MEDSURG 2 EXAM #3 Flashcards
Weeks 5, 6, & 7
What to study for EXAM #3
— Diarrhea, constipation, and incontinence
— What is the purpose and what does the RN need to do to help with issue
— Distinguish the process of food breakdown
— What to include in teaching for a procedure (pre/intra/post)
— Objective 1 for sureeee
— How to assess (order and direction)
— Difference b/w ostomies and kind of stools to expect; tx
— Types of hernias, location, which type is an considered an emergent event
— B12, Niacin for vitamin therapy with Cirrhosis patients
— Short gut syndrome
— Metabolic syndrome: detect DM
— Management for UGI if patient comes in = color of stool/vomitus vs. lower GI
— Guaiac test: detect if blood in stool + EGD = NPO + clear liquids + bowel prep (Go-Lytely), have gag reflux to make sure they can eat again
— Peptic Ulcer Disease
— Projectile vomiting may mean what? = ICP
— Protein formula = 0.8 * kg
- Describe the structures and functions of the organs of the gastrointestinal tract.
Hepatitis or Cirrhosis lab findings
— Elevated AST, ALT levels
- Describe the structures and functions of the liver, gallbladder, biliary tract, and pancreas.
Elevated ALP levels indicates ________ damage
liver
- Distinguish the processes of ingestion, digestion, absorption, and elimination.
- Explain the processes of biliary metabolism, bile production, and bile excretion.
- Link the age-related changes of the gastrointestinal system to the differences in assessment findings.
- Obtain significant subjective and objective assessment data related to the gastrointestinal system from a patient.
- Perform a physical assessment of the gastrointestinal system using appropriate techniques.
- Distinguish normal from abnormal findings of a physical assessment of the gastrointestinal system.
- Describe the purpose, significance of results, and nursing responsibilities related to diagnostic studies of the gastrointestinal system.
- Describe the etiology, clinical manifestations, and interprofessional and nursing management of malnutrition.
- Describe the components of a nutrition assessment.
What is malabsorption syndrome + results from?
Malabsorption Syndrome: impaired absorption of nutrients from the GI tract
May result from:
— ↓ enzymes
— Drug side effects
— ↓ bowel surface area
— Fever increases BMR
- Explain the indications, complications, and nursing management related to the use of enteral nutrition.
- Explain the indications, complications, and nursing management related to the use of parenteral nutrition.
- Compare the etiology, clinical manifestations, and nursing management of eating disorders.
- Discuss the epidemiology and etiology of obesity.
- Explain the health risks associated with obesity.
- Use classification systems to determine body size.
- Discuss comprehensive therapy for the patient with obesity.
- Distinguish among the bariatric surgical procedures used to treat obesity.
- Describe the nursing and interprofessional management related to surgical therapies for obesity.
- Describe the etiology, complications, and interprofessional and nursing management of nausea and vomiting.
- Describe the etiology, clinical manifestations, and nursing and interprofessional management of metabolic syndrome.
- Discuss the etiology, clinical manifestations, and interprofessional and nursing management of common oral inflammations and infections.
- Describe the etiology, clinical manifestations, complications, and interprofessional and nursing management of oral cancer.
- Explain the types, pathophysiology, clinical manifestations, complications, and interprofessional and nursing management of gastroesophageal reflux disease and hiatal hernia.
- Relate the pathophysiology, clinical manifestations, complications, and interprofessional management of esophageal cancer, diverticula, achalasia, and esophageal strictures.
- Compare acute and chronic gastritis, including etiology, pathophysiology, and interprofessional and nursing management.
- Distinguish gastric and duodenal ulcers, including etiology, pathophysiology, clinical manifestations, complications, and interprofessional and nursing management.
- Outline the clinical manifestations and interprofessional and nursing management of stomach cancer.
- Explain the common etiologies, clinical manifestations, and interprofessional and nursing management of upper gastrointestinal bleeding.
- Identify common types of foodborne illnesses and nursing responsibilities related to food poisoning.
- Explain common causes and interprofessional and nursing management of diarrhea, fecal incontinence, and constipation.
- Describe common causes of acute abdominal pain and nursing management of the patient after a laparotomy.
- Describe the interprofessional and nursing management of acute appendicitis, peritonitis, and gastroenteritis.
- Compare and contrast the inflammatory bowel diseases of ulcerative colitis and Crohn’s disease, including pathophysiology, clinical manifestations, complications, and interprofessional and nursing management.
- Distinguish among small and large bowel obstructions, including causes, clinical manifestations, and interprofessional and nursing management.
Ulcerative Colitis
Onset: teens to mid-30s. >60YO
Abdominal pain = common, severe constant
Diarrhea = common
Fever = during acute attacks
Malabsorption/nutritional deficiencies = minimal
Rectal bleeding = common
Tenesmus [gotta go, gotta poooo!] = common
Weight loss = rare
Location/distribution: usually starts in RECTUM and spreads in continuous pattern UP the colon; continuous areas of inflammation
Cobblestoning of mucosa? NOPE, rare
Depth of involvement = just mucosa
Peudopolyps = common, minimal small bowel movements
Increased risk of C.diff
Perinatal abscess/fistulas = rare
Strictures = occasional
Toxic mega colon = more common = common perforations
- Describe the clinical manifestations and interprofessional and nursing management of colorectal cancer.
Crohn’s Disease
Onset: teens to mid-30s. >60yo
Abd pain/diarrhea/fever: common w/ cramping; common
Malabsorption: common
Rectal bleeding + tenesmus: sometimes/rare
Weight loss = common, may be severe
Location = occurs anywhere along the GI tract; most common site = distal ileum
Cobblestoning of mucosa = common
Pseudopolyps = rare
Small bowel involvement = common
Increased risk of C.diff
Perforation = common (b/c inflammation involves entire bowel wall)
Abscess/fistulas/strictures = common
- Select nursing interventions to manage the care of the patient after bowel resection and ostomy surgery.
- Distinguish between diverticulosis and diverticulitis, including clinical manifestations and interprofessional and nursing management.
- Compare and contrast the types of hernias, including etiology and surgical and nursing management.
— Inguinal = most common
— Femoral
— Umbilical
— Ventral
— Incisional
- Describe the types of malabsorption syndromes and interprofessional care of celiac disease, lactase deficiency, and short bowel syndrome.
Celiac disease — AID that causes damage to small intesting
Lactase deficiency — condition in which the lactase enzyme is deficient or absent
Short gut syndrome — small intestestine doesn’t have enough S.A. to absorb nutrients, —> unable to meet E, F/E, nutritional needs to stay healthy on a normal diet | Tx: complex carbs (e.g. starch, white/brown rice, bread), high protein, moderate fat
- Describe the types, clinical manifestations, and interprofessional and nursing management of anorectal conditions.
- Distinguish among the types of viral hepatitis.
- Describe the interprofessional and nursing management of the patient with viral hepatitis.
- Explain the pathophysiology, clinical manifestations, complications, and interprofessional and nursing management of the patient with cirrhosis.
- Describe the clinical manifestations and management of liver cancer.
- Distinguish between acute and chronic pancreatitis related to pathophysiology, clinical manifestations, complications, and interprofessional and nursing management.
- Explain the clinical manifestations and interprofessional and nursing management of the patient with pancreatic cancer.
- Describe the pathophysiology, clinical manifestations, and interprofessional care of gallbladder disorders.
- Describe the nursing management of the patient undergoing surgical treatment of cholecystitis and cholelithiasis.
Cholecystitis: inflammation of gallbladder r/t gallstones
__________
Cholethiasis:
— BMI must be WNL
— Must have small, cholesterol-based stones
Know the Assessment of the GI system and ORDER
start from RLQ in zig-zag; end at LLQ
Inspection
Auscultate
Percuss
Palpate
Preparing patient for colonoscopy. What are the expectations for the nurse?
– Check stool to make sure they passed it
– Bowel prep to ensure intestines are cleared out
— Consent!
Steps for placing NG tube
What to check for tube feedings
Flush the tube with 30 mL of water
- tell patient what you are doing
- gather and dispose of all waste in the proper receptacle
- lower the head of the bed to no less than 30 degrees
-document the feeding, dose, solution, volume, time, and your initials
- be sure to document the patients response including any adverse reactions
Complications of enteral nutrition/feedings
Vomiting
Diarrhea
Constipation
Dehydration
— More calorically dense, less water formula contained
— Check for high protein content
Formula for protein intake
0.8 to 1g/kg of body weight
Example: Patient weighs 70kg x 0.8 = 56g protein DAILY
Which patients cannot tolerate a high protein diet?
Liver disease patients (cannot process protein well)
Which tubes will be least the risk for aspiration?
J-tube, because it is at the furthers distance
– Located in the small intestine
– Formula: pre-digested food b/c bypassing stomach (acid contents)
What must the RN do when preparing a parenteral nutrition (hanging TPN)? SATA
Slide 19 – hypovolemic shock
Scenario
Bland diet
NO SODAS
Hiatal Hernia Complications
–GERD
–Esophagitis
–Hemorrhage from erosion (= emergency)
–S
Labs, Dx, RN responsibility in the Dx tests, esophageal varices
Causes of diarrhea
What are the causes of consitpation?
Causes of acute abdominal pain
Rebound pain (pain after you release pressure)
Abdominal compartment syndrome
Acute pancreatitis
Appendicitis
Bowel obstruction
Cholecystitis
Diverticulitis
Gastroenteritis
Pelvic inflammatory disease
Perforated gastric or duodenal ulcer
Peritonitis
Ruptured abdominal aneurysm
Internal bleeding/trauma
Obstruction
What is peritonitis? What caused this and what to find in your assessment?
— Infection of peritoneal area
— Cause = infection r/t leaky gut; abdomen feels rigid/board-like
Hernias
— Determined if incarcerated or not?
If so —> OR b/c blood flow is not getting to intestinal wall…PROBLEM
Different types of diet foods
Why would you have 2 ostomy bags?
Temporary colostomy and resting other part of bowels.
Transverse (named b/c uses the part of the colon that goes across) or Double-loop
Important actions to be done prior receiving a patient for a procedure
— NPO
— “When was the last time you flushed the IV?”
RN Management for diarrhea
— Should be considered infectious until proven otherwise
Diarrhea, fecal incontinence, constipation
MOA of Bismuth subsalicylate (Pepto-Bismol)
— Decreases secretions and has weak antibacterial activity
— Purpose: prevent traveler’s diarrhea
MOA of Calcium polycarbophil (FiberCon)
— Bulk-forming agent that absorbs excess fluid from diarrhea to form a gel
— Purpose: when intestinal mucosa cannot absorb fluid
MOA of Diphenoxylate with atropine (Lomotil)
— Opioid and anticholinergic
— Purpose: decreases peristalsis and intestinal motility
MOA Ioperamide (Imodium, Pepto Diarrhea Control)
Inhibits peristalsis, delays transit, increases absorption of fluid from stools
MOA of Octreotide acetate (Sandostatin)
Suppresses serotonin secretion, stimulates fluid absorption from GI tract, decreases intestinal motility
MOA of Paregoric (Camphorated tincture of opium)
— Opioid
— Purpose: decreases peristalsis and intestinal motility
Fecal incontinence + prevention and treatment
Involuntary passage of stool
Tx: bowel training program
Constipation + prevention and treatment
Decrease in the frequency of BM from what is a patient’s “normal”
— Teach patient importance of dietary + activity measures to prevent
What are the goals of RN management for diarrhea, fecal incontinence, and constipation?
- Cessation and return of normal BM
- Normal fluid and electrolyte and acid-base balance
- Normalize nutritional status
- Prevent skin breakdown
Problems with diarrhea
— Life-threatening dehydration if severe enough
— Electrolyte problems (e.g. HYPOkalemia)
Infections of the colon and distal small bowels cause which S/Sx before diarrhea?
Examples of infections
— Fever (no-to-low grade)
— N/V
— Frequent bloody diarrhea w/ small volume
Examples: Shigella, Salmonella, C.difficile
Collaborative care concerns for diarrhea
— Preventing transmission, replacing F/E, and protecting the skin
— Depends on the cause to determine Tx
— Acute = self-limiting
Common causes of acute abdominal pain
— Appendicitis = inflammation of appendix
— Peritonitis = hole/infection in the bowel, penetrating the peritoneal
— Diverticulitis = cramping/bloating, tenderness
— Gastroenteritis = inflammation of stomach + intestines, usually from bacterial toxins/viral infections; N/V/D, cramps, low-grade temp
Expected output for ostomies
— Ileostomy: >1000mL/day, bile-colored, liquid
— Transverse colostomy: small semi-liquid w/ some mucus 2-3 days post surgery (with some blood)
— Sigmoid colostomy:
Foods that CAUSE odor for ostomies + treatment
Fish, eggs, asparagus, garlic, beans, dark leafy veggies
Tx: buttermilk, cranberry juice, parsley, yogurt DECREASES odor
Ileostomy Characteristics
— Consistency: liquid-semiliquid
— Fluid requirement: increased
— Bowel regulation: NOPE
— Pouch + skin barriers: YES
— Indications for surgery: UC, Crohn’s, or injured colon, familial polyposis, trauma, cancer
Foods that cause gas in ostomies + treatment
— Dark leafy greens, beer, carbonated beverages, dairy products, and corn
— Chewing gum, skipping meals, smoking
Tx: yogurt, crackers, toast DECREASE gas
Colonoscopy Characteristics
— Stool consistency: semi-liquid
— Fluid req.: INCREASED
— Bowel regulation: NO
— Pouch + skin barriers: YES
— Indications for surgery: Perforating diverticulum in lower colon, trauma, recto signal fistula, inoperable t muros of colon/rectum/pelvis
Client education with ostomy involving the small intestine
— Avoid high-fiber foods for the first 2 months postoperative
— Chew food well
— Increase fluid intake
— Evaluate for evidence of blockage when slowing adding high-fiber foods to diet
Transverse characteristics
— Stool consistency: semi-liquid to semi-formed
— Fluid req.: perhaps increased
— Bowel regulation: NO
— Pouch + skin barriers: YES
— Indications for surgery: same for ascending
Characteristics of stoma appearance
Viable/healthy: — pink/red, beefy-looking, and moist
May indicate anemia: — pale
Inadequate blood supply to stoma/bowel — blanching, dark red-purple
Sigmoid (single/double-barreled) characteristics
— Stool consistency: formed
— Fluid req: NO ∆
— Bowel regulation: YES, if there is a hx of a regular bowel pattern
— Pouch + skin barriers: dependent on regulation
— Indications for surgery: cancer of rectum/rectosigmoid area; perforating diverticula, trauma
Manifestations of stomach ischemia/necrosis
— Expected color: pale pink or blueish purple, ry
— Unexpected color = If stoma is BLACK/PURPLE = serious impairment of blood flow and requires immediate attention
If stoma is bleeding
Small amount = NORMAL
— when small amount is oozing form stoma mucosa when touched b/c of high vascular it’s
Moderate/large amount = NOT GOOD
— lower GI bleed, coagulation factor deficiency, stomal varices 2nd army to portal HTN
Peptic Ulcers
— Erosion of GI mucosa resulting from digestive action of HCl acid and pepsin
— Develops only in the presence of an acid environment
Difference between acute vs. chronic peptic ulcers
Acute
— superficial erosion
— minimal inflammation; resolves quickly when cause is ID’d and removed
_________________
Chronic
— muscular wall erosion w/ formation of fibrous tissue
— continuous for many months/intermittently throughout life; more common
Post-op care for stoma
— Assess wound, record bleeding, XS drainage, unusual odor
— Monitor for edema erythema, drainage around suture line
— Fever, HIGH WBC count
Pathophysiology of Ulcer
Etiology of peptic ulcer disease (PUD)
Route of transmission for Hepatitis
Fecal-oral: Hep A, Hep E
Blood: Hep B, Hep C, Hep D
S/Sx of someone experiencing perforation of a peptic ulcer
— board-like abdomen
— severe abdominal/back pain that radiates to R shoulder
IF HEMORRHAGING: vomiting of blood + shock (^HR/RR, decr BP)
What is hepatitis + their causes?
Inflammation of the liver
Causes:
— Viral (most common)
— Drugs (alcohol)
— Chemicals
— Autoimmune diseases
— Metabolic abnormalities
Hepatitis A laboratory results
Elevated: ALT, AST, ALP (can also be WNL), total bilirubin, Hepatits A virus antibodies (anti-HAV)
Clinical manifestations of Hep A
— Not chronic & incidence decreased w/ vaccination
— RNA virus transmitted via fecal-oral (e.g. contaminated food/water
— Vaccinate children @ 1yo
NOTE: the greatest risk of transmission occurs before clinical S/Sx are apparent
Hepatitis B laboratory results
Elevated: ALT, AST, ALP (also can be WNL), total bilirubin, HBsAG
Hep B clinical manifestations
— Transmission: percutaneous, parenteral (concurrent w/ HBV); sexual, shared needles, blood, birth canal
— Dx: liver biopsy (intensity and degree of liver damage)
— S/Sx: N/V, fever, fatigue, RUQ pain, dark urine/clay stools, joint pain, jaundice
— Labs: Elevated AST, ALT, bilirubin, HBV PCR DNA, HBsAg
— Tx: Tenofovir, adenovirus dip I odio, interferon alfa-2b, peginterferon alfa-2a, lamivudine, entecavir, & telbivudine (for chronic infxn)
— Vaccine?: YES
— Prevention: Engerix-b
At-risk populations for Hep B
Men who have sex with men
Household contact of chronically infected
Patients undergoing hemodialysis
Health care and public safety workers
Transplant recipients
HBsAg in the serum for 6 months or longer after infection indicates chronic HBV infection.
**NOTE: HBV can live on a dry surface for at least 7 days. HBV is much more infectious than HIV.
Normal ranges for Hepatitis laboratory values
Alanine aminotransferase (ALT) = 4-36u/L
Aspartate aminotransferase (AST) = 0-35u/L
Alkaline phophatase (ALP) = 30-120u/L
Total bilirubin level = 0.3-1.0mg/dL
Presence of antibodies for Hepatitis infection
Enzyme immunoassay (EIA)
HCV RNA polymerase chain reaction (PCR)
Hepatitis C laboratory results
Elevated = ALT, AST, ALP (or WNL), total bilirubin, anti-HCV, EIA, PCR
Clinical manifestations of Hep C (HCV)
Acute: asymptomatic
Chronic: liver damage
RNA virus transmitted percutaneously
IV drug use
High-risk sexual behaviors
Occupational exposure
Dialysis
Perinatal exposure
Blood transfusions before 1992
NOTE: majority of patients are unaware of their infection and usually develop chronic infection.
Hepatitis D (Delta) laboratory results
Presence of: identification of intrahepatic delta antigen, anti-HDV, co-infected with HBV
Clinical manifestations of Hep D (HDV)
also called delta virus
Transmission: percutaneous, parenteral (concurrent w/ HBV); sexual, shared needles, blood, birth canal
Dx: HBV PCR DNA, HBsAG
S/Sx: anorexia, N/V, fever, RUQ pain, dark urine/light stool, joint pain, jaundice (icteric)
Lab results: elevated ALT, AST, bilirubin,
Tx: NONE
Vaccine?: NONE, but vaccination against HBV reduces risk of HDV co-infection
Prevention:
Hepatitis E laboratory results
Presence of: anti-HEV
Hep E (HEV) clinical manifestations
primarily in developing countries (Inda, Asia, Mexico, Africa)
Transmission: fecal-oral, H20-borne
Labs: elevated ALT, AST, bilirubin,
S/Sx: flu-like (2wk-2mos)
Tx:
Prevention?: HH, lifestyle, BLEACH
Which pain medication should you question after surgery for a patient with Hep B?
Hydrocodone w/ acetaminophen because can acetaminophen can impair liver function.
Excessive aspirin vs. acetaminophen can cause damage to which organs?
Aspirin to the kidneys and cause elevated aminotransferase levels
Acetaminophen to liver
What happens during an acute viral hepatitis infection?
Acute infection
— Liver damage: lysis of infected cells
— Cholestasis
— Liver cells can regenerate in normal form after resolution of infection
Chronic infection
— Can cause fibrosis and progress to cirrhosis
Active vs. on-going systemic S/Sx of hepatitis viruses
Active:
Rash, Angioedema, Arthritis, Fever, Malaise, Cryoglobulinemia, Glomerulonephritis, Vasculitis
Intermittent/On-going: Malaise, fatigue, myalgias/arthralgias, hepatomegaly
S/Sx during incubation period of hepatitis viruses
Malaise, anorexia, weight loss, fatigue, N/V, abd discomfort, distantes for cigarettes, ↓ Sense of smell, H/A, low-grade fever, arthralgias, skin rashes
Serologic Events
— Incubation period
— Acute S/Sx: elevated ALT, jaudice (icteric)
— Convalescence: begins as jaundice is disappearing, lasts weeks-months
— Recovery: homologous immunity to HAV or HBV, but can become reinfected w/ other types and different strains (HCV)
What is cirrhosis + different types?
Cirrhosis: extensive scarring of the liver caused by necrotic injury or a chronic Tx to inflammation over a prolonged period of time
Types:
— Postnecrotic: viral hepatitis/mixed medications or toxins
— Laennec’s: chronic EtOH d/o
— Biliary: caused by chronic biliary obstruction/Autoimmune disease
What are the complications of hepatitis?
Chronic hepatitis:
— ongoing inflammation of liver
— results from HBV, HCV, or HDV
— increases risk for liver cancer
___________
Fulminant hepatitis:
— XS severe + fatal form of viral hepatitis
— Patient goes from viral hep w/in hrs —> severe liver failure
— No meds, simply supportive care
_______
— Cirrhosis of the liver
— Liver cancer/failure
— Hepatic encephalopathy: NH3 elevated causing neurological S/Sx (stupor, asterixis [hand-flapping], fetor hepaticus [fruity musty breath], seizures, and coma)
Complications for patients w/ cirrhosis?
— Portal HTN: increased portal venous pressure, s pleno metals, large collateral veins, ASCITES, gastric (upper)/esophageal varices (very fragile)
— Coagulation defects
— Jaundice
— Portal-systemic encephalopathy (PSE) w/ hepatic coma (inability to detoxify protein byproducts = elevated NH3
RF for Cirrhosis when assessing patient
EtOH, chronic HBV, HCV, or HCD, AID (hepatic), Steatohepatitis (causing chronic inflammation), biliary cirrhosis,
—
— Cardiac cirrhosis —> RHF inducing necrosis/fibrosis d/t lack of blood flow
Stages of Hepatic Encephalopathy
(1) —
(2) —
(3)
(4)
S/Sx of MEN vs. WOMEN w/ cirrhosis
MEN:
gynecomastia (benign growth of the glandular tissue of the male breast), loss of axillary and pubic hair, testicular atrophy, and impotence with loss of libido may occur because of increased estrogen levels.
WOMEN:
Young = amenorrhea Older = vaginal bleeding.
NOTE: liver fails to metabolize aldosterone adequately —> hyperaldosteronism w/ Na+/H2O retention & K+ loss
S/Sx of cirrhosis
Fatigue, weight loss, abdominal pain/distention, pruritis, confusion
Expected laboratory results for patients with cirrhosis
LDH
ALT/AST: elevated —> WNL b/c
Elevated (initially): LDH, ALT, AST (d/t hepatic inflammation) THEN ALT/AST —> normal (b/c liver unable to create inflammatory response)
ALP — elevated b/c of intrahepatic biliary obstruction
NH3 =
Early vs. Later S/Sx of cirrhosis
EARLY: fatigue (many unaware of liver condition)
Vs.
LATE: jaundice, peripheral edema, ascites, skin, hematologic , endocrine, and neurologic disorders
— Advanced —> liver becomes small and nodular
- Purpose of the liver? 2. What does the liver produce?
- S/Sx you have coagulation problems?
- Clotting factors
- Thrombin
- Bruising, bleeding gums, PETECHIAE on skin, spider angiomas (telangiectasia/spider nevi), heavy menstrual periods, palmar erythema (red area that blanches w/ pressure) on palms of hands
Dx procedures for cirrhosis
— ultrasound
— abdominal x-ray/CT scan
— MRI
— liver biopsy
— esophagagogastroduodenoscopy
— endoscopic retrograde cholangiopancreatography
RN care for cirrhosis patients
— RR status
— Skin integrity
— Fluid balance
— VS + pain level
— Neurological status: r/t hepatic encephalopathy —> Lactulose
— Nutritional status: HIGH carb & protein, moderate fat, and LOW Na+ diet
— GI status
Therapeutic procedures for Cirrhosis
— Paracentesis
— Endoscopic varicela ligation/endoscopic sclerotherapy
— Transjugular intrahepatic portosystemic shunt
— Surgical bypass shunting procedures = LAST RESORT for portal HTN/esophageal varices
— Liver transplantation
S/Sx of Hepatorenal Syndrome
— Renal failure w/ azotemia (^Nitrogen levels)
— Suddenly decrease in urinary flow (<500mL/24hr)
— ^BUN/Cr
— Intractable ascites
— Spontaneous bacterial peritonitis ››› IV Cefotaxime
Lab results for Cirrhosis
ELEVATED: AST, ALT, LDH, ALK, GGT, bilirubin, PT/INR
DECREASED: platelets, albumin
Goal + how to manage Cirrhosis
GOAL: slow progress of cirrhosis, prevent, tx any complications
— Rest
— B-complex vitamins (d/t insufficiency)
— AVOID EtOH, ASA, acetaminophen, NSAIDs
How to manage ASCITES
— Na+ restriction + fluid removal
— Albumin
— Diuretics (Spironolactone WITH Furosemide (Lasix))
— Tolvaptan (Samsca): correct HYPONa+ by ^ H20 excretion
— Paracentesis
— Transjugular intrahepatic portosystemic shunt (TIPS): if doesn’t respond well to Diuretics
GOAL + how to manage esophageal + gastric varices for cirrhosis patients
GOAL: Prevent bleeding/hemorrhage
— Avoid alcohol, aspirin, and irritating foods
— Screen for presence with endoscopy
— Nonselective β-blocker (Decrease high portal pressure)
A Rn is assessing a client who has advanced cirrhosis. The RN should ID which of the following findings as indicators of hepatic encephalopathy? SATA.
A. Anorexia
B. ∆ in orientation
C. Asterixis
D. Ascites
E. Fetor hepaticus
B, C, E
RATIONALE: A & D is present for liver dysƒ(x),
Which medication classes are metabolized in the liver? SATA.
Diuretics
Beta-blockers
Opioid analgesics
Sedatives
Acetaminophen
Opioid analgesics, sedatives, & NSAIDs (acetaminophen) are metabolized in the liver and should be AVOIDED for anyone w/ a viral hepatitis
A RN is caring for a client who has acute pancreatitis. Which of the following serum lab values should the RN anticipate returning to the expected reference range w/in 72hr after tx begins?
A. Aldolase
B. Lipase
C. Amylase
D. Lactic dehydrogenase (LDH)
Amylase
RATIONALE: Pancreatitis is the most common diagnosis for marked elevations in serum amylase. Serum amylase begins to increase about 3 to 6 hr following the onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to the expected reference range within 2 to 3 days.
— Lipase stays elevated for up to 14days
— Aldolase = inflammation of muscles = myositis
— LDH = anemia, leukemia, or liver damage
What is the purpose of an EGD?
A. To visualize polyps in the colon
B. To detect an ulceration in the stomach
C. To ID an obstruction in the biliary tract
D. To determine the presence of free air in the abdomen
B. To detect an ulceration in the stomach
RATIONALE: EGDs visualize the esophagus, stomach, and duodenum w/ light to ID a tumor, ulcer, or obstruction
A. ID polyps = sigmoidoscopy/barium enema in lower GI
C. ERCP is performed
D. Free air = gas = fluoroscopy/x-ray
S/Sx of cancerous lesions
-Rectal bleeding is most common
-Alternating constipation and diarrhea
-Change in stool caliber
-Narrow, ribbon-like
-Sensation of incomplete evacuation
-Obstruction
Clinical manifestations of colorectal cancer
— Insidious onset
— Symptoms often appear in advanced stages
— Change in bowel habits
— Unexplained weight loss
— Vague abdominal pain
— Weakness and fatigue
— Iron-deficiency anemia and occult bleeding
Parenteral nutrition uses
ROUTE: IV
— Chronic/severe D/V
— Complicated surgery/trauma
— Gi obstruction
— Intractable diarrhea
— Severe anorexia nerviosa/malabsorption
— Short bowel/gut syndrome
— GI tract anomalies + fistulae
— No more than 170 calories/L for Dextrose in H2O or dextrose in LRs
Nutrition/day
CARBS —
PROTEIN — 45-65g daily
RN Mgmt for Parenteral nutrition
Vital signs every 4 to 8 hours
Daily weights
Blood glucose
Check initially every 4 to 6 hours
Electrolytes
BUN
CBC
Monitor for S/Sx of infection or septicemia
Local: erythema, tenderness, exudate at catheter site
Systemic: fever, chills, N/V, malaise
Enteral delivery options
— Continuous infusion by pump
— Intermittent by gravity
— Intermittent bolus by syringe
— Cyclic feedings by infusion pump
Common enteral feeding locations
Nasogastric = NG-tube
Esophagostomy = E-tube
Nasoduodenal/nasojejunal = NJ-tube = nose —> small bowels for children
*Gastrostomy = G-tube
*Jejunostomy = J-tube
Percutaneous endoscopic gastrostomy = PEG-tube
*= used extended periods
NG-tube
most commonly used for ST feeding problems
— Inserted through the nasal cavity
Radiopaque: Allowing visualization from x-ray
↓ likelihood of regurgitation and
aspiration when placed in intestine
G-tube + J-tube
May be used in those needing tube feedings for extended period
Patient must have intact, unobstructed GI tract
Can be placed surgically, radiologically, or endoscopically
NOTE: Failure to flush the tubing after both drug administration and residual volume determinations can result in tube clogging; small amount of cola can help restore patency
BMI ranges + waist circumferences
BMI (kg/m2) = (weight in lbs.) x 703/ (height in inches)^2
Underweight: ≤18.5
WNL: 18.5-24.9kg/m^2
Overweight: 25-29.9
Obesity: 30-34.9
Extremely obesity: ≥40
__________
MEN: ≤40 inches
WOMEN: ≤35 inches
Percutaneous Endoscopic gastrostomy
— Requires esophageal lumen wide enough for endoscope
— Can start feedings when bowel sounds are present (~24hr after placement)
DO NOT PLACE DRESSINGS BENEATH BUMPER
Complete proteins vs. incomplete
Complete: eggs, fish, meats, milk + milk products, poultry
Incomplete: legumes, grain, nuts, seeds
Major minerals vs. Trace elements
Major minerals: Ca, Cl, Mg, P, K, Na, S
Trace elements: Cr, Cu, F, I Fe, Mn, Mo (Molybdenum) Se, Zn
Malnutrition terms
Cachexia — complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss that is often associated with anorexia; scaphoid appearance
Kwashiorkor — seen in children in places w/ limited food resources (e.g. swollen bellies, freq infxns) | Tx: SLOWLY increase calories then protein
Marasmus — form of severe malnutrition d/t E deficiency; a child will look emaciated + BW will be ≤60% weight fo r age
What clinical manifestations of refeeding syndrome may appear when tube feeding is started for a patient in a starvation state?
A. Diarrhea
B. Vomiting
C. Seizures
D. Abdominal distention
C. Seizures
RATIONALE: s a life-threatening metabolic complication resulting from hypophosphatemia, hypokalemia, hypomagnesemia which manifests with seizures, weakness, acute confusion, shallow respirations, and increased bleeding tendency. Patients receiving total enteral nutrition are generally at risk for diarrhea, vomiting, and abdominal distention due to overfeeding.
Drug therapies for Obesity
Extrapyramidal Syndrome S/Sx
Nutritional Algorithm
Why would enteral nutrition be ordered?
aka tube feeding
May be ordered for the patient who has a functioning GI tract but is unable to take any or enough oral nourishment.
— Stomach
— Duodenum
— Jejunum
Reasons/Indications for enteral nutrition
Anorexia
Orofacial fractures
Head/neck cancer
Burns
Nutritional deficiencies
Neurologic conditions
Psychiatric conditions
Chemotherapy
Radiation therapy
Delivery options for enteral nutrition/feeding
Continuous infusion by pump (for critically ill patients)
Intermittent by gravity
Intermittent bolus by syringe
Cyclic feedings by infusion pump
