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75 Cards in this Set

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GI Emergency signs
**abdominal pain
emesis and stools
abdominal tenderness

other: fever, tachycardia, hypotension, dehydration
To auscultate the abdomen use which side of the stethoscope?
diaphragm

should hear 5-25 gurgurls/ min
When should you palpate?
Last (after percussion)
Boborygums:
loud sound of gas passing through the intestines.
At what age do you need to look at the rectum during a physical exam?
40yo

looking for agitation, hemorrhoids
GI endoscopy
lower GI: colonoscopy or protosimoidoscopy) patient instructions
GI endoscopy - 1 week before tell patients to stop taking aspirin (and other anticoagulants) so that polyps will not get removed and cause bleeding.
3-4 days before – don’t eat products w/ little seeds (berries, cucumbers) they get stuck and may look like a growth. 1-2 days before switch to a clear liquid diet and may take supplements to facilitate bowel movement.
Lay on left side – b/c of curvature of intestines.
Esophogastroduodenoscopy:
Upper GI - from the throat down into the stomach
Fecal/ Urine tests and what they reveal
1) Bilirubin presence in urine?
2) fecal lipid (less then 7g/24hrs)?
3) fecal occult blood?
4) fecal urobilinogen
a) elevated?
b) lowered?
5) Stool culture w/ no pathogens?
6) no O & P (ova or parasites) in stool
1) biliary obstruction
2) possible insufficient pancreatic enzyme secretion.
3) positive GI bleeding
4) a) elevated: impaired liver function b) lowered: total biliary obstruction
5) presence of bacterial, viral, or fungal GI infection
6) possible infection
Why is motrin the drug of choice if someone is having liver problems?
Pt w/ liver problems may also have clotting problems so drugs need to not affect clotting.
What is the best way to apply pressure to the liver if there is bleeding?
have pt lay on right side
2 major issues of liver problems?
bleeding
pain
Radiographic testing for GI
-abdominal x-ray
- CT scan
- contrast radiography: barium above/ below, cholangiography, endoscope (dye into ampulla)
Drug therapy for GI DO
antacids
H2 receptor antagonists
PPI
laxatives
emetics
digestants
anti-emetics
Following surgery of the esophagus what are important aspects of care?
- Semi-fowlers
- antacids for relief
- excessive drooling could be indicative of a problem.
Peutz-Jehger's syndrome
freckles on mucosa (lips or anus) indicates hamartoma (benign tumors of the SI or colon)
Gastro Esophageal reflux disease (GERD):
3 Key S&S
GERD - increased risk if obese. More of a problem if obese b/c pressure of the wt., space, and physiologic changes – sphincter not as tight maskes gastric contents come up which causes digestion of esophagus.

- pyrosis (heart burn)
- chest pain
- regurgitation (burping w/ vomit or full on vomiting)
Management of GERD
- Start w/ conservative interventions first. Pharm or non-surg
- Reduce pH by diet changes – more alkaline foods, small frequent meals, don’t eat 3-4 hours before bed.
Pharm management of GERD
1) Why histamine receptor antagonist?
other pharm:
1) inhibit parietal cell activity to increase pH and dec. gastric volume.
other:
Antacids,
PPI (inhib parietal cell activity)
Fundoplication
surgical treatment of GERD
pull stomach up and wrap anterior part of stomach around lower esophagus to reinforce sphincter.
vomiting bright red or coffee ground material or black stools could be indicative of bleeding where? and possible reasons why?
bleeding of stomach or esophagus

possible reasons: ulcer, varices, liver disease, gastritis, mallory-weiss
bright red maroon bleeding could be indicative of what?
small intestine ulcer or tumor
Blood in stool indicative of?
colon cancer, polyps, colitis, diverticulosis
Bright red bleeding of rectum could be indicative of?
hemorrhoids, diverticulosis, tumor.
Varices:
blood freely flowing from a varix in the lower esoph creating a pool of blood, usually indicates a problem of the liver.
Nursing Assessment for GI bleeding
- monitor severity of blood loss
direct measures: lab values (Ht - Low indicates – losing blood from somewhere vomit or other), color and amt of blood, stool measurements
indirect measures: BP (down), HR (up), confusion, lethargy
Barium swallow reveals
reveals varices or strictures
would you give an NG tube if one is throwing up blood?
NO
Esophageal varices:

Physiology of:

40-70% will result in mortality this is usually caused by:
blood freely flowing from a varix in the lower esoph creating a pool of blood, usually indicates a problem of the liver.

phys: portal hypertension -> vessels dialate -> can be .5-1cm or larger

mortality from: exsanguination, liver failure, sepsis, cerebral edema, anemia
Tx for esophageal varices
1) Sclerotherapy:
2) Esophageal Banding
3) Balloon Tamponade
1) solution injected into bleeding varix or overlying submucosa -> obliterates the lumen by forming thrombosis, wheras injection produces inflamation followed by fibrosis
1st injection control bleeding in 80% of cases.
2) sucks varices in and clamps w/ band and tightens it so it dies and falls off. Fewer complications then slerotherapy.
3) balloon exerts pressure on the varix to control bleeding - use for a few days until you identify the problem.
Diverticulitis
small diverticuli in the esophagus - trapping of food is an issue
Mallory-Weiss:

treatment:
mucosal laceration caused by force of vomiting or severe coughing, generally at esophagogastric junction

tx: injection of epinephrine, coagulation therapy, surgery - rare

common in people who induce vomiting or have severe coughs (COPD). Not as profound as varices, but over time may cause them to lose more blood then they are producing.
Peptic ulcer disease (PUD):

causes:
lesions of lower esophagus, stomach, duodenum, or jejenum b/c of contact w/ HCl and pepsin

causes:
- H. Pylori
- use of NSAIDS
- inadequate protection of mucous membranes
- pathologic hypersecretory DO
Pharm drugs used to treat H. Pylori PUD
- Antibiotics: tetracycline, amoxicillin
- H2 blockers: cimetidine, rantidine
- PPI (proton pump inhib): omeprazole, esomeprazole
- stomach lining protector: bismuth, carafate, subsalicylate
Treatment of PUD
gastric lavage
gastroscopy w/ cautery or laser
-ostomy:

one prefix precedes -ostomy:

2 prefixes precedes -ostomy:
an opening into.

one prefix - surgical opening is to the exterior

2 prefixes - anastomose from one to the other.
Common Gastric Surgeries
- Vagotomy w/ gastroenterostomy
- vagotomy w/ antrectomy
- vagotomy w/ pyloroplasty
- Bilroth I
- Bilroth II
•Vagotomy – part of vagus nerve – anterior diversion of vagus nerve (parasympathetic nerve) causes sympathetic to take so over so GI slows down.
•Anterectomy – part of stomach taken out – removal of antrum (lower portion of stomach.
•Pyloroplasty – surgery to widen the opening of the end of the pylorus, which is found in the lower portion of the stomach, so that stomach contents can empty into the duodenum (small intestine).
•Bilroth I – top half of stomach is reconnected to the duodenum
•Bilroth II – some duodenum is left, but stomach is reconnected to SI
Aftercare for patients with gastric surgery
•Bowel sounds return.
•Are they passing gas.
•Get up and get moving to move things around.
•Opioids – will diminish bowel sounds
•*Ambulate
•TCDB – splint, IS
General anesthesia will have what 3 affects?
o Celia stop
o Breathing stops
o Pushing secretions down w/ negative pressure.
Dumping syndrome

At risk for _____ b/c of ____ nutrient deficiency.
part of GI is removed so as soon as one eats it goes right through, need to look at foods they are eating b/c they are not getting nutrients if dumping it out right away.
o B12 def – helps w/ clotting, don’t have as much colon any more so this gets depleted.
Wound complications of gastric surgery
dehiscence: wound edges are not approximated, rips open (rare)

eviseration:abdominal viscera protruding out.
Pancreatitis
enzymes used to aid in digestion are inappropriately activated inside the pancreas and the pancreas starts to digest itself -> enzymes begin to spill out into circulation
Acute Pancreatitis usually has a SUDDEN onset of what symptoms?

what enzymes are elevated in the blood as a result of this?

what test usually shows an abnormal result?
N/V, knife like pain in upper abdomen (seems to pass to the back and partially relieved by leaning forward)

amylase and lipase

liver function tests (jaundice may be present)
Whipple Procedure
pancreaticoduodenectomy - removes the head of the pancreas

usuallly done if tumor of pancreas or bile duct; inflamation of pancreas or chronic pancreatitis.
Gall bladder problems are usually indicative of what type of diet?
high fat
cholecystitis
blockage of cystic duct by gallstone (cholesterol stone)
-n/v/anorexia, elevated WBC, RUQ pain
MAIN Functions of the liver
-detoxify the blood of hormones, drugs & chemicals
-adds prothrombin & fibrinogen (clotting agents) to the blood
-secretes bile
-metabolizes carbs, fats & proteins
-makes glucose available
-stores fat-soluble vitamins, B12, copper & iron
-convert ammonia to urea
-form ketone bodies, acetate, lipoproteins, cholesterol & phospholipids
Hepatitis
-Acute or chronic 5 or more types: A, B, C, D, E most common causes
-other viruses such as cytomegalovirus and Epstein-Barr virus may cause hepatitis
-other causes: alcohol abuse, certain chemicals & drugs, autoimmune d/so
-amebic dysentery & malaria may also inflame the liver
Stages of Hepatitis and S&S w/ in each phase.
-following incubation (6-24 weeks), prodromal preicteric phase begins w/ lethargy, anorexia, n/v/, RUQ pain
-after 2 days -2 weeks of prodrome, icteric phase begins w/ dark urine, pale stools, jaundice, RUQ pain
-convalescent phase may be long and drawn out over several weeks w/ fatigue & malaise
Treatment of acute hepatitis
-initial stages: bed rest (decrease metabolic demands)
-after acute stage, pt can gradually resume normal activities
-pt need not be totally isolated
-specific precautions depend on type of hepatitis
-hep A: feces & urine must be carefully disposed of
-for B, C & D: avoid contamination by blood or other body fluids
-for people who have been in close contact w/ pt w/ hep A, injections of gamma globulin may be given (should be given)
-persons exposed to blood containing B virus may receive hep B immune globulin
What should those who have been in close contact with a person with Hep A receive?
injection of gamma globulin
What should those who have been exposed to blood containing Hep B virus receive?
Hep B immune globulin
What are symptoms of chronic hepatitis?
-liver inflammation lasts six months or longer
-accompanied by persistent nausea, fatigue, jaundice
-may be mild or lead to cirrhosis or cancer of the liver
How does alcohol cause hepatitis?
-because of toxic effects of alcohol on liver, frequent use of large quantities of alcohol can result in inflammation of the liver
-if left untreated, alcoholic hepatitis may lead to cirrhosis and eventually liver failure (high mortality rate)
Nursing interventions for hepatitis are geared towards what 2 things?
prevention &
symptom management
Hepatitis patient is treated at home unless FULMINANT FAILURE DEVELOPS, what is this?
-progression from jaundice to encephalopathy in less than one week
-brain exhibits cytotoxic edema
-encephalopathy is seen in chronic cirrhosis, slowly progressive liver failure does not produce cerebral edema or neurologic death
-latter complications are seen only in patients suffering the fulminant course and greatly complicate their management
-etiology of cerebral edema is unclear
cirrhosis - the 8th leading cause of death - what are the most common causes in the US?
chronic alcoholism & hep C
Alcoholic Liver Disease

Alcohol injures the liver by blocking what?
-alcoholic cirrhosis develops after more than a decade of heavy drinking
-amount of alcohol that can injure liver varies from person to person
-in women, as few as 2-3 drinks per day have been linked w/ cirrhosis (men 3-4)

-injures liver by blocking normal metabolism of protein, fats & carbs
Complications/problems caused by cirrhosis?
Edema, ascites, bruising & bleeding, itching, jaundice, gallstones

toxins in the blood or brain, senstivity to meds, portal hypertension, varices, impact other organs
Treatment of Cirrhosis
depends on cause and complications
-damage cannot be reversed
-treatment can stop or delay further progression
-depends on cause
-Hep related cirrhosis involves meds
Ascites:

4 causes
abnormal buildup of fluid in the peritoneal cavity

1) disease in cavity producing fluid
2) fluid back up from liver or large BV (portal hypertension)
3) low protein state in the body
4) miscellaneous
Treatment of ascites
Monitor what?
What meds?
monitor: fluid, diet (Na restriction), weight

diuretics (lasix)
Diuretic resistant ascites treatment
- paracentesis
- LeVeen or Denver (peritoneovenous) shunt
- liver transplant
- extracorporeal ultrafiltration of ascitic fluid w/ reinfusion
- transjugular intrahepatic portosystemic stent shunt (TIPSS)
TIPSS
transjugular intrahepatic portosystemic stent shunt

radiological procedure in which stent is placed
Denver shunt
from peritoneal into SVC (put extra fluid back in circulation)
Portal hypertension
increase in the pressure w/in the portal vein (vein that carries blood from the digestive organs to the liver)
Portal systemic encephalopathy (PSE)
(aka: hepatic enceph., hepatic coma)

Etiology:
neuropsychiatric syndrome caused by liver disease & usually associated with portal-systemic shunting of venous blood

etiology: liver cant metabolize and detoxify digestive products -> toxins escape into systemic circulation -> toxins bypass parenchymal cells -> results in toxic effect on the brain

usually precipitated by specific, potentially reversible causes (GI bleeding, infection, etc)
Assessment findings of PSE
- personality changes, impaired consciousness, frank coma/stupor as it advances
-constructional apraxia—literally can’t connect the dots
-asterixis—flapping of hands

possible agitation and seizures (seizures suggest another cause)
PSE treatment
- in mild cases treat the cause

-eliminate toxic products
-clean out bowels w/ enemas, dietary protein should be eliminated
-oral lactulose should be given
-sedation deepens encephalopathy and should be avoided
Lactulose:
syrup given orally or as a retentin enema

aka: Cephulac, Chronulac, Acilac
Hepatorenal syndrome

s&s:

What is the goal of treatment?
diseases that involve the liver and kidneys - acute and functional progressive reduction of renal blood flow and GFR s/t renal cortical vasoconstriction in the setting of decompensated cirrhosis

s&s: decr urine, dark urine, jaundice, weight gain, abdominal swelling, change in mental status, dementia, delirium, confusion, coarse muscle mvmt, n/v/, blood in vomit and/or stools

to improve liver function while supporting systems
How does lactulose work?
-not absorbed in SI, in LI it draws ammonia out & acts as laxative to eliminate accumulated ammonia from colon
What type is the majority of hepatitis cases?

How is it transmitted?

What is its most characteristic feature?
type C - THE SILENT EPIDEMIC

only by blood

elevations in serum ALT (alanine aminotransferase) in a fluctuating pattern)
What is the length of a typical cycle for Hep C?
typical cycle from infection to symptomatic liver disease takes 20 years
= “silent epidemic”
What is the treatment for HCV?
**combination therapy w/ a interferon (interferes w/ virus synthesis) and ribavirin (antiviral)

other treatments
corticosteroids – not been effective
Who should be tested for HCV?
-individuals w/ history of transfusion of blood or blood products prior to 1990
-who are on chronic hemodialysis
-history of injection drug use
-multiple sexual partners
-spouses or close houshold contact of hep C***
-who share instruments for intranasal cocaine