Gastrointestinal

Question 1

Describe the dietary changes expected of patients with liver cirrhosis.

Answer 1

Abstain from alcohol
High calorie diet, high carb, low fat
Do not restrict protein

Question 2

Describe the medications to avoid when a person has liver cirrhosis.

Answer 2

Avoid hepatotoxic medications (Tylenol, Statins)

Avoid Aspirin and NSAIDs when portal HTN or varices are present (due to bleeding risk)

Question 3

What activities should a patient with liver cirrhosis avoid?

Answer 3

Activities that increase intraabdominal pressure (straining, coughing, sneezing, vomiting, heavy lifting, tight clothing)

Question 4

When should a patient with liver cirrhosis seek medication attention?

Answer 4

Presence of blood when vomiting
Bloody or black, tarry stools
Altered mental status (encephalopathy)

Question 5

progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma

Answer 5

Liver cirrhosis

Question 6

What is the typical protein intake recommended for patients with liver cirrhosis?

Answer 6

1.2-1.5g/kg

Question 7

What two major issues are associated with hypomagnesia?

Answer 7

Ventricular arrhythmias - torsades the pointes
Neuromuscular excitability - similar to hypocalcemia (tremors, hyperactive reflex, positive Troussea and Chvostek, seizures)

Question 8

What two complications are associated with hypercalcemia?

Answer 8

Constipation and polyuria (due to diuretic effect)

Question 9

What type of history would be expected of a patient with hypomagnesia?

Answer 9

Alcohol abuse
inadequate nutritional intake
underlying GI or nephro issues

Question 10

What is the action of misprostol?

Answer 10

Synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration

Question 11

Misoprostol is often prescribed in patients to prevent gastric ulcers in clients receiving long-term _______ therapy

Answer 11

NSAID

Question 12

What medication type can often increase adverse effects of misoprostol?
What should be done in these instances?

Answer 12

Antacids can increase the adverse effects - e.g. diarrhea and dehydration
if antacids are required, clients should receive those that do not contain magnesium (e.g. Tums)

Question 13

What are instructions for the use of misoprostol?

Answer 13

Take with food to reduce side effects (abdo pain, cramping, diarrhea)
The drug is pregnancy category X - must discontinue if suspected pregnancy (med used for labour induction)

Question 14

What is the indication for the use of sodium polystyrene sulfonate?

Answer 14

(Kayexelate) Administered to clients with hyperkalemia

Question 15

What is the MOA of sodium polystyrene sulfonate?

Answer 15

Kayexelate resin replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich stool, thereby lowering serum potassium

Question 16

What is a major side effect of sodium polystyrene sulfonate?

Answer 16

Intestinal necrosis

Question 17

What is the purpose of the administration of neomycin enema?

Answer 17

Reduces the number of bacteria in the intestine in preparation for colon surgery

Question 18

The client with liver cirrhosis is at risk for developing this neurological condition.

Answer 18

hepatic encephalopathy

Question 19

What conditions/factors can predispose an individual with cirrhosis to hepatic encephalopathy?

Answer 19

Hypokalemia, high protein intake, GI bleeding, constipation, hypovolemia, infection

Question 20

Low albumin is often expected in liver failure, but what is the purpose of albumin transfusions in this popuation?

Answer 20

Albumin is infused to promote good diuresis when used in combination with furosemide

Question 21

What are common lab abnormalities in liver failure?

Answer 21

low albumin, elevated INR and elevated AST/ALT

Question 22

In the case of acute blood loss, what position is preferred?

Answer 22

Trendelemburg to promote blood perfusion to the brain and other vital organs

Question 23

What is the best indicator that a client is responding to medical nutritional therapy?

Answer 23

weight gain

Question 24

Why is serum albumin a poor indicator of acute change in nutritional status?

Answer 24

Albumin has a long half life; pre-albumin is preferred as it has a half-life of only 2 days and is quicker and more reliable

Question 25

Why does pruritis develop in patients with liver disease? | What are they at risk for in this case?

Answer 25

Pruritis develops due to buildup of bile salts beneath the skin, placing them at risk for skin breakdown due to secondary edema

Question 26

What is some teaching done to reduce the incidence of skin breakdown secondary to bile salt accumulation in liver disease?

Answer 26

``` Cut nails short wear cotton gloves and long-sleeved shirts baking soda baths calamine lotion cool, wet cloths bathe in tepid water (NOT HOT) ```

Question 27

What medication is often prescribed to help with pruritis from liver disease? What are important considerations for administration?

Answer 27

Cholestyramine (Questran) - mixed with food (applesauce or applejuice) and given 1 hour AFTER all other medications - increases bile salt excretion in feces

Question 28

Describe the important considerations for Bolus enteral feeding for the following: - Positioning - Flushes - GRV - Symptoms of feeding intolerance - pH

Answer 28

Elevate HOB to 30-40 degrees (semi-Fowler) and keep elevated for 30-60 minutes after (decrease aspiration risk) Flush feeding tube before and after to keep tube patent GRV is checked before - may be held if GRV >500mL - (often not done anymore) Intolerance - abdominal distension, nausea or vomiting pH - <5 if gastric, a pH of 6+ requires X-ray confirmation of tube placement

Question 29

Describe the dash diet for the following: - Fat - typical food types recommended - Protein - Carbs

Answer 29

- Fat-free or low-fat dairy - fresh fruits and veggies, whole grains - meats low in cholesterol (poultry and fish) and alternate protein sources (legumes) - limit simple carbs and high sodium foods

Question 30

What is the main concern following bariatric surgery? | What macronutrients are limited following surgery?

Answer 30

Dumping syndrome | Simple carbs limited

Question 31

Balloon tamponade tube used to temporarily control bleeding from esophageal varices.

Answer 31

Sengstaken-Blakemore tube

Question 32

What is the big risk with Senstaken-Blakemore tubes?

Answer 32

Airway obstruction

Question 33

What precautions are taken with a Senstaken-Blakemore tube?

Answer 33

Scissors are kept at the bedside as a precaution in the event of airway obstruction the nurse can emergently cut the tube for rapid balloon deflation and tube removal

Question 34

What is the highest priority intervention for an actively vomiting client with cholelithiasis?

Answer 34

Maintenance of strict NPO status to prevent additional gallbladder stimulation

Question 35

What treatments can be completed for an actively vomiting client with cholelithiasis?

Answer 35

``` Maintain strict NPO status - priority Promethazine suppository (promotes relief of nausea and vomiting and minimizes further fluid loss) Maintenance of fluid balance Insertion of an NG tube to low suction (provides gastric decompression, alleviates nausea and vomiting, and promotes bowel rest) ```

Question 36

What are the appropriate ranges for LDL, total cholesterol and TGs?

Answer 36

LDL < 2.6 Total cholesterol < 5.2 TGs < 1.7

Question 37

What is the normal range for ALT?

Answer 37

10-40 U/L

Question 38

Vegans are at risk for which nutritional deficiency, and thus which condition?

Answer 38

Risk for B12 deficiency and thus megaloblastic anemia and neurological symptoms

Question 39

Chronic B12 deficiency may lead to which neurological deficiencies?

Answer 39

``` Peripheral neuropathy (tingling and numbness) Neuromuscular impairment (gait issues, poor balance) Memory loss/dementia (in cases of severe/prolonged deficiencies) ```

Question 40

What are examples of B12 fortified foods?

Answer 40

Cereals, grain products, soy and nut milks, meat substitutes

Question 41

What is the mnemonic for the foods that Celiac disease patients must avoid?

Answer 41

BROW | - Barley, Rye, Oats, wheat

Question 42

How rapid will symptomatic relief of GI symptoms occur after patients with Celiac remove gluten from their diets?

Answer 42

Dramatic relief within a few days of eliminating gluten

Question 43

For a patient with an ascending colostomy, provide teaching for the following topics: - Fluids - Foods - When to empty - Irrigation

Answer 43

Fluids - 3L/day (unless contraindicated) Food - eliminate foods that produce gas and odour (broccoli, cauliflower, dried beans, brussel sprouts) Irrigation - stool produced in the ascending (And transverse) colon are semiliquid which eliminates the need for irrigation

Question 44

Describe the imbalances (metabolic, blood panel, immune) that occur with liver cirrhosis.

Answer 44

``` Low serum albumin High serum ammonia Elevated INR/prolonged PT Increased bilirubin level Low platelets ```

Question 45

Describe how low platelets affects a patient with cirrhosis.

Answer 45

Fluid overload (edema, ascites, weight gain)

Question 46

Describe how high serum ammonia affects a patient with cirrhosis.

Answer 46

Hepatic encephalopathy (confusion, lethargy, asterixis, coma)

Question 47

What is asterixis?

Answer 47

Tremor of hand when wrist is extended

Question 48

Describe how elevated INR/prolonged PT, low platelets and increased bilirubin levels affects a patient with cirrhosis.

Answer 48

Elevated INR/prolonged PT + low platelets - petechia, bruising, bleeding Increased bilirubin - jaundice, scleral ictus (scleral jaundice), itching

Question 49

What is the mainstay of treatment for hepatic encephalopathy?

Answer 49

Lactulose to excrete ammonia in feces

Question 50

What is the desired amount of BMs for a patient suffering from hepatic encephalopathy using lactulose?

Answer 50

2-3 soft BMs each day

Question 51

What electrolytes are off balance for receding syndrome?

Answer 51

PPM - phosphorus, potassium, magnésium

Question 52

What does octreatide do?

Answer 52

Reduces hepatic portal HTN (used for gastroesophageal varices