APPENDICITIS

 Remember this Terminologies

Cecum-or caecum is a pouch within the peritoneum that is considered to be the beginning of the large

intestine. It is typically located on the right side of the body

Edematous -relating to or affected with edema: abnormally swollen with fluid

Lymphoid hyperplasia-is an increase in the number of normal cells (called lymphocytes) that are
contained in lymph nodes. This most often happens when there is an infection with bacteria, viruses, or
other types of germs and is part of the body's reaction to the infection.

Ischemia -deficient supply of blood to a body part that is due to obstruction of the inflow of arterial
blood

Gangrene- localized death and decomposition of body tissue, resulting from either obstructed
circulation or bacterial infection.

McBurney’s point-the name given to the point over the right side of the abdomen that is one-third from
from the anterior superior iliac spine to the umbilicus (navel)

Rovsing’s sign-named after the Danish surgeon Niels Thorkild Rovsing (1862–1927), is a sign

of appendicitis. This maneuver elicits tenderness in the right lower abdomen, because contents of the
left lower abdomen are shifted upon application of pressure, further irritating the inflamed peritoneum

Psoas Sign- also called as Cope's psoas test  or Obraztsova's sign, is a medical sign that
indicates irritation to the iliopsoas group of hip flexors in the abdomen, and consequently indicates that
the inflamed appendix is retrocaecal in orientation (as the iliopsoas muscle is retroperitoneal).

Obturator sign-an indicator of irritation to the obturator internus muscle,  it is performed when acute
appendicitis is suspected

Paralytic ileus-Obstruction of the intestine due to paralysis of the intestinal muscles

Peritonitis-Peritonitis is inflammation of the peritoneum — a silk-like membrane that lines your inner
abdominal wall and covers the organs within your abdomen — that is usually due to a bacterial or fungal
infection

 The appendix is a small, finger-like appendage attached to the cecum just below the ileocecal
valve.

 Because it empties into the colon inefficiently and its lumen is small, it is prone to becoming
obstructed and is vulnerable to infection (appendicitis).
  The obstructed appendix becomes inflamed and edematous and eventually fills with pus. It is
the most common cause of acute inflammation in the right lower quadrant of the abdominal
cavity and the most common cause of emergency abdominal surgery. Although it can occur at
any age, it more commonly occurs between the ages of 10 and 30 years. (Brunner 2014)

PATHOPHYSIOLOGY

1. The appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a
fecalith (i.e., hardened mass of stool), tumor, lymphoid hyperplasia, or foreign body.

2. The infammatory process increases intraluminal pressure, initiating a progressively severe,

generalized, or periumbilical pain that becomes localized to the right lower quadrant of the abdomen
within a few hours.

3. Eventually, the inflamed appendix fills with pus (Spirt, 2010).

4. Once obstructed, the appendix becomes ischemic, bacterial overgrowth occurs.

5. Eventually gangrene occurs (Vissers & Lennarz, 2010). (Brunner 2014)

ASSESSMENT

 Vague epigastric or periumbilical pain (i.e., visceral pain that is dull and poorly localized)
progresses to right lower quadrant pain and is usually accompanied by a

 low-grade fever

 nausea

 Vomiting.

 Loss of appetite is common.

 In up to 50% of presenting cases, local tenderness is elicited at McBurney’s point when pressure
is applied (Black & Martin, 2012) (Fig.2). Rebound tenderness (i.e., production or intensification
of pain when pressure is released) may be present.

 Pain on defecation suggests that the tip of the appendix is resting against the rectum; pain on
urination suggests that the tip is near the bladder or impinges on the ureter. Some rigidity of the
lower portion of the right rectus muscle may occur.

 Rovsing’s sign may be elicited by palpating the left lower quadrant; this paradoxically causes
pain to be felt in the right lower quadrant . (https://youtu.be/6I03eiLO_lU)
  Psoas sign (i.e., pain that occurs upon slow extension of the right thigh with the patient lying on
the left side) https://youtu.be/n0a0PCwsVQ4

 Obturator sign (i.e., pain that occurs with passive internal rotation of the flexed right thigh with
the patient supine (Spirt, 2010). (https://youtu.be/jV80jcnhNtA)

 If the appendix has ruptured, the pain becomes more diffuse; abdominal distention develops as
a result of paralytic ileus, and the patient’s condition worsens.

NOTE:Constipation can also occur with appendicitis. Laxatives administered in this instance may result in
perforation of the inflamed appendix. In general, a laxative or cathartic should not be administered
when a person has fever, nausea, and abdominal pain. (Brunner 2014)

GERONTOLOGIC CONSIDERATIONS

 In the elderly, signs and symptoms of appendicitis may vary greatly. Signs may be very vague
and suggestive of bowel obstruction or another process; some patients may experience no
symptoms until the appendix ruptures. The incidence of perforated appendix is higher in the
elderly because many of these people do not seek health care as quickly as younger people.
(Brunner Handbook,2010)

 Be a Keen Observer for this Complications, OK!

 The major complication of appendicitis is perforation of the appendix, which can lead to
peritonitis,

 Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever of
37.7°C (100°F) or greater, a toxic appearance, and continued abdominal pain or tenderness.
Patients with peritonitis are often found to be supine and motionless (Spirt, 2010).

DIAGNOSTIC

Findings Diagnosis is based on results of a complete physical examination and on laboratory findings and
imaging studies.

 The complete blood cell count demonstrates an elevated white blood cell count with an
elevation of the neutrophils.

 Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant
density or localized distention of the bowel.

 A pregnancy test may be performed for women of childbearing age to rule out ectopic
pregnancy and before x-rays are obtained.
  A diagnostic laparoscopy may be used to rule out acute appendicitis in equivocal cases. (Brunner
2014)

MEDICAL MANAGEMENT

 Immediate surgery is typically indicated if appendicitis is diagnosed. To correct or prevent fluid

and electrolyte imbalance, dehydration, and sepsis, antibiotics and IV fluids are administered
until surgery is performed.

 Appendectomy (ie, surgical removal of the appendix) is performed as soon as possible to

decrease the risk of perforation. It may be performed using general or spinal anesthesia with a
low abdominal incision (laparotomy) or by laparoscopy.

 Both laparotomy and laparoscopy are safe and effective in the treatment of appendicitis with
perforation. However, recovery after laparoscopic surgery is generally quicker. Consequently,
laparoscopic appendectomy is more common.

 When perforation of the appendix occurs, an abscess may form. If this occurs, the patient may
be initially treated with antibiotics, and the surgeon may place a drain in the abscess. After the
abscess is drained and there is no further evidence of infection, an appendectomy is then
typically performed (treat infection and drain the abscess first before the appendectomy!)

NURSING MANAGEMENT

 Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating
infection due to the potential or actual disruption of the GI tract, maintaining skin integrity, and
attaining optimal nutrition.

Pre-Operatively

 The nurse prepares the patient for surgery, which includes:

 an IV infusion to replace fluid loss and promote adequate renal function and antibiotic therapy
to prevent infection.

 If there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted. An enema is not
administered because it can lead to perforation.

Post Operatively

 After surgery, the nurse places the patient in a HIGHFOWLER’S POSITION. This position reduces
the tension on the incision and abdominal organs, helping to reduce pain.
  An opioid, usually morphine sulfate, is prescribed to relieve pain. When tolerated, oral fluids are
administered. Any patient who was dehydrated before surgery receives IV fluids

 Food is provided as desired and tolerated on the day of surgery when normal bowel sounds are
present.

 The patient may be discharged on the day of surgery if the temperature is within normal limits,
there is no undue discomfort in the operative area, and the appendectomy was uncomplicated.
Discharge teaching for the patient and family is imperative.

Promoting Home- and Community-Based Care Teaching Patients Self-Care

 The nurse instructs the patient to make an appointment to have the surgeon remove the
sutures between the 5th and 7th days after surgery.

 Incision care and activity guidelines are discussed

 Heavy lifting is to be avoided postoperatively (pwedeng bumuka ang sutures), although

normal activity can usually be resumed within 2 to 4 weeks.

 If there is a possibility of peritonitis, a drain is left in place at the area of the incision. Patients at
risk for this complication may be kept in the hospital for several days and are monitored
carefully for signs of intestinal obstruction or secondary hemorrhage.

 Secondary abscesses may form in the pelvis, under the diaphragm, or in the liver, causing
elevation of the temperature, pulse rate, and white blood cell count.

 When the patient is ready for discharge, the patient and family are taught to care for the
incision and perform dressing changes and irrigations as prescribed. A home care nurse may be
needed to assist with this care and to monitor the patient for complications and wound healing

Cholecystitis
Cholecystitis (inflammation of the gallbladder which can be acute or chronic) causes pain, tenderness,
and rigidity of the upper right abdomen that may radiate to the midsternal area or right shoulder and is
associated with nausea, vomiting, and the usual signs of an acute inammation.

An empyema of the gallbladder develops if the gallbladder becomes filled with purulent fluid (pus).

CALCULOUS CHOLECYSTITIS

-is the cause of more than 90% of cases of acute cholecystitis (Feldman, Friedman, & Brandt, 2010; Rakel
& Rakel, 2011).
In calculous cholecystitis, a gallbladder stone obstructs bile outflow. Bile remaining in the gallbladder
initiates a chemical reaction; autolysis and edema occur; and the blood vessels in the gallbladder are
compressed, compromising its vascular supply.

Gangrene of the gallbladder with perforation may result.

Bacteria play a minor role in acute cholecystitis; however, secondary infection of bile occurs in
approximately 50% of cases. The organisms involved are generally enteric (normally live in the GI tract)
and include

 Escherichia coli,
 Klebsiella species, and
 Streptococcus.

Bacterial contamination is not believed to stimulate the actual onset of acute cholecystitis (Feldman et
al., 2010).

ACALCULOUS CHOLECYSTITIS

Describes acute gallbladder inflammation in the absence of obstruction by gallstones. Acalculous

cholecystitis occurs after:

• major surgical procedures,

• Severe trauma, or burns.

• torsion,

• cystic duct obstruction,

• primary bacterial infections of the gallbladder,

• and multiple blood transfusions.

• It is speculated that acalculous cholecystitis is caused by alterations in fluids and electrolytes and
alterations in regional blood flow in the visceral circulation.

• Bile stasis (lack of gallbladder contraction) and increased viscosity of the bile are also thought to
play a role.

• The occurrence of acalculous cholecystitis with major surgical procedures or trauma makes its
diagnosis difficult.

Cholelithiasis Calculi or gallstones, usually form in the gallbladder from the solid constituents of
bile; they vary greatly in size, shape, and composition
 • They are uncommon in children and young adults but become more prevalent with increasing
age.

• It is estimated that the prevalence of gallstones ranges from 5% to 20% in women between the
ages of 20 and 55 years from 25% to 30% in women older than 50 years.

• Cholelithiasis affects approximately 50% of women by age 70 years.

• The prevalence in men is approximately one third to one half the rates of occurrence in women
(Feldman et al., 2010).

PATHOPHYSIOLOGY

There are two major types of gallstones:

• Composed predominantly of pigment

• Composed primarily of cholesterol.

PIGMENT STONES probably form when unconjugated pigments in the bile precipitate to form stones;
these stones account for about 10% to 25% of cases in the United States (Feldman et al., 2010).

The risk of developing such stones is increased in patients with cirrhosis, hemolysis, and infections of
the biliary tract. Pigment stones cannot be dissolved and must be removed surgically.

CHOLESTEROL STONES account for most of the remaining 75% of cases of gallbladder disease in the
United States.

Cholesterol, which is a normal constituent of bile, is insoluble in water. Its solubility depends on bile
acids and lecithin (phospholipids) in bile.

In gallstone-prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis
in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form
stones.

The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant that
produces inflammatory changes in the mucosa of the gallbladder (Feldman et al., 2010).

*Two to three times more women than men develop cholesterol stones andgallbladder disease; affected
women are usually older than 40 years, multiparous, and obese (Feldman et al., 2010; Goldman &
Schafer, 2012).

Stone formation is more frequent in people who use oral contraceptives, estrogens, or clobrate; *these
medications are known to increase biliary cholesterol saturation (Feldman et al., 2010).
The incidence of stone formation increases with age as a result of increased hepatic secretion of
cholesterol and decreased bile acid synthesis.

In addition, there is an increased risk because of malabsorption of bile salts in patients with GI disease
.The incidence is also greater in people with diabetes (Chart 50-1).

CHOLELITHIASIS RISK FACTORS

• Obesity

• Women, especially those who have had multiple pregnancies or who are of Native American or U.S.
southwestern Hispanic ethnicity

• Frequent changes in weight

• Rapid weight loss (leads to rapid development of gallstones and high risk of symptomatic disease)

• Treatment with high-dose estrogen (e.g., in prostate cancer)

• Low-dose estrogen therapy—carries a small increase in the risk of gallstones

• Cystic fibrosis

• Diabetes

5 F’S

 Fat
 Forty
 Fertile
 Fair
 Female

CLINICAL MANIFESTATIONS

•May be silent, producing no pain and only mild GI symptoms

•May be acute or chronic with epigastric distress (fullness, abdominal distention, and vague upper right
quadrant pain); may follow a meal rich in fried or fatty foods

•If the cystic duct is obstructed, the gallbladder becomes distended, inflamed, and eventually infected;
fever and palpable abdominal mass; biliary colic with excruciating upper right abdominal pain, radiating
to back or right shoulder with nausea and vomiting several hours after a heavy meal; restlessness and
constant or colicky pain

•Jaundice, accompanied by marked itching, with obstruction of the common bile duct, in a small
percentage of patients

•Very dark urine; grayish or clay-colored stool

•Deficiencies of vitamins A, D, E, and K (fat-soluble vitamins)

GERONTOLOGIC CONSIDERATIONS

•Surgical intervention for disease of the biliary tract is the most common operation performed in the
elderly.

•Biliary disease may be accompanied or preceded by symptoms of septic shock: oliguria, hypotension,
mental changes, tachycardia, and tachypnea.

•Cholecystectomy is usually well tolerated and carries a low risk if expert assessment and care are
provided before, during, and after surgery.

MEDICAL MANAGEMENT

The major objectives of medical therapy are:

• to reduce the incidence of acute episodes of gallbladder pain and cholecystitis by supportive
and dietary management and, if possible,

• to remove the cause of cholecystitis by pharmacologic therapy, endoscopic procedures, or

surgical intervention.

• *Although nonsurgical procedures eliminate risks associated with surgery, these approaches
are associated with persistent symptoms or recurrent stone formation. Most of the nonsurgical
approaches, including LITHOTRIPSY and dissolution of gallstones, provide only temporary
solutions to gallstone problems and are infrequently used in the United States. In some
instances, other treatment approaches may be indicated; these are described later.

Removal of the gallbladder (CHOLECYSTECTOMY) through traditional surgical approaches has largely
been replaced by LAPAROSCOPIC CHOLECYSTECTOMY (removal of the gallbladder through a small
incision through the umbilicus). As a result, surgical risks have decreased, along with the length of
hospital stay and the long recovery period required after standard surgical cholecystectomy. In relatively
rare instances, a standard surgical procedure may be necessary.
PHARMACOLOGIC MANAGEMENT

• Ursodeoxycholic acid (UDCA [Urso, Actigall])

• Chenodeoxycholic acid (chenodiol or CDCA [Chenix]) are effective in dissolving primarily

cholesterol stones.

•Patients with significant, frequent symptoms; cystic duct occlusion; or pigment stones are not
candidates for therapy with UDCA.

SURGICAL MANAGEMENT

Goal of surgery is to relieve persistent symptoms, to remove the cause of biliary colic, and to treat
acute cholecystitis

• LAPAROSCOPIC CHOLECYSTECTOMY: performed through a small incision or puncture made

through the abdominal wall in the umbilicus.

• MINICHOLECYSTECTOMY: Gallbladder is removed through a small incision.

• Cholecystectomy: Gallbladder is removed through an abdominal incision (usually right

subcostal) after ligation of the cystic duct and artery (gallbladder)

• Choledochostomy: incision into the common duct for stone removal. (stone)

• Cholecystostomy (surgical or percutaneous): Gallbladder is opened, and the stone, bile, or

purulent drainage is removed. (stone, bile and drainage)

THE PATIENT UNDERGOING CHOLECYSTECTOMY

Assessment

• Assess health history: Note history of smoking or prior respiratory problems.

• Assess respiratory status: Note shallow respirations, persistent cough, or ineffective or adventitious
breath sounds.

• Evaluate nutritional status (dietary history, general examination, and laboratory study results).
Diagnosis Nursing Diagnoses

• Acute pain and discomfort related to surgical incision

• Impaired gas exchange related to high abdominal surgical incision

• Impaired skin integrity related to altered biliary drainage after surgical incision

• Imbalanced nutrition, less than body requirements, related to inadequate bile secretion

• Deficient knowledge about self-care activities related to incisional care, dietary modifications (if
needed), medications, reportable signs or symptoms (fever, bleeding, vomiting)

Collaborative Problems/Potential Complications

• Bleeding

• Gastrointestinal symptoms

Planning and Goals (Goals include relief of pain)

• adequate ventilation, intact skin and improved biliary drainage,

• optimal nutritional intake,

• absence of complications,

• and understanding of self-care routines.

Nursing Interventions

Postoperative

• Place patient in low Fowler’s position.

• Provide IV fluids and nasogastric suction.

• Provide water and other fluids and soft diet, after bowel sounds return.
Relieving Pain

• Administer analgesic agents as ordered.

• Help patient turn, cough, breathe deeply, and ambulate as indicated.

• Instruct patient to use a pillow or binder to splint incision.

Improving Respiratory Status

• Remind patient to take deep breaths and cough every hour, to expand the lungs fully and prevent
atelectasis; promote early ambulation.

• Monitor elderly and obese patients and those with preexisting pulmonary disease most closely for
respiratory problems.

Maintaining Skin Integrity and Promoting Biliary Drainage

• Connect tubes to drainage receptacle and secure tubing to avoid kinking (elevate above abdomen).

• Place drainage bag in patient’s pocket when ambulating.

• Observe for indications of infection, leakage of bile, and obstruction of bile drainage.

• Observe for jaundice (check the sclera).

• Note and report right upper quadrant abdominal pain, nausea and vomiting, bile drainage around any
drainage tube, clay-colored stools, and a change in vital signs.

• Change dressing frequently, using ointment to protect skin from irritation. Measure bile collected
every 24 hours; document amount, color, and character of drainage.

• Keep careful record of intake and output.

Improving Nutritional Status

Encourages the patient to eat a diet that is low in fats and high in carbohydrates and proteins
immediately after surgery. At the time of discharge, advise patient to maintain a nutritious diet and
avoid excessive fats; fat restriction is usually lifted in 4 to 6 weeks.
Monitoring and Managing Complications

Bleeding:

• Assess periodically for increased tenderness and rigidity of abdomen and report;

• Instruct patient and family to report change in color of stools.

• Monitor vital signs closely.

• Inspect incision for bleeding.

Gastrointestinal symptoms:

• Assess for loss of appetite,

• vomiting,

• pain,

• distention of abdomen,

• and temperature elevation;

• report promptly and instruct patient and family to report symptoms promptly; provide written
reinforcement of verbal instructions.

Promoting Home- and Community-Based Care

TEACHING PATIENTS SELF-CARE

• Teach about medications and their actions.

• Instruct patient to report to physician symptoms of jaundice, dark urine, pale stools, pruritus, or signs
of inflammation and infection (eg, pain or fever).

• Instruct patient, verbally and in writing, about care of drainage tubes and to report to physician
promptly changes in amount or characteristics of drainage.

• Refer for home care if necessary.

• Emphasize importance of keeping follow-up appointments

Evaluation Expected Patient Outcomes

• Reports decrease in pain

• Demonstrates appropriate respiratory function

• Exhibits normal skin integrity around biliary drainage sites

• Obtains relief from dietary intolerance

• Absence of complications

Inflammatory bowel disease (IBD)

Remember this Terminologies

Transmural lesions-existing or occurring across the entire wall of an organ or blood vessel.

Histopathology is the diagnosis and study of diseases of the tissues, and involves examining tissues
and/or cells under a microscope.

Granulomas- is a structure formed during inflammation that is found in many diseases. It is a collection

of immune cells known as macrophages. Granulomas form when the immune system attempts to wall
off substances it perceives as foreign but is unable to eliminate

Leukocytosis- is a condition in which the white cell (leukocyte count) is above the normal range in
the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection,
but may also occur following certain parasitic infections or bone tumors as well as leukemia

Proctosigmoidoscopy-Examination of the lower colon using a sigmoidoscope, inserted into the rectum.
A sigmoidoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool
to remove tissue to be checked under a microscope for signs of disease. Also called sigmoidoscopy.

A barium study/x-ray) examination of the gastrointestinal (GI) tract. Barium X-rays (also called upper
and lower GI series) are used to diagnose abnormalities of the GI tract, such as tumors, ulcers and other
inflammatory conditions, polyps, hernias, and strictures . The use of barium with standard X-rays
contributes to the visibility of various characteristics of the GI tract.

Barium is a dry, white, chalky powder that is mixed with water to make barium liquid. Barium is an X-ray
absorber and appears white on X-ray film (https://www.hopkinsmedicine.org/)
Inflammatory bowel disease (IBD) is a group of chronic disorders: Crohn’s disease (i.e., regional
enteritis) and ulcerative colitis that result in inflammation or ulceration (or both) of the bowel lining.
Both disorders have striking similarities but also several differences

The incidence of IBD in the United States has increased in the past century, and more than 30,000 new
cases occur annually. People between 15 and 30 years of age are at the greatest risk of developing IBD,
followed by those between 50 and 70 years of age. Women and men tend to be equally affected, and
family history appears to predispose people to IBD, particularly if a first-degree relative has the disease

 Since familial clusters also occur a genetic linkage is evident. A positive family history is the
most important independent risk factor for IBD

 Despite extensive research, the cause of IBD is still unknown. Researchers theorize that it is
triggered by environmental agents such as pesticides, food additives,tobacco, and radiation
(NDDIC, 2012b).

 Nonsteroidal anti-inammatory drugs have been found to exacerbate IBD.

 Allergies and immune disorders have also been suggested as causes. Abnormal response to
dietary or bacterial antigens has been studied extensively, and genetic factors also are being
studied

TIME to WATCH

Inflammatory response

(https://youtu.be/FXSuEIMrPQk)

(https://youtu.be/uc6IV85mf3s)

Crohn’s disease
Crohn’s disease is usually first diagnosed in adolescents or young adults but can appear at any time of
life. The incidence of Crohn’s disease has risen over the past 30 years (NDDIC, 2012b). Crohn’s disease is
seen more often in smokers than in nonsmokers (Peppercorn, 2012c).

Crohn’s disease is a subacute and chronic inflammation of the GI tract wall that extends through all
layers (i.e., transmural lesion). Although its characteristic histopathology changes can occur anywhere in
the GI tract, it most commonly occurs in the distal ileum and, to a lesser degree, the ascending colon. It
is characterized by periods of remission and exacerbation. It is posited that defects in the immune
system in genetically predisposed individuals allow bacteria to invade the gut mucosa, resulting in an
overactive adaptive immune response.

*NO CURE FOR CHOHN’S DISEASE

TYPES OF CROHN’S DISEASE

 Ileocolitis-inflammation found in ileum and colon

 Gastroduodenal Crohn’s- found parts of stomach and duodenum

 Jejunoileitis- found in Jejunum

 Ileitis- found in ileum

 Granulomatous Colitis- found only in colon

PATHOPHYSIOLOGY

1. The disease process begins with edema and thickening of the mucosa.
2. Ulcers begin to appear on the inflamed mucosa. These lesions are not in continuous contact
with one another and are separated by normal tissue. Hence, these clusters of ulcers tend to
take on a classic “cobblestone” appearance.
3. Fistulas, fissures, and abscesses form as the inflammation extends into the peritoneum.
Granulomas occur in 50% of patients (Hanauer & Norton, 2011).
4. As the disease advances, the bowel wall thickens and becomes fibrotic, and the intestinal lumen
narrows.
5. Diseased bowel loops sometimes adhere to other loops surrounding them

Onset of SYMPTOMS is usually insidious, with

 Prominent right lower quadrant abdominal pain and diarrhea unrelieved by defecation.

 Abdominal tenderness and spasm.

 Crampy pains occur after meals; the patient tends to limit intake, causing weight loss,
malnutrition, and secondary anemia.

 Chronic diarrhea may occur, resulting in a patient who is uncomfortable and is thin and
emaciated from inadequate food intake and constant fluid loss.

 The inflamed intestine may perforate and form intra-abdominal and anal abscesses.
  Fever and leukocytosis occur.

 Abscesses, fistulas, and fissures that bleed are common.

 Symptoms extend beyond the GI tract to include joint disorders (eg, arthritis), skin lesions (eg,
erythema nodosum), ocular disorders (eg, conjunctivitis), and oral ulcers.

Complications of Crohn’s disease include:

 intestinal obstruction or stricture formation

 perianal disease,

 fluid and electrolyte imbalances

 malnutrition from malabsorption,

 and fistula (channel/passage) and abscess formation.

Enteroenteric- intestine to intestine

Enterovesical- intestine to bladder

Enterovaginal- intestine to vagina

*The most common type of small bowel fistula caused by Crohn’s disease is the
enterocutaneous fistula (i.e., an abnormal opening between the small bowel and the skin). Abscesses
can be the result of an internal fistula that results in fluid accumulation and infection. Patients with
colonic Crohn’s disease are also at increased risk of colon cancer (Hanauer & Norton, 2011).

DIAGNOSTICS

 A PROCTOSIGMOIDOSCOPY is usually performed initially to determine whether the

rectosigmoid area is inflamed

 BARIUM STUDY of the upper GI tract is the most conclusive diagnostic aid; shows the classic
“string sign” of the terminal ileum (constriction of a segment of intestine) as well as
cobblestone appearance, fistulas, and fissures.

 Endoscopy, colonoscopy, and intestinal biopsies may be used to confirm the diagnosis.

 Stool examination for occult blood and steatorrhea (fat in stool).

 Complete blood cell count (decreased Hgb and Hct), sedimentation rate (elevated), albumin,
and protein levels (usually decreased due to malnutrition).
Remember this Terminologies!

 Hypocalcemia- is a condition in which there are lower-than-average levels of calcium in the

liquid part of the blood, or the plasma. Normal 8.6-10mg/dL
 Anemia- a condition marked by a deficiency of red blood cells or of hemoglobin in the blood,
resulting in pallor and weariness (extreme fatigue).
 Erythema nodosum is a type of skin inflammation that is located in a part of the fatty layer of
skin. Erythema nodosum results in reddish, painful, tender lumps most commonly located in
the front of the legs below the knees. The tender lumps, or nodules, of erythema nodosum
range in size from a dime to a quarter. They may be inflamed off and on for a period of weeks,
then shrink and become flat, leaving a bruised appearance.(WebMD.com)
 Uveitis is a form of eye inflammation. It affects the middle layer of tissue in the eye wall (uvea).
 Uveitis (u-vee-I-tis) warning signs often come on suddenly and get worse quickly. They include
eye redness, pain and blurred vision (www.mayoclinic.org)
 Antineutrophil cytoplasmic antibodies (ANCA) Antibodies are proteins that your immune system
makes to fight foreign substances like viruses and bacteria. But ANCAs attack healthy cells
known as neutrophils (a type of white blood cell) by mistake. This can lead to a disorder known
as autoimmune vasculitis. Autoimmune vasculitis causes inflammation and swelling of the blood
vessels.
 Partial colectomy involves removing part of the colon and may also be called subtotal
colectomy.
 Tenesmus is a cramping rectal pain that makes you feel that you need to have a bowel
movement, even if you already had one
 Parenteral nutrition (PN) is intravenous administration of nutrition, which may include protein,
carbohydrate, fat, minerals and electrolytes, vitamins and other trace elements for patients who
cannot eat or absorb enough food through tube feeding formula or by mouth to maintain good
nutrition status.
ULCERATIVE COLITIS
Begins with the rectum

PATHOPHYIOLOGY

 Ulcerative colitis affects the SUPERFICIAl mucosa of the colon and is characterized by multiple
ulcerations, diffuse OR ENTIRE inflammations, and desquamation or shedding of the colonic
epithelium.

 Bleeding occurs as a result of the ulcerations.

 The mucosa becomes oedematous and inflamed.

 The lesions are contiguous, occurring one after the other. Abscesses form, and infiltrate is seen
in the mucosa and submucosa, with clumps of neutrophils found in the lumens of the crypts
(i.e., crypt abscesses) that line the intestinal mucosa.

 The disease process usually begins in the rectum and spreads proximally to involve the entire
colon. Eventually, the bowel narrows, shortens, and thickens because of muscular hypertrophy
and fat deposits. Because the inflammatory process is not transmural (i.e., it affects the inner
lining only), fistulas, obstruction, and fissures are uncommon in ulcerative colitis (NDDIC,
2012b).

KEY SIGNS: ULCERS

 Urgent bowel movement

 Low Rbc/ WEIGHT

 Cramps

 Electrolyte imbalances/ elevated temp

 R ectal bleeding

PREDOMINANT SYMPTOMS

 Severe diarrhea, diarrhea, passage of mucus and pus, left lower quadrant abdominal pain,
intermittent tenesmus, and rectal bleeding.
 Bleeding may be mild or severe; pallor, anemia, and fatigue result.
 Anorexia, weight loss, fever, vomiting, dehydration, cramping, and feeling an urgent need to
defecate (may report passing 10 to 20 liquid stools daily).
 Hypocalcemia may occur.
  Rebound tenderness in right lower quadrant.
 Skin lesions, eye lesions (uveitis), joint abnormalities, and liver disease.
 Assess for tachypnea, tachycardia, hypotension, fever, and pallor.
 Abdomen is examined for bowel sounds, distention, and tenderness

DIAGNOSTIC

• Stool examination to rule out dysentery, occult blood test.

• Abdominal x-rays, computed tomography (CT), magnetic resonance imaging (MRI).

• Sigmoidoscopy or colonoscopy and barium enema.

• Blood studies (low hematocrit and hemoglobin, high white blood cell count, decreased albumin
level, electrolyte imbalance).

MEDICAL MANAGEMENT

Medical treatment for both Crohn’s disease and ulcerative colitis is aimed at reducing inflammation,
suppressing inappropriate immune responses, providing rest for a diseased bowel so that healing may
take place, improving quality of life, and preventing or minimizing complications.

• Nutritional Therapy

• Initial therapy consists of diet and fluid management with oral fluids;

• Low-residue, high-protein, high-calorie diets;

• Supplemental vitamin therapy; and iron replacementdue to bleeding.

• Fluid and electrolyte balance may be corrected by intravenous (IV) therapy.

• Additional treatment measures include smoking cessation and avoiding foods that exacerbate
symptoms, such as milk and cold foods.

• Parenteral nutrition (PN) may be provided as indicated

PHARMACOLOGIC THERAPY
• Sedative, antidiarrheal, and antiperistaltic medications

• Aminosalicylates: sulfasalazine (Azulfidine); effective for mild or moderate inflammation

Corticosteroids (eg, oral: prednisone [Deltasone]; parenteral: hydrocortisone [Solu-Cortef]; topical:
budesonide [Entocort])

• Immunomodulator agents (eg, azathioprine [Imuran])

• Biologic agents (eg, infliximab [Remicade])

SURGICAL MANAGEMENT

• When nonsurgical measures fail to relieve the severe symptoms of inflammatory bowel disease,
surgery may be recommended. A common procedure performed for strictures of the small
intestines is laparoscope-guided strictureplasty. In some cases, a small bowel resection is
performed. In cases of severe Crohn’s disease of the colon, a total colectomy and ileostomy may be
the procedure of choice

• A newer option may be intestinal transplantation, especially for children and young adults who
have lost intestinal function because of the disease. At least 25% of patients with ulcerative colitis
eventually have total colectomies. Proctocolectomy with ileostomy (ie, complete excision of colon,
rectum, and anus) is recommended when the rectum is severely diseased..

• Nursing Management

NURSING PROCESS THE PATIENT WITH INFLAMMATORY BOWEL DISEASE

Both regional enteritis (Crohn’s disease) and ulcerative colitis are categorized as inflammatory bowel
diseases.

Assessment

• Determine the onset, duration, and characteristics of abdominal pain; the presence of diarrhea or
fecal urgency, straining at stool (tenesmus), nausea, anorexia, or weight loss; and family history.

 Explore dietary pattern

•, including amounts of alcohol, caffeine, and nicotine used daily or weekly.

• Determine bowel elimination patterns, including character, frequency, and presence of blood, pus, fat,
or mucus.

• Inquire about allergies, especially to milk (lactose).

• Ask about sleep pattern disturbances if diarrhea or pain occurs at night.

  Nursing Diagnosis

 Hey Nurses What Do You Think Could Be Your Diagnosis?

 ????????????????????

 Nursing Diagnoses

• Diarrhea related to inflammatory process

• Acute pain related to increased peristalsis and gastrointestinal inflammation

• Deficient fluid volume related to anorexia, nausea, and diarrhea

• Imbalanced nutrition, less than body requirements, related to dietary restrictions, nausea, and
malabsorption

• Activity intolerance related to generalized weakness

• Anxiety related to impending surgery

• Ineffective individual coping related to repeated episodes of diarrhea

 Risk for impaired skin integrity related to malnutrition and diarrhea

 • Risk for ineffective management of therapeutic regimen related to insufficient knowledge

concerning process and management of disease

• Risk for ineffective management of therapeutic regimen related to insufficient knowledge concerning
process and management of disease Collaborative Problems/Potential Complications • Electrolyte
imbalance • Cardiac dysrhythmias related to electrolyte imbalances • Gastrointestinal bleeding with
fluid volume loss • Perforation of bowel

 Planning and Goals (Major goals )

 may include attainment of normal bowel elimination patterns,

 relief of abdominal pain and cramping,

 prevention of fluid volume deficit,

 maintenance of optimal nutrition and weight,

 avoidance of fatigue, reduction of anxiety,

 promotion of effective coping,

 absence of skin breakdown,

  increased knowledge about the disease process and therapeutic regimen, and avoidance of
complications.

 Nursing Interventions

 Maintaining Normal Elimination Patterns

 Provide ready access to bathroom, commode, or bedpan; keep environment clean and odor-
free.

 Administer antidiarrheal agents as prescribed, and record frequency and consistency of stools
after therapy has started.

 Encourage bed rest to decrease peristalsis.

Relieving Pain

• Describe character of pain (dull, burning, or cramplike) and its onset, pattern, and medication relief.

• Administer anticholinergic medications 30 minutes before a meal to decrease intestinal motility.

• Give analgesic agents as prescribed; reduce pain by position changes, local application of heat (as
prescribed), diversional activities, and prevention of fatigue.

Maintaining Fluid Intake

• Record intake and output, including wound or fistula drainage. • Monitor weight daily. • Assess for
signs of fluid volume deficit: dry skin and mucous membranes, decreased skin turgor, oliguria, fatigue,
decreased temperature, increased hematocrit, elevated urine specific gravity, and hypotension. •
Encourage oral intake; monitor IV flow rate. • Initiate measures to decrease diarrhea: dietary
restrictions, stress reduction, and antidiarrheal agents.

Maintaining Optimal Nutrition

• Use PN when symptoms are severe.

• Record fluid intake and output and daily weights during PN therapy; test for glucose every 6 hours.

• Give feedings high in protein and low in fat and residue after PN therapy; note intolerance (eg,
vomiting, diarrhea, distention).

• Provide small, frequent, low-residue feedings if oral foods are tolerated.

• Restrict activities to conserve energy, reduce peristalsis, and reduce calorie requirements.

Promoting Rest • Recommend intermittent rest periods during the day; schedule or restrict activities to
conserve energy and reduce metabolic rate. • Encourage activity within limits; advise bed rest with
active or passive exercises for a patient who is febrile, has frequent stools, or is bleeding. • If the patient
cannot perform active exercises, perform passive exercises and joint range of motion for the patient.

 Reducing Anxiety

Tailor information about impending surgery to patient’s level of understanding and desire for detail;
pictures and illustrations help explain the surgical procedure and help the patient visualize what a stoma
looks like.

Enhancing Coping Measures • Develop a relationship with the patient that supports all attempts to cope
with stressors of anxiety, discouragement, and depression. • Implement stress reduction measures such
as relaxation techniques, visualization, breathing exercises, and biofeedback. • Refer to professional
counseling if needed.

Preventing Skin Breakdown

• Examine skin, especially perianal skin. • Provide perianal care after each bowel movement. • Give
immediate care to reddened or irritated areas over bony prominences. • Use pressure-relieving devices
to avoid skin breakdown. • Consult with a wound–ostomy–continence nurse as indicated.

 Monitoring and Managing Potential Complications

• Monitor serum electrolyte levels; administer replacements.

• Report dysrhythmias or change in level of consciousness (LOC).

• Monitor rectal bleeding, and give blood and volume expanders.

• Monitor blood pressure; obtain laboratory blood studies; administer vitamin K as prescribed.

• Monitor for indications of perforation: acute increase in abdominal pain, rigid abdomen, vomiting, or
hypotension. • Monitor for signs of obstruction and toxic megacolon: abdominal distention, decreased
or absent bowel sounds, change in mental status, fever, tachycardia, hypotension, dehydration, and
electrolyte imbalances.

Promoting Home- and Community-Based Care

TEACHING PATIENTS SELF-CARE

• Assess need for additional information about medical management (medications, diet) and surgical
interventions. • Provide information about nutritional management (bland, low-residue, high-protein,
high-calorie, and highvitamin diet). • Give rationale for using corticosteroids and antiinflammatory,
antibacterial, antidiarrheal, and antispasmodic medications. • Emphasize importance of taking
medications as prescribed and not abruptly discontinuing regimen. • Review ileostomy care as
necessary. Obtain patient education information from the Crohn’s and Colitis Foundation of America.

Recommend low-residue, high-protein, high-calorie diet during an acute phase.

Encourage patient to keep a record

of foods that irritate bowel and to eliminate them from diet.

Recommend intake of eight glasses of water per day.

• Provide support for prolonged nature of disease because it is a strain on family life and financial
resources.

Arrange for individual and family counseling as indicated.

• Provide time for patient to express fears and frustrations.

 Evaluation Expected Patient Outcomes

• Reports decrease in frequency of diarrheal stools

• Experiences less pain

• Maintains fluid volume balance

• Attains optimal nutrition

• Avoids fatigue

• Experiences less anxiety

• Copes successfully with diagnosis

• Maintains skin integrity

• Acquires an understanding of the disease process • Recovers without complications

• Urolithiasis (Renal Calculi)

• What are kidney stones? 

• Hard insoluble crystallized minerals and salts that have formed out of the filtrate produced by
the nephron.

• Remember the nephron is the functional unit of the kidney that filters the blood and
reabsorbs/secretes mineral, water, and waste, which is urine. 

• Facts about Kidney Stones

• Kidney stones can vary in size: they can be very small (like a fine grain of salt) or large (like a
walnut….very painful), and are composed of various materials. Hence, there are different types
of stones 
 • Most stones tend to form within the kidney, but they can form anywhere throughout the
urinary system where there is a concentration of minerals (bladder, ureters).

• They can migrate throughout the urinary system where they can further grow or cause blockage
of urine.

• Most stones can be passed (very painful) if they are less than 5 mm If they are larger than this,
they can become stuck within the urinary system.

• Where can kidneys stones be located?

• Inside the kidney

• Ureters (top, middle, or bottom of ureter before entering bladder)

• Bladder

• Remember: For stones to form there has to be a concentration of minerals and salts in the
filtrate which will allow for crystallization of the minerals. When a crystal forms it can grow over
time and break off and travel through the urinary system. This can lead to the blockage of urine,
infection, or other complications.

• Types of Kidney Stones

1. Calcium Oxalate: most common type of kidney stone, and they tend to form in acidic urine. This type
of stone is composed of calcium and oxalate, and forms when there is a high concentration of calcium or
oxalate in the filtrate.

• What can increase the amount of calcium in the filtrate?

• Hypercalcemia/uria: taking excessive amounts of calcium supplements, eating too much salt
(increases the amount of calcium in the urine), renal tubule problems within the nephron,
consuming too much animal protein (increases the amount of calcium in the urine)

• Hyperparathyroidism: the parathyroid is responsible for secreting PTH (parathyroid hormone)

which causes the bones to release calcium into the blood…overactive parathyroid gland
increases calcium levels.

What can increase the amount of oxalate in the filtrate?

• High intake of foods with oxalates (see nursing interventions to see the foods high in oxalate)

• GI disorders like ulcerative colitis and Crohn’s disease due to malabsorption of fats.

Normally, calcium and oxalates bind together in the gut, therefore, oxalate is excreted in the
stool. However, when a GI disorder like ulcerative colitis is present there is a problem with
digesting fats. So, fats bind with calcium…leaving oxalates behind. The leads to the build-up of
oxalate in the urine.
 • Types of Kidney Stones

2. Uric Acid: forms when there is too much uric acid in the urine (acidic urine)

What can cause high amounts of uric acid in the urine?

• Eating a diet high in purine or animal protein. These substances are broken down into uric acid
and if too much of these products are consumed it can make the urine more acidic. Remember
the glomerulus of the nephron is responsible for filtering the blood and removing uric acid.

• Dehydration: urine becomes acidic and the filtrate contains low amounts of water…allowing uric
acid to crystallize.

• Gout: patients with Gout have high amount of uric acid in the body

• Metabolic problems like diabetes, especially Type 2 Diabetes

• Types of Kidney Stones

3. Cystine: forms where there is too much of the amino acid cysteine in the urine. This is rare and tends
to run in families.

• Remember amino acids are normally reabsorbed in the Proximal Convoluted Tubule (nearly
100%). However, the nephron fails to do this, so when there is too much cysteine in the urine it
crystallizes.

4. Struvite: this type of stone is also rare and usually forms due to chronic urinary tract infections (UTIs).

• WHY? Certain types of bacteria can cause the urine to become too alkaline and this allows
magnesium, ammonium, and phosphate to crystalize, which is the composition of the struvite
stone….this stone is also known as staghorn stone and can be fairly large in size.

5. Calcium phosphate: forms in alkaline urine and can be happen when renal tubule issues are present

• *most common type of kidney stone

• Pathophysiology

• Remember the nephron, specifically the glomerulus, filters the blood and all
minerals/water/waste are removed from the blood and leak down into Bowman’s Capsule
(these substances include nearly everything except proteins and blood cells).

• in patients who are NOT susceptible to kidney stones, these substances will travel through the
nephron and be reabsorbed or secreted at various points within the renal tubule. Then the
excess will be secreted as urine by exiting the collecting tubule/duct to the renal papilla, minor,
major calyx, renal pelvis, ureters, bladder, and urethra.
• Pathophysiology

• However, in patients with certain predisposing factors, there is an increase in the risk of these
minerals coming together to form a crystal. The crystal can grow over time as debris sticks to
the crystal and further crystallization happens. The crystal can travel out of the nephron and
stay in the renal papilla, ducts, or other parts of the urinary system and grow. In addition, it can
break off and travel through the system and get stuck.

• Causes of Kidney Stones

• Remember the word: “Crystal”

• Causes of Kidney Stones

• Consuming high amounts of oxalates, purine, animals protein, salt (eating too much salt keeps
the body from reabsorbing calcium in the urine), and taking excessive amounts of calcium
supplements with Vitamin D (calcium oxalate, uric acids type stones)

• Recurrent UTIs (struvite stones)

• hYpocitraturia, hYpercalemia/uria, hYperparathyroidism

• Hypocitraturia: Citrate plays a role in stopping the formation of calcium salt crystals (specifically
calcium oxalate and calcium phosphate binding). Therefore, citrate binds with calcium and stops
it from binding with oxalate or phosphate. Furthermore, it keeps the urine alkaline and prevents
it from becoming too acidic….hence preventing uric acid or cystine stones to form since these
stones form in acidic urine.

• Structural blockage or stasis of the urine (prostate problems, strictures, deformities)

• Too much uric acid (gout, dehydration, high diet in purine/animal proteins)

• Absorption problems: gut doesn’t absorb fats as with ulcerative colitis or crohn’s diseae…fats
bind with calcium and leaves oxalates behind, Acquired (family history)

• Low activity: immobile patients tend to have an increased amount of minerals and salts
compared to people who are physically active and the urine stays stagnant in the kidney…hence
increase risk of kidney stone formation.

• Signs and Symptoms of Renal Calculi

• Pain: characteristics of the pain depend on the location of the stone and it can change as the
stone moves through the urinary system:

• Renal colic: stone in the renal pelvis…dull, deep aching in the flank or costovertebral
area (see pic below)
 • Ureteral colic: stone residing in the ureter and as it moves it can cause…….intense,
sharp, radiating, wavelike pain to the genitalia (scrotum, vaginal area)The patient may
feel like they need to void but a small amount is voided.

• Can have blood in the urine due to stone scraping the ureter (hematuria)

• Signs and Symptoms

• Nausea and vomiting (due to the intense pain)

• Signs and symptoms of infection: fever, cloudy, odorous urine

• Urinary retention: especially if stone is stuck in neck of bladder…this makes it extremely hard to
completely pass all the urine in the bladder…(note the location of the neck of the bladder)

• Asymptomatic: until stone moves within the kidneys and to the ureters

• Complications 

• Obstruction: stones blocks the flow of urine. The urine can back up and causes hydrostatic
pressure (hence increase water pressure) within the kidney. This will increase pressure in
Bowman’s Capsule which will decrease the amount of blood the kidneys can filter.

• Hydronephrosis or Hydroureteronephrosis: due to the back up of urine which causes swelling

and dilation in various parts of the kidneys (renal pelvis, minor/major calyx and ureters)…
depending on where the stone is located. The end result is the loss of function to the kidney.

• Damage to the nephrons…hence renal failure

• Infection

• How is Renal Calculi Diagnosed?

• *as the nurse it is important to be familiar with tests the physician may order and your role as
the nurse

• KUB ULTASOUND- KAILANGAN FULL ang bladder (x-ray of the kidneys, ureters, and bladder)

• IVP (intravenous pyelogram): a special dye, which is iodine-based, is given through the patient’s
IV. Then x-ray images will be taken to assess the kidneys, bladder, ureters, and urethra.

• Nurse’s Role:

• Make sure patient isn’t allergic to iodine or shellfish, pregnant or might be, nursing a
baby, impaired renal function or taking metformin/Glucophage. Ultrasound or CT scan

• Urine tests:
 • U/A assess for crystals, infection

• 24 hour urine to measure concentrate of ions (calcium, sodium etc.), waste products in
urine (uric acid, creatinine), citrate, pH, kidney function

• Nurse’s Role

• Keep specimen cold by keeping it on ice for the whole 24 hours…if not
kept cold this can alter the test results.

• Nursing Interventions

**most patients will pass the stone and the nurse’s job is to keep the patient’s pain controlled, give
fluids, strain urine, and monitor for complications.

However, if the stone is large the patient need other treatments (discussed below).

• Control pain (very, very painful)…pain doesn’t go away until it is passed or removed. Patient
needs around-the-clock pain medications rather than PRN medications (where the patient has
to request it). This will help keep pain medication blood levels constant and hopefully help
control the pain. The physician may order NSAIDs to help control the inflammation which can
help the stone pass if it is stuck within inflamed areas.

• Closely monitor I/Os (intake and output)

•  WHY? The patient will be consuming a lot of fluids and the nurse needs to make sure
the kidneys are putting out enough fluid based on the intake. If the fluid output is low,
renal function may be impaired, an obstruction may be present or other complications
like hydronephrosis,etc.

• Monitor for signs and symptoms of UTI

• Strain urine and ASSESS very closely for stones (VERY IMPORTANT): Then notify the physician
who will give you an order to send it to the lab. This is crucial so the physician can determine
what type of stone is causing the problem and appropriate treatment can be ordered.

• Keep patient as mobile as possible and try to avoid supine position for long periods of time.
Remember immobility is one of the causes of kidney stone formation…if urine stays stagnant it
can allow crystallization. Keeping the patient mobile helps the stone pass. If the patient is
immobile, turn the patient more frequently.

• Prevention Education (can reoccur):

• Keep hydrated (prevents concentrated urine) 2L per day

• Take medication as prescribed: MD may order the following as preventive measures in

preventing kidney stone formation based on the type of stone the patient is susceptible to:
 • Allopurinol: decreases uric acid levels (used in gout)…uric acid stones

• “HCTZ” hydrochlorothiazide: decreases the amount of calcium in the urine…calcium

type stones

• Limiting calcium intake not recommended due to osteoporosis risk, unless patient has

metabolic problems or a problem with the nephrons of the kidney. Instead, limiting medication
forms of calcium supplements and vitamin D.

• Limiting animal proteins (high amount of protein increases the amount of calcium in the urine
and increases uric acid levels)

• Limit sodium to 2-3 g per day….sodium decreases the reabsorption of calcium which will leave
more calcium in the urine (watch hidden sodium foods like canned food, soda drinks, sandwich
meats, processed foods)

• Avoid foods high in purine: organ meats, beer, pork, red meats, seafood (scallops, anchovies,
sardines) (uric acid stones)

• Avoid high oxalate foods: spinach, cabbage, rhubarb, tomatoes, beets, nuts, chocolate, wheat
bran, strawberries, tea (calcium oxalate stones)

• How to stain urine and why it is important and to keep stone so it can be analyzed

• Treatments

• Extracoporeal shock wave lithotripsy (ESWL): NONINVASIVE: shockwaves are created to

penetrate though the skin and body tissue. Shockwaves will hit the stone and break it down into
grains of sand like particles which can be passed out. Several treatments may be required
depending on stone size. Stent may be placed to facilitate the passage of the fragments…not for
large stones

• Nurse’s Role

• Maintain fluid intake to facilitate stone fragment removal

• Keep patient mobile

• Control pain

• May have bleeding in urine

• Strain urine and send stone to lab

•
 • Percutaneous Nephrolithotomy: If larger than 5 cmINVASIVE: used when the stone is large or
can’t use ESWL. The kidney stone is removed by a urologist and doesn’t have to be passed by
the patient as with EWSL.

• An incision is made on the back where the kidney is and an nephroscope is used to
remove the stone. Sometimes lithotripsy is used to break up the stone.

• A nephrostomy tube may be placed to drain urine until healed (this is a catheter placed in the
renal pelvis to drain urine)

Nurse’s Role

• Maintain fluid intake of 3-4 liters

• Maintain nephrostomy: it drains kidney and stone fragments, empty the bag regularly, keep site
secure so tube doesn’t move, and monitor for infection

• Strain urine and send stones to lab

Ureteroscopy: no incision made…scope is inserted through the urinary system from urethra to the
kidneys…can remove the stone or break it up with a laser or lithotripsy…stent may be placed to allow
fragments to pass

Nurse’s Role

• Maintain fluid intake to facilitate stone fragment removal

• Keep patient mobile

• Control pain

• May have bleeding in urine

• Strain urine and send stone to lab

• Urinary Tract
Infection

• What is a urinary tract infection (UTI)? 

• It is an infection found within the urinary tract which can be caused by a bacteria (most
common), virus, or fungus.
 • Urinary tract infections can be found anywhere throughout the urinary system such as:

• Lower Urinary System:

• Urethra (Urethritis)

• Bladder (Cystitis)

• Upper Urinary System:

• Ureters (Ureteritis)…usually associated with bladder or kidney infection

• Kidneys (Pyelonephritis)

• UTIs typically start in the urethra and spread upward to the bladder and can be found in both
the lower or upper tract.

• If the infection is not treated promptly and correctly, it can spread to the ureters and kidneys.

• Pyelonephritis is extremely dangerous because the infection can enter the bloodstream and
lead to sepsis….remember that the kidneys are very vascular and work closely with the heart.

• When an infection exists in the urinary tract it leads to inflammation of the structure involved
which leads to pain, spasms, dark/cloudy urine, etc.

The female urethra is shorter than the males which allows for easier migration of an infectious agent to
the bladder AND the close proximity of the urethra and the rectum increases the chances of the bacteria
in the GI tract infecting the urinary system (wiping incorrectly…back to front or wearing tight underwear
or pants etc.).

• Defense systems in place to help prevent Urinary Tract Infections

*If one of these defense systems becomes compromised, there is an increased risk of a UTI developing.

Physiology of how urine flows downward: This keeps urine flowing out of the system and prevents the
retention or back flow of urine into the kidneys (hence bacteria can be easily flushed out). What
structures help with this?

• Ureterovesical Valves: these are one- way valves that connect at the ureters and bladder to
prevent the backflow of urine into the ureters from the bladder…in certain conditions like VUR
(vesicoureteral reflux) these valves are defected.

• Muscles of the Bladder: these muscles help squeeze the urine out of the bladder and prevent
residual urine…sometimes these muscles become weak (diabetes, immobile patients who
experience overextended bladder).

• Pressure created by the urine in the bladder: this keeps the urine traveling downward.
• Urine itself: it is normally sterile and possesses antiseptic qualities that can prevent bacteria
from sticking to the lining of the bladder. In addition, the acidic conditions of the pH and
amount of urea concentration can play a role in preventing a UTI….however, in some conditions,
like uncontrolled  diabetes mellitus  where there are high amounts of glucose in the urine, the
urine can act as a medium for bacteria growth.

• Lining of the urinary system has immune cells that work to fight off infection…a suppressed
immune system decreases the cells effectiveness.

• Prostate gland (males): it secretes a fluid that has antimicrobial properties to keep bacteria
out…in men with enlarged prostates the amount of fluid secreted is decreased.

• Normal flora in women: present in and around the vagina are bacteria (lactobacilli) that keeps
the area around the urethra acidic which prevents bacteria from migrating, especially E.coli from
the rectum….however, if a woman experiences a hormonal change (pregnancy, menopause,
birth control usage) the flora can be destroyed.

• Causes of Urinary Tract Infection

• “Hard to Void”

• *The most common type of bacteria that causes a UTI is E. coli, which is usually from the GI
system (rectum).

• Hormone changes: pregnancy, menopause, birth control (changes the normal flora in the vagina
that normally fights bad bacteria that can migrate into the urethra).

• Antibiotics: changes the normal flora of the body

• Renal Stones: cause blockage..urine stays in kidney and can’t drain

• Diabetes: compromised circulation…immune system not able to work as strong as it should to

fight the infection, high glucose in the urine: breeding ground for bacteria to flourish, bladder
doesn’t empty as it should (urinary retention from nerve damage)

• Toiletries: excessive bubble baths, powders, perfumes, especially scented tampons and sanitary
napkins

• Obstructive prostatic hypertrophy…seen in males with BPH: The urethra which is surrounded by
the prostate gland becomes squeezed shut from the large prostate gland….urine stays in the
bladder because the patient can NOT empty it completely, and the prostate gland isn’t able to
properly secrete that fluid with antimicrobial properties.

• Vesicoureteral reflux (VUR): most common in pediatric patients and is when urine from the
bladder backflows into the kidneys. It is usually a congenital defect to the ureterovesical valves
 that are found between the bladder and ureters. They don’t close properly and there is a
backflow of urine into the ureters.

• Overextended bladder: bladder is full for long periods of time and the bladder muscles become
weak which leads to urinary retention. Patients who are immobile are at risk for this.

• Indwelling catheters, Invasive procedures, Intercourse (especially with the usage of

spermicides), incontinence of the bowel

• Decreased immune system…can’t fight germs (immunosuppressed) and majorly at risk for UTIs
that are fungal and viral in origin.

• How is a UTI Diagnosed?

• Urinalysis (U/A): assesses for bacteria or WBCs in urine

Nurse’s role: properly collecting urine sample and educating the patient how to do this….WHY? to
prevent contamination to the specimen

• It is best to collect the urine when the bladder has been full for about 2-3 hours. It will
be more concentrated….don’t want diluted urine.

• First wipe with an antiseptic wipe

• Void small amount into the toilet

• Then collect the urine (midstream) and fill cup halfway

• Keep the cup a few inches away from the urethra

How to collect out of a Foley catheter? Use access port (found at the top of the tubing…never collect
from the Foley collection bag)…..clean access port with antiseptic and use needless sterile syringe to
withdraw urine.

• Urine culture: to assess what bacteria is causing the UTI…so antibiotics can be ordered correctly

• Cystoscopy: assesses the inside of the urethra and bladder (ordered for recurrent infections)

• Signs and Symptoms of Urinary Tract Infection

• Pain when voiding (burning)

• Persistent need to void but not a lot is voided or can’t void

• Strong odor to urine that is dark and cloudy (can have blood)

• Cramping in abdomen or pain at the costovertebral angle

 • Costovertebral angle is found under the 12th rib and between the spine (please watch
video above for a demonstration). Lay non-dominate hand flat over the angle and make
a fist with the dominate hand and firmly thump the fist onto the flat hand….if pain is
experienced a kidney infection may be present (pyelonephritis).

• Spasms of the bladder or urethra

• Fever

• Increased WBC on U/A

NOTE: In the geriatric population, confusion, sudden increase in falling, and agitation are typically
seen rather than the typical signs and symptoms above…they are less likely to have a fever or pain.

• Nursing Interventions

• Assess for signs and symptoms of UTI (catch it before it becomes complicated….many patients in
the hospital setting are at risk for a UTI)

• Maintain fluid status (intake and output) and monitor that urinary output is at least 30 cc/hr

• Control pain with nonpharmacological and pharmacology methods:

• Warm sitz bath or heating pad

• Tylenol, NSAIDs, or Pyridium per MD order

• Pyridium “Phenazopyridine”: analgesic that will coat bladder wall and urethra to
decrease spasms and help with urinary frequency/burning. However, that patient will
void ORANGE-COLORED urine…this is a normal side effect…educate patient about this.

• Monitor for complications (sepsis, renal failure)

• Administer antibiotic medications per MD order… Sulfonamide “Bactrim” (educate patient

about consuming 2.5 to 3 L of fluid/day to keep urine diluted due to crystalluria )…give
antibiotic at same time every day to keep blood level constant because a decrease in blood
levels can decrease the effectiveness of the medication.

If antibiotics are ordered for treatment along with urine culture…COLLECT URINE CULTURE BEFORE
starting the first dose of antibiotics

• Nursing Interventions

• Encourage the patient to take in 2.5 to 3L of fluid per day. WHY?  This keeps the urine diluted
and helps the system flush out the infection. In addition, if the urine becomes concentrated this
increases the risk of crystalluria in patients taking sulfonamides like Bactrim.

• Encourage frequent voiding at least every 2-3 hours.

• Remove indwelling catheter if present per MD order (remember a major cause of UTI)

• Patient Education for UTI:

• Take all the antibiotics

• Wipe front to back

• Urinate immediately after intercourse

• Avoid tight pants or underwear (wear cotton underwear that is loose fitting)

• Avoid bubble bath, powders, and perfumes in the genital area

• Change sanitary pads often and avoid tampons

• Avoid caffeine and alcohol…irritate bladder

• Every 2-3 hours void