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GICONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementGERDMay be caused by eating certain foods and taking certain medsOlder age (>50)ObesityPregnancyHiatal herniaMild to severe heartburnSour taste in morning, regurgitation, coughing, belching, chest painAtypical symptoms: asthma or coughComplications: Barrett’s esophagus/epithelium, esophageal strictures/cancerUpper endoscopy (persistent symptoms for more than 4 weeks)Other procedures: ambulatory esophageal pH, barium studiesCommon meds:Antacidshistamine 2 receptor-blockersproton pump inhibitorsPt Teaching:Eat 4-6 small meals/dayEliminate foods that decrease LES or increase acidDon’t lie down after eating (wait 4h)Meds and S/ELose weightHiatal HerniaSliding vs rollingSliding: obesity, pregnancy, intra-abd pressureRolling: can result in gastritis/ulcerationOlder age (>50)ObesityPregnancyHiatal herniaBoth types generally asymptomatic1? : reflux/heartburn, feeling full, belching, indigestionAtypical: substernal chest painUpper endoscopyAmbulatory esophageal pH monitoringBarium swallowEsophageal manometryCT/MRISame as aboveSX: increases LES pressureMost common: Nissen fundoplicationPeptic Ulcer DiseaseGastric vs DuodenalGastric – in stomach, weight loss, pain with eating, anorexia, relieved by antacidsDuodenal – in duodenum, relief from eating; will hurt after a few hours; awakens pt at nightAge 55-70 y/o (duodenal – 30-55 y/o, type O)Genetics (hyposecretors of prostaglandin in mucosal lining, hypersecretors of acid)NSAID useHypersecretion disorders (Zollinger-Ellison syndrome, hyperthyroidism, CF)SmokingCaffeine, alcohol, stressUpper abd pain – intermittent, gnawing, burning, aching, hunger-likeOlder adults: chest pain/anemiaComplications: hemorrhage - Coffee ground blood in vomitDark, tarry stoolsComplications: perforation – most serious: severe pain, peritonitis (rigid, boardlike abd)Pyloric outlet obstruction – projectile vomitingTesting for H. pyloriEndoscopy, EGD – NPO before; NPO after until gag reflex returns If H. pylori (70%), 2 ABX and PPI (and bismuth)When it’s gone, it’s gone – emphasize complianceAvoid increased acid – stress, smoking, alcohol, spicy, greasy foodGastrectomy for complications if tx fails - Deficiencies of vitamin B12, folic acid, and iron; impaired calcium metabolism; and reduced absorption of calcium and vitamin D develop as a result of partial removal of the stomach, caused by a shortage of intrinsic factor.Monitor CBC for megaloblastic anemia and leukopenia.CONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementCholecystitisAcute vs ChronicSludge – acalculus cholecystitisGallstone lodged in cystic ductInfectionGallbladder irritationMay lead to necrosis, gangrene, perforation, peritonitisCholelithiasis – obstructs bile flowbiliary stasischolecystitisabnormal bilecholesterol/ pigmented gallstones4F’s: fat, forty, female, fairWhiteDMHyperlipidemiaCirrhosisCrohn’s diseaseRapid weight loss, bariatric sxMedsRight epigastric (RUQ) pain, diffuse, radiates to backWorse after fatty meal/eatingN/VFatty stool (steatorrhea)Flatulence, bloating, abd distention, diarrhea, light-colored stool, chest painJaundiceUSNuclear scanBilirubinAmylaseLipaseALTASTWBCColecystogramSX: cholecystectomyNo high fat mealsLithotripsy – break up stones w/sound wavesEven w/o gallbladder, sludge can block bile ductLap chole – gas, distention, upper right shoulder pain from gas: walk aroundOpen chole – large stones, pus, abscess, adhesions, infection, perforation (to drain excess pus)T-tube managementSee Chart 38-6Cholelithiasis – ERCP (Endoscopic Retrograde Cholangiopancreatography) for stone removalPancreatitisAcute vs ChronicAcuteSerious, life-threateningCan be caused by gallstonesNecrotizing hemorrhagic pancreatitisUsually mild and self-limitingSevere necrosis of pancreasHeavy alcohol useObstructed biliary tractActivated trypsin = autodigestion= edema, vascular leakage, hemorrhage, necrosisChronic: alcohol, smoking, gallstones, CF, malnutrition, heredity, idiopathicSudden, severe, steady epigastric painN/VSometimes abd distention, decreased bowel sounds, rigidityAfter 3-6 days:Turner’s sign – ecchymosis in flanksCullen’s sign – bruising around umbilicusLess severe S/S for chronicEpigastric/LUQ pain, may be referred to left lumbar regionTender abd, mild guardingAnorexia, N/V, weight loss, flatulence, constipation, steatorrheaH&PElevated amylase, lipase, ALTSerum bilirubin, ALPImagingChronic:Amylase/lipase may be normalStool samplesERCPMRCPEndoscopic US w/tissue samplingMonitor for respiratory or cardiac disordersMorphine for painBowel rest NPO for flare-up/acuteNG tubeTPN/clear liquid after return of bowel sounds low-fat dietSX: infected necrotizing typeBed restLots of IV fluidsChronic: NSAID or other analgesic for daily pain controlEnzyme replacementInsulin txSX w/ biliary tract diseaseAlcohol abstinence, low-fat dietCONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementAppendicitisBacterial buildup, obstruction by fecal material, inflammation = ruptureYounger than olderRebound tendernessPain: RLQ abd pain, N/V, guarding, McBurney’s pointComplications: peritonitis due to ruptureWBCs highAbd X-4ayAbd CTSX: lap or openPerforation: broad-spectrum ABXManagement of fluid and electrolyte balance, pain, infectionAntiemetics for postop N/VEarly postop ambulationINFLAMMATORY BOWEL DISEASEWhitesGenetic susceptibilityImmunologic disease = idiopathic intestinal inflammationAbdominal pain, diarrhea, rectal urgency/tenesmus, frank bloodSystemic manifestations –, arthritis, mouth sores, uveitis, liver/pancreatic problemsColonoscopy – avoid when having a flare-upSerologic tests to differentiate UC and CDGenetic markersDecrease inflammation and prevent flare-ups, fluid/electrolyte balance, avoid triggers (individualized diet)SX: if too much damageCorticosteroids – for flare-ups onlyPsychosocial care (chronic, life-long, disruptive)Severe UC: ileal pouch anal anastomosis or continent ileostomyMeds, diet, stress reductionSupport networkUlcerative ColitisSuperficialLower intestinesUsu. Colon/rectumHigh risk of colon cancerBlood in stoolCrohn’s DiseaseFull-thicknessAnywhere in intestinesUsu. Jejunum/ileumSkip lesions, cobblestone appearanceComplications: Malabsorption, fistulas to bladder or abd liningPerforation, peritonitisDIVERTICULAR DISEASEAbnormal saclike outpouchings of intestinal wallLocated anywhere except rectumOld age >60NOT OBESITYLow-fiber dietComplications caused by: food stuck in diverticuli, disruption in immune processOften asymptomaticExacerbation: LLQ pain, fever, chilssDiverticulitis Complications: peritonitis, perforationCBC w/ diff – bleeding and infectionBarium enema – not when having a flareupUS, CT scanDiverticulitis: Elevated WBCDiet – 25-30 g daily fiberRest, meds for mild symptomsIV fluids, ABX, pain mgmt.SX: bowel resection w/ anastomosis if no improvementDiverticulosisSmall, bulging pouches form inside lower part of intestineConstipation can worsenFiber, adequate fluidsDiverticulitisPouches become infected or inflamedClear liquid, then low fiber/residueABX, anti-inflammatoriesCONDITIONWho is at risk?Signs/SymptomsLab/DiagnosticsNursing ManagementColon CancerAdenocarcinoma for 95% of tumorsOlder ageLow-fiber dietHigh red meat foodsHigh fatSmokingAlcoholIBDFamily historyUsually asymptomatic until advancedDepend on location/growthChange in bowel habits or stool texture (constipation)Rectal bleeding, hematochezia, passage of red blood via rectumAnemiaMass in abd, obstructionColonoscopy/sigmoidoscopyDouble-contrast barium enemaSwallow fluoroscopyChanges in bowel patternCT colonography (@50 y/o)Fecal occult blood – fresh/frankCRP – inflammationCEA markerH/H decreasedCT scan to detect metastasesPolypectomy, colectomyResection w/ diversionColostomy careMonitor fluid/electrolytesBeefy red, shiny stomaIntact peristomal skinFitting ostomy applianceBarrier creamsEmptyingAddress body image issue, smellIrrigation – obstruction commonly in lower intestinesNG tube – after ostomy, to decompress, let wound heal; Usually NPO w/ dextrosePain meds, bowel soundsPsychosocial support:current methods of copingsources of supportsigns of anticipatory grieving (crying)Chemo/radiationEarly detectionPre- and postop care/supportEmotional supportDietary modificationsExercise, reduce obesityIntestinal ObstructionPartial vs CompleteMechanical:adhesionstumorsherniasintussusceptionFunctional:paralytic ileusImmobilityGI SXPost-op ileusScar tissueCancerMultiple abdominal SXIBD (Crohn’s – scarring/fistula)N/V – fecal if distal small int.Hypoactive sounds distalHyperactive above obstructionLeakage of liquid stool if constipationAbdominal distention – PNA/atelectasisColicky pain that increasesSimple vs strangulatedX-rays, CT scan, CBC w/ diffWBCBarium swallow/enemaH&PNG tube to decompress stomachNPOBowel resection if necroticIf ileus: NG tube, different treatmentFluid/electrolyte replacement ................
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