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Med Surg II

Chapter 44 & 45 Gastrointestinal

What does the digestive tract consist of? Mouth, pharynx, esophagus, stomach, small intestine, large intestine, and anus
What do the accessory organs do? Aid in digestion
Describe the mouth Contains the tongue, digestion begins here, and the teeth are an accessory organ
Describe the stomach Digestion of protein begins here, food is broken down into chyme, the chyme then passes through the pyloric sphincter into the duodenum for the next phase of digestion
What contains villi that aids in digestion? Small intestine - end product of carbohydrate metabolism absorbed and put into the blood stream
What is the main function of the large intestine? Reabsorption of water
What is the sphincter in which feces are passed? Rectum
What produces bile, which is necessary to digest fat? Liver
What metabolizes proteins, fats, and carbohydrates? Liver
What is an indication of gallbladder disease? Change in color of urine or stool
What can detect lesions in the proximal colon, which would not be found by sigmoidoscopy? Colonoscopy
What are the NI for colonoscopy? Pt. clear liquids for 1-3 days prior to exam, NPO 8 hrs prior to procedure, administer bowel cleansers as ordered, assist patient to left sims position, assess for signs of bowel perforation after procedure
What is the stool assessed for in a stool culture? Ova & parasites (O&P) for suspected infection with a parasitic infection
How many stool specimens are collected for at stool culture? At least 3 on consecutive days
What is candidiasis? Infection caused by candida, also referred to as thrush
What is candidiasis treated with? Nystatin or Diflucan
What are the NI for candidiasis? Meticulous hand hygiene to prevent the spread of infection, assess regularly, administer meds as prescribed, treat pain
What is GERD? Gastroesophageal Reflux Disease - backward flow of stomach acid up into the esophagus
What are the typical symptoms of GERD? Burning and pressure behind the sternum (described as heartburn), dry cough, hoarseness, and sore throat
What is GERD treated with? H2 receptor antagonist, PPI, antiulcer medications, metoclopramide (Reglan), and Nissen fundoplication
What are the NI for GERD? Educate patient on diet and medications: 4-6 small meals/day, decrease caffeine, quit smoking, avoid alcohol, avoid tight clothing over abdomen, avoid working in bent-over position, elevate HOB
What is a malignant epithelial neoplasm that has invaded the esophagus? Carcinoma of the esophagus
What are the risk factors for carcinoma of the esophagus? Alcohol, tobacco use, acid reflux, obesity
What does prevention of carcinoma of the esophagus include? Stop smoking, good oral hygiene and dietary habits, regular check ups for any esophageal problems (especially dysphagia), limit alcohol intake
What are the clinical manifestations and assessment for carcinoma of esophagus? Progressive dysphagia over a six month period; assess for dysphagia, chronic cough, vomiting, hoarseness
What is achalasia? Also called cardiospasm; is the inability of a muscle to relax, particularly the cardiac sphincter of the stomach
What are the post op instructions for an esophageal dilation? Encourage fluids w/meals to increase lower esophageal sphincter pressure and to push food into stomach, have patient sit in semi-fowlers position for 2 hours after eating and while sleeping
What is gastritis? Inflammation of the lining of the stomach
What is the treatment for gastritis? Medications, NG tube, gastric lavage, and removal or avoidance of causative factors
What are the NI for gastritis? Monitor I&O, keep NPO until symptoms subside, administer IV feedings as indicated
What is a patient at risk for if they have chronic gastritis and why? B12 deficiency due to deterioration and atrophy of stomach lining
What is the chief enzyme of gastric juices, activate by hydrochloric acid to begin protein digestion? Pepsin
What is peptic ulcer disease? Ulcerations of the mucous membrane or deeper structures of the GI tract
Where do peptic ulcers commonly occur? Stomach and duodenum
What is the characteristic symptom of peptic ulcers? Pain, described dull, burning, or gnawing; pain with eating but does not usually awaken patient
What is dyspepsia? Indigestion, heartburn, nausea, abdominal fullness
What would be signs of hemorrhage? Hematemesis - may be bright red or coffee ground color; Malena - stool that is black & tarry
What is the treatment for peptic ulcer disease? NG tube, antacids, H2 receptor blockers, PPI's, gastric mucosal protectant
What are PPIs (Proton Pump Inhibitor)? Antisecretory agents that inhibit secretion of gastrin; examples are omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium)
What is an example of gastric mucosal protectant? Sucralfate (Carafate) - administer before meals and at bedtime
How is H. pylori treated? Antibiotics such as Flagyl, Amoxicillin, Biaxin; sometimes used with Bismuth (Pepto-Bismol) which may turn stools gray to black
What are the NI for peptic ulcer disease? NG or intestinal tube placement (irrigate w/NS as ordered to promote clotting; irrigation removes old blood from stomach), intermittent suction, admin. medications, assess frequently, monitor v/s
What is the diet for peptic ulcer disease? 6 small meals/day, avoid mile because it may cause dumping syndrome, avoid alcohol and caffeine, eliminate smoking
What are the possible complications of peptic ulcer disease? Hemorrhage if erosion is extensive, perforation (ulcer penetrates entire thickness of wall of stomach or duodenum, most lethal complication)
What are the s/s of perforation? Pain, emesis, fever, hypotension, and hematemesis
How do you avoid recurrence of peptic ulcer disease? Eliminate foods that aggravate condition, taking RX's such as PPI's and avoiding NSAIDS
What is the surgery called for cancer of the stomach? Gastrectomy
Why would a gastrectomy patient need supplemental B12 injections? Deficiency of intrinsic factor produced by the stomach which aids intestinal absorption
What is a possible complication of a gastrectomy? Dumping syndrome, caused by rapid gastric emptying which is caused by eating high carb foods over a short period of time
What are preventative measures to avoid dumping syndrome? Eat 6 small meals daily that are high in protein and fat but low in carbohydrates, eat slowly, and avoid fluids during meals
What treatments are there for cancer of the stomach? Surgery, radiation, and chemotherapy
What is clostridium difficile (C-diff)? Antibiotic associated pseudomembranous colitis; is a complication of tx w/variety of antibiotics; can be facility acquired infection bc hospitalized pt. often immunocompromised; antibiotic therapy is common, and spores can survive up to 70 days
What is the best way to keep C-diff from spreading? Hand washing with soap and water; antiseptic hand rub/gels do not destroy C-diff
What is ordered to aid in dx of C-diff? Stool specimen
What are the chain of events in celiac disease? Ingestion of gluten, Immune system damages inner lining of small intestine & destroys villi, Malabsorption occurs due to damage to lining of small intestine, Abdominal pain & diarrhea, Weight loss & vitamin deficiency, Systemic involvement (IIMAWS)
What is the some treatments for IBS? Stress management-biofeedback, relaxation therapy, and hypnosis. CAM therapies may be beneficial such as acupuncture, herbal therapy, and yoga but no data to determine their efficacy
What is the Rome Criteria (symptom based criteria) for IBS? Abdominal discomfort that occurs at least 3 days/mo. within the last 3 mo., and has at least 2 of the following: relieved w/defacation, onset assoc. w/change in stool frequency & appearance
What is the surgical control for UC? Colon resection or ileostomy; NG tube to suction
What is the post-op care for UC? Monitor NG tube for patency, maintain correct wall suction, and observe stoma for color and size
What is the treatment for Crohn's Disease? Anti-inflammatory mediations, corticosteroids, multivitamins, immunosuppressive therapy (Remicade, Humira), dietary modification, surgery
What is the treatment for severe Crohn's disease with marked weight loss? TPN, tube feedings allow rapid absorption in upper GI tract
What must you monitor when a patient is on immunosuppressive therapy (Remicade, Humira) for Crohn's disease? Frequency and consistency of BM's
What are the NI for a patient with a stoma? Assess skin integrity, assess for allergies to powders or adhesive, provide education on changing pouch, assess peristomal area for infection
What is appendicitis? Inflammation of the vermiform appendix; usually acute
What is appendicitis characterized by? Rebound tenderness in the RLQ; WBC count > 10,000/mm3
What are the NI for appendicitis prior to surgery? Maintain bed rest and NPO status, use ice bad to relieve pain, DO NOT use heat or enemas. Heat increases circulation to appendix which could lead to rupture; enemas could also lead to rupture
What is the treatment of choice for appendicitis? Emergency surgical intervention
What is diverticulitis? Inflammation of one or more of the diverticular sacs
What is diverticulosis? Presence of pouch like herniation's through the circular smooth muscle of the colon
What can inflammation in the colon lead to? Perforation, abscess, peritonitis, obstruction, and hemorrhage
What is the progression from diverticulitis to obstruction? Weakened wall of sigmoid, Increase in intra-abdominal pressure, Pouch protrudes through smooth muscle, Pouch fill with fecal matter, Inflammation of diverticula, Narrowing of bowel lumen (WIPPIN)
What is diverticulitis characterized by? Pain - mild to severe LLQ, fever, elevated WBC count, elevated SED rate, diarrhea, vomiting, and nausea
What can diverticulitis lead to if it is left untreated? Septicemia & septic shock - s/s hypotension & tachycardia
How is diverticulitis diagnosed? Ultrasound and CT
How is diverticulitis managed? Diet high in fiber, mainly fresh fruits and vegetables, decreased intake of fat and red meat, avoid gas forming food or foods containing indigestible roughage, seeds, or nuts since these foods become trapped in diverticula; weight loss, and exercise
What may be required if there are complications to diverticulitis? Antibiotics and surgical intervention - In cases of perforation, abscess, peritonitis, or fistula, resection of bowel w/temp colostomy is needed
When does closure of temporary colostomy usually occur? 6 weeks to 3 months after initial procedure
What is a hiatal hernia? Protrusion of the stomach and other abdominal viscera through an opening, or hiatus, in the diaphragm
How is hiatal hernia corrected? Surgery
What are the NI for hiatal hernia? Eat small frequent meals, limit amount of liquid taken with meals, and sit upright for at least 1 hour after eating
What is mechanical obstruction? Occlusion of the lumen of the intestinal tract. Ex: tumor, fecal impaction, lumen narrowed by inflammation, incarcerated hernia
What is non-mechanical obstruction? Decreases the muscle action of the bowel (may be neurologic or vascular disorders) Ex: paralytic ileus
What are the early phases of mechanical obstruction? Auscultation of the abdomen revels loud, frequent, high-pitched sounds; peristaltic activity increases proximal to obstruction
What is the medical management for fecal incontinence? Improve muscle tone of the sphincter
What are the NI for fecal incontinence? Bowel training - Encourage pater on consistent timing; familiar surroundings, teach importance of high fiber diet & sufficient fluid intake; Establish optimal time for defecation, usually after breakfast, use a glycerin suppository to stimulate defecation
What are the NI for constipation? Increase physical activity, increase fiber intake, bulk-forming laxatives, drink 8 - 10 glasses of fluid/day unless contraindicated
What is an anal fissure? Linear ulceration or laceration of the anus; usually results from trauma caused by hard stool
What are normal ranges for serum bilirubin? Direct bilirubin: 0.1-0.4 mg/dL, Indirect bilirubin: 0.2-0.8 mg/dL, Total bilirubin: 0.3-1.2 mg/dL, Serum lipase 10-140 units/L
What are the normal ranges for serum protein? Total protein: 6.4-8.3 g/dL, Albumin: 3.5-5 g/dL, Globulin: 2.3-3.4 g/dL, Albumin/globulin ratio: 1.2-2.2 g/dL
What does cholecystogram do? Provides roentgenographic visualization of the gallbladder after the oral ingestion of a radiopaque dye
How is the radiopaque dye administered to the patient? 6 tablets of iopanoic acid (telepaque); give 1 tablet every 5 minutes beginning after every meal
What are the NI for gallbladder scanning? Advise patient radioactivity is minimal and keep patient NPO prior to exam
What is a safe, simple, and valuable method of diagnosing pathologic liver conditions? Needle liver biopsy
What are NI for needle liver biopsy? Verify consent, examine related laboratory values, after procedure monitor the patient for symptoms of bleeding, have pt. lay on right side to splint puncture site for at least 2 hrs., assess for pneumothorax
What are the s/s to report after a liver biopsy? SOB, change in respiratory or cardiac rate, or decreased breath sounds on affected side
What is radioisotope liver scanning used for? Outline and detect structural changes of the liver
What are the NI for radioisotope liver scanning? Keep patient NPO prior to exam
What is an ERCP? Endoscopic retrograde cholangiopancreatography of pancreatic duct
What are the NI for ERCP? Keep patient NPO for 8 hrs prior to exam, check PT/INR level, instruct patient exam takes 1-2 hrs, keep patient NPO until gag reflex returns, assess for pancreatitis (abd. pain, n/v, fever, chills) monitor v/s
What are the stages of liver deterioration? Destruction, Inflammation, Fibrotic regeneration, Hepatic insufficiency, Liver Disease (DIFHL)
What lab value will be elevated with cirrhosis? Prothrombin time
What is the medical management of cirrhosis? Eliminate alcohol use, diet modification (increase green leafy veggies to assist in blood clotting, antiemetics (Zofran), Benadryl, and Dramamine
What nutrient should be restricted with cirrhosis and why? Protein - liver is unable to rid the body of ammonia made by the breakdown of protein
Why is there bleeding tendencies reflected by an increase in Prothrombin time in the liver? Liver cannot absorb vitamin K or clotting factors
What is a complication of cirrhosis? Fluid retention; diuretics commonly used; decreased albumin level may cause edema, LaVeen peritoneal shunt may be used, and paracentesis may be performed
What does a paracentesis do? Temporary relief from ascites - Patient must urinate immediately before procedure to prevent puncture of bladder, Pt. should sit on side of bed or be placed on high Fowlers,
How long does it take to remove fluid via paracentesis? 30 to 90 minutes to prevent sudden changes in blood pressure
What are the NI for after paracentesis? Apply dressing over insertion site, observe for bleeding and drainage, and monitor v/s
What is esophageal varices? Veins in the esophagus become enlarged and engorged
What are esophageal varices susceptible to? Ulceration and hemorrhage
What is a prophylactic treatment for esophageal varices? Beta blockers
How can varices rupture? Anything that increases abdominal venous pressure, such as coughing, sneezing, vomiting, or the Valsalva maneuver
What are the methods to control bleeding during the rupture of a varix? Sengstaken-Blakemore tube inserted to control bleeding, Balloons in esophagus or stomach may be inflated to press against bleeding vessels; band ligation-bands are placed to tie off bleeding vessels, portocaval shunt
What is hepatic encephalopathy? Type of brain damage caused by liver disease and consequent ammonia intoxication
What are s/s of encephalopathy? Inappropriate behavior, disorientation, asterixis (hand flapping tremor), and twitching of the extremities to stupor and coma
What is treatment of hepatic encephalopathy? Supportive care to prevent further damage to the liver - Neomycin, decreases number of ammonia producing bacteria in the gut
What is NAFLD? Nonalcoholic Fatty Liver Disease - results from fat building up in the liver; increased incidence due to growing obese population; assoc. with diabetes, coronary artery disease and use of corticosteroids
What are the two most common conditions of the gallbladder? Cholecystitis and cholelithiasis
What is an inflammation of the gallbladder called? Cholecystitis
What is the presence of gallstones in the gallbladder called? Cholelithiasis
What can cause Cholecystitis? Obstruction, gallstone, or tumor; may be acute or chronic
What is Cholecystitis characterized by? Indigestion, n/v, abrupt onset of intense pain in RUQ epigastric region that may radiate to back or right scapula, stools that contain fat and clay-colored caused by lack of bile in intestinal tract
How is Cholecystitis and cholelithiasis diagnosed? Ultrasound or HIDA scan
What is medical management usually aimed at for Cholecystitis and cholelithiasis? Surgical correction; eat small meals, meperdine (Demerol) and ketorolac (Toradol) common for pain management; Morphine is generally not used since it may cause spasms of the sphincter of oddi
What is pancreatitis? Inflammatory condition of the pancreas that may be acute or chronic
What causes pancreatitis? Alcohol ingestion or biliary disease
What aids in diagnosing pancreatitis? Serum amylase; elevation occurs within 2 hours of onset
What is treatment for pancreatitis? NPO (pancreas is stimulated when you eat or drink), medications, pain control, antiemetic's, H2 antagonist, and TPN
What is the most common risk factor for cancer of the pancreas? Cigarette smoking, other factors include exposure to chemical carcinogens, diabetes mellitus, cirrhosis, and chronic pancreatitis
How does pancreatic cancer begin? Vague symptoms: anorexia, nausea; abdominal pain in midepidgastric region; (half the patient w/cancer develop DM)
How is Hep A transmitted? Fecal-oral route - hand washing is imperative
How is Hep B transmitted? Body fluids - One of the best preventative measures especially for health care workers is the HBV vaccine
How is Hep C transmitted? Body fluids
How is Hep D transmitted? Body fluids, occurs concurrently with HBV
How is Hep E transmitted? Body fluids, occurs concurrently with HCV
What are the indications for liver transplantation? Congenital biliary abnormalities, inborn errors of metabolism, hepatic malignancy (confined to the liver), sclerosing cholangitis, chronic end-stage liver disease (hepatitis)
What is the most important NI for liver transplantation? Prevent infection
What is the most common treatment for Cholecystitis and cholelithiasis? Laparoscopic cholecystectomy - uses a laser or cautery to remove the gallbladder; replaces the open surgical prodecure 80-85% of the time
What are the advantages to laparoscopic cholecystectomy? Less invasive, scarring, pain, and quicker return to normal activity
What is the postsurgical care for laparoscopic cholecystectomy? Assess and treat pain, vital signs routinely, and provide patient education
What is the disadvantage of open cholecystectomy? Recovery time is longer, greater risk for infection, patient has to have T-tube drain placed
Describe the t-tube? Attached to a closed drainage bag with frequent checks to make sure tube does not get kinked and noting the color and amount of drainage
What happens when oral intake is resumed when a patient has t-tube? HCP may order t-tube to be clamped for 1 to 2 hours before meals and unclamped 1 to 2 hours after meals to aid in digestion of fat (if pt. develops abd. pain or n/v, unclamp tube immed.)
What is NI for patient following open abdominal cholecystectomy? Nursing care follows the same path as laparoscopy, however, drain care will also be performed and recovery will be more extensive; encourage patient to deep breathe, coughing and I/S; splint incision
The largest glandular organ in the body, which functions as an accessory organ of digestion, is the: Liver
A patient with carcinoma of the esophagus is about to undergo surgery, an esophagogastrectomy, and is very anxious about what to expect immediately after surgery. Which of the following statements would be appropriate to help calm his anxiety? “When you wake up, we will be monitoring you very closely. We will give you pain medication and do everything we can to keep you as comfortable as possible.”
Malabsorption can be a major problem with Crohn’s disease when what portion of the intestine is involved? Small intestine
A patient has been diagnosed with diverticulosis as a result of muscle thickening and increased intracolonic pressure. Which of the following recommendations would the nurse give her regarding food choices? Bran, fruits, and vegetables
A patient is undergoing a diagnostic tests to rule out carcinoma of the oral cavity. Which of the following symptoms have been associated with the disease? Difficulty chewing, swallowing, or speaking, constant earache, toothache, mouth edema, numbness or loss of sensation in part of the mouth, dysphagia
What is the preferred diagnostic test for visualizing the biliary tree in a patient with jaundice? Gallbladder ultrasound
What type of liver cirrhosis is caused by viral hepatitis, exposure to hepatotoxins (e.g., industrial chemicals), or infection? Postnecrotic cirrhosis
What is the top priority when managing a patient with a ruptured esophageal varix? Protection of airway
What is the most common form of hepatitis today, which has an incubation period of 10 to 40 days? Hepatitis A
Created by: tandkhopkins
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