Shelbye's CSON Notes Blog



GI EXAM 7 OUTLINEAssessment TechniquesHistoryHealthCA, anemias, heart disease, etcDietTypes of food, amounts, time of day you eat, general appetitePersonal & familyCurrent health problemsMaybe you just don’t feel good, symptoms are vague and hard to describe to a doctorEven socioeconomic statusSome people can afford better food than others. It’s cheaper to eat McDonalds than to buy organic crapPsychosocialMaybe you get the runs when you get nervous before a testPhysical AssessmentMouth & pharynxLook at the color of the membranes, are there any lesions there, are our teeth ok, are we able to chew well, etcAbdomenInspectAuscultate Listen to bowel sounds for an entire minute to properly assessPercuss To determine the density of a body partWhen we hear a high pitch that can mean air (like in an intestine)When we hear a dull or medium pitched it means the part is solidPalpateTenderness, masses, etc…Nasogastric and Nasoenteric Tube FeedingsGiven to meet nutritional requirements when oral intake is inadequate or not possible so long as the GI tract is functioning normallyNasogastric - feeding delivered to stomachNasoenteric - feeding delivered to distal duodenum or proximal jejunum used when esophagus and stomach need to be bypassed or pt has a risk for aspirationTotal Parenteral Nutrition (TPN)Method of supplying nutrients to bodyGoal - to attain improved nutritional status, weight gain, and improve healing abilityContain H20, amino acids, glucose, vitamins, & electrolytes . Provides approx 1000 cal & 6 g nitrogen/liter of TPNMost costly of all of the supplemental feedings for your patient. Cost can get up to thousands of dollars for bagInitiate & discontinue therapy slowlyRebound hypoglycemia if done too quicklyTPN is high in glucoseMay have to have insulin by injection while on TPN to help out the pancreasCentral line for administration (usually required)Aseptic site careb/c the high glucose concentration makes it desirable to bacteria and what notDedicated IV lineThis line gets TPN and TPN only!Gastrointestinal IntubationInsertion of short or long flexible rubber or plastic tube into the stomach or intestine by way of mouth or nose.Used for: decompression of stomachlavage stomach and remove toxic substancesdiagnose GI motility and gastric analysisadminister meds and feedingstreatment for obstruction or bleedingBe sure suction equipment is avl at the bedside when you are inserting a tube in case they aspirateGastrostomyTypesStamm - temporary & permanentJaneway - permanentPercutaneous endoscopic gastrostomy (PEG)upper midline or left upper quad incision for Stamm & JanewayGastrostomy not recommended for pt w/severe GERD because risk for aspirationLaxative UseBulk Forming – Causes colon to swell and leads to stimulation of peristalsis (Metamucil)Drink lots of H2O!!Saline Agent – draws H2O into intestines and leads to stimulation of peristalsis (Milk of Mag)Lubricant – softens fecal matter (mineral oil)Not for use with mealsStimulant – irritates colon causing increase in mucosal secretions (Dulcolax)Fecal Softener – hydrates stool by increasing wetness of intestinal H2O. No laxative action. (Colace)Osmotic Agent – Cleanses colon rapidly and induces diarrhea (Colyte)Laboratory AssessmentCBCLooking for anemias, infectionsSerum electrolytesLooking for depletions or excessive amounts of these guysWatch K with vomiting! Know This!Clotting factorsLiver functionAmylase and Lipase, will be elevated in problems like pancreatitisUrine Looking for billiruben Stool (FOBT)Fecal Occult Blood TestNot expensive, can be done at homeLooking for blood in your pooRadioGraphic TestsUpper GI seriesTo dx ulcers, tumors, varices, anatomic or functional derangement, malabsorption Pt prepNPO for 8 hours before testNo use of opiods or anticholinergic drugs for 24 hrs prior to exam – decreases motilityNo smoking morning of exam (can stimulate gastric motility)May need laxatives after the procedureLower GI series (Barium enema)Patient PreparationMeasures necessary to empty, clean bowelClear liquids evening beforePotent laxative evening beforeNPO p MNCleansing enemas till clear unless contraindicatedDetects stuff in the colonGastric AnalysisBasal Gastric secretionMeasures HCL acid secreted between mealsGastric stimulation testDone if small amounts of secretions collected with basal gastric secretion testHistalog give SC. Specimens collected at 15 minute intervalsDecreased gastric secretion suggests gastric carcinomaIncreased levels indicate Zollinger-Ellison syndrome and duodenal ulcersUpper GI Endoscopy (EGD)Allows direct visualization of gastric mucosa through lighted endoscopeUsed to detect esophageal, gastric, or duodenal abnormalitiesFiberscope is flexible, fiberoptic lens, can take color photosERCP - retrieves CBD stonesPatient PrepNPO p MN or 8-12 hours pre-procedureConscious sedationAtropine to dry secretionsLocal anesthetic to depress gag reflexFollow up care:Instruct pt not to eat or drink until gag reflex returns (1-2 hrs) to prevent aspirationObserve for bowel perforation (abdominal pain, unusual swallowing, rectal bleed, distension, temp, HRLozenges, saline gargle for minor throat irritation Lower GI EndoscopyProctosigoidoscopy Direct view of lower bowel via instruments (rigid or flexible)Can detect ulceration, polyps, tumors, or other pathological conditionsPolyps & cancer most often found in left side of colonIndications for sigmoidoscopy: rectal bleeding, positive occult blood & anemia with negative BEFlexible sigmoidoscopy can view 16-20" from anusrecommended as screening at age 50 the repeat in 1 year then q 3 yearsPatient prepLiquid diet for 24 hours priorCleansing enemasLaxative may be givenProcedure Left side, knee chest positionNo sedationMay biopsy, remove polypsColonoscopyDirect visual inspection of entire colonUsed as diagnostic aid for removal of foreign bodies, polyps, or tissue for biopsyPatient PrepLimit intake to liquids for at least 24 hrsNPO p MNMay order laxatives, suppositories, enemas Golytely given day prior to evacuate bowelRemember, you lose Na and K when you’re on laxatives…ProcedureLeft side w/legs drawn upDiscomfort from instilling air to open colonConscious sedationMay obtain specimensPerforation & hemorrhage possible but rareFollow up careFullness, cramping, flatus is normal for several hoursObserve for excessive bleeding, s/s perforationOther Diagnostic ProceduresAbdominal Ultrasound (US)Non-invasive, no radiationUsed for diagnosis of choleliathiasis, cholecyctitis, appendicitisIf barium studies ordered, must follow USComputed Tomography (CT)Provides cross-sectional imagesScans liver, spleen, kidney, pancreas, and pelvic organsHigh radiation dosesIf barium studies ordered must follow CTMagnetic Resonance Imaging (MRI)Used to supplement US & CTCreates image based on the magnetic field created between machine and target structureMay induce feeling of claustrophobiaNoisyContraindicated for pt w/permanent pacemakers and defibrillators, artificial heart valves, implanted insulin pumps, TENs units, or internal metal devices (joint implants, aneurysm clips)Stool ExamsOccult blood - Hemetest Inexpensive, done at home, non invasiveCI in presence of hemorrhoidal bleedingSpecimen applied to dry paper slide- sent to MDFalse positives - diet restrictions, medicationsEat red meat, poultry, salmon, things like that right before the test. Iron, Iodines, indocin, Vit C, salcilates all give false positivesRecommended annual screening beginning at age 50Stool exams looking forColor - varies from light to dark browneffected by foods, meds, bloodConsistency & appearanceSteatorrhea - commonly due to pancreatic diseasebulky, greasy, foamy, foul in odor stool is gray and has silvery sheen Biliary obstructionacholic, light gray or clay coloredChronic ulcerative colitismucus or pus visible Constipation, obstipation or fecal impaction passage of small, dry, rocky hard masses called scybalaGeneral Care ConsiderationsHydrationBlood transfusionNutritionGastric intubationLaxative useNursing Interventions for Gastric Surgery PatientPreoperativeReduction of anxietyPatient teachingBowel prepPostoperativePain reliefMaintenance of nutritionEarly ambulationRelief of dumping syndromeConditions of the Oral Cavity (Beginning of 2nd powerpoint)Stomatitis Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth. The word "stomatitis" literally means inflammation of the mouth. Usually painful, associated with redness, swelling, and occasional bleeding from the affected area. Bad breath may also be presentAphthous stomatitis Not infectious, usually occurs on the soft palate or buccal mucosa, sides of the tongue. Shallow and very painful ulcerations of the mouth, can last for months Herpes simplexCold sore, fever blister, etc. Can last up to 20 days. Sometimes a single lesion or in clusters. Usually last 10-14 days after they erupt. Caused from a virus and can occur readily in a person that is immunosuppressed. Very contagious, hand hygiene is important Candidiasis Produces cheesy white plaque in the mouth and when rubbed off leaves a red, bleeding base on the skin. Most common is candidia albicans (sp?)DM’s can get this, immunosuppressed, steroids inhalers can cause thisTreated with antifungal meds. May see a swish and spit thing at the hospital written to prevent them from getting this if they’re on a drug that causes thisNursing ConsiderationsOral examOral hygieneCan be painful for people with mouth problemsDietary considerationsStay away from too hot or too cold foods, really spicy foods, etcDrug TherapyAntiinfectivesAntibiotics, antifungals, antivirals, chlorhexidine oral rinse, and analgesicsCancer of the Oral CavityMay occur in any part of the mouthHighly curable if found earlyAssociated w/tobacco & alcohol useSynergistic carcinogenic effect75% occurs after 60 y/o with men more often afflictedIncreasing incidence in men under 30TypesLeukoplakia Like thrush, but can’t be scraped off. White, painless places. Caused by long term irritaiton. Sometimes called “smokers patch”Erythroplakia Red, velvity lesions in the mouth. Higher degree of malignancy than leukoplakia. Most are squamous cell, grow slowly, and develop over many years. Take many years to cause symptomsOral cancerProduces few or no symptoms in the first years, no s/s. Most frequent s/s is usually a painless sore that wont heal. A lot of times since it’s painless people aren’t likely to go in and get it checked out. If it doesn’t heal in 2 weeks, go in and have it checked outLip cancerUnhealing owund on the lip. Often caused by sunlightDiagnosisPhysical examAssessment of cervical lymph nodesBiopsyMedical InterventionsResection surgeryRadical Neck dissectionRadiation and/or chemotherapy Salivary Gland DisordersSialadenitis – inflammation of a salivary glandInfectious agents – staph, strep, E. coliIrradiation – cancer therapyImmunologic disorders – HIVTumorsRelatively rareMalignant or benignGeneral Nursing Considerations for Oral DisordersOral cavity healthNutritionAirway managementCough enhancementAspiration precautionsPatient educationConditions of the EsophagusAchalasiaLoss of esophageal motilitylack of peristaltic activity of the esophagus with failure of the LES to relax in response to swallowingSymptoms are hallmark of achalasia dysphagia -1° symptom?weight lossregurgitation?coughnoncardiac chest painGastroesophageal Reflux Disease (GERD)LES not working properly allowing stomach contents to reflux into esophagusSymptomspyrosis?hoarsenessdyspepsia?dysphagia regurgitation?need clear throatInterventionsdiet and lifestyle changesavoid eating 3 hrs before bedtimestop smokingavoid fatty foods, chocolate, peppermintelevate HOB 6-8 inches on blockslose weightmedication -H2 blockers, PPIs, Reglan surgeryBarrett’s esophagus - continuous irritation to esophagus causing scarring, narrowing and stricture; precursor to esophageal cancer Hiatal HerniaOpening in the diaphragm through which the upper stomach passes, pushing up into the chest cavity TypesSliding- about 95%Signs & symptoms – slidingAssociated with refluxHeartburnRegurgitation/aspirationDysphagia Paraesophageal Signs & symptoms – paraesophageal Associated with stretching or displacementFeeling of fullness p eatingFeeling of breathlessness/suffocationNo reflux because LES is patentTreatmentsame as for GERDFrequent small feedingsDo not recline for 1 hr p mealsElevate HOBIncrease ambulationMedicationsComplications - hemorrhage, obstruction, strangulation (bowel inside can twist and then die…major problem) Surgical intervention – Nissan repairDIverticulumOutpouching of mucosa and submucosa that protrudes thru weakened musculature Zenkers - pharyngoesophageal (upper) most common type 3x more frequent in malesusually over 60 years oldSymptomsdysphagia? halitosisbelching?sour taste in mouthregurgitation of undigested foodManagementDietary ModificationsPositioningSurgical removal of diverticulumTraumaBlunt injuriesChemical burnsEndoscopy/surgeryProtracted vomitingForeign objectsWill be candidates for TPNTumorsBenign or MalignantMalignantPrimary risk factorsTobacco useAlcohol ingestionGastric refluxRapid growth and metastasis5% - 5 year survival rateSigns & symptomsPrimary symptoms – dysphagia & weight lossLump in throatFoul breathInterventionsEsophagectomy - total resection of esophagus. May use jejunum or colon to rebuild esophagusChemo and radiation for palliationGeneral Nursing Interventions for Esophageal DisordersEncourage adequate nutritional intakeDecrease risk of aspirationRelieve painProvide patient educationGeriatric ConsiderationsDrier mucous membranesDecreased salivary gland activityTaste buds reduced (esp. sweet & sour)TeethDecreased esophageal motility, gag reflexReduced stomach motilityReduced hunger contractionsDecreases HCL & enzymesDecreased absorption of nutrients & vitaminsGastrointestinal System Lecture 3Geriatric Considerations in HCL, pepsin, lipase, pancreatic enzymes more susceptible to gastroenteritisincreased symptomology in motilityincreased abdominal discomfortmay eat less due to symptoms producedGastritisGastritis - inflammation of gastric mucosamost common pathologic condition of stomachstomach mucosal barrier destroyed reducing protection from self destruction of lining (auto acid digestion)More prevalent in heavy smokers and persons who abuse ETOHAcute GastritisShort livedInfectious agentNSAID and other drug useNPO statusStressUsually heals quicklyRepeated bouts can be a precursor to ulcersChronic gastritisH. pylori infection most common causePossible autoimmune pathogenesisSurgical proceduresOther systemic disordersChronic atrophic gastritisOlder adultsOccurs thru all layers of stomachDecreased number of parietal and chief cellsClinical Manifestations of GastritisAcuteRapid onsetN/VHematemesis/gastric hemorrhageDyspepsiaAnorexiaChronicMay be vague or absentAnorexia Dyspepsia, belching, N/VFood intolerancesPernicious anemiaPernicious AnemiaVitamin B12 deficiency due intrinsic factor secretion Chronic condition and can cause neurological damage if left untreated.Intrinsic factor deficiency most common after gastrectomy and with atrophic gastritisDevelops slowly, symptoms may not be apparent until HgB falls below 8 b/dL Treatment - 1000u Vit B12 daily x 1 wk then weekly x 1 month, then monthly for life Helobacter pyloriSpawned new body of medical literatureFragile bacteria lodges in gastric mucosaProbably from contaminated foodsFound in saliva, vomitus Found in every part of the worldImplicated in most gastritis, peptic ulcer and may be predisposing to gastric CADiagnosis by endoscopy, serum for HP antibodies, breath testIf HP present and ulcers have developed treatment is Peptobismol & antibioticsEradication prevents ulcers and may lead to more rapid healing of present ulcersPeptic Ulcer DiseaseUmbrella term that refers to ulcerations in the mucosal lining of the lower esophagus, stomach, or mon causes of PUDHelicobacter pylori---number 1 causeNSAIDS (most common cause in HP (-) pt.HCLGI UlcerationDecrease in mucosal synthesis of prostaglandins decreased mucous productionIf mucosal barrier penetrated gastritis occurs with exposure to HCLChronic gastritis Small vessel injury can lead to edema, hemorrhage, or ulcerationDuodenal UlcersMost common type of ulcer – 80%Major causesH. pylori confirmed in 95-100% of patients with duodenal ulcersHypersecretion of acid & pepsin, inadequate secretion of bicarbonate by duodenumPain usually occurs 30min-2 hours after eatingOther contributing FactorsGreater number of parietal cells in gastric mucosaHigh serum gastrin levelsFailure of feedback mechanismsRapid gastric emptyingUse of NSAIDSCigarette smokingClinical ManifestationsPain as stomach emptiesNocturnal painHematemesis or melena (blood in the stool)More likely to bleed Gastric UlcersOccur in stomach – usually antral regionChronic gastritis frequently precedes ulcer formationH. pylori found in 60%-80% of patientsDecreased mucosal synthesis of prostaglandinsDuodenal reflux of bile Longer healing timeManagement of Peptic Ulcer DiseaseStress reduction & restSmoking cessationDietary modificationsMedicationsEndoscopyDrug therapyAntacidsHistamine Receptors Antagonists (H2 blockers)Antibiotics & Bismuth saltsProton Pump InhibitorsCytoprotective drugs/mucosal barrier fortifiersOther Types of UlcersZollinger-Ellison Syndrome (Gastrinoma)Hypersecretion of gastric acidMultiple duodenal ulcersResistant to standard ulcer therapy Steatorrhea TreatmentHigh dose PPIsHigh dose H2 blockersSurgery Stress Ulcersacute ulceration of duodenum or gastric areasfollow stressful event - physical traumatreated prophylactically Cushings ulcers - common w/brain traumaCurlings ulcers - frequently occurs 72 hours post burnNSAID Inducedmostly gastricoften asymptomaticRisk factors>65 y/ohigh NSAID doseslong acting NSAIDconcurrent glucocorticoid usehistory of ulcersTreatment as with other ulcers but may take longer to healNursing AssessmentGI & Vascular StatusVS, skin colorPainBowel patterns/ Bowel soundsHemoglobin & Hematocrit (H & H)Nutritional statusMedication historyCoping styleKnowledge of conditionNursing InterventionsPain reliefReduction of anxietyPatient educationDrug therapyDiet therapySymptoms of complicationsLife style modificationsNursing Interventions for Complications of PUDHemorrhageassessmenttransfusionlavage Emergency treatmentlarge bore IVtreat hypovolemic shock NG tube/lavage O2Monitor VSSurgical InterventionLess frequent due to med therapy6-10 units of blood infused in 48 hoursLife threatening hemorrhageUsed for intractable ulcersPerforation - erosion of ulcer thru gastric serosa into peritoneal cavity---surgical emergencysudden, severe upper abdominal pain with radiation to shouldersvomiting & collapseextremely tender & rigid abdomenshockPenetration - ulcer penetrates to adjacent structures such as pancreas, biliary tract----EMERGENCYpain in back & epigastric area not relieved by pain medsPyloric obstruction - distal pylorus becomes scarred from repeated ulcersNG tubeUGI or endoscopyAntrectomy or vagotomy Dumping SyndromeInfoOccurs in 15-20% following gastric surgeryPassage of food from stomach to jejunum too rapidFluid ingestion causes passage of contents to jejunumRapid distension of jejunal loopHypertonic intestinal contents draw fluid from circulating blood volume to dilute S/SVasomotor responseVertigoTachycardiaSyncopeSweating PallorPalpitationsDesire to lie downDistension responseEpigastric fullnessCrampingNauseaVomitingDiarrheaTreatment small, frequent feedingssemi-recumbant position for mealslimit CHO intakelie down 20-30 minutes after mealsno liquids with mealslimit salt to prevent further fluid shiftantispasmotic drugsGastric CancerOccurs in antrum of stomachUsually adenocarcinomas Approx 14,000 deaths per year 2x more frequent in men than womenMuch greater incidence in JapanCause - unknownPrognosis - poorDiagnosis - EGD,UGI, CT of abdomenTreatment - surgery, radiation, chemoGastrointestinal System Lecture 4Irritable Bowel SyndromeInfoOne of the most common GI problemsMore common in womenOccurs mainly in colonPathoFunctional disorder of intestinal motilityMay be related to neurologic regulatory system, infection or irritation, or a vascular or metabolic disturbancePeristaltic wave affected at specific segments of intestine No inflammation or tissue changes in intestinal mucosa**CausesCertain foods - coffee, alcohol, spicesSmokingInfections & illnessesMost common cause is psychological stressDiagnosisStool testsBarium enemaEndoscopyTreatmentChange in dietExerciseStress reductionMedicationsConditions of MalabsorptionInfoMucosal disorders (celiac sprue, Crohn’s disease, radiation enteritis)Infectious diseases -tropical sprue, small bowel intestinal overgrowth, Whipple’s disease)Luminal problems - bile acid deficiency, ZESPostoperative - gastric or intestinal surgeryNutrient uptake - lactose intoleranceSymptomsHallmark of malabsorption is loose, bulky, foul-smelling stools that have an increased fat content and are often grayish.Usually patient is weak and malnourishedVitamin and mineral deficienciesTreatmentVitamin supplementsAntibiotics if infectious causeAntidiarrheals if indicatedFluids for hydrationEducationAbdominal HerniasAnatomical LocationsInguinalUmbilicalVentral or incisional FemoralClassificationsReducibleStrangulatedIntestinal ObstructionMechanical: obstruction of lumenintussusception volvulus tumorsstricturesNonmechanical: neuromusculature disturbanceendocrine or neurological disorderssurgery –paralytic or adynamic ileusSmall Bowel ObstructionInfo85% occur in small intestineAdhesions most common cause of small bowel obstruction (SBO)Obstruction can be partial or completeSeverity depends on region, degree of occlusion, and degree of ischemiaS/SCrampy pain that is wavelike and colickyMay pass blood & mucus but no fecal matter and no flatusVomitingDehydrationAbdominal distentionShock if uncorrectedManagementDecompression of bowel with NG or small bowel tubeSurgical intervention Type depends onlocation of obstructionduration of obstructioncondition of intestine at time of surgeryLarge Bowel ObstructionInfo15% of obstruction in large bowelMost found in sigmoid colonMost common causescarcinomadiverticulitisinflammatory bowel disordersbenign tumorsS/SConstipation for several daysCrampy lower abdominal painVisualization of bowel thru abdominal wallFecal vomitingShockManagementColonoscopyCecostomy Rectal tubeUsually surgical resectionTemporary or permanent colostomy Nursing InterventionsMonitor for symptoms of obstruction worseningMaintain hydration/electrolytesPatient teaching pre-opself-careColorectal CancerInfoMost often found in elderly2nd leading cause of cancer mortality in 55-74 y/oCancer of colon more common in womenCancer of rectum more common in menS/SRight colon cancersilent diseasedull abdominal pain & melena unexplained wt lossanemiaLeft colon cancerdisturbance of bowel habitslower abdominal painblood in stools---later s/sRectal cancersensation of incomplete evacuation of stoolrectal bleedingmucus dischargeTenesmus—painful bowel movementsOther symptomsFatigue, weight loss, anemia, and bowel obstructionTreatmentSurgery to remove tumorSegmental resection with anastomosis Abdominoperineal resection with permanent sigmoid colostomyTemporary colostomyPermanent colostomyDue to improved surgical techniques, colostomies are performed on less than 1/3 of pt with colon cancerComplications of ColostomyProlapse of stoma (usually due to obesity)Perforation-due to improper stoma irrigationStoma retractionFecal impactionSkin irritationLeakage from anastomotic siteNursing InterventionsPrepare patient for surgeryProvide emotional supportProvide post op careskin carecolostomy caremanage complicationsMaintain nutrition & hydrationPolyps of Colon and RectumMass of tissue that protrudes into the lumen of the bowelCan be found anywhere in the intestinal tractClassified as neoplastic or non- neoplastic May cause rectal bleeding & abdominal painRemoved & biopsied when foundDiseases of AnorectumHemorrhoidsdilated portions of veins in the anal canalby age 50, 50% of people have theminternal or externalsymptoms are itching & pain, bright red bleeding with defecation, may have severe pain when inflamedmay thrombose Hemorrhoid TreatmentGood hygiene & avoid strainingHigh fiber dietSitz baths, ointments, analgesicsSurgeryLecture 5 StuffAppendicitisInfoAppendix serves no definite functionMost common cause of emergency surgery1-2 out of 100 young adults are effected S/SRLQ pain at McBurney’s point(half way between the umbilicus and anterior superior Iliac spine on right side.Rovsing’s Sign—palpation of LLQ causes pain on RLQ.Rebound tendernessLow grade feverElevated WBC’s usually greater 10,000Chronic Inflammatory Bowel DiseaseRegional Enteritis (Crohn’s Disease)InfoInflammation extends thru all layers of the bowel wall from the intestinal mucosa. Bowel wall thickens.S/SInsidious, abdominal pain and diarrhea. Crampy, increased pain after meals, anorexia, malnutrition, anemia.TreatmentReduce inflammationRest bowelMedications anti-inflammatory, antidiarrheals, antibioticsUlcerative ColitisInfoAffects superficial mucosa of colon.Diffuse inflammation.Begins in rectum and may involve entire colon.Bowel narrows, shortens and thickensS/SDiarrhea—10-20 per dayCramping abdominal pain, rebound tenderness.Rectal bleedingAnorexiaComplicationsPerforationMegacolon BleedingTreatment—Bowel rest, reduce inflammation, maintain nutrition.Meds—anti-inflammatoryLiver and Biliary Disorders (Lecture 6)CirrhosisInfoDiffuse fibrotic bands of connective tissue that distort the normal architecture of the liverExtensive degeneration and destruction of hepatocytes With regeneration, disorganized nodular formation developsAlterations in flow of blood et lymphHepatic CirrhosisChronic and progressiveIrreversible reaction to hepatic inflammation/necrosisAlteration in vascular system/lymphatic bile duct channelsEtiology unknown, may be genetic componentChronic HBV is #1 cause of cirrhosis in the world!Types of CirrhosisLaennec’s or alcoholic cirrhosisPostnecrotic cirrhosisBiliary cirrhosisCardiac cirrhosisClinical Manifestations of CirrhosisEarly signsGeneralized weakness---first key is the weakness!Weight lossGI symptomsAbdominal pain/liver tenderness Late signsGI bleedingJaundiceAscites Spontaneous bruising Cirrhosis InterventionsNonsurgical management Diet therapyIf going into a coma they will be on a low protein dietDrug therapyParacentesis Comfort measuresFluid and electrolyteGastric intubationEsophagogastric balloon tamponade Surgical managementJaundiceIncrease in bilirubin concentration in bloodSeen in Sclerae SkinMucus membranesLevels above 2.5 mg/dlHemolyticHepatocellular ObstructiveHereditary hyperbilirubinemiaAscitesDefinition – Accumulation of free fluid containing almost pure plasma within the peritoneal cavityPathophysiology Increased hydrostatic pressure from PH causes plasma to leak into peritoneal cavityThis decrease, + inability of damaged liver to produce albunin results in decrease in effective serum colloid osmotic pressure in circulatory systemLiver Sweat - weeping of liver plasmaDecrease of effective intravascular circulation from massive ascites may causeRenal vasoconstrictionTriggers renin-angiotension systemSodium and water retentionIncreases hydrostatic pressure and lymph formationResulting in Viscous cycle of ASCITESClinical ManifestationsIncreased abdominal girthRapid weight gainSOBStriae et distended veinsFluid et electrolye abnormalitiesBulging flanks in supine positionAssessmentAbdominal percussionfluid wave & scratch testTreatmentGoal – Negative Na balance to decrease fluid retentionDietaryAvoid High Na food500 mg Na et Diuretics if no responseVitamin supplementationDiureticsSpirinolactone (Aldactone)Complications F/E abn et encepthalopathy Salt poor albuminParacentesis – no longer std is temporaryNursingDaily measurement abdominal girthDaily weightPt teaching important due to poor pt complianceMonitor serum ammonia levelsElectrolytes et response to tx Lecture 7 StuffGallbladderInfoPear shaped bulbous sacConcentrates et stores bileCystic ductHepatic CBD CholelithiasisInfoPresence of one or more gallstonesStones form when bile hardens into stone like materialAbnormal metabolism of cholesterol/bile saltsPancreatitisInfoInflammatory process of the pancreas Self-limiting to rapidly fatalAcute et chronic formsAutodigestion of pancreas- the pancreas itself is disintegrating obstructionhypersecretion of enzymesMany times people will become diabetic bc of lack of beta cells. AssessmentLab valuesCalciumAmylaseLipaseUrine amylaseBilirubin Have severe pain so pain management is crucial.Recurring upper and abdominal pain, loose weight. And steatorrhea- big bulky greasy stools. Medical ManagementPain MgmtICURespiratoryBiliary drainageSurgical interventionPostacute mgmtGerontologic considerationChronic Pancreatis Medical ManagementPain MgmtGive the pancreas restNonsurgical exocrineendocrineSurgical pancreaticojejunostomy Pancreatic Tumors4th leading cause of cancer deathsClinical picturepain, jaundice will cause itching/dryness…need lots of good skin care. Assessment/Dx/MgmtUS/CT/ERCP/Needle asp/Tumor markersExtensive surgeryNsg Mgmtpain, skin care …Lecture 8 StuffHepatitisInfoWidespread inflammation of liver cellsMost prevalent type - viral hepatitisCan result from transfusion of contaminated blood products, exposure to infected person parenteral drug use Five major categories of virusesFormsEnteral Forms1. Hepatitis A and E2. Transmitted by fecal-oral route (hand washing techniques) Parenteral Forms1. Hepatitis B, C, D2. Transmitted through venous blood/sexual contactAcute or chronic More InfoDefinition – widespread inflammation of liver cellsCauses-Viral, Toxic, Drug-InducedTypes, ABCDE… F,GTransmission - IncubationPreventionThree PhasesPre Icteric,Icteric,Post Icteric Complications of HepatitisFulminant HepatitisFailure of liver cells to regenerateProgression of necrosisMassive hepatic necrosisSevere, often fatalChronic HepatitisInflammation lasts longer than 6 monthsClinical Manifestations of HepatitisIcteric or Illness stageFew days to few weeks laterJaundiceDark-colored urineLight-colored stoolsSteatorrhea Hepatomegaly Other sx my continueAbdominal painArthralgia/myalgia Diarrhea/constipationFever/irritabilityLethargy/malaiseNausea/vomitingGoals of Treatment for HepatitisGoalsSLOW OR HALT PROGRESSION OF LIVER DISEASEAVOID HEPATOCELLULAR CARCINOMA AND NECESSITY OF TRANSPLANTATIONTREATMENT IS NOT ALWAYS EFFECTIVE ................
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