GI exam 2 Flashcards
acute pancreatitis
inflammation of pancreas
-can be mild / severe
mild acute pancreatitis
self limiting, no end organ dysfunction
-most fully recover
severe acute pancreatitis
pts may develops SIRS and end-organ dysfunction
acute pancreatitis risks
alcohol and gallstones
other acute pancreatitis risks
I GET SMASHED
I GET SMASHED
idiopathic
gallstones
ethanol
trauma
steroid use
mumps
autoimmune
scorpion stings
hypercalcemia / hypertriglyceridemia
ECRP
drugs / meds
acute pancreatitis s/s
sudden onset severe EPIGASTRIC pain!!
-radiates to flank / back / shoulder
-sharp, deep pain
n/v - bloody??
abd distention
hypotension and shock
tetany (hypocalcemia)
-trousseau’s sign
-chvostek’s sign
chvostek’s sign
twitch of facial muscles when touching someones cheek
trousseau’s sign
involuntary contraction of wrist muscle when BP cuff is inflated
severe hemorrhagic pancreatitis
from eroding blood vessels
-cullen’s sign
-grey-turner’s sign
cullen’s sign
bluish discoloration around umbilicus
grey turner’s sign
bluish discoloration of flanks
-must turn pt to see this!!
acute pancreatitis labs
CBC : wbc elevation
CMP : ast / alt elevation , direct bilirubin elevated, calcium decreased, albumin decreased
Lipase : elevated
acute pancreatitis dx test
abdominal CT with contrast!!!
abd US
EKG
CXR
acute pancreatitis US
look at gallbladder for dilated common bile duct
acute pancreatitis CT
confirming / viewing possible calcification in duct
acute pancreatitis dx
- acute onset on persistent , severe epigastric pain
- elevated lipase / amylase
- findings on dx imaging
** MUST have 2 OF 3 in order to have dx
ranson’s criteria
score > 3 indicates severe pancreatitis
Ransons admission
> 55 years old
WBC > 16,000
LDH > 350
AST > 250
glucose > 200
**KNOW THIS
Ransons at 48 hours
hematocrit decrease > 10%
BUN increase > 5
Calcium < 8
PaO2 < 60
base deficit > 4
fluid sequestration > 6
**KNOW THIS
acute pancreatitis management
fluid replacement : IV crystalloids
electrolyte replacement : hypocalcemia, hypomagnesmia, hypokalemia
acute pancreatitis fluids
IV crystalloids at 5-10 ml / kg / hr
acute pancreatitis I / O
urinary output < 50 mL / hr is early sign of HYPOVOLEMIA
acute pancreatitis BP
systolic BP > 100
MAP > 60
HR < 100
hypocalcemia s/s
widened QT interval
tetany , chvostek , trousseau
seizure PRECAUTIONS
what lab to monitor with hypocalcemia…
albumin levels
if potassium is needed for hypokalemia…
ALWAYS HANG POTASSIUM ON A PUMP
-no more than 20 mL / hr
-potassium burns going in
acute pancreatitis patients must….
remain NPO for 24 hours!!!
mild pancreatitis diet
oral feeding IF no vomiting / decreased pain / inflammatory markers improving
severe pancreatitis diet
enteral nutrition if unable to tolerate oral diet by 5 days!!!
acute pancreatitis comfort
PAIN MANAGEMENT is #1
-pain increase pts metabolism , IV opioids , PCA pump
antibiotics NOT recommended
acute pancreatitis pulmonary complications
ARDS
atelectasis , pneumonia , pleural effusion
hypoxemia
acute pancreatitis cardiac complications
cardiac dysrhythmias
hypovolemic shock
myocardia depression
acute pancreatitis GI complications
GI bleeding
pancreatic abscess
pancreatic pseudocyst
acute pancreatitis hematologic complication
DIC
coagulation abnormalities
acute pancreatitis renal complications
acute renal failure
elevated BUN
oliguria - low urine output
acute pancreatitis education
diet : small frequent meals, eats carbs , AVOID FAT AND PROTEIN
no alcohol
no smoking
acute pancreatitis improvement
lipase decreases and pain decreases
acute pancreatitis might have this in place if caused by alcohol….
seizure precautions
chronic pancreatitis
persistent inflammation , not reversible
chronic pancreatitis risks
heavy alcohol use
recurrent / severe acute pancreatitis!!!!
smoking
genetics
chronic pancreatitis s/s
-upper abd pain radiating to back : gets WORSE with eating / drinking (esp. alcohol)
-n/v
-weight loss
-pale / clay colored stool!!!
-steatorrhea (greasy , bad smelling stool)
chronic pancreatitis labs
CBC
CMP :
-alkaline phosphate : increase
-bilirubin : increase
-glucose : increase
Lipase and amylase increased
chronic pancreatitis dx test
abd CT
abd US
ERCP
*visualize pancreas and verify structural changes
chronic pancreatitis diagnosis
- chronic abd pain , recurring acute pancreatitis
- diarrhea, steatorrhea, weight loss
- pancreatogenic diabetes
- visual damage on imaging!!!
chronic pancreatitis pain control
opioids normally required
chronic pancreatitis meds
IV fluids
electrolyte replacement
histamine blocker
PPI
pancreatic enzyme replacement therapy (PERT)
provides amylase and protease
tx malnutrition and malabsorption
taken everytime pt eats
**Creon
chronic pancreatitis education
NO alcohol
avoid tobacco
pancreatic enzyme meds
limit fat
avoid irritating foods / drinks
-coffee, caffeine
pancreatic enzyme education
take with food and FULL glass of water
DO NOT chew tablets
chronic pancreatitis CT
will have MULTIPLE pancreatic calcifications
pancreatic cancer
diagnosis often occurs late in disease process
-very rapid growing
pancreatic cancer risks
smokers
diet high in fate
high meat consumption, fried food, refined sugar, nitrates
diabetes, chronic pancreatitis
family hx
> 60 years
pancreatic cancer s/s
VAGUE symptoms : present like all GI disorders
pain : dull and epigastric area
jaundice : bile duct obstruction
fatigue
weight loss
pancreatic cancer labs
not specific for dx but see how pancreas working:
CBC
CMP :
-lipase increase
-LFTs increase
-bilirubin increase
fecal fat in stool
pancreatic cancer dx test
ultrasound
CT scan
MRI
ECRP
**determines mass
pancreatic cancer definitive dx
made through biopsy
pancreatic cancer management
chemo and radiation normally used palliatively because tumor is metastisized
whipple procedure
major resection of pancreas / duodenum / stomach and gallbladder
-most pts not a canidate
pancreatic cancer nursing mgmt
vitals and i / o , weight
glucose monitor
monitor and tx pain
monitor weight
palliative care
whipple post op pancreatic cancer
1.maintain NPO
2. NG tube low suction
-NEVER MANIPULATE the NG post op
-call surgeon if it comes out
3. glucose monitor
4. post op drain tubes
5. semi-folwers
6. assess for surgical complications
whipple complications post op
diabetes
hemorrhage
wound infection
bowel obstruction
intra-abdominal abscess
pancreatic cancer education
post op care
medications
diet / nutrition : dietary supplements
s/s of hypo or hyperglycemia
coping skills / support groups / palliative care
cirrhosis
chronic disease that causes scarring of hepatic tissue
-not reversible only delay progression
cirrhosis causes
hepatitis C!!!
alcohol induced cirrhosis
smoking
NASH
autoimmune diseases
hepatotoxins / medications
former IV use
cirrhosis s/s
SOB
jaundice!!!
increased abd girth!!!
abd pain / bloating
spider angioma
hemorrhoids
bleeding / bruising
pruritis
asterixis
hepatic encephalopathy
cirrhosis patho changes
- ascites
- coagulopathy
asterixis
flapping tremor of hand when the wrist is extended
cirrhosis labs
CBC : decrease platelets
CMP :
-increase ast / alt
-increase bilirubin
-increase alkaline phosphate
-decrease albumin
-decrease sodium
Coags : increase PT / increase aPTT
Ammonia increase
cirrhosis dx test
abd US : enlarged liver
CXR : elevated diaphragm
liver biopsy: definitive test, not always done r/t risks
cirrhosis complications
bleeding
hyponatremia
hepatorenal syndrome
spontaneous bacterial peritonitis
hemorrhoids
hepatorenal syndrome
rapid deterioration of kidneys
spontaneous bacterial peritonitis
tx with antibiotics
fever, abd pain, encephalopathy
cirrhosis management
- ascites management
- portal HTN mangement
ascites management
paracentesis : invasive procedure to remove fluid from abdominal cavity
**both dx and tx
portal hypertension management
Sengstaken - Blakemore Tube
-should not be left in place for more than 24 hours
-keep scissors at bedside for emergency use
cirrhosis education
-low protein
-low sodium : < 2g / day
-no alcohol
-avoid meds metabolized in the liver : acetaminophen
-soft toothbrushes , careful flossing , shaving : bleeding precautions
cirrhosis nursing management
administer diuretics
electrolyte replacement
restrict sodium / fluid intake
elevate head of bed / legs
administer blood products
vitamin K
FFP
hepatic encephalopathy
spectrum of reversible abnormalities , main cause is AMMONIA and toxins in the blood
hepatic encephalopathy causes
ammonia
high protein diet
hypokalemia
GI bleeding!!!
-hypovolemia
-constipation
hepatic encephalopathy s/s
mood changes
slurred speech
asterixis
confusion
decreased LOC
-poor coordination
-coma
-disturbance in sleep
hepatic encephalopathy labs
Ammonia increased
CMP :
-increased liver enzymes
-increased bilirubin
-increased alkaline phosphate
-decreased potassium
hepatic encephalopathy dx
EXCLUSION of other causes
-labs
-CT to rule out cause
**elevated ammonia levels are NOT diagnostic alone
hepatic encephalopathy management
avoid protein overload : small frequent meals
LACTULOSE : prevents ammonia absorption
NEOMYCIN : abx that kills normal flora of bacteria
POTASSIUM
prevent GI bleed
restrict toxic meds
-opioid
-sedatives
-barbituates
hepatic encephalopathy education
factors that cause it
s/s
initial signs are subtle
lactulose
given to decrease ammonia levels , should produce 2-3 soft stools per day
variceal bleeding
MEDICAL EMERGENCY , caused by massive upper GI blood loss
variceal bleeding priority
hemodynamic stability and establish a PATENT AIRWAY
-dx of cause is priority before treatment
variceal tx
octreotide
vasopressin
endoscopic procedure
TIPS
esophagogastric tamponade
octreotide
used to slow / stop bleeding
IV bolus followed by INFUSION
monitor for hypo / hyperglycemia!!!
endoscopic procedure
sclerotherapy
endoscopic band ligation
TIPS
nonsurgical treatment for recurrent variceal bleeding after sclerotherapy
esophagogastric tamponade
inflation of balloon applies pressure to vessels stopping the bleeding
**sengstaken - blakemore tube
Sengstaken Blakemore Tube
3 lumen
normal inflation 20-45 mmHg
**deflate balloon every 8-12 hours
deflate esophageal BEFORE gastric
sengstaken blakemore tube complications
possible rupture
-all lumen are CUT and tube is removed
**KEEP SCISSORS at BEDSIDE
esophageal varices priority actions
- PROTECT AIRWAY : prepare to intubate
- two large IVs
- rapid fluid bolus
**blood products
esophageal varices labs
CBC
CMP
coags
stool
type and cross : in case of infusion
colon cancer risks
- family hx
- IBS for 10 or more years
- obesity
- dietary : high fat , red meats , processed
- cigarette use
- alcohol
colon cancer s/s
unexplained weight loss / fatigue
change in bowel regularity
blood in stool!!!
abd pain / distention
colon cancer labs
CBC : wbc increased
CMP : electrolyte imbalance
CEA : cancer specific lab
colon cancer dx tests
abdominal CT
MRI
abd x-ray
colon cancer colonoscopy
GOLD STANDARD for dx
-biopsy taken , polyps removed
colon cancer management
chemotherapy
radiation
surgical!!! - remove affected portion
colon cancer preop
physical assessment
bowel prep : laxative
pre-op abx
consent
colon cancer postop
vitals every 4 hours
monitor labs : H and H / WBC
assess for n/v
monitor i/o
monitor incision
pain control
early ambulation
cough / deep breathe
colon cancer teaching
prevent post op complications
ostomy teaching
ostomy post op
slight bleeding initially
slightly swollen but should subside
2-4 days to function post op
return of flatulus
stoma post op eval
reddish pink / moist
signs of ischemia
stoma ischemia
dark red / purple
unusual bleeding
transverse colostomy
semiliquid to semiformed stool
ascending colostomy
semiliquid stool
illeostomy
liquid to semiliquid stool
sigmoid colostomy
formed stool
descending colostomy
semiformed stool
ostomy pt teaching
care of ostomy , supplies , complications
SELF CARE is more successful when done BEFORE the procedure
peritonitis
inflammation / infection of membrane that lines abdominal cavity
life threatening peritonitis
- peristalsis slows / stops
- bowels become distended
- toxins and bacteria –> sepsis
- respiratory problems from increased abd pressure
peritonitis s/s
severe pain!!!
board like abd!!!
rebound tenderness!!
fever
decreased UO
diminished bowel sounds
resp distress
peritonitis labs
CBC : wbc elevated
CMP :
-electrolytes abnormal
-increase BUN / creatinine
Lactic acid increase
peritonitis dx tests
abd x-ray
abd CT scan
US
peritonitis diagnosis
based on physical assessment, labs , radiology
peritonitis nonsurgical mgmt
IV fluids
IV abx
NG tube : decompress stomach
NPO
peritonitis surgical
focus on removing foreign material and fluid
EXPLORATORY LAPAROTOMY
peritonitis nuring management
administer fluids and abx
pain management
monitor worsening condition
I/O
post surgical assessment
peritonitis worsening
decreased LOC
vitals
respiratory status decreased
“hot belly” is also known as….
peritonitis
malabsorption syndrome
chronic diarrhea
wt loss
s/s depend on what nutrient is not reabsorbed
malabsorption tx
antidiarrheal
IV fluids
antibiotics
steroids
gastric cancer causes
H. pylori
Smoking
-atrophic gastritis
gastric cancer s/s
most dx very late
-indigestion
-anorexia
-weight loss
-vague epigastric pain
-vomiting
-abd mass
gastric cancer labs
CBC : H and H decreased
CMP : ALT / AST elevated
CEA : increased
GUAIAC POSITIVE
gastric cancer dx
EGD : see esophagus , stomach , upper duodenum
CT
barium x-ray
gastric cancer surgery
gastric resection + chemo
complication = dumping syndrome
dumping syndrome
chyme enters bile too rapidly
early s/s
-dizziness
-tachycardia
-pallor
-sweating
-diarrhea
-palpitations
dumping syndrome late s/s
hypoglycemia-
weakness
sweating
dizziness
gastric cancer educations
small frequent meals, non irritating food
nutrition supplements
