Reading...
Play button
Play button
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;
137 Cards in this Set
- Front
- Back
|
Acute abdominal pain results from
|
- abdominal structures
- pelvic structures - Ischemia of blood vessels - may be a life-threatening illness (hemorrhage, obstruction, rupture) |
|
|
Causes of Acute abdominal pain
|
- appendicitis
- bowel obstruction - cholecystitis - Diverticulitis - gastroenteritis - renal calculi - UTI - pelvic inflammatory disease - perfortaed ulcer - peritonitis - ruptured AAA - ischemic bowel - ruptured ectopic pregnancy - testicular disorders |
|
|
Best way to assess abdominal pain
|
OLDCART
|
|
|
OLDCART
|
- onset
- location - duration - characteristic - associated sx - relieving and exacerbating factors - temporal issues |
|
|
h/H for dehydration and occult bleeding
|
up for dehydration, down for occult bleeding
|
|
|
urinalysis
|
- looking for protine, blood backteria, UTI, urobiligen would be up, ketones up if dehydrated
|
|
|
why do an ECG?
|
pain is cardiac pain unless it is ruled out, so ECGs always done
|
|
|
Ultrasound and CT
|
US: push fluids, must have full bladder
CT: may be NPO |
|
|
Goals for acute abdominal pain
|
- identify cause
- treat cause - monitor and treat complications (hypovolemia, shock) - pain management (don't treat unless know what it is, need pain to determine what it is!) - exploratory laparotomy |
|
|
things that may accompany pain
|
N/V (what color?)
bowel patterns (color?) Change in (clay colored?) |
|
|
Vital signs with acute abdominal pain
|
- increased pulse
- decreased BP (hypovolemia) - increased temperature (infection, inflammation) - intake and output must also be assessed |
|
|
Order of GI assessment
|
Inspection
Auscultation Palpation (gentle) Rectal (defer if appendicitis suspected) |
|
|
GI sounds for bowel obstruction
|
hyperactive proximal (before)
absent distal the obstruction (After) |
|
|
Initial management of acute abdominal pain
|
- assess
- ensure airway - oxygen if hypoxic - large bore IV (may need rapid fluid resuscitation) - labs/dx - Type/Crossmath, Type/Screen - NPO - Possible NG insertion - Prepare for emergency surgery |
|
|
Gi post op care
|
- fluid volume and electrolyte management
- NG tube (if upper Gi surgery will have 12 hours of dark red, dark brown, then will become more bile green/yellow) - N/V management - pain control - early ambulation - gradual advancement of diet - risk for clots, wound problems, pain management |
|
|
Blunt Abdominal trauma examples
|
- may not have visual evidence of injury
- falls - MVC - pedestrian event - assault with blunt object - crush injury - explosions |
|
|
Penetrating abdominal trauma examples
|
- knife
- gunshot wounds - other projectiles/missiles ***do not pull out objects!!! support them |
|
|
Clinical manifestations of abdominal trauam
|
- guarding and splinting of abdominal wall
- hard, distended abdomen (looks like peritonitits) - decreased or absent bowel sounds - contusions, abrasions, or bruising - Abdominal pain **pain over scapula (irritation of splenic nerve) - hematemesis - hematuria - S/S of hypovolemic shock - ecchymosis |
|
|
S/S of hypovolemic shock
|
- tachycardia
- orthostasis (do a tilt test if not dangerous for pt) ... |
|
|
Pain over scapula or shoulder pain
|
scapula- irritation of splenic nerve
shoulder- ectopic pregnancy |
|
|
Cullen's sign
|
ecchymosis around umbilicus
- abdominal trauma possible |
|
|
If pt is vomiting or has stool or anything...
|
do occult blood testing on them!!
|
|
|
Bowel sounds with peritonitis
|
absent
|
|
|
Bowel sounds with ruptured diaphragm
|
- bowel sounds can be heard in the chest
|
|
|
Why do a follow up H/H from very first one
|
- it takes a while for the H/H to drop so it make show normal in ER arrival, but will change later, look at serial H/H, takes like 24 hours
- H/H may also drop with fluid resuscitation (due to hemodilution not necessarily bleeding) be aware of this |
|
|
What dx study can be done at bedside
|
abdominal ultrasound
|
|
|
What is peritoneal lavage looking for?
|
- RBC > 100,000
- WBC > 500/uL - high amylase level - bacteria - bile (hepatic injury) - fecal matter (bowel perforation) |
|
|
Nursing management of abdominal trauma
|
- ensure patent airway
- maintain oxygenation - Apply pressure to external bleeding - 2 large bore IV catheters with WARM NS or LR (cold will make them hypothermic) - prepare for blood or volume expanders - Stabalize bulking dressing - don't remove penetrating objects - cover protruding organs or tissue with sterile saline - urinary catheter (with temp regulator) - NG if evidence of facial trauma - prepare for diagnostic peritoneal lavage (results will determine if pt needs emergent surgery) - ongoing assessment of vital signs, LOC, oxygen saturation, urine output - monitor temp, maintain warmth - pain management - nutrition - potentially complex wound care |
|
|
Peritonitis
|
local or systemic inflammation of peritoneum
|
|
|
Primary causes of peritonitis
|
- blood borne organisms (like blood sepsis)
- genital tract organisms (women that come in for pelvic inflammatory disease and STDs) - cirrhosis with ascites |
|
|
Secondary causes of peritonitis
|
- ruptured appendix
- blunt or penetrating trauma - ruptured diverticulitis - ischemic bowel - GI obstruction - Pancreatitis - Perforated ulcer - Peritoneal ulcer - Peritoneal dialysis - Post operative (belly opened up) |
|
|
Clinical presentation of Peritonitis
|
- Tenderness in infection area
- Rebound tenderness - Abdominal rigidity - Abdominal pain - Distention or ascites - N/V - increased temp - increased pulse and respirations - bowel changes |
|
|
Complications of Peritonitis
|
- hypovolemic shock
- sepsis - intraabdominal abcess - paralytic ileus - Acute respiratory distress syndrome - death (multi-organ dysfunction syndrome) |
|
|
CTs and cat scans can see what?
|
ascites and abscess
|
|
|
Treatment of peritonitis
|
surgical drainage and repair
|
|
|
Preoperative care for peritonitis surgery
|
- NPO
- IV and electrolyte replacement - NG placement - Antibx - Analgesics - Respiratory support - Surgical preparation |
|
|
Post operative management of peritonitis surgical pt
|
- NPO
- NG low intermittent suction - Semi-fowler's position - Vital sign assessment - IV replacement - I&O - TPN - Antibx (C-dif risk) - prn blood replacement - pain mangement - antiemetics - prn oxygen and pulmonary toliet/prevention - DVT prophylaxis - complex wound care if open procedure (drains, can't close belly if there is an infection in there) |
|
|
Acute Peptic ulcer disease (PUD)
|
superficial erosion
minimal inflammtion short duration resolves quickly when cause is removed |
|
|
Chronic PUD
|
erodes through muscular wall and forms scarring
- long duration, many months or intermittently - more common than acute (4x more) |
|
|
Gastric ulcers
|
- any portion of stomach
- most common in lesser curvature close to antral junction - in western countries duodenal are more common - older, women, <50yo |
|
|
Causes of gastric ulcers
|
- Aspirin, NSAIDS, corticosteroids
- chronic alcohol abuse - chronic gastritis - bile reflux - nicotine * majority present with H. Pylori |
|
|
Secretions in gastric and duodenal ulcers
|
Gastric acid is normal to low in gastric ulcers and higher in duodenal
|
|
|
H. Pylori
|
produces urease to buffer ammonia and mediate inflammation (which is why is survives for along time in GI tract)
- more destructive when combines with drugs and smoking |
|
|
Duodenal ulcers
|
- anyone, any age, usually 35-45 increased risk
- more common of peptic ulcers - famililal (O blood) - increased HCl secretion - H. Pylori infection is #1 cause of duodenal ulcers |
|
|
Medical conditions that increase risk for duodenal ulcers
|
- COPD (corticosteroids)
- liver cirrhosis - chronic pancreatitis - hyperparathyroidism - chronic renal disease - smoking and alcohol |
|
|
Zollinger-Ellison syndrome
|
rare condition
severe peptic ulceration gastric acid hypersecretion elevated serum gastrin |
|
|
Stress-related mucosal Disease
|
"physiologic stress ulcer"
- develop after major physiologic insult (trauma, surgery, mechanical ventilation) |
|
|
Prophylaxis of stress related mucosal disease (SRMD)
|
prophylactic H2 blockers
-----tidine Tagamet, Zantac, Pepcid, Axid OR Proton pump inhibitors - ---Prazole - Nexium, Prevacid, Aciphex, Protonix, Dexilant |
|
|
Clinical Manifestations of peptic ulcer
|
- common to have no pain or other symptoms (lack of sensory pain fibers)
- If there is pain it depends on gastric or duodenum |
|
|
Gastric ulcer pain
|
high in epigastrium
1-2 hours after meals Gastric acid pain is burning or gaseous |
|
|
Duodenal ulcer pain
|
mid epigastric region beneath xyphoid process
- back pain if posterior aspect - 2-4 hours after meals - tendency to occur, disappear and occur again |
|
|
3 main Aims of treatment of non-complicated PUD
|
- reduce gastric acid
- enhance mucosal defense - minimize harm on mucosa |
|
|
Medical regimen for PUD
|
- adequate rest
- dietary modification (not very good cause its just "don't eat what hurts you") - Drug therapy - eliminate smoking and alcohol - long term follow-up care - stress management - generally treated in ambulatory care settings - healing requires many weeks of therapy - pain subsides after 3-6 days |
|
|
Healing of PUD non complicated
|
complete healing 3-9 weeks
- assessed by xray or endoscopic exam - may stop aspirin and nonselective NSAIDS *very improtant for pts to finished PUD meds or it can become chronic! |
|
|
Meds for PUD
|
H2 blockers
Proton pump inhibitors Antibiotics Antacids Anticholinergics Cytoprotective |
|
|
Improtant thing about protin pump inhibitors
|
only for temporary use! not long term!
|
|
|
Antibiotics for PUD
|
amox, Biaxin, Flagyl (use multple antibx because of resistance)
- 7-14 days - multiple agents - lots of antibx cause nausea **Don't combine flagyl with alcohol |
|
|
Antacids
|
use with caution, used as adjunct therapy
- increase gastric pH bu neutralizing HCl - effects on empty stomach take 20-30 min - after meals may wait 3-4 hours |
|
|
Anticholinergics
|
to control acid secretions
|
|
|
Cytoprotective
|
Carafate, Cytotec (not to be used with pregnant pts unless inducing labor!)
|
|
|
Nutritional therapy for PUD
|
- bland diet during actue phase is controversial
- 6 small meals during symptomatic phase - individual for pt |
|
|
Acute exacerbation of PUD complications
|
perforation
hemorrhage Obstruction ** All considered emergencies! - treatment is same for all major GI complications |
|
|
S/S of PUD exacerbation
|
bleeding
increased pain and discomfort N/V |
|
|
Management of PUD exacerbation
|
- similar to upper GI bleed
- endoscopic eval to reveal amount of inflammation or bleeding and ulcer location (may cauterize or take samples) - 5 year follow-up plan recommended for acute exacerbation ***H pylori increases risk of gastric cancer*** |
|
|
GI obstruction causes
|
- ulcers in antrum and prepyloric and pyloric areas of stomach
- duodenum - edema - inflammation - pylorospasm - fibrous scare tissue formation - all contribute to narrowing of pylorus |
|
|
hematemesis
|
coffee grounds appearance
or bright red |
|
|
hematochezia
|
maroon colored stool
|
|
|
3 meds that cause diruption of gastric mucosa
|
aspirin, nsaids, corticosteroirds
|
|
|
Early phase of GI obstruction
|
gastric emptying is normal but over time more contractual force to empty stomach is needed and stomach wall hypertrophies
|
|
|
After long standing obstruction the stomach
|
dilates and becomes atonic
- most common near pyloris - symptoms are gradual |
|
|
Clinical manifestations of GI obstruction from ulcer or other GI obstructions
|
- usually long standing ulcer pain
- pain progresses to generalized upper abdominal pain - pain worse toward end of day as stomach fills and dilates - relief from belching or vomiting ***Hallmark of GI obstruction is projectile vomiting!*** - Constipation - Dehydration - swelling in stomach and upper abdomen - loud peristalsis, hyperactive bowel sounds (proximal) - no bowel sounds distal to obstruction - visible peristaltic wave (esp on thin person) - stomach may be palpable |
|
|
Borborygmi
|
hyperactive bowel sounds
|
|
|
Clinical priority for Gi obstruction
|
Decompress the stomach
- NG tube with intermittent suction for about 24-48 hours - continuous decompression |
|
|
Continuous decompression allows for-
|
- stomach to regain its normal muscle tone
- ulcer to begin to heal - inflammation and edema to subside |
|
|
After several days of suction...
|
- clamp NG and residual volumes checked periodically
- may start pt on fluids first to make sure they can tolerate that before pulling tube - common to clamp tube overnight for 8-12 hours and measure residual in morning |
|
|
Healthy residual amount
|
under 200mL
|
|
|
If pt has healthy residual then can...
|
clamp tube and can start on oral fluids at 30mL/hour and gradually increase
**assess pt for signs of distress and vomiting** as residual decreases solid foods are added and tube removed |
|
|
2nd Clinical priority for GI obstruction
|
Fluid electrolyte management
|
|
|
How much fluids to administer?
|
according to degree of dehydration, vomiting, and electrolyte imbalance
- correct any existing fluid and electrolyte imbalances - fluids and electrolytes are replaced by IV infusion until pt is able to tolerate oral feeding without distress |
|
|
3rd clinical priority for GI obstruction
|
Treatment of pyloric obstruction
|
|
|
How to treat pyloric obstruction?
|
endoscopically treated with balloon dilations
surgery may be required to remove scar tissue surgery if bowel rest, reintroduction of foods, etc. doesn't work |
|
|
Mechanical GI obstruction
|
- generally small intestines
- surgical adhesion (scar tissue, intestines stick together) - hernia - tumor/carcinoma (inside of bowel or pushing on it from outside) - strangulation/incarceration of bowel, torsion, twisting (***BOWEL EMERGENCY!***) |
|
|
Non-mechanical GI obstruction causes
|
- usually from failure of peristalsis
- neuromuscular or vascular disorders - neuropathy (gastroparesis to any part of the GI tract) - anything that can cause paralytic ileus (post op, peritonitis, inflammation, acute pancreatitis, appendicitis, hypokalemia, thoracic or spinal fractures, neuromuscular diseases) |
|
|
Pseudo obstruction
|
apparent mechanical obstruction without x-ray demonstration
|
|
|
Vascular obstruction
|
- emboli or mesenteric artery athersclerosis
|
|
|
Medication causes of obstruction
|
- opiods, antidepressants, psych meds (anti-SLUD, SSRI, TCA)
|
|
|
Clinical manifestations of SMALL intestine obstruction
|
- rapid onset
- frequent, copious vomiting (projectile, contains bile) - intermittent, colicky, crampy abdominal pain - will produce stool for short amount of time - greatly increased abdominal distention hyperactive bowel sounds above obstruction |
|
|
Clinical manifestations of LARGE intestine obstruction
|
- gradual onset
- vomiting is rare (if so, orange brown, smells like stool) - low, grade cramping abdominal pain - absolute constipation- no stool - increased abdominal distention both will have hyperactive sounds above area of obstruction - temp rarely goes above 100 unless strangulation or peritonitis occurred |
|
|
Conservative management of lower GI obstruction
|
- NPO
- NG tube - IV resuscitation (NS or LR) - Analgesics (which will slow bowel even more) - parenteral nutrition |
|
|
When surgical management for lower GI obstruction?
|
- Emergent of bowel strangulation suspected
- if no response to conservative mgt in 1-2 days |
|
|
When should you immediately report what urine output?
|
less than 0.5 mL/kg of body weight
-risk for renal failure! |
|
|
high intestinal obstruction metabolic ______
low intestinal obstruction, metabolic______ |
alkalosis
acidosis |
|
|
NG tube care
|
oral care
nose care (wash and dry area, apply water soluble lubricant, chack nose for irritation, retape tube) check NG tube for patency q 4h |
|
|
What is the most common complication of PUD
|
hemorrhage
|
|
|
Hemorrhage develops from
|
- granulation tissue found at base of ulcer during healing
- ulcer through a major blood vessel - esophogeal varices - esophagitis - Mallory-weiss tear - gastric cancer - blood dyscracias - anticoagulants - renal failure |
|
|
Younger age disease for polyps
|
Familial Adenomatous Polyposis
|
|
|
Lower GI hemorrhage causes
|
polyps
Inflammatory bowel disease Diverticulitis (can lose liters!) cx vascular abnormalities hemorrhoids |
|
|
Clinical presentation of GI hemorrhage
|
- hematemesis (bright red or coffee grounds)
- Melena (lower Gi bleed) - Bright red stools (hematochezia) - Changes in vital signs (assess q 15 min) - S/S of shock - look for presence or absence of bowel sounds |
|
|
CBC/Hgb and HCt of Gi bleed
|
provide a baseline, may take 4-5 hours to reflect loss
|
|
|
Management of Gi bleed first priority
|
Restore Fluid volume
|
|
|
Restoring fluid volume of GI bleed
|
- 2 large bore IV lines
- Intially isotonic crystalloid replacement (LR) - Blood replacement (more blood someone gets the more chance for reaction) |
|
|
Nursing assessment during fluid resuscitation
|
- assessment of fluid overload (CVP or hemodynamic monitoring)
- I&O - urinary catheter with UROMETER q 1 hour - BUN/Creatinine (At risk for renal failure) - Cardiac monitoring - Pulmonary assessment - Monitor serial HgB/Hct |
|
|
blood transfusion and hgb/hct monitoring
|
- pre and post transfusion
- 1 unit of blood = i gram of Hgb increase - so may need more than 1 unit of blood |
|
|
Next priority for management of GI hemorrhage
|
- gastric decompression
- NG with possible lavage - may have to have iced saline |
|
|
Medication used for Arterial GI bleeding (especially varices)
|
Pitressin (ADH, Vasopressin)
* acts as vasoconstriction on V1 receptors **watch for hypotension and SIADH |
|
|
More signs and symptoms of shock
|
- low BP
- rapid - weak pulse - increased thirst - cold, clammy skin - restlessness - for GI bleed monitor vitals q 15-30 min and inform MD of major changes, also obtain orthostatic vitals |
|
|
Control anxiety with GI bleed
|
use anxiolytics with care because restlessness is one of the warning signs of shock
|
|
|
Clinical presentation of GI hemorrhage
|
- change in vital signs (assess q 15min)
- Increase in amount and redness of aspirate (signal for massive upper GI bleed) - increase in amount of gastric contents - decreased pain because blood neutralizes acidic gastric contents |
|
|
IF pt has a venous pressure line or pulmonary artery catheter in place, record every...
|
1-2 hours
|
|
|
What is the most lethal complication of PUD?
|
Perforation because it leads to peritonitis, sepsis, and shock from multiorgan dysfunction
|
|
|
Mortality rates are high in what location of gastric ulcers?
|
gastric ulcers because lots of organs are by the stomach and acidic pH of 1 leaks around these organs.
however, most common perforation is duodenal ulcers |
|
|
smaller vs. larger ulcer healing
|
small perforation may seal itself
large perforations need immediate surgical closure |
|
|
Clinical manifestations of perforation
|
- sudden, dramatic onset
- severe abdominal pain spreads throughout abdomen - possible referral pain to shoulder - rigid, board-like abdominal muscles - shallow, rapid respirations - bowel sounds absent - N/V - Hx/reporting symptoms of indigestion or previous ulcer - hard to tell with symptoms where location of perforation is (gastric or intestinal ulcer) |
|
|
With perforation, the peritoneal cavity may contain...
|
- air
- HCl - Bacteria - Bile, pancreatic fluid, enzymes |
|
|
With perforation, what can occur within 6-12 hours
|
Bacterial peritonitis (that's quick!!)
|
|
|
Immediate focus of perforation
|
stop spillage of gastric or duodenal contents into peritoneal cavity
**early recognition and assess appropriately! ** Make sure pt gets proper care! |
|
|
2nd focus for perforation
|
- assess hemodynamic status q 15 min
- monitor for shock - central venous pressure line inserted and monitored hourly - ECG monitoring |
|
|
Treatment for perforation
|
- Restore circulating volume with LR, NS, or albumin
- Packed red blood cells may be becessary - continuous gastric decompression with NG tube (place by perforation helps reduce inflammation) - may require irrigation with order and repositioning. DO NOT IRRIGATE WITHOUT AN ORDER!! - NPO - broad spectrum antibx - pain meds - prepare for emergency surgery (open or laproscopic) |
|
|
Indications for Surgical therapy for PUD
|
- uncommon because antisecretory agents are used instead
- unresponsive to medical management - concern about gastric cx - drug induced but can't withdraw from drugs |
|
|
Billroth I
|
surgical procedure
- gastroduodenostomy - removal of distal 2/3 of stomach and anastomiosis of gastric stump to duodenum |
|
|
Billroth II
|
- surgical procedure for PUD
- gastroieiunostomy - removal of distal 2/3 of stomach and anastomiosis of gastric stump to jejunum *Preferred procedure |
|
|
Vagotomy
|
severeing the vagus nerve (to stomach), will decreased acid production in stomach. Don't like have to do this unless needed.
- done in conjunction with gastrectomy (vagus=parasympathetic system--> SLUD) |
|
|
Pyloroplasty
|
- surgical enlargement of pyloric sphincter
- commonly done with vagotomy - decrease gastric motility and gastric emptying - if accompanying vagotomy, increases gastric emptying |
|
|
Preop care for PUD surgeries
|
- educate pt about what type of surgery, what wound will be like (may not know before hand whether it will be laparoscopic or open)
- surgeon should educate pt/family on surgical procedure and nurse can clarify questions - Give instructions on comfort measures - pain relief - coughing and deep breathing - NG tube - IV fluids |
|
|
Post op care
|
- NG placed with suction to relieve suture pressure
** MUST be patent, DO NOT REMOVE TUBE!!!! if there is a lot of blood or clotting, call MD!!** - assess gastric aspirate (yellow green in 48 hours) - observe for signs of decreased peristalsis and lower abdominal discomfort (intestinal obstruction) - I&O - vitals q4h - pain control - pulmonary toileting - splinting of incisions - frequent position changes - assess dressing and drain output - IV therapy - Infection signs - long term complication (pernicious anemia) |
|
|
Post op complications of PUD surgical procedures
|
- similar to gastric bypass
- dumping syndrome - post prandial hypoglycemia - bile reflux gastritis |
|
|
Dumping syndrome
|
decreased ability of stomach to control amount of gastric chyme entering small instestine
- large bolus of hypertonic fluid enters intestine--> increase of fluid drawn into bowel lumen - symptoms are a result in lowered plasma fluid because fluid was drawn into GI |
|
|
When does dumping syndrome occur and what are S/S
|
- 15-30 minutes after eating
- weakness - sweating - palpations - dizziness - abdominal cramps - borborygmi - urge to defecare - lasts no longer than an hour |
|
|
Post prandial hypoglycemia
|
- a variant of dumping syndrome
- a result of uncontrolled gastric emptying of a bolus of high carbs into small intestine --> increased blood sugar--> excessive insulin release into circulation |
|
|
When does postprandial hypoglycemia occur and S/S
|
- 2 hours after meals
- sweating - weakness - mental confusion - palpitations - tachycardia - anxiety |
|
|
Symptoms of post pandreal hypoglycemia are relieved by
|
immediate ingestion of sugared fluids or candy
|
|
|
Bile reflux gastritis
|
- reflux of bile onto gastric mucosa
- causes damage to mucosa - may result in back-diffucion of H= ions through gastric mucosa --> PUD |
|
|
S/S of bile refluc gastritis
|
continuous epigastric distress that increases after meals
|
|
|
Treatment for Bile reflux gastritis
|
- cholestyramine (Questran) relieves irritation
- alluminum hydroxide antacids also used |
|
|
Post operatively, aspirate is observed for...
|
- color, amount odor
** bright red at first then darkening within first 24 hours ** color changes to yellow-green within 36-48 hours |
|
|
Post operative general info about nutritional therapy
|
- start immediately after post op period is successfully passed
- reduce drinking to 4 oz/none or less with meals |
|
|
Post op diet should consists of
|
- small, dry feedings daily
- low in carbs - restrict sugar with meals - moderate amounts of protein and fat - 30 minutes of rest after each meal |
