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
- Medical term describing an abnormally high blood glucose level
- Hallmark sign of diabetes (both type 1 and 2 DM)
HYPERGLYCEMIA
HYPERGLYCEMIA
Signs and Symptoms
- 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
HYPERGLYCEMIA
Precautionary Measures
- Follow diabetes meal plan, exercise program, and medication
routine - If blood sugar levels are above target range, drink extra liquids
- Monitor blood sugar often
HYPERGLYCEMIA
Treatment
- 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
- A life-threatening complication of DM that develops when
severe insulin deficiency occurs
DIABETIC KETOACIDOSIS (DKA)
DIABETIC KETOACIDOSIS (DKA)
The main clinical manifestations:
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
DIABETIC KETOACIDOSIS (DKA)
Assessment
- 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
DIABETIC KETOACIDOSIS (DKA)
Implementation
- 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
DIABETIC KETOACIDOSIS (DKA)
Prevention
- 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
- 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
HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
Signs and Symptoms
- 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)
HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
Implementation
- volume restoration
MEDICAL-SURGICAL MANAGEMENT
- NASOGASTRIC SUCTION TUBES
- ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
- BILLROTH I AND II
- TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
- LIVER TRANSPLANTATION
- BARIATRIC SURGERY
- REVERSE HYDRATION
- REVERSE KETOACIDOSIS
- ELECTROLYTE REPLACEMENT
- RAPID HYDRATION
primarily inserted for decompression of stomach
Nasogastric tubes
Nasogastric tubes types:
a. LEVIN (Single lumen) Pump
b. SALEM (Double Lumen) Pump
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
LEVIN (Single lumen) Pump
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
SALEM (Double Lumen) Pump
- Done via placement of Sengstaken-blakemore or Minnesota tube which are multi-lumen gastric tubes, placed nasally & extended into the stomach;
ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
2 balloons in ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
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
ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
Nursing Considerations:
- 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
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.
Subtotal Gastrectomy
- 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.
Billroth I
- 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.
Billroth II
WOF in BILLROTH I AND II
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
- 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.
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
- Surgery to remove a diseased liver and replace it with a healthy
one.
LIVER TRANSPLANTATION
LIVER TRANSPLANTATION
Indications:
- 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
Where does a liver for a transplant come from?
Two types:
a. Living donor transplantation
b. Cadaveric transplantation
* Liver transplant surgery takes between 6 and 12 hours
LIVER TRANSPLANTATION
POST-OP
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
LIVER TRANSPLANTATION
Complications
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
Liver Transplant Guidelines:
- Monitor prothrombin time, partial thromboplastin time, fibrinogen,
and factor V levels as ordered. - Monitor blood pressure: hypertension is common.
- GI assessment: Monitor for ascites, bowel sounds, tenderness,
nausea, vomiting and distention. - Do not reposition or irrigate the nasogastric tube without orders.
- Measure abdominal girth every 12 hours
- Monitor for biliary leak: Fever, jaundice, shoulder, sepsis.
- Monitor for biliary stricture: Jaundice, itching, abnormal bilirubin/
alkaline phosphatase.
- 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
BARIATRIC SURGERY
BARIATRIC SURGERY
Types:
a. Biliopancreatic diversion with duodenal switch
b. Roux-en Y Gastric bypass
c. Sleeve gastrectomy
BARIATRIC SURGERY
Indications:
- 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
PHARMACOLOGIC MANAGEMENT
COMPLIMENTARY/ALTERNATIVE THERAPY
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
