Unit 2 Flashcards
ileocecal valve
valve at junction of ileum of small intestine, cecum of colon (inferior), and ascending colon (superior)
appendix
- vermiform appendix
- worm-shaped tube connected to posterior aspect of cecum
- 1-8 in (avg 3 in)
GI health Hx
- age
- gender
- family Hx
- culture
- travel
- SDOH
- Hx of GI d/o, surgery, meds
- ASA
- NSAIDs
- laxatives
- enemas
- suppositories
- herbals
- health habits
- exercise
- smoking
- tobacco
- stress
- nutrition
- typical diet
- allergies
- wt loss/gain
- eating habit changes
- ETOH
- caffeine
- bowel patterns, concerns
- presenting Sx
GI physical assessment
- inspection
- auscultation
- percussion
- light palpation
abd assessment landmarks
- xiphoid process
- costal margin
- abd midline
- umbilicus
- rectus abdominis muscle
- anterior superior iliac spine
- inguinal ligament
- symphysis pubis
GI labs
- CBC: signs of bleed
- liver
- PT: clotting factors r/t fxn
- LFT: fxn
- CMP: fxn, albumin, BMP
- BMP:electrolytes, renal fxn
- pancreas fxn: amylase, lipase
- FOBT
FOBT
fecal occult blood test
GI imaging
- EGD
- esophagus, stomach, duodenum
- prep
- NPO for 6-8 hr before
- avoid blood thinners, NSAIDs
- check gag reflex before D/C of NPO
- ERCP
- pancreas, liver, gallbladder, bile duct
- exam and Tx of obstruction
- colonoscopy/sigmoidoscopy
- prep
- clear liquids 1 day, NPO 4-6 hr before
- avoid blood thinners and NSAIDs several days
- avoid red, orange, purple drinks
- bowel cleanse (go-lytely no appropriate for OA)
- post: monitor for bleeding, pain (perf)
- prep
IBD
inflammatory bowel dz
acute inflammatory bowel dz
- appendicitis
- gastroenteritis
- peritonitis
chronic inflammatory bowel dz
- ulcerative colitis
- Crohn’s dz
- diverticulitis
- celiac dz
appendicitis
- obstruction of lumen of appendix
- fecalith → infection in appendix wall
- at risk: adolescents, young adults
fecalith
mass of hardened fecal matter
appendicitis assessment
- Hx of illness and complete pain assessment
- abd pain → N/V → anorexia
- cramping pain in epigastric or periumbilical area
- light palp @ McBurney’s point
- guarding
- muscle rigidity
- rebound tenderness
- lab: possibly ↑ WBCs w/ shift to left
McBurney’s point
- exterior landmark for appendix
- about 1/3 of the way between the ASIS and umbilicus and 1-2 in above ASIS
ASIS
anterior superior iliac spine
appendicitis interventions
- hospitalization
- NPO to prep for possible surgery
- pain management
- surgery
- appendectomy when indicated (lap preferred)
- exploratory lap
- Dx not definitive
- high risk for complications
- post-op care including splinting to cough
peritonitis
- contamination of peritoneum by bacteria or chemicals
- acute inflammatory process
- local rxn → diffuse pertonitis
- peristalsis slows or stops
- fluid accumulates in intestine @ 7-8 L/day
- → septicemia → septic shock → death
peritoneum
- serous membrane
- forms closed sac
- encloses peritoneal cavity, potential space between layers of peritoneum
- contains ~50 mL sterile fluid
etiology of pertonitis
- bacterial: gains entry via perf
- appendicitis
- diverticulitis
- PUD
- external penetrating wound
- gangrenous gall bladder
- bowel obstruction
- ascending from genital tract
- surgery
- CAPD
- chemical
- bile leakage
- pancreatic enzymes
- gastric acid
peritonitis assessment
- Hx
- S/Sx
- abdomen
- rigid, board-like
- often rebound tenderness
- distention
- ↓ bowel sounds
- GI
- inability to pass flatus or stool
- anorexia
- N/V
- systemic/CV
- high fever
- tachycardia
- dehydration from fever
- GU: ↓ UOP
- abdomen
Dx of peritonitis
- labs
- WBC ≤ 20,000/μL, ↑ neutrophils
- blood cultures to Dx septicemia, ID organism
- fluid: H&H
- renal: BUN, Cr
- imaging to check for air/fluid in abd cavity
- abd X-ray
- US
peritonitis interventions
- assess VS frequently, monitor for signs of shock
- O2 PRN
- monitor I&O
- NGT for decompression
- possible surgery to find/repair cause
- restore fluid volume PRN
- abx as ordered
- manage pain
signs of septic shock
- hypotension
- ↓ pulse pressure
- tachycardia
- fever
- skin changes
- tachypnea
gastroenteritis
- inflammation of mucous membranes of stomach and/or small bowel
- trigger: bacterial or viral (most common) infection
- most cases self-limiting, ~ 3 days
- risk for
- fluid and electrolyte imbalance
- impaired nutrition
most common foodborne dz
norovirus
gastroenteritis assessment
- Hx: recent restaurant visit (24-36 hr) or travel
- S/Sx
- ill appearance
- N/V → abd cramping, diarrhea
- signs of dehydration
gastroenteritis interventions
- prevent spread
- handwashing
- sanitizing surfaces
- self-manage @ home unless severe
- oral fluid replacement w/ Gatorade, Powerade, or Pedialyte
- avoid antiemetics/antidiarrheals, or any drug that suppresses gastric motility
- abx may be needed for bacterial infection
UC
ulcerative colitis
Most UC pts are diagnosed at what ages?
most Dx @ 15-35 y/o
UC patho
- inflammation of rectosigmoid colon, can extend to whole colon
- priodic remissions and exacerbations
- mucosa →
- hyperemic
- edematous
- reddened
- bleed w/ small erosions
- possible abscesses → tissue necrosis
- → edema, mucosal thickening → partial bowel obstruction
UC complications
- abscesses
- hemorrhage (perf)
- tosic megacolon
- malabsorption
- nonmechanical bowel obstruction
- fistulas
- colorectal CA (Hx > 10 yrs)
- extraintestinal complications
extraintestinal complications of UC
- arthritis
- hepatic and biliary dz
- oral and skin lesions
- ocular d/o
assessment of UC
- fam Hx of IBD
- nutrition Hx and habits
- bowel elimination pattern
- onset of Sx
- VS
- abd distention, pain
- psychosocial assessment
UC clinical presentation
- abd distension
- blood and mucus in stool
- lower abd colicky pain relieved w/ defecation
- malaise
- fatigue
- anorexia
- wt loss
- extraintestinal manifestations
- fever
- anemia
- dehydration
UC severity scale
- mild: < 4 stools/day, non-bloody
- moderate: > 4 stools/day, w/ or w/o blood
- severe: > 6 bloody stools/day
- fulminant: > 10 bloody stools/day
fulminant
coming on suddenly and with great severity
labs for UC
- similar to those for Crohn’s dz
- ↓ H&H: chronic blood loss
- ↓ Na+, K+, and Cl-: diarrhea and malabsorption
imaging for UC
- MRE
- NPO 4-6 hr before
- contrast used
- colonoscopy
- bowel prep very uncomfortable for UC/CD pts
- frequent scopes recommended in 10+ yr Hx of UC d/t high CA risk
- barium enema w/ air contrast
MRE
magnetic resonance enterography
UC interventions
- meds: similar to those for Crohn’s
- 5-ASAs
- corticosteroids
- antidiarrheals
- BRMs (refractory, severe complications)
- nutrition
- bowel rest: NPO w/ TPN
- avoid
- caffeine
- ETOH
- some veggies, high-fiber foods
- lactose
- nuts
- carbonated drinks
- surgeries
surgical management of UC
- temp or perm ileostomy: prior abd surgery or abd scar may r/o lap
- RPC-IPAA
- total proctocolectomy w/ perm ileostomy
RPC-IPAA
restorative proctocolectomy w/ ileal pouch-anal anastomosis
restorative proctocolectomy w/ ileal pouch-anal anastomosis
- RPC-IPAA
- two-stage procedure to manage UC
- Stage 1
- colon and rectum removed and temp ileostomy placed
- internal pouch created from last part of small intestine and connected to anus, which remains intact
- Stage 2: ileostomy reversal
Crohn’s disease
- chronic inflammatory bowel dz
- sites affected
- small intestine, usually terminal ileum
- colon
- both
- remission-exacerbation cycles
- severe malabsorption by small intestine more common than in UC
- inflammation → bowel wall thickening
- fibrosis/scar tissue → strictures and obstruction
- ulcerations → risk for fistula
CD
Crohn’s Disease
CD clinical presentation
- varies by individual
- diarrhea, possibly w/
- steatorrhea
- bright red blood
- abd pain, RLQ, constant
- fever w/ abscess, inflammation, or fistula
- wt loss
- fluid/electrolyte imbalance
- anemia (blood loss + ↓ folic acid, B12)
psychosocial considerations for IBD
- chronicity: self-management is important
- requires lifestyle changes for pt and fm
- level of anxiety
- coping skills
labs for Crohn’s
- inflammation: ↑ C-reactive protein, ESR
- blood loss: ↓ H&H, albumin
- diarrhea, fistula: ↓ K+, Mg2+
- enterovesical fistula or pyuria: ↑ WBCs in urine
- CMP
imaging for CD
- purpose: to determine motility, bleeding, ulcerations, stenosis, fistulas
- types
- MRE
- abd/pelvic X-ray
- US
- CT
enterovesical fistula
- opening from bladder to intestine
- possible w/ IBD (esp. CD)
- → WBCs in urine
pyuria
- pus in urine
- → WBCs in urine (UA)
CD drug therapy
- 5-ASAs
- BRMs/mAbs
- abx as ordered
- glucocorticoids
5-ASA drugs
- aminosalicylates
- used to ↓ inflammation in bowel in IBD
- routes
- rectal suppository or enema
- PO
Glucocorticoids may mask S/Sx of _____.
infection
nutrition therapy for CD
- exacerbations may require bowel rest (NPO + TPN)
- avoid GI stimulants (caffeine, ETOH)
- 3,000 kcal/day to promote fistula healing
Skin care is important for pts w/ _____, who may require _____ to capture drainage.
- pts w/ fistulas
- pouches to capture drainage
surgical management of CD
- fistula repair or resection
- small bowel resection
- stricturoplasty
pt education for CD
- rest during periods of exacerbation
- ↓ stress, esp. if it’s a trigger
- proper nutrition
- wound/skin care w/ fistula (return demo)
- S/Sx of infection
- consult home health, SW, case management, dietician
- support groups
post-op care for CD
- pain mgmt
- explore nonpharm options
- goal: acceptable level of comfort for pt
- watch for GI bleed
- stool color/consistency
- H&H
- VS
- altered body image
- home health may be necessary
- psychosicial considerations
stoma assessment
- healthy: pink or red, moist
- unhealthy
- bleeding, leaking
- itching, painful
- swelling/bulging
- pale or purple
- dry
skin care for ileostomy
- crucial to logevity of device
- keep clean, dry
- have properly fitting wafer
- wound care team
- pt teaching w/ return demo
pt education for ileostomy
- avoid foods that cause gas or are high in fiber
- pt should ID well-tolerated foods
- get enough salt and water in diet
- find ostomy system that works best
- skin and stoma care
- ostomy care
- S/Sx of unhealthy stoma
- stoma changes
- ↑/↓ in stool output
- severe abd pain
- meds
- avoid enteric-coated or capsules
- NO laxatives or enemas
diverticulitis
- inflammation and infection of bowel mucosa
- etiology: bacteria, food, or fecal matter become trapped in one or more diverticula
diverticula
pouch-like herniations in intestinal wall
celiac dz
- chronic inflammation of small intestine mucosa
- autoimmune w/ genetic, environmental factors
- → bowel wall atrophy, malabsorption
immune dz pts at higher risk for celiac dz
- T1DM
- RA
manifestations of celiac dz
- (Sx vary by person)
- anorexia
- wt loss
- abd pain, distention
- diarrhea or constipation
- steatorrhea
atypical manifestations of celiac dz
- malnutrition
- osteoporosis
- Fe-deficiency anemia
- protein-calorie malnutrition
- joint pain, inflammation
- lactose intolerance
- migraine
- epilepsy
- depression
management of celiac dz
- only Tx option is gluten-free diet
- intestinal mucosa generally heal in 2 yrs
pt education for celiac dz
- avoid gluten-containing products
- wheat, other grains processed in wheat facility
- gluten can also be in additives, drugs, or cosmetics
- supplemental nutrition needed
noninflammatory intestinal d/o
- obstruction
- IBS
IBS
irritable bowel syndrome
intestinal obstruction
- complete or partial
- mechanical: physically blocked by object outside, inside, or in wall of intestine
- nonmechanical (paralytic ileus): ↓ or absent peristalsis; neuromuscular disturbance
complications of bowel obstruction
- fluid/electrolyte and acid-base imbalances
- severe hypovolemia → AKI
- risk for peritonitis w/ ↓ blood flow to intestine
- sepsis
- GI bleed
etiology of mechanical bowel obstruction
- adhesions
- tumor
- complications of appendicitis
- hernias
- fecal impaction
- strictures d/t inflammation or radiation Tx
- intussusception
- volvulus
- fibrosis
etiology of nonmechanical bowel obstruction
- POI
- peritonitis
- intestinal ischemia
POI
post-op ileus
volvulus
loop of intestine twists around itself and the mesentery that supplies it → obstruction
intestinal fibrosis
- excessive scarring in intestines → obstruction or stricture
- occurs in IBD
Sx of bowel obstruction
- pain and/or cramping, maybe sporadic
- vomiting possible
- bile, mucus in vomitus
- obstipation
- diarrhea (diarrhea partial obstruction)
- abd distention
- auscultation
- borborygmi above
- sounds absent below
borborygmi
rumbling, gurgling bowel sounds
obstipation
failure to pass flatus
interventions for bowel obstruction
- assess
- VS
- wt
- abd
- NPO until able to pass flatus, stool
- NGT for decompression
- disimpaction and/or enemas for lower fecal impaction
- IV fluid replacement PRN
- monitor electrolytes, fluid status
- frequent oral care
- surgery for complete mechanical obstruction
IBS
irritable bowel syndrome
irritable bowel syndrome
- functional GI d/o
- S/Sx: chronic or recurrent diarrhea, constipation, and/or abd pain and bloating
- 3 types
- IBS-C
- IBS-D
- IBS-A
IBS etiology
- environmental: caffeine, carbonation, dairy
- immunologic
- genetic
- hormonal
- stress-related
- infectious agents can be biomarkers for IBS
assessment for IBS
- GI Hx
- Sx and exacerbations, including flatulence, bloating, distention
- nutrition
- drugs
- pain, often in LLQ
- physical
- usually stable wt
- bowel sounds
- hypo w/ C
- hyper w/ D
- labs normal
interventions for IBS
- ambulatory care mgmt
- self-mgmt
- ↓ stress
- general health education
- ↑ dietary fiber, 30-40 g/day
- 64-80 oz water/day
- drug therapy
drug therapy for IBS
- (depends on main Sx)
- IBS-C: bulk-forming laxative (Metamucil)
- IBS-D: antidiarrheal (Imodium)
- others
- muscarinic receptor antagonists to ↓ motility
- probiotics
abd hernia etiology
- etiology
- weakness in abd muscle wall allows abd organs/structures to protrude
- congenital or acquired via ↑ intra-abd pressure
types of abd hernias
- indirect/direct inguinal
- femoral
- umbilical
- incisional
- epigastric
management of abd hernia
- nonsurgical or surgical
- reducible or irreducible
hernia strangulation
- protruding abd structure is tightly trapped → gangrene
- requires prompt surgery
- nonsurgical reduction contraindicated, will severely compromise Tx and outcome
- signs
- N/V
- fever
- sudden pain that intensifies quickly
- hernia bulge that turns red, purple, or dark
- inability to move bowels or pass flatus
hemorrhoids
- swollen or distended anorectal veins
- prolapse of veins d/t ↑ intra-abd pressure
- can be internal or external
- common
- significant if painful d/t thrombosis and bleeding
prevention of hemorrhoids
- ↑ fluids
- ↑ fiber
- avoid straining during BM
- exercise regularly
- maintain healthy wt
Tx of hemorrhoids
- nonpharm
- cold packs
- tepid sitz baths 3-4x/day
- drugs
- OTC topical
- anesthetics
- steroids
- stool softeners
- OTC topical
- diet ↑ fiber and fluids
- surgical: hemorrhoidectomy
hemorrhoidectomy
- surgical removal of hemorrhoids
- type depends on
- degree of prolapse
- presence of thrombi
- health of pt
biliary system
- parts
- liver
- gallbladder
- pancreas
- fxn: secrete enzymes for digestion in stomach and small intestine
gallbladder
- pear-shaped, hollow organ
- in RUQ inferior to liver
- holds bile
- bile flow
- liver common hepatic duct → gallbladder
- fat digestion triggers gallbladder ctx
- → cystic + common hepatic
- → common bile cystic + common hepatic
- → common bile duodenum
cholecystitis
- inflammation of gallbladder
- acute or chronic
- two types
- calculous: d/t gallstones: most common
- acalculous: w/o gallstones
cholelithiasis
- formation of gallstones when bile salts precipitate in gallbladder
- stones calcified or non
- asymptomatic unless bile flow is obstructed
acute calculous cholecystitis
- gallstones obstruct
- cystic duct (most common)
- gallbladder neck
- common bile duct
- → bile backup into gallbladder
- →
- irritation
- inflammation
- impaired circulation
- edema
- gallbladder distension
types of gallstones
- pigmented/calcified
- cholesterol
acute acalculous cholecystitis
- inflammation of gallbladder w/o calculi
- etiology: changes in filling or emptying of gallbladder (biliary stasis)
- ↓ blood flow to gallbladder
- anatomic issues
chronic cholecystitis
- repeated episodes of gallbladder inflammation
- often associated w/ calculi
- outcomes
- scarring, further gallbladder dysfunction
- pancreatitis
- cholangitis
bile obstruction →
- infection
- ↑ bilirubin
- chronic liver dz
risk factors for cholecystitis
- female gender
- age
- obesity
- high-fat diet
- rapid wt loss
- malabsorption syndromes
- HRT
- contraceptives
- genetics
- PG
- anatomical obstruction
- prolonged TPN
- ethnicity/race
- Native American
- Mexican
subjective data for cholecystitis
- RUQ pain, often radiating to rt shoulder
- rebound tenderness
- can present as general abd pain
- Sx after ingesting fatty food
- N/V
- belching
- flatulance
objective data for cholecystitis
- fever
- tachycardia
- dehydration (fever, vomiting)
- jaundice/icterus
- dark urine
- clay-colored stools
- steatorrhea
- dyspepsia
- eructation
- flatulence
- pruritus
- OA: may not have fever or pain
labs for cholecystitis
- ↑ WBCs
- biliary obstruction: ↑ ALP, AST, LDH, and bilirubin
- pancreatic involvement: ↑ amylas, lipase
diagnostics for cholecystitis
- US (best intially)
- abd X-ray, CT: shows only calcified stones
- HIDA scan: traces bile flow to determine patency
HIDA scan
- hepatobiliary iminodiacetic acid scan
- used to trace flow of bile in cholecystitis Dx
ERCP
endoscopic retrograde cholangiopancreatography
MRCP
magnetic resonance cholangiopancreatography
magnetic resonance cholangiopancreatography
- MRCP
- oral/IV contrast used
- detailed imaging of hepatobiliary and pancreatic structures
- less invasive, safer that ERCP
endoscopic retrograde cholangiopancreatography
- ERCP
- direct visualization of liver, gallbladder, bile ducts, and pancreas
- invasive
- allows for therapeutic procedures
- sphincterotomy
- gallstone removal
- stent placement
- balloon dilation
- Bx
ERCP with sphincterotomy
- cholecystitis
- a small cut made in papilla of Vater to enlarge opening of bile and/or pancreatic ducts
- goals: improve drainage or remove stones in ducts
- pancreatitis caused by gallstones
- opening created in sphincter of Oddi
- pacreatic duct sphincter enlarged if needed
nonsurgical management of cholecystitis
- dietary
- high fiber
- low fat
- small, frequent meals
- drug therapy
- ESWL
- percutaneous transhepatic biliary drain w/ cholecystostomy
surgical management of cholecystitis
- cholecystectomy: removal of gallbladder
- lap chole: gold standard Tx
- open: for severe obstruction
- NOTES: new MIS procedure
lap chole
- laparoscopic cholecystectomy
- process
- abd insufflated using 3-4 L CO2
- trocars puncture abd, laparoscope inserted
- bile aspirated, stones crushed
- gallbladder removed via umbilical port
insufflated
blow air or gas into a cavity
MIS
minimally invasive surgery
NOTES
natural orifice transluminal endoscopic surgery
NOTES cholecystectomy
- flexible scope passed through natural orifice to furth minimize size/number of incisions necessary
- decreases post-op complications, and possibly pain
- routes: mouth, vagina, anus
traditional/open cholecystectomy
- for severe biliary obstruction
- rarely done
- biliary ducts explored to ensure patency
- drain may be placed to reduce post-op fluid accumulation
- JP
- T-tube
classes of drugs used for cholecystitis
- pain
- opioids for acute pain
- ketorolac for mild-moderate pain
- N/V: antiemetics
- inflammation/infection: IV abx
- stones: bile acids
opioids for cholecystitis
- for acute biliary pain
- drugs
- morphine sulfate
- hydromorphone
- may cause sphincter of Oddi spasm
ketorolac for cholecystitis
- for mild to moderate biliary pain
- NSAID
- risk for GI bleed
bile acids for cholecystitis
- to dissolve cholesterol-based stones in pts who cannot or will not undergo surgery
- compounds naturally produced in body
- drugs: take w/ food or milk
- ursodiol
- chenodiol
ESWL
extracorporeal shock wave lithotripsy
ESWL for cholelithiasis/cholecystitis
- breaks up small, cholesterol-based stones
- good when surgery is contraindicated
- requirements
- average/normal wt
- good gallbladder fxn
- process
- pt lays on fluid-filled pad
- shock waves delivered via pad
- possible results
- spasms
- stone movement
- pain, discomfort
- meds: possible UDCA to further break up fragments
UDCA
- ursodeoxycholic acid
- bile acid
- sometimes used after ESWL to break up remaining fragments
JP drain
- Jackson-Pratt
- surgical drain with flexible bulb that uses gentle mechanical suction to remove accumulating fluid
- expected course
- diminishing amounts of serosanguineous
- color: red → light pink/yellow
- removal when drainage < 25 mL/day x2 days
- monitor and document output closely
- abx to prevent infection
T-tube management
- expected course
- sanguineous/serosanguineous → bile color
- ≤ 400 mL in first 24 hr, then ↓
- removal in 1-3 wks
- no drainage + N/V could mean obstruction
- monitor
- and record color, amount
- insertion site for inflammation, infection, leakage
- color of stools (white/clay = no bile)
- VS
- skin color
- pain level
- tolerance of diet/intake
- pain meds, abx
-
report immediately
- abd pain + fever + jaundice = bile peritonitis
- output 500 mL/24 hr
T-tube
- surgical drain placed in common bile duct after surgery and exploration
- prevents buildup of bile d/t postop swelling/inflammation
pt education for cholecystitis
- preop/postop info baseed on procedure
- dietary: avoid fatty and gas-causing foods
- post-op
- lap chole: early ambulation to expel CO2
- incision/drain care
- S/Sx of dehiscence or evisceration
- resume activity gradually
- open chole: no heavy lifting for 4-6 wks
- drain: showers, not baths, until removed
- S/Sx of infection, when to see provider
complications of cholecystitis and Tx
- bile duct obstruction
- gallbladder rupture
- peritonitis
- post-cholecystectomy syndrome
- hepatic CA
post-cholecystectomy syndrome
manifestations of gallbladder dz after removal
pancreas anatomy
- shape: elongated, tapered
- position
- retroperitoneal, posterior to stomach
- close to liver, near L1, L2 vertebrae
- head on right (larger end)
- in curve of duodenum
- connected by pancreatic duct
- tail on left (smaller), near spleen
- head lies in curve of duodenum, connected by pancreatic duct
- composition: 2 types of glands
- 95% exocrine by mass
- 1-2% endocrine
exocrine glands of pancreas
- makes up 95% of pancreas by mass
- secrete enzymes to break down starches, proteins, and fats
- activated by presence of food small intestine
endocrine glands of pancreas
- 1-2% of pancreas by mass
- consists of islets of Langerhans
- primary d/o associated w/ these glands: DM
substances secreted into duodenum by exocrine pancreas
- alkali: HCO3
- enzymes
- proteases
- trypsinogen
- chymotrypsinogen
- amylase
- lipase
- other enzymes
- proteases
HCO3
- bicarbonate
- alkaline/base
role of bicarbonate in digestion
- secreted from pancreatic duct cells → lumen → duodenum
- neutralizes HCl from stomach
substances secreted by endocrine pancreas
- insulin
- glucagon
- somatostatin
- pancreatic polypeptide
pancreatitis
- inflammation of pancreas
- etiology: not always known; possibilities are
- obstructions
- ETOH
- autimmune dz
- acute or chronic
acute pancreatitis
- inflammation of pancreas →
- ↑ duct pressure
- → duct rupture
- → enzymes released in pancreas
- → autodigestion of pancreatic tissue
- → inflammation, pain, fibrosis
- untreated → NHP
NHP
- necrotizing hemorrhagic pancreatitis
- result of untreated pancreatitis
necrotizing hemorrhagic pancreatitis
- result of untreated pancreatitis
- involves these processes
- diffuse bleeding of pancreatic tissue
- scarring
- tissue death
chronic pancreatitis
- → permanent damage
- almost always result of ETOH abuse
- several types
How does ETOH affect the pancreas?
↑ enzyme production
types of chronic pancreatitis
- chronic calcifying: usually r/t ETOH abuse
- chronic obstructive: usually r/t cholelithiasis
- autimmune
- idiopathic
- hereditary
pancreatitis risk factors
- ETOH and drug toxicity
- stones in common bile duct
- genetics
- cystic fibrosis
- trauma
- postop manipulation
- OA
- viral infection
- autoimmunity
symptoms of pancreatitis
- sudden onset of pain
- possible locations
- LUQ radiating to back
- mid-epigastric
- left flank
- left shoulder
- descriptions
- boring
- gnawing
- stabbing
- often relieved by bending abd
- worse when lying down
- possible locations
- N/V, w/ no relief of pain
- wt loss
signs of pancreatitis
- blood seeping into tissues
- Cullen’s sign
- Turner’s sign
- jaundice
- absent or hypoactive bowel sounds
- hyperglycemia
- abd guarding
- tachycardia
- fever
- ascites
- possible
- palpable mass
- paralytic ileus
- pleural effusion
- steatorrhea
- dark urine
- clay-colored stool
- polyuria
- polydipsia
- polyphagia
- hypocalcemia →
- MSK tetany
- Trousseau’s sign
- Chvostek’s sign
Cullen’s sign
- blood seeping into tissues → periumbilical discoloration
- blue/gray
- most often a sign of hemorrhagic pancreatitis
Turner’s sign
- blood seeps into tissues → ecchymosis on flanks
- most often a sign of hemorrhagic pancreatitis
Trousseau’s sign
- hand spasm occurs when BP cuff inflated
- indicates hypocalcemia
Chovstek’s sign
- face twitches when facial nerve is tapped
- indicates hypocalcemia
diagnostics for pancreatitis
- CT w/ contrast: reliable, accurate
- abd X-ray and/or US: to look for gallstones
- ERCP
- HIDA scan
nonsurgical management of pancreatitis
- pharm Tx
- ERCP w/ sphincterotomy
surgical management of pancreatitis
- cholecystectomy
- endoscopic pancreatic necrosectomy + NOTES
- pancreaticojejunostomy
pharm Tx of pancreatitis
- pain: opioids
- morphine
- hydromorphone
- NOT meperidine (sz, esp. in OA)
- inflammation/infection: abx
- imipenem
- usu. for necrotizing
- monitor for S/Sx of infection, sz
- acid reduction
- H2 blocker: ranitidine
- PPI: omeprazole
- digestive aid: pancrelipase
pancrelipase
- digestive aid used for pancreatitis
- give w/ every food/snack
- drink full glass of water
- can sprinkle capsule contents on nonprotein foods
- take after antacid or H2 blocker
- wipe and rinse mouth to prevent breakdown
cholecystectomy for pancreatitis
for pancreatitis caused by cholecystitis and cholelithiasis
longitudinal pancreaticojejunostomy (Roux-en-Y)
- reroutes pancreatic secretion drainage into the jejunum
- Roux-en-Y: anastamosis technique used in LPJ
Roux-en-Y
- anastamosis technique
- used in several surgeries
- pancreaticojejunostomy
- pancreatic head resection
- Tx of lesion in pancreatic head
surgical Tx for pancreatitis
- cholecystectomy
- endoscopic pancreatic necrosectomy and NOTES
- pancreaticojejunostomy
LPJ
longitudinal pancreaticojejunostomy
dietary considerations for pancreatitis
- NPO/gut rest until pain resolves
- TPN or J-tube feedings if condition not severe
- J-tube contraindicated if pt has paralytic ileus
- restarting solid food
- bland
- high-protein
- low-fat
- small, frequent meals
- no caffeine
- may need dietary consult
TPN
total parenteral nutrition
PPN
peripheral parenteral nutrition
nursing care of pancreatitis pts
- give meds as ordered: analgesics, abx, antiemetics
- position for comfort
- fetal
- side-lying
- HOB elevated
- sitting leaned forward
- monitor
- BG, give insulin as ordered
- hydration: I&O, labs, orthostatic BP
- give IV fluids, electrolytes as ordered
total parenteral nutrition
- hypertonic IV solution
- only give in central line
- complete nutrition
- usually
- ≤ 700 kcal/day
- ↑ glucose concentration
- can be given w/ lipids, ≤ 30% concentration
peripheral parenteral nutrition
- ≤ 10% dextrose
- given via PIV
types of IV solutions
- isotonic
- hypotonic
- hypertonic
isotonic IV solution
- NS
- osmolarity ≈ plasma
- solution stays in intravasular space
- expands intravascular compartment, ↑ fluid volume
hypotonic IV solutions
- 1/2 NS
- osmolarity lower than plasma
- draws fluid out of intravascular compartment
- hydrates cells and interstitial compartment
hypertonic IV solutions
- TPN, 3% NS
- osmolarity higher than that of plasma
- draws fluid into intravascular compartment from cells, interstitial compartment
TPN Rx must be verified by _____ _____.
another RN
pancreatitis labs
- cell injury
- ↑ serum amylase
- ↑ serum lipase
- ↑ serum trypsin
- ↑ serum elastase
- cell injury/↓ insulin release: ↑ serum glucose
- fat necrosis: ↓ Mg2+ and Ca2+
- hepatobiliary involvement
- ↑ bilirubin (obstruction)
- ↑ ALT
- ↑ AST
- inflammation: ↑ WBCs, ESR
things to monitor when administering TPN
- I&O +
- daily wt
- PO nutrient intake
- labs
- prealbumin
- albumin
- glucose
- electrolytes
- CBC
- infection
- fever, chills
- ↑ WBCs
- redness @ catheter insertion
allergies to check for before giving TPN
- soybeans
- safflower
- eggs (lipid solution)
TPN administration
- use
- micron filter
- IV pump
- strict asepsic technique
- rate
- start slowly
- increase to goal rate gradually
- NEVER catch up by increasing rate
- NEVER STOP SUDDENLY
- taper to D/C
- if next bag unavailable, use destrose solution
- change bag and tubing Q24H
- TOTAL INCOMPATIBLE
What other meds or solutions can be added to TPN?
none
How often should TPN bag and tubing be changed?
Q24H
When administering TPN with lipids, where should the lipids be connected?
distal to the filter
If TPN is unavailable, what solutions should be used in its place and why?
D10W or D20W
metabolic complications of TPN
- hyper- or hypoglycemia
- electrolyte imbalances
- dehydration
- fluid overload
mechanical complications of TPN admin
- catheter misplacement
- embolus
How can TPN cause dehydration?
hyperosmolar diuresis from hyperglycemia
What indicates fluid overload from TPN?
wt gain > 1 kg/day + edema
types of complications from TPN
- metabolic
- mechanical
- infectious (→ sepsis)
adjunct orders for TPN
- sliding scale or IV insulin for hyperglycemia
- dextrose for hypoglycemia
Why must TPN be tapered?
to avoid rebound hypoglycemia
You should notify the provider if a pt on TPN gains >.___ kg/day.
1 kg/day
pt education for pancreatitis
- S/Sx
- proper diet
- importance of med adherence, esp. if chronic
- ETOH cessation
- management of complications
complications of pancreatitis
- hypovolemia
- left pleural effusion → pneumonia
- DIC
- multi-system organ failure
- T2DM or T1 if pancreas is destroyed
- paralytic ileus
- pancreatic abscess
- pancreatic pseudocyst
- pancreatic CA
hypovolemia w/ pancreatitis
- cause: third-spacing
- → hypovolemic shock
third-spacing
too much fluid moves intravascular → interstitial
S/Sx of hypovolemic shock
- restlessness
- anxiety
- agitation
- confusion
- weakness
- lightheadedness
- tachycardia
- appearance: stable → critically ill
- AMS
- UOP < 30 mL/hr
- ↑ cap refill
- gooseflesh
nursing care of paralytic ileus 2/2 pancreatitis
- may require prolonged NGT for decompression
- assess for passage of flatus
Pancreatic abscess occurs with _____ pancreatitis.
necrotizing
pancreatic abscess considerations
- must be drained
- abx not effective alone
- ↑ mortality d/t easy spread to other organs
pancreatic pseudocyst considerations
- can rupture and cause
- hemorrhage
- abscess
- fistula
- Tx
- may resolve on its own
- surgical removal
pancreatic CA overview
- devastating
- low 5-year survival
- often found late
- well-developed
- aggressive
- very painful; pt often has vague abd pain
- common Tx: Whipple
Whipple procedure
- pancreaticoduodenectomy
- removal of
- head of pancreas
- parts of stomach
- duodenum
- gallbladder
- bile duct
- sometimes used as Tx for pancreatic CA
cirrhosis
chronic, irreversible inflammation and scarring of liver tissue
cirrhosis →
- loss of normal cellular fxn
- development of nodules and fibrous tissue
causes of cirrhosis
- chronic ETOH use
- drugs
- toxins
- hepatitis
- NAFLD
- gallbladder dz
- CV dz
What types of hepatitis cause cirrhosis?
- viral
- most common: B and D
- second most common: C
- autoimmune
NAFLD
non-alcoholic fatty liver dz
non-alcoholic fatty liver dz
- NAFLD
- associated w/
- obesity
- metabolic syndrome
- DM
types of cirrhosis
- post-necrotic
- Laennec’s (alcoholic)
- biliary/cholestatic
- compensated
- decompensated
cause of post-necrotic cirrhosis
- hepatitis
- drugs
- toxins
causes of biliary/cholestatic cirrhosis
- biliary obstruction
- AID
compensated cirrhosis
performs necessary fxn despite scarring
decompensated cirrhosis
obvious manifestations of liver failure
cirrhosis complications
- portal HTN
- ascites
- esophageal varices
- coagulation problems
- jaundice
- encephalopathy
- hepatorenal syndrome
- spontaneous bacterial peritonitis
portal HTN
↑ > 5 mm Hg in portal vein
portan HTN cause
- ↑ resistance of blood flow in portan vein
- obstruction prevents normal blood flow
cirrhosis → portal HTN →
- (blood rerouted to nearby vessels)
- esophageal varices
- ascites
- splenomegaly
acute mgmt of bleeding esophageal varices
- hemodynamic resuscitation
- octreotide
- blanding, sclerotherapy
- prophylactic abx
chronic mgmt of esophageal varices
- beta blockers
- endoscopic variceal ligation
ascites
collection of free fluid in peritoneal cavity
ascites causes
- ↑ pressure from portal HTN
- Na+ retention → renin-angiotensin activation
ascites process
- plasma protein accumulates in peritoneal fluid
- → ↓ plasma protein in blood + ↓ albumin production
- → ↓ osmotic pressure in vessels
- → fluid shift to abd
- → hypovolemia + edema
Bleeding esophageal varices are an _____.
emergency
esophageal varices cause
- ↑ pressure in portal vein
- → blood flow backup into esophagus
- → fragile, thin-walled veins in esophagus become tortuous
signs of bleeding esophageal varices
- hematemesis
- melena
cause of bleeding in esophageal varices
- spontaneous
- anything that ↑ pressure
- damage to esophagus
splenomegaly cause
- (blood flow backup into spleen)
- portal hypertension
- CHF
- splenic vein obstruction
- etc.
splenomegaly process
- spleen enlargment
- → platelet destruction
- → ↑ risk for bleed
Thrombocytopenia caused by _____ may be the first clinical sign of _____ dysfunction.
- caused by splenomegaly
- liver dysfunction
Cirrhotic liver does not produce enough _____.
bile
bile fxn
helps w/ absorption of fat-soluble vitamins
↓ bile production → ↓ vitamin ___ absorption, which is necessary for production of _____ _____
- vitamin K
- clotting factors
hepatocellular jaundice
- liver cells do not effectively excrete bilirubin
- → excess bilirubin in circulation
intrahepatic obstructive jaundice
- causes
- edema
- fibrous tissue
- scarring of channels, ducts
- interferes w/ bile and bilirubin excretion
medical term for jaundice
icterus
types of jaundice
- hepatocellular
- intrahepatic obstructive
PSE
- portal-systemic encephalopathy
- AKA hepatic encephalopathy
portal-systemic encephalopathy
- AKA hepatic encephalopathy, PSE
- complex cognitive syndrome
characteristics of PSE
- AMS
- speech problems
- mood changes
- sleep disturbances
- later
- altered LOC
- impaired thinking
- impaired neuromuscular fxn
hepatic encephalopathy
- acute or insidious
- etiology unknown, but unclear link to ↑ serum ammonia
- 4 stages
Stage I hepatic encephalopathy
- subtle changes in
- thinking
- personality
- behavior
Stage II hepatic encephalopathy
- ↑ Sx of
- confusion
- disorientation
- asterixis
asterixis
- abnormal muscle tremor
- involuntary jerking movements
- esp. in hands, but also seen in tongue, feet
Stage III hepatic encephalopathy
- marked confusion
- stupor
- hyperreflexia
Stage IV hepatic encephalopathy
- unresponsive
- unarousable
- Babinski
- fetor hepaticus
fetor hepaticus
mousy odor in the breath of people with severe liver impairment
Babinski sign in adults
- dorsiflexion of the great toe when the sole of the foot is stimulated
- in adults, could indicate
- lesion of the pyramidal (corticospinal) tract
- hepatic encephalopathy
- other neurological conditions
potential factors in development of hepatic encephalopathy
- high-protein diet
- infection
- hypovolemia
- hypokalemia
- constipation
- GI bleed
- drugs
Hepatorenal syndrome may occur after what 2 conditions?
- GI bleed + clinical deterioration
- onset of hepatic encephalopathy
hepatorenal syndrome signs
- sudden ↓ of UOP: < 500 mL/24 hr
- ↑ BUN
- ↑ Cr
- ↓ Na+ excretion
- ↑ urine osmolarity
possible cause of spontaneous bacterial peritonitis
- abnormally low protein levels
- bacteria from bowels → ascitic fluid
S/Sx of spontaneous bacterial peritonitis
- possibly none
- fever
- chills
- abd pain/tenderness
Dx of spontaneous bacterial peritonitis
- WBC count
- ascitic fluid culture
cirrhosis assessment Hx
- demographic data
- lifestyle
- ETOH, drug, toxin exposure
- illicit drugs
- OTC meds
- sexual Hx
- needle exposures
- travel
- close-quarter living
S/Sx of early or compensated cirrhosis
- vague Sx
- fatigue
- wt change
- GI Sx
- abd pain
- labs
- thrombocytopenia
- abnormal LFTs
S/Sx of advanced cirrhosis
- jaundice
- petechiae
- ecchymoses
- spider angiomas on
- nose
- cheeks
- thorax
- shoulders
- ascites
- edema
- peripheral
- sacral
- vitamin deficiency, esp. K
- hepatomegaly
- splenomegaly
- fetor hepaticus
- asterixis
- neurological dysfunction
- gynecomastia
3 important things to monitor in cirrhosis
- abd girth
- daily wt
- neurological fxn
lab assessment for liver dz
- may normalize w/ ↑ deterioration
- AST
- ALT
- LDH
- biliary obstruction
- GGT
- ALP
- bilirubin
- ↑
- PT/INR
- ammonia
- ↓
- serum protein
- albumin
- platelets
- RBCs
- H&H
- WBC
elimination assessment for liver dz
- urine: ↑ urobilirubin
- stool
- ↓ urobilinogen conc. r/t biliary obstruction
- clay-colored or light
diagnostics for liver dz
- imaging: hepatomegaly, splenomegaly, ascites, lesions/masses
- X-ray
- CT
- MRI
- Bx
- US: liver visualization, portal vein blood flow
- EGD
- visualization of esophageal varices, bleeding
- ulceration
- ERCP
- contrast to view sphincter of Oddi, biliary tract
- remove stones if necessary
nursing priority for liver dz
remove excess fluid
nutrition therapy for liver dz
Na+ restriction
vitamin, electrolyte replacement
IV vitamins for late-stage liver dz
meds for liver dz
- diuretics
- abx
- propranolol
paracentesis
- removal of excess ascitic fluid
- at bedside or in IR
Tx for fluid volume excess
respiratory support for hepatopulmary syndrome
respiratory support for hepatopulmary syndrome
- ↑ abd pressure r/t ascites
- prevents thoracic expansion
- monitor
- SpO2
- respiratory effort
- daily wt
- elevate
- HOB
- edmatous limbs
drug therapy for intact esophageal varices
- beta blockers
- ↓ HR
- ↓ hepatic venous pressure gradient
drug therapy for bleeding esophageal varices
- vasopressin
- ↓ blood flow
- ↑ vasoconstriction
- octreotide
- ↓ secretion of
- gastrin
- serotonin
- peptides
- → ↓ GI blood flow
- ↓ secretion of
EVL
endoscopic variceal ligation
Tx for bleeding esophageal varices
- EVL
- EST
- SB tube
- TIPS
- others
EST
endoscopic sclerotherapy
goals of EVL
- ↓ bleeding
- ↓ blood supply to varices
endoscopic sclerotherapy
- goal: stop bleeding
- process: catheter injects sclerosing agent into vein
- complications: ulceration of mucosa → further bleeding
Sengstaken-Blakemore tube
- procedure
- in mouth or nare → stomach
- balloon inflated to apply pressure to bleeding varices
- complications
- aspiration
- asphyxia
- esophageal perf
SB tube
- Sengstaken-Blakemore tube
- used to stop esophageal bleeding
TIPS
- transjugular intrahepatic portal-systemic shunt
- Tx for bleeding esophageal varices
transjugular intrahepatic portal-systemic shunt
- TIPS
- to treat bleeding esophageal varices
- performed in IR
- US-guided placement of stent in portal vein
- follow-up to ensure patency
NGT placement in Tx of bleeding esophageal varices
as needed to monitor for further bleeding
possible transfusions for esophageal varices bleed
- pRBCs
- FFP
- albumin
- platelets
labs for esophageal varices bleed
- PT/INR
- PTT
- platelets
nursing priority for hepatic encephalopathy
- SERUM AMMONIA
- liver can’t convert → remains in circulation → brain
- also produced by GI bacteria
- moderate-protein diet
- drug therapy
drug Tx for hepatic encephalopathy
- laxative: lactulose
- abx: ↓ GI bacteria
- rifaximin
- metronidazole
- vancomycin
pt education for liver dz
- nutrition
- follow diet
- supplements
- vitamin/electrolyte replacement
- meds
- avoid all OTCs
- supply of lactulose
- ETOH abstinence
- Fm education: S/Sx of
- encephalopathy
- fluid shift/retention
- bleeding
hepatitis etiology
- exposure to causative source → inflammation, necrosis
- causes
- viral strains A-E
- other viral hepatitis
- toxin- and drug-induced
- secondary infection
- Epstein-Barr
- herpes
- varicella-zoster
- CMV
hep A
- enterovirus
- prognosis
- generally recoverable
- more severe in OA
- destroyed by bleach and very high temps
hep B
- composed of antigens
- circulates in blood
- prognosis
- most adults clear infection, become immune
- others become carriers
hep B S/Sx
- fever
- anorexia
- N/V
- RUQ pain
- dark urine
- light stool
- jaundice
- joint pain
hep B transmission
- unprotected sex
- needles
- sharing
- accidental sticks
- transfusions
- hemodialysis
- close person-person contact w/ open wound
hep A transmission and S/Sx
- transmission: fecal-oral
- hand-hand
- food/water contamination
- S/Sx: flu-like
hep C
- HCV
- most common hep virus
- most are unaware of infection
hep C transmission
- blood-blood
- needles
- IV needle sharing
- accidental sticks
- tattoo equipment
- blood
- blood products
- organ transplant
hep C prognosis
untreated → chronic liver inflammation/scarring → cirrhosis
hep D
- defective RNA → needs HBV to replicate
- prognosis: usually becomes chronic dz
hep D transmission
- parenteral
- IV needle sharing
- sexual contact
hep E
- geographical prevalence
- Asia
- Africa
- Middle East
- Mexico
- Central and South America
- only among international travelers in U.S.
- prognosis: generally self-limiting, not chronic
hep E manifestations
similar presentation to hep A
flu-like Sx
hepatitis complications
- fulminant hepatitis
- chronic hepatitis
fulminant hepatitis
- severe acute hepatitis
- failure of liver cells to regenerate
- progression of necrosis
- can be fatal
chronic hepatitis
- inflammation > 6 mo
- etiology
- generally HBV or HCV
- also w/ combo infections and HIV
- → cirrhosis, liver CA
health promotion and maintenance for hepatitis
- vaccines
- HAV
- HBV
- HAV
- proper handwashing
- avoid contaminated food/water
- HBV
- avoid unprotected, risky sexual contact
- exposure to blood or bodily fluids
expected hepatitis labs
- ↑ ALT
- ↑ AST
drug usage → hepatitis
- OTC
- prescribed
- illicit
assessment for hepatitis
- LFTs
- drug usage
- ingestion of shellfish or contaminated water
- sexual activity
- living quarters
- travel Hx
physical assessment for hepatitis
- malaise
- N/V
- pruritis
- abd pain
- jaundice
- arthralgia
- myalgia
- stool and urine changes
psychosocial assessment for hepatitis
- emotions/coping
- depression
- fm involvement
- cost
- fear of infecting others
diagnostic labs for hep A
- current inflammation: ImM
- previous infection: IgG
diagnostic labs for hep B
- HBSAB: antibody present
- recovery and immunity
- vaccinated
- HBSAB: antibody present
diagnostic lab for hep C
ELISA
diagnostic lab for hep D
+delta-antigen
liver Bx for hepatitis looks for
characteristics and changes to liver
hepatitis Tx
- liver rest, recovery
- small, frequent meals
- drugs (HBV and HCV)
- antivirals
- immunomodulators
- prevent spread
nutrition for hepatitis recovery
- ↑ carb and kcal
- moderate fat and protein
- vitamin supplements
- no ETOH, drugs
steatosis
- accumulation of fats in and around hepatic cells
- NAFLD
- non-alcoholic steatohepatitis
non-alcoholic steatohepatitis
fatty liver dz
causes of NAFLD
- DM
- obesity
- ↑ lipids
steatohepatitis
- fatty liver dz
- degenerative changes in liver cells 2/2 fat deposits in hepatocytes
- generally asymptomatic
- may be found in liver Bx or imaging
Tx for fatty liver dz
- Tx of underlying cause
- monitor LFTs
- meds: lipid-lowering agents
liver trauma
- injury or assault to liver
- common cause: steering wheel in MVA
- complication: blood loss, hypovolemic shock
- Tx: blood products
- monitor coags
hepatic CA
- primary or metastatic
- main cause: cirrhosis 2/2 chronic HBV and HCV
liver CA early Sx
asymptomatic
later Sx of liver CA
- wt loss
- anorexia
- RUQ pain
lab for liver CA
AFP tumor marker
AFP tumor marker
- alpha-fetoprotein tumor marker
- indication of liver CA
Tx for liver CA
- tumor resection
- hepatic artery embolization
- radiofrequency ablation
- chemo
- transplant
- palliative care (late stages)
tumor resection for liver CA
- only available long-term Tx
- most tumors not resectable
hepatic artery embolization for liver CA
- causes cell death by ischemia in hepatic artery, which feeds most tumors
- most hepatic cells fed by portal vein
- IR procedure
- catheter guided by angiogram injects blocking agent into artery feeding tumor
transplant for liver CA
- indication: end-stage dz w/o response to conventional Tx
- exclusions
- severe cardiac or respiratory dz
- metastatic tumors
- inability to follow instructions/self-manage
liver donation
- most donors trauma victims
- liver preserved ≤ 8 hr
liver transplant complications
- acute graft rejection
- infection
acute graft rejection after liver transplant
- usually POD 4-10
- S/Sx
- tachycardia
- fever
- RUQ pain
- ↑ jaundice
- → multi-organ failure
- prophylaxis: immunosuppressants
infection after liver transplant
- common
- pneumonia
- wound infection
- UTI
- opportunistic
- in month after surgery
- S/Sx
- fever
- foul-smelling drainage
normal stool description
- medium to dark brown
- strong-smelling
- pain-free to pass
- passed 1-2x daily
- consistent in characteristics
changes in stool that could mean a problem
- smell
- frequency
- firmness
- color
minimum number of stools/wk
3
what makes stool brown?
bilirubin from breakdown of RBCs
The color of stool is affected by what 4 factors?
- foods ingested
- meds
- amount of bile
- presence of blood
possible stool colors
- brown
- green
- yellow
- grey/clay
- red
- black
green stool causes
- green foods
- diarrhea: ↓ time for chemical changes to bilirubin
yellow stool cause
- (undigested fat)
- d/o of
- liver
- pancreas
- gallbladder
- celiac dz
- giardiasis
- stress
- diet
grey/clay stool cause
- (↓ bile)
- hepatobiliary dz
red stool causes
- also dark red, maroon
- diet: red veggies or food dye
- lower GI bleed
black stool causes
- not sticky + odorless
- bismuth
- Fe supplements
- tarry + sticky + foul-smelling
- AKA melena
- upper GI bleed
BMP
- basic metabolic panel
- glucose
- electrolytes
- Ca2+
- Na+
- K+
- Cl-
- CO2
- BUN
- Cr
CMP
- comprehensive metabolic panel
- BMP+
- total bilirubin
- total protein
- albumin
- liver enzymes
- ALT
- AST
- ALP
Guaiac-based tests may yield _____ _____ results.
false positive
foods to avoid before guaiac test
- red meat
- raw fruits and veggies
meds to avoid before guaiac test
- x7 days before
- NSAIDs
- anticoagulants
FIT
fecal immunochemical test
fecal immunochemical test
- FIT, iFOBT
- type of FOBT that does not require pt prep
- also screening for colon CA
- detects blood from lower GI
Fat is normally absorbed in the _____ ______.
small intestine
malabsorption of fat →
- steatorrhea
- fatty stools
- yellow
When does gag reflex typically return after EGD?
30-60 min
SE of ERCP
- instilled air → colicky abd pain + flatulence
- severe
- bleeding
- perf
- sepsis
- pancreatitis
sedation for endoscopic upper GI procedures
- medazolam
- fentanyl
- propofol
most common indications for ERCP
- Dx and Tx of conditions of pancreas or bile ducts
- indications
- abd pain
- wt loss
- jaundice
- CT or US showing stones or massess
ERCP is sometimes used _____ or _____ gallbladder surgery to assist with that operation.
before or after
In suspected or known pancreatic dz, _____ helps determine the need for surgery or the best _____ to use.
- ERCP helps
- best procedure
GoLYTELY bowel prep for lower GI scope
- solution is best chilled
- watery stool starts ~1 hr after starting
- do not give to OA
At what age should healthy adults start having colonoscopies, and how often?
- 50 yo
- Q10yrs
What are indications for having colonoscopies more often than every 10 yrs?
- fm Hx of CA
- polyps
general manifestations and results of IBD
- nutritional deficits
- altered bowel elimination
- infection
- pain
- fluid/electrolyte imbalances
most common cause of RLQ pain
appendicitis
slow appendix inflammatory process →
abscess
rapid appendix inflammation process →
peritonitis
pain pattern for appendicitis
anywhere in abd, esp. periumbilical or epigastric → more severe → McBurney’s point
Clinical presentation of appendicitis is notoriously _____, and differential Dx is often _____, because it can mimic other ______ abd conditions.
- presentation inconsistent
- Dx challenging
- severe abd conditions
most common Sx of appendicitis
abd pain
Vomiting that precedes abd pain suggests _____ _____.
intestinal obstruction
pt positioning to relieve appendicitis pain
- lying down
- hips flexed
- knees drawn up
- keeping still
duration of Sx in appendicitis
- < 48 hr in ~80% of adults
- > 48 hr w/ perf or in OA
lapartomy nursing considerations
- may need
- wound drain
- wound vac
- NGT (decompression)
- meds
- abx
- opioids
- prevent complications: early ambulation
- VTE
- atelectasis
- pneumonia
laparotomy has more potential complications in
- OA
- chronic dz
laparotomy
surgical opening of abd
Peritoneum is the _____ and most _____ serous membrane in the body.
- largest
- most complex
parietal peritoneum
- outer layer of peritoneum
- attached to abd wall
visceral peritoneum
- inner layer of peritoneum
- wrapped around organs in intraperitoneal cavity
mesentery
- double layer of visceral peritoneum
- encloses the peritoneal cavity
peritoneal cavity
- enclosed by mesentery
- serous fluid-filled
- ~ 50 mL
- prevents friction during peristalsis
The abd cavity is normally _____.
sterile
Peritonitis is a _____-_____ infection of the lining of the abd cavity.
life-threatening
Peritonitis is the dominant cause of postop ____ 2/2 infection.
death
norovirus transmission and incubation
- transmission
- fecal-oral
- person-person
- contaminated food/water
- airborne via vomiting
- fecal-oral
- incubation: 1-2 days
ORT
oral rehydration therapy
similarities between UC and Crohn’s
- often develop in teens and young adults, but possible at any age
- affect the sexes equally
- Sx are similar
- unknown causes
- similar contributing factors
- both AIDs
difference between UC and Crohn’s
- UC affects innermost lining of colon
- Crohn’s occurs in all layers of bowel
indeterminate colitis
- ~10% of IBD
- has features of UC and Crohn’s
physical features of Crohn’s
- fat wrapping bowel
- fissures into mucosa and muscle
- muscle hypertrophy
- cobblestone appearance of mucosa
physical features of UC
ulceration within mucosa
UC puts pts, esp. OA, at risk for what health complications?
- fluid/electrolyte imbalance
- dehydration
- hypokalemia → dysrhythmias
- cellular changes → ↑ risk of colon CA
UC etiology
- exact cause unknown
- factors
- genetic
- immunologic (AID)
- environmental
What parts of the large intestine does UC mainly affect?
- rectum
- rectosigmoid colon
- may also spread to entire colon
ileocecal valve landmark
about halfway between umbilicus and anterior iliac spine
toxic megacolon
paralysis of colon → dilation → colonic ileus + possible perf → peritonitis and/or gangrene
malabsorption →
- anemia
- malnutrition
- bone loss
Fistulas are more common in the _____ form of chronic IBD.
Crohn’s
IBD-associated fistulas can occur anywhere, but are commonly found between the _____ and colon.
bladder
A bladder-colon fistula leads to _____ and _____.
- pyuria
- fecaluria
fecaluria
feces in the urine
pyuria
- > 10 WBCs per high-powered microscopic urinary field
- detected in UA
other conditions developed by IBD pts
- polyarthritis
- episcleritis
- uveitis
- aphthae
- renal calculi
- gallstones
- vitamin-deficiency anemia
- erythema nodosum
- Sweet’s syndrome
polyarthritis
inflammation of > 1 joint, and usually > 4
EIMs
extraintestinal manifestations
extraintestinal manifestations
conditions in other parts of the body that IBD patients can develop during active dz
erythema nodosum
tender, red nodular rash on the shins that typically occurs with another illness
episcleritis
inflammation of the subconjunctival layers of the sclera
uveitis
- nonspecific term for any intraocular inflammatory d/o
- uveal tract (iris, ciliary body, and choroid) usually involved
- other parts of the eye, including retina and cornea, may be involved
Sweet’s syndrome
- AKA acute febrile neutrophilic dermatosis
- distinctive eruption of tiny bumps that enlarge
- often tender to the touch
- on back, neck, arms or face
tenesmus
- urgent sensation to defecate, even though bowels already empty
- may involve straining, pain, and cramping
mild UC presentation
may be asymptomatic
moderate UC presentation
- mild abd pain
- nausea
- possibly ↑ CRP and ESR
severe UC presentation
- fever
- tachycardia
- anemia
- abd pain
- ↑ CRP and ESR
fulminant UC presentation
- ↑ Sx of severe
- may need transfusion
- possible colonic distention
CRP
C-reactive protein
C-reactive protein
- protein made by liver
- sent into bloodstream as response to inflammation
- interpretation
- low levels expected
- ↑ levels can mean
- serious infection
- other d/o
ESR
erythrocyte sedimentation rate
erythrocyte sedimentation rate
- measures how quickly RBCs settle to bottom of test tube of blood
- normal: slowly
- ↑ rate: inflammation
barium enema w/ air contrast for IBD
- shows
- differences between UC and Crohn’s
- complications
- depth of dz involvement
benefits of rectal/enema route in 5-ASA Tx
- ↓ systemic exposure
- targets colon
examples of 5-ASAs
- sulfasalazine
- mesalazine
- olsalazine
- balsalazide
immunomodulators
- drugs that alter a pt’s immune response
- not effective alone
- synergistic effect w/ corticosteroids: ↓ steroids needed
CWOCN
certified wound, ostomy, and continence nurse
Parenteral _____ are given within 1 hr of GI ostomy.
abx
acute coronary syndrome
- ACS
- any circumstance that suddenly impairs blood flow through the coronary arteries
ACS
acute coronary syndromes
coronary artery disease
- CAD
- narrowing of the coronary arteries, usually as a result of atherosclerosis
CAD
coronary artery disease
atherosclerosis
- most common form of arteriosclerosis
- marked by cholesterol-lipid-calcium deposits in walls of arteries that may restrict blood flow
arteriosclerosis
- disease of the arterial vessels marked by thickening and loss of elasticity in the arterial walls
- “hardening of the arteries”
angina
- ↓ blood flow and O2 to heart muscle → oppressive chest pain or pressure
- usually precipitated by exercise
myocardial infarction
death of myocardial tissue d/t ischemia
preload
- end-diastolic stretch of a heart muscle fiber
- at bedside: estimated by measuring CVP or pulmonary capillary wedge pressure
afterload
- force that impedes the flow of blood out of the heart
- primarily composed of
- peripheral vasculature pressure
- aortic compliance
- mass and viscosity of blood
heart failure
inability of the heart to circulate blood effectively enough to meet the body’s metabolic needs
acute heart failure
ejection fraction
- percentage of the blood emptied from the ventricle during systole
- normal: 50-70%
chronic heart failure
systolic heart failure
diastolic heart failure
endocarditis
infection or inflammation of the heart valves or of the lining of the heart
rheumatic endocarditis
valvular inflammation and dysfunction (esp. mitral insufficiency) occurring during acute rheumatic fever
colloquial terms for meds used to treat CV disease
- blood thinners
- antihypertensives
- heart medication
antiplatelet
agent that destroys or inactivates platelets, preventing them from forming blood clots
anticoagulant
agent that prevents or delays blood coagulation
antithrombotic
interfering with or preventing thrombosis
rivaroxaban
- class
- anticoagulant
- antithrombotic
- factor Xa inhibitor
- action: inactivates cascade of coagulation by blocking active site on factor Xa
beta blocker
blocks action of epinephrine on CV system
ACE inhibitor
- antihypertensive
- action
- blocks conversion of precursor angiotensin I to vasoconstrictor angiotensin II
- systemic vasodilation
ARB
angiotensin II receptor antagonist
antiotensin II receptor antagonist
- antihypertensive
- action
- blocks aldosterone-secreting and vasoconstrictor effects of angiotensin II
- ↓ BP, ↓ risk of death from CV dz
atrioventricular heart valves
- tricuspid
- mitral
semilunar heart valves
- pulmonic
- aortic
S1
- “lub”
- corresponds with
- closure of AV valves (mitral)
- ventricular ctx
- beginning of systole
- loudest at apex
S2
- “dub”
- corresponds with
- closure of semilunar valves (aortic)
- beginning of diastole
- loudest at base
heart auscultation sequence
- rate, rhythm
- high-pitched/normal sounds
- w/ diaphragm
- S1, S2
- low-pitched/extra sounds
- w/ bell
- S3, S4
- murmurs
peripheral vascular inspection
- color
- temp
- hair
- edema
- nailbeds
peripheral vascular palpation
- cap refill
- palpate pulses
- feel w/ fingertips
- compare bilaterally
- note
- rate
- rhythm
- amplitude/intensity
- quality
pulse intensity scale
- (0-4+)
- 0: no palpable pulse
- 1+: faint
- 2+: diminished
- 3+: normal
- 4+: bounding
types of impaired myocardial perfusion, or CAD
- chronic ischemic heart dz
- acute coronary syndromes
types of chronic ischemic heart dz
- stable angina
- variant (Prinzmetal’s) angina
types of acute coronary syndromes
- unstable angina
- myocardial infarction
types of myocardial infarction
- NSTEMI
- STEMI
NSTEMI
non-ST segment elevation myocardial infarction
STEMI
ST segment elevation myocardial infarction
alterations in cardiac fxn
- HF
- valvular dz/dysfunction
HF
heart failure
CHD
coronary heart dz
coronary artery dz
- CAD
- atherosclerosis in coronary artery → ↓ blood flow to area it supplies
- untreated →
- angina
- MI
patho of CAD
- progressive
- endothelial damage → deposits → vessel narrowing
- can → thrombus formation
- blockage grows → occlusion → tissue death
- begins early in life
progression of heart dz
atherosclerosis → CAD → angina → MI
LDL
- low-density lipoproteins
- less desirable lipoproteins
HDL
- high-density lipoproteins
- highly desirable lipoproteins
non-modifiable CAD risk factors
- genetics: gene variation can → extremely ↑ LDL
- ↑ age
- sex: male > female
- T1DM
modifiable CAD risk factors
- smoking
- diet
- obesity
- T2DM
- HTN
- physical inactivity
- hyperlipidemia
- hypertriglyceridemia
- metabolic syndrome
chronic ischemic heart dz
blood flow ↓ → ischemia in affected myocardium
acute coronary syndromes
partial or total occlusion of coronary arteries
S/Sx + descriptions of angina pectoris
- description
- tightness
- heaviness
- vise-like
- “elephant on chest”
- S/Sx
- pain radiating to left
- arm
- hand
- jaw
- shoulder
- nausea
- fatigue
- lightheadedness
- pain radiating to left
etiology of angina pectoris
- partially occluded coronary arteries →
- ↑ in myocardial O2 demand
- ↓ in myocardial O2 supply
Each type of angina has different _____, _____, and _____.
pattern, signs, and symptoms
stable angina trigger
predictable degree of exertion or emotion
Stable angina has a stable pattern of _____, _____, _____, and _____ factors.
- onset
- duration
- severity
- relieving factors
typical pattern of stable angina
- begins gradually and peaks over a period of minutes as activity continues
- activity → CP
- rest → relief
relieving factors for stable angina
- rest
- nitro
- both
variant angina pattern
- occurs during periods of rest, often at night
- not related to
- physical activity
- HR
cause of variant angina
coronary artery spasm
classic present Sx of CAD
angina
other Sx of CAD
- nausea
- dizziness
- SOB
- anxiety
- feeling of impending doom
possible presentation of CAD in women
- unusual fatigue
- sleep disturbance
- SOB
- indigestion
- anxiety
- chest discomfort: aching, tightness, pressure
percentage of CAD presentations in women that include chest discomfort
30%
What outward signs can be normal in CAD?
- wt
- VS
- all signs
possible signs of CAD
- hypo- or hypertension
- peripheral edema
- cyanosis or pallor
- diaphoresis
- dyspnea
- vomiting
- EKG changes
- abnormal heart sounds, rate, and/or rhythm
Signs of CAD depend on the condition’s _____.
severity
anginal equivalents
Sx suggesting cardiac ischemia w/o CP
What populations are more likely to experience anginal equivalents?
- women
- diabetics
- OA
other sites where pain may be felt during cardiac ischemia other than the chest
- jaw
- arm
- upper back
anginal equivalent S/Sx
- dyspnea
- fatigue
- lightheadedness
- dizziness
- pain in jaw, arm, upper back
- women: upper arm weakness
types of acute coronary syndromes
- unstable angina
- MI
- NSTEMI
- STEMI
unstable angina
- unpredictable CP
- w/ rest or minimal activity, possibly at night
- occurs with ↑ frequency and severity
- nitro doesn’t help
- requires immediate medical attention
MI
myocardial infarction
cause of MI
complete or near-complete occlusion of coronary artery
patho of MI
occlusion of coronary artery → ↓ O2 delivery → cell death
MI is the _____ cause of death in America and the end result of untreated or _____ treated _____.
- leading cause of death
- ineffectively treated CAD
cardiac biomarkers
- cardiac-specific: troponin I
- non-specific
- CK-MB
- myoglobin
protocol for cardiac biomarker lab draws
- Q6H
- multiple draws show trends
Cardiac biomarkers may be _____ on arrival at the hospital, then _____.
- negative on arrival
- then increase
troponin I
cardiac-specific muscle protein useful in lab Dx of heart attack
troponin I levels
- ↑ injury = ↑ numbers
- Normal: < 0.04 ng/mL
- Elevated: 0.04 – 0.39
- Probable MI: ≥ 0.40
- ↑ after heart cath
- ↑ 7-14 hrs after Sx onset
CK-MB
creatinine kinase-muscle/brain
creatinine kinase-muscle/brain
more cardiac-specific than myoglobin and other forms of CK
CK-MB levels
- normal: 5-25 IU/L
- MI
- ↑ 3-6 hrs after CP onset
- peak: 12-18 hrs
myoglobin
- O2-binding protein
- released after damage to heart or any skeletal muscle
myoglobin levels
- normal: 25-72 ng/mL
- MI
- detected within 2 hrs after
- sensitive indicator: second sample is x2 if drawn within 2 hrs of first sample
MI diagnostics
- EKG
- EST
- TEE
- transthoracic echo
- heart cath and angio
EKG/ECG
electrocardiogram
electrocardiogram for suspected MI
- 12-lead
- easiest and most effective test
- for every pt w/ CP
signs EKG can show in pt w/ CP and possible MI
- heart rhythm
- blood flow or ischemia
- heart attack
- thickened heart muscle
How does an EKG show a heart attack?
- ↓ blood flow → depolarization changes
- manifests as abnormal changes in ST segment and T wave
- ischemia/injury to different regions show on different leads
EST
exercise stress test
exercise stress test
- exercise + EKG
- evaluates myocardial perfusion
pt prep for EST
- don’t eat, smoke, or drink caffeine for several hrs
- hold CV meds for 24 hrs
- wear comfy clothes, shoes
CAD stress test findings
- normal ECG at rest
- abnormalities w/ ↑ O2 demand (activity)
EST procedure
- pt exercises
- per strict protocol
- w/ continuous EKG
- if myocardial ischemia suspected
- test immediately stopped
- Tx administered
indications of myocardial ischemia during EST
- angina
- ST segment depression ≥ 1 mm
- BP
- failure to ↑ systolic BP to ≥ 120 mm Hg
- sustained ↓ of ≥ 10 mm Hg with progressive ↑ in exercise
pharm stress test
induces CV stress with meds that dilate coronary vessels
pharm stress test indication
exercise contraindicated d/t arthritis, amputation, etc.
meds used for pharm stress test
- dobutamine
- adenosine
- dipyridamole
diagnostics used during pharm stress test
- EKG +
- echo
- nuclear testing (tracer injection)
myocardial perfusion imaging
nuclear testing (tracer injection) often used during pharm stress test to detect CAD
MPI
myocardial perfusion imaging
echocardiography
US used to assess functional structures of heart
issues that can be detected with echocardiography
- structural valve abnormalities
- atrial and ventricular chamber size
- diameter of great vessels
- heart wall motion
TEE
transesophageal echocardiogram
transesophageal echocardiogram
transducer is guided down esophagus to allow for visualization of heart w/o ribs or lungs in the way
cardiac cath
- thin catheter inserted into artery and threaded into coronary arteries
- +angio: visualize presence/degree of blockage
cardiac cath with angio
- catheter threaded into coronary arteries
- radiopaque contrast injected
- fluoroscopy used to visualize presence/degree of blockage
Heart cath is an _____ procedure that uses IV _____.
- invasive procedure
- IV contrast
Before a heart cath w/ angio, always ask about what allergies?
- iodine or shellfish allergies
- previous rxn to contrast
pot-cath VS monitoring
- Q15Min x4
- Q30Min x2
- Q1H x4
- Q4H
post-cath nursing care
- monitor VS frequently (per protocol)
- ensure pt lies flat w/ extremity straight for prescribed time
- neurovascular checks as prescribed; assess affected limbs together
- continuous telemetry, pulse ox
- antiplatelet/antithrombotic or thrombolytic therapy
- monitor UOP
- administer IVF
- sheath removal
Pts are commonly expected to lie flat for ___-___ hrs after heart cath, or _____ with closure device.
- 4-6 hrs
- shorter
neurovascular checks after heart cath
- body area: distal to catheter insertion site
- purpose: to ensure sensation and pulse are present
5 Ps of neurovascular checks
- pulses
- parethesias
- pain
- pallor
- paralysis
criteria for diagnosing chronic ischemic heart dz
- based on Hx and Sx patterns
- ECG changes only during EST
- no ↑ cardiac enzymes
diagnosing acute coronary syndromes
- Hx
- presence of unstable angina
- Sx consistent w/ partially occluded arteries
- no ↑ serum biomarkers
- possible, but not necessary: ST segment depression, T wave inversion
diagnosing MI
- ST segment and/or T wave changes, depending on type
- ↑ enzymes
- cell necrosis and infarction distal to occlusion
non-ST segment elevation myocardial infarction
- NSTEMI
- partial coronary artery blockage
- less damaging to heart
- depressed ST segment or T wave inversion
- ↑ serum cardiac enzymes
ST segment elevation myocardial infarction
- STEMI
- complete coronary artery blockage
- more damaging to heart
- elevated ST segment of ≥ 1 mm
- ↑ serum cardiac enzymes
behaviors to promote for CAD prevention
- healthy, balanced diet
- ↓ in BP
- ↓ in fat intake
- wt loss
CAD prevention meds
- antiplatelet/antithrombotic therapy
- ASA
- heparin
- enoxaparin
Treat all _____ _____ like _____ _____ until Dx is complete.
- all chest pain
- like myocardial infarction
nursing assessment for CP presentation
- general
- pain
- N/V
- focused cardiopumonary
- VS
- heart and lung sounds
- peripheral pulses
- skin color, temp, and moisture
- look for
- SOB
- diaphoresis during pain
impaired myocardial perfusion nursing interventions
- immediate 12-lead EKG (10 min)
- continuous tele + pulse ox
- start IV
- HOB @ 30°
- MONA meds as ordered
- additional Tx dictated by
- EKG
- labs
- risk to pt
MONA med administration for impaired myocardial perfusion
- immediate: ~325 mg nonenteric-coated ASA
- O2
- nitroglycerin
- morphine
nitroglycerin
- vasodilator
- prevents coronary artery spasm
- ↓ preload and afterload to ↓ O2 demand
nitroglycerin administration
- routes
- sublingual (tab or spray)
- TD
- dosage: 0.4 mg
- Q5Min ≤ 3x until CP relieved
- if no relief, explore other options
most common SE of nitroglycerin
- orthostatic hypotension
- HA
morphine for impaired myocardial perfusion
↓ CP where nitro is not successful
When giving morphine for impaired myocardial perfusion, watch for what SE?
- hypotension, esp. w/ vasodilator
- respiratory depression
beta blockers for impaired myocardial perfusion
- metoprolol and others
- action
- ↓ HR and afterload (↓ BP)
- → ↓ myocardial O2 demand
- can ↓ infarct size in acute MI
- ↓ HR and afterload (↓ BP)
SE to watch for when giving beta blocker for impaired myocardial perfusion
- orthostatic hypotention
- severe bradycardia
Ca channel blocker for impaired myocardial perfusion
- diltiazem, verapamil, and others
- NOT nifedipine
- action
- dilates coronary arteries
- ↑ O2 supply to myocardium
antiplatelet for impaired myocardial perfusion
- ASA, clopidogrel
- action
- inhibits platelet aggregation
- ↓ risk of clot formation
nursing implications for angina
- chronic: teach about lifestyle changes
- acute: considered acute MI until proven otherwise
NSTEMI treatment
- draw cardiac enzymes
- anticoagulation therapy
- ↓ workload of heart
- monitor pt closely
- may need surgical Tx
anticoag for NSTEMI
- heparin + ASA or clopidogrel
- rationale
- heparin prevents new clots
- ASA or clopidogrel ↓ platelet aggregation
monitoring a pt w/ NSTEMI
- continuous tele and pulse ox: dysrhythmias
- S/Sx of cardiogenic shock
candidates for surgical Tx of NSTEMI
- signs of HF
- v-tach
- hemodynamic instability
- persistent CP
- persistent/recurrent ST deviation
STEMI treatment
- optimal
- activate cath lab (≤ 90 min)
- IV access, x2 if done quickly
- nitro 0.4 mg
- IV nitrates
- IV morphine
- not near cath lab
- transfer within 120 min?
- if not, tPA (≤ 30 min)
- other possible meds
- beta blocker
- Ca channel blocker
cath lab goal time
- door → balloon inflation in ≤ 90 min
- ≤ 60 min even better
reperfusion in cath lab for STEMI pt
- restores blood flow to affected myocardium
- won’t reverse damage
- stops or limits future damage
getting IV access for STEMI pt
- get x2 if possible, but don’t delay Tx
- draw blood for enzymes now if possible
IV nitrates for STEMI pt
- usually starts at 5-10 mcg/min
- gradually increase until CP relieved
IV morphine for STEMI pt
- for refractory or severe pain
- dosage
- 2-4 mg IV push
- repeat Q5-10Min
fibrinolytic therapy
given for STEMI if within 12 hrs after Sx onset
time goal for tPA for STEMI pt
door to needle in 30 min
disadvantages of tPA
- can re-occlude
- will begin to c/o CP again
- small pieces travel distal, occlude smaller vessel
- compared to heart cath
- ↑ reperfusion outcomes
- ↓ complications and death
other possible meds with tPA
- beta blockers
- Ca channel blockers
focus of invasive Tx for ACS
restore blood flow to prevent further damage
types of invasive Tx for ACS
- percutaneous transluminal coronary angioplasty (PTCA)
- directional coronary atherectomy (DCA)
- intracoronary stents
- transcatheter aortic valve replacement (TAVR)
- coronary artery bypass graft (CABG)
PTCA
percutaneous transluminal coronary angioplasty
DCA
directional coronary atherectomy
TAVR
transcatheter aortic valve replacement
CABG
coronary artery bypass graft
PTCA procedure
- done during heart cath w/ coronary angiogram
- balloon-tipped catheter
- inserted into blocked artery
- inflated several times to open vessel
PTCA is good for blockages that are _____ and stable.
smaller
DCA procedure
- done during heart cath
- excises and removes plaque in blocked artery
- rotating blade shaves blockage material and stores it in cone
DCA is good for _____- to _____-sized vessels in the prosimal or middle portions.
medium- to large-sized
intracoronary stent placement
- done during heart cath
- inserted on tip of balloon cath
- balloon inflated, then deflated to leave stent in place
Intracoronary stents are a _____-term solution than PTCA.
longer-term
heart cath complications
- artery dissection
- cardiac tamponade
- hematoma
- allergic rxn
- external bleed at insertion site
- retroperitoneal bleed
- embolism
- restenosis of vessel
- AKI
nursing care for heart cath-associated hematoma
- palpate thoroughly all around insertion site
- feels like hard knot under skin
- intervention: pressure x15 min
retroperitoneal bleed
- possible complication of heart cath procedure
- happens with femoral insertion
- blood pools in posterior abd cavity
TAVR procedure
- to treat symptomatic aortic valve stenosis
- via cardiac cath
- new valve expands, pushes old valve leaflets aside
- new valve takes over blood flow regulation
indication for TAVR
pt not candidate for open-heart surgery because of dz, comorbidities, etc.
CABG indication
reperfusion by other methods not viable options
CABG procedure
- open-heart surgery
- uses veins from other parts of body to replace blocked artery or arteries
vessels commonly used for CABG
- saphenous vein
- internal mammary/thoracic veins
- radial artery
- gastroepiploic artery
post-CABG care
- pt → ICU
- monitor VS closely and meet surgeon’s parameters
- measure chest tube output closely
- frequent labs
- extubate ASAP
- after stable/extubated, walk and move as much as possible
- many pts D/C home within 4 days
What’s the optimal time frame for extubation after CABG?
4-8 hrs
MI complications
- dysrhythmias
- cardiogenic shock
- HF + pulmonary edema
post-CABG dysrhythmias
- SVT
- frequent PVCs
- v-tach
- v-fib
SVT
supraventricular tachycardia
PVC
premature ventricular contraction
HF and pulmonary edema as complications of CABG
- cause: ↓ functionality of myocardium
- usually manifests wks later
- pt education: warning signs, importance of follow-up
cardiogenic shock after CABG
not common COD, but possible
signs of cardiogenic shock
- hypotension
- diaphoresis
- tachycardia
Tx for cardiogenic shock
- vasopressors
- O2
- other Tx as ordered
- until heart recovers
nursing implications of MI
- stabilize pt during acute phase
- monitor for complications
- promote energy conservation
- educate pt on lifestyle changes
- prep for rehab
etiology of HF
changes in heart fxn due to intrinsic or extrinsic factors
HF is often _____, in which acute _____ are the cause of hospitalization.
- chronic
- exacerbations
HF patho
- progressive dz → cardiac remodeling
- left ventricle dilates, hypertrophies, and becomes more spherical
main types of HF
- left-sided
- right-sided
- high-output
two main types of left-sided heart failure
- systolic
- diastolic
normal ejection fraction
50-70%
ejection fraction in left-sided systolic HF
< 40%
possible causes of right-sided HF
- left ventricular failure
- less common
- right ventricular MI
- COPD
- pulmonary HTN
left-sided systolic HF
- heart can’t contract hard enough
- ↑
- preload
- afterload (d/t peripheral resistance)
- ↓
- contractility
- ejection fraction
- cardiac output
- BP
- UOP
S/Sx of left-sided diastolic HF are similar to those of systolic dysfunction except what?
- no S/Sx of ↓ cardiac output
- ejection fraction > 40%
right-sided HF
- ventricle can’t empty completely
- ↑ venous volume + pressure → peripheral edema
left-sided diastolic HF
ventricle can’t relax enough to fill completely during diastole
high-output HF
cardiac output remains ≥ normal
etiology of high-output HF
- ↑ metabolic needs
- usually in hyperkinetic conditions
- septicemia
- high fever
- anemia
- hyperthyroidism
HF risk factors
- HTN
- CAD
- cardiomyopathy
- substance abuse
- valvular dz
- congenital defects
- cardiac infections and inflammatory states
- dysrhythmias
- DM
- smoking/tobacco use
- family Hx
- obesity
- severe lung dz
- sleep apnea
- hyperkinetic conditions
types of valvular heart dz
- stenosis
- regurgitation
valve stenosis patho
- valve leaflets thicken, stiffen, or fuse together
- → ↓ blood flow and ↑ resistance
- → pressure backup
major types of valve stenosis
- mitral
- aortic
valve regurgitation patho
- valves don’t close completely
- → backflow into chamber
- → pressure backup
major types of valve regurgitation
- mitral
- aortic
- valvular prolapse
mitral valve stenosis
- narrowing of valve between LA and LV
- → slow LA filling time
mitral valve stenosis S/Sx
- pulmonary problems first
- crackles
- SOB
- ↑ HR can → CO drop
mitral valve stenosis risk factors
- rheumatic fever
- female sex
aortic valve stenosis patho
- valve hardens
- → restricted flow to aorta
- → pressure backup to LV
- → LV hypertrophy
- → cannot ↑ CO for ↑ demand
aortic valve stenosis risk factors
- rheumatic fever
- aging
mitral regurgitation patho
- mitral valve can’t close completely
- → blood flows back into LA → ↓ SV
- → LA works hard, hypertrophies
- can →
- left-sided HF
- right-sided HF
SV
stroke volume
stroke volume
volume of blood pumped from LV per beat
mitral regurgitation risk factors
- aging
- infective endocarditis
- rheumatic fever
left-sided HF subjective data
- difficulty breathing
- dyspnea
- orthopnea
- paroxysmal nocturnal dyspnea
- non-productive cough
- fatigue, weakness
- dizziness
- angina
right-sided HF subjective data
- fatigue
- tight feeling in extremities
- nausea d/t liver congestion
paroxysmal nocturnal dyspnea
severe SOB and coughing that occur at night
left-sided HF objective data
- respiratory
- wheezes
- crackles
- tachypnea
- pink, frothy sputum
- CV
- tachycardia
- palpitations
- weak peripheral pulses
- cool extremities
- S3, S4
- pallor
- other
- oliguria, nocturia
- ↓ LOC
right-sided HF objective data
- CV
- JVD
- dependent edema (esp. hands)
- enlarged liver, spleen
- ↑ LFTs
- ascites
- anorexia
- GU
- nighttime polyuria
- wt gain
oliguria
abnormally small amounts of urine
labs for HF
- chem panel
- CBC
- BNP
- ABGs
- LFTs
CBC can show what for suspected HF?
- severe anemia and/or infection
- anemia can cause or aggravate HF
BNP
brain natriuretic peptide
ABGs for suspected HF
- can show any acid-base imbalances or hypoxemia
- usually only done for resp. distress
brain natriuretic peptide
- AKA B-type, BNP
- hormone secreted by left ventricular cardiomyocytes 2/2 stretching and hard work w/ ↑ blood volume
- most specific test for HF
- level indicates severity
- abnormal: > 100 pg/mL
HF diagnostics
- ECG
- CSR
- echo
- CVP
EKG can help detect what factors → HF?
- heart dz
- MI
- enlarged heart
- dysrhythmias
echo for HF
- most useful diagnostic
- can differentiate HF w/ or w/o preserved left ventricular systolic fxn
CVP
central venous pressure
central venous pressure
- pressure in vena cava near RA
- estimates RA pressure
measures assessed via CVP in critically ill pts
- preload of RV, which regulates SV
- volume status
CVP is used to guide _____ _____.
fluid resuscitation
normal CVP
0-6 mm Hg
↑ CVP = possible Dx of
right-sided HF
reasons other than right-sided HF that CVP can be ↑
- ↑ in venous blood volume
- ↓ in venous compliance
HF pharm treatments
- O2
- diuretics
- ACE inhibitors
- beta blockers
- digoxin
- vasodilators (nitro)
- morphine
non-pharm treatments for HF
- elevate HOB
- Na+ restriction
- ↓ activity level, stress
- VAD
VAD
ventricular assist device
ventricular assist device
- requires open-heart surgery
- for right, left (LVAD), or both ventricles
- indication: ventricular dysfunction
- end Tx for those who are not transplant candidates
- rarely: temporary unti heart recovers
diuretics for HF
- for ↓ of FVE
- often w/ ACE inhibitor and beta blocker
- types
- thiazide: for mild Sx
- loop: for more severe Sx
- multiples used together if necessary
ACE inhibitors for HF
- captopril, lisinopril
- relaxes blood vessels to ↓ BP
- often used w/ beta blocker and diuretic
Hold ACE inhibitor if systolic BP is below ___ mm Hg.
100 mm Hg
beta blockers for HF
- carvedilol, atenolol, propranolol
- block effects of epinephrine: ↓ HR + ↓ force + vasodilation → ↓ BP
- usually used w/ ACE inhibitor and diuretics
- may not work as well in OA or those of African descent
digoxin toxicity level
> 2 ng/mL
digoxin therapeutic level
0.5-2 ng/mL
digoxin toxicity S/Sx
- fatigue
- dysrhythmias
- visual disturbances
preventing digoxin problems
- brady: hold for apical pulse < 60/min
- hypokalemia: check K+ before admin
- toxicity: check drug levels and hold per protocol
digoxin action
- affects Na+ and K+ inside heart cells to ↓ strain
- ↓ ventricular rate + improved strength → better filling
O2 admin for HF
- admin oxygen per order or protocol
- maintain SpO2 ≥ 90% (except in advanced COPD)
nursing actions for HF
- oxygenation
- O2 therapy (≥ 90%)
- high Fowler’s or on pillows
- arms on pillows (chest expansion)
- reposition, cough, and deep breathe Q2H
- check ABGs
- help pt group activities to conserve energy
- fluid/electrolyte balance
- monitor I&O, daily wt
- report wt gain of > 3 lbs
- may require ↑ diuretic dosage
- maintain Na+ restriction
- check electrolytes
types of inflammatory d/o of the heart
- pericarditis
- myocarditis
- rheumatic endocarditis
- infective endocarditis
How is the heart damaged in inflammatory d/o?
extended inflammatory response often → destruction of healthy tissue
pericarditis
inflammation of pericardium
etiology of pericarditis
- commonly follows resp. infection
- MI
pericarditis findings
- CV
- chest pressure/pain
- relieved when sitting, leaning forward
- worse on inspiration
- pericardial friction rub
- ↑ cardiac enzymes
- chest pressure/pain
- resp.
- coughing
- SOB
myocarditis
inflammation of myocardium
etiology of myocarditis
- virus
- fungus
- bacteria
- inflammatory dz, e.g. Crohn’s
myocarditis findings
- tachycardia
- murmur
- friction rub
- cardiomegaly
- CP
- dysrhythmias
rheumatic endocarditis
- complication of rheumatic fever → lesions in heart
- preceded by Group A betahemolytic streptococcal pharyngitis
rheumatic endocarditis findings
- CV
- CP
- tachycardia
- friction rub
- murmur
- SOB
- joint pain
- rash on trunk, extremities
- fever
infective endocarditis etiology
- organisms
- staphylococci
- streptococci
- fungi
- other
- most common in
- structural malformation
- cardiac devices
- prosthetic heart valves
- IV substance use
- other causes → bacteremia → endocarditis
- dental procedures,
- body piercing
- tattooing
infective endocarditis findings
- fever
- flu-like manifestations
- murmur
- petechiae
- splinter hemorrhages
- + blood culture
inflammatory cardiac d/o risk factors
- non-modifiable
- congenital defects
- heart valve replacement
- immune suppression
- rheumatic fever, other infections
- school-age children w/ long duration of strep
- modifiable
- malnutrition
- overcrowding
- lower socioeconomic status
inflammatory cardiac d/o diagnostics
- ECG
- rheumatic fever: heart block
- pericarditis: ST elevation in almost all leads
- echo
- inflamed heart layers
- pericardial effusion
labs for inflammatory cardiac d/o
- cultures: blood, throat
- CBC: WBC count
- cardiac enzymes: ↑ in pericarditis
- ESR, CRP: ↑ inflammation
nursing priorities for inflammatory cardiac d/o
- assess
- heart sounds for murmur, friction rub, or muffle
- pain
- review labs
- ABGs
- SaO2
- CXR
- monitor
- VS for fever
- ECG
- meds
- abx
- antipyretics
- bed rest
inflammatory heart d/o that cause fever
- infective endocarditis
- rheumatic endocarditis
inflammatory cardiac d/o that causes heart lesions
rheumatic endocarditis
inflammatory heart d/o that cause chest pressure/pain
- pericarditis
- myocarditis
- rheumatic endocarditis
findings for infective endocarditis that don’t happen with other inflammatory heart d/o
- flu-like manifestations
- petechiae
- splinter hemorrhages
- blood cultures
S/Sx of rheumatic endocarditis that don’t apply to other inflammatory heart d/o
- joint pain
- rash on trunk and extremities
- recent infection w/ Group A betahemolytic strep pharyngitis
What sound can be auscultated in pericarditis, myocarditis, and rheumatic endocarditis, but not infective endocarditis?
friction rub
In which of these inflammatory cardiac d/o will a heart murmur not be present?
pericarditis
myocarditis
rheumatic endocarditis
infective endocarditis
pericarditis
relieving and worsening factors for chest pain/pressure in pericarditis
- relief: sitting, leaning forward
- worsening: on inspiration
Which inflammatory heart d/o causes cardiomegaly and dysrhythmias?
myocarditis
Which 2 inflammatory cardiac d/o cause SOB?
- pericarditis
- rheumatic endocarditis
What 2 inflammatory cardiac d/o cause tachycardia?
- myocarditis
- rheumatic endocarditis
