X. GASTROINTESTINAL A. Pancreatitis · Reproduction prohibited without authorization and release by...

X. GASTROINTESTINAL

A. Pancreatitis: Auto-digestion of the Pancreas

1. Pathophysiology:

a. The pancreas has two separate functions:

1) Endocrine-_______________

2) Exocrine-_______________ enzymes

b. Two types of pancreatitis:

1) Acute: #1 cause = ________________ #2 cause = gallbladder disease

2) Chronic: #1 cause = ______________

2. S/S:

a. Pain- Does the pain increase or decrease with eating? ___________________

b. Abdominal distention/ascites (losing protein rich fluids like enzymes and blood into the abdomen) → ascites

c. Abdominal mass- swollen ___________________________

d. Rigid board-like abdomen (guarding or bleeding)

What does it mean? Bleeding that can lead to ______________________.

e. Bruising around umbilical area ____________sign; flank area Gray Turner’s sign.

f. Fever (inflammation)

g. N/V

h. Jaundice

i. Hypotension =_______________or ________________

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3. Dx:

a. Serum lipase and amylase _______

b. WBCs __________

c. Blood sugar ______________

d. ALT, AST-liver enzymes _______

e. PT, PTT___________________

f. Serum bilirubin ______

g. H/H (Hemoglobin & Hematocrit) ____________ or ___________

Why down _________________, up ____________________.

***Please note that all normal ranges for blood test depend on the lab performing the test. The values listed in this book are only to be used as a reference.

4. Tx:

a. Goal: Control pain

1) Decrease gastric secretions (___________, NGT to suction, bed rest)

Want the stomach empty and dry

2) Pain Medications:

PCA narcotics: morphine sulfate (Morphine®), hydromorphone (Dilaudid®)

fentanyl patches(Duragesic®)

b. Steroids, why? __________________________________

c. Anticholinergics, why? _____________________

benztropine (Cogentin®), diphenoxylate/atropine (Lonox®)

d. GI Protectants

1) pantoprazole (Protonix®) (proton pump inhibitor)

2) ranitidine HCI (Zantac®), famotidine (Pepcid®) (H2 receptor antagonists)

3) Antacids

e. Maintain fluid and electrolyte balance

f. Maintain nutritional status → ease into a diet

g. Insulin WHY?

__________________________

__________________________

__________________________

Normal Lab Values AST=8-40 U/L

ALT= 10-30 U/L

Normal Lab Values Hemoglobin:

Male: 14-18 g/dl (8.7-11.2) mmol/L Female: 12-16 g/dl (7.9-9.9 mmol/L)

Hematocrit:

Male: 42-52% (0.42-0.52 volume

fraction) Female: 37-47%

(0.37-0.47 volume fraction)

Normal Lab Values Amylase: 30-220 U/L Lipase: 0-110 U/L

*TESTING STRATEGY* Client with pancreatitis: Keep stomach empty and dry.

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h. Daily weights

i. Eliminate alcohol

j. Refer to AA if this is the cause.

B. Cirrhosis:

1. 4 Major Functions of the Liver:

________________ the body.

Helps your blood to __________________

The liver helps to metabolize (break down) ____________.

The liver synthesizes __________________ 2. Pathophysiology:

Liver cells are destroyed and are replaced with connective/scar tissue→ alters the ______________within the liver→ the BP in the liver goes _____, this is called portal ___________________________.

3. S/S: a. ___________, nodular liver

b. Abdominal pain – liver capsule has stretched

c. Chronic dyspepsia (GI upset)

d. Change in _____________ habits

e. Ascites

f. Splenomegaly

g. _________________ serum albumin

h. _________________ ALT & AST

i. Anemia

j. Can progress to hepatic encephalopathy/coma

*TESTING STRATEGY* If your liver is sick, your

#1 concern: Bleeding.

*TESTING STRATEGY* Never give Tylenol to people with liver

problems. Antidote for acetaminophen (Tylenol®) overdose is acetylcysteine (Mucomyst®).

*TESTING STRATEGY* When spleen is enlarged, the immune

system is involved.

*TESTING STRATEGY*

If your liver is sick, decrease the dose of medications.


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4. Dx:

a. Ultrasound

b. CT, MRI

c. Liver biopsy

Clotting studies pre-procedure: PT, INR and aPTT

Vital signs pre-procedure

How do you position this client? ________________________

Exhale and hold _____________________

Why? To get the _________________out of the way.

Post-procedure: Lie on _____________ side

Vital signs, worried about ______________________________.

5. Tx:

a. Antacids, vitamins, diuretics

b. No more ______________ (don’t need more damage)

c. I & O and daily ____________ (Any time you have ascites, you have a fluid volume problem.)

d. Rest

e. Prevent bleeding (bleeding precautions)

f. Measure abdominal girth. Why? ___________________________________

g. Paracentesis:

Removal of fluid from the __________________ cavity (ascites)

Have client void

Position ____________________________

Vital signs

With “shocky” clients, the BP goes ______ and the pulse goes ______.

h. Monitor jaundice – good ___________ care

i. Avoid _________________ - liver can’t metabolize drugs well when it’s sick.

*TESTING STRATEGY* Anytime you are pulling

fluids→ you can throw them into shock.


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j. Diet:

Decrease protein

Low Na diet

C. Hepatic Coma:

1. Pathophysiology:

a. When you eat protein, it transforms into ______________________, and the liver converts it to urea. Urea can be excreted through the kidneys without difficulty.

b. When the liver becomes impaired, it can’t make this conversion. What chemical builds up in the blood? _________________________

c. What does this chemical do to the LOC? _____________

2. S/S:

a. Minor mental changes/motor problems

b. Difficult to ______________

c. Asterixis

d. _____________________changes

e. Reflexes will decrease

f. EEG ________________________

g. What is fetor? Breath smells like _____________.

h. Anything that increases the ammonia level will aggravate the problem. i. Liver people tend to be GI bleeders.

3. Tx:

a. lactulose (decreases serum ammonia)

b. Cleansing enemas

c. Decrease _____________________________ in the diet

d. Monitor serum ammonia

Let’s Get Normal Straight First! Protein→ Breaks down to ammonia→ The Liver converts ammonia to urea→ Kidneys excrete the urea

*TESTING STRATEGY* If you give a liver client narcotics, it’s the same

thing as double dosing them.


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D. Bleeding Esophageal Varices

1. Pathophysiology:

a. High BP in the liver (_________________HTN) forces collateral circulation to form.

This circulation forms in 3 different places→ stomach, esophagus, rectum

b. When you see an alcoholic client that is GI bleeding it is usually esophageal varices.

Usually no problem until _______________

2. Tx:

a. Replace ____________

b. VS

c. CVP

d. Oxygen (any time someone is ____________, oxygen is needed)

e. octreotide (Sandostatin®) lowers BP in the liver.

f. Balloon Tamponade

Sengstaken-Blakemore Tube is a type of balloon tamponade tube.

It is an infrequently used emergency procedure that may be used to stabilize clients with severe hemorrhage. It should not be used more than 12 hours. Many of the safety implications for the Blakemore tube can be applied to other oropharynx or nasopharynx tubes.

What is the purpose? To hold ______________________ on bleeding varices

g. Cleansing enema to get rid of ________________________

h. lactulose (decreases ammonia)

i. Saline lavage to get blood out of _________________


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E. Peptic Ulcers:

1. Pathophysiology:

a. Common cause of GI ___________________________

b. Can be in the esophagus, stomach or duodenum

c. Mainly in males or females? _____________________, but increasing in _______________

d. Erosion is present

2. S/S:

a. Burning _________ usually in the mid-epigastric area/back

b. Heartburn (dyspepsia)

3. Dx:

a. Gastroscopy (EGD, endoscopy):

1) NPO pre-procedure

2) Sedated

3) NPO until what returns? _________________________

4) Watch for perforation by watching for ____________, bleeding, or if they are having trouble _______________________.

EVL or Endoscopic Sclerotherapy

EVL or Endoscopic Sclerotherapy are more commonly used for esophageal varices. EVL uses a banding procedure and Endoscopic Sclerotherapy is when the physician injects a sclerosing agent into the varices via an endoscope.


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b. Upper GI:

1) Looks at the esophagus and stomach with dye

2) NPO past midnight

3) No smoking, chewing gum, or mints. Remove the nicotine patch, too.

Smoking increases stomach ______________, which will affect the test, and

Smoking _______________ stomach secretions, which will increase the chance of aspiration.

4. Tx:

a. Medications:

1) Antacids: Liquid or tablets? _______________ (to ____________stomach)

Take when stomach is empty and at bedtime – when stomach is empty. Acid can get on ulcer… take antacid to protect ulcer.

2) Proton Pump Inhibitors: (decrease acid secretions)

omeprazole (Prilosec®), lansoprazole (Prevacid®), pantoprazole (Protonix®), esomeprazole (Nexium®)

3) H2 antagonist: ranitidine (Zantac®), famotidine (Pepcid®)

GI Cocktail (donnatal, viscous lidocaine, Mylanta II®)

Antibiotics for H. Pylori: clarithromycin (Biaxin®), amoxicillin (Amoxil®), tetracycline (Panmycin®), metronidazole (Flagyl®)

sucralfate (Carafate®): forms a barrier over the wound so acid can’t get on the ulcer.

b. Client Teaching:

Decrease _______________________________

Stop __________________________________

Eat what you can tolerate; avoid temperature extremes and extra spicy foods; avoid _____________________ (irritant).

Need to be followed for one year


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5. Classifications:

a. Gastric ulcers: malnourished: pain is usually half hour to 1 hour after meals; food doesn’t help, but ____________ does; vomit blood

b. Duodenal ulcers: well-nourished; night time pain is common and 2-3 hours after meals; __________ helps; blood in stools

F. Hiatal Hernia:

1. Pathophysiology:

a. This is when the hole in the diaphragm is too large so the __________ moves up into the thoracic cavity.

b. Main cause is a large ____________________.

c. Other causes of hiatal hernia: congenital abnormalities, trauma, and __________

2. S/S:

a. Heartburn

b. _________ after eating

c. Regurgitation

d. Dysphagia (difficulty __________________)

3. Tx:

a. Small frequent meals

b. Sit up 1 hour after eating Keep the stomach in down position.

c. Elevate HOB

d. Surgery

e. Teach life style changes and healthy diet

G. Dumping Syndrome:

1. Pathophysiology:

The stomach empties too quickly after eating and the client experiences many uncomfortable to severe side effects… usually secondary to gastric bypass, gastrectomy, or gall bladder disease.


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2. S/S:

a. Fullness

b. Weakness

c. Palpitations

3. Tx:

d. Cramping

e. Faintness

f. Diarrhea

a. Semi-recumbent with meals

b. Lie down after meals

c. No ___________ with meals (drink in between meals)

d. Meals should be small and frequent rather than large

e. Avoid foods high in _______________ and electrolytes

Carbs and electrolytes empty fast.

H. Ulcerative Colitis and Crohn’s Disease:

1. Pathophysiology:

a. Ulcerative Colitis→ ulcerative inflammatory bowel disease

Just in the large intestine

b. Crohn’s Disease→ also called Regional Enteritis; inflammation and erosion of the ________________ but it can be found anywhere in the small or large intestines.

2. S/S:

a. Diarrhea

b. Rectal bleeding

c. Weight loss

f. Dehydration

g. Blood in stools

h. Anemia

d. Vomiting

i. Rebound tenderness

e. Cramping j. Fever

What is rebound tenderness? Push in → let go→ _______________________

What does it mean? Peritoneal _____________________________

*TESTING STRATEGY* Lay on left side to keep food in the

stomach. Left side lying = Leaves it in Right side lying = Releases it


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3. Dx:

a. CT

b. Colonoscopy

_________________ liquid diet for 12-24 hours.

_________________ 6-8 hours pre-procedure

Avoid NSAIDs

Laxatives or enemas until ___________________

polyethylene glycol (Go-Lytely®)

To help your client drink a colon prep more easily, get it ____________ ______________.

Sedated for procedure

Post-op: watch for _______________________. We are going to assume the WORST! The signs of perforation are pain or unusual ________________.

c. Barium Enema

BE or lower GI series

Done if colonoscopy is incomplete.

4. Tx:

a. Diet:

High fiber or low fiber? ______________

Trying to limit GI motility to help save fluid.

Avoid cold foods, hot foods, and smoking

All of these can _______________ motility.

b. Medications:

Antidiarrheals

Only given with mildly symptomatic ulcerative colitis clients; does not work well in severe cases.

Antibiotics

Steroids (decrease_____________________)


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c. Surgery:

1) Ulcerative Colitis:

Total Colectomy (ileostomy formed)

Koch’s ileostomy or a J Pouch (no external bag)

A Koch’s Pouch has a nipple valve that opens and closes to _________intestines

The J Pouch procedure removes the colon and attaches the ileum to the rectum.

2) Crohn’s: (try not to do surgery)

May remove only the ________________ area.

The client may end up with an ileostomy or a colostomy. It just depends on the area affected.

An ostomy in the ileum is called an ________________ and an ostomy in

the colon is called a ______________________.

d. Post op Care:

1) Ileostomy Care:

It’s going to drain ___________________ all the time. Don’t have to irrigate ileostomies.

Avoid foods hard to digest and rough foods; ______________ motility.

Gatorade® or a similar electrolyte replacement drink in the summer

At risk for kidney stones (always a little _________________)

2) Colostomy Care:

What happens as waste moves through the colon? Water and nutrients are being absorbed and the _____________ is forming.

Biologics are genetically engineered medications that come from living organisms and their products, like proteins. Biologics like adalimumab (Humira®) and infliximab (Remicade®) are the newest class of medications for the treatment of UC and Crohn’s Disease. Biologics work by interfering with the body’s immune response. Biologic agents are advantageous because they act selectively, unlike steroids which tend to suppress the entire immune system.


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Colostomy → ascending and transverse→ semi __________ stools

Colostomy→ descending or sigmoid→ semi formed or ____________.

Which ones do you irrigate? __________________ & ______________

Why irrigate? ____________________________________________

When is the best time to irrigate?

Same ______________ everyday

After a __________________________

The further down the colon the stoma is, the more formed the stool will be because ________________is being drawn out. The stool is more normal.

When you are irrigating an ostomy, you use the same principles as if you were administering an enema.

Anytime you are giving an enema, if the client starts to cramp, ________

the fluids, lower the bag and/or check the _______________ of the fluid.

*TESTING STRATEGY* Positioning is very important to learn

as a brand new nurse.


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I. Appendicitis:

1. Pathophysiology:

Related to a ______________ fiber diet

2. S/S:

Generalized pain initially

Eventually localizes in the right lower quadrant (McBurney’s __________)

Rebound tenderness

Nausea and vomiting

Get good history (abdominal pain 1st then N & V)

Anorexia

3. Dx:

WBC______________

Ultrasound

CT

Do not give enemas or laxatives because you are worried about what? ________________

*TESTING STRATEGY* #1 thing to worry about is

rupture.


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4. Tx:

Surgery

Most done via laparoscope unless perforated.

After any major abdominal surgery, what is the position of choice? _____________________________

J. Total Parenteral Nutrition (TPN) Sometimes Called Hyperalimentation:

1. Nursing Considerations:

Keep refrigerated; warm for administration; let sit out for a few minutes prior to hanging.

Central line needed Filter needed

Nothing else should go through this line (dedicated line)

Discontinued gradually to avoid ___________________________

Daily ___________

May have to start taking _____________________

Blood glucose monitoring every 6 hours

Check urine (for ______________ & ______________)

Do not mix ahead- mixture changes everyday according to electrolytes.

Can only be hung for 24 hours.

Change tubing with each new bag.

IV bag may be covered with dark bag to prevent chemical breakdown.

Needs to be on a pump

Home TPN-emphasize hand washing

Most frequent complication→ _______________________________

*TESTING STRATEGY* Never want pressure on a suture line.

*TESTING STRATEGY* Protein can’t leak through the

glomerulus unless there is kidney damage.


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2. Assisting the Physician to Insert a Central Line:

Have saline available for flush; do not start fluids until positive confirmation of placement (CXR).

Position? __________________________to distend veins.

If air gets in the line, what position do you put the client in? _______________ __________________

When you are changing the tubing, how can you avoid getting air in the line?

Clamp it off

Valsalva

Take a deep ____________ and HUMMMMMM Why is an x-ray done post-insertion?

Check for __________________________________.

Make sure your client does not have a ________________________.

When an air embolus is suspected in the heart, the client may be taken to the cath lab for removal of the air.


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X. GASTROINTESTINAL A. Pancreatitis · Reproduction prohibited without authorization and release by...

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