MS2 - GI - Concepts Flashcards
1
Q
Patient position for tube feedings
A
- Elevate the head of bed to minimum of 30 degrees, preferably 45 degrees, to prevent aspiration
- Intermittent feedings: head should remain elevated for 30-60 minutes after feeding
2
Q
For patients with enteral feedings:
Check gastric residual volumes every ___ hours during the first ____ hours.
After enteral feeding goal rate is achieved, gastric residual monitoring may be decreased to every ___ to ___ hours in non-critically ill patients or continued every ___ hours in critically ill patients.
A
Check gastric residual volumes every 4 hours during the first 48 hours.
After enteral feeding goal rate is achieved, gastric residual monitoring may be decreased to every 6 to 8 hours in non-critically ill patients or continued every 4 hours in critically ill patients.
3
Q
If gastric residual volume is >___ mL, hold enteral nutrition and reassess patient tolerance.
A
500 mL
4
Q
Etiological factors and risks associated with GERD
A
Primary etiologic factor - incompetent LES (decreased LES pressure)
Things that decrease LES pressure:
Certain foods (caffeine, chocolate, peppermint/spearmint, fatty)
Drugs (anticholinergics, calcium channel blockers, diazepam, morphine, B-Adrenergic blockers, Nitrates, progesterone, theophylline)
Cigarette/cigar smoking
Other risks:
Obesity (due to increased intraabdominal pressure)
Common cause - hiatal hernia
5
Q
Patient teaching for GERD
A
- Avoid factors that trigger symptoms (particular attention to diet and drugs that affect LES, acid secretion, or gastric emptying)
- Small, frequent meals to prevent gastric distention
- Advise not to lie down 2-3 hours after eating, don’t wear tight closing around waist, and don’t bend over (especially after eating)
- Avoid eating within 3 hours of bedtime
- Recommend sleeping with HOB elevated on 4-6” blocks (approx 30 degrees)
- Info on any drugs the patient will receive
- Recommend weight reduction if overweight
- Encourage to cease smoking if applicable
- Stress coping techniques if applicable
6
Q
Two classifications of hiatal hernias
A
Sliding:
Junction of stomach and esophagus is above diaphragm - part of stomach slides through hiatal opening. Occurs when patient is supine, hernia usually goes back into abdominal cavity when upright. (Most common type).
Paraesophageal (rolling):
Esophagogastric junction remains in normal position, but fundus and curvature of the stomach roll up through the diaphragm - forms pocket alongside the esophagus. Acute paraesophageal hernia is a medical emergency.
7
Q
Human Digestive System Order
A
Mouth Pharynx Esophagus Lower Esophageal Sphincter Stomach Pyloric Sphincter Duodenum Jejunum Ileum Cecum Ascending colon Transverse colon Descending colon Sigmoid colon Rectum Anus
8
Q
Upper GI barium swallow
A
- Upper GI series - X-ray study with fluoroscopy (barium swallowed then x-ray)
- Examines organs of upper part of digestive system (esophagus, stomach, duodenum)
- Identifies disorders such as esophageal strictures, polyps, tumors, hiatal hernias, foreign bodies, peptic ulcers
Mgmt:
NPO/no smoking 8-12 hours
Pt will need to assume various positions on x-ray table
Need fluids and laxatives afterwards to prevent contrast medium impaction
Stool may be white for up to 72 hours
9
Q
Small Bowel Series
A
- Contrast medium (not barium) taken - clear w/motility accelerant
- Films/fluoroscopy taken every 20 min til contrast reaches terminal ileum
Mgmt:
- Same as Upper GI
- Paddle w/ball pressed against abdomen while patient in various positions
- May have diarrhea afterward
10
Q
Lower GI barium enema
A
- Examines rectum, large intestine, and lower part of small intestine
- Given in rectum as enema
- X-ray of abdomen shows strictures (narrowed areas), obstructions (blockages), other problems
- Air-contract or double-contrast has air infused after barium enema given
Mgmt:
- Colon must be clean - enemas, laxatives, drink gallon of electrolyte solution or combination
- Clear liquids 1-3 days in advance
- NPO after midnight
- Teach about barium enema, balloon inflation in rectum to retain barium and air, position changes, cramping, and need to defecate
- Fluids, laxatives, and/or suppositories to expel barium
11
Q
Ultrasound
A
- Used to view internal organs as they function, and to assess blood flows through various vessels
- Gel applied to area being studied and transducer placed on skin - sends sound waves into body that bounce off organs and return to machine to produce image
Mgmt:
- NPO 8-12 hours before
12
Q
Contraindications for Valsalva maneuver
A
- Head injury
- Eye surgery
- Cardiac problems
- Hemorrhoids
- Abdominal surgery
- Liver cirrhosis with portal hypertension
13
Q
Computed Tomography Scan (CT Scan)
A
- Noninvasive; combination of xrays and computer technology
- Produces cross-sectional images (slices), both horizontal and vertical
- Detailed images of any part of the body (including bones, fat, organs, muscles)
- More detailed than general xrays
- Contrast may be injected
Mgmt:
- Contrast: check for iodine allergies, forewarn if injected in lower pelvis feels very warm like urinating on self
14
Q
Magnetic Resonance Imaging (MRI)
A
- Combination of magnets, radiofrequencies, computer
- Detailed images of organs and structures within body
- Painless, noninvasive, no radiation exposure
Mgmt:
- Metal objects cannot be in MRI room - not for pts with pacemakers, metal clips/rods inside body. Remove jewelry
- NPO 6-8 hours preprocedure
- Pt may need sedative if issues with confined spaces or unable to hold still during test
15
Q
Esophageal manometry
A
- Helps determine strength of muscles in esophagus
- Helpful evaluating gastroesophageal reflux and swallowing abnormalities
- Small tube through nostril, into throat, then esophagus - measures pressure esophageal muscles produce at rest
16
Q
Esophagogastroduodenoscopy (EGD)
Upper GI endoscopy
A
- Thin, flexible lighted tube to see inside esophagus, stomach, duodenum
- Can insert instruments through scope for sample for biopsy if needed
Mgmt:
- NPO for 8 hours
- Need sign consent
- Throat will be sprayed with topical anesthetic or pt will gargle w/topical anesthetic
- Pt will have light sedation - may cause amnesia for 1-2 hrs
- Pt will be positioned on left side, keep chin tucked toward chest, and breathe through mouth
- Takes 5-10 min plus recovery time
- Keep NPO til gag reflex returns
- Notify HCP w/temp >101F, sharp severe chest ab pain, vomiting blood, black tarry stools
17
Q
Colonoscopy
A
- View entire length of large intestine, help id abnormal growths, inflamed tissue, ulcers, bleeding
- Long flexible lighted tube, to view, biopsy if needed, treat some problems found (polypectomy, cauterize bleeding)
Mgmt:
- Keep pt on clear liquids 1-3 days before procedure, no red liquids/jello
- Colon must be clean - enemas, laxatives, electrolytes until clear
- Light sedation at beginning, more later if needed - may cause amnesia for 1-2 hrs
- Positioned on left side, may feel cramping during procedure (biopsies will have no pain)
- 10-30 min + recovery time
- Gas, ab cramping, distention may occur afterward
- Contact HCP if >2 Tbsp rectal bleeding, persistent ab distention, severe ab or chest pain, temp >101F, tachycardia, diaphoresis
- Unless otherwise indicated, may eat as soon as sedation wears off
18
Q
Clinical manifestations of irritable bowel syndrome
A
Abdominal pain
Diarrhea and/or constipation
History of GI infection and food intolerances
Excessive flatulence, bloating, urgency, sensation of incomplete evacuation, fatigue and sleep disturbances
19
Q
Diet recommendations for IBS
A
Fiber Water (very important) Elimination of certain foods - only necessary for some pts (milk/lactose/fructose/gas-forming foods) Caffeinated beverages Alcohol
20
Q
Diagnostic studies for IBS
A
- History and physical examination
- Use of diagnostic tests to rule out other disorders
21
Q
Medications for IBS
A
Loperamide - synthetic opioid that slows intestinal transit - used to treat diarrhea
Alosetron - serotonergic antagonist used for iBS clients with severe symptoms of pain and diarrhea. Used only for women who have not responded to other treatments (can have serious side effects)
Lubiprostone - used for constipation in women
Linaclotide - IBS with constipation in men and women
22
Q
Differences between Crohn’s and ulcerative colitis
A
- High fiber and fruit intake decreases risk in CD; veg intake decreases risk in UC
- Skipped areas of lesions with CD (segments of healthy bowel between); continuous lesions with UC
- Weight loss more common with CD; bloody stools with UC
- All layers of bowel for CD (can lead to fistulas); mucosa and submucosa for UC (no fistulas)
- CD can be anywhere from mouth to anus (terminal ileum most common); UC is rectum to colon
- CD drug treatment (but surgery can be indicated later); UC colectomy
- CD cramp/pain in RLQ; UC LLQ
23
Q
Symptoms for IBD
A
- Diarrhea, bloody stools, weight loss, abdominal pain, fever, fatigue
- Mild to severe exacerbations occur at unpredictable intervals over many years
- With CD, weight loss (due to malabsorption), diarrhea, crampy pain more common
- UC: bloody stools more common
24
Q
Differences for complications between CD and UC
A
- Crohns: Fistulas, strictures, anal absess, perforation, nutritional problems, increased risk for small intestinal cancer
- Ulcerative colitis: Toxic megacolon, colorectal cancer
25
Diet modifications for IBD
Crohns: High calorie, high protein
UC: Low residue diet, low fat, high protein, no dairy (severe cases: NPO to rest bowel, TPN), avoid foods that exacerbate symptom
26
Toxic megacolon
- Complication of ulcerative colitis
- Usually involves transverse colon; dilates and lacks peristalsis
S/S:
- Fever
- Tachycardia
- Hypotension
- Dehydration
- Changes in stools
- Abdominal cramping
27
Jejunostomy
- Jejunum brought up to abdominal surface
Stoma site: RLQ preferred, RUQ also used
Precipitating disease: ischemic bowel, Crohn's disease, trauma
Characteristics of effluent: high volume output (close to 2400 mL/24 hrs), liquid to thick
Special considerations:
- Output starts @ 48 hours
- Proteolytic enzymes are caustic to peristomal skin
- Short bowel syndrome concern
- Monitor fluids/electrolytes closely
28
Ileostomy
- Ileum brought up to abdominal surface
Stoma site: RLQ
Precipitating disease: CUC, FAP, Crohn's disease, neurogenic bowel
Characteristics of effluent: immediate postop (500-1500 mL/24 hr), after adaptation (500-800), liquid to pasty consistency
Special considerations:
- Functioning within first 48-72 hrs
- High output: 1500-1800 mL/24 hrs
- Proteolytic enzymes are caustic to peristomal skin
29
Ascending colostomy
- Ascending colon brought to abdominal surface
Stoma site: RLQ
Precipitating disease: Obstruction (i.e., colon cancer), crohn's disease, ischemic bowel
Characteristics of effluent: becomes thick to pasty consistency once diet restored
Special considerations:
- Functioning by day 3
30
Transverse colostomy
- Transverse colon brought to abdominal surface- may be loop or double barrel construction
Stoma site: preferred is RLQ or LLQ (if surgeon can free up enough mesentery); more commonly seen near waistline either R or L side
Precipitating disease: obstruction (e.g., colon cancer), hirschsprung's disedase, anorectal malformation
Characteristics of effluent: becomes pasty
Special considerations:
- Functioning by day 3-4; if patient was obstructed, may begin functioning immediately
- Usually a quick surgical procedure
31
Sigmoid colostomy
- Descending or sigmoid colostomy
Stoma site: LLQ
Precipitating disease: rectal cancer, bowel perforation, diverticular disease, trauma, neurogenic bowel
Characteristics of effluent: soft to formed stool
Special considerations:
- Can become constipated
- Can "regulate" bowel movements by diet or regular (daily or every other day) irrigations
32
Low Anterior Resection (LAR)
- Rectal tumor is removed; sigmoid colon to distal rectum; anal spincters remain intact
Type of stoma: occasionally recovers a "covering" ileostomy or colostomy to protect the anastomosis; usually a loop; could be a transverse or descending
Precipitating disease: rectal cancer located in middle to UPPER 1/3 of rectum
Special considerations:
- Requires deep access through abdominal incision down to pelvis
- Need 7 cm for LAR so surgeon will gain more cm by "straightening" angles in rectum
- Choice to do LAR vs. APR depends upon surgeon's skill and tumor location
33
Abdominal Perineal Resection (APR)
| Miles Procedure
- Distal rectum, anal canal, and anus are removed; wide resection is required (surrounding tissue and lymph nodes) to reduce risk of cancer recurrence; sigmoid colon remains intact
Stoma: permanent END sigmoid colonostomy; typical location is LLQ
Disease: rectal cancer in lower 1/3 of rectum
Special considerations:
- Requires 2 surgeons and 2 incisions
- Rectal incision painful
- Wide resection will damage innervation for erections
- Many women experience dysparuenia
- Do not confuse with TPC
34
Total Proctocolectomy (TPC)
Pan Proctocolectomy
Brooke Ileostomy
- Removal of entire colon, rectum, and anal canal
Stoma: permanent ileostomy, brook ileostomy, end stoma construction, typical location is RLQ
Diseases: CUC, FAP, sometimes Crohn's
Special considerations:
- Requires 2 surgeons and 2 incisions
- Rectal incision painful
- Narrow resection of colon and rectum to preserve nerve function
- Many women experience dysparuenia
- Do not confuse with APR
35
Hartmann's Pouch
- Colon is transected in rectum or sigmoid area; distal bowel is "oversewn"; no resection of continence structures
Stoma: sigmoid or descending colostomy; end stoma; may be temporary or permanent
Diseases: perforated bowel, diverticulitis, obstructing rectal cancer, rectal trauma, ischemic bowel
Special considerations:
- Easy way to divert fecal stream and avoid inconvenience of double barrel or loop stoma construction
- Patient will experience passage of stool (short term) and mucus (long term) rectally & feelings of rectal fullness
36
Peritonitis
| Clinical manifestations
- Abdominal pain (most common symptom)
- Tenderness over involved area (universal sign)
- Rebound tenderness
- Muscular rigidity
- Spasm
- Movement causes pain
- Also may see: abdominal distention, fever, tachycardia, tachypnea, nausea, vomiting, altered bowel habits
37
Peritonitis - Lab Values
Infection:
- Elevated WBC (norm: 5,000-10,000/mm3)
- "Left shift" of WBC
Hemoconcentration:
- Elevated Hct (norm: 42-52% (male) 37-47% (female))
- Elevated Hgb (norm: 14-18 g/dL (male) 12-16 g/dL (female))
- Elevated Na+ (norm: 136-145 mEq/L)
38
Gastroenteritis
- Inflammation of mucosa of stomach and small intestine
- Sudden diarrhea, accompanied by N&V, abdominal cramping
- Viruses most common cause (Norovirus leading cause)
- Most cases self-limiting (elderly, chronically ill may get dehydrated - IV fluids if necessary, oral fluids with glucose & electrolytes [i.e., Pedialyte] as soon as tolerated)
- Nursing mgmt same as acute diarrhea
39
Ostomy teaching
- Teach ostomy use/care and have patient/SO demonstrate
- Minimal oozing of blood is normal, stoma has high vascular supply
- How to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection)
- Pt should chew thoroughly, avoid foods that caused digestive upset previously, add new foods one at a time
- Encourage support groups, resuming normal life
- Don't use alkaline soap on the skin (to prevent skin irritation)
- Water does not harm stoma, bathing and swimming can be done with or without pouching system
- Pt can resume ADLs 6-8 wks but not heavy lifting
40
Risks for hernia
- Ventral/incisional: obesity, multiple surgical procedures in same area, inadequate wound healing r/t poor nutrition or infection
41
S/S for hernias
- May be readily visible
- Discomfort as a result of tension
- If hernia strangulated - severe pain, symptoms of bowel obstruction (cramping abdominal pain, vomiting, distention)
42
Treatment for hernias
- Laparoscopic surgery treatment of choice (herniorrphaphy - surgical repair; hernioplasty - reinforcement of weakened area with wire, fascia, mesh)
- Strangulated hernias treated immediately with resection of involved area or temp colostomy to avoid necrosis and gangrene
Post op considerations:
- After hernia repair, pt may have trouble voiding (measure I&O, observe distended bladder)
- Scrotal edema - painful complication after inguinal repair - scrotal support, application of ice bag
- Deep breathing but not coughing (splint incision, keep mouths open when coughing or sneezing)
- Restricted from heavy lifting for 6-8 weeks
43
Major classes of medications to treat IBD
Aminosalicylates - first line therapy for mild-moderate CD, more effective for UC - achieve and maintain remission
- Decrease GI inflammation through direct contact with bowel mucosa
- Yellowish orange discoloration of skin and urine
Antimicrobials
- Prevent or treat secondary infection
Corticosteroids - used to achieve remission - given for SHORTEST period of time
- Decrease inflammation
- Tapered to low levels when surgery is planned
Immunosuppressants - maintain remission after corticosteroid induction therapy
- Suppress immune response
- Require regular CBC monitoring - can suppress bone marrow and lead to inflammation of pancreas or gallbladder
- Delayed onset of action
Biologic and targeted therapy
- Inhibit cytokine tumor necrosis factor (TNF); prevent migration of leukocytes from bloodstream to inflamed tissue
- Do not work for everyone; costly and may produce allergic reactions
- Most effective when given at regular intervals and must not be d/c'd unless pt can't tolerate
- Before starting anti-TNF, pt must be tested for TB and hepatitis; cannot receive live virus immunizations
44
Nursing care plan - patient with inflammatory bowel disease (IBD)
- Instruct pt to record color, volume, frequency and consistency of stools
- Perform actions to rest bowel (NPO, liquid diet)
- Stress-reduction techniques
- Frequent, small feedings, add bulk gradually; eliminate gas-forming and spicy foods
- Low-fiber, high-protein, high-calorie diet
- Weigh at specified intervals
45
2 most common causes of acute pancreatitis
```
Gallbladder disease (more common in women)
Chronic alcohol intake (more common in men)
```
46
Hepatitis A
- Mild flu-like illness or acute hep w/jaundice
- Does NOT result in chronic infection
- Fecal-oral route; fecal contamination of food or drinking water
- Incubation: 15-50 days (avg 28)
- Infectivity: Most infectious during 2 wk before onset of symptoms
- Preventative: Personal and environmental hygiene, handwashing, vaccination
47
Hepatitis B
- Sexual transmission, percutaneous or permucosal exposure to blood, perinatal transmission
- Can cause either acute or chronic disease (infection resolves in most)
- If chronic infection - may have severe liver disease
- CAN (rarely) spread through saliva or shared food, stays on dry surfaces for up to 7 days) - not urine, feces (w/out GI bleed), breast milk, tears, sweat
- Much more infectious than HIV
- Incubation: 45-180 days (avg 56-96)
- Infectivity: Before and after symptoms appear, carriers continue to be infectious for life
- Preventative: precautions against bodily fluids, Hep B vaccination
48
Hepatitis C
- Can become acute or chronic (majority chronic)
- Asymptomatic - difficult to detect without lab testing
- Most common causes injection drug use and high risk sexual behavior, also perinatal contact
- Chronic results in progressive liver disease - 20-30% develop cirrhosis
- No vaccination available
- Most common cause of chronic liver disease and most common indication for liver transplants
- Pts at risk for HBV and HIV infections (30-40% HIV-infected have HCV)
49
Hepatitis D
- HBV precedes HDV - chronic carriers of HBV always at risk
- Range from asymptomatic carrier to acute liver failure
- No vaccine for HDV - vaccination of HBV reduces risk of co-infection
50
Hepatitis E
- Fecal-oral route
| - Usual mode of transmission contaminated water - mostly occurs in developing countries
51
Nutrition for hepatitis patient
- No special diet required - emphasis on well-balanced diet as tolerated (decreased bile may lead to poor fat tolerance)
- Acute viral hep - adequate calories because patient can lose weight
- Vitamin supplements, especially B-complex vitamins, vitamin K
- Severe anorexia/N&V: IV solutions of glucose or enteral nutrition
- Adequate fluid intake (2.5-3 L/day)
- Drinking carbonated beverages and avoid very hot/cold foods
52
Nursing care for hepatitis patient
- Manage fluid and electrolyte balance - adequate calories for acute viral hepatiis
- Assess presence and degree of jaundice (light-skinned first in sclera of eyes then in skin; dark skinned first hard palate of mouth and inner canthus of eyes); urine may be dark brown or brownish red from bilirubin
- Comfort measures for pruritis (if present), headache, arthralgias (joint pain)
- Rest periods, limit environmental stimuli
- Anorexia usually not as severe in morning, plan larger meals earlier in day
53
Types of cirrhosis
Alcoholic cirrhosis (Laennec's cirrhosis)
- Alcohol causes metabolic changes in the liver - fatty infiltration - normally would heal but with continued abuse hepatocytes inflammed and eventually necrosis - necrosis causes fibrosis and scarring - scarring causes nodules to form - liver shrinks
- Malnutrition commonly present
Fatty liver
- Due to diets high in fat, epidemic of obesity
- Can cause liver failure
Biliary
- Primary - chronic inflammatory condition (exact cause unknown - genetic/environmental factors)
- Primary sclerosing cholangitis - associated w/ulcerative colitis
Posthepatic/postnecrotic
- Viral hepatitis
- Liver decreases in size, nodules and fibrosis
Cardiac cirrhosis
- Longstanded right-sided heart failure
- Liver is swollen
- Can be reversed if heart failure treated effectively (some fibrosis occurs)
54
Cirrhosis - risk factors
- Any chronic liver disease can cause cirrhosis
- Most common causes in US: chronic hep C infection, alcohol-induced liver disease
- Environmental factors, genetic predisposition
- 10-20% of those w/hep B
55
Cirrhosis - complications
- Portal hypertension with resultant esophageal and gastric varices
- Peripheral edema and ascites
- Hepatic encephalopathy (mental status changes, including coma)
- Hepatorenal coma
56
Toxic and drug induced hepatitis
- Drugs can cause hepatitis
| - Some of same symptoms as Hepatitis, depending on degree of inflammation
57
Autoimmune hepatitis
- Unknown cause, presence of antibodies and immunoglobins, frequently occurs with other autoimmune diseases
58
Fulminant hepatitis
- Rapidly progressive disease with liver failure within a couple of weeks of symptoms
- Rare
- Hep B, especially B+D
- Death usually occurs
59
Portal Hypertension and Esophageal & Gastric Varices - interventions
- Prevent bleeding and hemorrhage - avoid alcohol, aspirin, NSAIDs
- Upper endoscopy (EGD) to screen for varices
- B-blocker reduces incidence of hemorrhage, high portal pressure
Variceal bleeding:
- Stabilize patient, manage airway, IV therapy initiated (may include blood products) - combination of endoscopal therapy and drug therapy (vasopressin / nitroglycerin often combination therapy)
- Band ligation (band around base of varix) or sclerotherapy (injection of sclerosant solution) - may be used to prevent rebleeding
- Balloon tamponade if cannot be controlled via endoscopy and bleeding acute - mechanically compresses the varices (* deflate balloons for 5 min every 8-12 hrs to prevent tissue necrosis)
- Fresh frozen plasma, packed RBCs, vit K, PPIs, antibiotics to prevent infection
Shunting:
- Surgical and nonsurgical methods available
- Used more after 2nd major bleeding episode than 1st
- TIPS - nonsurgical - shunt between systemic and portal venous systems to redirect portal flow
- Surgical - usually portacaval shunt or distal splenorenal shunt
60
Interventions specific to balloon tamponade from bleeding varices
- Gastric balloon breaks or is deflated - esophageal balloon will slip upward, obstructing airway and causing asphyxiation - cut the tube or deflate balloon - keep scissors at bedside
- Minimize regurgitation - oral and pharyngeal suctioning, pt in semi-Fowler's
- Patient is unable to swallow saliva - encourage to expectorate, provide emesis basin and tissues
- Frequent oral and nasal care
61
Ascites
- Abdominal distention with weight gain
- Abdominal striae with distended abdominal wall veins
- Signs of dehydration (dry mouth/skin, sunken eyeballs, muscle weakness) and decreased urine output
- Hypokalemia common
Management
- Sodium restriction
- Diuretics
- Fluid removal (paracentesis - needle puncture of abdominal cavity to remove fluid or test for infection) - reserved for patient with impaired respiration or ab pain caused by severe ascites - temporary measure b/c fluid builds back up
- Usually NOT on fluid restriction unless severe ascites develops
- TIPS when ascites does not respond to diuretics
62
Interventions - Ascites/Edema
- Accurate I&O, daily weights
- Observe F&E imbalances - high risk for hypokalemia
- Measurements of abdominal girth and extremities
- Have patient void immediately before paracentesis to prevent bladder puncture
- After paracentesis - patient sits on side of bed or in high-Fowler's - monitor for hypovolemia, electrolyte imbalances; check dressing for bleeding/leakage
- Dyspnea - semi-Fowlers or Fowlers; use pillows to support arms and chest
- Edematous tissues subject to breakdown - meticulous skin care, turning schedule min 2 hr, alternating-air pressure mattress, ROM exercises, coughing/deep breathing
- Elevate lower extremities; scrotal support for scrotal edema
63
Hepatic encephalopathy
Clinical manifestations
- Changes in neurological/mental responsiveness
- Impaired consciousness
- Inappropriate behavior - range from sleep disturbances to lethargy to deep coma
- Asterixis - flapping tremors - characteristic manifestation
Goal of mgmt - reduce ammonia formation
- Lactulose - drug that traps ammonia in the gut and has laxative effect to expel (can be given orally, NG tube, enema)
- Antibiotics can be given
- Constipation should be prevented
- Treatment of precipitating causes (GI hemorrhage, constipation, hypokalemia, hypovolemia, infection, etc)
- Controlling GI bleeding, and removing blood from GI tract to decrease protein in intestine
64
Hepatic encephalopathy - nursing care
- Assess patient's level of responsiveness, sensory and motor abnormalities, fluid and electrolyte imbalances, acid-base imbalances, effect of treatment measures
- Neurologic status at least Q2H
- Institute measures to prevent constipation to reduce ammonia production - give drugs, laxatives and enemas as ordered, encouraged fluids if indicated
- Any GI bleeding will worsen encephalopathy
- Assess pt taking lactulose for diarrhea and excessive fluid/electrolyte losses
- Control factors known to precipitate, including anything that may cause constipation
65
Nissen fundoplication
Surgical therapy (antireflux therapy) for GERD - reserved for pts with complications of reflux, including esophagitis, intolerance of meds, stricture, Barrett's metaplasia, and persistence of severe symptoms
- Fundus of stomach is wrapped around the lower portion of the esophagus to reinforce and repair defective barrier
- Postop care: prevention of respiratory complications, maintenance F&E, prevention of infection
Open high abdominal incision - respiratory complications can occur
Assessment: respiratory rate and rhythm, pulse rate and rhythm, signs of pneumothorax (dyspnea, chest pain, cyanosis)
Laparoscopic - resp complications less common
- Small percentage of pts experience complications: pneumothorax, bleeding, perforation, infection, pneumonia, splenic injury, gastric or esophageal injury
When peristalsis occurs - only fluids given initially - solids added gradually with goal of resuming normal diet (teach to chew food thoroughly, and avoid gas forming foods to prevent gastric distention)
