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255 exam 5
| Question | Answer |
|---|---|
| GI tract | 30 feet Mucosa lining-absorb nutrients Submucosa connective tissue-provides structural support, elasticity, and nutritional supply to the mucosa, while housing blood vessels Muscle Serosa-secrete watery serous fluid for lubrication, reducing frictio |
| GI tract steps | Ingestion-stroke pts trouble swallowing Digestion & Absorption Elimination |
| Parasympathetic | increases peristalsis/ Sympathetic- decreases peristalsis |
| the main function of the GI system is to | supply nutrients to body cells. This is accomplished through the processes of (1) ingestion (taking in food), (2) digestion (breaking down food), and (3) absorption |
| nervous system | enteric nervous system or intrinsic nervous system (controls GI movements, controls secretions, and sensory function) Parasympathetic and sympathetic branches of the autonomic nervous system (ANS) innervate the GI tract. |
| venous blood draining the GI organs empties | the portal vein, which then perfuses the liver. This allows the liver to clean the blood of bacteria and toxins from the GI tract. Multiple arteries supply blood to the intestines. |
| appetite | desire to ingest food (controlled in hypothalamus) Hormones that affect appetite Ghrelin – appetite stimulation hypoglycemia, an empty stomach, and a decrease in body temperature Leptin – appetite suppression |
| Deglutition | swallowing Involves the mouth, pharynx, esophagus UES relaxes, LES contracts GERD |
| Process of digestion beginning | Begins in mouth (amylase/starches) Stomach - Stores food, mix food with gastric secretions and triggers release of hormones into the bloodstream |
| Process of digestion pt 2 | Chief cells: secrete pepsinogen Parietal cells: secrete hydrochloric acid, water and intrinsic factor, mixes food and detoxifies bacteria Hydrochloric Acid: protects from organisms Food with gastric secretions to form chyme |
| pepsinogen | converts to pepsin (begins to breakdown proteins) |
| chyme | small intestine, liquid form of food eaten |
| human makes | 1 liter of saliva a day |
| saliva contains | amylase which begins breakdown of starches |
| Digestion & absorption | Small intestine – 23 feet Extends from pylorus to ileocecal valve (valve prevents reflux of large intestine contents into small intestine) Chyme stimulates motility and secretion in small intestine |
| villi | fingerlike projections that produce digestive enzymes |
| elimination | Large intestine Hollow, muscular tube about 5-6 ft long Water and electrolyte absorption (most impt function) Forms feces and serves as a reservoir for fecal mass until defecation Food entering stomach and duodenum can trigger gastrocolic reflexe |
| liver | Largest inter. organ in the body w blood supply Metabolic, secretory, vascular and storage blood clotting, carb metabolism, detoxification, fat metabolism, protein metab., bile production, bilirubin, blood filtration and reservoir, store glucose |
| liver cells | Hepatic cells (hepatocytes) arranged in cords - secrete bile Lined with capillaries containing (phagocytic) Kupffer cells - remove bacteria and toxins from the blood |
| Biliary tract | Gallbladder & ducts Concentrate and store bile: fat presence causes contraction to release bile |
| Pancreas | Releases enzymes, insulin, glucagon, and pancreatic peptides |
| Upper GI series | Visualizes oropharyngeal area, esophagus, stomach, small intestine Pt must swallow contrast medium -can do x rays to watch it go down, if it stops it can indicate blockage Used to identify strictures, tumors |
| Endoscopy | Direct visualization through an endoscope Esophagogastroduodenoscopy (EGD): NPO, sedation Endoscopic Retrograde Cholangiopancreatography (ERCP): pancreatic and common bile ducts cannulated, can retrieve gallstone or biopsy; NPO, sedation |
| Lower GI series – Uses fluoroscopy/air | barium enema (fill the colon with barium then X-ray) Used to identify polyps or tumors in colon |
| Virtual Colonoscopy | using CT scanning and MRI images where no sedation is required Capsule Endoscopy is a noninvasive approach to visualize the GI tract. Colon capsule endoscopy is useful in diagnosing small bowel disease and monitoring inflammation in patients |
| amylase | enzyme secreted by pancreas, dx pancreatitis |
| Gastrin | hormone secreted by stomach, duodenum, and pancreatic islets of Langerhans.Stimulate the stomach to release hydrochloric acid (HCl) Help the stomach lining grow and stay healthy Increase stomach motility |
| lipase | enzyme secreted by pancreas, dx pancreatitis. breaks down dietary fats (triglycerides) into fatty acids and glycerol |
| Nutritional screening | JCAHO requires nutrition screening for all pts within 24 hours of admit If screening finds at risk, perform a full nutritional assessment |
| Gerontologic considerations | Decreased appetite Taste buds' decline Loss of teeth Decreased saliva Delayed emptying Decrease in intrinsic acid and HCl acid secretion Decreased motility = constipation liver size decrease |
| food groups for normal nutrition | Carbohydrates-main source energy Simple Carbs:glucose, fructose, sucrose, maltose, lactose *Complex Carbs: Polysaccharides (starches: cereal grains, potatoes and legumes) Fiber (28-30g per day) From fruits, vegetables, starches Fats, protein |
| Malnutrition etiology (causes) | Starvation, Primary malnutrition; when nutrition needs are not met, starvation without inflammation Chronic disease,Secondary malnutrition; diet intake does not meet tissue needs although it would under normal conditions R conditions with inflammation |
| Undernutrition Patho of starvation | Initially, body uses carbohydrates to meet metabolic needs (can deplete within 18 hours) Body begins to convert skeletal protein to glucose for energy Within 5-9 days, body uses fat to supply needed energy |
| Undernutrition Patho of starvation pt 2 | Once fat stores are gone, body uses visceral and body proteins (depletes rapidly) Liver function becomes impaired and albumin leaks out: leading to 3rd spacing of fluids |
| Diagnostics Undernutrition | Assess nutritional intake, functional status, body composition (weight loss) Obtain vital signs and height & weight, Potassium often increases RBC and hgb level can reflect anemia Liver enzymes may increase |
| undernutrition Anthropometric measurements | measuring various skinfolds (biceps, triceps, scapula, iliac crest, upper thigh, and mid arm circumference, waist circumference, hip to waist ratio |
| Acute Care Interventions undernutrition | Identify patients with increased stress (surgery, severe trauma, sepsis) Between meal supplements Appetite stimulants Megestrol acetate, dronabinol Enteral or parenteral feedings Daily weights, I&O , daily calorie count, bedpans out of sight |
| Enteral nutrition | Nutrition delivered through a NG tube or catheter (PEG or J-Tube) directly into the GI tract Patient must have a functioning GI tract before feeding Indications: Anorexia, orofacial fractures, head & neck cancer, neuro conditions preventing oral intake |
| Enteral nutrition contraindications | GI obstruction, prolonged ileus, severe diarrhea or vomiting, enterocutaneous fistula |
| Orogastric, nasogastric and nasointestinal (NI) tubes | Appropriate for short term feedings (< 4 weeks) NI Placement into the intestine decreases chance for aspiration |
| Gastrostomy (PEG tubs) and Jejunostomy tubes ( J-Tube) | Long term PEG tube: placed endoscopically with IV sedation J-Tube: used for aspiration risk |
| Enteral nutrition safety | Aspiration and dislodged tubes are biggest concern Always check tube placement before feeding or meds Assess bowel sounds and gastric residual Keep HOB elevated 30-45˚ flush tube before and after, residual greater than 250 call doc |
| Enteral nutrition problems | Constipation Dehydration Cause: diarrhea, vomiting, fluid intake, high protein formula Diarrhea Cause: feeding too fast, formula, infection, meds, tube migration Vomiting Delayed gastric emptying, improper tube placement |
| Parenteral nutrition | Administration of nutrients directly into bloodstream Used when GI tract cannot be used or to supplement feeding Contains dextrose, protein, and many electrolytes, vitamins and minerals Can be given centrally (TPN) or peripherally (PPN) |
| central PN | high protein and caloric requirements, long term , glucose content is from 20-50%, infused in large central vein to rapidly dilute solution |
| peripheral PN | short term, protein and caloric requirements not as high, or to supplement oral intake, has fewer nutrients, less risk for phlebitis, so can infuse in peripheral IV |
| PN monitor | monitor blood glucose levels (hyperglycemia), IV or central line site (phlebitis), s/s of infection Must be weaned off of TPN and PPN to prevent a drop in glucose |
| Metabolic syndrome (aeb) | Impaired fasting glucose >100 Hypertension >130/85 or on meds Elevated triglycerides >150 reduced HDL <40 in men; <50 in women Waist circumference (Visceral Fat) >40 in men; >35 in women Waist/Hip Ratio |
| waist circumfrence | >=40 in. men, >=35 in. women |
| glucose levels | >100 |
| triglycerides level | >150 |
| HDL levels | <40 men, <50 women |
| BMI levels | Underweight (<18.5) Normal (18.5-24.9) Overweight (25-29.9) Obese (>30) Extreme obesity (>40) (morbid obesity) |
| body shape | Apple shape Has more abd fat, greater risk for obesity-related complications Pear shape Has more upper thigh fat, better prognosis but harder to treat |
| Waist-to-Hip ratio | Divide waist measurement by hip measure |
| Obesity LABS | Glucose: >100 HDL below 40 for men and 50 for women Triglycerides: Elevated triglycerides: > 150 Chest x-ray: Enlarged heart ECG: Dysrhythmias – Nutrient and electrolyte imbalances Liver function tests: Decreased Bilirubin, Elevated AST, ALT, |
| bariatric surgery FOR OBESITY | Surgery on stomach and/or intestines to help a person with extreme obesity lose weight Must meet criteria: a BMI of 40 kg/m2 or more a BMI of 35 kg/m2 or more with at least 1 weight-related comorbidity |
| Restrictive Bariatric surgery | Adjustable gastric band limiting stomach size with inflatable band placed around fundus, inflated with subcutaneous port 75% of stomach is removed Gastric plication Folding stomach wall inward and sutured. Can reverse Intragastric balloon |
| Roux-en-Y Gastric Bypass | Restrictive & Malabsorptive Creates a small gastric pouch and attaches directly to small intestine Food bypasses 90% of stomach Many complications |
| Roux-en-Y Gastric Bypass complications | GI leaks, gastric remnant distention, ulcers, gallstones, hernias, poor iron absorption, anemias, cobalamin deficiency, dumping syndrome |
| pre op bariatric surgery | Have appropriately sized gowns, beds, and transfer equipment Assess for use of assistive devices, baseline BMI, weight, measurements. Assess baseline labs Teach IS, coughing, deep breathing, turning, positioning , assess sleep apnea, CPAP use |
| post op bariatric surgery | VTE prevention Pain meds as needed Assess for anastomosis leaking Position with HOB at least 45˚ Maintain IV fluids and monitor UOP |
| Bariatric surgery teaching | Avoid drinking with a straw Start with room temp liquids: 1-2 ounces every 15 minutes to achieve 4 ounces (30cc- med cups) per hour Once progressed to 16 (30cc) med cups successfully = 500cc able to advance diet to full liquids |
| Bariatric surgery teaching pt 2 | 10-14 days postop, begin pureed or soft foods Transition to a diet 4-6 weeks after surgery: Diet is high in protein with some carbs and fiber Avoid drinking 30 min. prior to food and 30 min after meals No carbonation, no caffeine, sugar free drinks |
| ANTIDIARRHEALS bismuth subsalicylate (Pepto Bismol) | Decreases secretions and weak antibacterial activity Contraindicated with salicylate allergy & GI bleed Side effect: darken stools and tongue |
| loperamide (Imodium) ANTIDIARRHEALS | Inhibits peristalsis Side effect: possible drowsiness, constipation, dry mouth |
| diphenoxylate/atropine (Lomotil) ANTIDIARRHEALS | Opioid & anticholinergic: dec. peristalsis & GI motility Side effects: dizziness, drowsiness, dry mouth, constipation, blurry vision General: Monitor VS, I&Os, abd. assessment Avoid GI irritants including milk products Increase fluid intake |
| Bulk-forming Laxatives | methylcellulose (Citrucel), psyllium (Metamucil) Absorb water to increase bulk in fecal mass, peristalsis stimulated Defecation in 12 hours to 3 days Side effects: abdominal discomfort, bloating, flatulence, N/V/D |
| Stimulant Cathartics laxatives | Senna (Senakot), bisacodyl (Dulcolax) Stimulate peristalsis via mucosal irritation or nerve plexus activity Defecation in 6-12 hours Side effects: N/V/D, abd. Cramps, electrolyte imbalance |
| Stimulant Cathartics laxatives contraindications | Take at bedtime for no more than 1 week Do not take within 1 hour of antacid or milk Contraindications: obstruction, abdominal pain, rectal bleeding, impaction |
| Hyperosmotic Cathartics | constipation. lactulose, polyethylene glycol (Miralax), glycerin Luminal retention of water, softening stool Defecation in 2-4 days Side effects: flatulence, abdominal cramps, diarrhea |
| Stool Softeners | docusate sodium (Colace) Emollient laxative: water and lipid penetration Softening in 1-3 days Side effects: mild cramping, diarrhea, bitter taste Inc fluids and fiber |
| Saline laxatives | magnesium hydroxide (Milk of Magnesia), sodium phosphate (Fleets) Inc intraluminal volume and stimulates peristalsis 30 mins to 6 hours; 2-15 mins Side effects: Cramping and urgency to defecate Watch for dehydration and electrolytes imbalance |
| Lubricants | mineral oil (indigestible) Lubrication and hinders water reabsorption Onset 6-8 hours Side effects: N/V/D, cramps, anal pruritis, irritation, dim. Vitamin absorption Do not give within 2 hours of food |
| Phenothiazines | blocks dopamine receptors in the chemoreceptor trigger zone (CTZ) Prochlorperazine (Compazine), promethazine (Phenergan) Side effects: anticholinergic effects, hypotension, sedation |
| Prokinetic agent: | blocks dopamine receptors in the CTZ; Increases gastric motility and promotes emptying Metoclopramide (Reglan) Side effects: anxiety, hallucinations, extrapyramidal reactions |
| antihistamines | anticholinergic effect, block histamine receptors that trigger N/V Meclizine (Antivert), Dimenhydrinate (Dramamine), Hydroxyzine (Vistaril) Side effects: dry mouth, hypotension, sedative effects, constipation, blurry vision |
| Serotonin (5-HT3) antagonists: | blocks serotonin receptors ondansetron (Zofran) Headache, fatigue, inc. LFTs |
| Anticholinergic | block cholinergic pathways to vomiting center scopolamine Side effects: xerostomia, fatigue (somnolence), anticholinergic side effects |
| H2-HISTAMINE RECEPTOR ANTAGONISTS | DINE blocks histamine at parietal cells = dec HCL acid; dec conversion of pepsinogen Side effects: HA, constipation, diarrhea, dry mouth, dysrhythmias Avoid antacid use within 1hr of administration Use caution with liver & renal impairment |
| PROTON PUMP INHIBITORS (PPIS) | PRAZOLE, locks acid production at parietal cells = dec HCL acid esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix) Side effects: HA, N/V/D, abdominal pain, flatulence, hyperglycemia, rash |
| PROTON PUMP INHIBITORS (PPIS) pt 2 | HA, N/V/D, abdominal pain, flatulence, hyperglycemia, rash, dec. bone density, inc. risk of C-diff. with pantoprazole Do not break or chew Take 1 hour before a meal: esomeprazole & omeprazole Monitor liver & renal function |
| CYTOPROTECTIVE AGENTS | sucralfate (Carafate) Forms protective layer over mucosal surface Side effect: constipation, N/V/D, dry mouth, HA Take 1 hr before meals and at bedtime or 2 hours after meals Take 2 hrs after medications or 2 hrs after antacid |
| ANTACIDS | luminum hydroxide, calcium carbonate (Tums), magnesium oxide, sodium bicarbonate (Alka-Seltzer), belching; Aluminum {constipation}, Calcium {constipation or diarrhea, hypercalcemia, renal calculi}, Magnesium {diarrhea, hypermagnesemia}, {hypernatremia} |
| ANTIMICROBIALS FOR H PYLORI | Triple/Quadruple Therapy PPI plus 2-3 antibiotics: Bismuth subsalicylate Clarithromycin Metronidazole |
| CHOLELITHIASIS/CHOLECYSTITIS | ursodiol Bile acid used to dissolve certain types of gallstones Side effects: n/v, constipation, diarrhea Avoid antacid use Can take up to 24 months |
| Irritable Bowel Syndrome (IBS-C)meds | loperamide for diarrhea, probiotics, lubiprostone IBS **Aminosalicylates Sulfasalazine, mesalamine, olsalazine Reduce inflammation in the lining of the intestine Antimicrobials- ciprofloxacin, clarithromycin Corticosteriods (acute) |
| IBD meds | Immunosuppressants Azathioprine, methotrexate, cyclosporine Biologics adalimumab (Humira), infliximab (Remicade) Antidiarrheals Iron & vitamins Polyethylene glycol |
| Hepatitis | Interferon (antiviral) Given only if there are signs of liver decompensation blocks viral entry into cells reduces amount of virus in body slows damage to liver |
| Bile Acid Sequestrants | Cholestyramine (Questran) to relieve pruritus. Binds to bile acid salt in the GI tract & excreted in feces |
| HEPATITIS portal HTN | Beta blockers (propranolol, nadolol) Esophageal Varices Beta blockers octreotide or vasopressin Ascites & Peripheral Edema IV albumin Diuretics |
| PANCREATIC ENZYME REPLACEMENT | pancrealipase contains amylase, lipase, and trypsin Side effects: nausea, diarrhea Take with food Enteric coated capsules: Do not crush or chew |
| Hepatic Encephalopathy | Lactulose Prevents absorption of ammonia in colon by acidifying stool Uses: chronic constipation, hepatic encephalopathy PO or rectal Monitor blood ammonia level and LOC |
| Hepatic Encephalopathy pt 2 | Rifaximin Antibacterial action against e.coli Uses: travelers diarrhea, hepatic encephalopathy, IBS PO, administer with or without food Assess GI system, blood in stool, diarrhea |
| Pancreatitis meds | PPI’s Antacids Dicyclomine: dec. vagal stimulation, motility, & dec. volume and concentration of pancreatic enzymes Possible antibiotics for necrotic pancreas |
| Pancreatic enzymes: pancrealipase | Take with food contains amylase, lipase, and trypsin Side effects: nausea, diarrhea Enteric coated capsules: Do not crush or chew |
| liver is in | right upper quadrant |
| liver functions | Detoxification Protein metabolism Steroid metabolism |
| bowel obstruction assesment | High-pitched sounds on abdominal auscultation |
| most dependent on cardiac output | Absorption |
| what to assess when starting PN | Electrolyte levels and daily weights |
| main source of food | polysacharides |
| Blacks, Hispanics, Native Americans, and Asians are at an increased risk for | development of metabolic syndrome. Other risk factors include people who have diabetes that cannot maintain a normal glucose level, have hypertension, and secrete a large amount of insulin, or who have survived a heart attack |
| what to assess for metabolic syndrome | Blood pressure Waist circumference Fasting blood glucose |
| Diarrhea Etiology & Patho | 3 loose or liquid stools per day Acute < 14 days Persistent > 14 days Chronic 30 day or > |
| Diarrhea Etiology & Patho viral | (most common, usually short lived 48hrs & mild) Rotavirus Norovirus |
| Diarrhea Etiology & Patho bacterial | Escherichia coli Shigella Salmonella Staphylococcus Campylobacter jejuni Clostridium perfringens Clostridium difficile |
| Diarrhea Etiology & Patho parasitic | Giardia lamblia Cryptosporidium |
| Infectious Causes of Diarrhea | Viral (most common, usually short lived 48hrs & mild) Rotavirus Norovirus Bacterial Escherichia coli Shigella Salmonella Staphylococcus Campylobacter jejuni parasitic-Giardia lamblia Cryptosporidium |
| Diarrhea Etiology & Patho risk factor | Contaminated foods or drinks Fecal – oral transmission Age Gastric acidity Intestinal microflora Immunocompromised Certain drugs- PPIs, Antibiotics, & Laxatives Food intolerances PPI, antibiotics, laxatives |
| Diarrhea Clinical Manifestations | Large-volume watery stools Abdominal cramping Periumbilical pain Low-grade fever, afebrile, or febrile N/V Leukocytes, blood, or mucus in stool Dehydration metabolic acidosis |
| Diarrhea Diagnostics | Stool for blood, mucus, WBCs, parasites, and cultures C.Diff toxin WBC count H&H BUN |
| Diarrhea interprofessional Care | Depends on cause Avoid offending agents Identify early diarrhea Prevent transmission Replace fluids and electrolytes (Think Potassium!!!) Oral fluids with glucose & electrolytes Protect skin |
| C DIFF CARE | WASH HANDS WITH SOAP & WATER Metronidazole or po Vancomycin Lactobacillus Clean with bleach or hydrogen peroxide Contact isolation/private room |
| C DIFF risk factors | immunosuppression, antibiotics, acid reducers (PPIs) |
| diarrhea Drug Therapy | Antidiarrheals Bismuth subsalicylate-not under 16 Decreases secretions Loperamide Inhibits peristalsis, inc. absorption of fluid from stools Diphenoxylate/atropine Opioid & anticholinergic: dec. peristalsis and intestinal motility |
| diarrhea Nursing Management | Nursing Assessment Subjective Objective Nursing Diagnoses Impaired Bowel Elimination Deficient Fluid Volume Risk for Electrolyte Imbalance |
| Fecal incontinence Etiology & Patho | Fecal incontinence Etiology & Patho |
| Fecal incontinence Diagnostics & Collaborative Care | H&P Digital rectal exam (DRE) Anorectal manometry, US, or electromyography, Promote regular defecation High fiber diet & increased fluids Fiber supplements Avoid coffee, artificial sweeteners, dairy, high gas-producing, & insoluble fiber |
| Dextranomer/hyaluronic acid (Solesta) is a | gel that can be used to build up the tissues in the anal area (injected into the submucosa of the anal canal. |
| Fecal incontinence Nursing Management | Bowel training Regular timing, 30 mins after breakfast Enema or suppository to help reestablish Digital stimulation Perianal skin integrity Fecal management systems & Incontinent briefs/pads Prompt cleaning, dry well, moisturizing barrier cream |
| Constipation etiology & patho | Normal BM frequency: 3x/daily - 3x/week Constipation: < 3 stools/week with straining, incomplete evacuation, bloating, hard or lumpy stools Causes: Insufficient fiber or fluids Decreased physical activity Ignoring defecation urge Drugs |
| drugs that cause constipation | Anticholinergics, diuretics, anti-diarrheals, calcium, and opiates |
| Constipation complications | Valsalva maneuvers(hold breath, contract abd. muscles, bear down) Hemorrhoids Obstipation or fecal impaction Perforation-emergency, sepsis Ulcers & fissures Diverticulosis |
| Valsalva maneuvers cause | cause increased abdominal and intrathoracic pressure from straining and can lead to reduces venous return to the heart. This results in a decreased HR & BP. Once the patient relaxes, the HR & BP increase. |
| Constipation Diagnostics & interprofessional Care | H&P with DRE Abd. XR Barium enema Colonoscopy, Prevention: fiber, fluids, and exercise Meds: Laxatives and enemas |
| mineral oil | temporary, electrolyte imbalance (risk for) |
| Constipation Nursing Management | Teach diet for prevention (Table 47.11) High fiber 20-30g/day (gradual increase) Increase fluids 2L/day unless contraindicated Exercise at least 3x/wk, abdominal strengthening Regular bowel pattern, do not suppress Knees higher than hips |
| enemas | Enemas are a fast-acting treatment and can offer immediate treatment, but must be used cautiously. Some contain sodium phosphate and magnesium. Can cause electrolyte imbalances in older adults and patients with heart and kidney disease. |
| Acute abdominal pain Manifestations | Acute pain N/V/D Constipation Flatulence Fatigue Fever Rebound tenderness |
| Acute abdominal pain diagnostics | H&P CBC UA Abd. XR ECG US CT |
| Acute abdominal pain nursing management | VS, I&O, S/S of hypovolemic shock, abd. assessment, associated symptoms Trauma: rigid abd., absent BS, Cullen sign, Turner sign, Hypovolemic shock Problems: Pain, Fluid imbalance, Risk for infection Planning: relief of pain, resolution of inflammion |
| Acute abdominal pain nursing management treat | underlying cause of pain, prevention of complications Manage fluid & electrolyte imbalances, pain, and anxiety Calm environment, provide information Pre- & Post-op care pending type of surgery needed |
| Chronic abdominal pain Causes | Irritable bowel syndrome (IBS) Peptic ulcer disease (PUD) Chronic pancreatitis Hepatitis Pelvic inflammatory disease |
| Irritable bowel syndrome (IBS) IBS-C, IBS-D, IBS-mixed | chronic abd. pain and altered bowel patterns Causes: unclear maybe related to food intolerances and GI infections and psychologic stressors Clinical Manifestations: Abdominal pain Diarrhea and/or constipation Distention Flatulence Bloating. |
| IBS Treatment | Psychological Dietary Low- FODMAP (fementable oligo, di, and monosaccharides and polyols) diet Gluten intolerance |
| IBS drugs | Loperamide (Immodium) for diarrhea Probiotics Lubiprostone (Amitiza) IBS constipation in women Linaclotide (Linzess) IBS constipation in men & women |
| Appendicitis Etiology & Patho | Most common reason for emergency abdominal surgery 7% people in U.S. 10-30 y.o. Cause: luminal obstruction Complication: gangrene, perforation, peritonitis |
| Appendicitis Manifestations | Initial: Persistent dull periumbilical pain Anorexia N/V Progressive: RLQ at McBurney’s point tenderness Rigidity Rebound tenderness Guarding Coughing or sneezing worsen the pain |
| mcburneys point | halfway between the umbilicus and the right iliac crest. RLQ |
| Rovsing sign | increased RLQ pain with LLQ palpation |
| Peritonitis Etiology, Patho | Inflammation of the peritoneum caused by bacteria and/or irritating chemicals Causes: Blood-borne organisms, cirrhosis w/ ascites Ruptured appendix, pancreatitis, perforated peptic ulcer, peritoneal dialysis, trauma, cancers |
| peritonitis complications | hypovolemic shock, sepsis, abscess, paralytic ileus, death |
| Peritonitis manifestations | Severe, constant abd. pain Tenderness, rebound tenderness, rigid abdomen, abd. distention Fever Tachycardia Tachypnea N/V |
| Peritonitis diagnostics & interprofessional care | Diagnostic: WBC count Peritoneal aspiration Abd. XR, US, CT Collaborative care: NPO Antibiotics NG suction Analgesics IV fluids |
| Peritonitis Nursing management | Assessment S&S of peritonitis and hypovolemic shock Clinical Problems Pain, Fluid imbalance, Impaired GI function, Risk for infection Planning Resolution of inflammation, relief of pain, freedom of complications, normal nutrition |
| Gastroenteritis | Inflammation of gastric and intestinal mucosa Diarrhea with N/V, abd. cramping, fever Norovirus leading cause Conservative treatments for symptoms Oral fluids & electrolytes watch dehydration and electrolyte imbalances |
| N&v manifestations | Nausea is subjective Anorexia Dehydration & electrolyte imbalance Metabolic alkalosis Weight loss |
| N&v implementation | NPO and IV fluids-at least 4 hrs NG tube (for bowel obstruction or ileus) Record I&O, vital signs Quiet, odor-free environment Oral care, assess mental status, aspiration risk |
| dehydration | bp down hr up |
| N&v nutrition therapy | Clear liquids first Water, small sips of room temp fluid (5-15 mL every 15-20 mins) Dry toast, crackers, plain gelatin Progress to bland foods: baked potato, rice, cooked chicken and cereal Avoid spicy, coffee, highly acidic, odorous foods |
| Oral inflammation | Can be due to specific oral conditions or other medical conditions Leukemia, vitamin deficiency, immunosuppression, corticosteroid inhalers Gingivitis, herpes simplex (fever blister), oral candidiasis, parotitis, stomatitis |
| Oral inflammation treat | Good oral care, medications if indicated (antivirals, antifungal, antibiotics), mouthwashes, soft bland diet |
| Oral cancer | Oral cavity cancer Starts in mouth, usu on lower lip Also seen under tongue and buccal mucosa Oropharyngeal cancer Develops in throat behind mouth (oropharynx) More common after age 35, average age at dx is 65 common in men |
| Oral cancer etiology | Do not know exact cause Risk factors: Lip CA: overexposure to sun, fair complexion, recurrent herpetic lesions, pipe stem irritation, syphilis, immunosuppression Oral cavity/tongue: poor oral hygiene, smoking, snuff, chewing tobacco |
| Oral cancer diagnostic tests | Oral cytology Biopsy Toluidine blue test Screening for oral CA, when applied topically, cancer cells take up the dye CT scan, MRI, PET scan |
| Oral cancer treatment | Surgical Most effective Can involve extensive resections (removing mandible, removing tongue, or floor of mouth, radical neck dissection) Non-surgical Radiation Usu 6 weeks after surgery (tissue becomes fibrotic and heals slower) |
| Gastroesophageal reflux disease (gerd) | Reflux of stomach acid into the esophagus Most common upper GI problem 15 million Americans Causes: incompetent LES, decreased LES pressure (obesity, foods or drugs) |
| factors decreasing LES tone | alcohol, chocolate, drugs (anticholinergics, beta blockers, morphine, nitrates, progesterone, calcium channel blockers, theophylline, progesterone), fatty foods, nicotine, peppermint, spearmint, tea, coffee, caffeine |
| Gerd manifestations | Mild to severe Heartburn (pyrosis) Chest pain Dyspepsia Regurgitation Resp symptoms |
| Gerd complications | Esophagitis & ulcers Strictures, dysphagia, scarring Barrett esophagus Precancerous lesion that increases risk for esophageal cancer Respiratory issues Bronchitis, cough, bronchospasm, asthma, pneumonia |
| Gerd diagnostic tests | H&P Endoscopy Biopsy & cytology Manometry and pH testing |
| Gerd management | Avoid factors that trigger Elevate HOB Do not lie supine for 2-3 hr after a meal Low fat diet Small frequent meals Stop smoking, alcohol, caffeine |
| Hiatal hernia | Herniation of a part of stomach into the esophagus through an opening in the diaphragm More common in older adults and women Sliding: Part of stomach slides through opening when lying supine, goes back into abd cavity when standing |
| Hiatal hernia treat and diagnostics | Esophagram (barium swallow) Treatment GERD tx, reduce intraabdominal pressure (remove constricting garments, avoid lifting and straining) Surgical Herniotomy (excision of hernia sac) Herniorrhaphy (closure of hiatal defect) Fundoplication |
| Diverticula | Saclike outpouchings of 1 or more layers of esophagus |
| Strictures | Caused by chronic GERD, narrowing of esophagus |
| Achalasia | Peristalsis of lower 2/3 of esophagus is absent, rare |
| Peptic ulcer disease (PUD) | Erosion of GI mucosa from HCL acid and pepsin Can involve any part of GI tract that is exposed 4.6 million people/year |
| Peptic ulcer disease etiology/patho | Need an acid environment to develop Helicobacter pylori (H. pylori) Major risk factor for PUD 80% of gastric and 90% of duodenal ulcers are related to H. pylori Medication induced NSAIDs Corticosteroids |
| Peptic ulcer disease manifestations | Gastric: High epigastric discomfort (1-2 hours after a meal, “burning”, “gaseous”) Food can worsen pain (if ulcer has eroded through gastric mucosa) Duodenal: Symptoms occur 2-5 hours after a meal “burning” “cramping” pain beneath xiphoid |
| gastric | Burning or gaseous pressure in high left epigastrum and back Pain 1-2 hrs after meals, sometimes with food Occasional N/V, wt loss Complications: hemorrhage, perforation, gastric outlet obstruction, intractability |
| DUODENAL | Burning, cramping, pressure across mid-epigastrum and back Pain 2-5 hrs after meals, periodic and episodic throughout day, pain relief with antacids and food Occasional N/V Complications: hemorrhage, perforation, obstruction |
| Peptic ulcer disease diagnostics | Endoscopy Most accurate, allows for direct visualization of gastric and duodenal mucosa Biopsy for h. pylori & urease testing Barium contrast study CBC, liver enzymes, serum amylase, stool sample |
| Peptic ulcer disease therapeutic management | Rest Drug therapy Smoking cessation Diet modifications (avoid spicy foods, carbonated beverages, caffeine, hot foods) Stop NSAIDs and ASA for 4-6 weeks Use enteric coated ASA if necessary for certain conditions-dissolves in intestines |
| Peptic ulcer disease medications | Antibiotics To eradicate h. pylori Combination of : Amoxicillin, clarithromycin, metronidazole, tetracycline Given for 14 days |
| Sucralfate (Carafate) | Forms protective layer over mucosal surface Side effect: constipation, N/V/D, dry mouth, HA Take 1 hr before meals and at bedtime or 2 hours after meals Take 2 hrs after medications or 2 hrs after antacid Avoid gastric irritants Increase water & fibe |
| Peptic ulcer disease complications | GI bleeding Most common complication Duodenal ulcers cause more bleeding than gastric ulcers Perforation Most lethal complication of PUD Risk is highest with penetrating duodenal ulcers |
| Peptic ulcer disease interventions | Bedrest NPO & NG suction IV fluids IV PPIs Blood transfusions |
| Peptic ulcer disease nursing care | Health promotion Identify those at risk for PUD Early detection Encourage pts who take NSAIDS/ASA/corticosteroids to take these drugs with food Acute care NPO, NG tube insertion and maintenance IV fluid replacement Oral care and strict I&O |
| Stomach cancer | Adenocarcinoma of stomach wall Asian Americans, Pacific Islanders, Blacks, and Hispanics highest rate Higher in men (2:1) Average age at dx is 68 |
| Stomach cancer etiology/patho | Likely a mucosal injury (h. pylori, autoimmune-related inflammation, repeated expose to irritants or NSAIDs) isks: smoking, obesity, diets high in smoked foods, salted fish & meat, pickled vegetables risk: atrophic gastritis, pernicious anemia |
| Stomach cancer manifestations | Often is spread before symptoms appear Unexplained weight loss, indigestion, abdominal discomfort Anemia Pale and weak Blood in stool Early satiety |
| Stomach cancer diagnostics | H&P Endoscopy and biopsy CBC Stool occult blood Liver enzymes Amylase |
| Stomach cancer interprofessional management | Surgical therapy Surgical removal of tumor Gastrectomy, partial gastrectomy, esophagojejunostomy Chemo and radiation Can be curative or palliative |
| Gastric surgery | Gastrectomy Resection of lower esophagus, removing entire stomach, and anastomosis of esophagus to the jejunum Vagotomy Severing of vagus nerve, decreases gastric acid secretion Pyloroplasty Surgical enlargement of pyloric sphincter |
| Gastric surgery post op | Dumping syndrome (sweating, palpitations, weakness, dizziness 15-30 min after eating—abd cramping then urge to defecate) Post prandial hypoglycemia (from uncontrolled gastric emptying) |
| Gastritis | Inflammation of gastric mucosa Patho: breakdown of normal mucosal barrier of stomach which allows HCl acid and pepsin to enter the mucosa Risks: drugs (NSAIDs, corticosteroids, ASA), diet, h. pylori infection, |
| gastritis meds | H2 receptor blockers, PPIs |
| Upper gi bleed etiology/patho | Severity of bleeding depends on if arterial or venous bleed Stomach/duodenal origin Due to peptic ulcers (h. pylori and/or NSAID use) Esophageal origin Due to chronic esophagitis, Mallory-Weiss tear, or esophageal varices |
| Upper gi bleed diagnostics | Endoscopy CBC, BUN, electrolytes, PT, PTT, liver enzymes, ABGs, type and crossmatch Stool for occult blood |
| Upper gi bleed nursing interventions | Acute care Use sedatives cautiously U/O hourly, Monitor I&Os Maintain Ivs & Hemodynamic monitoring Monitor VS & dysrhythmias NG tube maintenance |
| Foodborne illness pathogens | Staphylococcal: meat, bakery products, salad dressings Clostridial: meat cooked at low temp., rewarmed meat, improperly canned veggies Salmonella: Improperly cooked poultry, pork, beef, eggs Botulism: improperly canned veggies, fruits, fish e coli |
| Foodborne illness Prevention | Cook all ground beef and hamburger thoroughly Safe raw meat handling and cleaning surfaces afterwards Drink pasteurized milk or juice Wash fruits and vegetables thoroughly |
| famotidine relives | epigastric pain |
| h pylori meds | Antibiotic(s), proton pump inhibitor, and bismuth |
| signs pt with hematemesis is declining | Pallor and diaphoresis |
| After a Billroth I operation | dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel |
| Eating smaller meals during the day will | decrease the gastric pressure and symptoms of hiatal hernia. |
| acute gi bleed interventions | Establish 2 large bore IV lines. Initiate ECG monitoring. |
| The patient will have bloody drainage from the | nasogastric (NG) tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. |
| perforated peptic ulcer requires | IV replacement of fluid losses and continued gastric aspiration by NG tube. |
| There is a potential link between | proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine. |
| Inflammatory Bowel Disease Etiology & Patho | Chronic inflammation of the GI tract with periods of remission and exacerbation Cause: not clear Autoimmune Environmental factors (microbiome) Diet (high in refined sugar, fat, meat, polyunsaturated fat) Stress Smoking Drugs |
| drugs causing IBS | NSAIDs, Abx, oral contraceptives |
| Crohn’s dz | Diarrhea Abd. cramping Fever Weight loss Malabsorption Site: All layers, anywhere in tract, skip lesions |
| Ulcerative colitis | Teens to early adulthood Bloody diarrhea Abd. cramping Fever Rectal bleeding Tenesmus-urge for BM but cant Site: Mucosal layer of rectum & colon |
| chrohns complications | Colorectal cancer (CRC) C-Diff Perforation Fistulas Strictures Anal abscesses |
| Ulcerative colitis complications | Colorectal cancer (CRC) C-Diff Perforation Toxic megacolon-megacolon- risk for perforation and may need emergency surgery; deep inflammation in the muscles of the colon which causes it to weaken |
| IBD Diagnostics | CBC- can show Fe deficiency anemia due to blood loss , high WBC , Electrolytes Albumin ESR & CRP Stool cultures Barium enema US, CT, MRI Colonoscopy |
| IBD Interprofessional Care | Bowel rest Control inflammation Correct malnutrition Symptom relief Improve quality of life Nutrition Therapy Drug Therapy Surgical Therapy. Hospitalization needed if pt does not respond to drugs |
| IBD Drug Therapy | Amino salicylates- PO or rectally administered sulfasalazine, mesalamine, olsalazine Anti-TNF agents: adalimumab (Humira), infliximab (Remicade) |
| IBD antimicrobials | metronidazole, ciprofloxacin, clarithromycin |
| IBD corticosteroids | wbc + glucose prednisone Immunosuppressants azathioprine, methotrexate, cyclosporine |
| Ulcerative Colitis surgery | Total proctocolectomy with ileal pouch/anal anastomosis Total proctocolectomy with permanent ileostomy |
| Crohn’s Disease surgery | Segments removed and anastomosed |
| Ileal pouch | ileal pouch made and connected to the anus and stool is directed to pouch |
| Proctocolectomy | removal of colon, rectum and anus with closure of anal opening. End of terminal ileum brought out through abd wall for permanent ileostomy |
| Indications for surgery | bowel obstruction, abd abscess, fistulas, inability to decrease steroid use, lack of response to therapy, hemorrhage, perforation, anorectal disease, strictures, cancer suspicion |
| IBD Nutrition Therapy | Adequate nutrition without worsening symptoms Correct and prevent malnutrition Replace fluid and electrolyte losses Prevent weight loss Keep a food diary |
| IBD Nutrition Therapy pt 2 | Iron and zinc replacement Reduced absorption of cobalamin and bile acids Folate & K supplements Acute exacerbations: Liquid enteral nutrition Avoid triggers. no specific triggers |
| IBD Nursing Management | Assessment History, IBD S&S, Comp S&S (dehydration, nutritional deficits) Clinical Problems Impaired bowel elimination, nutritional compromise, difficulty coping, pain Planning Fewer or less severe exacerbations Maintain normal fluid/electrolytes |
| IBD Nursing Management acute care | I&Os, VS Monitor BMs, assess abdomen IV fluids, electrolytes, analgesics, anti-inflammatories Skin care measures Promote nutrition Preop & Postop Care |
| IBD Nursing Management Ambulatory Care | Rest & diet management Perianal care Drug actions & side effects Symptoms of recurrence When to seek medical care Diversional activities to reduce stress |
| Intestinal Obstruction etiology & patho | Mechanical vs Nonmechanical Small bowel or large bowel 6-8L fluid enter into small intestine daily Fluid, gas, and intestinal contents accumulate, distends, inc capillary permeability, third spacing, hypotension |
| A bowel obstruction occurs | when contents cannot pass through the GI tract. Mechanical: physical obstruction of the intestinal lumen. Most occur in the small intestine. Surgical adhesions are the most common cause of SBO |
| Obstruction Manifestations Small intestine | Rapid onset Frequent copious vomiting Colicky, cramping pain Some BM Greatly inc. abd distention |
| Large intestine Obstruction Manifestations | Gradual onset Rare vomiting Persistent cramping pain Absolute constipation Inc. abd. distention |
| Obstruction Manifestations | 4 Hallmark S&S: abd. Pain, N/V, distention, constipation Bowel sounds – absent below obstruction Complications: Dehydration & Sepsis, Electrolyte & Acid/Base imbalances |
| bowel sounds | may be high pitched above area of obstruction, absent with paralytic ileus |
| Obstruction Diagnostic & interprofessional Care | CT Abd XR Colonoscopy CBC BMP (electrolytes, renal fx) NPO NG tube for decompression Endoscopy IV fluids I&Os |
| Colorectal Cancer (CRC) Etiology & Patho | 2nd leading cause of cancer related deaths 148,000 Americans diagnosed annually Men more, older than 50 y.o., African American highest Risk factors: high red or processed meat, obesity, physical inactivity, alcohol, smoking, low fruits |
| CRC Clinical Manifestations & Diagnostics | Iron def. anemia, rectal bleeding, abd pain, bowel habit changes Early: asymptomatic, fatigue, weight loss Advanced: abd. tenderness, palpable mass, hepatomegaly, ascites |
| CRC Clinical Diagnostics | flexible sigmoidoscopy, colonoscopy, barium enema, CT Preventative colonoscopy: age 45 every 10 years for average risk: Age 40 and every 5 years for high risk FOBT or FIT every 1 year Stool DNA test every 3 years (Cologuard) |
| CRC Collaborative Care | TNM staging Surgical Therapy (curative or palliative) Tumor resection lymph node removal exploratory abd, restoration of bowel continuity Chemo & Radiation Therapy |
| Ileostomy | liquid stool |
| Sigmoid | formed stool |
| Diverticula | saccular dilations of the colon |
| Diverticulosis | multiple diverticula |
| Diverticulitis | inflammation of the diverticula More older adults More left colon Cause: Genetic & environmental high luminal pressure s/t deficiency of dietary fiber intake Can occur anywhere in GI tract but more common in left descending sigmoid colon |
| Diverticulitis manifestations | LLQ pain Distention Dec. bowel sounds N/V Fever |
| Diverticulitis complications | Perforation, Peritonitis, Hemorrhage |
| Diverticulitis diagnostics | Colonoscopy CT w/ oral contrast CBC |
| Diverticulitis Interprofessional Care | High fiber diet Fluid intake 2L/day Avoid inc. intraabdominal pressure |
| Diverticulitis acute care | Colon rest NPO initially Advance to clear liquids Antibiotics, analgesics, IV fluids NG suction or Surgery Strict I&O Frequent oral care |
| Diverticulitis notes | Avoid nuts/seeds Check NG tube q 4 hours for patency Observe for s/s bleeding Colon rest to let inflammation subside Monitor WBC count |
| CT scans can be done with no | contrast, IV contrast, oral contrast or combo. Mostly IV (nephrotoxic) |
| Hernias Etiology & patho | Protrusion of intestine through abdominal wall Reducible vs irreducible (incarcerated) Emergency surgery for hernias that are irreducible Types Umbilical Inguinal Femoral Incisional |
| Hernias Etiology & patho manifestations | Mild/mod discomfort unless bowel obstruction or incarceration May worsen with straining, lifting, coughing |
| Herniorrhaphy | Splint incision and keep mouth open when coughing/sneezing Restricted lifting for 6-8 weeks Surgical repair of the hernia, used with mesh Monitor for problems voiding, monitor I&O post, monitor for distended bladder |
| Hemorrhoids | Dilated hemorrhoidal veins s/t increased anal pressure Internal or external Risks: pregnancy, constipation, straining, diarrhea, heavy lifting, prolonged standing or sitting, obesity, ascites |
| Hemorrhoids manifestations | bleeding, anal pruritis, prolapse, dull, aching, burning pain |
| Hemorrhoids diagnostics | inspection, digital exam, scope |
| Hemorrhoids care | high fiber, reduce straining, topical antiinflammatory agents or astringents & anesthetics, rubber band ligation, cryotherapy, laser, hemorrhoidectomy |
| Post-op hemorrhoidectomy care | Warm sitz baths are recommended postop for hemorrhoidectomy. Pain meds especially before bowel movements Stool softeners Apply ice Use baby wipes or medicated wipes Assess for bleeding |
| Anorectal abscess: | collection of perianal pus s/t anal fissures, trauma, IBD |
| Anal fistula: | abnormal tunnel from rectum s/t crohn’s disease, anorectal abscess |
| Functions of the liver | Synthesis of clotting factors Carb metabolism: glycogenesis/glycogenolysis/gluconeogenesis Detoxification Fat metabolism: synthesis/breakdown of cholesterol, synthesis of fatty acids.Protein metabolism, store blood, bilirubin metabolism, store glycog |
| billirubin levels | 0.3-1 |
| albumin levels | 3.5-5 |
| ammonia levels | 10-80 |
| ALT levels | 4-36 |
| ALP levels | 30-120 |
| Hepatitis | Inflammation of the liver Causes Viruses: Hep A,B,C,D,E Toxins, chemicals, drugs Hepatobiliary obstruction Alcohol abuse Autoimmune diseases |
| Hepatitis-A (HAV) | Transmitted via fecal-oral route Contaminated food, milk, water, shellfish; crowded conditions; poor hygiene and sanitation Greatest risk of transmission is BEFORE symptoms appear |
| HAV present | in stool 1- 2 weeks before symptoms and up to 1 week after onset of illness. |
| Viral hepatitis Hepatitis B (HBV) | Transmitted via blood and other bodily fluids Percutaneous or mucosal exposure to infected blood and blood products Sexual contact Perinatal transmission Causes acute and chronic hepatitis |
| Viral hepatitis Hepatitis C (HCV) | Transmission via blood and body fluids Percutaneous or mucosal exposure to blood or blood products High risk sexual behavior Perinatal contact Contagious from 1-2 weeks before symptoms and continues |
| no vaccine for | hep c |
| Viral hepatitis Hepatitis d & e | Hepatitis D Uncommon in US Only those with HBV can be infected with HDV Same transmission as HBV More rapid progression & death HBV vaccination. Hepatitis E Fecal-oral transmission: contaminated water Acute and self-resolving |
| Viral Hepatitis Patho | Hepatocytes become targets of the virus Acute: large numbers are destroyedliver dysfunction Liver cells can regenerate after infection resolves Chronic: persistent and continual destructionscarringfibrosiscirrhosisfailure |
| Acute Hepatitis | Anorexia, dec. taste & smell, wt. loss Fatigue, lethargy, malaise Low grade fever Joint & muscle pain N/V/D, constipation RUQ tenderness Hepatomegaly, Splenomegaly Jaundice Pruritus Dark urine Clay-colored stools |
| Chronic Hepatitis | Fatigue & malaise Joint and muscle pain Hepatomegaly Jaundice Ascites & BLE edema Asterixis Hepatic encephalopathy Bleeding problems Palmar erythema Spider angiomas |
| Hepatic encephalopathy | results from the liver’s inability to remove toxins (AMMONIA!!) . Life threatening– causes neurological, psychiatric and motor disturbances. |
| Asterixis | “liver flap” – brief, shock like involuntary movements |
| Hemolytic jaundice | Blood transfusion reactions, hemolytic anemia, sickle cell crisis Increase amount of unconjugated bilirubin in blood |
| Hepatocellular jaundice | Cirrhosis, hepatitis, liver cancer Liver unable to conjugate or excrete bilirubin |
| Obstructive jaundice | Cirrhosis, hepatitis, liver cancer; common bile duct obstruction Decreased or obstructed flow of bile (clay-colored stool) |
| Viral hepatitis labs | Viral hepatitis antigen/antibody test Liver function tests Aspartate aminotransferase (AST) alanine aminotransferase (ALT) Alkaline phosphatase Serum bilirubin Prothrombin time Serum albumin RBC, H/H, ammonia |
| hepatitis labs results | LFTs increased PT prolonged (elevated) Albumin (normal or decreased) Urinary bili elevated Bilirubin elevated Ammonia buildup-neuro issues |
| viral Hepatitis Complications | Acute liver failure, Chronic hepatitis, Portal hypertension, Liver cancer |
| Viral hepatitis Treatment | Rest--reduces demand of liver Adequate nutrition Maybe low fat Avoid hepatotoxic medications/drugs i.e. acetaminophen, alcohol Vitamin Supplementation: B-complex vitamins, vitamin K Fluid and electrolyte maintenance/replacement |
| Viral hepatitis Nursing management | Assessment Subjective & Objective Clinical Problems Nutritional compromise Activity intolerance Risk for bleeding Planning Relief of discomfort Resume normal activities Normal liver function without complications |
| Viral hepatitis Nursing management implementation | Promote rest and adequate nutrition Comfort measures for itching, headache, joint pains Infection control/Safety PPE, handwashing, Safe injection practices |
| Cirrhosis Etiology & patho | Cirrhosis - end stage of chronic liver disease Extensive degeneration & destruction of liver cellsfibrosis as the liver attempts to regeneratedistorting liver structure and function Causes: Chronic HCV infection Alcohol induced liver disease (NASH) |
| Cirrhosis Manifestations early | Asymptomatic fatigue & enlarged liver Liver function tests may still be normal |
| Cirrhosis Manifestations late | Jaundice: dec. ability to conjugate and excrete bilirubin & bile duct obstructions Ascites & Peripheral edema Skin lesions: spider angiomas, palmar erythema Hematologic problems: thrombocytopenia, anemia, bleeding Endocrine problems |
| Cirrhosis Nursing Management | Sodium restriction, diuretics, and fluid removal Small frequent meals Assess skin (jaundice), daily weights, girth measurements Bed rest Assess color of urine and stool Assess edema / perform skin care HOB up |
| Cirrhosis complications: Portal Hypertension | Structural changes cause increased venous pressures in the portal circulation Increased venous pressure (Splenomegaly, ascites) Collateral veins (esophagus, anterior abd. wall, rectum) Varices (esophageal, gastric, caput medusae, hemorrhoid) |
| Ruptured esophageal varices are an | emergency and life-threatening |
| cirrhosis treat | Beta blockers Assess for melena and hematemesis |
| Varices | enlarged tortuous veins in esophagus or upper stomach. Fragile, do not tolerate pressure and bleed easily. Can cause hemorrhage. Ruptured esophageal varices are most life threatening |
| Cirrhosis complications: Esophageal & Gastric Varices | Tortuous, enlarged veins that tend to bleed Complications: Ruptured esophageal varices = medical emergency Treatment: EGD screenings and banding, Beta blockers, manage airway if bleeding occurs, octreotide or vasopressin, surgical treatments |
| Ascites | Serous fluid collection in peritoneal or abdominal cavity Causes: Portal hypertension proteins to shift out of vasculature and the osmotic pressure pulls fluid into the peritoneum Hypoalbuminemia decreased colloidal oncotic pressure can lead to peri |
| Ascites manifestations | distended abd., weight gain, eversion of umbilicus, abdominal striae, distended abd. wall veins Complication: Peritonitis |
| Ascites treat | Paracentesis, IV albumin, sodium restriction (500mg – 2g per day), Diuretics (spironolactone or triamterene often with furosemide) |
| Hepatic Encephalopathy | Neuropsychiatric manifestation of liver disease Causes: multifactorial, including neurotoxic effects of ammonia |
| Grading systems Hepatic Encephalopathy | Level of consciousness (awake to comatose) Intellectual function (orientation, memory, personality change, behaviors) Neurologic findings (asterixis, reflexes, posturing) |
| Hepatic Encephalopathy treat | Lactulose & rifaximin (abx) Maintain SAFE ENVIRONMENT Assess neuro status q2h |
| Hepatic Encephalopathy manifestations | asterixis (flapping tremors, involuntary) |
| Paracentesis | Have the patient void prior to the procedure Obtain baseline vitals, weight, pulse oximetry Complete a full abdominal assessment and measure girth Give sedation or pain meds if ordered Help the patient to sit in high-fowlers with feet on the floor |
| Paracentesis (Post-procedure) | Reassess everything you assessed before Watch for signs of hypovolemia Assess site and dressing Reweigh the patient Document amount and appearance of drainage Reposition the patient for comfort and safety |
| Primary Liver Cancer | 5th most common cancer worldwide Men more Most common cause of death in patients with Cirrhosis Cirrhosis caused by HCV is most common cause of liver ca Mets to lungs |
| Metastatic carcinoma in the liver | most common due to high rate of blood flow, size, and portal circulation |
| liver cancer manifestations early | Absent or subtle Symptoms of underlying cirrhosis |
| liver cancer manifestations late | Fever/chills Jaundice Anorexia Weight loss Palpable mass RUQ pain |
| Liver Cancer Diagnostics | US/CT/MRI scans – tumor identified Biopsy – confirm diagnosis & identify tumor type Tumor marker: AFP (Alpha Fetoprotein |
| liver cancer treat | Mode of treatment depends on extent and spread Small localized tumors surgically removed. Liver transplant Radiation therapy to shrink tumor –palliative Chemotherapy |
| Acute liver failure | Life threatening Rapid onset of severe liver dysfunction Causes: drugs (isoniazid, acetaminophen, sulfa drugs, |
| Acute liver failure manifestations | jaundice, coag problems, encephalopathy High serum bilirubin, PT increased, LFTs elevated |
| Acute liver failure treat | Critical care, monitor renal status, manage hemodynamic status, neuro checks |
| Pancreas Function | Exocrine: produces digestive enzymes Amylase & Lipase Endocrine: produces insulin & glucagon in alpha and beta cells |
| Acute Pancreatitis Etiology & patho | An acute inflammatory disorder that involves self destruction of the pancreas by its own enzymes through autodigestion Types: Mild pancreatitis- edematous Severe pancreatitis- necrotizing |
| Acute Pancreatitis causes | Gallbladder disease (women more) Chronic alcohol use (men more) Drug reactions (corticosteroids, thiazides, oral contraceptives, sulfonamides, NSAIDs) Pancreatic cancer.In severe pancreatitis, half of pts have permanent decreases in pancreatic func. |
| acute Pancreatitis Manifestations | ABD pain, N/V, low-grade fever leukocytosis jaundice abdominal tenderness & guarding decreased bowel sounds crackles in lungs hypotension & tachycardia, flank pain, brusing |
| Acute pancreatitis Diagnostics | Serum Amylase & Lipase elevated Amylase elevates early and remains for 24-72 hours Glucose elevated Triglycerides elevated LFTs elevated Bilirubin elevated Calcium decreased Abd US or CT |
| Acute pancreatitis Treatments | NPO, NG tube to suction Aggressive IV hydration/volume replacement (albumin or LR) Pain management (Morphine) PPIs (pantoprazole or omeprazole) |
| Acute pancreatitis Treatments pt 2 | Dicyclomine (antispasmotic): dec. vagal stimulation, motility, & dec. volume and concentration of pancreatic enzymes Possible antibiotics for necrotic pancreas ERCP if r/t gallstones O2 if needed (resp distress common) |
| Acute pancreatitis goal | pain relief, prevent or alleviate shock, reduce pancreatic secretions, correct fluid /electrolyte imbalance, treat infection, remove cause, monitor resp status |
| ERCP | endoscopic retrograde cholangiopancreatography – common bile and pancreatic ducts are cannulated to retrieve gallstone |
| Chronic Pancreatitis | Continuous, prolonged, inflammatory, and fibrosing of the pancreas Causes: Chronic alcohol use Gallstone obstruction (sphincter of Oddi) Tumor Trauma Autoimmune disease Cystic fibrosis |
| Chronic Pancreatitis Manifestations | Abdominal pain: recurrent attacks at intervals, can become constant heavy, gnawing, burning, cramping, not relieved with food or antacids Malabsorption with weight loss Constipation Mild jaundice Steatorrhea Diabetes |
| Chronic pancreatitis Diagnostics | Challenging, based on S&S, labs, imaging Amylase & Lipase mildly elevated or not at all Bilirubin & Alkaline Phosphatase may be elevated Mild leukocytosis ESR elevated CT, MRI, MRCP, abd. US |
| Chronic pancreatitis Treatment | Alcohol & smoking cessation Diet: small, bland, frequent meals, low fat, no caffeine Chronic pain medication Pancreatic enzymes: pancrealipase Usually enteric coated, take with food Monitor steatorrhea for effectiveness Insulin, oral hypoglycemic |
| Chronic pancreatitis Treatment surgical | ERCP, Surgery (Whipple): divert bile flow or relieve obstruction |
| Gallbladder Cholelithiasis & cholecystitis | Function: Stores and releases bile Cholelithiasis: gallstones Cholecystitis: inflammation of the gallbladder 10% of Americans have cholecystitis associated with gallstones risk for gallstones: Females, over 40, estrogen |
| Gallstone formation | Supersaturated bile with cholesterol Dec. bile acids Excess mucus Gallbladder dysmotility and stasis biliary sludge Stone migration & obstructions bile cannot escape cholecystitis |
| Cholelithiasis: | Varies (stationary, mobile, or obstruction) Biliary colic Steady mod. to severe pain RUQ tenderness 3-6 hours after high fat meal or lies down, lasting up to 1 hour |
| Cholecystitis: | Indigestion RUQ pain referred to right shoulder or scapula, +Murphy’s sign Fever/chills N/V leukocytosis inflammation of gallbladder |
| Murphy’s sign: | take deep breath and hold, palpate the subcostal region. If let out breath, positive S/S vary from indigestion to mod/severe pain depending on if bile duct is completely blocked |
| Cholelithiasis/Cholecystitis diagnostics | Gallbladder Ultrasound HIDA Scan ERCP – Endoscopic retrograde cholangiopancreatography can also be used to remove stones Serum Bilirubin may be increased LFTs CBC – increase WBC |
| Cholelithiasis/Cholecystitis complications | Gangrene Pancreatitis Perforation Peritonitis |
| Cholelithiasis/Cholecystitis Treatment | Conservative treatment if no symptoms Medications to dissolve stone: ursodiol ERCP ESWL |
| Cholelithiasis/Cholecystitis interventions | Nutrition – NPO during an acute attack Small, frequent Low fat meals May need NG tube Analgesics: morphine/meperidine IV hydration & Antiemetics Antibiotics (secondary infection) Surgery. t-tube |
| t tube used to | allow flow of bile when obstructed bile duct |
| Cholelithiasis/Cholecystitis Post op care | Monitor incision site Monitor for referred shoulder pain from CO2 gas Place on left side with right knee flexed Encourage deep breathing, ambulation Clear liquids, advance diet Monitor drains (if needed) |
| Cholelithiasis/Cholecystitis Postop care teach | Diet low in fat s/s of obstruction (can lead to pancreatitis) Avoid heavy lifting for 4-6 weeks CO2 gas can irritate the phrenic nerve and diaphragm, causing difficulty breathing postop |
| Reason One: Enteral Nutrition | Tube needed for nutritional intake • Patient can digest and absorb food, but cannot: 1. Ingest 2. Chew 3. Safely swallow 4. Or intake adequate amounts |
| Reason Two: Decompression | Empties the stomach • Bowel obstructions • Slowed/absent peristalsis |
| Tube Insertion | Placed in high-fowlers position & provided privacy. Draped towel & provided emesis basin. Inspected nasal patency. Place pulse oximeter. Prepared tape or securement device Measured distance from the tip of nose, to earlobe, to the xiphoid |
| Complications of Tube Insertion | Altered LOC 2. Abnormal blood clotting 3. Diminished gag or cough reflex |
| pH strips: | Fasting, NG tube: 5 or less • Fasting, NI tube: 6 or more |
| How to check placement with pH strip | Push 30ml of air to clear tube • You can skip this step on initial insertion since tube hasn’t been used 2. Pull back (aspirate) 5-10ml of gastric content 3. Place gastric content in med cup with pH strip |
| When to check tube placement | Every 4-6 hours or hospital policy • Before administering anything (meds, feeding, water) |
| Medication Administration ng tube | Make sure all meds can be crushed • Crush meds individually • Mix each med with 30ml of water • Flush with 15-30ml of water between each med • Sequence: Verify placement, flush, admin med, flush, admin med, flush |
| Irrigating Tube for Decompression | Checked for tube placement clamp tube. 30 ml of normal saline. Slowly instilled saline 6. Aspirated saline immediately after instillation 7. Reconnect suction and repeated irrigation if no return. 8. Instilled 10mL of air |
| PEG Tube Site Care | Remove old dressing • Clean site with saline or warm water then pat dry • Apply barrier cream • Apply dressing and secure with tape • No need to check placement |
| ostomy care | maintaining clean, healthy skin around the stoma, emptying the pouch when 1/3 to 1/2 full (1–3 times daily), and changing the appliance system every 3–7 days to prevent leaks and irritation. healthy stoma- red, moist, and pink. warm water to clean |
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cwehner125