgery, as described in Chapter 16. After surgery, care of the patient who has undergone an appendectomy is the same as that required for anyone who has received general anesthesia (see Chapter 18).

If peritonitis or abscesses are found, 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, such as atelectasis. He or she may be hospitalized for as long as 3 to 5 days and return to normal activity in 4 to 6 weeks.

Assessment

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.

Physical findings of peritonitis (Chart 60-1) depend on 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 of the inflammation.

The cardinal signs of peritonitis are abdominal pain and tenderness. In the patient with localized peritonitis, the abdomen is tender on palpation in a well-defined area with rebound tenderness in this area. With generalized peritonitis, tenderness is widespread.

White blood cell (WBC) counts are often elevated to 20,000/mm³ with a high neutrophil count. Blood culture studies may be done to determine whether septicemia has occurred and to identify the causative organism to enable appropriate therapy. The health care provider requests laboratory tests to assess fluid and electrolyte balance and renal status, including electrolytes, blood urea nitrogen (BUN), creatinine, hemoglobin, and hematocrit. Oxygen saturation and end–carbon dioxide monitoring may be obtained to assess respiratory function and acid-base balance.

Abdominal x-rays can assess for free air or fluid in the abdominal cavity, indicating perforation. The x-rays may also show dilation, edema, and inflammation of the small and large intestines. An abdominal sonogram may be useful in locating the problem.

Interventions

Patients with peritonitis are hospitalized because of the severe nature of the illness. If complications are extensive, the patients are often admitted to a critical care unit. Nursing interventions focus on the early identification of complications.

Nonsurgical Management

The physician prescribes IV fluids and broad-spectrum antibiotics immediately after establishing the diagnosis of peritonitis. IV fluids are used to replace fluids collected in the peritoneum and bowel. 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 and according to the patient’s respiratory status and oxygen saturation via pulse oximetry. Administer analgesics, and monitor for pain control. Document pain assessments thoroughly. A surgical consultation is requested in case surgery should become necessary.

Surgical Management

Abdominal surgery is the usual treatment for identifying and repairing the cause of the peritonitis. If the patient is so critically ill that surgery would be life threatening, it may be delayed. 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 the cavity and provide a route for irrigation after surgery.

The preoperative care is similar to that described in Chapter 16 for patients having general anesthesia. Chapter 18 describes general postoperative care for exploratory laparotomy. Multi-system complications can occur with peritonitis. Loss of fluids from the extracellular space to the peritoneal cavity, NGT suctioning, and NPO status require that the patient receives IV fluid replacement. Be sure that unlicensed assistive personnel (UAP) carefully measure intake and output. Fluid rates may be changed frequently based on laboratory values and patient condition.

The patient has one or more incisions and drains. If an open surgical procedure is needed, the infection may slow healing of an incision or the incision may be partially open to heal by second or third intention. These wounds require special care involving manual irrigation or packing as prescribed by the surgeon. 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. Fluid retention could cause abdominal distention or pain.

Assessment

The patient history can provide information related to the potential cause of the illness. Ask about recent travel, especially to tropical regions of Asia, Africa, or Central or South America. Some areas of Mexico may also be the source of gastroenteritis. Newcomers (immigrants) from these countries often have gastroenteritis. Traveler’s diarrhea can begin 3 days to 2 weeks after the patient’s arrival.

The patient who has gastroenteritis usually looks ill. Nausea and vomiting can occur with all types of gastroenteritis but are usually limited to the first 1 or 2 days. Patients have diarrhea, which varies in consistency and amount with the causative organism.

In patients with epidemic viral gastroenteritis, myalgia (muscle aches), headache, and malaise are often reported. Weakness and cardiac dysrhythmias may be the result of loss of potassium (hypokalemia) from diarrhea. Monitor for and document manifestations of hypokalemia.

Diarrhea associated with epidemic viral gastroenteritis is commonly limited to 24 to 48 hours. Infection with the Norwalk virus has a rapid onset of nausea, abdominal cramps, vomiting, and diarrhea. This enteritis is usually mild. Campylobacter enteritis is a more severe disease with foul-smelling stools containing blood, which can number 20 to 30 per day for up to 7 days. E. coli gastroenteritis may or may not have blood or mucus in the stool. Diarrhea can last for up to 10 days. Shigella causes stools to have blood and mucus, which can continue for up to 5 days. Monitor for and document the number of stools daily for the patient who is hospitalized.

As part of the laboratory assessment, Gram stain of stool is usually done before culture. Cultures positive for the organism are diagnostic (Pagana & Pagana, 2010). Many WBCs on Gram stain suggest shigellosis. The presence of WBCs and RBCs in the stool may indicate Campylobacter gastroenteritis.

Interventions

For any type of gastroenteritis, encourage fluid replacement. The amount and route of fluid administration are determined by the patient’s hydration status and overall health condition.

Fluid Replacement

Teach patients to drink extra fluids to replace fluid lost through vomiting and diarrhea. Depending on the patient’s age and severity of dehydration, he or she may be admitted to the hospital for gastroenteritis or may stay in the emergency department or urgent care center until adequate hydration is restored.

Obtain a weight, orthostatic blood pressure, and other vital sign measurements at admission. IV fluids such as half-strength normal saline (0.45% sodium chloride) to replace sodium lost in vomitus, with or without potassium supplements, are infused as prescribed. Potassium is usually needed for patients with excessive diarrhea. Continue to monitor the patient’s vital signs, intake and output, and weight. A rapid gain or loss of 1 kg (2.2 lbs) of body weight is equivalent to the gain or loss of 1 L of fluid. Advise the patient to alternate periods of rest and activity.

Depending on the type of gastroenteritis, especially if the geographic area is experiencing epidemic infections, the local health department may need to be notified. For example, it is mandatory that every case of shigellosis be reported. In some endemic areas, Campylobacter enteritis must be reported.

Drug Therapy

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. If the health care provider determines that antiperistaltic agents are necessary, an initial dose of loperamide (Imodium) 4 mg can be administered orally, followed by 2 mg after each loose stool, up to 16 mg daily.

Treatment with antibiotics may be needed if the gastroenteritis is due to bacterial infection with fever and severe diarrhea. Depending on the type and severity of the illness, 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 ) or ciprofloxacin are prescribed.

For relatively short-term diarrhea of 24 to 48 hours’ duration, the diagnosis is based primarily on the patient’s history and clinical manifestations, not by a stool examination. When diarrhea is severe or persists for long periods, the stool is examined to determine the causative organism and to begin specific treatment. It should be determined whether the diarrhea is caused by Salmonella or by parasites because these organisms respond to specific medications (see p. 1289 in the Parasitic Infection section). Diarrhea that continues longer than 10 days, especially if associated with nocturnal diarrhea, is probably not due to gastroenteritis.

Skin Care

Frequent stools that are rich in electrolytes and enzymes, as well as frequent wiping and washing of the anal region, can irritate the skin. 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 two or three times daily can also relieve discomfort.

If leakage of stool is a problem, the patient can use absorbent cotton or panty liner and keep it in place with snug underwear. For patients who are incontinent, remind unlicensed assistive personnel (UAP) to keep 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.

Teaching for Self-Management

During the acute phase of the illness, teach the patient and family about the importance of fluid replacement. Teaching the patient and family about reducing the risk for transmission of gastroenteritis is also important (Chart 60-2). Adhere to these precautions for up to 7 weeks after the illness or up to several months if Shigella was the offending organism.

Etiology and Genetic Risk

The exact cause of UC is unknown, but genetic and immunologic factors have been suspected. A genetic basis of the disease has been supported because it is often found in families and twins. Immunologic causes, including autoimmune dysfunction, are likely the etiology of extraintestinal manifestations of the disease. Epithelial antibodies in the IgG class have been identified in the blood of some patients with UC (McCance et al., 2010).

With long-term disease, cellular changes can occur that increase the risk for colon cancer. Damage from proinflammatory cytokines, such as specific interleukins (e.g., IL-1, IL-6, IL-8) and tumor necrosis factor (TNF)–alpha, have cytotoxic effects on the colonic mucosa (McCance et al., 2010).

Incidence/Prevalence

Chronic inflammatory bowel disease (IBD) affects about 1.4 million people in the United States and is split about equally between ulcerative colitis (UC) and Crohn’s disease (discussed later). Peak age for being diagnosed with UC is between 30 and 40 years and again at 55 to 65 years. Women are more often affected than men in their younger years, but men have the disease more often as middle-aged and older adults (Crohn’s and Colitis Foundation of America, 2008).

History

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 intolerance of milk and milk products and fried, spicy, or hot foods. 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 Clostridium difficile infection. Has the patient traveled to or emigrated from tropical areas? Ask about recent use of NSAIDs that can either present with the initial diagnosis or cause a flare-up of the disease. Ask about any extraintestinal symptoms such as arthritis, mouth sores, vision problems, and skin disorders.

Physical Assessment/Clinical Manifestations

Symptoms vary with an acuteness of onset. 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 along the colon. Patients with 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.

Psychosocial Assessment

Many patients are very concerned about the frequency of stools and the presence of blood. 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. Eating may be associated with pain and cramping and an increased frequency of stools. Mealtimes may become unpleasant experiences. Frequent visits to health care providers and close monitoring of the colon mucosa for abnormal cell changes can be anxiety provoking.

Assess the patient’s understanding of the illness and its impact on his or her lifestyle. Encourage and support the patient while exploring:

Laboratory Assessment

As a result of chronic blood loss, hematocrit and hemoglobin levels may be low, which indicates anemia and a chronic disease state. 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 as a result of frequent diarrheal stools and malabsorption through the diseased bowel (Pagana & Pagana, 2010). Hypoalbuminemia (decreased serum albumin) is found in patients with extensive disease from losing protein in the stool.

Other Diagnostic Assessment

A colonoscopy is the most definitive test for diagnosing UC. Annual colonoscopies are recommended when the patient has longer than a 10-year history of UC involving the entire colon. In some cases, a computed tomography (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 and identify complications, mucosal patterns, and the distribution and depth of disease involvement. In early disease, the barium enema may show incomplete filling as a result of inflammation and fine ulcerations along the bowel contour, which appear deeper in more advanced disease.

Analysis

The priority problems for patients with ulcerative colitis are: