GI Accessory Disorders Flashcards
Appendix becomes inflamed increased intraluminal pressure, causes edema and obstruction of orifice
Etiologies
Result of becoming kinked or occluded with stool
Lymphoid hyperplasia secondary to inflammation or infection - appendicitis can be with or without infection
Rarely, foreign bodies (seeds) or tumors
Patho - GI Accessory: Acute Appendicitis
Severe/steady pain
Right lower quadrant
McBurney’s point - push on area and release it have rebound tenderness
Rebound tenderness
Low grade fever/nausea
Complications
Largest: Ischemia, gangrene, perforation
Ruptured/disintegration = Peritonitis: go further and cause sepsis/death
CM - GI Accessory: Acute Appendicitis
As push down little tender but lot more as release
Halfway between umbilicus and ant iliac crest
Go down slow and up fast - pain throughout but greatest pain on rebound
Appendicitis McBurney’s Point: Rebound tenderness - GI Accessory: Acute Appendicitis
CBC
Elevated WBC & Neutrophils
Normal: WBC (5000-10000 mm3)
Normal: Neutrophils (55-70 %)
Urinalysis: r/o UTI/stones
CT: right lower quadrant density
appendix enlargement (6 mm or >) - show inflammation and thickening of walls around appendix: sign inflammed
Pregnancy test: r/o ectopic pregnancy
Diagnostics - GI Accessory: Acute Appendicitis
Appendectomy
Laparotomy - open
Laparoscopy - closed
Healing time much less and lot less chance infection
IV Fluids - not feel like drinking and after remove appendix have paralytic ileus need rehydrate
Antibiotics
med/surg - GI Accessory: Acute Appendicitis
Infection, risk for - if not already got infection
Pain - acute
Fluid volume deficit, risk for
Surgery, knowledge deficit
Anxiety
Risk for: atelectasis, DVT, or ileus - need be up, moving around, turn and cough and deep breathing - trying get lungs clear and get bowels moving to prevent ileus - need be on DVT prophylaxis until moving around again
N. diagnosis - GI Accessory: Acute Appendicitis
Educate patient on surgery - most specifically: educate what expected of pat post-surgery; warn: IS and how use it and how often
Administer pain medications - enough get pain at stated level that usually 4 - so doing turning, coughing, deep breathing without great deal of pain and splinting
Administer IV fluids/encourage PO fluids (after pass gas) - after bowels wake up
Provide post operative care
Prevent post op complications
Educate patient on T,C,DB; IS
Position: High Fowler’s
Auscultates abdomin-BS - LOT - getting things back again and movement
Ambulate
Abdomen stays soft and not rigid or developing peritonits
Discharge instructions - variety
N. interventions - GI Accessory: Acute Appendicitis
Inflammation of peritoneum usually result of:
Bacterial infection
External sources such as abdominal surgery or trauma
Peritoneal dialysis - BIG ISSUE; after two issues having this and peritonitis cannot have dialysis - must go to chemo
Inflammation other organs - such as appendicitis
Patho - GI accessory: peritonitis
Fever - >101-102
Pain
Begins as diffuse pain then constant, localized, more intense over site, increases with movement
Rigid abdominal muscles/Distention of abdomen
N&V; paralytic ileus from the pressure
Hypovolemia-lack of movement of fluid
Without intervention -can lead to sepsis/shock
CM - GI accessory: peritonitis
WBC elevated with Bands - will see >10% - throwing out immature neutrophils because cannot produce enough mature WBCs to fight infection
Electrolytes
altered levels of potassium, sodium, and chloride
Fluid volume shifts
C&S of aspirate - peritoneal taps - catheter/needle inserted into peritoneum and draw off fluid; know what type antibiotics on - start broad
Abdominal X ray
Look for air and fluid levels; distended bowel loops; bad sign: fre air within abdomen - means somewhere within bowel air leaking out and that is source of peritonitis
CT: abscess formation
MRI: Intra-abdominal Abscesses
Diagnostics - GI accessory: peritonitis
Find infection source
Fluid/electrolyte replacement
Pain medication - in lot of pain and bowel issues - not stop up already are
Antiemetics - Zofran - stop from vomiting and massive nausea
Antibiotics - before C&S done, look at starting broad spectrum (Zosin)
NG tube-relieve distention on stomach
Airway clearway - airway intubation and ventilator assistance needed end up in ICU if become extremely septic
med/surg - GI accessory: peritonitis
Risk for infection - peritonitis does not have to have an infection
Deficient fluid volume
Acute pain
Risk for imbalanced nutrition: Less than body requirements - not being able to eat or drink
Constipation - fluid shifts and pain meds
Nausea
Risk for dysfunctional GI motility - lot pressure in peritonitis on bowels and not move appropriately
N. diagnosis - GI accessory: peritonitis
May prep for surgery - open exploratory laparotomy since not know what is going ok
Monitor: Assessment/Vital signs - good look at abdomen - not rigid abdomen, massive fever
Focus on Bowel sounds
Administer medications - not able swallow meds and NG tube - not able take meds PO; have meds changed into diff form
Advance diet as tolerated
Intensive care for septic shock
N. interventions - GI accessory: peritonitis
Distentended abdomen - pressure making skin taut
Not corrected - can turn into abdominal compartment syndrome
Is this pt at risk for intra-abdominal HTN - GI accessory: intra-abdominal compartment syndrome; intra-abdominal HTN
Sepsis - pts been septic/cap leak
Burns - large total body surface area burns
Massive resuscitation
Something in common in terms treatment: fluids; some sorts process making cap leaky; catecholamines act on caps and vascular sys to dilate and become leaky and all fluid instead going through vascular sys leaks out and causes third spacing - edema; fluid from intravascular space - edema and swelling throughout for pt; pts at high risk for intraabdominal pressures
Septic: cram full fluid; burns: replace all fluids lost in burned tissue; massive resuscitation - cont hang fluids - 3-6 L run
Risk factors - GI accessory: intra-abdominal compartment syndrome; intra-abdominal HTN
Extra pressure on cavity - Splanchnic hypoperfusion (ganglia - when smushed not do job effectively; pressure put on it - not have blood flow or transmit neuron signals freely if not under pressure) - resulting in hepatic ischemia - liver not getting enough O2; liver not do job appropriately and getting squished and liver makes coag factors so get weird Coagulopathy - clot and bleed at same time = acidotic state pt for same time; metabolic acidosis need fix as well; Coagulopathy increase bleeding - Intra-abdominal bleeding - cavity under pressure under exces pressure now have blood loss that will exacerbate pressure prob; bleeding and more pressure in abdomen
Gut - colon, SI, stomach - not enough blood supply - stomach not enough blood supply to refresh rugae get gastric ulcers - hydrochloric acid - not get rugae replaced - eat through and get hydrochloric acid in stomach in peritoneal cavity - autodigestion of various organs causing inflammation and increased swelling and edema; free radicals from extra H floating around damage extra tissues - cause abdominal-compartment syndrome
IAH
Patho - GI accessory: intra-abdominal compartment syndrome; intra-abdominal HTN
Hepatic ischemia
Gut mucosal acidosis
Bowel edema
Free oxygen radicals
Distant organ damage
Coagulopathy hypothermia acidosis
Intra-abdominal bleeding
If unrelieved can lead to ACS
IAH - GI accessory: intra-abdominal compartment syndrome; intra-abdominal HTN
Hopefully have transfusion measures in ICU - fill up bladder and measure it; med-surg unit - not as accurate: keep track of it: abdominal girth measurements; ideally same person doing them - track changes over time - also do daily weights - most accurate measure fluid volume status on pt
How measure intra-abdominal pressure
Cut down through fascia to relieve fascia - ACS - relieve pressure; abdomen squishy - stretch more than cavities - need relieve pressure; laparotomy - incision on pt - swelling pushed it into a circle - same concept - relieve pressure by opening up cavity so organs and vessels not squished
Pt at risk for: infection, sepsis, HF - fluid volume overload issues, impaired gas exchange, TPN/PPN/NG tube/PEG tube, skin integrity issue
High mortality once to this pt - be open like this for long time; covering over it
Swelling go down: combo surgical closure, wound vac and exact situation and natural closure; closure in layers
Too much pressure in body cavity: organs and vessels not do job effectively; depending on organ and sys effected have systemic issues; once hemodynamically stable - fluid off; pressure to high do something to relieve it: surgical intervention
Past intra-abdominal HTN and abdominal compartment syndrome
formation of gallstones
Cholesis
Inflammation of gallbladder
Acute vs Chronic
Stones vs not
Women greater than men
Age greater than 40, obese, fertile
Four F’s: Fat, fertile, female, and forty
Patho - GI accessory: cholecystitis
Biliary colic pain in RU abdomen
Radiates R shoulder and back
N&V - esp after fatty meal
Obstruction (stones/tightening of gallbladder tract) causes jaundice
Urine/stool changes
Urine dark; putty colored stool - bilirubin unable to be conjugated
Vitamin Deficiency
Esp Fat soluble vits: A, D, E, and K - so much pain after fatty mean
Major comps: Complications stone
Necrosis, peritonitis
CM - GI accessory: cholecystitis
Radiographic
Abdominal X-Ray - looking for thickening of wall
Ultrasonography - looking for thickening of wall
Endoscopic retrograde cholangiopancreatography (ERCP)
Procedural
Look up into biliary tract and see if stones/sphincter of Oddi competent; treatment as well
Laboratory
Increased Bilirubin (0.3-1 mg/dL) - why see jaundice/itchy skin; usually above 2 - organ dysfunc - esp liver
Diagnostics - GI accessory: cholecystitis
Diet/Supportive Therapy - low fat diet
Pharmacologic therapy - meds: uracil: helps dissolve clots
Dissolve small, gallstones
Nonsurgical removal gallstones
catheter inserted percutaneously
Surgical management
Laparoscopic – less invasive; much easier heal time; can be same day surgery oftne
Open – more invasive
Med/surg - GI accessory: cholecystitis
Laparoscopic versus traditional
Lower complication rate
Low death rates
Rare bile duct injuries
Quicker recovery
Less postoperative pain
Preoperative, intraoperative, postoperative similarities and differences are pretty much equal with each other
Infected gall bladders that are gaseous often done open - teach pts about both before go to surgery - during surgery may need convert from one to another
Cholecystectomy - GI accessory: cholecystitis
Acute pain - pre and post-op
Impaired gas exchange - must splint
Impaired skin integrity - surgery
Imbalanced nutrition; less than - unable to eat, nausea caused by fat
Risk for infection –surgical site
Also see abdominal surgery diagnosis
N. diagnosis - GI accessory: cholecystitis
Nursing Post op care
Pain relief - esp improves resp status; hard take deep breath if painful
Improve resp status
Maintain skin integrity - more upright position
Promote biliary drainage
Low fat diet/high carb and protein - low fat for sev weeks or forever
Monitor and manage potential complications
Bleeding
Peritonitis
Disruption of GI function
Discharge care
N. interventions - GI accessory: cholecystitis
Gas pain from surgery; sit up right/walk to ease; take
Esp true for laparoscopic surgery - filled with gas so catheter can go in - tell sit upright, walk, pass gas, take pain med as prescribed
Managing pain - Pt edu: home care - GI accessory: cholecystitis
Light activity
Avoid lifting greater than 5 lb for 1 week
Resuming activity - Pt edu: home care - GI accessory: cholecystitis
Daily
Not remove steri strips
Caring for the wound - Pt edu: home care - GI accessory: cholecystitis
Fat in diet slowly - back to regular diet if tolerated in 4-6 weeks
Resuming eating - Pt edu: home care - GI accessory: cholecystitis
Know s&s of infection, N&V, abd pain
Managing follow-up care - Pt edu: home care - GI accessory: cholecystitis
