GI Flashcards
What is parenteral nutrition?
Administration of nutrients by route other than GI tract (i.e., bloodstream)
Storage and labelling of parenteral nutrition includes?
Must be refrigerated until 30 minutes before use; made daily, only good for 24 hours
Must be labeled with nutrient content, all additives, time mixed, and date and time of expiration
What are common indicators for PN?
- Chronic severe diarrhea and vomiting
- Complicated surgery or trauma
- GI obstruction
- GI tract anomalies and fistulae
- Intractable diarrhea
- Severe anorexia nervosa
- Severe malabsorption
- Short bowel syndrome - Occurs when a patient has a problematic portion of bowel cut out, and problems reoccur a few years later. Pt has more cut out, and it again occurs later on. Repeating.
What are common metabolic problems associated with PN?
- Altered renal function
- Essential fatty acid deficiency
- Hyperglycemia, hypoglycemia - Check blood glucose via finger blood stick q4-6hrs
- Hyperlipidemia
- Liver dysfunction
- Refeeding syndrome - Electrolyte imbalances, Fluid imbalances which lead to edema
What is nursing management of PN?
Vital signs q4-8hrs
Daily weights
Blood glucose
- Sliding scale
- Check every 4-6 hrs
Electrolytes
BUN
CBC
Liver enzymes
Dressing change
- Per policy
- Site observation is key!!
Refeeding syndrome
Infusion pump must be used
- Need to periodically check volume infused
- Check more often than regular IV
Watch for infection and sepsis
What are S/S of infection and sepsis with PN? and interventions if suspected?
Local manifestations - Erythema, Tenderness, Exudate at catheter insertion site
Systemic - Fever, chills, Nausea/vomiting, Malaise
If suspected:
- Blood and catheter cultures if infection suspected
- X-ray: To check changes in pulmonary status
- After PN therapy, daily dressing changes to infusion site until it fully heals (After catheter is removed)
BMI categories
< 18.5 Underweight 18.5-24.9 Normal weight 25.0-29.9 Overweight >29.9 Obese >40 Extreme Obesity
What are ways to assess obesity?
BMI
Waist circumference
Waist to hip ratio
body shape
Waist circumference measurements:
increased health risk if >40 in men and > 35 in women
Larger waist = increased heart disease
Waist to hip ratio
> 0.8 greater risk for health complications
Apple body shape is at risk for:
Heart disease
DM
Hypertension
Pear body shape is at risk for:
osteoporosis
varicose veins
All opportunities for patient education on obesity should stress (2), and should include (6).
healthy eating and exercise
- Meal planning
- Adequate fruits and vegetables to prevent constipation, meets vitamin A and C requirements
- Lean meat, fish, and eggs for protein and B-complex vitamins (B complex vitamins can be insufficient if diet has not carbs)
- Exercise
- Behavior modification
- Support groups
Bariatric surgery is used to treat ___.
extreme obesity. It is currently the only treatment found to have a successful and lasting impact for sustained weight loss
Criteria guidelines include:
- BMI ≥40 kg/m2 OR
- 35 with one or more significant co-morbidities (such as hypertension, DMII, HF, sleep apnea)
Not always covered by insurance; Screened for psychologic issues associated with poor outcomes (depression, binge eating disorder, drug/alcohol abuse)
The three broad categories of bariatric surgeries are:
restrictive (reduces size of stomach or amount allowed to enter the stomach),
malabsorptive (small intestine is shortened),
and a combo
Bariatric surgeries include:
Restrictive:
- Gastric banding
- Sleeve Gastrectomy
- Plication
- Intragastric Balloon
Combo:
5. Roux-en-Y Gastric Bypass (RYGB)
Gastric banding
restrictive surgery that limits the size of the stomach with an inflatable band, adjustable
- Port is subcutaneous that can be inflated or deflated by fluid injection in provider’s office
- Creates sense of fullness
- Delays in stomach emptying
- Can be modified or reversed later
Sleeve Gastrectomy
restrictive surgery in which 75% of stomach is removed, leaving a sleeve-shaped stomach
- Stomach function preserved
- Eliminates hormones made in the stomach that stimulates hunger
- Currently requires a surgical incision, research ongoing on laparoscopic approach
- Leakage related to stapling or sutures possible
- NOT reversible
Plication
restrictive surgery in which a 2. sleeve is created by suturing rather than removing stomach
- Minimally invasive surgery (compared to sleeve gastrectomy)
- Involves folding stomach wall inward, reducing the stomach volume
- Reversible
- Requires hospital stay
- Nausea common after procedure
- Blockage may occur from swelling or fold too tight
Intragastric Ballon
A restrictive procedure in which a balloon occupies space in the stomach
- Natural anatomy of the stomach is not altered
- Patients feel more full, appetite decreased
- Less invasive, placed using - - Balloon filled with saline, varying amounts can be used (400-700 mL) –OR- nitrogen gas (newer)
- Can only be left in for 6 months
Roux-en-Y Gastric Bypass
a combination surgery in which a stomach pouch is created, connected to jejunum, rest of stomach and first part of small intestine bypassed
- Food bypasses 90% of the stomach, duodenum, and a small segment of jejunum
- **Most common bariatric procedure **
- Excellent patient tolerance
- Has low complication rates
Possible complications of Roux-en-Y Gastric Bypass surgery:
- DUMPING SYNDROME
- also called rapid gastric emptying
- causing abdominal cramps and nausea and diarrhea, due to insulin surge, symptoms of hypoglycemia occur 2-3 hours later
- Avoidance of sugary foods, small frequent meals and dietician referral can all help - LEAK AT ANASTOMOSIS SITE - this is a concern for every stomach surgery procedure!
- ANEMIA
Preoperative Care for a Bariatric surgery:
Patients will likely have comorbidities, so team approach
Nurse myst prepare the room!
1. Have room ready for patient before arrival
- Larger blood pressure cuff
- Larger gown
- Patient transfer equipment
- Wheelchair with removable arms
(Note: Don’t make a large pt uncomfortable by making them feel like you have to provide special accommodations “Oh, I need a larger bp cuff, let me get it!” :O )
- Wound infection – skin prep important
- Breathing - Coughing, Deep breathing, Turning - These are super important in obese patients to avoid pulmonary complications*
- Venous access -> Have an extra long catheter
- Mechanical ventilation
Postoperative care for Bariatric Surgery:
- Close observation for complications
- Transfer with specially trained personnel
- Stabilize airway -
* *Elevate HOB to 35-40 degrees** - Adipose tissue problems
- Anesthetic agents stored in adipose tissue, may be slower to wake and/or re-sedation possible
- Excess adipose tissue compresses chest and abdomen which Causes CO2 retention - Manage pain
- Diligent turning and ambulating
- Hypoxemia, pulmonary hypertension, polycythemia
- Risk for deep venous thrombosis (DVT)
- TED hose and PCD devices should be put on at night or when pt is NOT moving around - Infection, dehiscence, delayed healing
- Nutrition is KEY!! - Keep skin folds clean and dry to prevent bacterial or fungal infections
- Attentive to placement of NG tube
- Careful transition to new diet
Post Bariatric Surgery diet is generally:
High protein Low carbohydrates Low fats Low roughage 6 small feedings Fluids not to be ingested with meals and <1000 ml/day
What are later complications of bariatric surgery?
Anemia Vitamin deficiencies Diarrhea Psychologic problems Peptic ulcer formation Dumping syndrome Small bowel obstruction
*Long-term follow-up care important
What is the order of a GI exam?
Inspection **Auscultation** Percussion Light palpation deep palpation
What is in the RLQ?
Lower pole right kidney Cecum and appendix Portion ascending colon Bladder Right ovary and fallopian tube Uterus if enlarged Right spermatic cord Right ureter
What is in the RUQ?
Liver and gallbladder Pylorus Duodenum Head of pancreas Right adrenal gland Portion right kidney Hepatic flexure of colon Ascending and transverse colon
What is in the LUQ?
Left lobe of liver Spleen Stomach Body of pancreas Left adrenal gland Portion of left kidney Splenic flexure of colon Transverse and descending colon
What is in the LLQ?
Lower pole left kidney Sigmoid flexure Descending colon Bladder Left ovary and fallopian tube Left spermatic cord Left ureter
Upper GI/small bowel series
Barium Swallow
- Use: detect structural changes in the esophagus, stomach, duodenum / small intestine
- Prep: NPO
- Post: fluids/laxatives, monitorstool for passage of barium
Lower GI Series
Barium Enema
- Use: detect anatomic changes in lower GI tract
- Prep: clear liquids, NPO, bowel prep (must have clear/empty bowel before procedure)
- Post: fluids/laxatives, monitor for passage of contrast
Abdominal Ultrasound
- Use: detect solid masses, cysts, or abdominal ascites
- Prep: NPO 8-12 hrs
- Post: none
Gallbladder ultrasound
- Use: detect masses, cysts, tumors or cirrhosis of liver or biliary tract
- Prep: NPO 8-12 hrs
- Post: none
Esophagogastroduodenoscopy (EGD)
- Use: direct visualization of mucosa of esophagus & duodenum, can perform biopsy or sclerotherapy
- Prep: NPO 6-12 hrs, consent, preop meds, sedation
- Post: * NPO until gag returns, assess for bleeding if biopsy*
Sigmoidoscopy
- Use: direct visualization of mucosa of colon to ileocecal valve vs rectum/sigmoid colon only
- Prep: clear liquid 1-2 days, bowel prep, NPO 8-12 hrs, consent, preop meds, sedation
- Post: assess rectal bleeding, signs of perforation, need to pass gas
- Bowel blown up w/air to do scope ->NEED to pass that gas
- Teach pt that to help with intestinal cramping: Pass gas!!,
Move around (walk)
**1st sign of perforation is PAIN **
Capsule endoscopy
- Use: images of stomach, small intestine
a. Pt swallows pill size camera - Prep: NPO 8-12 until 4 hours after swallow
- Post: patient passes capsule in bowel movement, images downloaded
Percutaneous cholangiography
- Use: local anesthesia, liver entered with needle using fluoroscopy, inject contrast to assess hepatic & biliary duct filling
- Prep: NPO
- Post: Assess for bleeding or bile leakage
Computerized tomography (CT) or magnetic resonance imaging (MRI)
Computerized tomography (CT scan)
- May require contrast dye
- Assess renal function and allergy to dye
Magnetic Resonance Imaging
- IV contrast may be used
- Use caution with metal implants (ie: pacemaker, joint replacements)
What are common lab studies done for GI issues?
Stool cultures Fecal analysis Occult blood Liver function studies Serum amylase Serum lipase Ammonia levels Serum protein levels
