GI ALterations Flashcards
– 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
ACUTE GI BLEEDING
ACUTE GI BLEEDING ETIOLOGY
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
ACUTE GI BLEEDING
Signs and Symptoms/ Clinical Presentation
- 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
ACUTE GI BLEEDING
Diagnostic Exams
- Endoscopy – considered the GOLD STANDARD for diagnosis of GI bleeding
- EGD
- Colonoscopy
- Radiographic procedures
- Serum blood studies
ACUTE GI BLEEDING
TREATMENT:
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
ACUTE GI BLEEDING
Nursing Management
- 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
- 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
Intraabdominal hypertension (IAH)
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
Abdominal Compartment Syndrome (ACS)
Effects of Increase IAP
- 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
- 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
Intra-abdominal Pressure Monitoring
TREATMENT FOR IAP
- 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
- 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
LIVER FAILURE
Types of Liver Failure
- Fulminant Hepatic Failure
o Encephalopathy starts within 8 weeks - Non Fulminant Hepatic Failure
o Encephalopathy starts between 8-26 weeks
- 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
Acute Liver Failure
LIVER FAILURE
Signs and Symptoms
- 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
LIVER FAILURE
Pharmacological Management
- 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
LIVER FAILURE
Nursing Managements
- 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
- 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
ACUTE PANCREATITIS
ACUTE PANCREATITIS
Assessment
- 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
ACUTE PANCREATITIS
Diagnostic Exams
- ↑ 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)
ACUTE PANCREATITIS
Medical Management
- 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
ACUTE PANCREATITIS
Therapeutic Management
- NPO with NGT
- IV and TPN
- Peritoneal lavage
- Cholecystectomy after acute pancreatitis is resolved
ACUTE PANCREATITIS
Nursing Management
- 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
