GI WKS Flashcards by Kelsey Klipfel

Which gastrointestinal changes occur in older adults? (Select all that apply.)
A. Increased hydrochloric acid secretion
B. Decreased absorption of iron and vitamin B12
C. Decreased peristalsis may cause constipation
D.Increased cholesterol synthesis
E. Decreased lipase with decreased fat absorption and digestion
F. Decreased liver enzyme activity depresses drug metabolism

Answer: B, C, E, F
Rationale: liver cells sclerosis so will be decreased in fat absorption
As age things get worse
Decreased hydrochloric acid secretion and cholesterol synthesis (cells sclerose in liver)
More constipation and more prone incontinence
Higher risk for sterrhoea - fatty stools
Much higher risk for toxicity - liver and GI - and decreased functioning in kidneys (filter less)

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Atrophy of Gastric Mucosa
Decrease in hydrochloric acid levels
Decrease in the number and size of hepatic cells and increase in fibrous tissue
Distension and dilation of pancreatic ducts
Calcification of pancreatic vessels and a decrease in lipase production
Peristalsis decreases and intestinal nerve impulses dulled
Decreased sensation to defecate can result in postponement of bowel movements

GI changes with aging

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Decreased absorption of iron and vitamin B12
Proliferation/more of bacteria
Atrophic gastritis occurs as a consequence of bacterial overgrowth

Decrease in hydrochloric acid levels

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Leads to decreased protein synthesis and changes in liver enzymes
Depresses drug metabolism - increased risk toxicity

Decrease in the number and size of hepatic cells and increase in fibrous tissue

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Decreased lipase level results in decreased fat absorption and digestion
Excess fat in the feces (steatorrhea)occurs because of decreased fat digestion

Calcification of pancreatic vessels and a decrease in lipase production

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Leads to constipation and impaction and incontinence

Decreased sensation to defecate can result in postponement of bowel movements

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Encourage bland foods high in vitamins and iron - risk for irrational; risk for malnutrition with decreased absorption
Assess for epigastric pain to detect gastritis
Assess for adverse effects of medications, specifically drug toxicity; adjust doses
Encourage small, frequent meals
Assess for diarrhea and dehydration
Encourage a high-fiber diet and 1500 mL of fluid intake daily - facilitate peristalisis
Encourage as much activity as tolerated

GI changes with aging interventions

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Helps prevent steatorrhea

Encourage small, frequent meals

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These interventions increase the sensation of needing to defecate

Encourage as much activity as tolerated

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Visual exam/scope of the esophagus, stomach, duodenum with use of fiberoptic scope
Visual scope of esophagus, gastric, duodenum

What type of exam is the EGD and what does it evaluate? - EGD

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NPO for 6-8 hours and avoid anticoagulants, aspirin, platelet meds, NSAIDS several days before procedure - not want to give anything that increases bleeding
NPO, hold anticoags, ibuprofen, aspirin, NSAIDS

Preparation for the procedure: - EGD

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conscious/Moderate sedation – not completely under but sedation under enough where amnesia and pain medication where deep sleep but breathing on own
Numb throat
sedation/anesthesia
numb throat

What is done to minimize discomfort during the procedure? - EGD

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Keep patient NPO until gag reflex returns
monitor for bleeding;
Hbg and Hct;
frequent VS (BP down; HR up);
Gag reflex before eating or drinking
Check airway

Post procedure care: - EGD

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Priority care includes preventing aspiration and assess for any bleeding or pain that could indicate perforation
Priority for care is to monitor for complications: aspiration, bleeding, ABCs
Can have perforation so watch for signs of this

What is the priorities for post procedure? - EGD

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Someone to drive them home

If discharged the same day, what precaution should be taken? - EGD

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The nurse is caring for a patient scheduled for a colonoscopy in three days after discharge. What does the nurse teach the patient about preparations for this diagnostic test? (Select all that apply.)
A. “Take only clear liquids the day before the procedure.”
B. “You may drink red, orange, or purple beverages the day before the test.”
C. “Avoid aspirin, anticoagulants, or antiplatelet medications for several days before the procedure.”
D. “You will have watery diarrhea shortly after taking the medication prescribed for cleansing the bowel.”
E. “You will have an IV placed to receive medication to help you relax during the procedure.”

Answer: A, C, D, E
Clear liquids - easier bowel prep
Red, orange, purple - dye bowel to think something going on
You will have watery diarrhea shortly after taking the medication prescribed for cleansing the bowel - goal and want to completely clean them out
IV placed - conscious/full sedation

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What is the goal of the bowel preparation?

Clear liquid BM, so able to visualize colon

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Bleeding; Perforation (concerned about infection - peritonitis [rigid boardlike abdomen] and infection/sepsis quickly); AB - considered since under anesthesia so take VS

What should the nurse monitor for post procedure?

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Endoscopic exam of the entire large intestine
Baseline test should be done at age 50 and every 10 years if norm
Preparation:
Procedure: Moderate sedation and procedure lasts 30-60 minutes
Post procedure:

Colonoscopy

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Can be used to visually diagnose, biopsy and treat

Endoscopic exam of the entire large intestine - Colonoscopy

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Clear liquids the day before
NPO 4-6 hours prior
Avoid aspirin, anticoagulants, and antiplatelet drugs for several days before
Adequate bowel cleansing is essential
Follow provider orders for oral and rectal preparation; Patient should be passing clear liquid prior to procedure

Preparation: - Colonoscopy

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Observe for signs of perforation (severe pain) and hemorrhage
Feelings of fullness and cramping are expected - air gets into bowel
Fluids are permitted after the patient passes flatus to indicate that peristalsis has returned

Post procedure: - Colonoscopy

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Visual and radiographic exam of the liver, gallbladder, bile ducts, and pancreas - back and look in all areas
Use radiopaque dye
Used to diagnose obstruction as well as treat obstructions
Preparation: NPO for 6-8 hours and typically avoid anticoagulants as determined by provider - sim to EGD
Procedure: Moderate sedation and lasts 30 minutes to 2 hours
Post procedure:

Endoscopic retrogrand cholangiopancreatography (ERCP)

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Keep patient NPO until gag reflex returns
Priority care includes preventing aspiration and assess for any bleeding or pain that could indicate perforation
Assess for gallbladder inflammation and pancreatitis - pancreatic inflammation - acute onset of severe abdominal pain, nausea and vomiting, fever and elevated lipase

Post procedure: - Endoscopic retrogrand cholangiopancreatography (ERCP)

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Abdominal x-ray Acute abdominal series Abdominal computerized tomography (CT) - unique: DYE GIVEN PO AND IV Abdominal magnetic resonance imaging (MRI) Upper GI series (Barium Swallow) Small bowel follow-through Barium enema Magnetic resonance cholangiopancreatography (MRCP)

Imaging tests

Can identify tumors, strictures and obstructions

Abdominal x-ray

Includes chest x-ray, supine and upright abdominal x-ray

Acute abdominal series

X-ray from mouth to duodenojejunal junctions with use of barium Or through NG tube Gives better pics

Upper GI series (Barium Swallow)

Extension of the upper GI x-ray with use of barium Gives better pics

Small bowel follow-through

X-ray of large intestine with use of barium Gives better pics

Barium enema

Looking at pancreas, bile duct, gallbladder, liver area - done via MRI

Magnetic resonance cholangiopancreatography (MRCP)

Diet Elimination patterns Psychosocial Family history Physical assessment Symptoms

Other assessments when there are GI issues

Big one; huge impacts on GI tract

Diet

Stress - certain things are exacerbated by stress

Psychosocial

Bowel sounds Abdomen - stomach shape, firm, soft Stool

Physical assessment

Nausea and vomiting, diarrhea Pyrosis - heartburn Abd pain Regurgitation Constipation

Symptoms

is a type of secondary stomatitis. Long-term antibiotic therapy destroys other normal flora and allows it to overgrow.

Candida albicans - like opportunistic infection

Fungal - white patches on tongue; sometimes redness and inflammation if really bad

What type of infection is this?

immunocompromised

What might put a patient at risk for this type of infection?

Oral care, soft brushes, mycostatin, bland food, don’t use commercial mouthwashes Remove dentures - irritation worse Oral hygiene imp Mouth clean Painful and uncomfy - may use swabs to clean mouth Avoid things with acid/anything with alcohol - painful and not want cause further irritation Always swab mouth with: nystatin

What nursing interventions should be included in the care of the patient?

lower esophageal sphincter, which allows the reflux of gastric contents into the esophagus and exposure of the esophageal mucosa to acidic gastric contents. Not staying tight enough so refluxing acid into esophagus which not meant to be exposed to that low pH - irritating to mucosa and causes symp and eats away at lining

Most common cause of GERD is excessive relaxation of the

dyspepsia (indigestion), pyrosis (heartburn) and regurgitation

Key features of GERD are:

spicy or acidic foods supine position (will happen a lot at night); positioning - easier to reflux up Chocolate Foods that cause excessive relaxation of LES large meals - stomachs full push on LES

What can aggravate GERD?

Barium swallow - do Xray after EGD pH - in esophagus and if matches esophagus then have GERD

How is it diagnosed?

Which statements about Barrett’s esophagus are accurate? (Select all that apply.) A. It is considered to be a premalignant condition B. It is associated with excessive intake of fresh fruits and vegetables C. It results from exposure to acid and pepsin D. Is associated with an increased risk for cancer in patients with prolonged GERD E. Is an ulceration of the lower esophagus

Answer: A, C, D, E Chronic GERD not treated well acid mutates cells and makes it premalignant cells in lower part esophagus and can lead to esophageal cancer; goal treat GERD so not at risk for Barrett’s

Diet: avoid spicy food - further irritate; avoid food that decrease the LES pressure (peppermint, chocolate, alcohol, fatty foods, carbonation, caffeine-coffee, citrus, tomato) Eliminate tobacco - stop smoking Frequent small meals 4-6 times a day Elevate HOB at night Remain upright after meals Lose weight - overweight higher risk because all about pressure on LES Avoid snacks before bed or eating right before bed Remain upright for 1-2 hours after meals Alcohol, chocolate put them at risk Eat slowly and chew thoroughly Don’t wear constrictive clothing pushing on LES Avoid heavy lifting, straining and working in a bent over position Chew antacids thoroughly and follow with a glass of water

What patient teaching about health promotion and lifestyle changes should the nurse provide to a patient with GERD?

Medication adherence Decrease symptoms/exacerbations - help pain: heartburn/pain Treat esophageal irritation/esophagitis Prevent chronic GERD complications: Barrett’s esophagus and strictures and esophageal cancer

Goals of treatment for GERD include what?

Antacids-neutralize gastric acids; buffer acid not as much acid refluxing up H2 antagonists and Proton pump inhibitors-decrease/suppress gastric acid secretions Prokinetic-increase gastric emptying; moves things through GI tract faster; not as commonly used

What medications will we use to help reduce symp?

asymptomatic, but some may have daily symptoms similar to those with GERD. Protrusion of stomach up through esophageal hiatus that runs through diaphragm; if present, which not supposed be, protrudes up will have reflux so have sim s/s; not have tight LES

Many patients with hiatal hernia are

GERD; provider typically prescribes antacids and PPIs.

Nonsurgical interventions are similar to those for

Protrusion of the stomach through the esophagus hiatus of the diaphragm into the chest Asymptomatic or symptoms similar to those with GERD Diagnostic testing Interventions

Hiatal hernia

Barium swallow study with fluoroscopy is the most specific diagnostic test EGD may be performed to visualize sliding hernias

Diagnostic testing - Hiatal hernia

Provider typically prescribes antacids and a PPI

Nonsurgical Interventions - Hiatal hernia

Can do where pull stomach down and suture it to keep below diaphragm Hard recovery so not done often Only done if strangulated

surgical Interventions - Hiatal hernia

Inflammation of gastric mucosa or submucosa after exposure to local irritants or other causes - stomach lining exposed to something that causes irritation; irritation of stomach lining by med/bacteria Etiology/risk factors:

Gastritis

If the stomach muscle is affected, hemorrhage could occur Chronic gastritis

Long period time Walls and lining of the stomach thin and atrophy Intrinsic factor (critical for absorption of vitamin B12) is lost - not produced Vitamin B12 stores are depleted, pernicious anemia results - anemia related not enough IF to make enough RBCs Amount and concentration of acid in stomach secretions gradually decrease Associated with increased risk for gastric cancer

Chronic gastritis

Helicobacter pylori (gram-negative bacterium) Long-term NSAID use Diet: alcohol; coffee; caffeine - LOT Corticosteroids Radiation therapy for cancer to certain area Accidental or intentional ingestion of corrosive substances/toxic

Etiology/risk factors: - Gastritis

Rapid onset of epigastric pain nausea/vomiting dyspepsia (indigestion); pyrosis (heartburn) gastric hemorrhage - not common; can lead to this so watch for this Hematemesis - not common; can lead to this so watch for this

Key features of acute gastritis may include:

Eliminate the causative factors Avoid foods that can irritate gastric lining further (spicy foods) Avoid smoking Manage stress Medications:

Interventions for gastritis may include:

NSAIDS; steroids; caffeine; alcohol; H.pylori

Eliminate the causative factors - Interventions for gastritis may include:

PPIs; H2 antagonists; antibiotic for Hpylori; Mucosal barrier fortifier; antacids; B12 injections if had sig pernicious anemia Decrease acid secretion - PPIs; H2 antagonist; santacids Barriers - given before meals to coat lining stomachs

Medications: - Interventions for gastritis may include:

Chronic gastritis can lead to pernicious anemia-atrophy of stomach lining leads to decrease in absorption of vitamin B12

What is a complication of chronic gastritis?

Vague report of epigastric pain that is relieved by food Anorexia Nausea or vomiting Intolerance of fatty and spicy foods Pernicious anemia

Symptoms of chronic gastritis

Which types of ulcers are included in peptic ulcer disease (Select all that apply.) A. Esophageal ulcers B. Gastric ulcers C. Pressure ulcers D. Duodenal ulcers E. Stress ulcers

Answer: B, D, E

Mucosal lesion of the stomach or duodenum - gastritis getting worse; open sore in GI tract Occurs when mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin 3 types of ulcers Most gastric and duodenal ulcers are caused by H. pylori infection

Peptic ulcer disease

Gastric Duodenal Stress

3 types of ulcers

Develop in the antrum of the stomach near acid-secreting mucosa

Gastric

Develop in the upper portion of the duodenum

Duodenal

Occur after an acute medical crisis or trauma Uncommon

Stress

Can be undiagnosed in older adults because of vague symptoms associated with physiologic changes of aging and comorbidities that mask dyspepsia Test for it - do via EGD and breath test

Most gastric and duodenal ulcers are caused by H. pylori infection

Hemorrhage: Perforation: Pyloric obstruction: Intractable disease:

Ms. Kim is a 55-year-old woman with a history of peptic ulcer disease (PUD). Her past medical history is otherwise unremarkable. She has been experiencing little relief with the medication prescribed for her during last month's visit. She tells the nurse that she experiences pain within 2 hours of ingesting food. What complications are possible with ulcers?

more common in gastric ulcers life threatening symptoms-vomiting blood (hematemesis)-look coffee ground emesis; sharp and sudden epigastric or abdominal pain; bloody or black stools GI bleeding and perforation most common Best way check via EGD = see if have bleeding Frank looking blood Will test stools

Hemorrhage:

life threatening symptoms-sharp sudden pain with board like abdomen (peritonitis) Ulcer eroded enough to where perforated full linings through bowel and stomach Rigid, boardlike abd; address quickly Die quickly from sepsis

Perforation:

scarring from chronic irritation symptoms-abdominal bloating and nausea vomiting More with chronic; scar due to consist irritation

Pyloric obstruction:

does not respond to conservative treatment Meds not working

Intractable disease:

NSAIDS and H Pylori

The etiology of peptic ulcers is associated primarily with

Dyspepsia (indigestion): Most common symptom; Described as sharp, burning, or gnawing pain Epigastric tenderness - Most common symptom N/V

Physical assessment/clinical manifestations: - PUD

Esophogastroduodenoscopy (EGD) Nuclear medicine scan to test for bleeding Serologic testing for H. pylori antibodies Breath test Decreased hemoglobin and hematocrit, if bleeding Stool may be positive for occult blood, if bleeding

Diagnostic testing: - PUD

Allow mucosa to heal Avoid eating at night Avoid triggers: tobacco, caffeine and alcohol Try CAM therapies to reduce stress Mucosal barrier before eat Eliminate H. pylori infection

Besides drug therapy, what additional teaching information will you give to Ms. Kim upon discharge?

bland diet avoid foods that irritate-spicy, citrus

Allow mucosa to heal

Yoga, meditation, etc

Try CAM therapies to reduce stress

PPI triple therapy PPI quadruple therapy

Eliminate H. pylori infection

PPI Two antibiotics

PPI triple therapy

PPI Any two antibiotics as above Bismuth (Pepto-Bismol)

PPI quadruple therapy

Low H/H

GI bleed

High AST/ALT Low Albumin High Ammonia High Bilirubin High Alkaline phosphatase

Liver disease (ex: hepatitis, cirrhosis)

High Amylase High Lipase

Pancreatitis

Present Ova and Parasites

Parasitic infection

High Bilirubin High Alkaline phosphatase

Biliary obstruction

Increased/High WBC

Cholecystitis - inflammation of gallbladder

High CA 19-9 High CEA

GI cancers

Low K; lose electrolytes during this

Vomiting, gastric suctioning, diarrhea

increases pH of gastric contents by deactivating pepsin/buffer

Antacids (ex. Calcium carbonate; Maalox)

decreases gastric acid secretions

H2 antagonists (ex. Famotidine)

binds with bile acids and pepsin to protect stomach mucosa Coating on stomach stimulates mucosal protection may cause the stools to be discolored black

Mucosal barrier fortifier (ex. Sucralfate)

Decrease gastric acid secretion

Proton pump inhibitors (PPI) (ex. Pantoprazole)

Increases gastric emptying

Prokinetic (ex. Metoclopramide)