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nctc 3rd level MS 1


Upper GI tract Begins at mouth, ends at the jejunum
Lower GI tract Begins at the ileum, ends at the anus
GI Assessment: History ID specific problem & its possible cause Chief complaint, nutritional, & elimination patterns Appetite, discomfort, weight gain or loss, allergies
GI Assessment: Physical Exam General appearance Skin: color, turgor Mouth: cracks, inflammation, sores, hygiene Abdomen: bowel sounds, girth, tenderness
What do you expect to see in the emesis due to old blood? Emesis will be coffee ground looking
What do you expect to see in the emesis due to new blood? bright red hematemesis
What is your first intervention with emesis of new blood? * Turn pt on side * Notify charge nurse or physician * Prepare to insert an NG tube * Explain procedure to pt
Pt. has emesis 650ml new blood - VS are now: 100/50, 128, 30 – what do you do next? * Lay pt flat * Head flat on bed-no pillow-feet elevated on two pillows * Continue to monitor VS q 5 min
Pt. has emesis 650ml new blood - What is the purpose of the NG tube in this situation? * Gastric decompression
How do you measure for NG insertion? Tip of nose, over ear and down below sternum, to xyphoid process
How do you check placement of the NG tube? * 10-20cc bolus of air * Aspiration * Test GI contents on litmus paper pH should be around “4”
What nursing care is needed after insertion of the NG tube? * Tape NG securely to nose Take care that NGT dose not cause pressure Allow some slack in tubing so it doesn’t pull, especially with movement, and then pin to the gown
What lab is drawn when a patient is on Coumadin and what is the normal value? PT & INR Therapeutic PT: 10-14 (70-100% of the control) Therapeutic INR: 2-3
What assessment findings might you expect with an admit Dx of perforated ulcer? * Gastric ulcers Burning pain upper gastric area 1-2 hours after meals * Perforated ulcer Sharp, sudden onset of intense burning pain, N/V of bright red blood
Gastric ulcers Burning pain upper gastric area 1-2 hours after meals
Perforated ulcer Sharp, sudden onset of intense burning pain, N/V of bright red blood
In what order do you assess the abdomen? * Inspection * Auscultation * Percussion * Palpation
What is the name of the sphincter between the esophagus and stomach? * Cardiac sphincter
What is the name of the sphincter between the Stomach and small intestine? * Pyloric sphincter
bowel sounds - Normoactive 5-30 per minute
Hyperactive bowel sounds - >30 per min
Hypoactive bowel sounds <5 per min
Where does the majority of digestion occur? * In the small intestine
What is the classification of Tagamet (cimetidine) and what is its purpose? * Anti-secretory drug * H2 receptor blocker * Decrease HCl production
What S/S are associated with PUD? * S/S-burning, gnawing, abdominal pain after eating (1-2 hrs: gastric; 2-4 hrs: duodenal)
What Complications are associated with PUD? * Hemorrhage-avoid ASA, alcohol * Perforation * Peritonitis-usually due to perforation, NPO, will need NG * Pyloric obstruction
What is gastritis? * Inflammation of the lining of the stomach
* Potential causes of gastritis? * Helicobacter pylori (H. pylori) * Excessive intake of hot, spicy, food or alcohol * Food poisoning * Chemical irritation * Reflux
What complications can occur with chronic gastritis? * Hemorrhage is most serious * Pernicious anemia
* Subtotal Gastrectomy Part of distal portion of stomach is removed Remainder anastomosed to duodenum
Vagotomy A branch of the vagus nerve that supplies stomach is severed Decreased stimulation of gastric secretions
Subtotal Gastrectomy and Vagotomy nursing interventions Assessment Pain control Antiemetics for N/V, monitor weight
What complications are associated with gastrectomy & vagotomy? * Feeling of fullness * Diarrhea * Dumping syndrome
Dumping syndrome Occurs due to decreased size of stomach or loss of vagus nerve prevents normal pacing of chyme movement Fluid is drawn out of the blood within 15-30 min of eating to moisten food BP falls, becomes dizzy, diaphoretic and weak
What is peritonitis? * Infection of the peritoneum
What are Causes of peritonitis? * Perforated peptic ulcer * Perforated bowel * Perforated appendix * Lack of surgical asepsis * Trauma: GSW, stab wound * Peritoneal dialysis
What are the complications of peritonitis? * Paralytic ileus due to lack of peristalsis * Sepsis * Death
What is an UGI (upper GI) series? * Diagnostic test to see abnormalities in esophagus and stomach (Barium swallow), & evaluate for aspiration * Pt drinks contrast dye & radiologist watches it travel through esophagus, & observes filling and emptying of stomach
* Pt teaching for upper GI series includes: * Drink plenty of fluids after to help expel barium Monitor stools for 2 days – will be white or gray * May need to use laxative * Must be NPO for 6-12 hours prior Assess allergies
What diagnostic endoscopic procedures are done to examine the lower GI tract? * Colonoscopy * Proctoscopy * Sigmoidoscopy
What is a colonoscopy? * Colonoscopy - visualizes colon
What is a EGD? * EGD - Esophagogastroduodenoscopy -visualizes esophagus, stomach & duodenum
What prep is necessary for a patient recieving a colonoscopy & EGD? * NPO for 6-8 hr before exam * clear liquids for lunch & dinner the day before * Colon prep: bowel cleansing before a colonoscopy
What are the expected outcomes following a colonoscopy & EGD? * The abnormality will be visualized * There will be no S/S of perforation * fever, abdominal pain and distention, rectal bleeding
What lab test helps determine residual bowel cancer after surgery? Carcinoembryonic antigen-CEA
What S/S occur late in bowel cancer? * Obstruction of the bowel * Thin ribbon-like or pencil-like stools
What types of surgeries are used to treat colon cancer? * Depends on location and extent of cancer * above rectum-diseased portion removed * healthy ends anastomosed * Possible removal of rectum and creation of colostomy
* Dumping syndrome-15-30 minutes after meals; chyme moving through intestines draws fluid out of the blood. Blood volume falls causing weakness, dizziness, diaphoresis & palpitations * divide meals into 6/day * eat diet low in carbs and refined sugar, moderate in fat & moderate to high in protein * drink fluids between meals, not with them * lie down for 30 min after meals
Pernicious Anemia, malabsorption: * Vit B12, folic acid, iron, calcium and Vit D absorption impaired * Gastrectomy causes loss of parietal cells that produce intrinsic factor, which is necessary for absorption of Vit B12 * Vit. B12 necessary for production of RBC’s * supplement with B12 injections
* Unable to eat same volume of food as before, which leads to weight loss * eat small frequent meals-about 6/day * eventually will be able to eat 3/day when stomach stretches out
What type of suction should be used for the NG and why? * Low intermittent suction Order will be written as LIWS Prevents damage to the stomach lining
Four hours after surgery, she has bright red drainage in the NG and vomits bright red hematemesis as well.What are your first interventions? * Check VS * Assess for S/S of hypovolemia
If after surgery a pts NG tube becomes dislodged. You should do what first? * Notify RN or physician Reinsert only if ordered
What would you do if the NG had become obstructed? * Irrigate with normal saline * Be sure you have a Dr’s order
How much fluid is used for NG tube irrigation? * 20-30cc – max 30cc
What are the S/S of gastric distention? * Enlarged abdomen * Nausea & vomiting
What is the purpose of TPN? * Bypasses the digestive tract by delivering nutrition directly into the bloodstream * Used when the patient is unable to eat, or take in nutrition into the GI system, for long periods of time
What labs must be monitored while on TPN? * Blood glucose levels * TPN mixed in a D10W solution or higher * Abnormally raises serum glucose levels * May need to administer insulin
List other points that are important to remember when caring for a patient on TPN. * Adm. into central circulation * Use sterile technique when changing dressings * Follow agency policy RT frequency * Inspect site for S/S of infection * Monitor flow rate * Must be on a pump
more points that are important to remember when caring for a patient on TPN. If given too rapidly can lead to circulatory overload, hyperglycemia or excessive diuresis * Label TPN lines * Nothing except lipids can infuse with TPN If TPN empties before pharmacy sends a new one, you must hang D10 W in its place
What S/S of appendicitis may be found during an abdominal assessment? Initial pain around the umbilicus * Pain shifts to right lower quad at McBurney’s point found midway between umbilicus and the right anterior iliac crest * Rovsing’s sign: rebound pain w/palpation * Elevated temp * Nausea and vomiting * Elevated WBC’s
Rovsing’s sign: rebound pain w/palpation
McBurney’s point midway between umbilicus and the right anterior iliac crest
What complications can occur with appendicitis? * Rupture causing peritonitis S/S are absence of bowel sounds, increased pulse, temp, N/V, rigid abdomen, shock
What are the S/S, complications, for constipation? * S/S: hard, dry, infrequent stools that are difficult to pass * Straining when performing a valsalva maneuver can cause brief drop in BP and HR, then a rapid rise in BP and pulse. This change causes syncope. * Complication: Hemorrhoids
treatment for constipation? * Tx: laxatives, stool softeners (Surfak, Colace, Metamucil) suppositories, enemas, increase in fluids
What class of medications can contribute to constipation? * Opioid analgesics * Over use of laxatives * They can dull the gastrocolic reflex & can cause loss of colonic motility & intestinal tone
What are the causes, S/S, of diarrhea? * Causes - spoiled foods, allergies, infections, diverticulitis, stress, cancer, fecal obstruction, meds, malabsorption * Passage of loose, liquid stools with increased frequency. May have cramps, abdominal pain and urgency
complications of diarrhea? * Complications: dehydration, electrolyte imbalances, metabolic acidosis, vitamin or nutritional deficiencies
What is diverticulosis? * Small sac-like pouches in the intestinal wall called diverticula that herniate outward
s/s & causes of diverticulosis? * Causes - lack of dietary fiber, age, constipation, obesity, stress * S/S: often asymptomatic; may report: rectal bleeding, pain in left lower abdomen, N/V, change in bowel habits, urinary problems
What diagnostic tests are done to aid in diagnosis of diverticulitis or diverticulosis? * Stool tested for occult blood * Abdominal CT * Barium enema or colonoscopy * May be contraindicated for severe inflammation
What dietary recommendations are made at discharge, for diverticulitis or diverticulosis? * Diet high in fiber * Avoid irritating foods and alcohol
Ulcerative colitis usually occurs in adulthood, inflammation of intestinal lining, begins in rectum and moves upward
Crohn’s disease can occur at anytime from infancy to adulthood, inflammation of intestinal lining, can occur anywhere in intestinal tract
List the different types of inflammatory bowel diseases. Ulcerative colitis Crohn’s disease
What type of complications can occur with inflammatory bowel disease? * Hemorrhage * Obstruction * Perforation * Abscesses * Fistulas * Megacolon
What treatments are necessary for Crohn’s disease treated with drugs, diet and rest olsalazine, mesalamine must take 30 minutes before meals * ATB * Low roughage diet; no milk products * IV fluids or TPN * Occasional surgical intervention Requires creation of ileostomy * Recurrence likely within 1 yr
What treatments are necessary for ulcerative colitis? drugs, diet and rest * olsalazine, mesalamine * must take 30 minutes before meals * Low roughage diet; no milk products * IV fluids or TPN * Occasional surgical intervention * Curative for ulcerative colitis * Requires creation of ileostomy
What is an ileostomy? * An opening in the ileum, the distal portion of the small intestine * Necessary when entire colon must be bypassed due to cancer, IBD, congenital defects or bowel trauma
What type of stools do you see with an ileostomy? * Fecal matter in the ileum is liquid
What type of stools do you see with a colostomy? * Stool in the colostomy may be liquid, semi-solid or solid depending on which part of the colon is brought to the surface
What does the normal stoma look like? * New - beefy red with some bleeding * Healed - rosy red, slightly darker than oral mucosa * Impaired circulation - pale, bluish or black * CALL DR. IMMEDIATELY
What is the nurse’s highest priority after ileostomy/colostomy surgery? * ABC’s * VS * Assess stoma/abdomen for bleeding * Assess NGT * Make sure on low intermittent suction * Assess IV fluids, right fluid and rate
What are the S/S of an obstructed ileostomy and what interventions are needed? * Abdominal distention * N/V of bile contents, followed by fecal matter * Same interventions as for bowel obstruction * May need to irrigate ostomy:
to irrigate ostomy: * insert a lubricated irrigating catheter about 2-4 inches into stoma, which is attached to an enema fluid container (must clear air from tubing before inserting) & irrigate with 500-1000cc normal saline * repeat as necessary
What do you as a nurse need to include in your DC teaching for the patient ? * Skin care * must be clean and dry before applying appliance * Application of the appliance * Diet
What are S/S for bowel obstructions? * Severe abdominal pain * Projectile vomiting * N/V of gastric contents, followed by fecal matter is common * Gastric distention will occur, especially if colon obstruction * Bloody or purulent rectal drainage
treatment for bowel obstructions? * NGT for decompression and evacuation * IV fluids * Possible surgical intervention
Name the different causes of Mechanical Bowel Obstruction. * Adhesions * Intussusception * Volvulus * Hernia * Tumor * Paralytic ileus * Adynamic: lacking peristalsis
How do you verify placement of a feeding tube and when is this done? * Auscultate over stomach while injecting a bolus of 10-20cc of air * Can verify with an x-ray if there’s any doubt * Immediately after placement and before initiating all tube feedings * Once per shift & prn if continuous TF * Follow agency policy
Residual for you patient is 90cc. What do you do next? * Continue tube feeding
* If the residual was greater than 100cc, you may hold feeding and recheck in 1 hour * Return up to 100cc of residual * Prevents loss of nutrients & enzymes * Follow Dr’s order or agency policy
What nursing interventions can you do to promote acceptance of a gastric tube by your patient? * Demonstrate acceptance by spending time with patient * Allow patient to share her thoughts about the tube * Be accepting of patient’s feelings
What is going on with this patient? * The patient has an incarcerated or irreducible hernia * The trapped loop of intestine may get a reduced blood flow causing it to become gangrenous - this is known as a strangulated hernia
Herniorrhaphy – repositioning of the intestine in the abdominal cavity, & repair of muscle defect by suturing
Hernioplasty repair and strengthening of abdominal wall with reinforcement Uses mesh or gauze, wire or fascia
What post-op interventions need to be done for a Herniorrhaphy or Hernioplasty patient? * ABC’s * VS * Assess for hemorrhage * Assess bowel and bladder elimination * Assess wound healing * DC teaching: no increased stress on healing surgical wound by lifting or straining see pg. 868
What immediate post-op interventions must you do for a Herniorrhaphy or Hernioplasty patient? Assess respiratory status frequently for S/S of edema, bleeding, & dyspnea, restlessness & tachycardia * Oral suctioning for oral secretions and nasotracheal suctioning may be necessary extreme caution to avoid compromising surgical wound
What is stomatitis and how do you prevent this post-op? * Inflammation of the oral mucosa * Prevention includes good daily oral care with a gentle toothbrush * Non-alcohol rinses * For pts whom have had oral surgery, must have Dr’s orders before initiating any mouth care * Good nutrition essential
What are the 4 parts of the abdominal physical assessment? * Inspection * Auscultation * follows inspection * 5-30 bowel sounds per minute considered normal * Percussion * Palpation * do not depress abdomen more than 1” look for muscle tension and rigidity, tenderness, rebound pain
What terms are used for the yellowing of the skin seen in liver and gallbladder disorders? * Icterus * Jaundice
How and why does this occur? * Liver is unable to convert bilirubin into a water-soluble compound that can be excreted in the feces * Serum bilirubin rises and changes the skin color to yellow * Total serum bili > 2.5 mg/dL results in jaundice * Normal: 0.2-1.3 mg/dL
* Hepatitis A – HAV caused by oral-fecal route, from a contaminated host
* Hepatitis B – HBV * from blood
* Hepatitis C – HCV, non-A, non-B hepatitis sources: contaminated blood, needle sharing, sexual transmission
* Hepatitis D – HDV contaminated blood; cannot infect alone, infects with HBV
Hepatitis E – HEV oral-fecal route; most common in undeveloped countries
What lab values might be elevated for Hepatitis? erum bilirubin and urobiligen, ESR from inflammatory process and specific antigen markers, prolonged PT/PTT
What medical treatment and patient teaching is necessary for a Hepatitis pt? * rest and adequate hydration for healing * no alcohol or drugs known to be toxic to liver * limited activity with BRP, increase activity as tolerated prevention includes good hand washing and vaccines for HBV and HAV
List some of the functions of the liver. * Bile production and excretion * Glucose metabolism * Protein metabolism Lipid metabolism -Synthesizes fibrinogen and prothrombin * Detoxification
Portal Hypertension obstruction of blood flow through the liver increases pressure causing development of collateral vessels in the esophagus, abd wall, and rectum
Esophogeal varices distended, engorged vessels in esophagus * fragile, bleed easily
Ascites accumulation of fluid in the peritoneal cavity
* Hepatic encephalopathy * caused by increasing levels of ammonia * pt has decreased LOC and changes in neuromuscular function * Leads to hepatic coma
* Hepatorenal syndrome * renal failure due to cirrhosis
List the diagnostic tests used to diagnose cirrhosis * History and physical * Labs * increased serum and urine bilirubin * decreased serum protein, prolonged PTT * CBC: low WBC, low RBC, low platelets * Liver biopsy * Ultrasound * CT, MRI
What are the early S/S of cirrhosis? fatigue, weight loss, fever, dull heaviness RUQ
What are the late S/S of cirrhosis? jaundice, spider angiomas over abdomen, decreased LOC
What nursing interventions should be done to prevent complications from a liver biopsy? * Monitor for S/S of hemorrhage * Frequent VS * Lay pt on right side on rolled towel for 2 hours * Complete bed rest during this time
What is the purpose of the treatment for ascites? * To eliminate and reabsorb fluid in the abdomen * May initially use diuretics and low Na diet * Combination of diuretics more effective than just one
Name a potassium-sparing diuretic used for cirrhosis patients. Spiranolactone-Aldactone
What invasive procedure can be done to remove the fluid in ascites? * Paracentesis * Only indicated when the ascites interferes with breathing * Up to 6-8 L of fluid may be removed over 60-90 minutes * IV Albumin adm. simultaneously
What is the nurses role before a paracentesis? * Before - explain procedure, obtain consent, obtain baseline VS and assessment, insert Foley catheter per Dr. order, position pt in sitting position
What is the nurses role during a paracentesis? During - VS and emotional support
What is the nurses role after a paracentesis? monitor VS q 15 min until stable, assess dressing for bleeding, measure obtained fluid and send to lab, monitor for blood in urine, document procedure and how pt tolerated
What techniques are used to control hemorrhage from bleeding esophogeal varices? * Drug therapy - carafate * Esophogeal - gastric balloon tube called a Sengstaken-Blakemore tube * Gastric suction to continuous suction * Injection sclerotherapy - inject meds to cauterize * Variceal banding - banding to stop bleeding
What Nursing Dx. & interventions are appropriate for the pt with cirrhosis? * Activity intolerance * Risk for impaired skin integrity RT retained bile salts & pruritis * Ineffective breathing * Risk for injury RT decreased clotting factors
Goals of treatment for pt w/cirrhosis: * Limit the deterioration of liver function * Prevent complications * Ascites * Bleeding esophogeal varices
What is the function of the gallbladder? Stores bile, & contracts to deliver bile from the liver to the duodenum to emulsify fats
What S/S diagnose cholecystitis? * Indigestion * N/V * Severe right upper epigastric pain * May radiate to back or shoulder * Fever * Jaundice
Describe the tests used in the diagnosis of cholecystitis. * Ultrasound * Oral cholecystography * used to identify stones in gall bladder * ERCP * endoscopic retrograde cholangiopancreatography * Labs * serum and urine bilirubin elevated; elevated WBC; prolonged PT * HIDA scan * IV cholangiography
What drugs are used to dissolve gallstones? When are they appropriate? * Oral bile salts - Actigall * Dissolution agents – MTBE * injected directly into gall bladder to dissolve stones * Only work on small cholesterol stones
What treatments are available for gallbladder disease? * Non-invasive * Drug treatment * ESWL * Invasive * Cholecystectomy - laparoscopic or traditional
What are the most common complications associated with cholecystitis? * Pancreatitis, rupture of gall bladder, cholangitis
Rupture of the gall bladder, which causes hemorrhage, is a complication of a cholecystitis. What would your first interventions be? * Check VS, position pt in modified trendelenberg, call charge nurse or Dr.
What does the nurse monitor for after a cholecystectomy? * Acute pain * Dehydration * Pneumonia * Infection * Peritonitis
What is a T-tube and what is it’s purpose? * Always empty bag when ½ full
What is pancreatitis ? Inflammation of the pancreas that can be acute or chronic
and what are the causes of pancreatitus? * Autodigestion-Caused by pancreas’ own digestive enzymes digesting pancreatic tissue * Most often caused by biliary tract disorders and alcoholism, can also be caused by viral infections, trauma or surgery
What S/S are common to pancreatitis? * Abdominal pain is #1 * severe with sudden onset * LUQ or epigastric region & radiates to back * Severe vomiting, flushing, cyanosis, dyspnea, can have low grade fever, tachypnea, tachycardia, hypotension, flatulence, steatorrhea
What interventions can the nurse use that will improve coughing and deep breathing? * Pain medicine 30 minutes before C & DB * Teach pt to splint the abdomen with pillow during cough
How do hemorrhoids develop? How can they be avoided after surgery? * Dilated veins in the rectum * Blood clots that form in external hemorrhoids are considered thrombosed. * Most common symptom is rectal pain * Avoided by walking after surgery and using stool softeners to prevent straining
Created by: kcorkinsnctc