Gastrointestinal

COMMON LABORATORY TESTS FOR GASTROINTESTINAL DISORDERS 1. Blood a. b. c. d. e. f. g. h. i. j. k. l. m. 2. Stool a. b. c. d. e. f. g. h. 3. Urine a. b. c. d. e. f. Endoscopy 1. obtain operative permit prior to procedure 2. tell the client about the procedure 3. remove dental appliances before the procedure 4. keep client NPO before procedure 5. hoarseness is normal; watch for laryngospasm or bronchospasm 6. watch client and maintain NPO until gag and swallowing reflexes return 7. mild analgesics may relieve post procedure discomfort Barium contrast studies 1. 2. 3. 4. barium swallow upper gastrointestinal and small bowel series barium enema specific nursing interventions with barium 1. low residue diet or clear liquid diet for two days 2. client NPO after midnight 3. use cathartic: magnesium citrate, GoLYTELY 4. before test, give suppository or enema 5. retained barium may harden and cause an obstruction; examine client's stools; a mild laxative or cleansing enema may be ordered to help client expel barium CBC Serum electrolytes Serum chemistry Enzyme-linked immunosorbent assays (ELISA) Serum amylase Differential blood count Prothrombin time ALT, AST, Alanine aminotransferase, LDH Serum bilirubin Glucose Ammonia Serum lipase Alkaline phosphatase Occult blood pH Ova & parasites Qualitative fat Reducing substances Bacterial cultures Vital pathogens Leukocytes Osmolality Sodium Potassium Nitrogen Urobilinogen pH

5.

6. clear liquid before and force fluids after a barium procedure 7. encourage drinking of more fluids to aid in elimination of barium white stools for 24 to 72 hours are common

Esophageal function studies a. client swallows three thin tubes which pass into stomach b. transducers measure esophageal pressures

Paracentesis

a. drains abdominal fluid of client with ascites b. small incision is made just below umbilicus and trocar is inserted

c. nursing interventions i. client should void before procedure ii. sit client with feet firmly on floor iii. remove fluid slowly over a period of 30-90 minutes to prevent sudden changes in blood pressure iv. monitor client for hypovolemia or electrolyte imbalance v. observe incision site for leaking or bleeding vi. obtain and label specimens for laboratory analysis vii. standard precautions Gastrointestinal intubation 1. Routes a. nasopharynx: nasogastric, nasointestinal b. oropharynx c. through abdominal wall by incision: gastrostomy, jejunostomy d. via endoscopy: percutaneous endoscopic gastrostomy (PEG) or jejunostomy, (PEJ) Requires a provider's order Uses a. diagnostic b. gastric decompression c. gastric irrigation d. feeding Nasogastric and nasointestinal a. types of tube 1. nasogastric 1. single lumen: Levine 2. Salem 2. nasointestinal 1. single lumen: Cantor, Harris 2. double lumen: Miller-Abbott b. complications of prolonged nasal intubation 1. nasal erosion, sinusitis 2. pharyngitis, esophagitis, esophageal sphincter incompetence 3. gastric ulceration, pulmonary aspiration 4. aspiration risk is higher with nasal tubes c. nursing interventions in gastric or intestinal intubation:

2. 3.

4.

Gastrostomy/jejunostomy a. tube placement is in upper left quadrant of abdomen b. for clients who cannot tolerate nasal route, or for long term enteral feeding c. provides more secure and reliable access d. nursing care i. cleanse skin around insertion site daily with warm water and mild soap ii. apply dressing if indicated iii. observe for complications e. complications i. skin breakdown at insertion site ii. infection iii. seepage of enteral formula or gastric drainage Ostomy

1.

Surgical procedure which creates an opening into the abdominal wall for fecal or urinary elimination (enterostomy) 2. Portion of intestinal mucosa or ureter brought through abdominal wall creating a stoma through which feces or urine drains 3. Types a. bowel: ileostomy or colostomy b. urinary diversions i. ileal conduit (ileal loop) ii. ureterostomies 4. Ileostomy a. stool is liquid, frequent, highly alkaline, contains digestive enzymes b. requires constant pouching and frequent emptying 5. Colostomy: thicker, formed stool a. transverse colon: must be pouched at all times b. sigmoid colon: can be managed by daily irrigation, so no need for pouch

Nursing interventions for a client with ostomy; additional guidelines for nursing care: a. empty pouches when they are about 1/3 to 1/2 full, standard precautions b. if needed, protect skin around ileostomy stoma c. ostomies threaten body image. d. fears of mutilation, shame, rejection are common e. clients may feel powerless because they cannot fully control bodily functions f. assist client to establish normal elimination routine. Report immediately if: i. stoma oozes blood when touched ii. you see blood in pouch iii. you see bleeding from stoma iv. urinary diversion output is less than 30cc/hour v. urine smells foul vi. there is blood in urine, or it is very cloudy vii. client reports burning sensation around base of urinary diversion stoma viii. client reports back pain, chills, or fever g. teach client i. the types of equipment and their use ii. how to irrigate colostomy iii. prevention of complications iv. how to avoid constipation, diarrhea, excessive gas v. that it is vital to drink plenty of fluids Gastric analysis a. b. c. are aspirated d. e. smoking f. standard precautions are required masures gastric secretions under fasting conditions histamine is injected via nasogastric tube and secretions indications: suspected gastric ulcer or malignancy before test, client NPO for about eight hours and no

instruct client to expectorate saliva rather than swallow it g. withhold the following drugs for 24 hours prior to test: antacids, anticholinergics, alcohol, H2 blockers, reserpine and adrenergic blockers h. standard precautions are required i. used to determine presence of blood (Guaiac test), fat and for cultures j. aseptic technique required k. client must defecate into clean dry bedpan to avoid contaminating specimen with urine or water (only a sample is required) l. timed test for fecal fat may be performed

I.

Anatomy & Physiology

A.

Upper gastrointestinal tract 1. Mouth: teeth and salivary glands 2. Esophagus 3. Stomach

B.

Lower gastrointestinal tract 1. Small intestine - digests and absorbs, mixes via peristalsis, receives secretions from liver, gallbladder and pancreas a. duodenum - proximal section of small intestine joins pylorus of the stomach divided by the pyloric sphincter is about ten inches long b. jejunum - middle section, is about eight feet long c. illeum - lower section, is about 12 feet long 2. Colon - approximately six feet long, absorbs water and sodium a. ascending b. transverse c. descending d. sigmoid e. rectum - last seven - eight inches of intestines

Accessory digestive organs 1. Liver - largest gland of the body a. lobes dived into lobules by blood vessels and fibrous material b. ducts - hepatic duct from liver; cystic duct from gallbladder; common bile duct formed by joining of hepatic duct and cystic duct and drains into duodenum c. functions: Metabolism of fat, carbohydrates and protein

C.

converts glucose to glycogen for storage converts glycogen to glucose and releases into blood forms glucose from fats or proteins breaks down fatty acids into ketones stores fat synthesizes triglycerides, phospholipids, cholesterol, and choline (B complex factor) vii. synthesizes various proteins viii. converts amino acid to ammonia ix. converts ammonia to urea d. other functions i. secretes bile, which is important in the emulsifying of fats ii. detoxifies substances such as drugs, hormones iii. metabolizes vitamins 2. Pancreas a. fish-shaped organ extending from duodenal curve to the spleen b. both an endocrine and exocrine gland i. pancreatic cells - empty into duodenum at the hepatopancreatic papilla; secrete enzymes which digest fats, carbohydrates and proteins ii. islet of Langerhans alpha cells secrete glucagon to promote liver glycogenolysis and gluconeogenesis which ultimately increases blood glucose level beta cells secrete insulin

i. ii. iii. iv. v. vi.

3.

Gallbladder Here's a simplified story of what the normal G-I system does a. similar size and shape as a pear b. made up of smooth musclefood mixed with saliva to stomach. Esophagus- conveys and lined with rugae-arranged mucosa c. only purpose is - secretes digestive juices, including hydrochloric acid. Stomach to store bile Stomach contents (chyme) go through pylorus into d. empties bile into duodenum when fat is present there small intestine
Small intestine - whose parts (in order) are duodenum, jejunum, and ileum; their walls absorb nutrients. From ileum, chyme advances into cecum of large intestine. Meanwhile, Liver - makes many crucial proteins, vitamins, fats, iron compounds, etc.; neutralizes toxins such as alcohol, and converts ammonia into urea; conjugates bilirubin, excretes it in bile. Bile passes via the hepatic duct into the gallbladder Gallbladder - stores bile, which goes to small intestine via the cystic duct / common bile duct to break down fat Large intestine - undigested matter is further absorbed and processed; remnants form as feces in the sigmoid colon and rectum.

D. Process of digestion 1. Purpose - converts foods into a form which can be absorbed and used by the body 2. Digestive enzymes 3. Basic processes a. absorption - accomplished by active transport via intestinal cells. Water and solutes move through the intestinal mucosa in opposite direction expected in osmosis and diffusion b. metabolism - consists of the sum of all physical and chemical changes that take place within an organism c. catabolism - series of chemical reactions that take place within the cell; breaks down food molecules to produce energy i. anabolism - synthesis of compounds from simpler compounds

II.

Disorders of Stomach and Colon A. Pernicious anemia - anemia caused when tissues fail to absorb enough
vitamin B12 1. Definition/etiology/risk a. mucosa and parietal cells of stomach atrophy; stomach fails to produce intrinsic factor, thus cannot properly absorb vitamin B12 b. possibly an autoimmune disease c. may follow gastric resection 2. Pathophysiology a. large RBCs - macrocytic normochromic b. hydrochloric acid 3. Findings a. anemia - findings depend on severity b. tissue hypoxia producing fatigue, weakness, dyspnea, pallor, palpitations c. GI symptoms: sore tongue, anorexia, nausea, vomiting, abdominal pain, neurological symptoms d. neurological symptoms: paresthesia in hands and feet, weakness, impaired coordination, changes in LOC 4. Complications: GI symptoms are reversible, but neurological changes are not 5. Diagnostics a. CBC b. bone-marrow biopsy c. lack of free hydrochloric acid in stomach d. Schilling test 6. Management a. lifelong vitamin B12 therapy with lack of intrinsic factor must be given parenterally b. adequate nutrition c. blood transfusions as needed 7. Nursing interventions a. monitor for impaired gas exchange b. manage fatigue c. risk of injury from depressed LOC and impaired coordination d. knowledge deficit- need to understand chronic illness

B.

Peptic ulcer diseases - include disorders that ulcerate any part of stomach or intestines. 1. Gastric ulcers a. definition/etiology I. incidence higher in the middle-aged and elderly; most common in men ages 45-55 II. risk factors: aspirin, NSAIDs, steroids, caffeine, and alcohol intake; stress

2.

3.

pathogen: H. pylori b. pathophysiology I. something disrupts mucosal layer and acid diffuses back into mucosa II. commonest site: junction of fundus and pylorus III. normal gastric acid secretion c. findings I. pain, burning or gas, worse with food II. pain in left upper epigastric area III. nausea/vomiting IV. bleeding; hematemesis d. diagnostic studies I. endoscopy II. complete blood count (CBC) III. test stool for occult blood e. complications I. hemorrhage I. administer intra-arterial vasopressin II. administer intravenous fluids and blood replacement II. perforation and peritonitis I. finding: severe abdominal pain II. finding: board-like abdomen III. paralytic ileus (obstruction): scarring may obstruct pylorus Duodenal ulcers a. etiology/risk factors I. excess production of hydrochloric acid II. more rapid gastric emptying III. familial tendency IV. stress V. more frequent in people with type O blood VI. more common in men ages 25 to 50 b. pathophysiology I. located 0.5 to 2 cm below pylorus II. arteriosclerotic changes in adjacent blood vessels III. vagus nerve stimulation causes tissues to release gastrin, which increases secretion of hydrochloric acid c. findings I. pain, heartburn occur during night or when stomach is empty II. pain relieved by food intake III. melena (tarry stool; black with digested blood) d. diagnostic studies I. endoscopy - esophagogastroduodenoscopy II. complete blood count (CBC) III. test stool for occult blood e. complications I. hemorrhage I. administer intra-arterial vasopressin II. administer intravenous fluids and blood replacement II. perforation and peritonitis I. finding: severe abdominal pain II. finding: board-like abdomen III. paralytic ileus (obstruction): scarring may obstruct pylorus Management of peptic ulcer disease a. NPO (nothing by mouth) b. nasogastric tube

III.

4.

5.

antibiotics: clarithromycin (Biaxin); metronidazole (Flagyl) H2 receptor antagonists: cimetidine (Tagamet); rantidine hydrochloride (Zantac); famotidine (Pepcid); nizatidine (Axid) e. anticholinergics: dicyclomine hydrochloride (Bentyl) f. antacids; aluminum hydroxide (Amphogel); aluminummagnesium combinations (Maalox, Mylanta, Gelusil); calcium carbonate (Tums) g. cytoprotective: sucrulfate (Carafate) h. proton pump inhibitors: omeprazole (Prilosec), iansoprazole (Prevacid) i. anxiolytics j. blood administration k. surgical Intervention I. vagotomy: eliminates stimulation of gastric cells II. pyloroplasty: widening pylorus to improve gastric emptying III. subtotal gastrectomy IV. billroth I (gastroduodenostomy) V. billroth II (gastrojejunostomy) VI. total gastrectomy Postoperative complications a. dumping syndrome - from rapid emptying of the stomach I. tachycardia, palpitations, syncope, diaphoresis, diarrhea, nausea, abdominal distention II. more common with Billroth II III. subsides after several months IV. decrease with slow eating, low-carbohydrate, highprotein and fat diet V. avoid liquids with meals b. pernicious anemia secondary to loss of intrinsic factor Nursing interventions a. pain relief b. assess for bleeding c. discuss life-style changes: stop smoking, decrease stress d. teaching - medications, diet e. assess for post-operative complications - infection, bleeding, respiratory complications f. maintain patency of NG tube g. observe drainage for signs of bleeding (drainage should be dark red after 24 hours) h. mouth care

c.

d.

III.

Disorders of Intestines A. Inflammatory intestinal diseases - chronic, recurrent inflammation;

etiology unknown 1. ulcerative colitis a. definition/etiology i. affects young people ages 15 to 40 b. pathophysiology i. ulceration and inflammation entire length of colon ii. involves mucosa and submucosa iii. begins in rectum and extends to distal colon iv. abscess and ulcers lead to bleeding and diarrhea v. colon cannot absorb, so fluids and electrolytes go out of balance vi. protein is lost in stools vii. scarring produces narrowing, thickening, and shortening of colon viii. remissions and exacerbations c. findings

i. ii. iii.

iv.
v. vi.

bloody diarrhea ranging from two to three per day to ten to 20 per day stools may also contain pus and mucus abdominal (tenderness and cramping) pain fever, weight loss, anemia, tachycardia, dehydration impaired absorption of fat-soluble vitamins such as E, K systemic manifestations skin lesions - erythema nodosum joint inflammation inflammation of the eyes - uveitis liver disease

d. diagnosis i. sigmoidoscopy ii. colonoscopy iii. barium enema iv. complete blood count (CBC) e. management i. rest ii. fluid, electrolyte, and blood replacement iii. steroids as anti-inflammatories iv. immunosuppressives v. anti-infectives: sulfasalazine (Azulfidine) primary drug of choice vi. anticholinergics vii. antidiarrheals viii. dietary restrictions - high calorie and high protein ix. surgical management total proctolectomy and ileostomy ileorectal anastomosis total proctolectomy with continent ileostomy (Kock pouch) total colectomy with ileal pouch (reservoir)

BARIUM ENEMA

With a barium enema - bowel prep prior to test, including cathartics, enemas; after study use cathartic again to cleanse bowel Increased fiber may cause flatulence Increase fluid to 3000cc/day (unless contraindicated)

Don't confuse these three! Ileum = last part of the small intestine, before it empties into the large intestine. (An ileal pouch is filled from the ileum.) Ileus = an obstruction (often in an intestine). Ilium = part of the hipbone f. complications i. increased risk of colon cancer ii. fluid and electrolyte imbalances g. nursing interventions i. manage pain ii. manage diarrhea

iii. iv. v. vi.

teach weight loss and nutrition teach coping remedy knowledge deficit reduce anxiety

2. Crohn's disease a. definition/etiology i. young people 15 to 30 years old ii. inflammation of segments of bowel, especially ileum, jejunum, and colon, with areas of normal bowel between inflamed bowel - cobblestone appearance iii. inflammation involves all layers of bowel wall transmural iv. ulceration, fissures, fistula, and abscess formation v. bowel wall thickens and narrows, producing strictures vi. slowly progressive b. findings

diarrhea with steatorrhea (fats not processed) abdominal pain - right lower quadrant fatigue, weight loss, dehydration, fever systemic manifestations arthritis, clubbing of fingers skin inflammations nephrolithiasis c. complications i. obstruction from strictures ii. fistula formation iii. bowel may perforate and infect: peritonitis iv. medical management rest nutritional support hyperalimentation diet high in calories and protein, low in roughage and fat steroids as anti-inflammatories immunosuppressives anti-infectives: sulfasalazine (Azulfidine) primary drug of choice anticholinergics antidiarrheals loperamide (Imodium) drug of choice balloon dilation of strictures

i. ii. iii. iv.

surgery will not cure Crohn's disease; may limit damage 1. colectomy with ileostomy 2. subtotal colectomy with ileostomy or ileorectal anastomosis d. nursing interventions i. after surgery, monitor diarrhea fluid balance and nutrition skin integrity coping and self-care sexuality medications

B. Diverticular disease - outpouching of the intestinal mucosa

1. Definition/etiology a. most common in sigmoid colon b. constipation, low fiber diet, obesity c. colon wall thickens with increased pressure in bowel d. stool and bacteria retained in diverticulum become inflamed and small perforations occur e. inflammation of surrounding tissue 2. Findings a. frequently asymptomatic b. crampy, lower, left abdominal pain c. alternating constipation and diarrhea d. low grade fever, chills, anorexia, nausea e. leukocytosis 3. Diagnosis a. barium enema b. complete blood count, urinalysis, stool for occult blood c. colonoscopy 4. Management a. diverticulosis (outpouching) 1. high fiber diet 2. bulk laxatives 3. stool softeners 4. anticholinergics b. diverticulitis (inflammation) 1. NPO 2. rest bowel 3. antibiotics 4. surgery 1. bowel resection 2. temporary colostomy 5. Complications a. abscess formation b. perforation with peritonitis c. fistula d. bowel obstruction 6. Nursing interventions a. teach appropriate diet b. avoid straining, coughing, lifting c. avoid increased abdominal pressure C. Constipation 1. Definition/etiology

2.

3. 4.

5.

a. change in normal bowel habits characterized by 1. decreased frequency 2. stool is hard, dry, difficult to pass 3. stool is retained in rectum b. etiology/risk factors 1. insufficient dietary fiber 2. insufficient fluid intake 3. medications, especially opiates 4. lack of activity 5. ignoring urge to defecate 6. chronic laxative abuse 7. lack of privacy/psychological factors 8. pregnancy 9. neuromuscular impairment 10. hypothyroidism Findings a. hard, dry stool b. abdominal distention c. decreased frequency of usual patterns d. straining e. nausea/anorexia f. palpable mass g. hemorrhoids h. fecal impaction with diarrhea Complications a. obstruction/perforation b. cardiovascular alterations Management a. cathartics 1. saline laxatives - milk of magnesia 2. stimulant laxatives - bisacodyl (Dulcolax) 3. bulk-forming laxatives - psyllium (Metamucil) 4. lubricant-emollient - mineral oil 5. stool softeners - docusate sodium (Colace) b. enemas 1. cleansing - saline, soap solution 2. softening - oil retention Nursing interventions a. teach nutrition, increased fiber, and increased fluids b. teach: obey urge to defecate c. provide privacy and comfort d. increase activity

D. Diarrhea 1. Definition/etiology - loose stools due to a. fecal impaction b. ulcerative colitis c. intestinal infections d. increased fiber e. medications 2. Finding - loose watery stools 3. Complications - dehydration, electrolyte imbalance 4. Management a. mild diarrhea - oral fluids to replace lost fluid b. moderate diarrhea - drugs that decrease motility (Lomotil, Imodium) c. severe diarrhea - due to infection, antimicrobials and fluid replacement 5. Nursing interventions a. monitor for fluid and electrolyte imbalance b. prevent skin excoriation

c. teach client about foods that may affect bowel elimination, e.g., fruits, vegetables E. Bowel obstruction 1. Definition/etiology a. mechanical: adhesions, hernias, neoplasms, volvulus, intussusception b. nonmechanical: paralytic ileus, occlusion of vascular supply c. distended abdomen from accumulation of fluid, gas, intestinal contents d. fluid shifts due to increased venous pressure with hypotension and hypovolemic shock e. bacteria proliferate 2. Findings a. abdominal pain b. distention (more with large bowel obstruction) c. nausea/vomiting (more with small bowel obstruction) d. hypoxia e. metabolic acidosis f. bowel necrosis from impaired circulation 3. Complications a. perforation and peritonitis b. shock c. strangulation of bowel 4. Diagnosis a. upper-GI and lower-GI series b. abdominal X rays show air in bowel c. low fluid volume increases white blood cells, hemoglobin & hematocrit, BUN 5. Management a. decompress the abdomen b. nasointestinal tube c. surgical bowel resection 6. Nursing interventions a. manage pain, but avoid morphine or codeine, which slow bowel motion b. measure abdominal girth c. with nasogastric or nasointestinal tubes, provide oral care d. nasogastric tubes: Salem sump (double lumen), Levin (single lumen) e. nasointestinal tubes 1. cantor tube - single lumen, mercury filled weight on tip 2. miller-Abbott - double lumen with mercury weighted tip 3. advance two inches per hour f. maintain fluid and electrolyte balance F. Colon cancer 1. Definition/etiology a. may develop from adenomatous polyps b. risk factors - low residue diet, high-fat diet, refined foods 2. Pathophysiology a. adenocarcinoma is the most common type b. most common locations are sigmoid rectum and ascending colon c. often metastasizes to the liver d. classification (staging) systems: TNM or Duke's 3. Findings a. rectal bleeding

4.

5. 6.

7.

b. change in bowel habits - constipation, diarrhea c. change in shape of stool d. anorexia and weight loss e. abdominal pain, palpable mass Diagnostics a. colonoscopy b. sigmoidoscopy c. digital examination d. stool for occult blood e. barium enema f. CT scan g. carcinoembryonic antigen (CEA) h. alkaline phosphatase and AST (aspartate aminotransferase) Complications - obstruction Management a. radiation b. chemotherapy c. treatment of choice is surgery - bowel resection, colostomy 1. right hemicolectomy - involves ascending colon 2. left hemicolectomy - involves descending colon 3. abdominal-perineal resection: removal of sigmoid colon and rectum with formation of a colostomy Nursing interventions a. manage pain b. monitor for complications 1. wound infection 2. atelectasis 3. thrombophlebitis PLASMA VALUES c. maintain fluid and electrolyte balance d. care of ostomy

A. Albumin: 3.6-5.0 g/dl (see also Proteins, below) B. Alcohol: negative IV. Disorders of the Liver C. Alkaline phosphatase adults 30-85 ImU/ml children greater than two years 85-235 ImU/ml o two to eight years 65-210 ImU/ml o nine to 15 years 60-300 ImU/ml D. Ammonia adults 9-33 mol/liter children 40-80 g/dl newborns 90-150 g/dl E. Bilirubin, direct - up to 0.3 mg/dl F. Bilirubin, indirect - 0.1-1.0 mg/dl G. Bilirubin total adults and children 0.3-1.1 mg/dl newborns 1-21 mg/dl H. Bleeding time one to nine minutes I. Fibrinogen 150-360 mg/dl J. Gamma globulin 0.8-1.6 g/dl K. Lead 120 (g/dl or less) <25 g/dl L. Lipids (total) 400- 800 mg/dl M. Cholesterol <200 mg/dl N. HD females: 30-85 mg/dl males: 30-65 mg/dl O. ldl< 190 mg/dl P. Triglycerides <250 Q. Phospholipids 180-320 mg/dl R. Free fatty Acids 9.0-15.0 mM/L S. Partial thromboplastin time, activated (APTT) 21-32 seconds tow to three times when anticogulated) T. Protein (total) 6.2-8.2 g/dl albumin 3.6-5.0 g/dl globulin 2.3-3.4 g/dl U. Prothrombin Time (PT) 11.3-18.5 seconds (two to three times when anticoagulated) V. Urea Nitrogen 8-25 mg/L W. Uric acid 3-8 mg/dl

A.

Hepatitis 1. Definition/etiology - acute inflammatory disease of the liver caused by viral, bacterial, or toxic ingestion 2. Pathophysiology a. inflammation of liver, enlargement of Kupffer cells, bile stasis b. regeneration of cells with no residual damage c. types i. hepatitis A transmitted from infected food, water, milk, shellfish fecal-oral route of infection common in poor sanitation/overcrowding higher incidence in fall and winter new vaccine available ii. hepatitis B blood-borne and sexually transmitted may become a carrier iii. hepatitis C transmitted parenterally (post-transfusion hepatitis) and possibly fecal-oral route may become a carrier iv. hepatitis D blood borne coexists with hepatitis B v. hepatitis E water borne contaminated food or water; rare in the United States Hepatitis B 1. Risk factors/infection route a. homosexuality b. iv drug use c. health professionals d. hemodialysis e. transmission routes i. sexual ii. fecal-oral route: incubation 12 to 14 weeks or longer iii. contaminated body fluids f. pathophysiology

B.

i.

ii.
iii. iv. 2.

hepatitis B has three distinct antigens HBsAg - surface antigen HBcAg - core antigen HBeAg - e antigen damage to the hepatocytes causes inflammation and necrosis liver function decreased in proportion to damage healing takes three - four months

3.

4.

Findings a. jaundice if liver fails to conjugate bilirubin or excrete it b. clay-colored stools from lack of urobilin c. urine is dark from urobilin excreted in urine rather than stool d. urine foams when shaken e. pruritus from bile salts excreted through skin f. right upper quadrant pain from edema and inflammation of liver g. anorexia, nausea, vomiting, malaise, weight loss h. prolonged bleeding from impaired absorption of vitamin K i. anemia from decreased RBC lifespan Diagnostics - serologic markers of HBV a. HBsAg - hepatitis B surface antigen b. anti-Hbc - antibodies to B core antigens c. elevated alanine aminotransferase (ALT previously SGPT) d. elevated bilirubin e. elevated aspartate aminotransferase (AST; previously SGOT) f. elevated alkaline phosphatase g. prolonged prothrombin time Management - nonspecific and supportive a. symptomatic treatment of pain HEPATITIS b. antiemetics as needed

Smokers who develop hepatitis often dislike cigarettes; hepatitis may impair the sense of smell. Hepatitis develops in three stages: 1. Pre-icteric (pre-jaundice) or prodromal when general flu-like symptoms occur 2. Icteric or stage during which jaundice occurs (not all patients with hepatitis develop jaundice) 3. Post-icteric (post-jaundice) or recovery stage: patient continues to have fatigue and malaise For the client with hepatitis: Provide a restful environment For clients with hepatitis or other severe liver disease, use Acetaminophen cautiously. Avoid over-the-counter medications that contain aspirin or NSAIDs Steroids may mask signs of infections Monitor hydration status if NPO Monitor hemoglobin, hematocrit , and electrolytes Monitor vital signs for shock If blood products given, monitor vital signs for adverse effects Monitor drainage from nasogastric tube Assess for signs of perforation Monitor for signs of dumping syndrome Avoid foods and drinks that are spicy, hot, or cold; avoid caffeine and alcohol Administer antacids after meals Do not give antacids at the same time as H2 receptor antagonists (histamine blockers) Maintain gastric pH >3.5 After surgery, teach effective coughing only if secretions are present. Coughing increases pressure in the chest and narrows airways. In clients with reactive airways, it can cause bronchospasms and wheezing.

5. Nursing interventions a. fatigue - provide rest periods; may require bed rest initially b. maintain skin integrity c. client will tolerate less activity d. nutrition needs: i. increase carbohydrates and proteins; decrease fat ii. avoid alcohol iii. eat frequent, small meals e. remedy knowledge deficit f. arrange for home care needs g. teach infection control i. use disposable utensils and dishes or keep separate from others ii. good handwashing iii. do not share razors, toothbrush, etc. 6. Prevention a. hepatitis B vaccine provides active immunity b. hepatitis B immune globulin provides passive immunity c. observe Standard and Enteric Precautions d. good handwashing

C. Cirrhosis 1. Definition/etiology - irreversible, chronic, progressive degeneration of the liver, with fibrosis and areas of nodular regeneration a. types i. Laennec's cirrhosis - related to alcohol abuse ii. post-necrotic - associated with viral hepatitis or exposure to hepatotoxin iii. biliary cirrhosis - associated with inflammation or obstruction of gallbladder or bile duct iv. cardiac cirrhosis - associated with congestive heart failure 2. Pathophysiology a. nodular liver with fibrosis and scar tissue b. destroys hepatocytes and kills tissue (necrosis) c. necrosis, nodules, and scar tissue obstruct flow of blood, lymph, and bile d. impaired bilirubin metabolism 3. Findings a. weakness, fatigue, weight loss, hepatomegaly b. right upper quadrant pain c. jaundice, pruritus, steatorrhea (decreased absorption of fat and fat-soluble vitamins) d. clay-colored stools e. increased bilirubin in urine, producing dark colored urine f. impaired aldosterone metabolism resulting in edema g. impaired estrogen metabolism: gynecomastia, menstrual changes, changes in distribution of body hair, vascular changes - spider angiomas, palmar erythema

h. impaired metabolism of protein, carbohydrate, and fat i. produces less plasma protein, resulting in edema and ascites ii. produces less of proteins needed for clotting (fibrinogen and prothrombin) iii. absorbs less vitamin K, resulting in prolonged bleeding iv. liver fails to convert glycogen to glucose, resulting in hypoglycemia 4. Diagnostics a. liver function studies - ALT, AST, alkaline phosphatase b. prothrombin time, CBC c. decreased cholesterol because liver synthesis impaired d. elevated serum bilirubin and urine bilirubin e. ERCP to examine bile ducts f. CT scan of liver g. liver biopsy 5. Management a. steroids for post-necrotic cirrhosis b. replace B vitamins and fat-soluble vitamins c. diet i. increased carbohydrates ii. protein may be restricted, depending on amount of damage and symptoms iii. no alcohol 6. Nursing interventions a. monitor for bleeding b. alteration in nutrition i. 2,000-3,000 calories daily ii. low fat c. provide rest periods; client will not tolerate strenuous activities d. remedy any knowledge deficit about cirrhosis and its therapies e. changes in LOC i. confusion ii. avoid sedation f. impaired skin integrity, from edema and pruritus g. monitor fluid balance h. measure abdominal girth daily i. weigh daily j. measure I & O 7. Complications a. portal hypertension b. ascites c. hepatic encephalopathy D. Portal hypertension 1. Definition/etiology - increased pressure in portal circulation 2. Pathophysiology: normal blood flow is altered producing an increased resistance to flow through the liver. Congestion in the portal system dilates veins, especially in esophagus and rectum. 3. Findings a. prominent abdominal-wall veins (caput medusa) b. hemorrhoids c. enlarged spleen d. anemia from increased destruction of RBCs e. esophageal varices and GI bleeding 4. Diagnostics: endoscopy 5. Management a. sclerotherapy - injection of a sclerosing agent into varices b. balloon tamponade

Sengstaken-Blakemore tube is inserted into the stomach ii. gastric balloon is inflated and presses on lower esophagus while allowing suctioning iii. esophageal balloon places pressure on varices iv. pressure is released as ordered to prevent necrosis v. traction for increased pressure added by attaching tube to football helmet vi. assess for bleeding and signs of shock vii. assess for respiratory distress - aspiration or displacement of tube, suction PRN viii. keep head of bed elevated c. medications i. vasopressin A. constricts veins and decreases portal blood flow B. given IV or into superior mesenteric artery C. side effects include hypothermia, myocardial ischemia, acute renal failure ii. nitroglycerin will decrease myocardial effects iii. beta-adrenergic neuron-blocking agents may decrease risk of recurrent bleeding by decreasing pressure in portal system iv. cathartics to remove blood from GI tract and decrease absorption of ammonia d. surgical intervention i. shunt to decrease blood flow to liver and therefore pressure splenorenal shunt A. mesocaval shunt B. portacaval shunt ii. TIPS (transjugular intrahepatic portosytsemic shunt) - shunt placed between hepatic and portal vein 6. Nursing interventions a. prevent bleeding b. avoid intake of alcohol, irritating or rough food c. avoid increased pressure in abdomen d. if bleeding occurs - administer transfusions, fresh frozen plasma, vitamin K e. monitor for infection

i.

E. Ascites 1. Definition/etiology - accumulation of fluid in the peritoneum

2. Pathophysiology a. portal hypertension causes increased plasma and lymphatic hydrostatic pressure in portal system b. hypoalbuminemia causes decreased colloid osmotic pressure c. hyperaldosteronism due to liver's inability to metabolize aldosterone causes body to retain sodium and water d. abdomen will have excess fluid, blood vessels too little fluid 3. Findings a. abdominal distention, protruding umbilicus, dull sound on percussion of abdomen, fluid wave b. bulging flank c. dyspnea 4. Diagnostics a. abdominal x-ray b. CT scan c. ultrasound

ASCITES - PARACENTESIS

Paracentesis - aspiration of abdominal ascites, usually 1000-1500cc removed Before paracentesis: empty client's bladder During procedure: client sits upright After procedure: take frequent vital signs; monitor urine output; and monitor for drainage from puncture site

5. Medical management a. diuretics - spirnolactone (Aldactone) - aldosterone antagonist, spares potassium b. iv albumin c. paracentesis to remove fluid d. diet low in sodium e. peritoneal venous shunt - allows drainage of fluid from the peritoneum to superior vena cava 6. Nursing interventions a. measure I & O, daily weight, abdominal girth, skin turgor b. restrict fluids c. monitor for ineffective breathing patterns d. semi-Fowler's position e. monitor for impaired skin integrity f. remedy knowledge deficit F. Hepatic encephalopathy - mental dysfunction associated with severe liver disease 1. Definition/etiology a. impaired ammonia metabolism in liver poisons brain tissue b. ammonia produced in bowel from action of bacteria on protein 2. Findings a. changes in LOC from confusion to coma b. changes in sleep pattern c. memory loss d. asterixis - flapping tremor e. impaired handwriting f. hyperventilation with respiratory alkalosis g. fetor hepaticus - musty, sweet odor to breath 3. Diagnostics - serum ammonia level 4. Management a. neomycin sulfate (Mycifradin) - inhibits action of intestinal bacteria b. lactulose (Cephulac) - absorbs ammonia and produces evacuation of the bowel c. low protein diet 5. Nursing interventions a. tremor, confusion can lead to injury: maintain safety b. ascites and low intake decrease fluid volume c. diarrhea from medications

V.

Disorders of Pancreas and Gallbladder

A. Acute pancreatitis 1. Definition/etiology - inflammation of the pancreas a. alcohol ingestion b. gall stones c. drug ingestion d. viral infections e. trauma

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3.

4.

Pathophysiology a. autodigestion from premature activation of pancreatic enzymes b. proteases and lipases, normally active in small intestine, are activated in the pancreas c. phospholipase A digests adipose and parenchymal tissues d. elastase digests elastic fibers of blood vessels, producing bleeding e. amylase digests carbohydrates f. inflammation response occurs from enzyme release Findings a. left upper quadrant abdominal pain b. pain worsens after eating and when lying flat c. nausea and vomiting d. fever, agitation, confusion e. hypovolemia and shock f. hemorrhage into retroperitoneal space may produce ecchymosis in flank or around umbilicus g. tachypnea, pulmonary infiltrates, atelectasis from circulating enzymes Diagnostics a. elevated enzymes: serum amylase, serum lipase, and urinary amylase b. elevated WBCs, decreased hemoglobin and hematocrit c. elevated LDH and AST (SGOT) d. hyperglycemia e. hypocalcemia f. chest x- ray, CT scan, ultrasound, ERCP

Endoscopy helps diagnose and treat many abdominal (and other) disorders. Here are two endoscopic procedures designed for the abdomen: Endoscopic retrograde cholangiography (ERCP) outlines the common bile duct and helps diagnose pancreatitis. (If it helps, think of the P in ERCP as pancreatitis and "picture" because ERCP pictures the duct.) Endoscopic retrograde catheterization of the gallbladder (ERCG) helps diagnose cholecystitis. (Think of the G in ERCG as gallbladder.)

Complications a. respiratory problems - atelectasis, pneumonia from the immobility imposed by pain b. tetany from decreased calcium levels c. abscess or pseudocyst 6. Management a. treat cause b. pain relief - meperidine (Demerol) c. fluid maintenance to prevent shock d. insulin for hyperglycemia e. calcium replacement f. decrease stimulation of pancreas i. NPO-TPN (nothing by mouth; total parenteral PANCREATITIS nutrition) ii. NG tube Acute pancreatitis can becomeanticholinergics chronic iii.

5.

Morphine sulfate is not used to treat pain since it can cause the sphincter of Oddi to spasm iv. h2-receptor antagonists Pain may be relieved by side-lying If clients lose pancreatic function, they may have to take pancreatic enzymes and bile salts with meals. With pancreatitis, avoid stimulation of the pancreas: do not use enteral feedings

7.

Nursing interventions a. manage pain b. monitor alteration in breathing patterns c. monitor nutritional status d. oral care when NPO e. if eating is allowed, diet high in proteins and carbohydrates and low in fat f. monitor fluid and electrolyte balances

B. Cholecystitis 1. Definition/etiology - inflammation of the gallbladder a. usually due to gallstones (Cholelithiasis) b. types i. cholesterol - most common ii. pigment - unconjugated bilirubin c. bile is blocked, and infects tissue d. more common in women, especially those over 40 and those who use birth control pills 2. Pathophysiology a. common bile duct is obstructed by a gallstone b. bile cannot be excreted, some is reabsorbed c. remaining bile distends and inflames gall bladder d. may scar gallbladder, resulting in less storing of the bile from the liver e. can perforate gall bladder 3. Findings a. colicky pain in right upper quadrant with possible radiation to right shoulder and back b. indigestion after eating fatty foods c. nausea and vomiting d. jaundice (if the liver is involved or inflamed or the common duct obstructed) e. low grade fever Diagnostics a. endoscopic retrograde cholangiography (ERCP) b. endoscopic retrograde catheterization of the gallbladder (ERCG) c. ultrasound Management a. rest b. low-fat diet c. removal of stone in common duct by endoscopy d. to dissolve cholesterol stones I. chenodeoxycholic acid (Chenodiol) - side effects are diarrhea and hepatotoxicity II. ursodeoxycholic acid (UDCA) e. control pain - meperidine (Demerol) is drug of choice f. replace vitamin K if bleeding time is prolonged

4.

5.

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extracorporeal shock wave lithotripsy - may have hematuria after procedure, but not longer than 24 hours h. choledocholithotomy - to remove or break up stones i. laparoscopic laser cholecystectomy j. cholecystectomy Nursing interventions a. monitor vital signs b. monitor pain and medicate as needed c. teach client - dietary restriction of fatty foods

g.

Points to Remember

Most obstructions occur in the small bowel. Most large bowel obstructions are caused by cancer. Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel habits, nausea and vomiting. Management of cirrhosis is directed towards avoiding complications. This is achieved by maintaining fluid, electrolyte and nutritional balance. A client with esophageal varices must be monitored for bleeding (e.g., melena stools, hematemesis, and tachycardia.) The rupture of esophageal varices is life threatening and associated with a high mortality rate. Pancreatitis is often associated with excessive alcohol ingestion. Pancreatic cancer is an insidious disease that often goes undetected until its later stages. Diverticula are most common in the sigmoid colon. Clients with diverticulosis are often asymptomatic. A deficiency in dietary fiber is associated with diverticulitis. Colostomies: an ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation; a descending colostomy drains solid feces and can be controlled. Frequent liquid stools can be indicative of a fecal impaction or intestinal obstruction. Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.