Flashcards in Exam #4 GI Deck (183):
What are the purposes of gastrointestinal intubation?
Decompress the stomach, lavage (pump) the stomach, dx GI disorders, admin meds and feeding, to tx an obstruction, to compress a bleeding site, to aspirate gastric contents for analysis
What are the goals of parenteral nutrition?
To improve nutritional status and to attain a positive nitrogen status
What does a complex mixture of parenteral nutrition contain?
Proteins, carbs, fats, electrolytes, vitamins, trace minerals, and sterile water
What is the BEST way to confirm nasogastric tube placement? Other ways?
X-Ray. Air bolus (auscultate) and pH of gastric contents
How do you measure the placement of a nasogastric tube?
Take the distal end of the tube up to the nostril and stretch it to the earlobe, then from the earlobe to the xiphoid process
Where is the nasogastric tube secured?
Taped to the nose and pinned to the patient's gown
What are some indications for parenteral nutrition?
Intake is insufficient to maintain anabolic state, ability to ingest food is impaired, pt unwilling or not interested in eating, medical conditions, pre-op and post-op nutritional needs are prolonged
What nursing care is needed for a pt with any type of feeding tube?
Pt. teaching, tube insertion, confirming placement and securing it, monitoring the pt, maintain tube function, oral and nasal care, and tube removal
What are some collaborative problems and potential complications of enteral feedings?
Diarrhea, N/V, gas/bloating/cramping, dumping syndrome, aspiration pneumonia, tube displacement or obstruction, nasopharyngeal irritation, hyperglycemia, dehydration and azotemia
What is azotemia?
A condition where the patient's blood contains uncommon levels of urea, creatinine, and other compounds rich in nitrogen
What is the difference between enteral and parenteral feeding tube placement?
Enteral is placed directly into the GI tract and parenteral goes into a vein
What are the advantages of enteral feedings vs. parenteral?
If the gut works, use it; Less envasive, less risk of infection (not breaking the skin); its cheaper than TPN
What happens to the stomach/bowel if its not used?
If you don't use it, you lose it; the stomach/bowel will die
What are the 2 methods of enteral feedings?
Intermittent and continuous
How does intermittent enteral feedings work?
Cans of feeding poured slowly into a feed bag and placed on a gravity drip
How does continuous enteral feedings work?
They are hooked up to a pump
What is done with the residual volume after you have checked it?
Put the residual back in
Why would a patient on enteral or parenteral feedings get hyperglycemia?
Any time your body is under stress (such as having a feeding tube) it causes the flight or fight response which releases extra sugar into the blood to try and heal the body (even if its not needed)
What is sometimes added to TPN feedings to prevent hyperglycemia?
Name a big risk of having a feeding tube?
Skin breakdown (especially in the nares)
What must you do if a patient aspirates while on a continuous enteral feeding?
Stop the feeding and turn the patient on their side
What is Dumping syndrome?
Quickly evacuating stool (within an hr of eating) due to not absorbing the nutritional values of the product
Which patients are more likely to get dumping syndrome?
Ones that had bariatric or gallbladder surgery
How would a patient get aspiration pneumonia during a tube feeding?
If tube is not in the correct place or HOB is lowered during feeding, the feeding may aspirate into the lungs
When do you flush an enteral or parenteral feeding tube?
Before and after feedings and before and after medications
What are the complications of administering tube feedings too fast?
Dumping syndrome, aspiration, abdominal cramping
What type of water is used with medication during a tube feeding?
What is the #1 complication of enteral feedings?
What is another big problem with enteral feedings and what are the 2 major causes of it?
Dumping syndrome due to gallbladder and bariatric surgery
With an intermittent enteral feeding, what is considered too much residual volume?
More than 1/2 of the last feeding
With a continuous enteral feeding, what is considered too much residual volume?
Per facility protocol. Usually between 150-200 mL
Which nares do you put the tube down?
Most patent and if the patient has a deviated septum, place it down the larger side
What needs to be checked frequently on a patient with enteral feedings?
The nares for skin breakdown.
Which tube feeding is more expensive, enteral or parenteral?
What is a slurry?
Crushed medication mixed with water
When is a gastronomy or jejunostomy tube used instead of nasogastric?
For long term feedings
When do you check the residual volume in an intermittent and continuous feedings?
Intermittent - before next feeding; Continuous - q8hrs (usually q4-6hrs)
How much of an intermittent feeding is given at one time?
Never any more than 4 hrs worth at a time in an open system
How must a continuous parenteral feeding be given?
An IV pump
How big must the syringe be that is used in enteral feedings?
Greater than or equal 30 mL (Don't forget to flush before and after)
How do you prevent dumping syndrome?
Infuse slowly and avoid cold solutions in the tube feedings
What position should the patient be in when receiving enteral feedings?
30-45 degrees during feeding and for at least 1 hr after
What do you need to assess for in a patient with an NG tube?
Patient knowledge, self care ability, skin and nutritional/fluid status
Aspiration is a risk with any type of enteral feeding, but what is an added risk with a gastronomy tube?
How often do you change the dressing on a gastronomy tube?
How often do you change the dressing on a PICC line?
24 hrs after insertion and then q7days
Enteral feeding can cause hyperglycemia, what about parenteral?
Hyperglycemia and rebound hypoglycemia
What is another possible complication that is distinct to parenteral feeding?
Pneumothorax from PICC line insertion
How often do you take vitals on patients on parenteral feedings?
q4hrs including temperature or by protocol
What kind of procedure is a dressing change on a PICC line?
Sterile procedure with gloves and mask. Patient needs to either turn head to cough or wear a mask themselves
What do you do if a parenteral infusion runs out and why?
Hang 10% dextrose solution and call Dr. This prevents the patient's blood sugar from getting too high or too low
What are you going to assess for a patient on parenteral feedings?
Daily weight, I&O, electrolyte balance and blood glucose
What are the 4 different methods for administering tube feedings?
Intermittent bolus, intermittent gravity drip, continuous infusion, and cyclic feedings
What is a cyclic feeding?
Periodic feedings given over a short period of time
What is the purpose of enteral feedings?
Meet nutritional requirements when oral intake is inadequate or not possible, and the GI tract is functioning
What are the advantages of enteral feedings?
Safe and cost-effective; Preserve GI integrity; Preserve the normal sequence of intestinal and hepatic metabolism; Maintain fat metabolism and lipoprotein synthesis; Maintain normal insulin and glucagon ratios
What are some interventions for tube feedings?
Maintain hydration by supplying additional water and assess for signs of dehydration; Promote coping by support and encouragement, encourage self-care and activities; Reduced risk of aspiration; Pt teaching
What determines the type of tube used for feedings?
It is determined by where it enters the body (G-tube goes into the stomach and J-tube goes directly into the jejuneum)
List some nursing diagnoses for a patient with a gastrostomy.
Imbalanced nutrition, Risk for infection, Risk for impaired skin integrity, Ineffective coping, Disturbed body image, Risk for ineffective therapeutic regimen management
What are some collaborative problems/potential complications with a gastrostomy?
Wound infection, GI bleeding, premature removal of tube, aspiration, constipation and diarrhea
Can you cut gauze to place around a gastrostomy and why?
No because the fibers can fragment and get into wounds. It is better to leave the dressing off until you can get the right gauze
What are the indications for TPN?
Bowel obstruction, CA, can't swallow, Crohn's disease, anorexia, hyperemesis
List some potential complications of parenteral nutrition.
Pneumothorax (when inserting PICC or peripheral lines), clotted or displaced catheter (PICC line is close to the heart and can mess with it), sepsis, hyperglycemia, hypoglycemia (from over-correcting hyperglycemia), and fluid overload (may be too much fluid for patient to tolerate it)
Can you put TPN in peripheral veins?
No. Will most likely blow the vein
How often is the tubing for parenteral nutrition changed?
All tubing and bag needs changed q24hrs (even if there is TPN left in the bag)
What steps are taken to maintain fluid balance when on parenteral nutrition?
Use infusion pump (flow rate should not be increased or decreased rapidly), monitor indicators of fluid balance and electrolyte levels, I&O, weight and monitor blood glucose levels
What is a peptic ulcer?
Erosion of a mucous membrane forms an excavation
What type of pain does a peptic ulcer produce?
Dull gnawing pain or burning in the mid-epigastrium; Heartburn and vomiting may occur
Where are peptic ulcers located?
Stomach, pylorus, duodenum, or esophagus
What infection often causes/exacerbates peptic ulcers?
What are some risk factors for peptic ulcers?
Excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs, alcohol, smoking (decreases gastric blood flow and can increase the harmful effects of H. pylori) and familial tendency
What is a Bilroth I treatment for?
Gastroduodenostomy for gastric ulcers
What is a Bilroth II treatment for?
Gastrojejunostomy for duodenal ulcers
Describe the Bilroth I surgical procedure.
Removal of distal portion (75%) of stomach and anastamosed (attached) to duodenum
Describe the Bilroth II surgical procedure.
Removal of distal 50% of stomach and remaining is attached to proximal jenjunum THEREFORE bypassing the duodenum
What 3 complications are associated with peptic ulcer surgeries (Bilroth I & II)?
Nutritional problems, pernicious anemia, and dumping syndrome (all depends on how much of the stomach and/or duodenum is removed)
What type of pain is associated with a gastric peptic ulcer?
High left epigastric or upper abdominal burning/gnawing pain
When is the pain increased with a gastric ulcer?
Increased 1-2 hrs after meals (PC) or with food
What would the emesis look like in a gastric ulcer?
What occurs with a duodenal peptic ulcers?
Rapid gastric emptying combined with the hypersecretion of acid
What type of pain is associated with a duodenal peptic ulcer?
Mid epigastric/upper abdominal burning/cramping pain
When is the pain increased with a duodenal ulcer?
Increases 2-4 hrs after meal/middle of the night
What would a pt's stool look like if they have a duodenal ulcer that is bleeding?
Melena (black, tarry stools if bleeding)
Which type of peptic ulcer is most common?
What can relieve the pain associated with a duodenal ulcer?
Food and antacids
What diagnostic tests are done for peptic ulcers?
Test for H. pylori in the gastric secretions, upper GI series (Barium swallow) and EGD (scope)
List the therapeutic interventions for a peptic ulcers.
Antibiotics, Proton pump inhibitors, Histamine H2 antagonists, Bismuth subsalicylate (Pepto-Bismol), sucralfate (Carafate), antacids, bland diet
What irritants should a patient with a peptic ulcer avoid?
Smoking, caffeine and alcohol, spicy and acidic foods
Why would you treat a peptic ulcer with an antibiotic?
To treat the H. pylori (2 antibiotics to decrease resistance)
What is the action of sucralfate (Carafate) on a peptic ulcer?
It is not greatly absorbed into the body through the GI tract it works mainly in the lining of the stomach by adhering to ulcer sites and protecting them from acids, enzymes, and bile salts. Used to treat an active ulcer, can heal an active ulcer but no prevent future ones
What are some complications from a peptic ulcer?
Bleeding, perforation, and obstruction
What needs to be done to prevent/treat bleeding complications from a peptic ulcer?
Monitor for s/s of shock, stop bleeding (cauterize), and replace volume and electrolytes (give fluids and blood products)
What can a perforated peptic ulcer lead to and what is done to treat it?
Perforation can lead to peritonitis, septicemia, and hypovolemic shock. This is a medical emergency that requires surgical intervention
What causes an obstruction in a peptic ulcer and how is it treated?
Obstruction due to scar tissue. Need to repair the damage and rinse the peritoneal cavity
What is peritonitis?
When an ulcer ruptures into the peritoneal cavity and all of the gastric secretions cause infection
What is sucralfate?
Anti-ulcer drug that adheres to damaged tissue and protects it from acid and enzymes
What are the s/s of a perforation or peneration of a peptic ulcer?
Severe upper abdominal pain that may be referred to the shoulder, vomiting and collapse, tender board-like abdomen, and symptoms of shock/impending shock
What are the s/s of shock?
Pallor, decreased BP, Increased respirations and HR
What is shock due to blood loss called?
What are the s/s of pyloric obstruction?
N/V, constipation, epigastric fullness, anorexia, and (later) weight loss
What is the treatment for a pyloric obstruction?
Insert NG tube to decompress the stomach, provide IV fluids and electrolytes. Balloon dilation or surgery may be required
Black, tarry stools
What are the s/s of gastric bleeding?
Bleeding, hematemesis or melena, and symptoms of shock/impending shock and anemia
What are some causes of gastric bleeding?
From ulcer perforation, tumor, gastric surgery
What are some treatments for gastric bleeding?
IV fluids, NG, and saline or water lavage; oxygen, treatment of potential shock including monitoring of VS and urinary output; may require endoscopic coagulation or surgical intervention
What are the s/s of an upper GI bleed?
Black, tarry stools (melena); hematemesis; coffee ground emesis
What are the s/s of a lower GI bleed?
Melena if in or above the small bowel; hematochezia (bright red blood from the colon or rectum)
What is done for a patient with gastric bleeding?
NPO, IV fluids, blood transfusions, NG tube, oxygen
What are the s/s of hypovolemic shock?
Hypotension, tachycardia, chills, palpitations, diaphoresis
What labs will be ordered and monitored for a patient with a gastric bleed?
Why is oxygen therapy required if there is a gastric bleed?
Need if a large amount of blood is lost due to not enough RBCs to provide adequate oxygen to the body
How does liver disease affect PT time?
It is prolonged. It won't return to normal with vitamin K if damage is severe
What does serum ALP indicate?
It is a sensitive measure of biliary tract obstruction
How does the liver affect ammonia levels?
The liver converts ammonia to urea, so damage can cause a rise in serum ammonia
What markers are elevated in alcoholics?
What are some additional diagnostic studies that are done to determine liver function?
Liver biopsy, ultrasonography, CT, MRI
Why would you use an NG tube to decompress the stomach when there is a gastric bleed?
To evacuate the bleeding; Would rather suction out the blood than have the patient vomit it up
When testing liver function, what lab tests are included in the pigment studies?
Total (indirect) and direct serum bilirubin, urine bilirubin and urobilinogen and fecal urobilinogen (infrequently used)
When testing liver function, what lab tests are included in the protein studies?
Total serum protein, serum albumin, serum globulin, serum protein electrophoresis albumin (Globulins: alpha1, alpha2, beta, gamma), and albumin/globulin (A/G) ratio
What is the clinical function of pigment studies when determining liver function?
These studies measure the ability of the liver to conjugate and excrete bilirubin. Results are abnormal in liver and biliary tract disease and are associated with jaundice clinically
What is the clinical function of protein studies when determining liver function?
Proteins are manufactured by the liver. Their levels may be affected in a variety of liver impairments: albumin is affected in cirrhosis, chronic hepatitis, edema and ascites, globulins are affected in cirrhosis, liver disease, chronic obstructive jaundice, and viral hepatitis
What is the albumin/globulin (A/G) ratio in chronic liver disease?
The A/G ratio is reversed (decreased albumin and increased globulin)
What is the clinical function of prothrombin time when determining liver function?
Prothrombin time may be prolonged in liver disease. It will not return to normal with vitamin K in severe liver cell damage
When testing liver function, what lab tests are included in the serum aminotransferase studies?
AST, ALT, GGT, GGTP & LDH
When testing liver function, what lab tests are included in the cholesterol studies?
Ester, HDL (high-density lipoprotein) and LDL (low-density lipoprotein)
What is the clinical function of ammonia (plasma) when determining liver function?
Liver converts ammonia to urea. Ammonia level rises in liver failure
What is the clinical function of serum alkaline phosphatase when determining liver function?
Serum alkaline phosphatase is manufactured in bones, liver, kidneys, and intestine and excreted through biliary tract. In the absence of bone disease, it is a sensitive measure of biliary tract obstruction.
What is the clinical function of serum aminotransferase AST and ALT studies when determining liver function?
These studies are based on release of enzymes from damaged liver cells. These enzymes are elevated in liver cell damage
What is the clinical function of serum aminotransferase GGT, GGTP, LDH studies when determining liver function?
Elevated in alcohol abuse. Marker for biliary cholestasis
What is the clinical function of cholesterol studies when determining liver function?
Cholesterol levels are elevated in biliary obstruction and decreased in parenchymal liver disease
What is jaundice?
Yellow- or green-tinged body tissues; Sclera and skin due to increased serum bilirubin levels
Where on the body is it best to assess for jaundice?
The hard palate of the mouth and the sclera of the eyes
What are the 4 types of jaundice?
Hemolytic, hepatocellular, obstructive, and hereditary hyperbilirubinemia
Which of the 2 types of jaundice are most closely associated with liver disease?
Hepatocellular and obstructive jaundice
What is hemolytic jaundice?
Rupturing of the RBCs
What is hepatocellular jaundice?
Infection that has made its way to the liver
What is obstructive jaundice?
Damaged liver cells that the blood cannot flow through
What are the s/s of hepatocellular jaundice?
May appear mildly or severely ill; Lack of appetite, nausea, weight loss; Malaise, fatigue, weakness; HA, chills, and fever if infectious in origin
What are the s/s of obstructive jaundice?
Dark orange-brown urine and light clay-colored stools; Dyspepsia and intolerance of fats, impaired digestion; Pruritis
What is portal hypertension?
Obstructed blood flow through the liver results in increased pressure throughout the portal venous system
What can portal hypertension result in?
Ascites and esophageal varices
What is ascites?
Fluid in the peritoneal cavity
What can cause ascites?
Portal hypertension; Vasodilation of splanchnic circulation; Not metabolizing aldosterone; Decreased synthesis of albumin; Movement of albumin into the peritoneal cavity
What does ascites caused by portal hypertension result in?
Increased capillary pressure and obstruction of venous blood flow
What does ascites caused by vasodilation of splanchnic circulation result in?
Increased blood flow to the major abdominal organs
What does ascites caused by changes in the ability to metabolize aldosterone result in?
Increase of fluid retention
What does ascites caused by decreased synthesis of albumin result in?
Decrease of serum osmotic pressure
What is included in the assessment of ascites?
Abdominal girth and weight (daily); Straie, distended veins, and umbilical hernia; Fluid in abdominal cavity by percussion for shifting dullness or by fluid wave; Fluid and electrolyte imbalances
How do you treat ascites?
Low sodium diet, diuretics, bed rest, paracentesis, administer of salt-poor albumin, and transjugular intrahepatic portosystemic shunt (TIPS)
What are the s/s of appendicitis?
RLQ pain, fever, N/V, anorexia, and increased WBCs
How is appendicitis treated?
Is heat or ice applied to the site prior to surgery for pain relief associated with appendicitis and why?
Ice b/c heat may increase inflammation and cause the appendix to rupture
What is TCDB exercises?
Turn, cough, deep breathing
What is the most important post op appendectomy care, besides the incisional wound itself?
NPO until bowel function returns, then clear liquids and advance as patient tolerates; Pain control; TCDB exercises or incentive spirometry; Early ambulation; Monitor VS and s/s of peritonitis
What interventions are needed for peritonitis, which is a complication of an appendectomy?
Monitor for s/s; Employ constant nasogastric suction; Correct dehydration as prescribed; Administer antibiotic agents as prescribed
What are the s/s of peritonitis, which is a complication of an appendectomy?
Abdominal tenderness and rigidity, fever, vomiting and tachycardia
Does acute pancreatitis usually lead to chronic pancreatitis?
What happens with acute pancreatitis?
The pancreatic duct becomes obstructed and enzymes back up into the pancreatic duct, causing auto digestion and inflammation of the pancreas
What happens with chronic pancreatitis?
Cells are replaced by fibrous tissue, and pressure within the pancreas increased. Mechanical obstruction of the pancreatic and common bile ducts and destruction of the secreting cells of the pancreas occur
What is chronic pancreatitis?
A progressive inflammatory disorder with destruction of the pancreas
What might a patient with acute pancreatitis develop?
Respiratory distress, hypoxia, renal failure, hypovolemia, and shock
What are the s/s of acute pancreatitis?
Patient appears acutely ill, severe abdominal pain, abdominal guarding, N/V, fever, jaundice, confusion, agitation may occur, and ecchymosis in the flank or umbilical area may occur
What are the s/s of chronic pancreatitis?
Recurrent attacks of severe upper abdominal and back pain accompanied by vomiting, weight loss, and steatorrhea (presence of excess fat in feces)
As a nurse, what do you focus on with acute pancreatitis?
Focus on abdominal pain and discomfort
What assessments are done on a patient with acute pancreatitis?
Pain, fluid, and electrolyte status, medications, alcohol use, GI assessment and nutritional status, respiratory status, and anxiety and coping
How is pain and discomfort associated with acute pancreatitis relieved?
Analgesics, nasogastric suction (to relieve nausea and distention), frequent oral care, bed rest, and measures to promote comfort and relieve anxiety
What are the 4 types of hernias?
Umbilical, direct and indirect inguinal hernia, and femoral hernia
What are the s/s of abdominal hernias?
What is a complication of abdominal hernias?
Strangulated incarcerated hernia
What is a strangulated incarcerated hernia?
Blood and intestinal flow are cut off
What can a strangulated incarcerated hernia lead to?
Perforation or obstruction
What is the treatment for a strangulated incarcerated hernia?
What are the s/s of a strangulated incarcerated hernia?
N/V, abdominal pain
What are the 2 surgical procedures for an abdominal hernia?
Herniorrhaphy & Hernioplasty
What is a herniorrhaphy?
Abdominal incision to replace contents and sewing the weakened tissue
What is a hernioplasty?
Placing back into abdomen and reinforcing the weakened muscle wall with mesh, wire, etc.
What post op instructions are given with a hernia surgery?
No coughing, only deep breathing or use of incentive spirometry to keep the lungs clear and activity restrictions (no lifting, driving, sex)
What is important for the patient to report after hernia surgery?
Difficulty urinating, bleeding, and s/s of an infection
Are esophageal varicies an emergency?
Bleeding esophageal varices are
What else besides esophageal varices is caused by alcohol abuse?
Cirrhosis of the liver