Week 2 Upper and lower Gi disorders Flashcards
What are the four concepts we should utilize when talking about the digestive system
nutrition
elimination
inflammation
pain
name two characteristics that can best describe nutrition
is essential for growth development, for cellular functional as well as cellular repair when we experience illness or injury
Anytime our ability to ingest, absorb, or metabolize nutrients is affected, our
nutritional status is directly impacted
what is elimination?
refers to excretion of waste products to the skin, kidneys, lungs or intestines
what is inflammation ?
alters the normal functioning abilities of these organs
What is pain?
primary symptom of many of the disease that involve GI tract structure dictates function, If an organ changes as a result of a disease process, it’s function will change as well
Describe what upper GI TRACT ?
from the mouth to the stomach or the very first portion of the small intestines which we also refer to duodenem
Describe what lower GI tract ?
lower down in gastrointestinal tract including the appendix as wella s the large intestine
what is this describing ? long hollow tube and it starts at the mouth and it reaches to the anus at the very end, at various points throughout it’s connected to glands that will help with the process of digestion
GI TRACT
What are the major functions of Gi tract ?
ingestion of food ( chewing and swallowing )
absorption of digested food
elimination of waste products by defecation
what is a voluntary process? what is an involuntary process
voluntary process is something that we have to consciously tell our body to do
involuntary process is something that our body almost autopilots for us
would chewing and swallowing be considered as a voluntary or involuntary process ?
this would be considered as a voluntary processes as these contents are controlled by the brain.
The digestive tract : how is it made ?
mucosa
submucosa
muscularis
serosa
Describe to me what these terms mean ?
Mucosa
Submucosa
Muscularis
serosa
mucosa is the innermost layer, thin layer of smooth muscle as well as specialized exocrine gland cells
this is an epithelial layer that produces mucus, digestive enzymes, and absorbs nutrients
submucosa : connective tissue layer containing nerves, blood, and lymph vessels
muscularis: smooth muscle layer surrounding the submucosa and responsible for propulsion of food through the GI tract and this is what we were also referred to as peristalsis
serosa: outer connective tissue layer forms from the visceral peritoneum
( connects to the posterior wall of the abdominal cavity )
true or false.Changes in the GI tract directly cause changes in its function?
true
Gi tract surface changes related function” In the small intestine, the mucosa layer contains numerous finger like projections called ____ and ____ and these increase the surface area of the small intestine to maximize absorption of nutrients, water, and electrolytes.
villi and microvilli
Define what the chief cells contribute in the stomach
chief cells and these secrete pepsinogen which is the main digestive enzyme for breaking down protein
define what parietal cell contribute in the stomach
parietal cells secrete hydrochloric acid as well s intrinsic factor. There are also mucus cells and these secrete mucus and is responsible for creating the protective mucosal barrier of the stomach. Now this mucosal barrier protects the inner lining of the stomach from being broken down by its own digestive system
Define what the endocrine cell contribute in the stomach ?
this is located at the bottom of these pits and these cells are responsible for secreting histamine and somatostatin
what are the four gastric gland that can be found in the stomach ?
mucous neck cell
chief cell
endrocrine cell
parietal cell
true or false. The mucosa of the large intestine contains crypts which produce mucus and the primary function of this area is reabsorption of water and electrolytes, primarily sodium and potassium.
true
The mucosa of the large intestine contains crypts, now explain to me wha the primary function of this crypt is and what it produces ?
The mucosa of the large intestine contains crypts which produce mucus and the primary function of this area is reabsorption of water and electrolytes, primarily sodium and potassium.
Fluid in the Gi tract, what is entering the GI tract and what is leaving the Gi tract ?
7 liters of fluid enter GI tract every day (including saliva, bile, and stomach, intestinal, and pancreatic secretions)
+ 2 liters of fluid/day consumed by average adult
9 liters/day
8.8 L fluid is reabsorbed
So what can go wrong with the GI tract ?
Common problems in the GI tract, list them
1.acid issues
2.inflammation/erosion
3.motility issues ( structural/neural )
each problem can interrupt the normal processes of nutrition and elimination
Name 7 major function of GI tract ** important to know**
- Ingestion of food
- Propulsion of food and waste from mouth
to anus - Secretion of mucus, water, and enzymes
- Mechanical digestion of food particles
- Absorption of digested food
- Elimination of waste products by defecation
- Immune and microbial protection against infection
antiemetics: what are the different categories that undergoes this class
serotonin receptor antagonists
glucocorticoids
dopamine antagonists
cannabinoids
antihistamines/anticholinergics
DRUG CARD : Serotonin receptor antagonists: ondansetron
define trade name :
indications :
trade name : zofran
works in the CTZ ( chemoreceptor trigger zone )
acts on serotonin blocking receptors which results in less available serotonin
often used with dexamethasone which increases effectiveness
can be administered via po/iv/im
indications : nausea associated with chemotherapy, radiation, anesthesia, viral gastritis and pregnancy
This med is used for naseau vomiting stimulated by opioids and chemotherapy agents, any type of GI motion and anything that can affect viral mucosa
serotonin receptor antagonists : ondansetron
direct pathway can be divided into two things, what are they ?
directly pathway ( can be divided into two things )
emotional responses ( smell and sight ) higher sensory input
strong emotional reaction ( higher cortext of the brain = vestibular motion sickness
Serotonin antagonist : ondansentation adverse effects and nursing considerations
adverse effects : headache, constipation, diarrhea, dizziness, urinary retention, muscle pain, QT prongongatuion
nursing considerations : monitor EKG in patients at risk
monitor for effectiveness
what type of drugs should we use with a lot of caution with cardiac history ?
should e ask for vital signs such as heart rat e, blood pressure during the nursing considerations ?
serotonin antagonist : ondansetron
yes we should ! this is fundamental
DRUG CARD : Antiemetics : glucocorticoid: dexamethasone
( this is steroid : great drugs for fast symptom relief but do not maintain on long term )
used for inflammation
mechanism unknown
can be used alone or combined with other antiemetics ( ondansetron )
administered PO?Iv
when used briefly for symptom management of Nausea there are no negative effective effects
indications : nausea associated with chemotherapy
true or false. Glucocorticoid dexamethasone would be safer than prednisone with people with diabetes ?
true
Antiemetic : dopamine antagonist : metoclopramide
trade name : maxeran
pro kinetic drug
blocks dopamine and serotonin receptors in the CTZ, enhances upper GI tract response to acetylcholine ( increase peristalsis )
this can be taken PO or Iv
indications : nausea caused by post op, caner medications, opioids, toxins, radiation
this drug is helpful for Nausea and vomiting because it is an antagonist in which blocks dopamine ( pro kinetic )
antiemetic : dpamine antagonist : metoclopramide
Dopamine antagonist : metoclopramide adverse effects and nursing considerations
adverse effects :
- in high doses, diarrhea, and sedation are common
- with long term use : risk of tardive dyskinea ( repepetitive, involuntary movements of arms, legs, facial muscles )
CI: patients with gi obstruction, perforation, or hemorrhage
nursing considerations :
- gi assessment
-assess mental status ( drowsiness )
-look for uncontrolled movement
DRUG CARD : Antiemetic : cannabinoids : nabilone
mechanism is liely to activation of receptors around teh vomiting center
used to suppress chemo insduced nausea and vomiting
second line drugs due to psyschotomimetic effects and potential for abuse
nursing considerations
- monitor dor drwsiness
side effects:
- CNS: temporal disintegration n, dissociation ( avoid in patients with psychiatric disorders )
CVS: tachycardia & hypotension ) avoid in patients with cardiovascular disease )
do not mix with alcohol avoid some certain activity and ask alot about meditational history and we want to keep in mind CNS depressants : what is this describing ?
antiemetic : cannabinoids: nabilone
Upper Gi Disorders : What can go wrong? Mouth and throat issues
True or false. Nutrition always starts with the mouth we rely on the voluntary ability to chew and swallow food safely to start the nutrition process?
true
the concept : What can go wrong ? mouth and throat issues
What do we have to think about when thinking about the issues in the mouth
think about what you need to properly chew food
What do we have to think about the throat when connecting to the issues of it ?
swallowing is a voluntary act controlled by a skeletal motor neurons
dysphagia can occur from mechanical obstruction or functional impairment ( nerve or muscle problem)
if a patient has an impaired swallow, their overall ____ is impacted additionally an impaired swallow also places an individual at a way higher risk of ____ or _____.
nutrition
choking
aspirating
What are the common symptoms associated with upper GI disorders
anorexia
nausea
vomiting
True or false. Anorexia is completely different from anorexia nervosa ?
yes this is true
what is the definition of anorexia ?
lack of desire to eat, loss of appetite
define the characteristics of anorexia
non specific symptom
often associated with nausea, abdominal pain, diarrhea, and psychological stress
can be a side effect of medication
frequently accompanies diseases such as cancer, heart disease, and kidney disease
True or false. Nausea is often but not ALWAYS accompanied by vomitting.
true
To treat nausea and vomiting, what are these group of medications we refer to as ?
antiemetics
true or false. Vomiting is a reflex and there are multiple different pathways that trigger vomiting reflex
true
define what nausea is as a major symptom associated with GI disorders
subjective feeling of discomfort in epigastrium with a conscious desire to vomit
what’s another word that could be refer to as vomiting ?
emesis
Define what vomiting as a major symptom associated with GI disorders
foreceful ejection of partially digested food and secretions ( emesis ) from the upper Gi tract
true or false. Nausea can occur alone or with vomitting as well as other Gi symptom such as dyspepsia.
what is dyspepsia?
true
Indigestion = also called dyspepsia or an upset stomach, this is discomfort in your upper abdomen.
Which type of patients would we see nausea and vomiting in ?
pregnancy
infectious disease
CNS disease
cardiovascular disease
metabolic disorders
allergies, stress/fear
The concept: What causes the sensation of nausea and vomiting ? both are controlled by what centre and where is this location ?
both are controlled by the emetic centre in the medulla
What causes the sensation of nausea and vomitting ?
define the characteristics that undergoes this category
( what are the first three )
- chemoreceptors trigger zone lies outside the BBB and uses receptors for dopamine, serotonin, opiate, acetylcholine
- The vestibular system sends information to the brain via cranial nerve VIII and plays a major role in motion sickness and is rich in muscarinic receptors
- Enteric and vagus nervous system inputs transmits information about the state of gastrointestinal system. Irritation of the Gi mucosa by chemotherapy, radiation, disintention, or acute infectious gastroenteritis activates the serotonin receptors.
What is gastroenteritism ?
food poisoning
this is responsible for processing information about our external environment for balance and for spatial awareness . Pregnancy also activates this pathway
muscarinic receptors
Whether they’re nervous or anticipating something or fearful it can be triggered by this certain sensory
muscarinic receptors
causes of nausea/vomitting
what are the three major causes ?
inflammation in any part of the Gi tract
Irritation/injury to the CNS
Reaction to a drug
causes of nausea/vomitting
inflammation in any part of the GI tract :
define what undergoes this
- Gastritis ( inflammation fot he gastric wall )
- gastroenteritis and food poisoining
– Gastroesophageal reflux disease
– Pyloric stenosis, bowel obstruction, peritonitis, Ileus
– Overeating
– Food allergies
– Cholecystitis, pancreatitis, appendicitis, hepatitis
causes of nausea/vomitting
irritation/injury to the CNS :
define what undergoes this
– Motion sickness
– Concussion
– Cerebral hemorrhage
– Migraine
– Brain tumors and ICP
causes of nausea/vomitting
Reaction to a drug :
define what undergoes this
– Alcohol – Opioids
– Selective serotonin reuptake inhibitors (SSRIs)
– Many chemotherapy drugs
What is the first complication that can occur when experiecing nausea or vomitting ?
aspiration or entering of stomach contents into the respiratory tract , normally during vomiting the epiglottis closes to protect the respiratory system for stomach contents
true or false. In situations that would put your patients at an increased risk of aspiration during vomiting would be loss of that muscle tone say for stroke or from a decreased level of conciousness due to sedation
true
Implications for nursing : when stomach contents enter the lungs, what happens?
this creates the opportunity for it to sit there and a develop pneumonia faster which is an infection to the lungs
Implications for nursing :
Several complications can occur when a patients vomits : such as
aspiration–> infection
mallory weiss tear–> bleeding
fluid and electrolytes imbalance–> metabolic alkalosis
what occurs with very forceful vomiting, what is this referred to as in the several complications that can occur ?
mallor weiss tear
What are the type of electrolyte imbalance we could lose when a severe vomits occur ?
hypokalemia and hypochloroemia
When a pt vomits severely, and excessive loss of acidic gastric content results in decrease in hydrogen ions, what does this result as?
throws off complications ad delicate acid based balance of the body causing metabolic alkalosis
What happens if vomiting is prolonged ? what are the clinical manifestation?
dehydration can include hypotension and dizziness
What happens if vomiting is prolonged ?
what are the three mechanisms to explain this complications
1) a risk for dehydration increases
2) a patient can develop metabolic acidosis
three mechanisms to explain this complications:
a) Physical loss of HCO3- as duodenal secretions (which are alkaline) are lost in the vomit
b) Consumption of HCO3- through lactic acid production (caused by hypovolemia and increased muscle activity)
c) Depletion of liver stores of glucose causes ketoacidosis
What can go wrong in the upper GI tract?
Gastroesophageal reflux disease (GERD)
Hiatal Hernia
GI Bleeding
Esophageal Cancer*
Peptic Ulcer Disease (PUD) Gastritis
True or false. normally during digestion, the lower esophageal spinchter , which a thick muscularis layer, tightens.
true
what is this describing ?
there is inappropriate relaxation of that sphincter, which allows for the backflow of acidic stomach contents, to go back up into the esophagus
Gastroesophageal reflux disease (GERD)
What does Gastroesophageal reflux disease (GERD) simplify to ?
gastro- stomach
esophageal - esophagus
reflux - that backward motion
what does peptic ulcer disease look like?
can contain erosion, acute ulcer and chronic ulcer and scarring
initially starts in the mucose and submucosa, then leads to muscular and serosa, few can develop all at once
** huge risk for blood loss and hypovolemic shock
what are the symptoms of peptic ulcer disease?
can be asymptomatic
pain described as “burning:
gastric ulcer: “gaseous” in epigastric area, 1-2 hr after eating
duodenal ulcer: “cramp-like” in midepigastric or back pain, 2-4 hr after eating
what are the complications of PUD?
hemorrhage: due to erosion of granulation tissue at base of ulcer(more common in duodenal ulcer) - Hematemesis, Melena, or Occult Bleeding
perforation:ulcer penetrates serosal surface and gastric/duodenal contents enters peritoneal cavity Peritonitis
Gastric Outlet obstruction: ongoing inflammation can cause obstruction of gastric outlet Belching, Projectile Vomiting
what is gastritis? def, causes, clinical mani and complications
def: inflamed stomach mucosa with significant risk of GI bleeding (esp in hospitalized pts)
causes: alc, NSAIDS, H.pylori, Crohn’s disease and stress
clinical mani: mostly asymptomatic but can be anorexia, n and v, epigastric tenderness and feeling of fullness
complications: bleeding
lower GI disorders common symptoms and disorders?
symptoms: diarrhea and constipation
common lower GI disorders: Appendictis - Peritonitis
IBDs - intestinal obstruction
Malabsorption syndrome
colon Ca
what is a normal bowel pattern?
terms for poop:
stool
feces
bowel movement (BM)
defecation
diarrhea
melena (bleeding in the GI tract, partially digested blood)
stool with frank
Some variation in BM consistency/frequency is normal
true or false regarding diarrhea:
Diarrhea if defined as the frequent passage of watery stools
GI secretions are rich in HCO3- and K+
true
What are some of the common causes of diarrhea?
Common causes include:
1) Decreased fluid absorption (drugs, malabsorption, mucosal damage)
2) Increased fluid secretion (infections, drugs, food, hormones)
3) Motility disturbances (irritable bowel syndrome, diabetic enteropathy
what are some complications of prolonged diarrhea?
if left untreated - life threatening
metabolic acidosis: Prolonged diarrhea can result in metabolic acidosis due to loss of HCO3- in the GI secretions and pancreatic juice.
HYPOkalemia: Occurs with severe diarrhea and can lead to cardiac arrythmias
Dehydration
Eventually, hypovolemic shock can occur
The most at risk populations are children and older adults.
what is constipation?
Definition: infrequent or hard to pass bowel movements
■ Cause of painful defecation
■ Severe constipation can lead to fecal impaction-> obstruction
what can cause constipation?
diet - low fibre lower liquid intake
medications (opioids, diuretics, antidepressants, anticonvulsants, antihistamines, aluminum/calcium antacids, Ca channel blockers)
metabolic and muscular disorders (hypercalcemia, hypothyroidism, diabetes mellitus, cystic fibrosis, celiac disease, muscular dystrophy)
structural and functional abnormalities ((spinal cord lesions, Parkinsons, colon cancer, anal fissures, paralytic ileus)
■ Psychologic reasons (voluntary withholding of stool, depression & stress)
can psychologic resins and structural and functional abnormalities be a cause for constipaiton?
yes
DRUG CARD : ANTIEMETIC : antihistamine ( dimenhydrinate )
trade name :
MOA :
adverse effects
nursing considerations
trade name : gravol
MOA: blocks H1 receptors in the Gi tract and muscarinic receptors in the vestibular system ( anticholinergic )
adverse effects :
Drowsiness, constipation ,and dry mouth
- avoid with CNS depressants
- should not be taken with pts history of glaucoma or chronic lung disease, difficulty urinating
nursing considerations : GI assessment
Assess alertness ( safely )
vital signs ( check often with CVD )
monitor for signs od retention ( bowel and bladder )
what are the indications that we can use antiemetic antihistamine ( dimenhydrinate )
motion sickness, radiation sickness, post op nausea, drug induced nausea
true or false. suppressing the rest and digest ( mechanism of glaucoma ) dilation we can block the drainage in the eye therefore put them in a higher risk
true
DRUG CARD : Antiemetic : muscarinic antagonist : scopolamine
MOA
ROUTE
motion sickness
blocks nerve impulses between vestibular apparatus in inner ear and vomitting center
- most effective drug for preventing and treating motion sickness
route : PO/SC/transdermal dosing
indications : motion sickness
form of admin is a patch ( the best)
Because muscarinic antagonist still binds with acetylcholine, what is this considered as ?
this is considered as anticholinergic
what are the nursing considerations and adverse effects for muscarinic antagonist : scopolamine
adverse effects : common :
dry mouth, blurred vission, drowsiness
less common : urinary retention, constipation, disorientation
nursing consideration : GI assessment, monitor for signs od retention ( bowel and bladder ) and assess alertness ( safely )
what are the four categories that undergoes laxatives
bulk forming
surfactant
stimulant
osmotic
What is the definition of GERD?
Gerd is a condition where gastric contents move into the esophagus creating the sensation of heartburn and/or esophagitis
what are the different medication that can cause GERD ?
calcium channel blockers and anticholinergics
Why do people get GERD ?
GERD can be caused by ?
1) weak or incompetent LES
2)hiatal hernia
3) impaired esophageal motility
4)increased abdominal pressure
5) delayed gastric emptying
what does incompentent LES mean?
modifiable risk factors of dietary habits or lifestyle habits and this can include consumption of caffeine, chocolate, spicy foods, and alcohol as well as smoking ( these are contribute to gerd )
describe what hiatal hernia initially contribute to GERD
hearniation of a protion of the stomach , part of the upper stomach or the stomach and esophagus join through an opening in the diaphragm and into the chest activity
what does impaired esophageal motility mean in terms of contributing to GERD
this means that esopahagus isnt finishing stuff down properly, things become stuck int he esophagus
increased abdominal pressure, what does it mean in terms of contributing to gerd ?
can happen in instances of pregnancy or obesity
delayed gastric emptying can cause GERD, explain how
can result from an infection which is usually viral or form diseases that affect the nervous system
GERD common symptoms are…
heartburn and Regurgitation
what’a another word for heartburn (PYROSIS)
dyspepsia
why is heartburn occurring ( as a a GERD symptom )
acid is coming into contact with the unprotected tissue of the esophageal mucosa
define the characteristics that undergoes heartburn
■ Burning/tight sensation felt intermittently beneath lower sternum and spread to throat/jaw
■ Occurs 30-60 mins after meal and worse when bending at waist
true or false.if contained one of those trigger foods such as caffeine, chocolate, spicy foods, and alcohol as well as smoking discussed and if you choose to lie in recumbent position after eating ( makes it worse ) –> heartburn.
true
define the characteristics that undergoes Regurgitation ( symptom of GERD )
effortless return of gastric contents. Often described as hot bitter, or sour liquir
what is this describing : this is due to the stomach contents coming up high enough to the mouth or throat.
regurgitation
what are the respiratory symptoms of GERD
aspiration or stomach contents can cause wheezing, coughing, and dyspnea
true or false. respiratory symptoms are directly related to inflammation of the respiratory tract caused by acidity of the backup of those stomach contents
true
GERD: Chronic Complications
With ongoing esophagitis ….
describe what this could mean
or inflammation of the esophagus which can further develop into ulcers and potentially become a source of gastrointestinal bleeding, or upper gastrointestinal bleeding
GERD chronic complications :
With ongoing esophagitis
define what undergoes this
1) ulceration and bleeding
2) esophageal stricture : narrowing of esophagus caused by scar tissue formation ( leads to dysphagia )
3) barret’s esophagus : replacement of esophageal stratified squamous epithelium with simple columnar epithelium (like stomach/intestine)
True or false. 10 % of patients with Barret’s will develop esophageal cancer
true
Define another definition that could help describe what barret’s esophagus mean ?
inflammation to the muscosa of the esophagus, 5 to 10 years can result in cellular changes of the esophagus that takes on the cell structure of the stomach
why does scar tissue form when esophageal stricture occurs ?
scar tissue occurs in the esophagus as response to that on going inflammation, and the narrowing of the esophagus can cause with the difficulty of swallowing which is what we refer to as dysphagia
as we know 10 % of patients with barret’s will develop esophageal cancer what do we need to monitor?
frequent monitoring with endoscopy in order to assess and detect these concerning cellular changes that could lead to esophageal cancer
what is this describing : herniation of a portion of the stomach into the esophagus through an opening in the diaphragm
this is what we call hiatal hernia
what is the definition of hiatal hernia ?
herniation of a portion of the stomach into the esophagus through an opening in the diaphragm
what are the contributing factors of hiatal hernia
weakening of muscles in the diaphragm around esophogastric opening, increase in intra- abdominal pressure (obesity, pregnancy, ascites, tumours, heavy lifting)
what are the symptoms of hiatal hernia
similar to GERD and often occur when supine, after large meal, with smoking/alcohol
Increase abdominal pressure is a contributing factor to hiatal hernia, explain how pts with liver disease and tumor deal with this abdominal pressure ?
patients that have liver disease they get a collection of this third spacing fluid in the abdomen known as ascites that can also increase the intra abdominal pressure as well as if somebody has a tumor growing in that area. Heavy lifting on a regular basis can also contribute to that increased abdominal pressure.
esophageal cancer : what kinds of symptoms do you think a patient would experience?
asymptomatic ( early )
dysphagia
Meat ( first ) –> soft food–> liquids
neck pain
sore throat
weight loss
bleeding ( complication )
sometimes it can go undetected ( high anal hernias) are detected as an incidental finding during imaging or something that is completely different
asymptomatic ( early )
this is restricting the esophagus that pathway of food to travedown in order to reach the stomach
dysphagia
this is a relation to the location and proximity of the cancer to these structures
neck pain and sore throat
What is this describing : the presence of cancerous tumour can change the way the body uses nutrients as a whole as a result weight loss
weight loss and bleeding ( complication )
what is this describing :? as the tumour erose the mucosa lining the esophagus this can also pose a threat ir become a source of upper gastrointestinal weaving
bleeding
Peptic Ulcer Disease ( PUD ): when does this occur
PUD occurs when ulcerative lesions are caused by exposure of the stomach or duodenal mucosa to HCL acid pepsin secretions
Gi mucosa normally protected by mucus containing HC03 and mucin, ulcers develop when there is excess acid or diminished mucosal defense. What does this category undergoes to ?
Peptic Ulcer Disease
most common causes of peptic ulcer disease
H.pylori infection
NSAID use
this help neutralize to those acidic contents gram negative bacilli in the stomach or duodenem
HC03
how does peptic occur ?
peptic results when those protective or what we call defensive ( when they become impaired and they can no longer protect the epithelium of the stomach known as gastric ulcer ( duodenal ulcer in the duodenum ).
what are the aggressive factors for peptic ulcer disease ( PUD )
H.pylori , NSAIDS Acid, Pepsin, smoking
what are the defensive factors for peptic ulcer disease ( PUD )
mucus
bicarbonate
blood flow
prostaglandins
true or false. Stimulated increased mucus and bicarb secretion as well as vasodilation to the area to increase blood flow.
true
More info on PUD etiology
what are the causes ?
H. pylori and nsaid user
go more in depth about H. pylori and NSAID users
up to 90% of people with PUD are infected with H.pylori., but many people that are infected dont develop ulcers
20-% chronic nsaid users will develop users
what are the risk factors for PUD etiology
diet - lack of protective foods ( vitamin A )
smoking
alcohol
stress
what is this describing : gram negative bacilli remains to be asymptomatic and wont develop ulcers but sometimes the presence of this specific bacteria can cause damage to the stomach and the duodenum which over time can damage the mucosal wall and alter those gastric peptic ulcer disease
H.pylori
what is this describing : inhibits prostaglandins which is a key defensive mechanism , the culprit for the development of peptic ulcer disease
nsaids
what is a significant defensive factor for helping protect that Gi mucosa
Prostagladin
Prostaglandin Functions…
what are the three?
- Promotes secretion of bicarb and protective mucus
- Suppress secretion of gastric acid
- Maintains submucosal blood flow via vasodilation
NSAIDs suppress prostaglandin; increasing the risk for peptic ulcers and GI bleeding (GIB) by:
- Decrease in that protective mucous
production, decrease in neutralizing bicarb 2. Increased production of gastric acid - Decreased blood flow to the GI submucosa
(due to VASOCONSTRICTION).
true or false.less blood flow, more likely tissue injury, and less blood cells therefore moving though that area, less platelets to help with clotting and less white blood cells to help with immunity
true
what is appendicitis?
inflammation of the appendix due to obstruction by fecalith or if bowel becomes twisted
obstruction causes: increase pressure within appendix leading to schema and necrosis
true or false: Inflammation can increase permeability of appendix, causing localized peritonitis
As pressure increases, appendix can rupture leading to generalized peritonitis (life threatening)
trueeeeee
what does appendicitis feel like?
clinical manifestations ? eventually how will it feel ? and what should you look for signs ?
clinical mani: periumbilical pain (persistent and continuous)
eventually: pain will localize to the McBurney point (halfway between umbilicus and right iliac crest)
look for: anorexia, N and V, localized tenderness, rebound tenderness (pain from release of palpation), muscle guarding and low grade fever
what is peritonitis?
this is the inflammation of peritoneal membranes from chemical irritation or bacterial infection
Bulk forming laxatives : Psyllium
Similar action to fiber (↑bulk leads to soft
formed stool)
Made of polysaccharides and cellulose derived from grains and plants (nondigestible)
Not absorbed systemically (side effects rare)
Should be administered with large glass of water to avoid obstruction/impaction (esophageal)
Produces a soft but still formed stool in 1-3 days
Osmotic Laxatives : Lactulose
Combination of galactose and fructose
Poorly absorbed and not digested by enzymes in the GI tract = N/V side effects
Turns into lactic acid in the colon which has an osmotic action similar to other osmotics
Hepatic encephalopathy – helps with excretion of ammonia
More adverse effects and actually more expensive than other laxatives
Produces a soft stool in 1-3 days
Osmotic Laxatives: Laxative salts - Magnesium Hydroxide
Poorly absorbed salts and osmotic action draw water into the intestinal lumen
Low dose therapy stool in 6-12 hr
High dose used for bowel evacuation prior to surgery or to purge poisons (2-6 hours)
At risk of dehydration
Magnesium salts are contraindicated in patients with kidney disease
Osmotic Laxatives: Polyethylene Glycol
Non absorbable compound, retain water in the intestinal lumen
Causes the feces to swell and soften
Used for chronic constipation
GI side effects
(N/bloating/cramping/flatulence/diarrhea)
Can be used as bowel cleanse prior to colonoscopy or other procedures at high doses
Time of onset – dose dependent
- Low→6-12 hours
- High→2-6 hours
Stimulant Laxatives:
Bisacodyl
Trade name: Dulcolax
Stimulate intestinal motility & Increase the amount of water and electrolytes within the bowel
Opioid induced constipation
Common drug for laxative abuse
Available as rectal suppository or by mouth Oral
route - 6-12h
Rectal route – 15-60 mins
Often given at bedtime to produce a stool the next day
SURFACTANT laxatives: Docusate Sodium
Trade name: Colace
Slow onset
Work in the small intestine and colon
Softens the stool by facilitating penetration of water
Also causes secretion of water and electrolytes into the intestine
Produces soft stool in 1-3 days
Adverse Effects: mild cramping, diarrhea
Nursing consierations and assesment for laxatives
Most laxatives are given until desired effect achieved (soft BM) and should be used for short term
Laxatives can be abused
Water consumption is important (bulk forming and osmotic)
GI assessment important to identify if desired effect (or if too effective- diarrhea)
Most laxatives are not absorbed systemically so side effects will be primarily GI related
What is gastroenteritis?
inflammation of the mucosa of the stomach and small intestine due to an infection (viral, bacterial, or parasitic)
true of false: the clinical manifestations of gastroenteritis include: N&V, diarrhea, abdominal cramping and distension, high fever, high white blood cells, blood/mucus in the stool
true
should patients with gastroenteritis be NPO until vomitting resolves?
yessss
gastroenteritis: Most cases are self-limiting but can be dangerous for older adult or chronically ill (++ risk for dehydration)
true of courseeeee
what are the two types of inflammatory bowel disease?
crohns disease and ulcerative colitis
what is inflammatory bowel disease? what are the complications?
chronic inflammatory bowel diseases which are autoimmune in nature
complications: disease trajectory follows pattern of periods of execrations and remissions
increase risk of colon cancer
can develop associated autoimmune diseases: iritis, arthritis, dermatitis, vasculitis and thromboembolism
what are the characteristics and location of crohn’s disease?
location: most often effects ilium but can be anywhere in GI tract
characteristics: Inflammatory ulcerative “skip” lesions that involve the entire thickness of GI wall and create cobble stone appearance.
genetic: onset is teens to mid 30’s
what is the location and characteristics of ulcerative colitis?
location: begins in the rectum and progresses proximally through the large intestine
characterisitics: inflammation affects only mucosa and submucosa (bleeding)
onset is 18-30’s
what are the unique symptoms and complications of the two types of IBD’s? (what are the names you should knowwww)
Crohn’s disease symptoms: Weight loss, malabsorption and nutrient deficiencies
complications crohns: fistulas
strictures
Ulcerative Colitis: unique symptoms: rectal bleeding (anemia), tenesmus
complications: toxic megacolon
what is a common complication for both crowns disease and ulcerative colitis?
intestinal obstruction
what is an intestinal obstruction?
anytime there is impaired movement of the intestinal contents. Most commonly occurs in the small intestine, but can occur in large intestine, where symptoms develop slowly.
where is intestinal obstruction most common?
in the small intestine
what are the two different causes of intestinal obstruction?
1) Mechanical obstruction: occurs where there is a physical obstruction in the intestine. Examples: adhesions from surgery (sml intestine), tumour (lrg intestine), inguinal hernia, volvulus, and intussusception
2) Nonmechanical obstruction (Functional): occurs from a neurological impairment or failure of propulsion of the intestine. Often called paralytic ileus. Examples: peritonitis, pancreatitis, Crohn’s disease, Ulcerative colitis, spinal chord injuries or electrolyte imbalances.
What should the nurse be looking for in a patient with a possible intestinal obstruction? for specifically small bowel!
symptoms onset will be rapid and include frequent vomiting with colicky, cramp-like abdominal pain. The patient may continue to have bowel movements for a period of time.
What should the nurse be looking for in a patient with a possible intestinal obstruction? for specifically large bowel!
the symptom onset will be gradual and include low-grade cramping abdominal pain, significant abdominal distension, and absolute constipation (no BMs). so no gas
intestinal obstruction diagram from 1-8 small bowel
- site of obstriction
- increased fluid and gas lead to distension
- distention causes increased peristalsis to force contents past obstruction leading to colicky pain
- severe vomitting from distention and pain leads to dehydration and electrolyte imbalance
- increased pressure on wall causes more fluid to enter intestine
- decreased blood pressure ad hypovolemic shock (third spacing) fluid shift into intestine continues
7.continued pressure on intestinal wall causes edema and schema of wall and decreased peristalsis - prolonged ischemia causes increased permeability and necrosis of wall. intestinal bacteria and toxins leak into blood and peritoneal cavity (peritonitis)
what is malabsorption syndrome?
Results from impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins
what are some possible causes of malabsorption syndrome?
■ Enzyme deficiencies
■ Bacterial proliferation
■ Disruption of small intestine mucosa
■ Disturbed lymphatic and vascular circulation
■ Surface area loss
what is the most common malabsorption disorder? what are some others
lactase deficiency. IBD, celiac disease, and cystic fibrosis
what is lactase deficiency?
Lactase deficiency: a condition in which lactase enzyme is deficient or absent
what are the clinical manifestations and management of malabsorption syndrome?
Clinical manifestations: abdominal bloating and cramps, flatulence, diarrhea, nausea, borborygmi, and vomiting
Management: lactose avoidance and/or lactase supplementation
what is colorectal cancer?
is the second most common cause of cancer death in Canada
■ 20% of tumours are within reach of the examining finger and 50% are within reach of a sigmoidoscope
what are the risk factors and clinical manifestations of colorectal cancer?
Risk Factors: diet high in red/processed meat, obesity, physical inactivity, alcohol, smoking, low intake of fruit and veg
■ Manifestations: nonspecific (early), rectal bleeding (occult), changing bowel patterns, abdominal cramps, gas, bloating, narrow ribbon-like stool, loss of appetite, weight loss
what are the nonspecific antidiarrheals?
opioids: loperamide, diphenoxylate atropine and bismuth subsalicylate
true of false regarding antidiarrheals opioids: Most effective antidiarrheal agents
Activate opioid receptors in GI to slow intestinal motility (more time for absorption of fluid and electrolytes)
May cause toxic megacolon in patients with IBD
all true
drug card opioids: diphenoxylate (+Atropine)
brand name lomotil
opioid used only for diarrhea
atropine is added to discourage abuse (unpleasant side effects at high doses)
available in PO only (so cant abuse IV)
what are the adverse effects of diphenoxylate?
Adv Effects: dizziness, drowsiness, light- headedness, headache, N&V
drug card: opioids loperamide
brand name: Imodium
suppresses bowel motility and bowel secretions
Used to reduce volume of discharge from ileostomies Large doses do not produce morphine like effects
what is the one antidiarrheals in this course thats NOT opioid? and describe it!!!!
bismuth subsalicylate:
Coats the walls of the GI tract
Binds to causative bacteria or toxin which is then eliminated in stool
Adv effects: increased bleeding time, constipation, dark stools (can be mistaken for melena), hearing loss, tinnitus, metallic taste, blue gums
what are the four classes of drugs for PUD? can it be used to manage GERD
H2 receptor antagonist
proton pump inhibitor
other antacids
antibiotics
and YES
what are the goals of drug with PUD?
(1) alleviate symptoms
(2) promote healing
(3) prevent complications (hemorrhage, perforation,
obstruction…)
(4) prevent recurrence.
what is red difference between GERD and PUD
GERD
Goals of drug therapy:
▪alleviate symptoms
▪promote healing of esophageal mucosal injury (ulceration or bleeding)
▪prevent complications (esophageal strictures, Barrett’s esophagus…).
PUD
Goals of drug with PUD:
▪alleviate symptoms
▪promote healing of gastric/duodenal mucosa
▪prevent complications (hemorrhage, perforation, obstruction…)
▪prevent recurrence.
drug card: histamine-2 receptor antagonist: ranitidine
Not to be confused with “antihistamines” H1 receptors antagonists that are targeted towards allergy symptoms
* H2 receptors are located in the parietal cells of stomach
* Blocking these receptors reduces the volume of gastric juice and decreases concentration of acid
* Require long term therapy to heal gastric and duodenal ulcers (6-12 weeks)
* End in “tidine”
indications include PUD, GERD
what are the nursing considerations and assessment for ranitidine?
Adverse Effects (uncommon)
CNS: confusion, hallucinations, CNS depression (crosses BBB poorly so this is rare)
Increased risk for pneumonia (loss of acidic buffer = ↑ pH)
assessment:
Assess for epigastric pain, abd pain or signs of GI bleeding (hematemesis, frank blood or occult blood in stool)
Assess for signs of confusions (especially in older adults)
Administer antacids an hour apart from other medications
Monitor for signs of pneumonia
drug card: proton pump inhibitor: omeprazole
enteric coated - do not crush needs to reach area as whole drug
Causes irreversible inhibition of H+, K+ ATPase, the enzyme that generates gastric acid
A single dose inhibits acid production by 97% in 2 hrs
Effect is irreversible (no new acid until new enzyme is made which may take days to weeks)
Drug is acid-labile so capsules contain enteric coated granules that dissolved in duodenum
indications: PUD, GERD
what are the adverse effects of omeprazole?
MINOR
Headache Diarrhea N&V
More Severe:
Pneumonia
Fractures
Rebound acid hypersecretion DYSPEPSIA Hypomagnesemia
monitor: admin doses before meals, monitor serum Mg. with prolonged use, monitor for signs of pneumonia and monitor for fractures
drug card: other anti ulcer drugs: sucralfate
indication: GERD, duodenal ulcers
Protects against ulcers by creating a mucosal
barrier against acid and pepsin
Undergoes chemical reaction in acidic environment of stomach to form a sticky gel
Adheres to ulcer for 6 hours Eliminated in the feces
Oral administration only
adverse effects and nursing considerations of sucralfate:
Adverse Effects
Constipation (rare)
No systemic side effects because not absorbed
Nursing Considerations
PO Route only
Should not be taken within 30 minutes of antacids
Can alter absorption of many other meds: should be taken 2hrs apart
what another antiulcer drug? what are the indications
misoprostol: it Replaces endogenous prostaglandin
- suppresses secretion of gastric acid - promotes secretion of bicarb/mucus - increases mucosal blood flow
Indication: limited to prevented NSAID induced gastroduodenal ulcers
Often seen as a combination drug with NSAIDS
Misoprostol: adverse effects and nursing considerations (hint what does M stand for…)
ADVERSE EFFECTS
Minimal Diarrhea
NURSING CONSIDERATIONS
Contraindicated in pregnancy – will cause spontaneous abortion
drug card: other antiulcer drug: antacids
Alkaline compounds that neutralize stomach acids Raise pH of stomach (above 5)
Reduce pepsin activity
Stimulate production of prostaglandins
Not systemically absorbed (except Sodium bicarbonate)
incdications: GERD, PUD and gastritis
examples: Magnesium hydroxide (MOM), Aluminum hydroxide, Calcium carbonate (TUMS), sodium bicarbonate
adverse effects for antacids?
Magnesium Hydroxide (Milk of Magnesia)
Diarrhea (often administered with aluminum hydroxide to counteract this effect)
Avoid in patients with undiagnosed abd. Pain
Mg. can accumulate in people with renal dysfunction Aluminum Hydroxide (Almajel)
Constipation
High affinity for phosphate (can cause hypophosphatemia)
Calcium Carbonate (TUMS)
Constipation, belching, flatulence (release C02) Risk for acid rebound
Calcium can accumulate in kidney failure (not recommended)
Sodium Bicarbonate
Belching, flatulence (releases C02)
In renal failure can cause systemic alkalosis
High risk of sodium loading (dangerous for HTN, HF)
nursing considerations of antacids?
Monitor GI function (constipation/diarrhea) Monitor electrolytes (Mg., Phos., Ca.)
- Hypermagnesia
- Hyperphosphatemia
- Hypecalcemia
Give after meals
Unpleasant to digest, adherence is difficult
Available as liquid & chewable (liquid is more effective)
antibacterial drugs - drugs for PUD
select all that is true:
indications: PUD caused by H Pylori ONLY
Always in combination to create broad coverage and to minimize resistance against H. Pylori Normally, a regimen of 2-3 antibiotics along with a PPI for PUD
N/V are most common side effects 10-14 days of therapy
Compliance is key
Allergies to antibiotics are common
amoxicillin, clarithromycin, metronidazole and tetracycline
TRUUUUUU
drugs for IBD include….
5-Aminosalicylates: Sulfasalazine
Glucocorticoids: Budesonide
Immunomodulator: Infliximab
Immunosuppressant: Cyclosporine
drug card: 5- Aminosalicylates: Sulfasalazine
indications: mild to moderate IBD, maintain remission
Used to treat mild or moderate IBD
Maintain remission after symptoms have improved
Action on prostaglandin synthesis and suppression of migration of inflammatory cells into the affected region
Nursing Considerations: Monitor CBC periodically – can cause hematological disorders
Adverse Effects: Nausea/fever/rash/arthralgia
drug card: Glucocorticoids: Budesonide remember what do we know about gucocorticoids!!!
Anti-inflammatory action
Use is to induce remission, not for long term maintenance
IV/PO (enteric coated capsule)
Nursing Considerations: prolonged use of glucocorticoids can cause severe adverse effects, adrenal suppression, osteoporosis, increased risk for infection, Cushing’s syndrome
Mild to mod. UC – works locally within the ileum and ascending colon
drug card: Immunomodulator: Infliximab
indications: moderate to severe UC and Crohns
Monoclonal antibodies
Designed to neutralize TNF, a key immunoinflammatory modulator
Infections: TB and other opportunistic infections are the most common
Infusion reactions: Fever, chills, pruritis, urticaria, cardiopulmonary reactions (chest pain, hypertension, hypotension)
Increased risk of lymphoma
6 week regimen followed by maintenance infusions every 8 weeks after
drug card: Immunosuppressant: Cyclosporine
Long term therapy
Calcineurin Inhibitor – Very strong immunosuppressant
Faster acting and stronger than other
immunosuppressants
Continuous IV infusion, can also be administered orally in low does to maintain remission
Increased lymphoma risk, further increased with used with other immunosuppressants
Nursing Considerations:
Potentially toxic compound: can cause renal impairment, neurotoxicity, Generalized suppression of the immune system = ↑ risk of infection
Indications: severe disease that has not responded to other therapies, both UC and Crohns
