Question

1. What is a bowel perforation? What is a hemicolectomy?
2. What would be your priority assessment?
3. What are signs/symptoms of a pulmonary embolism?
4. List 5 things for this patient that you would like to know in morning report.
5. List some focus points for patient teaching.

Answer 1

Bowel perforation.

Gastrointestinal perforation, also known as ruptured bowel, is a hole in the wall of part of the gastrointestinal tract. The gastrointestinal tract includes the esophagus, stomach, small intestine, and large intestine. ... A hole in the stomach can also lead to a chemical peritonitis due to gastric acid.

Hemicolectomy.

A hemicolectomy is a type of surgery done to remove part of your large intestine called your colon. Your colon can be partially removed without affecting the way it works in your digestive system. Once the affected part is removed, the remaining ends are joined together with almost no impact on your digestion.

This procedure is done if your colon has been affected by a condition or has become cancerous. Some common conditions treated by a hemicolectomy include:

• cancer of your colon or bowels
• trauma or injury to your abdominal area
• inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn’s disease
• polyps, or tissue growths in your colon that can become cancerous
• diverticulitis, which happens when diverticula (small pouches) in your colon get infected or inflamed

Priority Assessment

Focused Gastrointestinal Assessment When conducting a focused gastrointestinal assessment on your patient, both subjective and objective data are needed. Components may include:

• Chief complaint

• Present health status

• Past health history

• Current lifestyle

• Psychosocial status

• Family history

• Physical assessment

Communication during the history and physical must be respectful and performed in a culturally-sensitive manner. Privacy is vital, and the healthcare professional needs to be aware of posture, body language, and tone of voice while interviewing the patient. Take into consideration that a patient’s ethnicity and culture may affect the history that the patient provides.

Taking a Focused Gastrointestinal History

It is important to begin by obtaining a thorough history of abdominal or gastrointestinal complaints. You will need to elicit information about any complaints of gastrointestinal disease or disorders. Gastrointestinal disease usually manifests as the presence of one or more of the following:

• Change in appetite

• Weight gain or loss

• Dysphagia

• Intolerance to certain foods

• Nausea and vomiting

• Change in bowel habits

• Abdominal pain

Past Gastrointestinal Disease and Medication History

Past Gastrointestinal Disease

Ask about any past history of gastrointestinal disorders such as ulcers, gall bladder disease, hepatitis, appendicitis, hernias. Ask the patient if they received treatment and if the treatment was successful. History should also include past abdominal surgeries, any abdominal problems after the surgery, and abdominal x-rays or tests (including colonoscopy) and their results .

Medication History

Many medications can produce gastrointestinal symptoms. Almost every class of drugs has the potential for gastrointestinal side effects. Most of the side effects include nausea, vomiting, diarrhea, and/or constipation. Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may cause abdominal pain and may increase the likelihood of gastrointestinal bleeding. Dietary supplements and the use of over the counter medications should also be included

Social History and Lifestyle Risk Factors

In taking a complete history, it is important to address lifestyle risk factors and social behaviors that may contribute to unhealthy lifestyles and increase the risk of gastrointestinal disorders. Ask your patients about the frequency and duration of alcohol consumption, caffeine intake, and cigarette smoking at this time. Alcohol can cause liver cirrhosis and esophageal varices. Cigarette smoking and regular ingestion of caffeine can lead to gastric reflux and gastric ulcers. Also ask about recreational drug use such as marijuana, opiates, or amphetamines. The use of illicit drugs can increase or suppress appetite and affect GI function.

Nutritional Assessment

Assessing nutritional status of your patients is important for several reasons. A thorough nutritional assessment will identify individuals at risk for malnutrition and provide baseline information for nutritional assessments in the future. Some of your patients that will require a thorough nutritional assessment include those patients with:

• Recent unintentional weight loss

• Chemotherapy or radiation

• Recent weight gain

• Food allergies or intolerance

• Decreased appetite

• Multiple medications

• Alterations in sense of taste

• Dieting history

• Difficulty chewing or swallowing

• Vomiting

• Mobility problems

• Diarrhea

• Inability to feed self

• Recent surgery or major illness or injury

• Substance abuse

• Chronic conditions

• Potential for social isolation

• Low income

The Physical Exam

When performing a focused assessment, you will use at least one of the following four basic techniques during your physical exam:

inspection,

auscultation,

percussion, and

palpation.

These techniques should be used in an organized manner from least disturbing or invasive to most invasive to the patient . Inspection is first, as it is non-invasive. Auscultation is performed following inspection; the abdomen should be auscultated before percussion or palpation to prevent production of false bowel sounds. For accurate assessment of the abdomen, patient relaxation is essential. The patient should be comfortable with knees supported and arms at the sides, and should have an empty bladder. The environment should include a comfortable temperature, with good light.

Abdominal Pain

Introduction

If your patient is experiencing abdominal pain, have them point to the exact location of the pain. Abdominal pain can be classified as:

• Visceral

• Parietal

• Referred Visceral Pain

Visceral pain is usually described as dull, crampy, squeezing, or aching. It can be constant or intermittent. The pain may be difficult to localize orand may be located over an abdominal organ .

Parietal Pain

Parietal pain is usually from inflammation over the peritoneum. Peritoneal inflammation usually indicates an underlying emergency and should be assessed quickly. Parietal pain is usually intense, constant, and on one side. It can be aggravated by extension of the lower extremity on the affected side, coughing, or eliciting rebound tenderness .

Referred Pain

Referred pain is usually visceral pain that is felt in another area of the body when a common nerve pathway is shared. It occurs with specific gastrointestinal disorders such as appendicitis (can cause umbilical pain in early stages), gall bladder disease (referred to right upper scapula), and pancreatitis (referred to the mid-back).

Mnemonic for Pain Assessment

Introduction

In general, the mnemonic, PQRST, is very useful in assessing abdominal pain and other gastrointestinal symptoms, such as distention, nausea, and vomiting. It provides a methodology in which communication to other healthcare providers will be efficient and informative. After eliciting information about any experienced signs or symptoms of gastrointestinal disease, ask about your patients past abdominal or gastrointestinal history, medications, and nutritional status.

P Provocative or Palliative: What makes the pain or symptom(s) better or worse?

Q Quality: Describe the pain or symptom(s) (burning, dull, sharp)

R Region or Radiation: Where in the body does the pain or symptom(s) occur? Is there radiation or extension or the pain or symptom(s) to another area of the abdomen?

S Severity: On a scale of 1-10, (10 being the worst) how bad is the pain or symptom(s)? Another visual pain scale may be appropriate for patients that are unable to identify with this scale.

T Timing: Does it occur in association with something else? (e.g. eating, exertion, movement)

Assessing Abdominal Pain:

Muscle Tests

The patient history is extremely important in assessing abdominal pain. Pain may be chronic or acute and related to inflammation, infection, allergy, or food intolerance. It can also result from trauma or obstruction. There are also a few physical exam techniques that can be used to assess acute abdominal pain. These are the iliopsoas muscle test, obturator test, and Blumberg test .

Iliopsoas Muscle Test

The iliopsoas muscle test is used most often when acute abdominal pain is present and appendicitis is suspected. When your patient is lying in the supine position ask him or her to lift their right leg straight up, flexing only at the hip. Push down on the lower part of the thigh when your patient is trying to hold their leg up. If the patient feels pain in the iliopsoas muscle (the right lower quadrant of the abdomen) the test is positive and may indicate a perforated or inflamed appendix. Anticipate further investigatory tests to confirm a suspected diagnosis

The Obturator Test

The obturator muscle test is also performed when acute abdominal pain is present and appendicitis is suspected. When your patient is lying in the supine position ask him or her to lift their right leg straight up, flexing at the hip, and 90 degrees at the knee. Hold the ankle and rotate the leg internally and externally. If the patient feels pain in the area of the internal obturator muscle (the right lower quadrant of the abdomen and pelvis) the test is positive and may also indicate a perforated or inflamed appendix

The Blumberg Sign

Blumberg Sign is also known as rebound abdominal tenderness. Choose a site away from the suspected area of tenderness. Holding your hand 90 degrees to the abdomen, press inward deeply, then release quickly. Pain on release of pressure is an indicator of peritoneal irritation

Signs and Symptoms of Pulmonary Embolism (PE)

5 things for the patient that I would like to know in morning report.

• Pulse Oximetry. Often, the first test performed when PE is suspected is a blood oxygen level. ...
• Arterial Blood Gas. ...
• Chest X-Ray. ...
• Ventilation-Perfusion Scan (VQ Scan) ...
• Spiral Computed Tomography of the Chest. ...
• Pulmonary Angiogram. ...
• Echocardiogram.

• Understanding PE Diagnosis.

  A number of different things may alert a physician that a person may be experiencing a pulmonary embolism, or blood clot in their lung. When this is suspected, a number of crucial tests may be performed, including:

  Pulse Oximetry

  Often, the first test performed when PE is suspected is a blood oxygen level. The simplest way to measure the blood oxygen level is with a pulse oximeter. Pulse oximetry is a noninvasive way (does not involve a blood draw or needle stick) to monitor the percentage of hemoglobin that is saturated with oxygen. Hemoglobin is the unique molecule in red blood cells that has the ability to carry oxygen.

  The pulse oximeter consists of a probe or sensor plus a computer. The probe, which looks like a padded clothespin, is placed on a relatively thin part of a person’s body, such as a finger or earlobe. Both red and infrared light are then transmitted through the tissue by the probe. Based on the absorption of the red and infrared light caused by the difference in color between hemoglobin that is saturated with oxygen (red) and unsaturated hemoglobin (blue), the computer can estimate the proportion of hemoglobin that is oxygenated. The pulse oximeter then displays this result as a percentage. A blood oxygen saturation level less than 95 percent is abnormal. It may be explained by a lung or heart problem already present, such as emphysema or pneumonia, or by PE (or both).

  Arterial Blood Gas

  A more precise measurement of blood oxygen level is obtained from a sample taken directly from an artery with a needle or a thin tube (catheter). An arterial blood gas (ABG) measures the levels of both oxygen and carbon dioxide in the blood to determine how well the lungs are working. While most blood tests are performed on samples taken from a vein, an ABG is performed on a sample taken from an artery. In most cases, the artery in the wrist is used for this purpose, but other arteries may be used. The levels of blood gases are measured as partial pressures in units of millimeters of mercury (mm Hg). A partial pressure of oxygen less than 80 mm Hg is abnormal.

  Chest X-Ray

  A chest x-ray cannot prove that PE is present or absent because clots do not show up on x-ray. Nevertheless, a chest x-ray is a useful test in the evaluation for PE because it can find other diseases, such as pneumonia or fluid in the lungs, that may explain a person’s symptoms. Occasionally, when pulmonary infarction occurs, the x-ray may suggest this diagnosis, although more testing is necessary to prove it with certainty. A normal or negative chest x-ray with a low, otherwise unexplained blood oxygen level, however, raises the suspicion for PE.

  Ventilation-Perfusion Scan (VQ Scan)

  A VQ lung scan may be a useful test to determine whether a person has experienced PE. This test evaluates both air flow (V = ventilation) and blood flow (Q = perfusion) in the lungs. About one hour before the test, a slightly radioactive version of the mineral technetium mixed with liquid protein is administered through a vein to identify areas of the lung that may have reduced blood flow. Multiple images are taken from different angles, using a special camera that detects radioactivity. For half of the images, the person breathes from a tube that contains a mixture of air, oxygen, and a slightly radioactive version of the gas xenon, which reveals air flow in different parts of the lung. For the other half of the images, the camera tracks the technetium, which reveals blood flow in different parts of the lung. PE is suspected in areas of the lung that have significant “mismatches”—that is, good air flow but poor blood flow.

  Except for the minor discomfort from having an intravenous catheter placed, a VQ lung scan is painless and usually takes less than an hour. The exposure to radioactivity from the test is very minor and results in no side effects or complications.

  A radiologist interprets the images from the VQ lung scan and decides whether the probability of a PE is high, low, or intermediate. If the probability is high, the diagnosis is made. If the probability is low or intermediate (that is, nondiagnostic), or if the VQ scan cannot be interpreted clearly, other testing must be considered. Even when PE is ultimately proven to be present, the VQ scan may be nondiagnostic. If clinical suspicion is low and the VQ scan reveals a low probability of PE, generally no further testing is needed. A normal VQ scan means PE is not present.

  Spiral Computed Tomography of the Chest

  An alternative to the VQ scan is a spiral computed tomography (CT) of the chest. A spiral CT of the chest uses special equipment to obtain multiple cross-sectional x-ray images of the organs and tissues of the chest. CT produces images that are far more detailed than those available with a conventional x-ray. Many different types of tissues—including the lungs, heart, bones, soft tissues, muscles, and blood vessels—can be seen.

  When PE is suspected, contrast dye (usually iodine dye) is administered through a vein to make the blood vessels stand out.

  During the spiral CT, radiation is emitted from a rotating tube. Different tissues absorb this radiation differently. During each rotation, approximately 1,000 images are recorded, which a computer then reassembles to produce a detailed image of the interior of the chest. The x-ray rotates as the patient passes through the CT scanner in a spiral path—hence the term “spiral” CT. The amount of radiation exposure is relatively low, and the procedure is not invasive.

  Pulmonary Angiogram

  If the VQ scan interpretation is low, intermediate, or uncertain probability of PE, or if the spiral CT is normal yet the symptoms are still suspicious, then the definitive test is a pulmonary angiogram. An angiogram is an invasive test that uses x-rays to reveal blockages or other abnormalities within the veins or arteries. Contrast dye (usually iodine dye) helps blood vessels show up clearly on x-rays. During an angiogram, contrast dye is injected into a blood vessel, and its path is tracked by a series of x-rays.

  A pulmonary angiogram examines the arteries that carry blood from the heart to the lungs and is performed to see if PE is present. Using x-rays in real-time (fluoroscopy), the radiologist inserts a catheter into a vein and advances it until it reaches the vena cava (the very large vein that carries blood to the heart). Next, the radiologist advances the catheter still farther into the right side of the heart and finally into the pulmonary artery, the large artery that carries blood to the lungs. The radiologist directs the tip of the catheter into the different branches of the right and left pulmonary arteries and injects the contrast dye, which illuminates the arteries on x-ray. If PE is present, it will show up as a blockage.

  Risks associated with a pulmonary angiogram include the possibility of damage caused by the catheter, bleeding, and an allergic reaction to the contrast dye. The amount of radiation from the x-rays is too small to cause any harm.

  Echocardiogram

  An echocardiogram is an ultrasound of the heart. Doppler ultrasound, B-mode ultrasound, and M-mode ultrasound (a rapid sequence of B-mode images that allows motion to be visualized) are combined to give information about the size of the heart, the function of the valves, and the strength of the heart muscle. (Duplex ultrasound is discussed in detail in Question 9.) The echocardiogram can spot areas of the heart that are not working well. When patients with a PE have an echocardiogram, approximately 40 percent will be found to have abnormalities of the right side of the heart, particularly the right ventricle. While an echocardiogram is not actually used to diagnose a PE, it can identify strain on the right side of the heart caused by a large PE as well as certain heart problems that may imitate a PE.

• Patient Instructions for Pulmonary Embolism

  A deep vein thrombosis (DVT) is a blood clot in a large vein deep in a leg, arm, or elsewhere in the body. The clot can separate from the vein, travel to the lungs and cut off blood flow. This is a pulmonary embolism (PE). Pulmonary embolism is very serious and may cause death.

  Healthcare providers use the term venous thromboembolism (VTE) to describe both DVT and PE. They use the term VTE because the two conditions are very closely related. And, because their prevention and treatment are closely related.

  Home care

  Taking care of yourself is very important. To help prevent more blood clots from forming, follow your healthcare provider's instructions. Do the following:

• Take your medicines exactly as instructed. Don’t skip doses. If you miss a dose, call your healthcare provider and ask what you should do.  

• Have all lab tests as recommended. This is very important when you take medicines to prevent blood clots.

• If your healthcare provider has instructed you to do so, wear elastic (compression stockings).

• Get up and get moving.

• While sitting for long periods of time, move your knees, ankles, feet, and toes.

• Lifestyle changes

  To help prevent problems with your heart and blood vessels, do the following:

• If you smoke, get help to quit. Talk with your healthcare provider about medicines and programs that can help.

• Stay at a healthy weight. Talk to your healthcare provider about losing weight, if you are overweight

• Try to exercise at least 30 minutes on most days. Before starting an exercise program, talk with your healthcare provider.

• When traveling by car, make frequent stops to get up and move around.

• On long airplane rides, get up and move around when possible. If you can’t get up, wiggle your toes, move your ankles and tighten your calves to keep your blood moving.

• When to seek medical advice

  Call your healthcare provider if you have pain, swelling, and redness in your leg, arm, or other body area. These symptoms may mean another blood clot.

  And, call your healthcare provider if you have signs and symptoms of bleeding, like blood in your urine, bleeding with bowel movements, or bleeding from the nose, gums, a cut, or vagina.

  Call 911

  Call 911 or get emergency help if you have symptoms of a blood clot in the lungs including:

• Chest pain

• Trouble breathing

• Coughing (may cough up blood)

• Fast heartbeat

• Sweating

• Fainting

• Also call 911 if you have:

• Heavy or uncontrolled bleeding. If you are taking a blood thinner, you have an increased chance of bleeding.

• Follow-up care

  Make a follow-up appointment

  Have your lab work done .