GI ALterations

Question 1

– refers to any bleeding that starts in the GI tract
* Bleeding may come from any site along the GI tract, but is often
divided into:
o Upper GI Bleeding – The upper GI includes the esophagus
(tube from mouth to stomach), stomach, and first part of the
small intestine
o Lower GI Bleeding – the lower GI includes much of the small
intestine, large intestine or bowels, rectum, and anus

Answer 1

ACUTE GI BLEEDING

Question 2

ACUTE GI BLEEDING ETIOLOGY

Answer 2

Upper GIT disorders
* Peptic ulcer disease
* Duodenal ulcer (20-30%)
* Gastric ulcer (10-20%)
* Gastric or duodenal
erosions (20-30%)
* Gastroesophageal varices
(15-20%)

Lower GIT disorders
* Anal fissures
* Colitis; Radiation,
ischemic, infectious
* Colonic sarcoma
* Colonic polyps
* Diverticular disease
* IBD (ulcerative colitis,
Crohn’s disease)
* Internal hemorrhoids

Question 3

ACUTE GI BLEEDING
Signs and Symptoms/ Clinical Presentation

Answer 3

• Hematemesis
• Melena – black stools; old blood; upper GIT bleeding
• Hematochezia – red stools; fresh blood; lower GIT bleeding
• Syncope
• Dyspepsia (indigestion)
• Epigastric pain
• Heartburn
• Diffuse abdominal pain
• Dysphagia
• Weight loss
• Signs of shock
  o Hypotension
  o Decreased pulses
  o Decreased urine output
• Jaundice

Question 4

ACUTE GI BLEEDING
Diagnostic Exams

Answer 4

• Endoscopy – considered the GOLD STANDARD for diagnosis of GI bleeding
• EGD
• Colonoscopy
• Radiographic procedures
• Serum blood studies

Question 5

ACUTE GI BLEEDING
TREATMENT:

Answer 5

Treatment: Fluid resuscitation
* Adequate resuscitation and stabilization is essential
* Px with active bleeding should receive IVF (e.g. 500 mL of NS or
RL over 30 minutes) while being crossmatched for blood
transfusion
* Blood transfusion
o Must be individualized
o Approach is to initiate BT if hemoglobin is <7 g/dL (70 mg/L)
* Hemostasis
o Early intervention to control bleeding is important to
minimize mortality, particularly in elderly px
* Airway
o Endotracheal intubation should be considered in px who
have inadequate gag reflexes or are obtunded or
unconscious, particularly if they will be undergoing upper
endoscopy
* Active variceal bleeding
o Can be treated with endoscopic banding, injection
sclerotherapy, or transjugular intrahepatic portosystemic
shunting (TIPS) procedure
* General support
o Supplemental oxygen via nasal cannula
o NPO
o PIVC (16G / 18G) or a central venous line should be inserted
o Placement of a pulmonary artery catheter
o Elective endotracheal intubation

Question 6

ACUTE GI BLEEDING
Nursing Management

Answer 6

• All critically ill px should be considered at risk for stress ulcers
  and therefore GI hemorrhage.
• Maintaining gastric fluid pH 3.5-4.5 is a goal of prophylactic
  therapy
• Major nursing interventions are:
  o Administering volume replacement
  o Controlling bleeding
  o Maintaining surveillance for complications (i.e. hemorrhagic
  shock)
  o Educating family and px

Question 7

• Intrabdominal pressure – pressure concealed within the
  abdominal cavity

o Sustained pathological elevation of IAP greater than or equal
to 12 mmHg:

Grade I - IAP between 12-15 mmHg
Grade II - IAP between 16-20 mmHg
Grade III - IAP between 21-25 mmHg
Grade IV - IAP >25 mmHg

Answer 7

Intraabdominal hypertension (IAH)

Question 8

o Organ dysfunction caused by intraabdominal pressure >20
mmHg
o This is a MEDICAL EMERGENCY

• Prevalence
  o IAH and ACS are not only r/t trauma
  ▪ IAH and ACS are equally prevalent in medical px
  ▪ Can be found in every critical care population

Answer 8

Abdominal Compartment Syndrome (ACS)

Question 9

Effects of Increase IAP

Answer 9

• Renal
  o Compression of renal veins and collecting systems
  o Oliguria, activation of RAA system, acute tubular necrosis,
  and renal failure (if prolonged)
• Neurological
  o ↑ ICP
  o ↓ Cerebral perfusion pressure (CPP)
• Gastrointestinal
  o Edema
  o Necrosis

Question 10

• The gold standard for diagnosing intra-abdominal hypertension
• Measure IAP at least q 4-6 hours
• IAP is measured by measuring bladder pressure
  o Requires placement of indwelling urinary catheter
  o Drainage bag clamped
  o Px in flat supine position (recommended)
  ▪ If not tolerated, may place in supine 30-degree reverse
  Trendelenburg
  ▪ Note px position at the time of pressure measurement
  in medical record
  o Instill 25 mL of sterile 0.9% normal saline thru catheter
  o Transducer attached to catheter sample port (transducer
  zeroes to mid axillary line, at the level of the iliac crest)
  o Obtain pressure reading during end-expiration
  o Subtract instilled volume from urine output
  o Monitor for trends and signs of organ dysfunction

Answer 10

Intra-abdominal Pressure Monitoring

Question 11

TREATMENT FOR IAP

Answer 11

• Titrate therapies for IAP <= 15 mmHg
• Optimize fluid status
• Optimize systemic perfusion
  o Goal abdominal perfusion pressure (AP) of >= 60 mmHg
  o APP = MAP – IAP
• Evacuate intraintestinal contents
• Evacuate intra-abdominal lesions
• Improve abdominal wall compliance
• Consider emergent abdominal decompression
  o Percutaneous drain to remove fluid
  o Decompressive Celiotomy
  o Bedside laparotomy

Question 12

• An uncommon condition in which rapid deterioration of liver
  function results in coagulopathy and alteration in mental status
• Liver failure indicated that liver has sustained injury

Answer 12

LIVER FAILURE

Question 13

Types of Liver Failure

Answer 13

• Fulminant Hepatic Failure
  o Encephalopathy starts within 8 weeks
• Non Fulminant Hepatic Failure
  o Encephalopathy starts between 8-26 weeks

Question 14

• Is a rare condition characterized by the ABRUPT onset of severe
  liver injury
• Loss of liver function that occurs rapidly—in days or weeks—
  usually in a person who has no pre-existing liver disease
• It’s a MEDICAL EMERGENCY that requires hospitalization

Answer 14

Acute Liver Failure

Question 15

LIVER FAILURE
Signs and Symptoms

Answer 15

• Jaundice
• Hepatic encephalopathy
  o Mental confusion
  o Difficulty concentrating
  o Disorientation
• Pain and tenderness in the upper right side of the stomach
• Electrolyte imbalances
  o Hypoglycemia
  o Hypokalemia
  o Hypomagnesemia
  o Hypocalcemia
  o Hypophosphatemia
• Melena
• Ascites
• Ankle edema
• Malaise, drowsiness, and muscle tremors
• Bleeding, cerebral edema, hematemesis, coma

Question 16

LIVER FAILURE
Pharmacological Management

Answer 16

• Treatment of acute liver failure consists of drugs and liver
  transplantation
• Pharmacological management includes certain antidotes to
  reverse the effects of ALF and various medication to reduce ICP
  o Penicillin G
  o Activated charcoal
  o N-acetylcysteine
  o Osmotic diuretics
  o Barbiturate
  o Benzodiazepine
  o Anesthetic agents

Question 17

LIVER FAILURE
Nursing Managements

Answer 17

• Assess, report, and record S/S and reactions to treatment
• Monitor fluids I&O closely
• Provide adequate diet with high proteins, CHO, and vitamins
  (carefully in encephalopathy)
• Monitor for signs of possible bleeding
• For coagulopathy / GIT bleeding
  o Vit. K can be given to treat abnormal PT
• Hypotension should be treated with fluids
• Pulmonary complications – mechanical ventilation may be
  required
• HOB should elevated to 30 degrees
• Monitor neurologic status
  o Goal is to maintain ICP below 20 mmHg, and CPP above 50-
  60 mmHg
  o Judicious administration of sedation and analgesia for px
  experiencing agitation during certain stages of hepatic
  encephalopathy

Question 18

• Occurs suddenly as 1 attack or can be recurrent with resolutions
• Can be a medical emergency
• Due to self-digestion of pancreas by its own proteolytic enzymes

Answer 18

ACUTE PANCREATITIS

Question 19

ACUTE PANCREATITIS
Assessment

Answer 19

• Acute steady and severe epigastric pain that occur in the
  umbilical area and may radiate into the back
• Associated with ingestion of alcohol or fatty meal (cardinal sign)
• Pain is usually the main symptom in pancreatitis and is
  aggravated when lying down
• Nausea & vomiting worsens with oral intake and does not relieve
  the pain
• Vital signs:
  o Fever
  o Hypotension
  o Tachycardia
• Abdominal rigidity,
  tenderness, distention, and
  decreased bowel sounds
• Grey Turner’s Sign
  o Reddish-brown to bluish discoloration along the flanks and
  represents accumulation of blood in the area; a sign of
  severe necrotizing pancreatitis
• Cullen Sign
  o Bluish discoloration around the umbilicus
  o Also a sign of severe necrotizing pancreatitis
• Steatorrhea
  o Fat content increase in volume as pancreatic insufficiency
  worsens

Question 20

ACUTE PANCREATITIS
Diagnostic Exams

Answer 20

• ↑ Serum lipase, amylase levels
• ↑ urine amylase
• Leukocytosis
• Hyperglycemia
• Hypocalcemia
• Increase C-reactive protein
• Increase bilirubin and liver function test (indicates hepatic
  involvement)
• Imaging studies (Abdominal x-ray, UTZ, CT Scan)

Question 21

ACUTE PANCREATITIS
Medical Management

Answer 21

• Narcotic analgesics
  o Drug of choice: Meperidine (Demerol)
• Antiemetics, antispasmodics, and anticholinergics
• Somatostatin – a treatment for acute pancreatitis, inhibits the
  release of pancreatic enzymes
  o Known to inhibit GI, endocrine, exocrine, pancreatic, and
  pituitary secretions, as well as modify neurotransmission and
  memory formulation in the CNS
• Fluid resuscitation and electrolyte replacement
• Insulin administration as prescribed
• Antibiotics

Question 22

ACUTE PANCREATITIS
Therapeutic Management

Answer 22

• NPO with NGT
• IV and TPN
• Peritoneal lavage
• Cholecystectomy after acute pancreatitis is resolved

Question 23

ACUTE PANCREATITIS
Nursing Management

Answer 23

• Administer pain management as ordered
• Keep NPO with gastric decompression
• Monitor lab results, v/s, I&O, bowel sounds
• Maintain bed rest and may increase activity as tolerated
• Place px in knee-chest position
• Oral feeding is resumed when amylase levels return to normal
  and when pain is relieved
• Small, frequent, low fat, feedings with no alcohol after acute
  phase

Question 24

• Medical term describing an abnormally high blood glucose level
• Hallmark sign of diabetes (both type 1 and 2 DM)

Answer 24

HYPERGLYCEMIA

Question 25

HYPERGLYCEMIA
Signs and Symptoms

Answer 25

• 3 Ps
  o Polyuria
  o Polydipsia
  o Polyphagia
• Viscous blood – poor circulation
• Altered sensation
• Glycosuria
• Diabetic foot
• Risk for infection and dehydration
• Hot and dry skin
• HTN (with headache)
• Fatigue, blurred vision, slurring of speech

Question 26

HYPERGLYCEMIA
Precautionary Measures

Answer 26

• Follow diabetes meal plan, exercise program, and medication
  routine
• If blood sugar levels are above target range, drink extra liquids
• Monitor blood sugar often

Question 27

HYPERGLYCEMIA
Treatment

Answer 27

• Control of high glucose level
  o Raise insulin dose as prescribed
  o Recommend dietary changes
  o Recommend more exercise (at least 3 times/week)
  o Recommend closer glucose monitoring

Question 28

• A life-threatening complication of DM that develops when
  severe insulin deficiency occurs

Answer 28

DIABETIC KETOACIDOSIS (DKA)

Question 29

DIABETIC KETOACIDOSIS (DKA)
The main clinical manifestations:

Answer 29

o Hyperglycemia
o Dehydration and electrolyte loss
o Acidosis
* Occurs in px with Type I DM
* Causes:
o Decreased or missed dose of insulin
o Illness or infection

Question 30

DIABETIC KETOACIDOSIS (DKA)
Assessment

Answer 30

• Elevated blood glucose level: 300-800 mg/dL
• Decreased serum bicarbonate and pH
• Sodium and potassium may be low
• Glycosuria; polyuria; dehydration
• Metabolic acidosis: Kussmaul’s breathing
• Sweet breath odor
• When to CALL physician
  o Decreased consciousness
  o Difficulty breathing
  o Fruity breath

Question 31

DIABETIC KETOACIDOSIS (DKA)
Implementation

Answer 31

• Restore circulating blood volume
• Treat dehydration with rapid IV infusions (e.g. bolus PNSS to
  promote circulation and dilute sugar)
• Treat hyperglycemia with IV regular insulin
• Cardiac monitoring & electrolyte replacement
• Treat acidosis according to cause (check ABG)
  o Antacid: Sodium bicarbonate

Question 32

DIABETIC KETOACIDOSIS (DKA)
Prevention

Answer 32

• Restore circulating blood volume
• Educate px in recognizing early s/s of DKA
• Emphasize not to eliminate insulin doses when nausea and
  vomiting occur
• Should have available foods for use on a “sick day”
• Drink fluids q hour to prevent dehydration
• In people with infections or who are on insulin pump therapy,
  measuring urine ketones can give more information than glucose
  measurements alone

Question 33

• AKA Hyperosmolar hyperglycemic state
• Extreme hyperglycemia without ketosis and acidosis
• Characterized by hyperglycemia, hyperosmolarity, and
  dehydration without ketosis
• Occurs in px with Type II DM
• Onset is usually slow and takes hours or days to develop
• Causes
  o Leading cause: inadequate fluid replacement
  o Insufficient insulin
  o Major stresses

Answer 33

HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME

Question 34

HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
Signs and Symptoms

Answer 34

• Blood glucose is from 600-1200 mg/dL
• Hypotension
• Dehydration
• Tachycardia
• Mental status changes and neurological deficits
• Seizures
• Polydipsia, polyuria, increased plasma osmolality
  o (> 320 mosm/kg)
  o (NV: 275-295 mOsm/kg),
  o high urine specific gravity (>1.010)

Question 35

HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
Implementation

Answer 35

• volume restoration

Question 36

MEDICAL-SURGICAL MANAGEMENT

Answer 36

1. NASOGASTRIC SUCTION TUBES
2. ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
3. BILLROTH I AND II
4. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
5. LIVER TRANSPLANTATION
6. BARIATRIC SURGERY
7. REVERSE HYDRATION
8. REVERSE KETOACIDOSIS
9. ELECTROLYTE REPLACEMENT
10. RAPID HYDRATION

Question 37

primarily inserted for decompression of stomach

Answer 37

Nasogastric tubes

Question 38

Nasogastric tubes types:

Answer 38

a. LEVIN (Single lumen) Pump
b. SALEM (Double Lumen) Pump

Question 39

o (channel within a tube or catheter) and is made of
plastic/rubber. This is tube is connected to low intermittent
suction (30-40 mmHg) to avoid erosion or tearing of the
stomach lining

Answer 39

LEVIN (Single lumen) Pump

Question 40

o radiopaque (easily seen on x-ray), clear plastic, doublelumen gastric tube. The blue port vent is always open to air for continuous atmospheric irrigation; prevent reflux by having the blue vent port above patient’s waist

Answer 40

SALEM (Double Lumen) Pump

Question 41

• Done via placement of Sengstaken-blakemore or Minnesota tube which are multi-lumen gastric tubes, placed nasally & extended into the stomach;

Answer 41

ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES

Question 42

2 balloons in ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES

Answer 42

o Esophageal balloon – at the esophageal area, when inflated,
tamponades the bleeding in the esophagus
o Gastric balloon - serves as anchor

a. Sengstaken-Blakemore tube
* triple lumen gastric tube (one lumen allows inflation of
esophageal balloon, the other allows inflation of gastric balloon
while third lumen allows for gastric aspiration)
b. Minnesota tube
* quadruple lumen gastric tube; a modified Sengstakenblakemore tube with an additional lumen for aspirating
esophagopharyngeal secretions

Question 43

ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
Nursing Considerations:

Answer 43

• Closely monitor patient’s condition and lumen pressure
• Careful surveillance of patient’s vital signs, oxygen saturation,
  and cardiac rhythm (a change may indicate new bleeding)
• Monitor respiratory status and observe for respiratory distress
  o If respiratory distress= CUT balloon ports and REMOVE tube.
  o Keep scissors at bedside
• Provide support for patient
• Deflate esophageal balloon for about 30 minutes every 12 hours
  or according to hospital policy/procedure

Question 44

a generic term referring to any surgery that involves partial removal of the stomach, may be
accomplished by either a Billroth I or a Billroth II procedure.

Answer 44

Subtotal Gastrectomy

Question 45

• Surgeon removes part of the distal portion of the stomach,
  including the antrum.
• The remainder of the stomach is anastomosed to the duodenum
• This combined procedure is more properly called
  gastroduodenostomy
• It decreases the incidence of dumping syndrome that often
  occurs after a Billroth II procedure.

Answer 45

Billroth I

Question 46

• Billroth II resection involves reanastomosis of the proximal
  remnant of the stomach to the proximal jejunum
• Pancreatic secretions and bile continue to be secreted into the
  duodenum, even after gastrectomy
• Surgeons prefer the Billroth II technique for treatment of
  duodenal ulcer because recurrent ulceration develops less
  frequently after this surgery.

Answer 46

Billroth II

Question 47

WOF in BILLROTH I AND II

Answer 47

Dumping Syndrome – rapid gastric emptying in which your
food moves too quickly from the stomach to the duodenum = let
patient lie on the LEFT SIDE

Question 48

• Involves the threading of a cannula into the portal vein via the
  transjugular route
• an expandable stent is inserted & serves as an intrahepatic shunt
  between the portal circulation & hepatic vein, reducing portal
  hypertension.

Answer 48

TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)

Question 49

• Surgery to remove a diseased liver and replace it with a healthy
  one.

Answer 49

LIVER TRANSPLANTATION

Question 50

LIVER TRANSPLANTATION
Indications:

Answer 50

• Liver transplantations is needed for patients who are likely to die
  because of liver failure
• Common conditions requiring liver transplant include:
  o Noncholestatic cirrhosis
  o Biliary atresia
  o Acute hepatic necrosis

Question 51

Where does a liver for a transplant come from?

Answer 51

Two types:
a. Living donor transplantation
b. Cadaveric transplantation
* Liver transplant surgery takes between 6 and 12 hours

Question 52

LIVER TRANSPLANTATION
POST-OP

Answer 52

Patient is advised to stay in the hospital for an average of 1-3
weeks to ensure that new liver is
working
* Patient is required to take lifetime medicines (e.g. immunosuppressive medications) to prevent rejection and
infections

Question 53

LIVER TRANSPLANTATION
Complications

Answer 53

a. Rejection
* Immune system works to destroy foreign substances that
invades the body. The immune system, however, can’t
distinguish between transplanted liver and unwanted invaders,
such as viruses and bacteria.
* Therefore, immune system may attempt to attack and destroy
the new liver. This is called rejection episode
* Antirejection medications are given to ward off the immune
attack

b. Infection
* Because antirejection drugs that suppress immune system are
needed to prevent the liver from being rejected, it places patient
at increased risk for infections

Question 54

Liver Transplant Guidelines:

Answer 54

1. Monitor prothrombin time, partial thromboplastin time, fibrinogen,
   and factor V levels as ordered.
2. Monitor blood pressure: hypertension is common.
3. GI assessment: Monitor for ascites, bowel sounds, tenderness,
   nausea, vomiting and distention.
4. Do not reposition or irrigate the nasogastric tube without orders.
5. Measure abdominal girth every 12 hours
6. Monitor for biliary leak: Fever, jaundice, shoulder, sepsis.
7. Monitor for biliary stricture: Jaundice, itching, abnormal bilirubin/
   alkaline phosphatase.

Question 55

• Gastric bypass and other weight-loss surgeries—known
  collectively as bariatric surgery—involves making changes to the
  digestive system to help lose weight.
• Done when diet and exercise haven’t worked or when you have
  serious health problems because of your weight

Answer 55

BARIATRIC SURGERY

Question 56

BARIATRIC SURGERY
Types:

Answer 56

a. Biliopancreatic diversion with duodenal switch
b. Roux-en Y Gastric bypass
c. Sleeve gastrectomy

Question 57

BARIATRIC SURGERY
Indications:

Answer 57

• Done to help lose excess weight and reduce risk of potentially
  life-threatening weight-related health problems, including:
• Heart disease and stroke
• High blood pressure
• Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic
  steatohepatitis (NASH)
• Sleep apnea
• Type 2 diabetes
• In general, bariatric surgery could be an option if:
  o Body mass index (BMI) is 40 or higher (extreme obesity)
  o BMI is 35-39.9 (obesity), and patients who have serious
  weight-related health problems threatening complication which would lead to sepsis if left
  untreated)
• NPO for at least 1-2 days
• Diet: Liquids → pureed, very soft foods → regular foods
• Frequent medical checkups to monitor health in first several
  months after surgery

Question 58

PHARMACOLOGIC MANAGEMENT
COMPLIMENTARY/ALTERNATIVE THERAPY

Answer 58

Medicinal uses of Ginger:
* Ginger has been used to treat problems such as vomiting,
diarrhea, coughing, inflammatory joint diseases including
rheumatism and arthritis.
* Ginger may lower cholesterol and help prevent blood from
clotting.
* Other studies suggest that ginger may help improve blood sugar
control among people with type 2 diabetes
How to take it:
Pediatric:
* DO NOT give ginger to children under 2
* Children over 2 may take ginger to treat nausea, stomach
cramping, and headaches. However, a consult with a physician is
recommended to find the right dose
Adult:
* In general, DO NOT take more than 4g of ginger per day,
including food sources.
* Pregnant women should not take more than 1g/day.
Possible Interactions:
* Blood-thinning medications
o Warfarin (Coumadin), clopidogrel (Plavix), aspirin
o Ginger may increase risk of bleeding
* Diabetes medications
o Ginger may lower blood sugar. That can raise the risk of
developing hypoglycemia or low blood sugar
* High blood pressure medications
o Ginger may lower blood pressure, thereby raising the risk of
hypotension or irregular heartbeat
2. BITTER GOURD OR BITTER MELON (AMPALAYA)
* Scientific name: Momordica charantia
* A climbing vine with tendrils that grow up to 20 cms long
* Fruits have ribbed and wrinkled surface that are fleshy green
with pointed end at length and has a bitter taste
Uses:
* Lowers blood sugar levels
* Diabetes Mellitus (Mild-non insulin dependent)
Preparation:
* Gather and wash young leaves very well.
* Chop.
* Boil 6 tablespoons in two glassfuls of water for 15 minutes under
low fire.
* Do not cover pot.
* Cool and strain.
* Take one third cup 3 times a day after meals
V. CLIENT EDUCATION
VI. EVALUATION OF OUTCOME OF CARE
VII. REPORTING AND DOCUMENTATION OF CARE