Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
127 Cards in this Set
- Front
- Back
|
GI tract
|
Supplies nutrients to body by ingestion, digestion and absorption Enteric nervous system has receptors for pressure and movementVenous blood drains from GI tract to liver Parietal layer covers abdominal cavity wall & visceral layer covers organs |
|
|
Ingestion
|
Appetite stimulated by ghrelin and suppressed by leptin
Mastication and saliva in mouth Deglutition (swallowing) by mouth, pharynx and esophagus Upper esophagus striated skeletal muscle and distal is smooth muscle with an upper and lower esophageal sphincter |
|
|
Digestion
|
Stomach mixes food with gastric secretions
Parietal cells secrete HCl to create acidic environment, chief cells secrete pepsinogen to break down proteins, and intrinsic factor promotes B12 absorption Small intestine continues digestion and absorbs nutrients with villi Carbohydrates broken down to monosaccharides, fats to glycerol & fatty acids |
|
|
Elimination
|
Large intestine absorbs water and electrolytes
Microorganisms break down proteins & synthesize vitamin K & some B vitamins Valsalva maneuver increase intra-abdominal pressure, contraindicated cardiac problems due to decrease BP |
|
|
Liver
|
Lobule is functional unit
Rows of hepatocytes around central vein and Kupffer cells between Blood enters liver from portal vein |
|
|
Pancreas
|
Endocrine and exocrine functions
Consists of head, body and tail Secretes enzymes for digestion: trypsinogen, chymotrypsin, amylase and lypase Makes hormones in the Islets of Langerhans: beta cells secrete insulin and amylin, alpha cells secrete glucagon |
|
|
Subjective assessment of GI
|
History: pain, n/v/d, constipation, last BM, weight loss
Diet history: 24 hour recall Recent travel: exposure to hepatitis or parasite Allergies Past medical history of GI problems Medications: may effect n/v or liver problems |
|
|
Objective assessment of GI |
Start at oral cavity: moist and pink mucosa, lesions, teeth, protrusion of tongue in midline, swallowing Abdomen: masses, scars, bowel sounds in 4 quadrants, tenderness, nonpalpable liver or spleen, tympany Anus: lesions or hemorrhoids, sphincter tone, stool soft, brown, heme negative |
|
|
Diseases that cause constipation/diarrhea
|
Ulcerative colitis
Cancer Diverticulitis Anxiety disorders Parasitic infections Food allergies Celiac disease |
|
|
Electrolyte imbalance
|
In acute situation, imbalance can happen rapidly
Vomiting & gastric suctioning Loss of H+, Cl-, K+ Metabolic alkalosis & hypokalemia (<3.5meq/L) Diarrhea Loss of K+, Na+, Mg+ Metabolic acidosis, hypokalemia & hypomagnesemia (<1.5meq/L) |
|
|
Blood Tests
|
Amylase and Lipase: diagnoses acute pancreatitis
Gastrin: secreted by stomach antrum & duodenum to produce gastric acid, diagnose tumor or reason for gastric ulcers |
|
|
Radiology
|
Upper GI and small bowel series: fluoroscopic x-ray study w contrast to diagnose structural abnormalities, NPO 8-12 hr, stool may be white Ultrasound: show size & configuration of organ, NPO 8-12 hr Barium enema: fluoroscopic x-ray to test motility and function, contrast medium administered rectally, bowel prep pre-op, cramping and laxative after Cholangiography: images of biliary, hepatic and pancreatic ducts CT scan: may use oral or IV contrast medium |
|
|
Liver Biopsy
|
Percutaneous procedure
Check coagulation status and explain holding breath after expiration when need is inserted After procedure, keep patient lying on right side for 2hr and flat for 12 hr, check vital signs |
|
|
Endoscopy
|
Gold standard for diagnosis: uses flexible fiber-optic scope Esophagogastroduodenoscopy (EGD): visualize esophagus to duodenum, conscious sedation, NPO for 8 hr before & until gag reflex returns, warm saline gargle for sore throat, vitals & tempColonoscopy: visualize colon up to ileocecal valve for polyps and routine screening, bowel prep (Golytely or enema) with clear liquid diet 1-2 days, may cause cramping due to air inflation, observe for rectal bleeding & vitals |
|
|
Fecal tests
|
Fecal analysis: examined for mucus, blood, parasites and fat content, must keep diet free of red meat for 24-48 hr before occult blood test
Stool culture: presence of bacteria i.e. C. diff |
|
|
Obesity
|
Weight gain in adulthood characterized by adipocyte hypertrophy: cell volume increases several thousandfold to accommodate lipid storage
Epidemic proportions: in US most common nutritional problem affecting 1/3 of the population 2nd leading cause of preventable death & 3rd reason for liver transplant |
|
|
Body mass index
|
BMI = weight (kg) / height (m) squared
< 18.5 underweight 18.5 - 24.9 normal 25 - 29.9 overweight > 30 obese > 40 severely obese |
|
|
Bariatric surgery
|
Restrictive bariatric surgery reduces the size of the stomach or the amount allowed to enter the stomach
Malabsorptive procedures decrease the length of the intestine so less food is absorbed Weight loss can be considerable during first 6-12 months |
|
|
Bariatric surgery criteria
|
BMI > 40 with 1+ obesity related complication 18 years or older Understands risks and benefits Has been obese for >5 years and tried and failed to lose weight No serious endocrine problems Psychiatric and social stability Availability of team of health care providers Surgery would decrease or eradicate high-risk conditions |
|
|
Bariatric Surgery Pre and Post-Op
|
Preoperative ensure that over-sized equipment is available
Postoperative keep HOB 40 degrees to reduce abdominal pressure, assess for re-sedation due to storage of anesthetics in adipose tissue, delayed wound healing and pain Diet is sugar-free clear liquids, high-protein liquid diet by discharge followed by high protein, low carb/fat/fiber in 6 small meals |
|
|
Bariatric long-term complications
|
Overeating leads to gaining back weight
Malnutrition i.e. anemia, chronic diarrhea, malabsorption Guilt Flabby skin after weight loss Pain associated with eating Postpone pregnancy for at least 12 months due to malnutrition |
|
|
Health risks associated with obesity
|
High LDL & triglycerides
HTN & chronic inflammation Type 2 diabetes GERD, gallstones & non-alcoholic steatohepatitis Decreased total lung capacity & sleep apnea Osteoarthritis & gout Cancer i.e. breast, colorectal, pancreatic Metabolic syndrome Psychosocial problems i.e. low self-esteem and major depression |
|
|
Metabolic syndrome (syndrome X)
|
Characterized by 3 or more of the following conditions:
Waist circumference >40 men and >35 women Triglycerides > 150 HDL <40 men or <50 women Blood pressure >130/85 Fasting blood glucose >110 |
|
|
Upper GI bleeding Symptoms
|
Above junction of duodenum and jejunum Hematemesis: bloody vomitus, appears bright red if active or like coffee grounds if slow due to interaction with HCl in stomachMelena: black tarry stools caused by digestion of blood in GI tract due to iron, metallic smell, color change may be caused by diet i.e. beets or iron supplements |
|
|
Bleeding: esophageal origin
|
Chronic esophagitis r/t GERD, mucosa-irritating drugs (NSAIDs), alcohol, cigarettes
Mallory-weiss tear (tear in mucosa near esophago-gastric junction) r/t severe retching/vomiting, emergency Esophageal varices dilated tortuous veins in lower esophagus as a result of portal hypertension, anything increasing pressure (cough, sneeze) or irritation (vomit) may cause massive bleeding |
|
|
Bleeding: stomach and duodenal origin
|
Gastric cancer
Hemorrhagic gastritis Peptic ulcer disease Polyps Stress-related mucosal disease Risk factors: NSAIDS, GERD, steroids, alcoholism |
|
|
Upper GI bleeding: assessment
|
Keep in Bed, emergency until diagnosed VS every 15-30 minAssess shock sxs i.e. decreased urine, pallor, hypotension, tachycardia, weak pulse, cool extremities, prolonged cap refill Assess respiratory status and apply O2 Assess abdomen including bowel sounds, rigid & board-like may indicate perforation and peritonitis Treatment ASAP |
|
|
Upper GI bleeding: management
|
2 IV lines 16 or 18 gauge established for fluid and blood replacement, check if patent by flushing
Begin with isotonic (lactated Ringer's solution) Packed RBC and fresh frozen plasma if massive hemorrhage (orthostatic hypotension with 10 mmHg drop in DBP denotes 1,000 mL loss) Insert indwelling urinary catheter to monitor urine output Endoscopic cauterization to thrombose bleeding vessel Drugs to decrease bleeding and HCl secretion or neutralize |
|
|
Lower GI bleeding |
Large and small intestine Causes: diverticulosis, radiation therapy, cancer, inflammatory conditions, infection SXS: melana, maroon or blood in stools, fever, dehydration, hematochezia, abdominal pain or distention |
|
|
Hiatal hernia
|
Protrusion of stomach through esophageal hiatus of diaphragm into thorax due to weakening muscles of diaphragm and increased abdominal pressure i.e. obesity, pregnancy, ascites, heavy lifting
Sliding hernia: most common, occurring when esophago-gastric junction and portion of fundus slide upward, usually only when supine Rolling hernia: fundus and greater curvature of stomach rolls into thorax forming a pocket, acute version is a medical emergency Conservative treatment similar to GERD, surgery if unresponsive |
|
|
Abdominal Hernia |
Displacement or protrusion of a segment of the bowel through an area of weakness in the abdominal wall i.e. umbilicus or inguinal Reversible (positioned with gentle pressure) or irreversible Strangulated: leads to small bowel obstruction Manifestations: visible protrusion, diffuse pain, diagnosis by CT or US Risk factors: male gender, advanced age, pregnancy, obesity, genetics Treatment: surgery if strangulated, no lifting, prevent constipation |
|
|
Esophagitis |
Inflammation of the mucosal lining Causes: GERD, infection (Candida, CMV, HIV, herpes), chemo or radiation Symptoms: heartburn, dyspepsia, dysphagia, retrosternal chest pain Diagnosis: CBC, fecal occult blood, barium studies and endoscopy, ECG Complications: anorexia, weight loss, Barrett's esophagus, perforation (rare) Tx: Pain management, H2RB, PPI, lifestyle changes (GERD), corticosteroids (IBD) |
|
|
Gastroesophageal reflux disease (GERD)
|
Backward flow GI contents into esophagus
Reflux esophagitis characterized by acute symptoms of inflammation Due to elevated gastric volume or intra-abdominal pressure, decreased tone or inappropriate relaxation of lower esophageal sphincter (LES) Risk factors: Alcohol, asthma or BP meds, obesity, tobacco Complications: esophagitis, Barrett's esophagus (metaplastic changes and risk of adenocarcinoma), respiratory problems |
|
|
GERD clinical manifestations
|
Dyspepsia (heart burn) Regurgitation (acid in mouth) Hypersalivation or water brash Dysphagia (difficulty) or odynophagia (painful swallowing) Chronic cough, asthma Atypical chest pain Eructation, flatulence or bloating after eating Nausea and vomiting |
|
|
GERD collaborative care
|
Decrease high-fat foods
Fluids between rather than with meals Avoid milk products and snacking 3 hours before bed Avoid triggers i.e. alcohol, chocolate, peppermint, caffeine, tomatoes, orange juice, colas Elevate HOB with 6 inch blocks Weight reduction Decrease HCl with proton pump inhibitors and H2 receptor blockers |
|
|
Gastritis
|
Inflammation of the gastric mucosa due to breakdown of gastric mucosal barrier
Acute or chronic Risk factors: NSAIDs & corticosteroids inhibit prostaglandin synthesis, alcohol abuse, irritating spicy foods, H. pylori and E. coli Most common cause is bacterial Autoimmune gastritis related to intrinsic factor deficiency (B-12) Hyperplasia may lead to esophageal or gastric cancer |
|
|
Gastritis clinical manifestations
|
Acute: abdominal tenderness, bloating, n/v, anorexia
If bleeding, hematemesis, melena, intravascular depletion and shock Chronic: same symptoms or asymptomatic, loss of intrinsic factor may lead to pernicious anemia and neurologic complications, associated with gastric adenocarcinoma and MALT lymphoma |
|
|
Gastritis treatment |
Acute: fluid and electrolyte balance, discontinue causative agents i.e. NSAIDs and corticosteroids, H2 blockers and PPI, antibiotics for H. pylori Chronic: specific to causative agents (3 antibiotic course for H. pylori and long-term surveillance), assess hemorrhage |
|
|
Peptic ulcer disease (PUD)
|
Mucosal lesion of stomach (gastric) or duodenum (most common) due to impaired gastric mucosal defenses
Use endoscopy to differentiate H . Pylori may alter gastric secretion and produce tissue damage NSAIDs inhibit prostaglandins Smoking, high stress, alcohol and coffee stimulates acid secretion |
|
|
Stress ulcer
|
Acute gastric mucosa lesion occurring after an acute medical crisis or trauma
Associated with head injury, major surgery, burns, respiratory failure, shock and sepsis Principle manifestation: bleeding caused by gastric erosion |
|
|
PUD complications
|
Hemorrhage causing hematemesis
Perforation emergency requiring immediate surgical closure, sudden severe abdominal pain, rigid abdominal muscles, weak pulse/tachycardia Pyloric obstruction causes vomiting due to stasis and gastric dilation Intractable disease no longer responds to conservative treatment or recurrences interfere with ADLs |
|
|
PUD clinical manifestations
|
Epigastric tenderness at mid-line between umbilicus & xiphoid process
Dyspepsia Sharp, burning or gnawing pain, often 30 minutes-2 hours after meals if gastric or 2-5 hours if duodenal Sensation of abdominal pressure, fullness or hunger |
|
|
PUD pain management
|
Discontinue NSAIDS
May give Tylenol or narcotics if severe pain Promoting healing of gastric mucosa: H2 receptor blockers, PPI (long-term) Eradicate H. pylori infection: amoxicillin and clarithromycin for 1-2 weeks with subsequent testing |
|
|
PUD diet therapy
|
Directed toward neutralizing acid and reducing hyper-motility
Bland, nonirritating diet is recommended during acute symptomatic phase Avoid bedtime snacks, carbonated beverages, alcohol and tobacco |
|
|
PUD complications: perforation
|
Monitoring and early recognition of complications is critical
If small may heal itself, if larger sudden cramping abdomen or back, rigid and board-like, shallow/rapid respirations, weak pulse, no bowel sounds Blood volume replaced with Lactated Ringer's, albumin solution, packed RBC Monitor urine output, NPO, give antibiotics and pain medications Open or laparoscopic procedure to repair |
|
|
PUD complications: hemorrhage
|
Acute exacerbation: managed as an upper GI bleed
Acid suppressive agents used to stabilize clot by raising gastric pH |
|
|
PUD complications: gastric outlet obstruction
|
Pyloric obstruction related to edema, spasm and fibrous tissue Generally responds to medical therapy Decompress stomach with NG tube suction Clamped after several days to measure gastric residual volume, when < 200 mL, start oral fluids gradually IV fluids and electrolytes administered according to electrolyte and fluid imbalances |
|
|
PUD surgical therapy
|
Excision of lower stomach if complications are unresponsive to treatment: Billroth I (connected to duodenum) or Billroth II (to jejunum)
Monitor for acute upper GI bleeding Delayed gastric emptying for 1 week: use NG tube suctioning to let bowel rest Recurrent ulceration in about 5% of clients |
|
|
PUD risk for nutritional deficit
|
Deficiencies of Vit B12, folic acid and iron
Impaired calcium metabolism Reduced absorption of calcium and vitamin D absorption as result of partial removal of stomach Caused by shortage of intrinsic factor Monitor CBC for signs of megaloblastic anemia and leukopenia |
|
|
Gastric cancer
|
Adenocarcinoma in the stomach wall
Early cancer may be asymptomatic Ingestion & abdominal discomfort Risk factors: gastritis, H. pylori, autoimmune inflammation, exposure to irritants i.e. anti-inflammatory agents, tobacco Associated w consumption of smoked foods, salted fish/meat, pickled vegetables |
|
|
Complications of gastric surgery
|
Hemorrhage
Reflux aspiration Wound infection Sepsis Reflux gastritis Paralytic ileus Bowel obstruction Dumping syndrome |
|
|
Dumping syndrome
|
Food rapidly enters jejunum without duodenal processing
Caused by rapid movement of extracellular fluids into bowel Fluid shift creases circulating blood volume Usually subsides in 6-12 months |
|
|
Dumping syndrome: symptoms
|
Vertigo
Tachycardia Syncope Diaphoresis Pallor Palpitations Nausea Desire to lie down |
|
|
Dumping syndrome: interventions
|
High protein, moderate fat, low carb diet
Lie down after meals Eat little and often Chew food well Don't drink with meals |
|
|
Irritable bowel syndrome (IBS)
|
Alternating diarrhea and constipation, abdominal pain, bloating
Collection of symptoms, lab tests rule out other disorders Individualized treatment focused on triggers i.e. stress or diet Increase fiber slowly, avoid gassy foods (broccoli, cabbage, milk) Psychologic therapies Drug therapy for symptoms Probiotics |
|
|
Inflammatory bowel disease (IBD)
|
Autoimmune disease of widespread tissue destruction in intestinal tract: Crohn's disease or Ulcerative colitis
Characterized by periods of remission and exacerbation SXS: diarrhea, bloody stools, weight loss, abdominal pain, fever, fatigue Diagnosis: r/u infection, endoscopy, imaging, serum and stool studies |
|
|
Crohn's disease
|
Regional enteritis: occurs anywhere along GI in skipping lesions (cobblestone appearance), distal ileum and R colon most common
Chronic inflammation with remissions and exacerbations Usually involves entire thickness of bowel wall (transmural) RLQ pain and cramping Associated with other autoimmune diseases (arthritis) Occurs in younger folks, esp. whites |
|
|
Ulcerative colitis
|
Starts in rectum, spreads in a continuous fashion up the colon
Involves only mucosa and sub-mucosa Ulcerations, thickening, edema, bleeding, abscesses Occurs in all ages, more common than Crohn's 10 to 20 stools per day, bowel, obstruction, tenesmus, LLQ pain Complications: water & electrolytes imbalance (malabsorption), protein loss (cell breakdown), rectal hemorrhage, perforation May be cured by total colectomy |
|
|
IBD treatment
|
Start with Aminosalicylates and progress to antibiotics, corticosteroids and immunomodulators
Bowel rest by decreasing food intake Accurate I&O, # and appearance of stool Quitting smoking (stimulated GI tract), reduction of stress, emotional support Emergency care: hemorrhage, megacolon or obstruction |
|
|
Diverticulosis
|
Diverticula are saccular dilation or out-pouching of mucosa that develop in the colon Diverticulosis (state of) and diverticulitis (inflammation) Symptoms: may be asymptomatic, N/V, LLQ pain, fever, chills, palpable mass Most common >45 and obese Higher risk of diverticulitis if diagnosed before age 50 Risk factor: low fiber diet, related to pressure of stool staying inside colon |
|
|
Diverticular disease
|
Occurs when particles or bacteria are caught in diverticula, becomes irritated and inflamed, congested with blood
May bleed or lead to perforation when trapped mass erodes bowel wall, leading to hemorrhage and peritonitis Treatment: Bowel rest, IV fluids, antibiotics, nasogastric decompression Clear liquid to low fiber to high fiber diet Surgery (colectomy) based on Hinchey classification of inflammatory changes and integrity of bowel wall |
|
|
Diverticular disease prevention
|
Primary: high fiber diet, lose weight if obese
Secondary: bulk laxatives, avoid straining, coughing, lifting Tertiary: surgery (colon resection), prevention of complications |
|
|
Colorectal cancer (CRC)
|
Third most common cancer, second cause of death, men>women
Adenomatous polyp grows, invades muscularis mucosa, often metastasizes to liver Risk factors: genetic, smoking, low fiber/fruits/veg, high red/processed meat, irregular bowel movements, obesity, physical inactivity Symptoms: often asymptomatic in early stages, abdominal pain, mass, change in bowel habits, anemia, obstruction, bright red blood in stool, rectal discomfort |
|
|
Colon cancer prevention
|
Primary: low fat & high fiber diet, limited ingestion of refined food, 2-3 L fluid intake
Secondary: early detection by annual fecal occult blood test (yearly) and rectal exam if > 50 or >40 if high risk, regular flexible sigmoidoscopy (every 5 years), colonoscopy (gold standard, every 10 years) Tertiary: surgery, chemotherapy, radiation |
|
|
Colon cancer diagnostic tests
|
Digital rectal exam
Fecal occult blood test (FOBT) Sigmoidoscopy and colonscopy: visualize and remove polyp to test for cancer Clear liquid diet for 24-48 hours and 4L of polyethylene glycol (PEG) the evening before, stools should be clear or yellow |
|
|
Colon cancer treatment
|
Surgery: tumor resection with margins, removal of lymph nodes and exploration of abdomen to determine spread
A temporary and permanent ostomy may be placed Chemotherapy if stage II+ Radiation as adjunct post-op or palliation |
|
|
Colon surgery pre-op care
|
Assess knowledge
Provide information: ostomy, NG tube, changes in bowel function, pain Assist to verbalize feelings about treatment Prep for surgery: reduction of colonic bacteria w polyethylene glycol lavage (GoLytley or MiraLax) and oral antibiotics |
|
|
Bowel surgery nursing diagnosis
|
Risk for infection
Anxiety Risk for body image disturbance Alteration in nutrition less than body requirements Risk for ineffective management of therapeutic regimen |
|
|
Bowel surgery post-op care
|
Pain management
Pulmonary care Assess bowel function and provide bowel rest (NG tube suction), progress to clear liquids to normal diet Wound care, often drains (Jackson-Pratt, Hemovac) Ostomy care Nutritional needs Sexual dysfunction due to cutting nerves Monitor for infection: edema, erythema & drainage, WBC count, fever |
|
|
Ileostomy
|
Ileum is brought to abdominal wall and stoma is created
Indications: ulcerative colitis, Crohn's, cancer, trauma Fecal material is more liquid, larger volume and electrolyte malabsorption |
|
|
Ostomy
|
Surgical procedure that allows intestinal contents to pass from bowel to opening on abdomen, permanent or temporary
Assess stoma every 4 hours: dark pink to beefy red, blue indicates ischemia & black-brown necrosis, no excessive bleeding, may be swollen for 2-3 weeks Keep skin clean, dry, odor free, assist to visualize and do self-care Skin barrier, ensure adhesion, empty when 1/3 full, clear pouch post-op |
|
|
Colostomy
|
Colon is brought to abdominal wall and stoma is created
The more distal the ostomy, the more fecal resemblance May use irrigation and have regular bowel movements if sigmoid Indications: rectal cancer, trauma, perforating diverticulum |
|
|
Ileostomy
|
Ileostomy is liquid and drains continuously
Pouch is worn at all times: drainable pouch changed every 4-7 days Monitor post-op for Na, K and fluid deficit 2-3L minimum intake, low-fiber diet and well-chewed food at first to prevent obstruction Indications: Ulcerative colitis, Crohn's disease, trauma, cancer |
|
|
GI Emergencies
|
Hemorrhage, dehiscence, evisceration, perforation of ulcer, peritonitis, obstruction
ABCs: Airway, oxygen, IV access (2 16/18 gauge) and BP management NPO Vital signs |
|
|
Wound dehiscence and evisceration
|
Due to infection, edema, pressure
Common abdominal surgery due to pressure of movement Use moist sterile dressing and prepare for surgery |
|
|
Bowel obstruction
|
Content cannot pass through GI at pylorus (gastric outlet), small intestine or bowel, may be partial or complete Mechanical: adhesion, tumor, volvulus (twisting), intussusception (telescoping), herniaNon-mechanical: decreased peristalsis, neurogenic disorder Symptoms: N/V, abdominal distention and cramping, anorexia, metabolic acidosis, severe electrolyte and fluid loss, no gas or BM Caution with inserting any tubes |
|
|
Special nutrition
|
NG tube: for short term feeding
HOB >30 during feeding and 2 hours after, may be NPO, suction or feeding, assess placement & residual prior to feeding, flush, oral and nasal care, site care, prevention of infection Percutaneous endoscopic gastrostomy (PEG): long-term (>3 weeks) Regurgitation less likely because cardiac sphincter remains intact |
|
|
Functions of liver
|
Metabolic functions: carbohydrate, protein and fat metabolism, synthesis of plasma proteins & clotting factors, detoxification, makes corticosteroid hormones
Bile synthesis: bile salts, cholesterol & bilirubin, stored in gallbladder Storage: glucose (glycogen), vitamins, fatty acids, amino acids (albumin) Mononuclear phagocyte system: breakdown old RBCs, WBCs & bacteria into billirubin |
|
|
Bilirubin cycle
|
RBCs destroyed by macrophages: hemoglobin to heme & globin
Globin & iron are recycled, heme becomes unconjugated bilirubin (insoluble) & is attached to albumin Bilirubin is conjugated in liver, excreted in bile to intestines, reduced by intestinal bacterial Excreted in feces (stercobilin) & urine (urobilin): causes fecal matter to be dark brown and urine to be yellow |
|
|
Hepatitis
|
Inflammation of liver
Acute viral hepatitis is most common (Hepatitis A through G, CMV, Epstein-Barr, adenovirus) Non-infectious hepatitis may be caused by drugs (recreational and prescription), autoimmune disease, metabolic disorders, alcohol abuse |
|
|
Hepatitis etiology
|
Viral hepatitis caused by one of 5 major viruses, A-E
A, B & C are most common in US 90% of post-transfusion and community acquired hepatitis are caused by viruses Viruses identified by presence of antigens in blood Symptoms: mild-flu like symptoms (nasuea, fatigue, malaise, RUQ pain) or acute hepatitis with jaundice Phases: Asymptomatic infection (1), mild symptoms (2), progressive liver dysfunction (3), recovery (4) |
|
|
Hepatitis A
|
Fecal-oral route: small outbreaks r/t fecal contamination of food, water, poor hygiene, crowded conditions, poor sanitation, institutions, raw fish or shellfish from contaminated water
Prevent by vaccine & immune globulin (IG) post-exposure, hand-washing & private room if stool incontinent |
|
|
Hepatitis B
|
IV or SQ exposure to blood & body fluids, perinatal (high risk), sexual activity (considered 100x more infectious than HIV)
May cause acute or chronic disease: carrier if presence of HBsAg (HBV antigen) in blood for >6 months Treatment: antivirals to decrease adenocarcinoma incidence Vaccine for Hep B (3 IM injections) |
|
|
Hepatitis C
|
Parenteral or mucosal exposure to blood or blood products, sexual contact, perinatal
Majority develop chronic infection, leading to liver disease & cirrhosis Leading need for a liver transplant Associated w HIV infection |
|
|
Hepatitis D
|
Transmitted with or after HBV infection (co-infection)
Causes more virulent strain of hepatitis Endemic in Mediterranean & Middle East |
|
|
Hepatitis E
|
Fecal-oral route, often transmitted by contaminated water
Rare in US, epidemic in India |
|
|
Hepatitis G
|
Transmitted by blood transfusion
Recently discovered |
|
|
Hepatitis pathophysiology
|
Acute infection: liver damage due to cytotoxic cytokines & NK cells that lyse infected hepatocytes & inflammation, cells can regenerate if not complications
Chronic infection: chronic inflammation leading to fibrosis & cirrhosis Inflammation can interferes with bile production, causing cholestasis & increased pressure around portal vein Body's immune response to clear virus & damaged liver cells associated w lab changes |
|
|
Hepatitis lab values
|
Elevated serum transaminase (AST) (10-40 IU/L) may be 3 times normal
Elevated ALT (6-50 IU/L) Elevated alkaline phosphatase (ALP) Elevated total bilirubin (0.3 to 2 mg/dL) Prolonged PT (<20 sec) Low serum albumin (made only in liver) Thrombocytopenia |
|
|
Hepatitis: preicteric phase sxs
|
Inflammatory process
Elevated temp & chills N/V, fatigue, loss of appetite Dyspepsia Joint pain Enlarged lymph nodes Viral antibodies present Elevated AST & ALT |
|
|
Hepatitis: icteric phase sxs
|
Impaired bilirubin metabolism
Jaundice (sclera, hard palate, or skin if light-colored) Pruritus due to bile salts under skin Elevated total bilirubin Dark, amber urine Light brown to gray stools RUQ tenderness |
|
|
Hepatitis: posticteric phase
|
Lab values return to normal
Decreased jaundice Improved appetite Fatigue may last a long time |
|
|
Hepatitis: nursing diagnosis
|
Fatigue: rest in bed and slowly increase activity
Fluid volume deficit: due to vomiting Risk for infection Altered nutrition: anorexia, pain while eating, impaired fat breakdown Pain (right upper quadrant) Impaired skin integrity r/t pruritus & itching, avoid harsh soap Risk for injury r/t bleeding |
|
|
Hepatitis treatment |
Acute disease: nutrition (small, frequent meals, esp. morning), 2-3L fluid, physical & psychological rest Chronic B&C: drug therapy using interferon & nucleoside analogs to prevent viral replication, diet of adequate calories to maintain weight & low fat if not tolerated, maintain fluid & electrolyte balance |
|
|
Cirrhosis of the liver pathology
|
Chronic disease of the liver, characterized by diffuse inflammation & fibrosis (scar tissue) resulting in drastic structural changes and significant loss of liver function Fatty infiltration leads to acute inflammation to cirrhosis 3/4 liver can be destroyed due to fibrotic changes prior to symptoms Increased pressure on portal veins affects spleen, gallbladder & liver function |
|
|
Cirrhosis of the liver risk factors
|
Viral Hepatitis (C is most common cause) Non-alcoholic fatty liver disease (NAFLD) related to diabetes, obesity and HLD Alcoholic liver disease (Laennec's Cirrhosis)Sarcoidosis Primary biliary cirrhosis Right-sided heart failure Alpha 1 antitrypsin deficiency |
|
|
Cirrhosis of the liver symptoms
|
Early symptom is fatigue, often asymptomatic until advanced
Ascites with portal hypertension Anorexia, n/v, GI distress, malnutrition Weight loss masked by water retention Jaundice Anemia, leukopenia, thrombocytopenia Coagulation disorders: Spider angiomas and increased bleeding Encephalopathy |
|
|
Portal hypertension
|
Pressure is elevated as liver damage (disorganized regeneration) results in abnormal blood vessels and impedes blood flow
Ascites Esophageal & gastric varices (most dangerous complication) Hemorrhoids |
|
|
Ascites
|
Decreased synthesis of albumin (allowing movement of fluid out of blood vessels) and poor hepatic lymph flow Increased nitric oxide leads to vasodilation, sodium retention of kidneys Sodium restriction (<2g/day) & diuretics Paracentesis may be required for respiratory distress: sterile procedure, complications include peritonitis & bleeding, monitor for hypovolemia & shock |
|
|
Esophageal varices: pathology
|
High risk for hemorrhage
Small, tortuous veins that are enlarged and swollen due to portal hypertension Increased abdominal pressure (cough, sneeze, Valsalva) cause bleeding Screening every 2-3 years (may be asymptomatic until rupture) |
|
|
Esophageal Varices: treatment |
Risk of rupture: constipation, vomiting, coughing, alcohol Stool softeners Beta blockers Prophylactic surgery if >5mm: endoscopic band ligation Active bleeding is emergency: endoscopy with ligation, vasopressin, intra-hepatic porto-systemic shunt, balloon tamponade (keep scissors at bedside to cut if obstructs airway) with crystalloid and colloid fluids |
|
|
Portal systemic encephalopathy
|
Major complication of cirrhosis
High levels of toxic substances, can occur quickly or over several days Change in LOC, intellect, behavior, neuromuscular Characteristic manifestation: flapping tremors of arms & hands Due to elevated serum ammonia, hemorrhage, hypoxia |
|
|
Portal systemic encephalopathy: nursing interventions
|
Decrease ammonia: restrict protein, increase CHO, enemas, neomycin to kill bacteria in GI, lactulose as laxative, hemodialysis
Skin integrity r/t malnutrition, pruritus, ascites, frequent stools Prevent infection, careful drug admin, nutrition, good oral hygiene, small frequent meals (20-40g/day protein) |
|
|
Cirrhosis of the liver: nursing diagnosis
|
Ineffective breathing patterns r/t ascites: high fowlers
Fatigue: rest Excess fluid volume Risk for infection: spleen inflammation Risk for injury: bleeding, falls Imbalanced nutrition: high calorie, low fat, normal protein Pain Skin integrity r/t pruritus & edema Body image r/t jaundice |
|
|
Cirrhosis: treatments |
Antivirals (Viral Hepatitis) Diuretics, beta-blockers, digoxin (Cardiac conditions) Immunosuppressants (autoimmune disorder) Symptomatic: treatment of pruiritis, zinc deficiency and osteoporosis Liver Transplant |
|
|
Galbladder
|
Problems of the biliary system and pancreas extends to other organs i.e. gallstones interfere or obstruct normal bile flow to duodenum, causes vascular congestions (decrease venous flow, edema & congestion contribute to initial inflammatory response) |
|
|
Cholelithiasis
|
Gallstones develop when cholesterol, bile salts & calcium precipitate Associated w disturbance in cholesterol metabolism & infection Supersaturation of bile with cholesterol (most common type of stone), bile stasis, delayed emptying or change in bile concentration Risk factors: genetics, sedentary lifestyle, female, obesity (fat), middle-aged women (40), estrogen therapy, oral contraceptives & pregnancy (changes cholesterol production or delays emptying of gallbladder) Diagnosis: LFT and abd ultrasound |
|
|
Acute cholecystitis
|
Inflammation of the gallbladder
Calculous cholecystitis (associated w gallstones or biliary sludge) is most common Acalculous cholecystitis r/t immobility, fasting, infection Symptoms: Colicky severe epigastric pain radiating RUQ, indigestion & N/V, children and elderly may have vague tenderness or jaundice C/B perforation or gangrene |
|
|
Chronic cholecystitis
|
Repeated episodes of cystic duct obstruction result in chronic inflammation may lead to pancreatitis, jaundice & pruritus
Flatulence, fat intolerance, dyspepsia, eructation, anorexia, n/v, abdominal pain Biliary colic or steady pain: RUQ to R shoulder Murphy's sign (deep breath while palpated R subcostal area illicits pain) Steatorrhea |
|
|
Cholelithiasis: nonsurgical
|
Low-fat diet, fat-soluble vitamin supplements, bile salts
Opioid analgesia w meperidine hydrochloride, antispasmodic or anticholinergic drugs, antiemetics Percutaneous transhepatic biliary catheter insertion Bowel rest, IV fluids Antibiotics |
|
|
Cholelithiasis: surgical
|
Laparoscopic cholecystectomy (preferred treatment)
Post-op: shoulder pain due to carbon dioxide retention in abdomen, use Sim's position (L side with L leg flexed), deep breathing & ambulation, return to activities in 1-3 weeks Traditional cholecystectomy Post-op: patient-controlled analgesia pump, antiemetics, prevent respiratory complications, wound care, T-tube care placed in common bile duct, NPO, diet is liquids to light meals avoiding excessive fat |
|
|
Acute pancreatitis pathophysiology
|
Rapid onset and progression Excessive pancreatic enzymes resulting in inflammation, increased pancreatic vascular permeability, edema, hemorrhage and eventually necrosis and shock Etiology: idiopathic, alcoholism, biliary tract disease, infection, antibiotics, chemo post-op GI surgery (ERCP) Diagnosis by history, labs and physical exam (ECRP if biliary disease) |
|
|
Acute pancreatitis symptoms
|
Pain LUQ or middle abdominal, piercing & severe Abdominal tenderness w rigidity & guarding Nausea, vomiting, diarrhea Low-grade fever & tachycardia Intravascular damage from trypsin: blue ecchymoses on flanks (Turner's sign) or peri-umbilical (Cullen's sign) Complications: sepsis, RDS, renal failure, GI hemorrhage, jaundice Labs: elevated serum amylase, lipase & glucose, low calcium |
|
|
Acute pancreatitis complications
|
Hemorrhage Paralytic ileus Cardiovascular: hypotension, hypovolemic or septic shock, renal failure Pulmonary: pleural effusion, respiratory distress syndrome, pneumonia Trypsin can increase clotting: disseminated intravascular coagulation Diabetes mellitus Multi-system organ failure |
|
|
Acute pancreatitis treatment
|
Analgesics NPO & TPN or IV fluids early stages Antiemetics for N/V Small, frequent moderate to high carbohydrate, high protein, low fat Avoid foods that cause GI stimulation Abstain from alcohol Fat-soluble vitamin supplements Surgery to repair pancreatic duct or biliary tree |
|
|
Endoscopic retrograde cholangiopancreatography (ERCP)
|
Pre-op: NG tube may be inserted Post-op: monitor drainage tubes, record output, meticulous skin care and dressing changes, maintain skin integrity |
|
|
Bowel Obstruction treatment |
Gastric or enteric decompression Bowel rest with IV fluids Tumor excision or colectomy Emergency treatment for peritonitis or hemorrhage |
|
|
Chronic pancreatitis
|
Progressive destructive disease of pancreas, characterized by remission and exacerbations, replaced by fibrotic tissue
Manifestations: gnawing or cramping abdominal pain, mild jaundice, malabsorption, weight loss, steatorrhea, may develop diabetes Nonsurgical management: drug therapy, analgesics, enzyme replacement (amylase, lipase, trypsin), insulin, small bland meals, low fat, no caffeine, alcohol or smoking |
|
|
Appendicitis |
Inflammation of veriform appendix, from cecum at the terminal end of ileum Obstruction of lumen by accumulated fecaliths, bacteria or parasites Surgical emergency: risk of perforation and sepsis Symptoms: anorexia, periumbilical pain to RLQ, vomiting Treatment: antibiotics and appendectomy |
|
|
Barrett's esophagus |
Metaplasia from flat to columnar epithelial cells due to GERD Increases cancer risk due to enzymes Treatment: corticosteroids, lifestyle changes |
|
|
Peritonitis |
Inflammatory process affecting peritoneum: irritation/pathogens from perforated gallbladder or stomach Abdominal pain, N/V, fever, chills, altered peristalsis, encephalopathy Diagnosis: blood cultures, CT, x-ray Treatment: aggressive antibiotics, control inflammatory process |
|
|
Foreign Body |
Swallowed object lodged in oropharynx, small intestine (>2cm) or pylorus (>6cm) Symptoms: gagging, dysphagia, respiratory distress, bloating Diagnosis: radiograph, ultrasound Treatment: high Fowler's, pro-motility medications Battery or magnet may be medical emergency due to necrosis, or obstruction |
|
|
Gastroenteritis |
Diarrhea and vomiting with fluid loss, electrolyte deficiency, fever, abdominal pain Causes: osmotic, inflammatory, secretory, motility Children and elderly most common Organisms are spread by contact i.e. Norovirus (#1) and Salmonella (#2) Treatment: broad spectrum abx, supportive (fluids and electrolytes) C/B: colitis, toxic megacolon, perforation, sepsis |
|
|
Intussusception |
Abnormal movement of bowel that is folded back Causes: common in infants due to altered peristalsis and respiratory infections, bariatric surgery, IBD, tumors Untreated fatal in 5 days Symptoms: lethargy, vomiting, colicky abdominal pain, palpable mass, diarrhea with blood/mucous Diagnosis by contrast enema Treatment: Reducing agent (barium, water-based, air) if no peritonitis/perforation, laparoscopic reduction or surgical resection |
|
|
GI trauma |
Penetrating: Gunshot or stabbing injury Blunt force: Automobile accidents or domestic violence Seatbelt may cause Cullen's sign (periumbilical trauma) or abdominal bruit (vascular trauma) Symptoms: hemorrhage, altered consciousness, tachycardia, hypotension Treatment: estimate blood loss, restore fluid status with colloids and crystalloids, prevent infection, surgical repair |
|
|
Malnutrition: lab values and half life |
Albumin 3.5-5.5 g/dL, 20 days Pre-albumin 16-40 mg/dL, 3 days Retinal binding protein 2.6-7.6mg/dL, 12 hours Transferrin 200-400 mg/dL Total Lymphocyte 1,800-3,000 |
|
|
Malnutrition: symptoms |
Rapid turnover of epithelial and mucosal cells Dry flaky skin Brittle hair and nails Bleeding gums Muscle wasting Ascites and peripheral edema |
