Week 3 - GI Flashcards
1
Q
General GI problems include:
A
- N/V
- Diarrhea
- Constipation
- Irritable Bowel Syndrome
2
Q
Upper GI Problems include:
A
- GERD
- Gastritis
- PUD
- Hiatal Hernia
- Upper GI Bleed
3
Q
Lower GI Problems include:
A
- Acute ABD Pain
- Appendicitis
- Peritonitis
- Intestinal Obstruction
- Diverticulosis/Diverticulitis
- Hernia
4
Q
Key points to remember with general GI issues; nausea/vomiting:
A
Fluid status/ dehydration
>Hypovolemia symptoms
Electrolytes
5
Q
Key points to remember with upper GI problems
(GERD, gastritis, PUD, hiatal hernia, upper GI bleed):
A
Lifestyle/ food choices
Life-threatening (bleeding)
Surgery-endoscopy
PPI & H2 blockers
6
Q
Key points to remember with lower GI problems
(acute ABD pain, appendicitis, peritonitis, obstruction, diverticulosis/diverticulitis, hernia)
A
Emergency
Infection
Surgical procedures often required
7
Q
Key points to remember with IBD
A
anemia
nutrition
psychosocial
8
Q
Key points to remember with obesity/stomach cancer:
A
Lifestyle (food, exercise, health risks)
Stomach cancer- pain management, post-surgical needs
8
Q
Most common manifestations of GI disease:
A
nausea
9
Q
Vomiting - Forceful __________ of _________________________ (emesis) from upper GI tract
A
Vomiting - Forceful ejection of partially digested food and secretions (emesis) from upper GI tract
9
Q
Nausea & vomiting Occurs from
-GI disorders
- Pregnancy
- Infection
-CNS disorders
-Cardiovascular problems
-Metabolic disorders
-General anesthesia
- Side effects of drugs
- Psychologic factors
-Over irritated GI tract
A
-GI disorders
- Pregnancy
- Infection
-CNS disorders
-Cardiovascular problems
-Metabolic disorders
-General anesthesia
- Side effects of drugs
- Psychologic factors
-Over irritated GI tract
10
Q
Nausea - Feeling of discomfort in __________ area with a conscious desire to ________
A
Nausea - Feeling of discomfort in epigastric area with a conscious desire to vomit
11
Q
Vomiting is a complex act
- Requires ___________ activity
- Closure of _______
- Deep inspiration with contraction of diaphragm
- Closure of _________
- Relaxation of stomach and LES
- _____________ of abdominal muscles
A
- Requires coordinated activity
- Closure of glottis
- Deep inspiration with contraction of diaphragm
- Closure of pylorus
- Relaxation of stomach and LES
- Contraction of abdominal muscles
12
Q
[N/V] Chemoreceptor trigger zone (CTZ)
- Located in _____________
- Responds to chemical stimuli of drugs, toxins, labyrinthine stimulation
- Site of action of drugs used to induce ________
- Transmits impulses to __________________
A
- Located in brainstem
- Responds to chemical stimuli of drugs, toxins, labyrinthine stimulation
- Site of action of drugs used to induce vomiting
- Transmits impulses to vomiting center
13
Q
Nausea
- ____________ complaint
-Usually accompanied by __________
A
-Subjective complaint
-Usually accompanied by anorexia
14
Q
Vomiting Complications
- _______________ can rapidly develop when nausea and vomiting is prolonged
- Loss of water and essential ___________
- Metabolic ___________: from loss of gastric HCl
- Metabolic ___________: from loss of bicarbonate if contents from small intestine are vomited
- Weight loss from fluid loss can occur
A
- Dehydration can rapidly develop when nausea and vomiting is prolonged
- Loss of water and essential electrolytes
- Metabolic alkalosis: from loss of gastric HCl
- Metabolic acidosis: from loss of bicarbonate if contents from small intestine are vomited
- Weight loss from fluid loss can occur
15
Q
Contents of emesis
- Fecal odor and bile indicate a ________ intestinal obstruction
- ________ of emesis aids in determining presence and source of any bleeding
A
- Fecal odor and bile indicate a lower intestinal obstruction
- Color of emesis aids in determining presence and source of any bleeding
16
Q
N/V PHARMACOLOGY
Many antiemetics act on CNS in CTZ to block _____________ that trigger _________________
A
Many antiemetics act on CNS in CTZ to block neurochemicals that trigger nausea and vomiting
17
Q
N/V PHARMACOLOGY
Serotonin (5-HT3) receptor antagonists
- Ondansetron (________)
Used to treat
- Chemotherapy-induced vomiting (CINV)
- Migraine headache
- Anesthesia
- Anxiety
- Postoperative nausea and vomiting (PONV)
A
Zofran
18
Q
N/V PHARMACOLOGY
Neurokinin-1 receptor agonist (NK1RA)
- Aprepitant (Emend)
Phenothiazines
- Prochlorperazine
- Chlorpromazine
Anticholinergics
- Scopolamine transdermal (Transderm-Scōp)
Antihistamines
- Dimenhydrinate
- Meclizine
- Hydroxyzine
- Diphenhydramine
A
Neurokinin-1 receptor agonist (NK1RA)
- Aprepitant (Emend)
Phenothiazines
- Prochlorperazine
- Chlorpromazine
Anticholinergics
- Scopolamine transdermal (Transderm-Scōp)
Antihistamines
- Dimenhydrinate
- Meclizine
- Hydroxyzine
- Diphenhydramine
19
Q
N/V PHARMACOLOGY
Other drugs with antiemetic properties
- Dexamethasone
- Cannabinoid
- Dronabinol (Marinol)
- Benzamides
- Metoclopramide (Reglan)
A
- Dexamethasone
- Cannabinoid
- Dronabinol (Marinol)
- Benzamides
- Metoclopramide (Reglan)
20
Q
N/V TREATMENT
-IV therapy to replace fluids, electrolytes, glucose
-NG tube suction to decompress stomach
-Clear liquids after symptoms subside
-5–15 mL fluid every 15–20 minutes
-No extremely hot/cold liquids
-Room-temperature carbonated beverages without carbonation okay
-Warm tea
-Begin with dry toast, crackers
-High-carbohydrate, low-fat foods next, because they are easier to digest
-Baked potato, plain gelatin, cereal with milk
-Eat slowly and in small amounts
A
-IV therapy to replace fluids, electrolytes, glucose
-NG tube suction to decompress stomach
-Clear liquids after symptoms subside
-5–15 mL fluid every 15–20 minutes
-No extremely hot/cold liquids
-Room-temperature carbonated beverages without carbonation okay
-Warm tea
-Begin with dry toast, crackers
-High-carbohydrate, low-fat foods next, because they are easier to digest
-Baked potato, plain gelatin, cereal with milk
-Eat slowly and in small amounts
21
Q
N/V NURSING ACTIONS - Persistent vomiting
-Hospitalization
- IV fluids
-Nothing-by-mouth (NPO) status
- NG tube may be used for possible obstruction
- Record I & O
- Monitor VS
- Assess for signs of dehydration
- Maintain quiet, odor-free environment
A
-Hospitalization
- IV fluids
-Nothing-by-mouth (NPO) status
- NG tube may be used for possible obstruction
- Record I & O
- Monitor VS
- Assess for signs of dehydration
- Maintain quiet, odor-free environment
22
Q
DIARRHEA
-At least ____ loose or liquid stools per day
-Chronic diarrhea last > ____ days
A
3;
30
23
DIARRHEA Primary Cause
- Ingesting ________________
- _________ – most are mild and last 24 hours; however some can cause serious complications leading to death
- _________ - most common cause of bloody diarrhea in US
- Ingesting infectious organism
- Viruses – most are mild and last 24 hours; however some can cause serious complications leading to death
- E-coli most common cause of bloody diarrhea in US
24
DIARRHEA
Diagnostics - Only in __________ cases
Treatment - Depends on cause
- Fluid & Electrolytes
- Acid/base imbalance – severe cases
Safety - ___________!
Diagnostics - Only in prolonged cases
Treatment - Depends on cause
- Fluid & Electrolytes
- Acid/base imbalance – severe cases
Safety - Hypotension!
25
_______________ - defined by difficult or infrequent stools, hard, dry stools, stools that are difficult to pass, or feelings of incomplete evacuation
CONSTIPATION
26
Common causes of constipation
- ___________
- Insufficient dietary _______
- Decreased physical activity
- Ignoring urge to defecate
- Dehydration
- Insufficient dietary fiber
- Decreased physical activity
- Ignoring urge to defecate
27
CONSTIPATION
A ___________ in the frequency of bowel movements from what is “normal” for the individual
Hard, difficult-to-pass stools; decrease in stool volume; and/or _________ of feces in the rectum
A decrease in the frequency of bowel movements from what is “normal” for the individual
Hard, difficult-to-pass stools; decrease in stool volume; and/or retention of feces in the rectum
28
IBS - Chronic abd discomfort/pain and alterations between:
constipation and diarrhea
29
IBS Has no known organic cause at this time - symptoms intermittent
- Abdominal pain
- Diarrhea or constipation
- Abdominal distention
- Excessive flatulence
- Bloating
- Urgency
- Sensation of incomplete evacuation
- Abdominal pain
- Diarrhea or constipation
- Abdominal distention
- Excessive flatulence
- Bloating
- Urgency
- Sensation of incomplete evacuation
30
IBS
Diagnosed based on symptoms
No single treatment
- Depends on presentation / symptoms
- Avoid ________/____________ that cause/contribute
- Psychosocial factors are important to treatment
- Cognitive Behavior Therapy and ________ management
- Depends on presentation / symptoms
- Avoid foods/situations that cause/contribute
- Psychosocial factors are important to treatment
- Cognitive Behavior Therapy and stress management
31
IRRITABLE BOWEL SYNDROME (IBS) Diagnosis
- Rule out other causes
Rome criteria III
- ____ months of abdominal pain with:
--- Relieved with _____________
--- Onset associated with _________ in stool frequency
--- Onset associated with a __________ in stool appearance
- 3 months of abdominal pain with:
--- Relieved with defecation
--- Onset associated with change in stool frequency
--- Onset associated with a change in stool appearance
32
GERD
-Common problem
-Chronic symptom of ___________ damage
-Not a disease, but a __________
-No one single cause
-Results when defenses of lower esophagus are overwhelmed by _______________________ gastric contents into lower esophagus
-Common problem
-Chronic symptom of mucosal damage
-Not a disease, but a syndrome
-No one single cause
-Results when defenses of lower esophagus are overwhelmed by reflux of acidic gastric contents into lower esophagus
33
GERD Predisposing factors
- Incompetent lower esophageal sphincter (LES)
- Decreased LES pressure
- Increased intraabdominal pressure
- Hiatal hernia
- Incompetent lower esophageal sphincter (LES)
- Decreased LES pressure
- Increased intraabdominal pressure
- Hiatal hernia
34
GERD
Incompetent _____
- Primary factor in GERD
- Results in ↓ pressure in distal portion of esophagus
- Gastric contents move from stomach to esophagus
- Can be due to certain foods (caffeine, chocolate) and drugs (_______________)
Incompetent LES
- Primary factor in GERD
- Results in ↓ pressure in distal portion of esophagus
- Gastric contents move from stomach to esophagus
- Can be due to certain foods (caffeine, chocolate) and drugs (anticholinergics)
35
GERD SYMPTOMS
_____________
- Most common clinical manifestation
- Burning, tight sensation felt beneath lower sternum and spreading upward to throat or jaw
- Felt intermittently
Other symptoms of GERD
- Dyspepsia
- Regurgitation
- Described as hot, bitter, or sour liquid coming into throat or mouth
GERD-related ________________
- Described as burning, squeezing
- Radiating to back, neck, jaw, or arms
- Can mimic angina
- More common in older adults with GERD
- Relieved with antacids
Heartburn
- Most common clinical manifestation
- Burning, tight sensation felt beneath lower sternum and spreading upward to throat or jaw
- Felt intermittently
Other symptoms of GERD
- Dyspepsia
- Regurgitation
- Described as hot, bitter, or sour liquid coming into throat or mouth
GERD-related chest pain
- Described as burning, squeezing
- Radiating to back, neck, jaw, or arms
- Can mimic angina
- More common in older adults with GERD
- Relieved with antacids
36
What foods can exacerbate GERD?
caffeine
chocolates
spicy foods
37
More GERD symptoms
May report respiratory symptoms
- Wheezing
- Coughing
- Dyspnea
- Nocturnal discomfort and coughing with loss of sleep
Otolaryngologic symptoms include
- Hoarseness
- Sore throat
- Globus sensation (Lump in throat)
- Hypersalivation
- Choking
May report respiratory symptoms
- Wheezing
- Coughing
- Dyspnea
- Nocturnal discomfort and coughing with loss of sleep
Otolaryngologic symptoms include
- Hoarseness
- Sore throat
- Globus sensation (Lump in throat)
- Hypersalivation
- Choking
38
GERD COMPLICATIONS
- Related to direct local effects of gastric acid on esophageal mucosa
- Esophagitis
- Inflammation of esophagus
- Frequent complication
- Repeated exposure: scar formation, esophageal stricture, dysphagia
- Related to direct local effects of gastric acid on esophageal mucosa
- Esophagitis
- Inflammation of esophagus
- Frequent complication
- Repeated exposure: scar formation, esophageal stricture, dysphagia
39
GERD COMPLICATION- Barrett’s esophagus
- __________ esophagus (esophageal metaplasia)
- Replacement of flat epithelial cells with ____________ epithelium
- Precancerous lesion
- Thought to be primarily due to GERD
- Diagnosed in ________ % of patients with chronic reflux
- Signs and symptoms: none to perforation
- Must be monitored every 2–3 years by endoscopy
Barrett’s esophagus
- Barrett’s esophagus (esophageal metaplasia)
- Replacement of flat epithelial cells with columnar epithelium
- Precancerous lesion
- Thought to be primarily due to GERD
- Diagnosed in 5% to 20% of patients with chronic reflux
- Signs and symptoms: none to perforation
- Must be monitored every 2–3 years by endoscopy
40
GERD COMPLICATIONS - ______________
- From irritation of upper airway by secretions
- Cough
- Bronchospasm
- Laryngospasm
- Potential for asthma, bronchitis, and pneumonia
Respiratory
- From irritation of upper airway by secretions
- Cough
- Bronchospasm
- Laryngospasm
- Potential for asthma, bronchitis, and pneumonia
41
GERD COMPLICATIONS - ________ erosion
- From acid reflux into mouth
- Especially __________ teeth
Dental erosion
- From acid reflux into mouth
- Especially posterior teeth
42
GERD Diagnostics
- Upper GI ____________
- Assesses LES competence
- Biopsy of tissue
endoscopy
43
GERD - Nutritional therapy
- Avoid foods that decrease LES pressure or irritate the esophagus
- chocolate, peppermint, tomatoes, coffee, and tea
- Small, frequent meals
- Avoid certain foods (tomato-based, orange juice, cola, red wine) may irritate esophagus
- Avoid ______________ meals
- Drink fluids between meals so as to not over distend the stomach during meals
- Chewing gum and oral lozenges
- Increase saliva production may help with mild symptoms
- Avoid foods that decrease LES pressure or irritate the esophagus
- chocolate, peppermint, tomatoes, coffee, and tea
- Small, frequent meals
- Avoid certain foods (tomato-based, orange juice, cola, red wine) may irritate esophagus
- Avoid late evening meals
- Drink fluids between meals so as to not over distend the stomach during meals
- Chewing gum and oral lozenges
- Increase saliva production may help with mild symptoms
44
GERD PHARMACOLOGY - Proton pump inhibitors (PPIs)
- Decrease ______ secretion
- Promote esophageal healing in 80% to 90% of patients
- Available in prescription and OTC preps
- Example: ___________ (Prilosec)
- ___________: Most common side effect
- Long-term use or high doses of PPIs may increase risk of __________ of hip, wrist, and spine
- Associated with increased risk of C. difficile infection in hospitalized patients
- Decrease acid secretion
- Promote esophageal healing in 80% to 90% of patients
- Available in prescription and OTC preps
- Example: omeprazole (Prilosec)
- Headache: Most common side effect
- Long-term use or high doses of PPIs may increase risk of fractures of hip, wrist, and spine
- Associated with increased risk of C. difficile infection in hospitalized patients
45
Proton pump inhibitors (PPIs) and ________________ receptor (H2R) blockers are the most common and effective treatments for symptomatic GERD
histamine-2
46
GERD PHARMACOLOGY - Histamine-2 receptor (H2R) blockers
- Decrease secretion of __________
- Reduce symptoms and promote esophageal healing in ___% of patients
- Example: cimetidine
- Side effects uncommon
Histamine-2 receptor (H2R) blockers
- Decrease secretion of HCl acid
- Reduce symptoms and promote esophageal healing in 50% of patients
- Example: cimetidine
- Side effects uncommon
47
[GERD]
-PPIs are more effective in healing esophagitis than H2-receptor blockers.
-PPIs beneficial in decreasing incidence of esophageal ___________, complication of chronic GERD.
strictures
48
[GERD]
-PPI’s are available in prescription or OTC preparations. Therapy should start with __________ dosing, before the first meal of the day
once a day
49
GERD PHARMACOLOGY - Antacids
- ________ but short-lived relief
- ____________ HCl acid
- Taken 1–3 hours after meals/at bedtime
- Example: Maalox, Mylanta
- Quick but short-lived relief
- Neutralize HCl acid
- Taken 1–3 hours after meals/at bedtime
- Example: Maalox, Mylanta
50
GERD SURGERY/INTERVENTIONS
-Nissen and Toupet fundoplications
-LINX Reflux Management System
> Titanium beads w/ magnetic core strung together and implanted laparoscopically into LES
-Nissen and Toupet fundoplications
-LINX Reflux Management System
> Titanium beads w/ magnetic core strung together and implanted laparoscopically into LES
51
GERD NURSING ACTIONS
-Elevate head of bed ___ degrees
-Do not ___________ for 2–3 hours after eating
-Avoid factors that cause reflux
-Stop __________
-Avoid alcohol and caffeine
-Avoid ________ foods
-Stress reduction techniques
-Weight reduction, if appropriate
-Small, frequent meals
-Elevate head of bed 30 degrees
-Do not lie down for 2–3 hours after eating
-Avoid factors that cause reflux
-Stop smoking
-Avoid alcohol and caffeine
-Avoid acidic foods
-Stress reduction techniques
-Weight reduction, if appropriate
-Small, frequent meals
52
GASTRITIS - Inflammation of ____________________
gastric mucosa
53
GASTRITIS
-One of most common problems affecting the stomach
-May be acute or chronic
-Result of a breakdown in gastric __________________
-Stomach tissue unprotected from ______________ by HCl acid and pepsin
-Diagnosed by symptoms and history
-One of most common problems affecting the stomach
-May be acute or chronic
-Result of a breakdown in gastric mucosal barrier
-Stomach tissue unprotected from autodigestion by HCl acid and pepsin
-Diagnosed by symptoms and history
54
GASTRITIS
Stomach acid and pepsin can diffuse back into the mucosa resulting in:
-Tissue ________
- ____________ of capillary walls
- With loss of plasma into gastric lumen
-Possible hemorrhage
Stomach acid and pepsin can diffuse back into the mucosa resulting in:
-Tissue edema
- Disruption of capillary walls
- With loss of plasma into gastric lumen
-Possible hemorrhage
55
GASTRITIS Risk factors
- Drugs
- Direct irritating effect on gastric mucosa
- _________ , including aspirin and corticosteroids, inhibit prostaglandin synthesis
Risk factors for NSAID-induced gastritis
- Being _________
- Being over age ____
- History of ulcer disease
- Taking anticoagulants, other NSAIDs, or ulcerogenic drugs
- Having chronic debilitating disorder
- Drugs
- Direct irritating effect on gastric mucosa
- NSAIDs, including aspirin and corticosteroids, inhibit prostaglandin synthesis
Risk factors for NSAID-induced gastritis
- Being female
- Being over age 60
- History of ulcer disease
- Taking anticoagulants, other NSAIDs, or ulcerogenic drugs
- Having chronic debilitating disorder
56
ACUTE GASTRITIS Risk factors
Diet- ____________________
Microorganisms
- __________________
- Important cause of chronic gastritis
- Promotes breakdown of gastric mucosal barrier
- Other bacterial, viral, and fungal infections may play a role
Diet- Alcoholic drinking binge and alcohol use
Microorganisms
- Helicobacter pylori
- Important cause of chronic gastritis
- Promotes breakdown of gastric mucosal barrier
- Other bacterial, viral, and fungal infections may play a role
57
ACUTE GASTRITIS S/S
Self-limiting, lasts a few hours to a few days, complete healing of mucosa expected
- Anorexia
- Nausea
- Vomiting
- Epigastric tenderness
- Feeling of fullness
- Hemorrhage
- Common with alcohol abuse
Self-limiting, lasts a few hours to a few days, complete healing of mucosa expected
- Anorexia
- Nausea
- Vomiting
- Epigastric tenderness
- Feeling of fullness
- Hemorrhage
- Common with alcohol abuse
58
CHRONIC GASTRITIS - Symptoms are similar to those of acute gastritis
-Loss of __________ factor can occur when acid-secreting cells are lost or nonfunctioning
- Essential for absorption of cobalamin (vitamin B12)
- Once body’s cobalamin stores in the liver are depleted, state of __________________ exists.
- Because it is essential for the growth and maturation of RBCs, the lack of cobalamin results in ____________________ and neurologic complications
-Loss of intrinsic factor can occur when acid-secreting cells are lost or nonfunctioning
- Essential for absorption of cobalamin (vitamin B12)
- Once body’s cobalamin stores in the liver are depleted, state of cobalamin deficiency exists.
- Because it is essential for the growth and maturation of RBCs, the lack of cobalamin results in pernicious anemia and neurologic complications
59
GASTRITIS Treatment
- Eliminating the cause
- Supportive care similar to N/V
If vomiting
- Rest
- NPO
- IV fluids
- Antiemetics
If patient is at risk for hemorrhage
-Frequent VS
- Test vomitus for blood
Focuses on evaluating and eliminating specific cause
-Cessation of alcohol intake
- Abstinence from drugs
-H. pylori irradication: antibiotics
Patient with pernicious anemia- Lifelong cobalamin therapy
- Eliminating the cause
- Supportive care similar to N/V
If vomiting
- Rest
- NPO
- IV fluids
- Antiemetics
If patient is at risk for hemorrhage
-Frequent VS
- Test vomitus for blood
Focuses on evaluating and eliminating specific cause
-Cessation of alcohol intake
- Abstinence from drugs
-H. pylori irradication: antibiotics
Patient with pernicious anemia- Lifelong cobalamin therapy
60
GASTRITIS - Lifestyle changes
Diet
Alcohol
Smoking
cessation
61
PEPTIC ULCER DISEASE (PUD) - _________________________ resulting from digestive action
of HCl acid and pepsin
Erosion of GI mucosa
62
PEPTIC ULCER DISEASE (PUD)
-About ___ million people in United States are affected by PUD in their lifetime
Ulcer development can occur in
- Lower esophagus
- Stomach
- Duodenum
- Margin of gastrojejunal anastomosis after surgical procedures
25
63
PEPTIC ULCER DISEASE (PUD)- Acute VS chronic
- Depends on degree and duration of mucosal involvement
Acute
- __________ erosion
- Minimal inflammation
- _______ duration: resolves quickly when cause is identified and removed
Chronic
- _______ duration
- ____________ wall erosion with formation of fibrous tissue
- Present continuously for many months or intermittently throughout person’s lifetime
- More common than acute erosions
Acute
- Superficial erosion
- Minimal inflammation
- Short duration: resolves quickly when cause is identified and removed
Chronic
- Long duration
- Muscular wall erosion with formation of fibrous tissue
- Present continuously for many months or intermittently throughout person’s lifetime
- More common than acute erosions
64
PUD - Gastric or duodenal - Differ in their incidence and presentation !
Gastric or duodenal - Differ in their incidence and presentation !
65
PUD - Destroyers of mucosal barrier
-___________
- Produces enzyme urease
-Urease activates immune response
- Antibody production
- Release of inflammatory cytokines
- Response to H. pylori is variable
________________
- Inhibit prostaglandin synthesis
-Increase gastric acid secretion
- Reduce integrity of the mucosal barrier
- Responsible for majority of non-H. pylori peptic ulcers
- NSAIDs in presence of H. pylori increase risk of PUD
-H. pylori
- Produces enzyme urease
-Urease activates immune response
- Antibody production
- Release of inflammatory cytokines
- Response to H. pylori is variable
Aspirin and NSAIDs
- Inhibit prostaglandin synthesis
-Increase gastric acid secretion
- Reduce integrity of the mucosal barrier
- Responsible for majority of non-H. pylori peptic ulcers
- NSAIDs in presence of H. pylori increase risk of PUD
66
PUD - other destroyers of mucosal barrier
_______________
↓ Rate of mucosal cell renewal
↓ Protective effects
Lifestyle factors
- Alcohol and coffee stimulate acid secretion
- Alcohol stimulates acid secretion.
- Coffee (caffeinated and decaffeinated) is a strong stimulant of gastric acid secretion.
- Smoking and psychologic distress
Corticosteroids
↓ Rate of mucosal cell renewal
↓ Protective effects
Lifestyle factors
- Alcohol and coffee stimulate acid secretion
- Alcohol stimulates acid secretion.
- Coffee (caffeinated and decaffeinated) is a strong stimulant of gastric acid secretion.
- Smoking and psychologic distress
67
PUD (GASTRIC ULCER)
-Occur in any portion of stomach
-Less common than duodenal ulcers
-More prevalent in women
-Peak incidence >___ years of age
-More likely than duodenal ulcers to result in obstruction
- Pain generally high in epigastrium
- 1–2 hours after meals
- “____________ ” or “gaseous”
- Food aggravates pain if ulcer has eroded through gastric mucosa
-Occur in any portion of stomach
-Less common than duodenal ulcers
-More prevalent in women
-Peak incidence >50 years of age
-More likely than duodenal ulcers to result in obstruction
- Pain generally high in epigastrium
- 1–2 hours after meals
- “Burning” or “gaseous”
- Food aggravates pain if ulcer has eroded through gastric mucosa
68
PUD Risk factors
- H. pylori
- Medications
- Bile reflux
- Alcohol use and _________ are associated with ulcer formation
- Multiple stress ulcers of the stomach, highlighted by ______, digested blood on their surfaces.
- H. pylori
- Medications
- Bile reflux
- Alcohol use and smoking are associated with ulcer formation
- Multiple stress ulcers of the stomach, highlighted by dark, digested blood on their surfaces.
69
PUD (GASTRIC ULCER) - SRMD – Stress Related Mucosal Disease
-Also called physiologic stress ulcer
-Acute ulcers that develop after major physiologic insult
- Trauma or surgery
-Also called physiologic stress ulcer
-Acute ulcers that develop after major physiologic insult
- Trauma or surgery
70
PUD (DUODENAL ULCER)
Occur at _____ age and in anyone ↑ Between ages of 35 and 45 years
-Account for ~80% of all peptic ulcers
-_________ is found in 90% to 95% of patients
-Associated with increased HCl acid secretion
Increased risk of duodenal ulcers
- COPD
- Cirrhosis of liver
- Chronic pancreatitis
- Hyperparathyroidism
- Chronic kidney disease
Occur at any age and in anyone ↑ Between ages of 35 and 45 years
-Account for ~80% of all peptic ulcers
-H. pylori is found in 90% to 95% of patients
-Associated with increased HCl acid secretion
Increased risk of duodenal ulcers
- COPD
- Cirrhosis of liver
- Chronic pancreatitis
- Hyperparathyroidism
- Chronic kidney disease
71
Duodenal ulcer pain
- _____________ region beneath xiphoid process
- Back pain—if ulcer is located located in posterior aspect
- 2–5 hours after meals
- “Burning” or “cramplike”
- Tendency to occur, then disappear, then occur again
Midepigastric
72
PUD COMPLICATIONS
Three major complications
________________
________________
________________
-All considered emergency situations
-Hemorrhage
- Perforation
- Gastric outlet obstruction
73
PUD PERFORATION
-Most _______ complication
-Common in large penetrating duodenal ulcers
-Perforated gastric ulcers often located on lesser curvature of stomach
-Mortality rate associated with perforation of ________ ulcers is higher
-Most lethal complication
-Common in large penetrating duodenal ulcers
-Perforated gastric ulcers often located on lesser curvature of stomach
-Mortality rate associated with perforation of gastric ulcers is higher
74
PUD PERFORATION Clinical manifestations
- Sudden, dramatic onset
- Initial phase (0–2 hours after perforation)
- Sudden, severe upper abdominal pain- quickly spreads throughout abdomen
- Pain radiates to the back
- Rigid, boardlike abdominal muscles
- Shallow, rapid respirations
- Tachycardia, weak pulse
- Bowel sounds absent
- Nausea/vomiting
- History of reporting symptoms of indigestion or previous ulcer
- Bacterial peritonitis may occur within 6–12 hours
- Difficult to determine from symptoms alone if gastric or duodenal ulcer has perforated
- Manifestations of peritonitis are the same
- Sudden, dramatic onset
- Initial phase (0–2 hours after perforation)
- Sudden, severe upper abdominal pain- quickly spreads throughout abdomen
- Pain radiates to the back
- Rigid, boardlike abdominal muscles
- Shallow, rapid respirations
- Tachycardia, weak pulse
- Bowel sounds absent
- Nausea/vomiting
- History of reporting symptoms of indigestion or previous ulcer
- Bacterial peritonitis may occur within 6–12 hours
- Difficult to determine from symptoms alone if gastric or duodenal ulcer has perforated
- Manifestations of peritonitis are the same
75
PUD DIAGNOSTICS
___________ with biopsy
- Most often used as it allows for direct viewing of mucosa
- Tissue specimens can be obtained to identify H. pylori and rule out stomach cancer
- Determine degree of ulcer healing after treatment
Noninvasive tests for H. pylori
- Urea breath test
- Can determine active infection
- Stool antigen test
- Serum or whole blood antibody tests
--- Immunoglobin G (IgG)
--- Will not distinguish between past and current infection
Endoscopy with biopsy
- Most often used as it allows for direct viewing of mucosa
- Tissue specimens can be obtained to identify H. pylori and rule out stomach cancer
- Determine degree of ulcer healing after treatment
Noninvasive tests for H. pylori
- Urea breath test
- Can determine active infection
- Stool antigen test
- Serum or whole blood antibody tests
--- Immunoglobin G (IgG)
--- Will not distinguish between past and current infection
76
PUD TREATMENT
Treatment regimen consists of
- Adequate rest
- Drug therapy
- Smoking cessation
- Dietary modification
- Long-term follow-up care
Generally treated in ambulatory care setting
- Pain disappears after 3–6 days
- Ulcer healing requires many weeks of therapy
- Endoscopic examination most accurate method to monitor healing
Treatment regimen consists of
- Adequate rest
- Drug therapy
- Smoking cessation
- Dietary modification
- Long-term follow-up care
Generally treated in ambulatory care setting
- Pain disappears after 3–6 days
- Ulcer healing requires many weeks of therapy
- Endoscopic examination most accurate method to monitor healing
77
PUD TREATMENT
H. pylori eradication!
Triple drug therapy (7-14 days)
- PPI
- Amoxicillin
- Clarithromycin
Quadruple drug therapy (10-14 days)
- PPI
- Bismuth
- Tetracycline
- Metronidazole
H. pylori eradication!
Triple drug therapy (7-14 days)
- PPI
- Amoxicillin
- Clarithromycin
Quadruple drug therapy (10-14 days)
- PPI
- Bismuth
- Tetracycline
- Metronidazole
78
HIATAL HERNIA
-Herniation of portion of stomach into ___________ through an opening or hiatus in diaphragm
-Also referred to as diaphragmatic hernia and esophageal hernia
-Most common abnormality found on ________ GI x-ray
-More common in older adults and ________
-Herniation of portion of stomach into esophagus through an opening or hiatus in diaphragm
-Also referred to as diaphragmatic hernia and esophageal hernia
-Most common abnormality found on upper GI x-ray
-More common in older adults and women
79
HIATAL HERNIA - 2 types
1. ________
- Stomach slides through hiatal opening in diaphragm when patient is supine, goes back into abdominal cavity when patient is standing upright
- Most __________ type
2. Paraesophageal or ________
- Fundus and greater curvature of stomach roll up through diaphragm, forming a pocket alongside the esophagus
- Paraesophageal junction remains in normal position
- Acute paraesophageal hernia is a medical emergency
1. Sliding
- Stomach slides through hiatal opening in diaphragm when patient is supine, goes back into abdominal cavity when patient is standing upright
- Most common type
2. Paraesophageal or rolling
- Fundus and greater curvature of stomach roll up through diaphragm, forming a pocket alongside the esophagus
- Paraesophageal junction remains in normal position
- Acute paraesophageal hernia is a medical emergency
80
HIATAL HERNIA
Many factors involved
- Structural changes occur with aging
- Weakening of muscles in diaphragm
Increased intraabdominal pressure
- Obesity
- Pregnancy
-Heavy lifting
-May be asymptomatic
Symptoms include
- Heartburn
- After meal or when lying supine
- Dysphagia
Many factors involved
- Structural changes occur with aging
- Weakening of muscles in diaphragm
Increased intraabdominal pressure
- Obesity
- Pregnancy
-Heavy lifting
-May be asymptomatic
Symptoms include
- Heartburn
- After meal or when lying supine
- Dysphagia
81
HIATAL HERNIA Diagnostics
Esophagogram (_________ swallow)
- May show protrusion of gastric mucosa through esophageal hiatus
_____________
- Visualize lower esophagus
- Information on degree of inflammation or other problems
Esophagogram (barium swallow)
- May show protrusion of gastric mucosa through esophageal hiatus
Endoscopy
- Visualize lower esophagus
- Information on degree of inflammation or other problems
81
HIATAL HERNIA - Complications
- GERD
- Esophagitis
- Hemorrhage from erosion
- Stenosis
- Ulcerations of herniated portion
- GERD
- Esophagitis
- Hemorrhage from erosion
- Stenosis
- Ulcerations of herniated portion
82
HIATAL HERNIA Treatment
Conservative Therapy
- Lifestyle modifications
- Eliminate alcohol
- Elevate head of bed
- Stop smoking
- Avoid lifting/straining
- Reduce weight, if appropriate
- Use antisecretory agents and antacids
Surgical Therapy - Goals
- Reduce hernia
- Provide acceptable lower esophageal sphincter (LES) pressure
- Prevent movement of gastroesophageal junction
Conservative Therapy
- Lifestyle modifications
- Eliminate alcohol
- Elevate head of bed
- Stop smoking
- Avoid lifting/straining
- Reduce weight, if appropriate
- Use antisecretory agents and antacids
Surgical Therapy - Goals
- Reduce hernia
- Provide acceptable lower esophageal sphincter (LES) pressure
- Prevent movement of gastroesophageal junction
83
UPPER GI BLEED - EMERGENCY!
-Each year, 300,000 hospital admissions for UGI bleeding
-Approximately 60% of patients are older than 65 years
-Mortality rate has been ________% for past 45 years
-Most serious loss of blood from UGI characterized by sudden onset
-Insidious occult bleeding can be a major problem
Severity depends on bleeding origin
- Venous
- Capillary
- Arterial
-Each year, 300,000 hospital admissions for UGI bleeding
-Approximately 60% of patients are older than 65 years
-Mortality rate has been 6% to 13% for past 45 years
-Most serious loss of blood from UGI characterized by sudden onset
-Insidious occult bleeding can be a major problem
Severity depends on bleeding origin
- Venous
- Capillary
- Arterial
84
Types of UGI bleeding
_________ bleeding
- Hematemesis
- Bloody vomitus
- Appears fresh, bright red blood or “coffee grounds”
_________
- Black, tarry stools
- Caused by digestion of blood in GI tract
- Black appearance—due to iron
__________ bleeding
- Small amounts of blood in gastric secretions, vomitus, or stools
- Undetectable by appearance
- Detectable by guaiac test
Obvious bleeding
- Hematemesis
- Bloody vomitus
- Appears fresh, bright red blood or “coffee grounds”
Melena
- Black, tarry stools
- Caused by digestion of blood in GI tract
- Black appearance—due to iron
Occult bleeding
- Small amounts of blood in gastric secretions, vomitus, or stools
- Undetectable by appearance
- Detectable by guaiac test
85
UGI BLEED CAUSES
Chronic esophagitis
- GERD
- Mucosa-irritating drugs
- Smoking
- Alcohol use
-Mallory-Weiss tear
-Esophageal varices
-Peptic ulcer disease - Bleeding ulcers account for 40% of cases of UGI bleeding
-Drugs - Aspirin, NSAIDs, corticosteroids
-Stress-related mucosal disease (SRMD) AKA physiologic stress ulcers
- Most common in critically ill patients
- Severe burns, trauma, or major surgery
- Patients with coagulopathy on mechanical ventilation
Chronic esophagitis
- GERD
- Mucosa-irritating drugs
- Smoking
- Alcohol use
-Mallory-Weiss tear
-Esophageal varices
-Peptic ulcer disease - Bleeding ulcers account for 40% of cases of UGI bleeding
-Drugs - Aspirin, NSAIDs, corticosteroids
-Stress-related mucosal disease (SRMD) AKA physiologic stress ulcers
- Most common in critically ill patients
- Severe burns, trauma, or major surgery
- Patients with coagulopathy on mechanical ventilation
86
UGI BLEED DIAGNOSTICS
-______________ - Primary tool for diagnosing source of upper GI bleeding and TREATING!
Laboratory studies
- Complete blood cell count (CBC)
- Blood urea nitrogen (BUN)
- Serum electrolytes
- Prothrombin time, partial thromboplastin time
- Liver enzyme measurements
-ABG measurements
- Typing/cross matching for possible blood transfusions
- Test vomitus/ stools for presence of gross and occult blood
-Endoscopy - Primary tool for diagnosing source of upper GI bleeding and TREATING!
Laboratory studies
- Complete blood cell count (CBC)
- Blood urea nitrogen (BUN)
- Serum electrolytes
- Prothrombin time, partial thromboplastin time
- Liver enzyme measurements
-ABG measurements
- Typing/cross matching for possible blood transfusions
- Test vomitus/ stools for presence of gross and occult blood
87
Esophageal varices & PUD can cause ________________ BLEED
UPPER GI
88
UPPER GI BLEED assessment
Immediate physical examination with focus on
- BP
- Rate and character of pulse
- Peripheral perfusion with capillary refill
- Neurologic status
- Indwelling urinary catheter for assessment of hourly output
- Hemodynamic monitoring for accurate blood pressure assessment
- Central venous pressure line for assessment of fluid volume status
- Supplemental oxygen
Abdominal examination
- Presence or absence of bowel sounds
- Tense, rigid, boardlike abdomen: may indicate perforation and peritonitis
Immediate physical examination with focus on
- BP
- Rate and character of pulse
- Peripheral perfusion with capillary refill
- Neurologic status
- Indwelling urinary catheter for assessment of hourly output
- Hemodynamic monitoring for accurate blood pressure assessment
- Central venous pressure line for assessment of fluid volume status
- Supplemental oxygen
Abdominal examination
- Presence or absence of bowel sounds
- Tense, rigid, boardlike abdomen: may indicate perforation and peritonitis
89
UPPER GI BLEED - Signs/symptoms of ______
- Low BP
- Rapid, weak pulse
- Increased thirst
- Cold, clammy skin
- Restlessness
SHOCK
- Low BP
- Rapid, weak pulse
- Increased thirst
- Cold, clammy skin
- Restlessness
90
UPPER GI BLEED - NURSING
-Place IV lines - preferably 2, with 16- or 18-guage needle for fluid and blood replacement
-Administer fl uid and blood replacement as ordered
-Evaluate LOC
-VS every 15–30 minutes
-Skin color
-Capillary refill
-Abdominal distention, guarding, peristalsis
-NG tube placement
-Accurate I/O record
- Record urine output hourly
- At least _____ mL/kg/hr indicates adequate renal perfusion
-Measure urine specific gravity
-Maintain NG patency and position
-Observe older adults and patients with history of cardiovascular problems closely
-- ECG monitoring; Vital signs
-Place IV lines - preferably 2, with 16- or 18-guage needle for fluid and blood replacement
-Administer fl uid and blood replacement as ordered
-Evaluate LOC
-VS every 15–30 minutes
-Skin color
-Capillary refill
-Abdominal distention, guarding, peristalsis
-NG tube placement
-Accurate I/O record
- Record urine output hourly
- At least 0.5 mL/kg/hr indicates adequate renal perfusion
-Measure urine specific gravity
-Maintain NG patency and position
-Observe older adults and patients with history of cardiovascular problems closely
-- ECG monitoring; Vital signs
91
UPPER GI BLEED Medications
- IV _____
- Somatostatin or somatostatin analog octreotide
-Used for upper GI bleeding
--- Reduces blood flow to GI organs and acid secretion
--- Given in IV boluses for 3–7 days after onset of bleeding
-H & H
-Coags
- IV PPI
- Somatostatin or somatostatin analog octreotide
-Used for upper GI bleeding
--- Reduces blood flow to GI organs and acid secretion
--- Given in IV boluses for 3–7 days after onset of bleeding
-H & H
-Coags
92
Appendicitis - Inflammation of the appendix
-May be difficult to diagnose
Commons symptoms
- Dull, periumbilicus pain
-Anorexia
- Nausea
- Vomiting
- Slight fever
- Pain is persistent – eventually shifts to RLQ
- Rebound tenderness
Inflammation of the appendix
-May be difficult to diagnose
Commons symptoms
- Dull, periumbilicus pain
-Anorexia
- Nausea
- Vomiting
- Slight fever
- Pain is persistent – eventually shifts to RLQ
- Rebound tenderness
93
APPENDICITIS Diagnostics
- __________ exam
- ___ scan
- Labs – WBC (slightly elevated)
- Physical exam
- CT scan
- Labs – WBC (slightly elevated)
94
APPENDICITIS Complications – Serious!
- __________ – pain resolves
- ___________ !
- Rupture – pain resolves
- Peritonitis!
95
PERITONITIS - Local or generalized inflammation of:
the peritoneum
96
PERITONITIS
Signs and Symptoms
- ABD pain
- Tenderness
- Muscular rigidity – board like abdomen
- ABD spasms
- ABD distention
- Fever; tachycardia; tachypnea; n/v; altered bm’s
Complications
- Hypovolemic shock
- Sepsis!!!
- Abscess
- Paralytic ileus
- Acute respiratory distress syndrome
Signs and Symptoms
- ABD pain
- Tenderness
- Muscular rigidity – board like abdomen
- ABD spasms
- ABD distention
- Fever; tachycardia; tachypnea; n/v; altered bm’s
Complications
- Hypovolemic shock
- Sepsis!!!
- Abscess
- Paralytic ileus
- Acute respiratory distress syndrome
97
PERITONITIS
Diagnostics
- CBC
- ABD x-ray
- Ultrasound
- CT
Treatment
- IV antibiotics
- NG to suction
- IV fluids
- Surgery
Diagnostics
- CBC
- ABD x-ray
- Ultrasound
- CT
Treatment
- IV antibiotics
- NG to suction
- IV fluids
- Surgery
98
OBSTRUCTION - Intestinal contents cannot:
pass through GI tract
99
OBSTRUCTION - 2 types
___________
- Most occur in the small intestine
- Surgical adhesions are most common cause
- Hernia
- Strictures
- Colon cancer can cause obstruction in colon
_______________ - Reduced or absent peristalsis
Mechanical
- Most occur in the small intestine
- Surgical adhesions are most common cause
- Hernia
- Strictures
- Colon cancer can cause obstruction in colon
Non-mechanical - Reduced or absent peristalsis
100
OBSTRUCTION
Signs & Symptoms
- Abd pain, vomiting, distention, constipation
Assessment
- Decreased or absent bowel sounds
- Distention
- N/V
- Pain
Signs & Symptoms
- Abd pain, vomiting, distention, constipation
Assessment
- Decreased or absent bowel sounds
- Distention
- N/V
- Pain
101
OBSTRUCTION
-NPO
-NG tube for decompression
-Surgery – if perforation or strangulation
-IV fluids
-IV pain meds
Nursing
- I and O!!
- Color, consistency of NG tube (blood?)
-NPO
-NG tube for decompression
-Surgery – if perforation or strangulation
-IV fluids
-IV pain meds
Nursing
- I and O!!
- Color, consistency of NG tube (blood?)
102
DIVERTICULAR DISEASE - Saccular dilations or _______________ of the ___________ that develop in the colon
outpouchings of the mucosa
103
___________ – presence of multiple noninflammed diverticula
___________ – inflammation of one or more diverticula, which can lead to perforation, abscess, fistula, and bleeding
Diverticulosis – presence of multiple noninflammed diverticula
Diverticulitis – inflammation of one or more diverticula, which can lead to perforation, abscess, fistula, and bleeding
104
DIVERTICULAR DISEASE Signs & Symptoms
- Often ______
- Abd pain, bloating, flatulence, changes in bowel patterns
- Diverticulitis - cute pain (LLQ), n/v, fever, bloody stool
- Often none
- Abd pain, bloating, flatulence, changes in bowel patterns
- Diverticulitis - Acute pain (LLQ), n/v, fever, bloody stool
105
DIVERTICULAR DISEASE Diagnostics
- CT scan
- Labs
- ______ increased, shift to the left
- CT scan
- Labs
- WBC increased, shift to the left
106
DIVERTICULAR DISEASE
Treatment
-Acute = hospitalization
- PO/IV antibiotics
- IV fluids
-______ bowel – NPO and/or clear liquids
Nursing
- Diet – High ______ , increased fluids, stool softeners (avoid constipation),
- Education on disease
Treatment
-Acute = hospitalization
- PO/IV antibiotics
- IV fluids
-Rest bowel – NPO and/or clear liquids
Nursing
- Diet – High fiber, increased fluids, stool softeners (avoid constipation),
- Education on disease
107
4 types of hernias :
- Inguinal – most common
- Umbilical
- Femoral
- Ventral/incisional
108
HERNIAS Signs & Symptoms
- ______ – worsens with activities that increase abd pressure
- May be visible or not
Pain
109
HERNIAS Treatment
- ____________ (herniorrhaphy or hernioplasty)
- Emergency if its is “strangulated”
- Blood supply to the herniated bowel is cut off/decreased
- Surgical (herniorrhaphy or hernioplasty)
- Emergency if its is “strangulated”
- Blood supply to the herniated bowel is cut off/decreased
110
IBD - Characterized by chronic, recurrent _________________________
- Periods of remission are interspersed with periods of exacerbation
- Exact cause is unknown; no cure
-On the basis of clinical manifestations, IBD is classified as either
Ulcerative colitis
- Inflammation and ulceration of colon and rectum
Crohn’s disease
- Inflammation of any segment of GI tract from mouth to anus
IBD - Characterized by chronic, recurrent inflammation of intestinal tract
- Periods of remission are interspersed with periods of exacerbation
- Exact cause is unknown; no cure
-On the basis of clinical manifestations, IBD is classified as either
Ulcerative colitis
- Inflammation and ulceration of colon and rectum
Crohn’s disease
- Inflammation of any segment of GI tract from mouth to anus
111
IBD May occur at any age
- Commonly occur during teenage years and __________________
- Second peak in sixth decade
- Commonly occur during teenage years and early adulthood
- Second peak in sixth decade
112
IBD - autoimmune disease
- Involves an ___________ reaction to a person’s own intestinal tract
- Some agent(s) triggers an ___________, inappropriate, sustained immune response
- Results in widespread ____________ and tissue destruction
- Involves an immune reaction to a person’s own intestinal tract
- Some agent(s) triggers an overactive, inappropriate, sustained immune response
- Results in widespread inflammation and tissue destruction
113
IBD Signs & Symptoms
- Diarrhea
- Weight loss
- Abdominal pain
- Fever
- Fatigue
- Diarrhea
- Weight loss
- Abdominal pain
- Fever
- Fatigue
114
Although the manifestations of Crohn’s disease and ulcerative colitis are similar (diarrhea, weight loss, abdominal pain, fever, and fatigue), there are differences.
In Crohn's disease, diarrhea and cramping abdominal pain are common symptoms. If the small intestine is involved, weight loss occurs from inflammation of the small intestine causing
_________________ .
Rectal bleeding more __________ with ulcerative colitis.
Although the manifestations of Crohn’s disease and ulcerative colitis are similar (diarrhea, weight loss, abdominal pain, fever, and fatigue), there are differences.
In Crohn's disease, diarrhea and cramping abdominal pain are common symptoms. If the small intestine is involved, weight loss occurs from inflammation of the small intestine causing malabsorption.
Rectal bleeding more common with ulcerative colitis.
115
In ulcerative colitis, the primary manifestations are __________________________
Pain may vary from the mild lower abdominal cramping associated with diarrhea to severe, constant pain associated with acute perforations.
bloody diarrhea and abdominal pain.
116
Ulcerative Colitis
- Mild: diarrhea may consist of _____ semiformed stools daily that contain small amounts of blood. The patient may have no other manifestations.
- Moderate: (______ stools/day), increased bleeding, & systemic symptoms (fever, malaise, mild anemia, anorexia).
- Severe: _______ x diarrhea, bloody, contains mucus; fever, rapid weight loss greater than 10% of total body weight, anemia, tachycardia, and dehydration are present
- Mild: diarrhea may consist of 1-4 semiformed stools daily that contain small amounts of blood. The patient may have no other manifestations.
- Moderate: (up to 10 stools/day), increased bleeding, & systemic symptoms (fever, malaise, mild anemia, anorexia).
- Severe: 10-20x diarrhea, bloody, contains mucus; fever, rapid weight loss greater than 10% of
total body weight, anemia, tachycardia, and dehydration are present
117
IBD COMPLICATIONS
- Hemorrhage
- Strictures
- Perforation (with possible peritonitis)
- Abscesses
- Fistulas
- CDI (c-diff infections)
- Colonic dilation (toxic megacolon)
-High risk for colorectal cancer
-Systemic complications- Joint, eye, mouth, kidney, bone, vascular, and skin problems
--- Circulating cytokines trigger inflammation
-Liver failure
- Hemorrhage
- Strictures
- Perforation (with possible peritonitis)
- Abscesses
- Fistulas
- CDI (c-diff infections)
- Colonic dilation (toxic megacolon)
-High risk for colorectal cancer
-Systemic complications- Joint, eye, mouth, kidney, bone, vascular, and skin problems
--- Circulating cytokines trigger inflammation
-Liver failure
118
IBD Diagnostics
History and physical examination
- Blood studies
-- CBC (iron deficiency due to blood loss)
-- Serum electrolyte levels
-- Serum protein levels (hypoalbuminemia – poor nutrition)
Stool examination- Pus. Blood, Mucus
Stool cultures
Imaging studies
-Double-contrast barium enema study
- Small bowel series
- Transabdominal ultrasonography
- CT; MRI
Colonoscopy
History and physical examination
- Blood studies
-- CBC (iron deficiency due to blood loss)
-- Serum electrolyte levels
-- Serum protein levels (hypoalbuminemia – poor nutrition)
Stool examination- Pus. Blood, Mucus
Stool cultures
Imaging studies
-Double-contrast barium enema study
- Small bowel series
- Transabdominal ultrasonography
- CT; MRI
Colonoscopy
119
Goals of treatment of IBD
- ______ the bowel
- Control _______________
- Combat infection
- Correct malnutrition
- Alleviate stress
- Relieve symptoms
- Improve quality of life
- Rest the bowel
- Control inflammation
- Combat infection
- Correct malnutrition
- Alleviate stress
- Relieve symptoms
- Improve quality of life
120
IBD PHARMACOLOGY
Goals of drug treatment are to induce and maintain remission
- Aminosalicylates
- Antimicrobials
-Corticosteroids
- Immunosuppressants
-Biologic and targeted therapy
Drug selection depends on severity and location of inflammation
_______ approach
- Less toxic therapies first- More toxic medications started when initial therapies do not work
_________ approach
Uses biologic and targeted therapy first
Goals of drug treatment are to induce and maintain remission
- Aminosalicylates
- Antimicrobials
-Corticosteroids
- Immunosuppressants
-Biologic and targeted therapy
Drug selection depends on severity and location of inflammation
Step-up approach
- Less toxic therapies first- More toxic medications started when initial therapies do not work
Step-down approach
Uses biologic and targeted therapy first
121
IBD PHARMACOLOGY
-Medications containing 5-ASA (5- aminosalicylic acid)
- Mainstay in achieving and maintaining remission and preventing flare-ups of IBD
- Sulfasalazine (Azulfidine)
- New generation of sulfa-free drugs
- Olsalazine (Dipentum)
- Mesalamine (Pentasal)
* The exact mechanism of action of 5-ASA is unknown, but _____________ proinflammatory cytokines and other inflammatory mediators.
_____________
- Decrease inflammation
- Used to achieve remission
- Helpful for acute flare-ups
-Medications containing 5-ASA (5- aminosalicylic acid)
- Mainstay in achieving and maintaining remission and preventing flare-ups of IBD
- Sulfasalazine (Azulfidine)
- New generation of sulfa-free drugs
- Olsalazine (Dipentum)
- Mesalamine (Pentasal)
* The exact mechanism of action of 5-ASA is unknown, but suppresses proinflammatory cytokines and other inflammatory mediators.
Corticosteroids
- Decrease inflammation
- Used to achieve remission
- Helpful for acute flare-ups
122
IBD PHARMACOLOGY - Immunosuppressants
- Suppress immune response
- Maintain remission after corticosteroid induction therapy
- Require regular CBC monitoring
Biologic and targeted therapies
______ (antitumor necrosis factor) agents
- Infliximab (Remicade)
- Adalimumab (Humira)
- Certolizumab pegol (Cimzia)
- Golimumab (Simponi)
_________ receptor antagonists
- Natalizumab (Tysabri)
- Vedolizumab (Entyvio)
IBD PHARMACOLOGY - Immunosuppressants
- Suppress immune response
- Maintain remission after corticosteroid induction therapy
- Require regular CBC monitoring
Biologic and targeted therapies
TNF (antitumor necrosis factor) agents
- Infliximab (Remicade)
- Adalimumab (Humira)
- Certolizumab pegol (Cimzia)
- Golimumab (Simponi)
Integrin receptor antagonists
- Natalizumab (Tysabri)
- Vedolizumab (Entyvio)
123
IBD NUTRITION - Dietary consultant
Goals of diet management
1. Provide adequate nutrition without exacerbating symptoms
2. Correct and prevent ___________
3. Replace fluid and _________ losses
4. Prevent weight loss
Nutritional deficiencies are due to
- Decreased oral intake
- _______ loss
- ____________ of nutrients
- Depends on location of inflammation
Goals of diet management
1. Provide adequate nutrition without exacerbating symptoms
2. Correct and prevent malnutrition
3. Replace fluid and electrolyte losses
4. Prevent weight loss
Nutritional deficiencies are due to
- Decreased oral intake
- Blood loss
- Malabsorption of nutrients
- Depends on location of inflammation
124
IBD NUTRITION - Medications can contribute to nutritional problems
Sulfasalazine - Daily folic acid supplements
Corticosteroids - __________ supplements to prevent osteoporosis; Potassium supplements
Vitamin ___ deficiency is common
Sulfasalazine - Daily folic acid supplements
Corticosteroids - Calcium supplements to prevent osteoporosis; Potassium supplements
Vitamin D deficiency is common
125
IBD NUTRITION
During acute exacerbations
- Regular diet may not be tolerated
- Liquid __________ feedings are preferred
---High in calories and nutrients
---__________ free
--- Easily absorbed
- Regular foods are reintroduced gradually
During acute exacerbations
- Regular diet may not be tolerated
- Liquid enteral feedings are preferred
---High in calories and nutrients
---Lactose free
--- Easily absorbed
- Regular foods are reintroduced gradually
126
IBD SURGICAL TREATMENT
Exacerbations are debilitating and frequent
- Massive bleeding, Perforation, Strictures and/or obstruction, Tissues changes indicating dysplasia or carcinoma
-Surgery is indicated if treatment fails
Procedures for chronic ulcerative colitis
- Total protocolectomy with ileal pouch/anal anastomosis
- Total protocolectomy with permanent ileostomy
--- Can be performed laparoscopically
Exacerbations are debilitating and frequent
- Massive bleeding, Perforation, Strictures and/or obstruction, Tissues changes indicating dysplasia or carcinoma
-Surgery is indicated if treatment fails
Procedures for chronic ulcerative colitis
- Total protocolectomy with ileal pouch/anal anastomosis
- Total protocolectomy with permanent ileostomy
--- Can be performed laparoscopically
127
IBD SURGICAL TREATMENT
Total proctocolectomy with ileal pouch/anal anastomosis (IPAA)
- Most commonly used surgical procedure for ________________
- A diverting ileostomy is performed
- An ileal pouch is created and anastomosed directly to anus
Total proctocolectomy with ileal pouch/anal anastomosis (IPAA)
- Most commonly used surgical procedure for ulcerative colitis
- A diverting ileostomy is performed
- An ileal pouch is created and anastomosed directly to anus
128
IBD SURGICAL TREATMENT -
________
- Combination of two procedures
- Performed 8–12 weeks apart
- Patient able to resume control of defecation at the anal sphincter
--- Major complication: acute or chronic pouchitis
Total _________________________
- One-stage surgery
- Removal of colon, rectum, and anus with closure
- Continence is not possible
IPAA
- Combination of two procedures
- Performed 8–12 weeks apart
- Patient able to resume control of defecation at the anal sphincter
--- Major complication: acute or chronic pouchitis
Total protocolectomy with permanent ileostomy
- One-stage surgery
- Removal of colon, rectum, and anus with closure
- Continence is not possible
129
IBD SURGICAL TREATMENT - Commonly performed for complications
- Strictures
- Obstructions
- Bleeding
-Fistula
-Most patients eventually require surgery
-Disease often recurs at anastomosis site
Commonly performed for complications
- Strictures
- Obstructions
- Bleeding
-Fistula
-Most patients eventually require surgery
-Disease often recurs at anastomosis site
130
IBD SURGICAL TREATMENT - Postoperative care
Ileostomy - Monitoring of
-________ viability
- Mucocutaneous juncture
- Peristomal skin _________
- Output may be as high as 1500–1800 mL per 24 hours
Observe for
- Fluid and electrolyte imbalance
- Hemorrhage
- Abdominal _________
- Small bowel obstruction
- Dehydration
Initial drainage will be liquid
-Transient incontinence of mucus from manipulation of anal canal
- Kegel exercises
- Perianal skin care
Ileostomy - Monitoring of
-Stoma viability
- Mucocutaneous juncture
- Peristomal skin integrity
- Output may be as high as 1500–1800 mL per 24 hours
Observe for
- Fluid and electrolyte imbalance
- Hemorrhage
- Abdominal abscess
- Small bowel obstruction
- Dehydration
Initial drainage will be liquid
-Transient incontinence of mucus from manipulation of anal canal
- Kegel exercises
- Perianal skin care
131
IBD NURSING
____________ ___________
- Intermittent exacerbations and remission of symptoms can be common
- Frustration, depression, anxiety need managed
- Therapy, Stress management, Support groups
Expected Outcomes
- Decreased number of _____________
- Body weight __________ within normal range
- Freedom from pain and discomfort
- Use of effective coping strategies
Emotional support
- Intermittent exacerbations and remission of symptoms can be common
- Frustration, depression, anxiety need managed
- Therapy, Stress management, Support groups
Expected Outcomes
- Decreased number of diarrhea stools
- Body weight maintained within normal range
- Freedom from pain and discomfort
- Use of effective coping strategies
132
Hct (Hematocrit)
Male: 42% – 52%
Female: 37% – 47%
133
Hgb (Hemoglobin)
Male: 14 – 18g/dL
Female: 12 – 16g/dL
134
PT
11.0 – 12.5 seconds
135
INR
DVT - 1.5 -2.0
Atrial fibrillation - 2.0 – 3.0
Prosthetic valve - 3.0 – 4.0
136
____________ is a protein in your red blood cells that carries oxygen to your body's organs and tissues and transports carbon dioxide from your organs and tissues back to your lungs
Hemoglobin
137
Prothrombin time (PT) evaluates:
ability to clot
138
international normalised ratio (INR) ensures that results from a ____ test are the same from one lab to another
PT
139
Partial thromboplastin time (PTT) determines if _______________ therapy is effective
blood-thinning
140
________ : Forceful ejection of partially digested particles from the Upper GI
vomiting
141
_________: feeling of discomfort in epigastric area with conscious desire to vomit; subjective complaint; usually accompanied by anorexia
nausea
142
Chemoreceptor Trigger Zone (CTZ) responds to ___________________ from drugs, toxins, and labyrinthine stimulation (e.g., motion sickness) by transmitting impulses to vomiting center
* Vomiting center in the _____________; it is a coordinated activity
Chemoreceptor Trigger Zone (CTZ) responds to chemical stimuli from drugs, toxins, and labyrinthine stimulation (e.g., motion sickness) by transmitting impulses to vomiting center
* Vomiting center in the brainstem; it is a coordinated activity
143
“coffee ground” appearance in emesis→ _________ bleeding
gastric
144
fecal odor and bile in emesis→ lower intestinal ____________
obstruction
145
NAUSEA AND VOMITING treatment
* Determine underlying cause and provide symptomatic relief first, then 🡪
* Use anti-emetic drugs
* 5-HT3 (Serotonin) receptor antagonists are effective in reducing chemotherapy-induced vomiting; ex: ondansetron (Zofran)
* May also use anticholinergic (scopolamine) and antihistamines
* IV fluid therapy! Electrolyte and fluid replacement
* Determine underlying cause and provide symptomatic relief first, then 🡪
* Use anti-emetic drugs
* 5-HT3 (Serotonin) receptor antagonists are effective in reducing chemotherapy-induced vomiting; ex: ondansetron (Zofran)
* May also use anticholinergic (scopolamine) and antihistamines
* IV fluid therapy! Electrolyte and fluid replacement
146
S/S of ___________
* Elevated HR
* Orthostatic hypotension – BP drops when standing / sitting
* General hypotension
* Skin turgor
* Dry mucous membranes
dehydration
147
DIARRHEA - At least ___ loose stools in one 24hr period
3
148
* Chronic Diarrhea🡪 More than ____ days
30
149
DIARRHEA causes
* ingesting infectious org (Bacteria, viruses) most common
* Most cases mild & last 24hrs; extreme circumstance may cause death from becoming septic
1. ________ – most common for bloody diarrhea in the US from undercooked chicken/beef/fruits and contaminated veggies
* ingesting infectious org (Bacteria, viruses) most common
* Most cases mild & last 24hrs; extreme circumstance may cause death from becoming septic
1. E.coli – most common for bloody diarrhea in the US from undercooked chicken/beef/fruits and contaminated veggies
150
C-diff needs treatment with ________________________________________
C-diff causes most serious abx-associated diarrhea
C-diff needs treatment with flagyl (metronidazole) or vancomycin (Vancocin);
C-diff causes most serious abx-associated diarrhea
151
CONSTIPATION Causes
* dehydration
* insufficient dietary fiber
* decreased physical activity
* Polypharmacy (many drugs, especially opioids)
* ignoring urge to defecate
* dehydration
* insufficient dietary fiber
* decreased physical activity
* Polypharmacy (many drugs, especially opioids)
* ignoring urge to defecate
152
CONSTIPATION Complications
1. ______________
2. Colonic _____________ – impaction
🡪 occurs in the presence of obstipation (severe constipation with no passage of gas or stool) or fecal impaction secondary to constipation perforation (life threatening)
🡪 causes severe abd pain, N/V, fever, and elevated WBC
1. Hemorrhoids
2. Colonic perforation – impaction
🡪 occurs in the presence of obstipation (severe constipation with no passage of gas or stool) or fecal impaction secondary to constipation perforation (life threatening)
🡪 causes severe abd pain, N/V, fever, and elevated WBC
153
_____ - Chronic functional disorder of the colon causing recurrent abd discomfort/pain and alterations between constipation/diarrhea
* Unknown cause; related to abnormal bowel motility, visceral hypersensitivity
* Women more than men
IBS - Chronic functional disorder of the colon causing recurrent abd discomfort/pain and alterations between constipation/diarrhea
* Unknown cause; related to abnormal bowel motility, visceral hypersensitivity
* Women more than men
154
IBS Symptoms
* Related to psychological stressors associated with depression, anxiety, panic disorders,
posttraumatic stress disorder that worsen IBS
* bloating, urgency, flatulence, abd pain/discomfort for at least 3 months
* abd pain usually subsides after BM
* Related to psychological stressors associated with depression, anxiety, panic disorders,
posttraumatic stress disorder that worsen IBS
* bloating, urgency, flatulence, abd pain/discomfort for at least 3 months
* abd pain usually subsides after BM
155
IBS
Diagnosis
* No specific physical findings; dx depends on presentation/sx (many stress-related)
Treatment
* psychologic and ________ (avoid short-chain carbs); target sx
* cognitive behavior therapy and ______ management
Dietary;
stress
156
GERD
* Results from _______________________ into LE caused by transient LES relaxation (esophageal defenses overwhelmed→ acid reflux)
* Results from reflux of stomach acid into LE caused by transient LES relaxation (esophageal defenses overwhelmed→ acid reflux)
157
GERD
* Incompetent _____ is primary cause
LES
lower esophageal sphincter
158
GERD clinical Manifestations
* _________________ most common, dyspepsia (indigestion), regurgitation, chest pain (relieved by antacids, unlike angina), burning, tight sensation, dysphagia r/t esophageal stenosis
1. dyspepsia: pain or discomfort centered in upper abdomen
2. regurgitation: hot, bitter or sour liquid comes into throat or mouth
3. respiratory symptoms: wheezing, coughing, dyspnea
Pyrosis (heartburn)
159
GERD complications
1. _____________: Inflamed esophagus. Common complication caused by ↓LES pressure allowing acidic contents through; can lead to scar formation, dysphagia
2. _____________________ (esophageal metaplasia): reversible change from one type of cell to another * flat epithelial cells in distal esophagus change into columnar epithelial cells (intestinal cells) due to prolonged exposure to acidic contents from reflux; a compensation mechanism due to acidic changes * this precancerous lesion can increase risk for esophageal
adenocarcinoma→ perforation
3. _____________: cough, bronchospasm, laryngospasm, and cricopharyngeal spasm * due to gastric secretions irritating upper airway * asthma, chronic bronchitis and pneumonia may develop from aspiration into respiratory system
4. ____________ : erosion may result from acid reflux into mouth--especially posterior teeth. Go to the dentist regularly!
1. Esophagitis: Inflamed esophagus. Common complication caused by ↓LES pressure allowing acidic contents through; can lead to scar formation, dysphagia
2. Barrett’s esophagus (esophageal metaplasia): reversible change from one type of cell to another * flat epithelial cells in distal esophagus change into columnar epithelial cells (intestinal cells) due to prolonged exposure to acidic contents from reflux; a compensation mechanism due to acidic changes * this precancerous lesion can increase risk for esophageal
adenocarcinoma→ perforation
3. Respiratory: cough, bronchospasm, laryngospasm, and cricopharyngeal spasm * due to gastric secretions irritating upper airway * asthma, chronic bronchitis and pneumonia may develop from aspiration into respiratory system
4. Dental: erosion may result from acid reflux into mouth--especially posterior teeth. Go to the dentist regularly!
160
Drugs: aid in decreasing volume and acidity of reflux, improving LES function, increasing esophageal clearance, protecting esophageal mucosa
1. _____ - “-prazoles” give before meals; decrease acid secretion, esophageal healing (90%); more effective than H2R
2. _____ blockers: reduce sx and promote esophageal healing in 50% of patients. “-tidine, give at bedtime”
3. ___________ drugs (bethanechol) increase LES pressure, improve esophageal emptying in supine position and increase gastric emptying
1. PPIs- “-prazoles” give before meals; decrease acid secretion, esophageal healing (90%); more effective than H2R
2. H2R blockers: reduce sx and promote esophageal healing in 50% of patients. “-tidine, give at bedtime”
3. cholinergic drugs (bethanechol) increase LES pressure, improve esophageal emptying in supine position and increase gastric emptying
161
HIATIAL HERNIA
* Herniation of portion of _______________________ through an opening (hiatus) in diaphragm
* most common abnormality found on x-ray exam of upper GI tract; common in older adults and occur more often in women
* Herniation of portion of stomach into esophagus through an opening (hiatus) in diaphragm
* most common abnormality found on x-ray exam of upper GI tract; common in older adults and occur more often in women
162
HIATIAL HERNIA - 2 types
Sliding (more common): stomach & gastroesophageal jx slides through opening in diaphragm when supine, then back into abdominal cavity when standing upright. Also occurs when swallowing.
Paraesophageal or Rolling: fundus & greater curvature of stomach roll up through diaphragm, forming a pocket alongside esophagus * paraesophageal junction remains in normal position at all times * acute: emergency
163
_________ - * Inflammation of gastric mucosa; may be acute or chronic
GASTRITIS
164
GASTRITIS Medications to reduce acid production:
_____ blockers “-tidine”
* Histamine receptor antagonists
* Prevents the binding of histamine to the parietal cells in stomach
* Thereby decreasing acid production
____ (long acting) “-prazole”
* Proton-pump-inhibitor
* PPI’s prevent the release of H+ (a proton) which would have normally bound
with Cl to create HCL= acid
H2
PPI
165
PEPTIC ULCER DISEASE (PUD)
______________________ from digestive action of HCl & pepsin causing epigastric pain; any portion of GI tract that has contact with gastric secretions is susceptible. 70% caused by H.Pylori
🡪 can develop in lower esophagus, stomach, duodenum, the margin of gastrojejunal
anastomosis
Erosion of mucosa from digestive action of HCl & pepsin causing epigastric pain; any portion of GI tract that has contact with gastric secretions is susceptible. 70% caused by H.Pylori
🡪 can develop in lower esophagus, stomach, duodenum, the margin of gastrojejunal
anastomosis
166
PEPTIC ULCER DISEASE (PUD) TYPES
* ________ : associated with superficial erosion and minimal inflammation; short duration
and resolves quickly when cause is identified and removed. NOT AS DEEP AS
* __________ (more common): long duration, eroding through muscular wall with
formation of fibrous tissue (scar)
* _________ : can occur in any portion of the stomach; less common than duodenal.
More common in women; more likely to result in obstruction. peak >50 y/o
* ___________ : account for about 80% of all ulcers; occur most between ages 35-45
y/o. H.pylori main cause
* Acute: associated with superficial erosion and minimal inflammation; short duration
and resolves quickly when cause is identified and removed. NOT AS DEEP AS
* Chronic (more common): long duration, eroding through muscular wall with
formation of fibrous tissue (scar)
* GASTRIC: can occur in any portion of the stomach; less common than duodenal.
More common in women; more likely to result in obstruction. peak >50 y/o
* DUODENAL: account for about 80% of all ulcers; occur most between ages 35-45
y/o. H.pylori main cause
167
PUD
Pt with H. pylori infection needs ________________
. After ulcer has healed, they can stop h2 receptor blocker and PPI therapy.
ABX and PPI
168
______________ : most common complication of PUD; duodenal ulcers account for greater percentage of upper GI bleeding episodes than gastric ulcers
Hemorrhage
169
UPPER GI BLEED
* Mortality _____ % for past 45 years
6-13
170
UPPER GI BLEED Vomitus types:
* Profuse, bright red= little/no contact with gastric Hcl secretion
* “coffee ground emesis”= blood has been in stomach for a while
* Melena (black tarry stools) indicates slow bleeding from upper GI source; ODOROUS
* occult bleeding undetectable by appearance; small amounts in gastric secretions, vomitus, or stools
* Profuse, bright red= little/no contact with gastric Hcl secretion
* “coffee ground emesis”= blood has been in stomach for a while
* Melena (black tarry stools) indicates slow bleeding from upper GI source; ODOROUS
* occult bleeding undetectable by appearance; small amounts in gastric secretions, vomitus, or stools
171
UPPER GI BLEED Complications
anemia, hypovolemia
172
A patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation is to start oral intake. Which of these should the nurse offer to the
patient?
A. A glass of orange juice
B. A dish of lemon gelatin
C. A cup of coffee with cream
D. A bowl of hot chicken broth
B. A dish of lemon gelatin
173
The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates that additional patient education about GERD is needed?
A. "I take antacids between meals and at bedtime each night."
B. "I sleep with the head of the bed elevated on 4-inch blocks."
C. "I quit smoking several years ago, but I still chew a lot of gum."
D. "I eat small meals throughout the day and have a bedtime snack.
D. "I eat small meals throughout the day and have a bedtime snack.
174
When admitting a patient with a stroke who is unconscious and unresponsive to stimuli, the nurse learns from the patient's family that the patient has a history of gastroesophageal reflux disease (GERD). The nurse will plan to do frequent assessments of the patient's
A. apical pulse.
B. bowel sounds.
C. breath sounds.
D. abdominal girth.
C. breath sounds.
[risk of aspiration]
175
A patient who is nauseated and vomiting up blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about:
A. the amount of fat in the diet.
B. history of recent weight gain or loss.
C. any family history of gastric problems.
D. use of nonsteroidal anti-inflammatory drugs (NSAIDs).
D. use of nonsteroidal anti-inflammatory drugs (NSAIDs).
176
A patient with peptic ulcer disease associated with the presence of Helicobacter pylori is treated with triple drug therapy. The nurse will plan to teach the patient about
A. sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol).
B. amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec).
C. famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix).
D. metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan).
B. amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec).
177
A patient who has had several episodes of bloody diarrhea is admitted to the emergency department. Which action should the nurse anticipate taking?
A. Obtain a stool specimen for culture.
B. Administer antidiarrheal medications.
C. Teach about adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs).
D. Provide education about antibiotic therapy
A. Obtain a stool specimen for culture.
178
A patient is hospitalized with vomiting of "coffee-ground" emesis. The nurse will anticipate
preparing the patient for:
A. endoscopy.
B. angiography.
C. gastric analysis testing.
D. barium contrast studies.
A. endoscopy.
179
A patient with a peptic ulcer who has a nasogastric (NG) tube develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen. Which action should the nurse take next?
A. Irrigate the NG tube.
B. Obtain the vital signs.
C. Listen for bowel sounds.
D. Give the ordered antacid.
B. Obtain the vital signs.
180
Twelve hours after undergoing a gastroduodenostomy (Billroth I), a patient complains of increasing abdominal pain. The patient has absent bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The most appropriate action by the nurse at this time is to:
A. notify the surgeon.
B. irrigate the NG tube.
C. administer the prescribed morphine.
D. continue to monitor the NG drainage.
A. notify the surgeon.
181
Which information will be best for the nurse to include when teaching a patient with peptic ulcer disease (PUD) about dietary management of the disease?
A. "Avoid foods that cause pain after you eat them."
B. "High-protein foods are least likely to cause pain."
C. "You will need to remain on a bland diet indefinitely."
D. "You should avoid eating many raw fruits and vegetables."
A. "Avoid foods that cause pain after you eat them."
182
Which information about a patient who has just been admitted to the hospital with nausea and vomiting will require the most rapid intervention by the nurse?
A. The patient has taken only sips of water.
B. The patient is lethargic and difficult to arouse.
C. The patient's chart indicates a recent resection of the small intestine.
D. The patient has been vomiting several times a day for the last 4 days
B. The patient is lethargic and difficult to arouse.
183
An _________ is the surgical creation of an opening called a _______that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen.
An ostomy is used when the normal elimination route is no longer possible.
An ostomy is the surgical creation of an opening called a stoma that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen.
An ostomy is used when the normal elimination route is no longer possible.
184
Surgical __________________ may be done to:
● remove cancer
● repair a perforation, fistula, or traumatic injury
● relieve an obstruction or stricture
● treat an abscess, inflammatory disease, or hemorrhage.
resection of the bowel
185
A positive McBurney's sign could mean:
appendicitis
186
_______________ results from a localized or generalized inflammatory process of the peritoneum
that occurs when organisms or chemicals enter the sterile peritoneal cavity.
It can occur when sterility is inadequate during peritoneal dialysis and when an organ perforates, releasing its contents into the peritoneal cavity.
Peritonitis results from a localized or generalized inflammatory process of the peritoneum
that occurs when organisms or chemicals enter the sterile peritoneal cavity.
It can occur when sterility is inadequate during peritoneal dialysis and when an organ perforates, releasing its contents into the peritoneal cavity.
187
* _____________ are outpouchings of the mucosa that develop in the colon.
Diverticula
188
* ____________ is the presence of multiple non inflamed diverticula
Diverticulosis
189
DIVERTICULITIS Contributing factors: lack of ______________
dietary fiber
190
DIVERTICULITIS Patient teaching:
● High-______ diet
● Decreased intake of ____ and red meat
● Weight reduction
● High-fiber diet
● Decreased intake of fat and red meat
● Weight reduction
191
* A hernia is a protrusion of tissue, such as the intestines, through an ____________________ or a weakened area in the wall of the cavity in which it is normally contained.
abnormal opening
192
If the hernia becomes _____________, the patient will have severe pain and symptoms of a bowel obstruction, such as vomiting, cramping abdominal pain, and distention. ___________________ is needed to treat a strangulated hernia.
* Laparoscopic surgery is the treatment of choice
* Herniorrhaphy or hernioplasty (mesh)
If the hernia becomes strangulated, the patient will have severe pain and symptoms of a bowel obstruction, such as vomiting, cramping abdominal pain, and distention. Emergency surgery is needed to treat a strangulated hernia.
* Laparoscopic surgery is the treatment of choice
* Herniorrhaphy or hernioplasty (mesh)
193
Ulcerative Colitis: Usually limited to the _______
colon
194
Crohn’s Disease:
* Can involve any segment of GI tract from _________________
mouth to anus
195
Ulcerative Colitis - can be cured with a total ______________ since the colon and rectum are not needed for “survival”
Crohn’s Disease - surgery is a______________ because of high recurrence rates and the risk for developing short bowel syndrome.
Ulcerative Colitis - can be cured with a total colectomy since the colon and rectum are not needed for “survival”
Crohn’s Disease - surgery is a last resort because of high recurrence rates and the risk for developing short bowel syndrome.
196
PPIs side effects-
Headache, abdominal pain, nausea, diarrhea, vomiting, flatulence
197
H2 blockers side effects-
Headache, abdominal pain, constipation, diarrhea
198
Zofran side effects-
Constipation, diarrhea, headache, fatigue, malaise, ↑ liver function tests
199
Zofran indications
Prevent nausea and vomiting
200
PPis action
acid suppression
