GI Flashcards
Leading cause of acute and chronic pancreatitis
Alcohol
Two functions of pancreatitis
Endocrine-insulin
Exocrine-digestive enzymes
Second cause of acute pancreatitis
Gallbladder disease
S/S of pancreatitis
Pain Abdominal distention/ascites Abdominal mass-swollen pancreatitis Rigid board-like abdomen (guarding or bleeding) Bruising around umbilical area (Cullen's sign) Flank area bruising (Gray Turner's sign) Fever N/V Jaundice Hypotension=bleeding or ascites
Pancreatitis
Auto-digestion of pancreatitis-it’s eating itself
Does pain with pancreatitis increase or decrease with eating?
Increase
Diagnostic labs for pancreatitis
Increased serum lipase and amylase Increased WBCs Increased BS ALT, AST-liver enzymes increased PT, PTT longer Serum bilirubin increased H/H increased or decreased (Down with bleeding, up with dehydrated)
Normal amylase labs
30-220 U/L
Normal lipase labs
0-110 U/L
Normal AST labs
8-40 U/L
Normal ALT labs
10-30 U/L
Tx of pancreatitis
Control pain (Decrease gastric secretions: NPO to suction, bed rest. If anything gets in their stomach, they think they have to make digestive enzymes, increasing pain.)
Steroids to decrease inflammation
Anticholinergics to keep stomach dry and empty (Benztropine, atropine/diphenoxylate)
GI protectants (pantoprazole, ranitidine, famotidine, antacids)
Maintain nutrition status then ease into diet
Insulin-sick pancreas, not making insulin, on steroids which increase BS, on TPN
If you stay on steroids too long what could you get?
Cushing’s
4 major functions of liver
- Detoxify body
- Helps blood clot
- Metabolize drugs
- Synthesized albumin
If liver is sick, do what with meds?
Decrease dose
If liver is sick, #1 concern is what?
Bleeding
Antidote for acetaminophen
Acetylcysteine
Cirrhosis patho
Liver cells are destroyed and replaced with connective/scar tissue which alters the circulation within the liver, the BP in the liver goes up, called portal HTN
S/S of cirrhosis
Firm, nodular liver Abdominal pain-liver capsule stretched Chronic dyspepsis Change in bowel habits Ascites Splenomegaly Decreased serum albumin Increased ALT and AST Anemia Can progress to hepatic encephalopathy/coma
Are you suppose to be able to feel the liver normally?
No
Never give what to someone with liver problems?
Acetaminophen
Male hemoglobin
14-18
Female hemoglobin
12-16
Male hematocrit
42-52%
Female hematocrit
37-47%
Cirrhosis Dx
Ultrasound
CT, MRI
Liver biopsy
Liver biopsy procedure
Clotting studies pre procedure: PT, aPTT, INR
Vitals pre procedure
Position supine with right arm over head
Exhale and hold breath to keep diaphragm out of the way
Lie on right side post procedure, worried about bleeding so take vitals
Tx of cirrhosis
Antacids, vitamins, diuretics
No more alcohol
I&O, daily weights
Rest
Prevent bleeding, no IM injections or aspirin
Measure abdominal girth to see if ascites is increased
Paracentesis
Monitor jaundice-good skin care, short nails
Avoid narcotics-liver can’t metabolize drugs well when it’s sick
Decrease protein, low Na diet
Paracentesis
Removal of fluid form the peritoneal cavity
Have client void
Position sitting up
Vitals
With “shocky” clients, the BP goes down and pulse goes up
Why worry about shock with paracentesis?
Any time you pull fluids, you can throw them into shock
Protein breaks down to what?
Ammonia, then the liver converts ammonia to urea, then the kidneys excrete the urea
Patho of hepatic coma
When you eat protein, it transforms into ammonia, and the liver converts it to urea. Urea can be excreted through the kidneys without difficulty
When the liver becomes impaired, it can’t make this conversion, so ammonia builds up in the blood
Serum ammonia decreases LOC (acts like sedative)
S/S of hepatic coma
Minor mental changes/motor problems Difficult to awaken Asterixix-flaping tremor of hand Handwriting changes Reflexes will decrease EEG slow Fetor-breath smells like ammonia (acetone, cut grass) Anything that increases ammonia level aggravates the problem-protein Liver people tend to be GI bleeders
Tx of hepatic coma
Lactulose to decrease serum ammonia
Cleansing enemas
Decrease ammonia in diet
Monitor serum ammonia
Patho of bleeding esophageal varices
High BP in the liver (portal HTN) forces collateral circulation to form in stomach, esophagus, rectum
Usually no problem until rupture
Protruding vessel, same thing as a hemorrhoid
When you see an alcoholic client that is GI bleeding it is usually what?
Esophageal varices
Tx of esophageal varices
Replace blood VS, CVP Oxygen (needed whenever someone is bleeding) Octreotide to lower BP in liver Balloon tamponade Cleansing enema to get rid of old blood Lactulose to decrease ammonia Saline lavage to get blood out of stomach
Type of balloon tamponade tube
Sengstaken-Blakemore
Balloon tamponade
Infrequently used emergency procedure that may be used to stabilize clients with severe hemorrhage. Should not be used more than 12 hours. Many of the safety implications for the Blackemore tube can be applied to other oropharynx or nasopharynx tubes
Purpose of balloon tamponade
To hold pressure on bleeding varices
EVL or Endoscopic Sclerotherapy
More commonly used for esophageal varices. Uses a banding procedure and endoscopic sclerotherapy is when the physician injects a sclerosing agent into the varices via an endoscope
Patho of peptic ulcers
Common cause of GI bleeds
Can be in esophagus, stomach or duodenum
Mainly in males, but increasing in females
Erosion is present
S/S of peptic ulcers
Burning pain usually in the mid-epigastric area/back
Heartburn
Might point to a “hunger” region after they already ate
Diagnosis of peptic ulcers
Gastroscopy (EGD, endoscopy)
- NPO pre procedure
- Sedated
- NPO until gag reflex
- Watch for perforation by watching for pain, bleeding, or if they are having trouble swallowing
OR
Upper GI:
-Looks at the esophagus and stomach with dye
NPO past midnight
No smoking, chewing gum, or mints. Remove nicotine patch. Smoking increases stomach motility, which will affect the test. Smoking also increases stomach secretions which will increase the chance of aspiration
Tx of peptic ulcers
Antacids
Proton pump inhibitors
H2 antagonist
What do you do if balloon tamponade is stuck in clients throat and they can’t breathe?
Deflate the balloon by keeping scissors at HOB and chop it in half for immediate deflation, reestablish airway
Why antacids for peptic ulcers?
Liquids, coat stomach
Take when stomach is empty and at bedtime.
Acid can get on ulcer, take antacid to protect ulcer
Why proton pump inhibitors for peptic ulcers?
To decrease acid secretions
Omeprazole, lansoprazole, pantoprazole, esomeprazole
Why H2 antagonists for peptic ulcers?
Ranitidine, famotidine
GI cocktail (donnatal, siscous lidocaine, mylanta)
Antibiotics for H. Pylori
Sucralfate to form barrier over the wound so acid can’t get on the ulcer
Client teaching for peptic ulcers
Decrease stress
Stop smoking
Eat what you can tolerate, avoid temp extremes and extra spicy foods, avoid caffeine
Need to be followed for one year
Gastric ulcers
Malnourished (bc throwing up helps): pain is usually half hour to one hour after meals, food doesn’t help, vomiting helps, vomit blood
Duodenal ulcers
Well nourished: night time pain is common and 2-3 hours after meals, food helps, blood in stools
Hiatal hernia patho
When the hole in the diaphragm is too large so the stomach moves up into the thoracic cavity
Main cause is a large abdomen
Other causes are congenital abnormalities, trauma, sx
S/S of hiatal hernia
Heartburn
Fullness after eating
Regurgitation
Dysphagia
Tx of hiatal hernia
Small frequent meals, sit up 1 hour after eating, elevate HOB, sx, teach life style changes and healthy diet (keep stomach in down position)
Dumping syndrome
The stomach empties too quickly after eating and the client experiences many uncomfortable to sever side effects. Usually secondary to gastric bypass, gastrectomy, or gall bladder disease
S/S of dumping syndrome
Fullness Weakness Palpitations Cramping Faintness Diarrhea
Tx of dumping syndrome
Semi recumbent with meals
Lie down after meals
No fluids with meals (drink in between meals)
Meals should be small and frequent rather than large
Avoid foods high in carbs and electrolytes, carbs and electrolytes empty fast
Ulcerative colitis patho
Ulcerative inflammatory bowel disease, just in large intestine
Crohn’s Dz
Also called regional enteritis, inflammation and erosion of the ileum but it can be found anywhere in the small or large intestines
S/S of ulcerative colitis and crohn’s disease
Diarrhea Rectal bleeding Weight loss Vomiting Cramping Dehydration Blood in stools Anemia Rebound tenderness Fever
Rebound tenderness
Push in, let go and hit hurts
Means peritoneal inflammation
Diagnosis of ulcerative colitis and crohn’s disease
CT
Colonoscopy-best
Barium enema-Lower GI series, done if colonoscopy is incomplete
Colonoscopy procedure
Clear liquid diet for 12-24 hours
NPO 6-8 hours pre procedure
Avoid NSAIDs to avoid GI bleeding
Laxatives or enemas until clear
Polyethylene glycol-don’t drink with straw, will swallow air
To help your client drink colon prep more easily, get it as cold as possible
Sedated for procedure
Post op: watch for perforation. We are going to assume the worst, signs of perf are pain or unusual discomfort
Tx of ulcerative colitis and crohn’s
Low fiber diet, try to limit GI motility to help save fluid
Avoid cold foods, hot foods, smoking-these all increase motility
Medications for ulcerative colitis and crohn’s
Antidiarrheals-only given with mildly symptomatic UC clients, doesn’t work well in severe cases
ABX
Steroids to decrease inflammation
Sx for UC
Total colectomy with ileostomy formed
Koch’s ileostomy or a J pouch (no external bag)
Koch Pouch
qNipple valve that opens and closes to empty intestines
J pouch
Removes the colon and attaches the ileum to the rectum
Sx for crohn’s
Try not to do sx
May remove only affected area
Client may end up with an ileostomy or colostomy, depends on area affected
An ostomy in the ileum is called an ileostomy and an osmotic in the colon is called a colostomy
Post op ileostomy care
It’s going to drain liquid all the time. Don’t have to irrigate ileostomies
Avoid foods hard to digest and rough foods: increase motility
Gatorade or a similarly electrolyte replacement drunk in summer
At risk for kidney stones (always a little dehydrated
Post op colostomy care
As waste moves through the colon, water and nutrients are being absorbed and the stool is forming
Irrigate for regularity. Same time every day, after a meal
The further down the colon the stoma is, the more formed the stool will be because water is being drawn out. The stool is more normal
When you’re irrigating an osmotic, use same principles as if you’re administering an enema
Any time you’re giving an enema, what do you do if the client starts to cramp?
Stop fluids, lower bag and/or check the temp of the fluid
Stools with ascending and transverse colostomy
Semi liquid
Stools with descending or sigmoid colostomy
Semi formed for formed
Which colostomies do you irrigate?
Descending and sigmoid
Positioning of colons
Ascending, transverse, descending, sigmoid, rectum
Patho of appendicitis
Related to a low fiber diet, number one thing to worry about it rupture
S/S of appendicitis
Generalized pain initially: eventually localizes in the right lower quadrant (McBurney’s Point)
Rebound tenderness
N/V
Get good hx ( abdominal pain first then N/V)
Anorexia
Which side do they lay on for enemas
Left, normal flow of GI tract
If irrigating a stoma, they don’t have to be on their side bc they don’t have a rectum, any position is okay
Diagnosis of appendicitis
Increased WBC
Ultrasound
CT
Do not give enemas or laxatives because you are worried about ruptured appendix
Tx of appendicitis
Sx
Most done via laparoscope unless perforated
After any major abdominal sx, the position of choice is sitting up, no tension on suture
Why put client on right side with HOB elevated after ensure?
Stomach will empty quicker, if they vomit they won’t aspirate, it will come out
TPN considerations
Sometimes called hyperalimentation Keep refrigerated, warm for administration, let sit out for a few minutes prior to hanging Central line needed Filter needed Nothing else should go through this line (dedicated line) D/C gradually to avoid hypoglycemia Daily weights May have to start taking insulin BG monitoring q 6 Check urine for glucose and ketones Do not mix ahead: mixture changes every day according to electrolytes Can only be hung for 24 hours Change tubing with each new bag IV bag may be covered with dark bag to prevent chemical breakdown Needs to be on a pump Home TPN: emphasize hand washing Most frequent complication: infection
If appendix ruptures, what do you do?
Straight to sx, they’ll be leaking bowel contents into abdomen, they’ll get septic
Put on right side and sitting up so all bowel contents will settle in one spot
Assisting physician with inserting a central line
Have saline available for flush, don’t start fluids until positive confirmation of placement with CXR
Trendelenburg to distend veins
If air gets in central line, what position do you put the client in?
Left side trendelenburg
*When an air embolus is suspected in the heart, the client may be taken to the cath lab for removal of the air
Han you are changing the central line tubing, how can you avoid getting air in the line?
Clamp it off, valsalva, take a deep breath and HUMMMM
Why is an x-ray done on post insertion of central line
To check for placement and make sure they don’t have a pneumothorax
