GI emergencies Flashcards
when are you concerned about intestinal integrity?
-obstruction
-perforation
-ischemia
when are you concerned about infection?
-diverticulitis
-appendicitis
-peritonitis
what causes a bowel obstruction?
-functional (maybe it’s blood flow, twist, scar tissue)
-mechanical (intrinsic lesions & extrinsic lesions)
most commonly seen bowel obstructions
-adhesions
-tumor
functional bowel obstructions
(Ileus)
-inactive intestinal muscles producing blockage or obstruction of the intestine
-most often seen post abdominal surgeries
-can also be caused by medications, electrolyte abnormalities, infections
who’s at risk for an abdominal obstruction?
-prior abdominal surgery
-ischemia
-hernia
-abdominal cancer
-abdominal radiation
-IBS
-decreased gut motility
-decreased general mobility
obstructions - priority assessments
-failure to pass stool or flatus
-diarrhea
-abdominal pain
-abdominal distension
-nausea and vomiting (loosing bicarb & potassium)
-changes in bowel sounds
-tympany
-tachycardia
-hypotension
-fever
-localized tenderness, rebound, guarding (suggesting peritonitis)
obstructions - priority interventions
-NG tube insertion to decompress the gut
-antiemetic medications (metocloprmide for partial/functioning obstruction, halodol for complete/malignant obstructions)
-isotonic IV fluids to replace volume deficit
-replete electrolytes as necessary
-bowel rest
-consult surgery asap
NG tube management
-make them NPO
-do oral care
-double lumen w/ vent
-intermittent suction not high suction
gold standard for checking NG tube placement
pH check
obstructions - surgical management
-~25% of cases will require surgical intervention
-complete mechanical obstruction can cause strangulation and necrosis
-strangulation is surgical emergency
-may require diverting ileostomy or colostomy
GI ischemia
lack of perfusion to the gut is catastrophic for the patient, mortality is 50%
GI ischemia etiology
-compromise in blood flow to the intestine
-acute occlusion usually due to cardiogenic embolus
-results in tissue injury, death, and eventually necrosis
underlying causes for GI ischemia
-hypovolemia
-arrhythmias
-hypercoagulable states
-mechanical obstructions
-vascular diseases
-trauma
-vasoconstrictors
who’s at risk for ischemia
-obstruction
-DM
-dyslipidemia
-smoking
-heart failure
-aortic or coronary artery bypass surgery
-shock
-afib (watch for clots)
-atherosclerosis
ischemia signs and symptoms
-abdominal pain “out of proportion to the physical examination”
-peritoneal signs (abdominal guarding and rebound tenderness)
-acute onset colicky, severe left lower abdominal pain
-diarrhea
-abdominal distension
-decreased bowel sounds
-hematochezia (bloody stools)
-abdominal tenderness
order of assessing abdomen
inspect
auscultate
percuss
palpate
ischemia priority assessment
-strong physical assessment
-leukocytosis
-metabolic acidosis
-elevated lactate
-elevate LDH
-signs and symptoms of sepsis
-hemodynamic stability
ischemia priority interventions
-isotonic IV fluids to replace volume deficits
-broad spectrum antibiotics
-hemodynamic stability
-NG tube insertion to decompress the gut
-replete electrolytes as necessary
-bowel rest
-possibly consult vascular
-treat underlying cause fast
intestinal perforation etiology
-ischemia (bowel obstruction, necrosis)
-infection (appendicitis, diverticulitis)
-erosion (malignancy, ulcerative disease)
-physical disruption (trauma, iatrogenic injury (accidentally hitting bowel during surgery))
intestinal perforation
full-thickness injury of the bowel wall
who’s at risk for intestinal perforation?
-recent abdominal procedures
-recent traumas
-foreign body ingestion
-violent vomiting
-IBDS
-cancer
intestinal perforation priority assessments
-thorough abdominal history and examination
-imaging to look for intraperitoneal air
-signs & symptoms of sepsis
-nausea and vomiting
-perioneal signs (abdominal guarding & rebound tenderness)
-rigid abdomen
intestinal perforation priority interventions
-hemodynamic stability
-broad spectrum antibiotics
-consult surgery
-possibly consult vascular surgery (aorta is in there)
diverticulitis etiology
inflammation of one or more diverticula
diverticulitis risk factors
-age
-low intake of dietary fiber
-slow colonic transit time
-obesity
-cigarette smoking
-history of frequent constipation
-regular use of NSAIDs
-family history
diverticulitis priority assessment
-cramping pain in lower left quadrant (hallmark sign)
-constipation
-bloating
-nausea
-fever
-leukocytosis
-monitor for evolving signs and symptoms
diverticulitis priority interventions
-spectrum of treatment depending on severity
-uncomplicated vs complicated
uncomplicated diverticulitis priority interventions
-rest, oral fluids, analgesics medications
-high-fiber, low-fat diet
-selective antibiotic use
complicated diverticulitis priority interventions
-hospitalization
-NPO
-IV fluids
-gastric decompression
-broad-spectrum antibiotics
diverticulitis priority interventions
-abscess formation requires intervention (CT-guided percutaneous drainage, IV antibiotics)
-possible surgery after recovery to prevent recurrence
appendicitis etiology
-appendix prone to obstruction and infection
-obstruction causes inflammation (increased pressure, edema, ischemia, bacterial growth)
appendicitis priority assessments
-vague periumbilical pain progresses to right lower quadrant pain
-McBurney’s sign
-Rovsing’s sign
-monitoring for changes in signs and symptoms
McBurney’s sign
RLQ pain
Rovsing’s sign
LLQ pain
appendicitis priority interventions
-pain relief (morphine)
-isotonic IV fluids to replace volume deficit
-antibiotics
-post surgical nursing interventions (prevent atelectasis, high fowler position, early ambulation, monitor for bowel sounds)
Peritonitis
inflammation of the peritoneum
primary peritonitis
spontaneous bacterial infection of ascitic fluid
secondary peritonitis
perforation of abdominal organs with spillage that infects with serous peritoneum
tertiary peritonitis
superinfection in a patient who is immunocompromised
who’s at risk for primary peritonitis
liver failure
who’s at risk for secondary peritonitis
-appendicitis
-ulcerative disease
-diverticulitis
who’s at risk for tertiary peritonitis
HIV progressed to AIDS
peritonitis priority assessments
-difficult to differentiate early signs (signs and symptoms of underlying cause)
-generalized, diffuse pain that becomes localized
-distended, rigid abdomen
-nausea and vomiting
-anorexia
-signs and symptoms of sepsis and septic shock
-monitor labs
peritonitis priority interventions
-infection source control is priority
-antibiotics
-isotonic IV fluids to replace volume deficit
-replete electrolytes as necessary
-hemodynamic stability
Nutrition for the critically ill patient
-Enteral nutrition (EN) is preferred
-Parenteral nutrition only is EN is not feasible
-beware of nutrition intolerances with gastric resections (dumping syndrome, refeeding syndrome)
