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GI DISTURBANCES

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					GI DISTURBANCES: MIDD LE AGED ADU LT
NURSING 2118- HUBBARD

GASTRIC CANCER
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INCIDENCE DECREASING 60@ IN PAST 40 YEARS JAPAN HAS HIGHEST INCIDENCE ENVIRONMENTAL - SOIL - WATER -PRESERVED FOODS GENETIC - AGE -PERNICIOUS ANEMIA -ACHLORHYDRIA -GASTRIC POLYPS -PUD -BLOOD TYPE A OTHER FACTORS LOW SOCIOECONOMIC POOR NUTRITIONAL VITAMIN A DEFICIENCY FOOD ADDITIVES SMOKING ALCOHOL CONSUMPTION CARCINOGENIC AGENTS CELLULAR CHARACTERISTICS MOST ARISE FROM EPITHELIAL TISSUE- ADENOCARCINOMA OR SARCOMA MORE COMMON IN PYLORUS , ANTRUM, LESSER CURVATURE OF STOMACH EARLY SYMPTOMS - VAGUE SENSE OF FULLNESS, DISTENTION AFTER EATING LATER SYMPTOMS: - WEIGHT LOSS D/T ANOREXIA - ANEMIA - DYSPHAGIA - EPIGASTRIC PAIN - HEMATEMESIS, MELENA METASTASIS OCCURS MOST FREQUENTLY TO LYPMPH NODES AND THEN LIVER, BONE, BRAIN

GASTRIC CANCER: ETIOLOG Y

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GASTRIC CANCER: ETIOLOG Y
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GASTRIC CA: PATHOPH YSIO LOG Y
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GASTRIC CA: PROGRESSION OF D ISEASE

GASTRIC CA: PROGRESSION
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GASTRIC CANCER: TNM STAGING SYSTEM
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T= TUMOR CHARACTERISTICS N= LYMPH NODES  M= METASTASIS  STAGES PROGRESS FROM MILD TO SEVERE  STAGE 0 T1,NO, MO  STAGE 1A T1,N0, M0  STAGE 1B

T1,N1, M0 OR T2, N0,MO STAGE II T1, N2, M0 OR T3, NO,MO  STAGE III A T2,N2,MO OR T4,N0,M0  STAGE IIIB: T3,N2, MO OR T4,N1  STAGE 1V: T4,N2, M0 OR A NY T , ANY N, M1
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GASTRIC CA: METASTASIS
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VIRCHOUS NODE IRISHS NODE KRUKENBURG TUMOR SISTER JOSEPH’S NODES BLUMERS RECTAL SHELF

GASTRIC CA: SURGER Y
SUBTOTAL GASTRECTOMY BILLROTH I BILLROTH II  TO TAL GASTRECTOMY  SUBTOTAL ESOPHAGOGASTRECTOMY

GASTRIC CA: SURGER Y
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BILLROTH I: GASTRODUODENOSCOPY RESECT 1ST PORTION OF DUODENUM, DISTAL STOMACH, PYLORUS, BLOOD VESSELS (STOMACH ANASTOMOSED TO DUODENUM) BILLROTH II: REMOVE ANTHRUM, PYLORUS, 1ST PART OF DUODENUM, CIRC. STRUCTURES, LYMPH NODES ( STOMACH ANASTOMOSED TO JEJUNUM)

GASTRIC CA: PROBLEMS RES ULTING FRO M SUBTOTALGASTRECTOMY
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STEATORRHEA DUMPING SYNDROME N&V WEIGHT LOSS DIARRHEA VITAMIN DEFICIENCY ANASTOMOTIC LEAK ENTIRE STOMACH IS REMOVED ALONG WITH SUPPORTING MESENTARY AND LYMPH NODES ESOPHAGUS ANASTOMOSED TO JEJUNUM COMPLICATIONS: PNEUMONIA, INFECTION, ANASTOMOTIC LEAK, HEMORRHAGE, REFLUX ASPIRATION STOOL FOR OCCULT BLOOD CBC- ANEMIA CEA BARIUM SWALLOW CT SCAN ULTRASONOGRAPHY

GASTRIC CA: TOTAL GASTRECTOMY

GASTRIC CA: DIAGNOSTIC TESTS
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GASTRIC ANALYSIS

GASTRIC CA: PRE/PO ST OPERATIVE CARE SUBTOTAL GASTRECTOMY
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PREOP: FLUID/ELECTROLYTE BALANCE ORAL/PARENTERAL FLUIDS NGT BEFORE SURGERY TEACH WHAT TO EXPECT POST-OP CARE: NGT-2 TO 3 DAYS TO KEEP SUTURE LINE CLEAN W/O PRESSURE NGT DRAINAGE- DK RED OR BROWN AT FIRST THEN GREENISH YELLOW IRRIGATION WITH STERILE SALINE USUALLY ORDERED I & 0, TCDB, EARLY AMBULATION, PAIN CONTROL, DRESSINGS NPO 1-2 DAYS LOW FOWLER’S POSITION

GASTRIC CA: SUBTOTAL GASTRECTOMY COMPLICATIONS
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BLEEDING - WATCH VS DUMPING SYNDROME - RAPID DUMPING OF FLUIDS & FOOD THROUGH GASTROENTEROSTOMY INTO JEJUNUM. SYMPTOMS R/T RAPID DISTENTION OF JEJUNUM - WEAK, FAINT, PERSPIRE, PALPITATIONS, DIARRHEA, CRAMPING, >GLUCOSE-INSULIN RELEASED--HYPOGLYCEMIA HYPERTONIC INTESTINAL CONTENTS DRAW EXTRACELLULAR FLUID FROM CIRCULATING BLOOD VOLUME INTO JEJUNUM TO DILUTE THE HIGH CONCENTRATION OF ELECTROLYTES AND SUGARS

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POST SURGER Y: SUBTOTAL GASTRECTOMY COMPLICAITONS CONTINUED
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DUMPING SYNDROME TX: SEMI RECUMBENT POSITION DURING MEALS, LIE DOW N 1/2 HR AFTER EATING EAT SMALL FREQUENT FEEDINGS- CHO INTAKE LOW SEDATIVE/ ANTISPASMODICS GIVEN INCREASE TIME FOOD REMAINS IN STOMACH RETENTION & GASTRIC ATONY: MAY BE DUE TO OBSTRUCTION, ADHESIONS, INTUSSUSCEPTION OR PARALYTIC ILEUS DUODENAL STUMP DEHISCENCE- SURGERY INFECTION/ABCESS THORACIC CAVITY AS WELL AS ABDOMINAL CAVITY ENTERED ( W ILL HAVE CHEST TUBE) LITTLE NG DRAINAGE ORAL FEEDINGS-1 WK POST OP BLAND, SMALL, FREQUENT FEEDINGS MAY NEED J-TUBE OR HYPERAL B-12 INJECTIONS CHEMOTHERAPY - MAY HELP CONTROL SYMPTOMS AND INCREASE SURVIVAL 12% SURVIVAL RATE OVER 5 YEARS PROGNOSIS POOR & SURGERY IS USUALLY PALLIATIVE MAY REMOVE SPLEEN (METASTASIS TO SPLEEN NODES COMMON)

TOTAL GASTRECTOMY: CARE AFTER SU RGER Y

COLORECTAL CANCER: INCIDEN CE

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THIRD IN INCIDENCE TO CA OF LUNG/PROSTATE IN MALES AND LUNG/BREAST IN FEMALES HIGH INCIDENCE IN RECTUM AND DISTAL SIGMOID BUT PROGRESSIVE SHIFT TO R. COLON IN LAST 30 YRS EXACT CAUSE UNKNOWN BUT MORE FREQUENT IN URBANIZED COUNTRIES RELATED TO ENVIRONMENT DIET HIGH IN FAT, LOW IN FIBER DELAYED MOTILITY CHOLESTEROL/BILE ACIDS INTESTINAL FLORA RISK FACTORS - ULCERATIVE COLITIS - GI POLYPS/POLYPOSIS - FAMILIAL HISTORY - INCREASES AFTER AGE 50 CHANGE IN BOWEL HABITS TENESMUS BLOOD IN STOOLS CHANGE IN BOWEL HABITS- ALTERNATING CONSTIPATION & DIARRHEA IN RECTAL CA PAIN IN RECTUM/SACRAL AREA IN LATE DISEASE MAY GET BOWEL OBSTRUCTION LUMEN OBSTRUCTED DISTENTION OF BOWEL P A IN EDEMATOUS BOWEL COMPROMISED BLOOD SUPPLY NECROSIS SEPTIC SHOCK FROM BURSTING OF INTESTINE DISTENTION INCREASED PERISTALSIS ABDOMINAL PAIN-COLIC LIKE WITH PERISTALTIC CONTRACTION PAIN REFERRED TO SACRAL AREA DIARRHEA WITH PARTIAL OBSTRUCTION -0- STOOLS/FLATUS WITH A COMPLETE OBSTRUCTION BOWEL SOUNDS ABOVE OBSTRUCTION ARE INCREASED, NOTHING BELOW FLUID/ELECTROLYE CHANGES VOMITING METABOLIC ACID/ALKA INCREASED RR, TEMP, LEUKOCYTOSIS NGT, MILLER ABBOTT TUBE ASSESS DISTENTION, CHECK NG FUNCTION, BS MOUTH CARE, FOWLERS, O2, VS, MONITOR LAB I&O, PAIN MED., CHOLINERGICS-ILOPAN, PROSTIGIMIN

COLORECTAL CANCER: EPIDE MIO LOG Y-THEORIES
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CANCER OF COLON AND RECTUM

COLORECTAL SIGNS AND SYMPTOMS
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BOW EL OBSTRUCTION: PATHOPHYS IOLOG Y

BOW EL OBSTRUCTION: SIGNS AND S YMPTOMS

BOW EL OBSTRUCTION:SIGNS/SYMPTOMS CONT.

BOW EL OBSTRUCTION: TREATMENT

COLON CA: DIAGNO STIC TESTS
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STOOL FOR OB CBC BE CEA SIGMOIDOSCOPY COLONOSCOPY

SIGMOIDO SCOP Y
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EXAMINES LINING OF SIGMOID- MAY ALSO BIOPSY PRIOR LIQUID DIET/NPO KNEE CHEST POSITION WATCH FOR SIGNS OF PERFORATION: PAIN, FEVER, MALAISE, DISTENTION, PURULENT DRAINAGE, BLEEDING

COLONOSCOPY
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SCOPE ENTIRE COLON TW O DAY PREP: CL LIQ DIET, LAXATIVE, ENEMAS  PRE-OP  LIE ON L. SIDE  DILATE SPHINCTER, INSERT FLEXIBLE TUBE, INJECT FLUID, AIR TO AID VISUALIZATION  MONITOR VS, BLEEDING COLON CANCER: SURGICAL CARE  RESECTION MAY BE NECESSARY OR COLOSTOMY, ABDOMINAL PERINEAL RESECTION  PRE OP CARE: NEOMYCIN OR ANTIBIOTIC TO STERILIZE THE INTESTINE  CLEANSING ENEMAS  NG TUBE- PREVENT ACCUMULATION OF FLUID  IMPORTANT TO EXPLAIN PROCEDURE

COLON CANCER: SURG ICAL CARE
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POSSIBLE BLOOD TRANSFUSION FOLEY CATHETER IN SURGERY: IN SITU CANCERS ARE REMOVED THROUGH SCOPE. BOWEL RESECTION INDICATED FOR STAGE 1,2,3 & SOMETIMES 4 - REMOVE TUMOR AND AREA INVOLVED WITH LYMPH NODES CA OF RECTUM- TW O PROCEDURES REQUIRED-1ST ABD. INCISION- SIGMOID DIVIDED AND PROXIMAL EDGE BROUGHT OUT ONTO ABDOMEN TO MAKE A COLOSTOMY- 2ND- PLACE IN LITHOTOMY POSITION, PERINEAL INCISION & ANUS, RECTUM, DISTAL SIGMOID REMOVED ARTIFICIAL OPENING OF THE LARGE BOWEL BROUGHT OUT TO THE ABDOMEN MADE INTO A STOMA- SERVES AS AN EXIT FOR FECAL MATERIAL THE STOMA IS A SMALL ROUND STRUCTURE, PINK, MOIST, VELVETY, SMOOTH WHICH CHANGES IN SIZE, COLOR WITH ACTIVITY, EMOTIONS- ANGER RED, FEAR BLANCHING DESCRIBED BY PURPOSE, DURATION, LOCATION LOCATION: ASCENDING, TRANSVERSE, DESCENDING, SIGMOID DURATION: TEMPORARY, PERMANENT, CURATIVE, PALLIATIVE PURPOSE: SINGLE OR DOUBLE BARREL (LOOP) WET

SURGICAL CARE: COLON CANCER
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COLOSTOMY
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COLOSTOMY T YPES
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COLOSTOMIES CONT: DOUBLE BAR REL

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DOUBLE BARREL- PART OF BOWEL REMOVED, BOTH ENDS BROUGHT TO ABDOMINAL SURFACE CALLED PROXIMAL AND DISTAL OPENINGS. PROXIMAL ( USUALLY THE ONE ON THE RIGHT) IS THE FUNCTIONING STOMA ( FECES) AND THE DISTAL PORTION IS NONFUNCTIONING (MUCOUS)LEADS FROM STOMA TO ANUS DB IS USUALLY A TEMPORARY PROCEDURE TO ALLOW IRRITATION, INFECTION TO HEAL. THE BOWEL IS RE-CONNECTED IN 1-16 MO. SINGLE-CONSISTS OF 1 OPENING THROUGH WHICH FECAL MATTER IS PASSED. THE DISTAL PORTION HAS BEEN SURGICALLY REMOVED AND THE COLOSTOMY IS PERMANENT. LOOP COLOSTOMY: A LOOP OF INTESTINE BROUGHT TO ABD. WALL DIVERTING FECAL MATERIAL LOOP= HOLLISTER LOOP A TEMPORARY PROCEDURE- HEALS 2L-3 MO. WET COLOSTOMY- BOTH FECES AND URINE ARE EXCRETED BECAUSE OF TRANSPLANTATION OF URETERS IN COLON. NEVER IRRIGATE THESE. KNOW LOCATION & CHARACTERISTICS OF EFFLUENT ASCENDING- SEMI LIQUID TRANSVERSE- SEMI LIQUID TO PASTY DESCENDING - SEMI SOLID STRICT I & 0- IV FLUIDS FIRST 4-5 DAYS, LOSS OF NA AND K ( GI FLUID LOSS) KEEP STOMA CLEAN- 1ST DAY STOMA CLAMPED DAILY W T, SKIN TURGOR, NG TUBE CHECK STOMA FOR COLOR, BLEEDING CHECK FOR BOWEL SOUNDS ABDOMINAL GIRTH EMPTY PLASTIC POUCH WHEN 1/2 FULL IRRIGATE- COLOSTOMY FUNCTION BEGINS 3-6 DAY S POST OP WATER OR SOAP & WATER TO CLEANSE APPLIANCE WON’T STICK UNLESS CLEAN AND DRY SKIN BARRIERS- POWDERS, PASTE, GELS, WAFERS STOMA STABILIZES IN 6-8 WEEKS AND WILL CHANGE IN SIZE. LEAVE 1/8” AROUND STOMA IRRIGATION: STANDARD METHOD- START W ITH 500CC AND GO UP TO 1-2 LITERS OF NS OR TAP H20. SCHEDULE PROGRESS TO QOD THEN Q 3 D OR 2 X WK BULB SYRINGE METHOD- SHORT RUBBER CATHETER W AITH 50-100CC SOLUTION AT A TIME NON-IRRIGATION METHOD- USE OTHER DEVICES SUCH AS PRUNE JUICE, MILD LAXATIVE, SUPPOSITORIES TAKES ABOUT 7 DAYS TO ESTABLISH A PATTERN FOR EVACUATION, MAY HAVE 3-4 MOVEMENTS DAILY AT FIRST SIT ON CHAIR OR TOILET W ITH IRRIGATION SHEATH DIRECTED INTO TOILET BOWL BAG OF WARM SOLUTION HUNG 18” ABOVE STOMA LUBRICATE CATHETER, INSERT INTO STOMA CAREFULLY 2-3” BY ROTATING CATHETER INSTILL WATER SLOWLY WAIT 20-30 MIN. OBSERVE RETURN MAY NEED TO GENTLY MASSAGE ABDOMEN, TIGHTEN ABD. MUSCLES, TAKE DEEP BREATHS, RELAX, TW IST BODY SIDE TO SIDE- MAY PUT IN UP TO 2000 CC- IF AMOUNT YOU PUT IN COMES BACK

COLOSTOMY: SING LE BARRE L, LOOP, W ET
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COLOSTOMY CARE
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COLOSTOMY C ARE CONT

COLOSTOMY MAN AGEMENT METHODS
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COLOSTOMY: IRRIGATION PROC EDURE
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KATONA- PATTERN OF BOWEL ACTIVITY- IRRIGATE ON REG. SCHED REGULAR DIET, AVOID GAS FORMING FOODS & THOSE WITH A CELLULOSE BASE CLOTHING- AVOID TIGHT FIT AROUND STOMA TRAVEL- CARRY EQUIPMENT TO REMEDY A LEAK OR MAKE A QUICK CHANGEVARIETY OF APPLIANCES AVAILABLE OTHER HINTS: H20 THAT IS NOT SAFE TO DRINK SHOULD NOT BE USED FOR IRRIGATION, CLIMATE MAY INTERFERE WITH ROUTINE, USE CAUTION IN TRYING EXOTIC FOODS, MAKE A LIST OF ITEMS TO TAKE ALONG, EMERGENCY #’S, “OSTOMY QUARTERLY” CARRIES LIST OF SUPPLIES ANDOSTOMY ASSOC. HEMORRHOIDS ARE HYPERPLASTIC AREAS OF VASCULAR TISSUE IN THE ANAL AREA- VERY COMMON TYPES - INTERNAL & EXTERNAL ITCHING, PAIN, BLEEDING RELIEVED BY GOOD PERSONAL HYGIENE & AVOIDING STRAINING, HIGH RESIDUE DIET W ITH FRUIT & BRAN SITZ BATHS- OINTMENTS, SUPPOSITORIES WITH ANESTHETICS AND ASTRINGENTS ARE HELPFUL. BEDREST HELPS ENGORGEMENT TO SUBSIDE NON- OP TX: INFRARED PHOTOCOAGULATION, BIPOLAR DIATHERMY, OR INJECTING SCLEROSING SOLUTIONS SURGERY- RUBBER BAND LIGATION PROCEDURE CRYOSURGERY- FREEZE TISSUE LASER EXCISION HEMORRHOIDECTOMY- SURGICAL EXCISION- POST OP- STOOL SOFTENERS, ASA, TYLENOL, NORMAL BM W/O PAIN IN 1 WK

COLOSTOMY: DIET

HEMORRHOID ECTOMY
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REMOVAL O F HE MORRHOIDS
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