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Health Assessment Oral > GI/Liver Assessment > Flashcards

GI/Liver Assessment Flashcards

1
Q

What are guidelines for NPO Status?

A

Balance risk of fasting against pulmonary aspiration

In “healthy patients” liberal fasting guidelines can be followed:

  • No chewing gum or candy after midnight
  • Sip of water or liquid pre-med up to 1 hour before OR
  • Clear liquids up to 2 hours before OR
  • Breast milk up to 4 hours before OR
  • Light meal, milk, formula up to 6 hours before OR
  • Fatty foods, fried foods, meats 8 hours or more
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2
Q

What patients considered an aspiration risk?

A
  1. Age extremes < 1 yr or > 70 yr
  2. Ascites (ESLD)
  3. Collagen vascular disease, metabolic disorders (Diabetes obesity, ESRD, hypothyroid, Ehlers- Danlos)
  4. Hiatal Hernia/GERD/Esophageal disorder
  5. Mechanical obstruction (pyloric stenosis, intestinal obstruction)
  6. Prematurity
  7. Pregnancy > 12 WEEKS
  8. Neurologic diseases
  9. Morbid obesity
  10. Severe pain/ anxiety
  11. Eaten food
  12. Trauma
  13. Appendicitis (“Acute/Hot Abdomen”)
  14. Achalasia (LES constantly constricted)
  15. Gastroparesis
  16. Nissen esophageal surgery* (any esophageal surgery)
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3
Q

Describe mendelson syndrome, the risk factors and manifestations associated with it?

A
  • Chemical pneumonitis or aspiration pneumonitis
    • Characterized according to:
      • pH
      • volume
      • gastric material aspirated
  • Risk factors for aspiration sequelae include
    • pH < 2.5
    • Gastric volume of 0.4ml/kg (25 ml/70kg) (~ >20 ml fluid in stomach)
    • Any acidic particulate matter aspirated
      • → chemical pneumonitis (know volume, pH, acidic particulate matter)
  • Manifestations:
    • Respiratory distress with bronchospasm
    • Cyanosis
    • Tachycardia
    • dyspnea
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4
Q

What are meds that can be given to prevent aspiration?

A
  • H2 Antagonists
    • Cimetidine, Ranitidine and Famotidine (Pepcid) →(best result)
    • Acts as competitive antagonist of histamine binding to H2 receptors on gastric parietal cells
    • Reduces acid secretion
    • ]Best if given the night before and repeated 45-60 minutes before surgery
  • Metoclopramide (Reglan)
    • Dopamine antagonist
    • Increases the pressure of the lower esophageal sphincter and enhances GI motility which speeds gastric emptying
    • Prevents or alleviates N/V
    • Contraindicated in the presence of an obstruction
    • Aspiration Prophylaxis
  • Sodium Citrate - Bicitra
    • Non-particulate antacid
    • Customary dose of 15-30 ml PO to raise gastric pH
      • ~ if ends up aspirating, wont be as irritating to lungs
    • Disadvantage: Increases gastric volume
    • Give 15 minutes before surgery
      • Lasts 1-3 hours
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5
Q

What is a hiatal hernia and s/s associated with the disease?

A
  • Protrusion of portion of stomach through hiatus of diaphragm upward into thoradic cavity
  • increased aspiration risk
  • s/s
    • retrosternal discomfort
    • burning after meals
    • reflux +/-
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6
Q

What are some symptoms that can be asked to the patient who presents to you in preop with GERD?

A
  • Retrograde movement of gastric contents through the lower esophageal sphincter into esophagus
    • Signs (mimic heart prob)
      • Heartburn
      • Noncardiac chest pain
      • Dysphagia
      • Pharyngitis, cough, asthma, hoarseness
  • Treatment:
    • Metoclopramide, H2 blockers, PPIs
  • Aspiration risk
  • High incidence of bronchospasm
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7
Q

What are the various causes of gastroparesis?

A

Partial paralysis of the stomach

Leads to prolonged food retention

Aspiration risk

  • Vagus nerve- stomach contraction-injury
  • Autonomic Neuropathy
    • Diabetes- most common cause
  • Connective tissue diseases
    • Scleroderma
    • Ehlers-Danlos
  • Opioids
    • slows food down in stomach
  • Anticholinergics
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8
Q

What are Carcinoid Tumors? S/S of these?

A
  • SLOW growing
  • Commonly found in the GI tract (appendix), metastasis
  • Can produce carcinoid syndrome or crisis (tumor secretes vasoactive substances)
    • Normally → if substances secreted, goes to portal circulation and liver will take care of it
    • If tumor in ovaries/lungs → wont go through portal circulation → *MASSIVE SYSTEMIC EFFECT*
  • produced by the effects of hormones and substances secreted in the GI tract and systemic circulation
    • bradykinin
    • histamine
    • serotonin
    • dopamine
  • S&S Carcinoid Syndrome
  • cutaneous flushing
  • diarrhea
  • tachycardia, arrhythmias
  • dyspnea, wheezing, bronchospasm
  • hypotension
  • hypertension
  • orthostasis
  • fibrosis of pulmonary and tricuspid valves
  • right-sided valvular heart dz

• Pre-op test are guided by physical findings→ BIG WORKUP

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9
Q

What are some techniques you should consider when assessing a patient with a carcinoid tumor?

A

NO palpating abdomen

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10
Q

What are some preoperative testing that should be ordered on a patient with carcinoid tumor?

A
  • CBC
  • Electrolyte panel
  • LFTs
  • Blood glucose
  • ECG
  • Echo
  • Urine 5-HIAA level
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11
Q

What are some preoperative Considerations for GI patient?

A

• Aspiration risk

  • Prophylaxis and airway management considerations
  • Bleeding anemia
  • Nutritional deficits and/or electrolyte disturbances
  • Pain control
  • Medications: stress-dose steroids?
  • If carcinoid tumor → cardiac workup needed? Hemodynamically stable?
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12
Q

Questions to ask pertaining to liver history?

A
  • scleral icterus
  • jaundice
  • palmer erythema
  • spider angiomata, petechiae, and ecchymosis
  • easy bruising?
  • pruritus or fatigue
  • gynecomastia
  • anorexia or weight changes
  • N&V or pain with fatty meals
  • Abdominal distention
  • GI Bleeding
  • hepatomegaly or splenomegaly
  • dark urine
  • recreational drugs/Alcohol
  • current medications including herbals
  • family history of jaundice and liver disease
  • history of blood transfusions
  • travel history
  • Occupational history
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13
Q

What are some hepatotoxic drugs?

A
  • Tyelnol
  • Halodol
  • Antibiotics- PCN, Bactrim, Tetracyclines, erythromycins
  • Amiodarone
  • NSAIDS
  • Cancer drugs- methotrexate, cyclophosphamide, cisplatin
  • Sulfonylurea
    • THAANCS
  • Dilantin
  • cocaine
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14
Q

What will you see on physical exam for a patient with liver disease?

A
  • General inspection (wt., vital signs, mental status)
  • Exam patient’s hands, looking for:
    • Koilonychia “spoon nails” → anemia
    • Leukonychia- white spots on nails
    • Palmar erythema- reddening of palms portal HTN
    • Asterixis - profound hand tremor (jerking/flapping) hepatic encephalopathy
    • Dupuytren’s contracture- increased risk with alcoholic cirrhosis (contracted hand)
    • Gynecomasta
    • Edema- dependent
    • Jaundice
    • Pallor
    • Itching (puritis)
      • KLAPeD GEJ PI
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15
Q

What are the functions of the liver?

A
  • Liver is responsible for a LOT of compelex and interrelated functions:
    • Reservoir of blood – 10 -15% of total blood volume
    • Maintains normal clotting
    • Mediator of endocrine functions
    • Bilirubin excretion
    • Metabolism
    • Synthesis of proteins
    • Immunologic function
    • Pharmacokinetics
      • Has a large functional reserve
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16
Q

What is considered when deciding if a patient is a candidate for a liver transplant?

A

(MELD score)

  • Serum creatinine
  • Bilibrubin
  • INR
17
Q

What is expected on physical exam with a patient who has cirrhosis?

A
  • Regenerative nodules surrounding surrounded by fibrous bands in response to chronic liver injury –> portal HTN and ESLD
  • BF wont go, shunts around liver
  • Commonly due to hepatitis C and alcoholism
    • Picture:
      • esophageal varices
      • ascites and edema
      • coagulation disorders w/ bleeding
      • encephalopathy
      • portal hypertension
      • splenomegaly
      • caput medusae
      • hemorrhoids
18
Q

What are some assessment findings you will see on a patient with pancreatitis?

Lab findings on a patient with pancreatitis?

A
  • Cullins sign- brusing around umbilius
  • Grey turner - ecchymosis/bruising on left flank area
  • Pain- severe
    • worse when supine
  • N/V
  • Fever
  • hypotension
  • CV- pericardial effusions, s/s mimicking acute MI, cardaic depression

Lab findings:

  • increased amylase and lipase
19
Q

What are the most useful labs you can obtain for a GI patient?

A

Useful Lab values

  • Hematocrit
  • Serum electrolytes
  • BUN
  • Serum albumin (prealb)
20
Q

Describe the various causes of liver disease. (3 origins)

A

Prehepatic –> bilirubin overload

  • hemolysis/whole blood transfusion → tons of bilirubin needs to be cleared

Intrahepatic –> hepatocellular damage

  • viruses, drugs, sepsis, cirrhosis (ex: Tylenol overdose)

Post-hepatic –> cholestatic dysfunction

  • gallstones, tumors (obstruction)
21
Q

Describe the process for a GI physical exam.

A

GI Physical → know order of exam done

  • General inspection
  • Weight, vital signs
  • Abdominal examination
      1. Inspect
      1. Auscultate (listen before pushing bc alter bowel sounds!)
      1. Palpate
        * Note guarding, pain, organomegaly
      1. Percuss
22
Q

What are some abdominal assessment findings on a GI patient?

A

Inspection:

  • Pink-purple striae/lines = Cushing syndrome
  • Dilated veins (caput medusae) = cirrhosis/portal HTN
  • Ecchymosis = intra/retroperitoneal hemorrhage
  • Bulges = hernias
  • Increased peristaltic waves = intestinal obstruction

Auscultation:

  • Bruits = vascular occlusive disease
  • Altered bowel sound = paralytic ileus, obstruction, etc
  • Ileus (no bowel sounds)

Percussion:

  • Tympany = NORMAL
  • What is heard in the GI tract (gas/air in the tract)
  • Dullness = usually suggests masses, organs (solid), fluid-filled cavities

Palpation:

  • May reveal abdominal masses, tumors, AAA, gravid uterus
23
Q

What are the indications that your patient has a nutritional deficiency? and what is associated with having a nutritional deficiency?

A

Malnutrition is associated with:

  • prolonged hospital stay
  • wound infection
  • abscess
  • respiratory failure
  • death

Severe Nutritional Risk:

  • Serum Albumin level: < 3 g/dL
  • Wt loss > 10% in last 6 mo
  • BMI < 18.5 (Normal: 18.5)

Health Assessment Oral (12 decks)

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