GI / hepatic

Question 1

• Treatment of ketoacidosis can cause:

Answer 1

Hypoglycemia

Question 2

What med needs to be taken for life by someone who have had total gastrectomy?

Answer 2

Pt with total gastrectomy - what medication is needed to be taken for life.
• cyanocobalamin - synthetic vitamin b12
• Stomach secreted intrinsic factor needed by body to absorb b12

Question 3

What is a whipple procedure?

Answer 3

What is a whipple procedure
• sx to remove tumor in the pancreas, head of pancrease removed
• Pt would now have impaired fat, glucose metabolism and bile not delivered into intestine.
• Coz of malabsorption pt needs low fat, high protein moderate carbs and supplements

Question 4

Why is PeG tube preferred over exiting ng tube on client

Answer 4

Less risk of aspiration

Question 5

Priority Postoperative care after laparoscopic cholecystectomy

Answer 5

• to get rid of the CO2 tha has been put into the abdominal cavity during the procedure to inflate the cabity and visualize the organs. Co2 can irritate phrenic nerve and dialhragm. Pt will have shallow breathing and referred pAin to the right shoulder
• Early ambulation is the priority - gets rid of excess Co2, prevents thromboembolism, stimulates return of normal of peristalsis which slows doen coz of anedthetics and opiods
• Anti embolism stockings, stool softeners

Question 6

ERCP

Priority before and after procedure

Answer 6

• endoscopic retrograde cholangiopancreatography
• Procedure in whichan endocope is inserted through the mouth and into the duodenum to assess billiary and pancreatic ducts. Uses flouruscopy with contrast media to visualize and perform tmts like dilating stricture, removal of obstructiins, biopsies

Before procedure: NPO at least 8 hours prior to prevent risk for aspiration
After procedure highest priority is to check pulse and blood. pressure to monitor for hypovolemia coz procedure can cause esophageal and or duodenal perforation

Question 7

Complication of ERCP

Answer 7

• perforation - leads to acute pancreatitis - autodigestion
• Epigastric or upper left quadrant pain which radiates to the back, rapid increase in pancreatic enzymes - lipase , amylase

Question 8

Complications of acute pancreatitis

Answer 8

• hypovolemia coz of capillarly leak - third spacing
• Hypoxia or acute respiratory distress syndrime
• Peritonitis
• Hypocalcemia

Pseudocyst - cyst like pockets of fluid that collect in pancreas. Can rupture and cause internal bleeding and infection

Hypoxia or respiratory distress syndrom - coz pancreatitis cause

Hyperglycemia

Question 9

Hypocalcemis signs

Answer 9

• chvosteks sign - facial twitching
• Trosseaus sjgn - carpal spasm when bp cuff inflated

Tetany
Arrythmias

Question 10

Colonoscopy complications

Answer 10

Colonoscopy complications
- Rectal bleeding
- Perforation
- symptoms: abdominal pain, distension, rigid boardlike, tenesmus, guarding, positive rebound tenderness
- expected findings: during procedure air is put in the bowels, it stims peristalsis so abdominal cramping post procedure expected. Gas also expected. Loose water stools coz pre procedure involves water, cathartics and enemas
- nausea and vomitting.. Sidelying position to prevent aspiration
Administer ondansetron an antiemetic
Monitor potassium - its needed for contraction of heart muscles
- atelectasis
Can occur after any procedure dt anesthesia, restricted breathing from pain and retained secretions
- Alveoli collapsed
Crackles can be heard which can resolve with deep breathing bu isomg incentive spirometer

Question 11

IBS

Answer 11

Irritable bowel syndrome

• altered intestinal motility which disrupts peristalsis and causes consti, diarrhea
• Mgmt is thru diet - eat lots of fibers and avoid gas producing foods like beans, and cruciferous veg like brocolli, cabbage. caffeine, alcohol, and gastric irritants like dairy, spicy and oily foods. protein and bland foods usually tolerated

Question 12

Abdo pain

Rlq
Llq
Ruq
Epigastric burning

Answer 12

Abdominal pain

1. Right lower quadrant
   - assoc with appendicitis. Appendix located. At junction between small and large intestines. When it is blocked or infected it becomes inflammed. Symptoms rlq continuous pain starting at periumbilicus and ending in mcburneys point (over appendix) . Anorexhia n and v. Rebound tenderness and guarding. Pt will attempt to relive the pain by lying still, flexing right leg and preventing intraabdominal pressure like cough, sneezing breathing deep etc
2. Upper abdomen burning
   - may be dt duodenal or epigastric ulcers which may radiate to back if ulcer is located posteriorly
3. Left lower abdominal pain
   - often assoc with diverticulitis (often sigmoid colon) symptom: tender palpable mass and systemic signs of infection (creactive protein elevated, leukocytosis, fever)
   4 right upper quadrant
   - often acute cholecystitis
   - N & v, restlessness, diaphoresis, indigestion

Question 13

Peptic ulcer disease

Answer 13

Peptic ulcer disease
- Breaks on mucusa of esophagus, stomach or duodenum which turn into ulcers - causes gastric acid and digestive enzymes to leak and damage tissues - can lead to GI bleed or perforation
- Risk factors
H. Pylori infection
Stress, diet, lifestyle
Chronic nsaids -
Caffeine soda smoking alcohol- stim gastric acid secretion
Eating short frequent meals or before bed time stims acid secretion

Question 14

Hepatic encepalopathy

Answer 14

Hepatic encepalopathy

• life threatening complication of end stage liver disease
• Liver cannot detox ammonia in blood. Ammonia levels rise
• Lethargy, confusion, can lead to coma
• Asterixis - extend arms with hands facing down. Hands will have flapping tremors
• Tmt: lactulose, rifaximin (antibiotics - stop growth of bacteria that can worsen encepalopathy

Question 15

Diarrhea

Answer 15

Diarrhea

• usually last 4 days or less. treated with acetaminophen, rest, fluids. Loperamide (immodium) if no fever to slow peristalsis. But not to be given if fever or more than 2 days coz retention of bacteria can cause toxic megacolon
• If more than 4 days — MD (assess dehydration, fluid and e status, underlying cause - infection like cdiff, GI problems malabsorption. intolerances. Med side effect

Question 16

GERD with esophagitis

Answer 16

chronic reflux of stomach contents into the esophagus causing inflammation of esophagus mucosa

• Factors that precipitate it - increase pressure in the stomach (eating too much at once) weakened muscle tone of lower esophageal aphincter (alcohol, caffeine, soda) delayed gastric emptying (fatty foods)
• Lifestyle changes
• Small, frequent meals
• Weight loss to lose abdo fat
• Avoid triggers; caffein alcohol nicotine carbonated drinks chocolate peppermint
• Elevate head when sleeping
• Dont lie down right away after eating
• Chew gum - salivation - neutralize acid in esophagus

Question 17

Cirrhosis

Answer 17

Cirrhosis

• usually the end stage of many liver diseases
• Liver tissue changed to fibrosis and become nodules. Altered structure impairs blood flow and normal functioning of the liver.
• Liver cannot conjugate and excrete billirubin causing jaundice
• Liver cannot make coagulation factors - clotting time longer thus pt, aptt, inr would be elevated
• Liver cannot detoxify ammonia (product of deamination of amino acids) and turn them to urea which is excreted by urine. Ammonia crosses the blood brain barrier and cause hepatic encepalopathy
• Liver cannot make enough albumin. Albumin holds water inside vascular space. Low albumin causes water to leak out to interstitial space. Kidneys will take it as sign of low perfusion and try to reabsorb sodium and water. But still too much water compared to sodium - dilutional hyponatremia

Question 18

Pt with total gastrectomy - what medication is needed to be taken for life.

Answer 18

Pt with total gastrectomy - what medication is needed to be taken for life.
• cyanocobalamin - synthetic vitamin b12
• Stomach secreted intrinsic factor needed by body to absorb b12

Question 19

What is a whipple procedure

Answer 19

What is a whipple procedure
• sx to remove tumor in the pancreas, head of pancrease removed
• Pt would now have impaired fat, glucose metabolism and bile not delivered into intestine.
• Coz of malabsorption pt needs low fat, high protein moderate carbs and supplements

Question 20

Why is percutaneous endoscopic tube (peg) preffered over existing NG tube on client?

Answer 20

Why is percutaneous endoscopic tube (peg) preffered over existing NG tube on client?
• less chance of aspiratiom

Question 21

Priority Postoperative care after laparoscopic cholecystectomy

Answer 21

Priority Postoperative care after laparoscopic cholecystectomy
• to get rid of the CO2 tha has been put into the abdominal cavity during the procedure to inflate the cabity and visualize the organs. Co2 can irritate phrenic nerve and dialhragm. Pt will have shallow breathing and referred pAin to the right shoulder
• Early ambulation is the priority - gets rid of excess Co2, prevents thromboembolism, stimulates return of normal of peristalsis which slows doen coz of anedthetics and opiods
• Anti embolism stockings, stool softeners

Question 22

ERCP

Complications

Answer 22

• endoscopic retrograde cholangiopancreatography
• Procedure in whichan endocope is inserted through the mouth and into the duodenum to assess billiary and pancreatic ducts. Uses flouruscopy with contrast media to visualize and perform tmts like dilating stricture, removal of obstructiins, biopsies

Complications

• perforation - leads to acute pancreatitis - autodigestion
• Epigastric or upper left quadrant pain which radiates to the back, rapid increase in pancreatic enzymes - lipase , amylase

Question 23

Complications of acute pancreatitis
• hypovolemia coz of capillarly leak - third spacing
• Hypoxia or acute respiratory distress syndrime
• Peritonitis
• Hypocalcemia

Signs of hypocalcemia

Answer 23

Complications of acute pancreatitis
• hypovolemia coz of capillarly leak - third spacing
• Hypoxia or acute respiratory distress syndrime
• Peritonitis
• Hypocalcemia
•
Hypocalcemis signs
• chvosteks sign - facial twitching
• Trosseaus sjgn - carpal spasm when bp cuff inflated

Question 24

Symptoms of chronic pancreatitis

Lab value elevated with acute exacerbation

Factors associated with chronic pancreatitits

Answer 24

Steatorrhea - fatty, frothy, foul smelling stool due to decrease in pancreatic enzyme prod

Lab values: amylase and lipase (normal 23-85 and 0-60 U/L) will be increase 3 times the normal values within 24 hours of acute exacerbation

Factors

1. alcohol use is often associated with chronic pancreatitis and can cause acute exacerbation
2. Corticosteroids, thiazide diuretics, and oral contraceptives can cause chronic pancreatitis but does not cause acute exacerbation if just taken in the last 24 hours
3. Stress stimulates pancreas to secrete enzymes

Question 25

Medications fo acute exacerbation of chronic pancreatitis

Diet

Answer 25

Medications

1. Morphine - used as first line pain med for moderate to severe pain (Others are fentanyl, hydromorphone, methadone, oxycodone)
2. Omeprazole - proton pump inhibitor. Decreases gastric secretions (acid)
3. Pancrelipase - pancreatic enzyme med. made from pig pancrease so important to ask if pt is allergic to pork. Take with meals as this med enhances digestion of food as it is an artificial pancreatic enzyme

Diet for acute exacerbation
1. NPO to prevent stimulation of pancreas and secretion of pancreatic enzymes
2. after a few days if food and fuids not tolerated, then pt needs a TPN
TPN is administered through a central line

Question 26

Why TPN is administered thru central line?

How often to change tpn tubing

Answer 26

TPN has a high glucose content. Glucose exerts osmotic pressure that is harmful to the lining of peripheral veins. Thus often through a subclavian vein. Nurse assists MD with line insertion
TPN is administered via an IV pump
TPN tubing changed withh every bag to prevent bacterial growth
Monitor

Question 27

What to monitor in pt who has acute exacerbation of pancreatitis

Intervention before transfering pt to medical floor from emerg

Position to alleviate pain

Answer 27

Monitor

1. Record daily weight to monitor nutritional status which could also be affected by the pancreatitis
2. Blood glucose every 4-6 hours. UAP can get BG reading but nurse must analyze findings and what to do about it

Intervention prior to transferring from ED to medical floor

• Insert NG tube connected to low intermittent suction to relieve N+V, distension, paralytic ileus and remove HCL so it does not enter duodenum and stimulate pancreas
• Need to admin O2 via nasal cannula to decrease workload of respiratory system

Positions to help alleviate pain from pancreatitis
- Side lying with pillow under head and legs to chest.
Pain is due to stretching of peritoneum due to edema from inflamed pancreas
Other positions are sitting up, leaning forward or fetal position
Oxygenation

Question 28

Complicatjons of chronic pancreatitis

Answer 28

1. Diabetes - so BG should be monitored
2. Recurring attacks become more painful so important to seek help once first attack begin
3. Weight loss often due to anorexia or fear of another attack

Question 29

Symptoms of cirrhosis

Answer 29

Jaundiced skin and sclera
Enlarged liver on palpation
Lethargy
Ascites - buildup of fluid between abdomen and abdominal organs. results from portal htn. Monitor for FVE an abdominal girth
and low levels of albumin
Fruity breath d.t. Inability to metabolize the amino acid methionine
Clay colored stooled dt decrease in amount of bile in stool
Urine will be dark dt to increase in bilirubin in urine

Question 30

Types of cirrhosis

Answer 30

Postnecrotic cirrhosis - most common, due to hepatotoxins like viral hepatitis, toxic chemicals like pesticides, long term hepatotoxic meds use
Billiary cirrhosis - due to obstruction in liver and common bile ducts
Laennec’s cirrhosis - due to alcoholism

Question 31

Tests for cirrhosis

Answer 31

Paracentesis - removal of peritoneal fluid. Pt should be asked to void prior procedure to prevent accidental rupture of bladder. After the procedure pt must be assessed for signs of peritonitis or peritoneal bleeding
Angiography with portal pressure measurements - to visualize and also assess for portal hypertension
Lab
Serum albumin would be decreased because the liverr is unable to produce albumin efficiently
Liver enzymes increased
APTT prolonged

Question 32

Meds for cirrhosis

Answer 32

Spinorolactone - potassium sparing diuretic so monitor for hyperkalemia
Furosemide
Albumin
Vitamin K - reduce bleeding tendencies
Folic acid and B12 - coz pt with cirrhosis is likely malnourished

Question 33

Complications of cirrhosis

Answer 33

Hepatic encepalopathy
Dt Increase in serum ammonia coz liver can’t convert ammonia into urea
Pt will be administered lactulose and neomycin to fast track BM to increase excretion of ammonia and improve neurological status
Assess glasgow coma scale (highest is 15)
Eye opening response
4,3,2,1 spontaneous, to sound, to pain, never
Motor response
6,5,4,3,2,1 obeys commands, localizes pain, withdrawal, flexion, extension, none
Verbal response
5,4,3,2, 1 oriented, confused, inappopriate, incomprehensible, none
shock
Dizzy, vomiting blood, pale, skim cold and clammy
Position in sidelying position coz this is a sign of impending shock
Vitals will show increased pulse and respiration and decreased BP and O2 stat: apply O2, ensure IV patency, notify MD, transfer to critical care

Question 34

Colonoscopy is done when

Answer 34

colonoscopy is recommended every 10 years starting at age 50

Question 35

Colonoscopy before, during, and after procedure

Answer 35

Before procedure
Clear liquids 24 hours before to have a clear colon for visualization
Drink polyethyl glycol - a laxative. Causes retention of fluid in the intestinal lumen. By end of the prep most clients expel almost clear watery stool
IV is inserted. Make sure to prime tubing set first before insertion
Before any procedure or sx with general anesthesia - Hgb and Hct must first be checked. Normally require Hgb to be higher than 10 g/dL
after proccedure
Pt will have lots of gas dt air pumped into the colon during the procedure. Gas should be expelled normally to prevent painful distention
Have significant someone drive pt back home dt to residual effects of sedation or weakness from procedure

After procedure
- Important to assess HR as tachycardia coud be a sign of many complications like dehydration, shock…, assess potassium if there is vomitting, assess respirations might have atelectasis, assess for DVT

During procedure
o Normal sedation reactions: ptosis, slurred speech
o Sx with general anesthesia require Haemoglobin to be 10 or higher to ensure adequate o2 carrying capacity. Check this before sx and notify MD if abnormal

Question 36

Warning signs for prostate cancer and colorectal cancer

Risk factors

Answer 36

Warning signs of colorectal cancer: bleeding from rectum, black or tarry stools, rectal pain, change in bowel habits (constipation or diarrhea)
o Warning signs of prostate cancer: problems urinating, polyuria, nocturia, hematuria, pain in lower back, pelvis, upper thighs
o Risk factors: Personal or family History of colorectal cancer, polyps, IBD; 40 years old and above
o Diet linked to bowel cancer: high fat or low fibre
o Medications: laxatives and cathartics repeated use can cause diarrhea and loss of intestinal muscle tone, codeine causes constipation, iron turns feces to black and tarry

Question 37

Health promotion for colonoscopy

Answer 37

Health Promotion colonoscopy.
o After age 50, ppl increase risk to develop colon cancer, and that risk increases with each succeeding decade of life.
o Colonoscopy - prevention by removing polyps before they become cancerous and detecting tumors before symptoms occur.
o For the average-risk individual, the recommended screening schedule is every 10 years, starting at age 50.