Test 3 (GI, Endocrine, DM, Neuro) Flashcards
Gastrectomy
partial or full removal of stomach. Complication = dumping syndrome (occurs 30 min after eating, group of vasomotor symptoms, vertigo, tachycardia, syncope, sweating, pallor, palpitations. Eat small meals, high protein, high fat, low carbs).
Colostomy/Stoma
healthy stoma is red, pink, moist & protrudes 1-3cm and ¾ width. Avoid heavy lifting/straining. 1-2wk usual activities. Monitor bleeding/infection.
GI @ high risk for…
infection, inflammation, autoimmune d/o, cancer, motility issues, structural/mechanical alterations
Functions of GI
secretion, digestion, absorption, motility, elimination
Aging changes w/ GI
atrophy of gastric mucosa (absorption malfunction), ↓ peristalsis (nerves dull w/ elimination), calcification of pancreatic vessels (distention/dilation fat absorption), immune system issues/GI flora dysfunction
Stomatitis
inflammation in the oral cavity. Disrupts a person’s ability to eat, talk, sleep. Affects mouth, gums, tongue, lips, palate, inner cheeks. Risk factors = women. Avoid any acidic foods or hard/crunchy foods.
Types: primary (noninfectious canker/aphthous sore - eroded tissue integrity causing pain, bleeding, and infection. Caused by coffee, citrus, gluten); secondary/systemic (virus, fungi, bacteria, thrush, cancer, lesions), candida, herpes simplex, traumatic ulcers.
Oral Tumors
Squamous cell carcinomas (most common. Occurs on lips, tongue, inner cheek, oropharynx. Red raised eroded lesions), Basal cell carcinomas (skin cancer, sun exposure), kaposi sarcoma (vascular painless tumor in mouth, tongue, gums, palate. Caused by AIDS).
Esophageal Tumors
squamous cell carcinoma (upper ⅔), adenocarcinoma (distal ⅓ - most common). High risk for metastasis w/ mucosa/lymph tissue to spread. Risk factors = ETOH, obesity, smoking, GERD. “silent tumor.” S/S = persistent and progressive dysphagia, obstruction, hoarseness, anorexia, regurgitation.
Oral cancer
S/S = bleeding from mouth, poor appetite/compromised nutritional status, difficulty chewing/swallowing, unplanned weight loss, thick/absent saliva, painless oral lesion that is red/raised/eroded, thickening or lump in cheek. Priority = gas exchange/airway management.
Sialadenitis
acute inflammation of the salivary gland. Affects parotid & submandibular glands. Cause = bacteria, virus, CMV, ↓ saliva production (oral, head, or neck radiation), systemic drugs (phenothiazines, tetracycline). Assessment = oral cavity, facial cranial nerves, fever/malaise. Treatment = underlying cause. Complications = abscess/systemic infection.
GERD
upper GI d/o where backflow of stomach contents into esophagus (regurgitation). Risk factors = obesity, H pylori, nutrition (coffee, caffeine, ETOH, citrus, tomatoes, chocolate), meds/lifestyle (smoking, CCB, anticholinergic, estrogen). S/S = asymptomatic (early), chest pain, burning, heartburn, sour stomach, morning hoarseness, odynophagia (painful swallowing). Complications = asthma, cough/wheezing, aspiration,), Barrett’s Esophagus (premalignant and risk of cancer. Epithelium causes resistance to acid/healing),, dental decay, cardiac disease (esophageal irritability), hemorrhage (varices), aspiration pneumonia. Interventions = balance nutrition, manage pain, drugs (antacids, H2 blockers, PPIs).
Hiatal Hernias
protrusions of the stomach through lining. Complications = volvulus (twisting), obstruction, strangulation (stricture), iron-deficient anemia, hemorrhage (rare). S/S = asymptomatic (early), GERD-like, worse pain after eating, dysphagia, supine is worse/fullness/breathless w/ meals. Diagnostic = barium swallow surgery (fluoroscopy). Interventions = non-surg (nutrition, lifestyle, PPI/GERD meds), surg (LNF - invasive surgery. Complications = bleeding, infection, DVT, respiratory. Post op - soft diet, PPI/H2 blockers, wound care).
Esophageal trauma
causes = blunt trauma, inhalation, surgery, seve vomiting, chemical burns w/ ingestions of caustic substances (acid - superficial mucosa affected, alkaline - deeper penetrating injury).
Gastritis
: Inflammation of the gastric mucosa (stomach lining). Prevention = balanced diet, regular exercise (maintains peristalsis which helps prevent gastric contents to irritate), stress reduction.
Acute Gastritis
ocal irritants causing the inflammation (thick red mucosa). Risk factors = bleeding and hemorrhage. Causes = long term NSAIDs, ETOH, coffee, caffeine, stress, smoking, drugs (steroids, aldosterone antagonists, SRIs). S/S = epigastric pain, dyspepsia, GI bleeding, hematemesis, melena. Diagnostic = EGD w/ biopsy. Interventions = treat symptoms, diet choices, drugs (PPI’s, H2 receptor antagonist, antacids), surgery (partial gastrectomy for major bleeding or severe ulcers)
Chronic Gastritis
chronic/systemic disorders causing the inflammation (patchy, diffuse). Risk factors = stomach cancer, bleeding, hemorrhage, CKD, inflammatory conditions. Causes = ETOh, smoking, radiation, chrons, uremia, surgery that ↑ acid production. Complications = pernicious anemia (vit B12), helicobacter pylori (type B gastritis). S/S = upper abdominal pain, anorexia, N/V, constant pain after eating. Diagnostic = EGD w/ biopsy, monitor DI tests w/ trends. Interventions = treat cause and symptoms, drugs (same as acute but may be lifelong).
Peptic Ulcer Disease
GI mucosal defenses become impaired and no protection from acid or pepsin. Causes = bacterial infection (H. pylori), long use of NSAIDs, family hx. S/S = upper GI bleeding (hematemesis, melena), ↓ H & H, ↓ BP, ↑ HR, weak pulse, acute confusion (OA), vertigo, dizziness, syncope. Complications = high risk (gastric ulcers, age), perforation (full thickness ulcer that erodes the GI wall splitting contents into peritoneal cavity. Tender, rigid abdomen - peritonitis. Untreated causes sepsis and hypovolemic shock), pyloric obstruction (caused by scarring, edema, inflammation, tumor. S/S = abdomen bloating, fullness pain, n/v), metabolic alkalosis (the loss of large quantities of gastric secretions), hypokalemia (from N/V or metabolic alkalosis). Diagnostic = CBC, H. pylori serum or stool test, stool antigen test, EDG. Interventions = manage acute/persistent pain, manage upper GI bleeding (priority. Fluid volume loss, blood loss, non surg - NG tube/lavage, surg - laparoscopy, gastrectomy, pyloroplasty), drugs (PPI, abx).
Gastric: Located in the antrum of the stomach. Inflammation of the mucosa. Causes = bacteria (transmission = oral to oral or fecal to oral).
Duodenal: most common w/ deep lesions. Located in upper portion of duodenum. High gastric secretion (excess acid w/ low pH). Causes = same as gastric.
Stress: stress of body no personal (acute gastric lesion). High mortality. Causes = sepsis, burns, head injury, trauma, untreated bacteria infection. Treatment = abx (clarithromycin, amoxicillin, tetracycline, metronidazole).
Gastric Cancer
Adenocarcinomas (abnormal mucosal cells in the lining of stomach), precancerous (gastritis & metaplasia - abnormal tissues). Risk factors = men and women > 50yo. 5 year survival rate d/t asymptomatic early. If untreated, metastasis to lymph w/ direct invasion to liver, pancreas, colon. Causes = H pylori, polyps, gastritis, anemia. S/S = early (dyspepsia, abdominal discomfort that can be relieved by antacids, feeling of fullness, epigastric/back/retrosternal pain), late (N/V, iron deficiency anemia, palpable epigastric mass, enlarged lymph, weakness/fatigue, progressive weight loss). Diagnostic = ↓ H&H, + guaiac stool, ↓ albumin, ↑ LFT). Treatment = radiation, chemo, surgery (tumor resection, gastrectomy), palliative (advanced).
Colorectal Cancer
cancer of large intestine and rectum. Risk factors = age, genetic, hx of Chrons or UC. Early diagnosis = highly curable. Causes = adenomatous polyps, smoking, ETOh, obesity, red mean and high fat diet (d/t high bile acid secretion and antibiotics in foods). Promotion = diagnostic screening, colonoscopy Q10 yr. S/S = rectal bleeding, change in stool, elimination habits, abdominal fullness/pain, anemia, weakness, weight loss, bloating, gas pain. Labs = guaiac stool test, fecal occult blood test, CEA, CBC. Diagnostic = CT, sigmoid/colonoscopy w/ biopsy. Interventions = pathology staging, chemo, radiation, removal of tumor/lymph nodes/colon resection.
Colorectal Cancer
cancer of large intestine and rectum. Risk factors = age, genetic, hx of Chrons or UC. Early diagnosis = highly curable. Causes = adenomatous polyps, smoking, ETOh, obesity, red mean and high fat diet (d/t high bile acid secretion and antibiotics in foods). Promotion = diagnostic screening, colonoscopy Q10 yr. S/S = rectal bleeding, change in stool, elimination habits, abdominal fullness/pain, anemia, weakness, weight loss, bloating, gas pain. Labs = guaiac stool test, fecal occult blood test, CEA, CBC. Diagnostic = CT, sigmoid/colonoscopy w/ biopsy. Interventions = pathology staging, chemo, radiation, removal of tumor/lymph nodes/colon resection.
IBS
(spastic/nervous colon) functional GI d/o that causes chronic/recurrent diarrhea, constipation, or abdominal pain. Causes = environmental/foods, hormonal, genetic, bacteria overgrowth, stress w/ mental illness. S/S = pain, wkns, bloating, diarrhea, constipation. Labs = CBC, albumin, ESR (inflammatory), stools for occult blood. Interventions = stress reduction, counseling. Drug = symptom control (bulk forming or antidiarrheals, probiotics, antidepressants, rifaximin, alosetron.
Obstructions
Blockage. All obstructions can lead to abdominal distention d/t contents accumulating at/above the area of obstruction (inability to absorb the contents & move waste. Peristalsis ↑ to move contents as compensatory rxn, bowel becomes edematous, plasma leaking into peritoneal cavity and fluid trapped in intestinal lumen). Complications = hypovolemic → hypovolemic shock (↓ blood volume), electrolyte imbalances, metabolic alkalosis (obstruction high in small interesting and lower tract causes loss in alkaline fluids), metabolic acidosis (obstruction at end of small interesting and lower tract causes loss in alkaline fluids). Untreated → AKI, bacterial peritonitis, blood flow complications (compartment syndrome). Assessment = Hx, hiccups, hypotn, could be peritonitis. Labs = no labs for obstruction. WBC could indicate strangulation/infarction/gangrene, increased H&H/BUN d/t dehydration. Diagnostic = CT, MRI, KUB, US, endoscopy, colonoscopy. Interventions = NPO, monitor, pain, NG tube (for bowel rest - salem sump w/ vent, assess Q4hr), surgery, prevent recurrence, bowel regimen, diet teaching, (high fiber foods, hydration, warm beverages to stimulate peristalsis).
Mechanical: bowel is physically blocked. Can be outside the intestine (adhesions), in the bowel wall (stricture in chrons), in intestinal lumen (tumors), hernias, can be intussusception/volvulus.. Risk factor = >60yo. Intervention = surgery (exploratory lap) —
Non-mechanical: paralytic ileus or functional obstruction. Post op ileus (POI - common by handling intestines during surgery) or intestinal ischemia (vascular insufficiency by arterial or venous thrombosis - mesenteric. Severe cases cause bowel infarction, gangrene, sepsis/shock). –
Small-bowel: abdominal discomfort or pain possibly accompanied by visible peristaltic waves in upper & middle abdomen. Upper or epigastric abdominal distention. Nausea and early, profuse vomiting (may contain fecal matter), obstipation, severe F/E imbalance, metabolic alkalosis. —
Large-bowel: intermittent lower abdominal cramping, lower abdominal distention, minimal or no vomiting, obstipation/ribbon like stools, no major f/e imbalance, metabolic acidosis.
Hemorrhoids
unnaturally swollen/distended veins in the anorectal region. Arterioles shunt blood to distended veins. Increase IAP, distended veins separate from smooth muscle resulting in prolapse of hemorrhoidal vessels. Can get blood clots w/in hemorrhoids. Causes = IAP from pregnancy, constipation w/ straining, obesity, HF, prolonged sitting/standing, weightlifting, strenuous activity. S/S = swelling, bleeding, prolapse/ bulging, bright red streaks of blood, rectal pain (thrombosed), itching, discharge. Interventions = treat symptoms/causes. Sitz bath, cold packs, topical anesthetics, high fiber/fluid diet, soft stools to avoid straining. Surgery = hemorrhoidectomy(for severe)
Types: Internal (above anal sphincter), external (below anal sphincter), prolapsed (thrombosed or inflammed, bleeding).
Appendicitis
acute inflammation of the vermiform appendix. Inflammation occurs where opening is obstructed leading to infection as bacteria enter the wall of the appendix. Causes = feces w/calcium deposits, mucous, salts. Complications = sepsis, peritonitis, gangrene. Labs=WBC >10-18K w/ L shift (immature WBC) or >20K if perforation of appendicitis. Diagnostic = US/CT. Intervention = pain control, appendectomy, lap or open surgery, education (abx, pain meds).
Peritonitis
acute inflammation and infection of the visceral/parietal peritoneum & endothelial lining of the abdominal cavity. Cause = contamination of peritoneal cavity by bacteria (e coli, strep, staphylococcus, pneumococcus, gonococcus) or chemicals (leakage of bile, pancreatic enzymes, gastric acid; perforation entry for appendicitis/diverticulitis/bowel segment, bowel obstruction, tumor, surgery complication, infection from peritoneal dialysis. S/S=rigid abd, abd pain, distended abd, N/V, anorexia, ↓ bowel tones, high fever, dehydration, tachycardia, ↓ urine output. Complications (if untreated) = fluid shift (↓ circulatory vol, hypovolemic shock), insufficient perfusion of kidneys (AKI w/ impaired F/E), septicemia (septic shock), ↑ abd pressure (IAP - respiratory distress). Labs = CBC, WBC (>20K w/ ↑ neutrophil), blood culture, gram -/+, renal labs (AKI/sepsis), ABG (metabolic acidosis/sepsis). Diagnostic = XR, US, CT. Interventions=monitor for septic shock (hypotn, tachycardia, fever, tachypnea, confusion), pain management, IV fluids, abx, O2, surgery (laparotomy, open abd surgery - identify cause and repair).
Gastroenteritis
very common health problem causes D/V r/t inflammation of mucous membranes of stomach/intestinal tract. Viral (more common) or bacterial. Assessment = travel, restaurant, camping, markets, raw/undercooked foods. Complications = (older adults) wkns, cardiac dysrhythmias, hypokalemia, hypovolemia. S/S = pale, diarrhea (blood, mucous), N/V, fever, abd pain/cramping, dehydration (late stage - poor skin turgor, fever, dry mucous membranes, orthostatic BP, hypotn, oliguria). Interventions = fluid replacement, oral replacement, IV fluids. Drugs = not recommended in early stage, loperamide( if cultures -), antinausea, abx (if bacterial).
Ulcerative Colitis
extensive (entire colon) disease that creates widespread chronic inflammation of the rectum and rectosigmoid colon. High risk for colorectal cancer. S/S = intestinal mucosa, edema, red, stool, mucous, blood, abd pain/distention, tachycardia, malaise, anorexia, anemia, fever, dehydration, severe (bloody stool w/ sm erosions/ulcers, abscess or tissue necrosis, edema could cause bowel obstruction), peritonitis/bowel perforation. Labs = WBC, ESR, CRP (inflammation), low Na/K/Cl (diarrhea) or CBC (blood loss). Diagnostic = MRE (enterorrhaphy) or upper endoscopy, colonoscopy. Interventions = managing diarrhea, monitor GI bleed, manage pain, nutrition therapy, drug therapy (aminosalicylates, glucocorticoids, antidiarrheals), surgical (optional, toxic megacolon, hemorrhage, bowel perforation, colorectal cancer), ileostomy (output is green, loose, dark, blood - may irritate skin more d/t bile salts and enzymes).
Ulcerative Colitis
extensive (entire colon) disease that creates widespread chronic inflammation of the rectum and rectosigmoid colon. High risk for colorectal cancer. S/S = intestinal mucosa, edema, red, stool, mucous, blood, abd pain/distention, tachycardia, malaise, anorexia, anemia, fever, dehydration, severe (bloody stool w/ sm erosions/ulcers, abscess or tissue necrosis, edema could cause bowel obstruction), peritonitis/bowel perforation. Labs = WBC, ESR, CRP (inflammation), low Na/K/Cl (diarrhea) or CBC (blood loss). Diagnostic = MRE (enterorrhaphy) or upper endoscopy, colonoscopy. Interventions = managing diarrhea, monitor GI bleed, manage pain, nutrition therapy, drug therapy (aminosalicylates, glucocorticoids, antidiarrheals), surgical (optional, toxic megacolon, hemorrhage, bowel perforation, colorectal cancer), ileostomy (output is green, loose, dark, blood - may irritate skin more d/t bile salts and enzymes).
Crohn’s
chronic inflammatory disease of the small intestines (occasionally large intestines). Recurrent, remissions, exacerbations. Fatty lining may cause fatty stools (steatorrhea). Cause = genetic, autoimmune, environmental. Risk factors = tobacco, stress, nutrition, jewish, young adults 15-35. S/S = diarrhea, anemia, hemorrhage, deep ulcers/fistular. Labs= anemia, vit B12 deficiency folic acid, CRP (inflammation abnormal if > 10), ESR (inflammation, abnormal if > 13), F/E balance (hypokalemia, hypomagnesemia). Diagnostic = XR, MRE. Interventions = symptom control, nutrition therapy (low residue, high calorie, avoid dairy/gluten), drug (azathioprine, mercaptopurine, methotrexate, glucocorticoid), surgical (laparoscopy - MIS, resection of diseased area or perforation/hemorrhage/obstruction/abscess/cancer)
Diverticular Disease
pouch-like herniations of the mucosa through the muscular wall in the small or lg intestine, usually in sigmoid colon. Is a weakness in the intestinal wall. Inflammation occurs w/ food, bacteria trapped and could perforate/abscess or peritonitis/GI bleeding.
Diverticulosis: presence of abnormal pouches (diverticula). Asymptomatic and undiagnosed except routine colonoscopy.
Diverticulitis: acute inflammation or infection of diverticula. S/S = fever, abd pain, nausea, LLQ, elimination changes, bleeding, distention. Labs = EBC, low CBC, stool studies for blood. Diagnostic = XR (free air), CT (abscess), US. Complications = peritonitis, rebound tenderness, sepsis, hypotn, hypovolemic shock. Interventions = pain control, drugs (metronidazole, sulfa, ciprofloxacin, IV fluids, avoid laxatives - motility issues), monitor for GI bleeding, surgery (if peritonitis, abscess, bowel obstruction, fistula, bleeding - colon resection - colostomy), education (high fiber diet, avoid gassy foods, avoid seeds, corn, veggies w/ seeds, nuts).
Celiac disease
a chronic inflammation of the small intestine mucosa that causes bowel wall atrophy, malabsorption, diarrhea. Multisystem autoimmune disease. Cause = genetic, immunologic, environmental factors. Severe = cancer, non-hodgkin’s lymphoma, gastric cancer. S/S = typical (anorexia, diarrhea, constipation, fatty stools, abd pain, bloating, distention, weight loss), atypical (osteoporosis, joint pain, anemia, migraine, epilepsy, infertility, autoimmune).
Parasitic infection
Lab = ↑ WBC, stool studies (O&P). Drugs = metronidazole/ paromomycin, amebicide
Cirrhosis
extensive, irreversible scarring of the liver, usually caused by hepatic inflammation and necrosis. Inflammation caused by toxins or disease w/ extensive degeneration/destruction of liver cells (hepatocytes). Liver nodules block bile ducts and blood flow → ↓ liver function over weeks to years. Scarring impairs cellular regulation leading to end stage liver disease. Cause = chronic alcoholisms, chronic viral hepatitis, bile duct disease, hepatitis B & C, age, obesity, DM, genetic (latinos). Types = post necrotic cirrhosis (viral hepatitis, drugs - isoniazid, flutamide), alcoholic cirrhosis, biliary cirrhosis (chronic biliary obstruction/autoimmune disease), nonalcoholic fatty liver disease. Assessment = hx (family, social, medical - abd surgery, blood transfusions, autoimmune, obesity, lipid panel, HF, respiratory d/o, liver injury, psychosocial - cognitive, personality changes, agitation, sleep patterns, emotional), physical (jaundice, icterus, itching, rashes, edema, ascites, fatigue, changes in weight, GI symptoms, nausea, abd pain, hernias (high risk), hepatomegaly, splenomegaly, neurologic function, girth measurements, asterixis (coarse tremors w/ flexion). Labs = abnormal liver function tests, AST, ALT, LDH, GGT, Alk phos, total bili, albumen, hyponatremia (ascites). Diagnostic = XR, CT, MRI, US, EGD. Priorities = fluid overload d/t third spacing of abd & peripheral fluid (ascites), potential for hemorrhage d/t portal HTN & subsequent GI varices, acute confusion & other cognitive changes d/t increased serum ammonia levels and/or alcohol withdrawal, pruritus d/t increased serum bilirubin and jaundice. Education = nutrition therapy, alcohol cessation, drug therapy (diuretic, K replacement, PPI; avoid OTC NSAIDs, tylenol, smoking drugs), psychosocial support.
Alcohol withdrawal s/s - tremors, jitters (6-8hrs after last drink), delirium tremens (DT), confusion, anxiety, odd behaviors, tachycardia, ↑ BP, sweaty.
Complications of cirrhosis
PORTAL HYPERTENSION: Increase in pressure within the portal vein < 5 mmHg. Obstruction/blockage of blood flow in portal vein causing splenomegaly. Veins in the esophagus, stomach, intestines, abdomen, and rectum dilate. Splenomegaly is from backup of blood into the spleen → enlarged spleen destroys platelets causing thrombocytopenia. Early sign of liver disease = low platelets.
ASCITES: Portal HTN causes ascites. A collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal HTN. FLuid shifts from the vascular system to their spacing. Risk = hypovolemia & edema.
ESOPHAGEAL VARICES: Fragile thin walled esophageal veins gets distended from pressure. Portal HTN blood backs up from liver and enters esophageal and gastric veins. Life threatening medical emergency causing hypovolemic shock.
BILIARY OBSTRUCTION: genetic. Obstruction of the bile duct that leads to biliary cirrhosis. Production of bile is decreased which prevents clotting factors to produce prevention of vit K absorption. Cause = gallbladder disease or autoimmune disease.
HEPATIC ENCEPHALOPATHY: complex cognitive syndrome from liver failure and late cirrhosis. Shunts portal venous blood into central circulation so liver is bypassed. Labs = elevated ammonia > 45 (liver protein breakdown). S/S = early (confusion, mental status changes, mood, insomnia, speech difficulties), late (altered LOC, impaired thinking, neuromuscular problems).
JAUNDICE: yellow coloration of skin. Causes = hepatocellular disease liver cells cant excrete bilirubin, intrahepatic obstruction (edema, scarring on hepatic bile ducts interferes w/ excretion). Jaundice pts report itching excessively.
Managing fluid volume - preventing/managing hemorrhage r/t cirrhosis
nutrition (low sodium, IV supplements - thiamine, folate, MVT), drug (diuretics, oral potassium, IV abx), Paracentesis (invasive procedure to remove fluid), hemorrhage (prevent varices - beta blocker, vasoactive drugs, TIPS for severe esophageal varices), managing confusion (lactulose to remove excretion of ammonia in the flood for hepatic encephalopathy and pneumonia), manage itching.
Hepatitis
widespread inflammation and infection of the liver cells. Viral (acute or chronic). Risk factors = advanced age, chronic liver disease. Causes = environmental, liver injury from hepatotoxins, autoimmune. S/S = abd pain, yellow sclera, joint/muscle pain, diarrhea/constipation, light colored stools, dark urine, jaundice, fever, fatigue, n/v, itchy/dry skin. Labs = Hep A/B (lab test), Hep C/D/E (antibody titers), elevated liver tests (ALT, AST, Alk phos, bili). Diagnostic = liver biopsy, CT scan. Education = handwashing, community education.
Liver transplant
common procedure for end stage liver disease/liver failure. Cirrhosis is #1 reason for transplant. Transplant complications = acute graft rejection (tachycardia, fever, abd pain, jaundice), infection (prophylactic abx, immunosuppressants).
Functions of biliary system
secretes enzymes, promotes food digestion in the stomach & sm intestine, impairment in the biliary system impairs digestion leading to inadequate nutrition.
Cholecystitis
Inflammation of the gallbladder. Assessment = hx (nutrition, GI symptoms), physical (abd pain, atypical s/s w/ DM and age, rebound tenderness, jaundice, dark urine, icterus, steatorrhea, inflammation, fever, tachycardia, dehydration, pain triggered by meal, anorexia, dyspepsia, eructation, flatulence).
Acute cholecystitis
chemical irritation and inflammation from gallstones and calculi (from bile salts, cholesterol metabolisms, calcium, proteins. Mixed w. Mucous and viscous bile builds gallstones) that obstructs the cystic duct, gallbladder neck or common bile duct. How it happens = Gallbladder gets inflamed, bile is trapped & reabsorbed and irritates the gallbladder wall, bile-edema-gallbladder distension, impaired circulation, infection/inflammation/ischemia, tissue sloughing w/ necrosis/gangrene or gallbladder ruptures/perforates causing abscess/peritonitis (if severe). Labs = differential diagnosis to r/o other GI problems, WBC > 10k, elevated AST/LDH, amylase/lipase. Diagnostic = abd XR, US, HIDA scan, ERCP, MRI. Interventions = managing acute pain, non surg (prevention, diet controlled, high fiber, avoid fatty foods, acute (hydration, IV fluids, pain meds, abx), surg (procedure for breaking up gallstones like kidney stones - lithotripsy; lap chole).
Gallbladder complications: motility issues - lead to stone formation by delaying bile emptying and causes biliary stasis. Can be from a twist or kinking of GB neck or cystic duct or acalculous cholecystitis.
Gallstones: Causes = obesity, genetics (nutrition & genetic marker), high cholesterol, american indian, pregnancy, HRT decreasing bile emptying. Four F’s (female, fat, forty, fertile).
Chronic cholecystitis
recurrent episodes of cystic duct obstruction caused by chronic inflammation. Calculi present. GB becomes weak, fibrotic atrophy, decreased motility, deficient absorption. Causes = diet low in fat, vegetarian diet, pancreatitis, cholangitis (bile duct), back up bile (obstruction and jaundice).
Acute pancreatitis
serious and life threatening inflammation of the pancreas. 4 major patho processes = lipolysis (lipase enzyme), proteolysis (thrombus. gangrene), necrosis of blood vessels and inflammation (bleeding), mild involvement evidenced by edema & inflammation. Causes = ETOH, gallstones, obstructive pancreatitis, trauma, chole, gastrectomy. Complications = jaundice, pancreatic pseudocyst, hyperglycemia, pleural effusions, pulmonary failure, multisystem organ failure, ARDS, coagulation/hemorrhage (DIC, necrotic tissue), shock & hypovolemia (ARF), pancreatic infection, AKF, T2DM. S/S = inflammation, abd issues, jaundice, bowel tones, rigid abd. Labs = amylase, lipase, trypsin, elastase, glucose, bili, ALT, AST, CRP, leuko, BUN, triglycerides; Ca, Mg, platelets, albumin - decreased labs. Diagnostic = US, CT, XR, ERCP. Interventions = symptom control, nutrition therapy, IV therapy, NG tube, NPO, drug (PPI, H2 receptors, abx, antiemetics, ca or mg replacement), surgical (ERCP or lap chole).
Chronic Pancreatitis
Progressive, destructive disease of the pancreas that has remission and exacerbations. Inflammation w/ tissue fibrosis, pancreatic insufficiency, diminished organ function. S/S = intense abd pain, ascites, steatorrhea, jaundice, dark urine. Labs = increase amylase, lipase, bili, alk phos, glucose; decreased albumin. Diagnostic = ERCP, CT, MRI, US. Interventions = calories up to 4000/day to maintain weight, foods high in carbs/protein, avoid ETOH and high fat foods, drugs (pain, pancreatic enzymes, H2 blockers, PPIs, TPN/enteral feeding), Surgical (lap chole, sphincterotomy, partial resection, transplant)
Pancreatic Cancer
(adenocarcinoma/head of pancreas) rapid growing tumor w/ rapid mets to lymph & vascular systems. High risk pts = DM, cirrhosis, obesity, smoking, age, genetic, family hx, red meat intake. S/S: early asymptomatic, abd pain, clay stools, GI bleed, palpable mass, hepatomegaly, jaundice, weakness, weight loss. Venous thromboembolism is common complication. Labs = increase LFT, amylase, lipase, alk phos, bili. Genetic marker (CEA). Interventions = prevent tumor spread and decreasing symptoms, no cure, pain management, chemo and radiation, surgical (partial pancreatectomy, whipple)
Surgical complications: DM, hemorrhage, wound infection, bowel obstruction, intra-abd abscess. Whipple complications = hemorrhage, hypovolemia, MI, HF, thrombophlebitis, pulmonary complications (atelectasis, PNA, PE, ARDS, pulmonary edema), metabolic (renal failure), wound infection.
Type 1 DM
Insulin prod is absent d/t autoimmune pancreatic beta-cell destruction — susceptible genes, autoantigens, environmental factors, viruses, diet.
Type 2 DM
insulin resistance and decreased insulin secretion. Inability to suppress hepatic glucose production, impaired glucose uptake. Some beta cell dysfunction.
Indications for testing ppl for T2DM = BMI > 25, first degree relative w/ DM, physically inactive, high-risk ethnic population, gave birth to baby weighing > 9# or had gestational diabetes, A1C>5.7%
S/S of DM
fatigue, 3P’s (polyuria, polydipsia, polyphagia), recent infections, skin injuries, changes in vision, sensory changes
Screening for DM
Korean/Vietnam vet (exposure to agent orange, digoxin), recommended for pts > 45yr
Metabolic syndrome
simultaneous presence of metabolic factors that increase risk for developing T2DM and CVD. (abdominal obesity, hyperglycemia, HTN, hyperlipidemia, HDL < 40/50
Absence of Insulin
glucose regulation requires insulin to move glucose into many tissues. Lack of production or a problem w/ insulin use at cell receptors. The absence of insulin causes glucose to build up in the blood causing hyperglycemia - disturb f/e balance (leads to polyuria, polydipsia, polyphagia). Insulin secreted daily in a two step manner (low level secretion during fasting - basal insulin secretion; two phase release after eating - prandial - an early burst of insulin secretion occurs within 10 min of eating, followed by an increasing release that lasts until BG level returns to normal)
Insulin stimulators
Stimulate insulin release from pancreatic beta cells. Used for pts who are still able to produce insulin (functioning pancreas). Include sulfonylureas (glipizide), meglitinide analogs (repaglinide). Education = s/s of hypoglycemia, take w/ or just before meals to prevent hypoglycemia
Biguanides: (Metformin)
lower BG by inhibiting liver glucose production, decreasing intestinal absorption of glucose and increasing insulin sensitivity (on cells). Education = no ETOH, must be stopped b4 using contrast agents and not started again for 48hr after testing d/t increased risk for kidney damage and lactic acidosis. Administer w/ meals to minimize GI effects. May cause hypoglycemia if combined w/ sulfonylurea.
Insulin Sensitizers (thiazolidinediones (TZDs or glitazones))
Increase cellular use of glucose, which lowers BG. Black box warning - serious side effects - heart related deaths. Education = weigh daily (report 2lbs in one day or 4-5lbs in one week). Report vision changes immediately. Weight gain and peripheral edema are common.
Incretin Mimetics (GLP-1 Agonist) (Dulaglutide):
reduces liver glucose production and delays gastric emptying. Can cause hypoglycemia when used w/ insulin, sulfonylureas or meglitinides. Education = s/s of hypoglycemia, how to inject (SQ), report persistent abd pain/nausea, read pens carefully (some ER is only ejected weekly).
Dipeptidyl peptidase-4 (DPP-4) Inhibitors (Alogliptin)
breaks down natural gut hormones (GLP-1 & GIP). Works w/ body’s insulin. Reduces BG levels by delaying gastric emptying. Education = hypoglycemia, report a rash/persistent abd pain/dyspnea on exertion/cough esp when lying down. Associated w/ HF.
