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Flashcards in MS2 - GI - Concepts Deck (65):
1

Patient position for tube feedings

- 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

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.

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

If gastric residual volume is >___ mL, hold enteral nutrition and reassess patient tolerance.

500 mL

4

Etiological factors and risks associated with GERD

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

Patient teaching for GERD

- 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

Two classifications of hiatal hernias

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

Human Digestive System Order

Mouth
Pharynx
Esophagus
Lower Esophageal Sphincter
Stomach
Pyloric Sphincter
Duodenum
Jejunum
Ileum
Cecum
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus

8

Upper GI barium swallow

- 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

Small Bowel Series

- 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

Lower GI barium enema

- 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

Ultrasound

- 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

Contraindications for Valsalva maneuver

- Head injury
- Eye surgery
- Cardiac problems
- Hemorrhoids
- Abdominal surgery
- Liver cirrhosis with portal hypertension

13

Computed Tomography Scan (CT Scan)

- 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

Magnetic Resonance Imaging (MRI)

- 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

Esophageal manometry

- 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

Esophagogastroduodenoscopy (EGD)
Upper GI endoscopy

- 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

Colonoscopy

- 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

Clinical manifestations of irritable bowel syndrome

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

Diet recommendations for IBS

Fiber
Water (very important)
Elimination of certain foods - only necessary for some pts (milk/lactose/fructose/gas-forming foods)
Caffeinated beverages
Alcohol

20

Diagnostic studies for IBS

- History and physical examination
- Use of diagnostic tests to rule out other disorders

21

Medications for IBS

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

Differences between Crohn's and ulcerative colitis

- 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

Symptoms for IBD

- 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

Differences for complications between CD and UC

- 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)