GASTROINTESTINAL

1.

Liver - largest gland of the body (illustration ) 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 hepatic duct and cystic duct and drains into duodenum c. functions: Metabolism of fat, carbohydrates and protein i. converts glucose to glycogen for storage ii. converts glycogen to glucose and releases into blood iii. forms glucose from fats or proteins iv. breaks down fatty acids into ketones v. stores fat vi. 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 Pancreas (illustration ) 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 I. alpha cells secrete glucagon to promote liver glycogenolysis and gluconeogenesis which ultimately increases blood glucose level II. beta cells secrete insulin Gallbladder (illustration ) a. similar size and shape as a pear b. made up of smooth muscle and lined with rugae-arranged mucosa c. only purpose is to store bile d. empties bile into duodenum when fat is present there Pancreas (illustration ) 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 I. alpha cells secrete glucagon to promote liver glycogenolysis and gluconeogenesis which ultimately increases blood glucose level II. beta cells secrete insulin Gallbladder (illustration ) a. similar size and shape as a pear b. made up of smooth muscle and lined with rugae-arranged mucosa c. only purpose is to store bile d. empties bile into duodenum when fat is present there Pancreas (illustration ) 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

2.

3.

4.

5.

6.

I. II.

alpha cells secrete glucagon to promote liver glycogenolysis and gluconeogenesis which ultimately increases blood glucose level beta cells secrete insulin

II.

Gallbladder (illustration ) a. similar size and shape as a pear b. made up of smooth muscle and lined with rugae-arranged mucosa c. only purpose is to store bile d. empties bile into duodenum when fat is present there Disorders of Stomach and Colon C. 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 tissue hypoxia producing fatigue, weakness, dyspnea, pallor, palpitations 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. Complications: GI symptoms are reversible, but neurological changes are not Diagnostics a. CBC b. bone-marrow biopsy c. lack of free hydrochloric acid in stomach d. Schilling test Management a. lifelong vitamin B12 therapy b. adequate nutrition c. blood transfusions as needed 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 c.

7.

b.

4. 5.

6.

7.

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 iii. 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

2.

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 1. treat with tap water lavage to control bleeding administer Intra-arterial vasopressin 3. administer Intravenous fluids and blood replacement ii. perforation and peritonitis 1. finding: severe abdominal pain 2. finding: board-like abdomen iii. paralytic ileus (obstruction): scarring may obstruct pylorus management i. NPO (nothing by mouth) ii. nasogastric tube iii. antibiotics: clarithromycin (Biaxin); metronidazole (Flagyl) iv. H2 receptor antagonists: cimetidine (Tagamet); rantidine hydrochloride (Zantac); famotidine (Pepcid); nizatidine (Axid) v. anticholinergics: dicyclomine hydrochloride (Bentyl) vi. antacids; aluminum hydroxide (Amphogel); aluminum-magnesium combinations (Maalox, Mylanta, Gelusil); calcium carbonate (Tums) vii. cytoprotective: sucrulfate (Carafate) viii. proton pump inhibitors: omeprazole (Prilosec), iansoprazole (Prevacid) ix. anxiolytics x. blood administration xi. surgical Intervention 1. vagotomy: eliminates stimulation of gastric cells 2. pyloroplasty: widening pylorus to improve gastric emptying 3. subtotal gastrectomy 4. billroth I (gastroduodenostomy)

2.

f.

3.

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

5. 6.

billroth II (gastrojejunostomy)

2.

decrease with slow eating, low-carbohydrate, high-protein and fat diet v. avoid liquids with meals b. pernicious anemia secondary to loss of intrinsic factor 4. 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 Disorders of Intestines B. 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. bloody diarrhea ranging from two to three per day to ten to 20 per day ii. stools may also contain pus and mucus iii. abdominal (tenderness and cramping) pain iv. fever, weight loss, anemia, tachycardia, dehydration v. impaired absorption of fat-soluble vitamins such as E, K vi. systemic manifestations 1. skin lesions - erythema nodosum 2. joint inflammation 3. inflammation of the eyes - uveitis 4. liver disease d. diagnosis i. sigmoidoscopy barium enema - definition iv. complete blood count (CBC) management i. rest ii. fluid, electrolyte, and blood replacement iii. steroids as anti-inflammatories

iv.

ii. iii.

colonoscopy

e.

iv.
v.

vi.

immunosuppressives anti-infectives: sulfasalazine (Azulfidine) primary drug of choice anticholinergics

anticholinergic 1. Impeding the impulses of cholinergic, esp. parasympathetic, nerve fibers. 2. An agent that blocks parasympathetic nerve impulses. The side effects, which include dry mouth and blurred vision, are seen in phenothiazine and tricyclic antidepressant drug therapy. SYN: parasympatholytic.

2.

antidiarrheals dietary restrictions - high calorie and high protein surgical management 1. total proctolectomy and ileostomy 2. ileorectal anastomosis 3. total proctolectomy with continent ileostomy (Kock pouch) 4. total colectomy with ileal pouch (reservoir) f. complications i. increased risk of colon cancer ii. fluid and electrolyte imbalances g. nursing interventions i. manage pain ii. manage diarrhea iii. teach weight loss and nutrition iv. teach coping v. remedy knowledge deficit vi. reduce anxiety 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 i. diarrhea with steatorrhea (fats not processed) viii. ix.

vii.

ii.
iii. iv.

abdominal pain - right lower quadrant (illustration fatigue, weight loss, dehydration, fever systemic manifestations 1. arthritis, clubbing of fingers 2. skin inflammations 3. 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 • surgery will not cure Crohn's disease; may limit damage o colectomy with ileostomy

o
d.

subtotal colectomy with ileostomy or ileorectal anastomosis

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3.

nursing interventions i. after surgery, monitor • diarrhea • fluid balance and nutrition • skin integrity • coping and self-care • sexuality • medications Diverticular disease - outpouching of the intestinal mucosa 1. Definition/etiology c. most common in sigmoid colon d. constipation, low fiber diet, obesity e. colon wall thickens with increased pressure in bowel f. stool and bacteria retained in diverticulum become inflamed and small perforations occur g. inflammation of surrounding tissue 2. Findings c. frequently asymptomatic d. crampy, lower, left abdominal pain e. alternating constipation and diarrhea f. low grade fever, chills, anorexia, nausea g. leukocytosis 3. Diagnosis c. barium enema d. complete blood count, urinalysis, stool for occult blood e. colonoscopy 4. Management c. diverticulosis (outpouching) i. high fiber diet ii. bulk laxatives iii. stool softeners iv. anticholinergics d. diverticulitis (inflammation) i. NPO ii. rest bowel iii. antibiotics iv. surgery • bowel resection • temporary colostomy 5. Complications c. abscess formation d. perforation with peritonitis e. fistula f. bowel obstruction 6. Nursing interventions c. teach appropriate diet d. avoid straining, coughing, lifting e. avoid increased abdominal pressure Constipation 1. Definition/etiology c. change in normal bowel habits characterized by i. decreased frequency ii. stool is hard, dry, difficult to pass iii. stool is retained in rectum d. etiology/risk factors i. insufficient dietary fiber ii. insufficient fluid intake iii. medications, especially opiates

iv. v. vi. vii. viii. ix.

x.
2. Findings c. d. e. f. g. h.

lack of activity ignoring urge to defecate chronic laxative abuse lack of privacy/psychological factors pregnancy neuromuscular impairment hypothyroidism

3. 4.

5.

fecal impaction with diarrhea Complications c. obstruction/perforation d. cardiovascular alterations Management c. cathartics i. saline laxatives - milk of magnesia ii. stimulant laxatives - bisacodyl (Dulcolax) iii. bulk-forming laxatives - psyllium (Metamucil) iv. lubricant-emollient - mineral oil v. stool softeners - docusate sodium (Colace) d. enemas i. cleansing - saline, soap solution ii. softening - oil retention Nursing interventions c. teach nutrition, increased fiber, and increased fluids d. teach: obey urge to defecate e. provide privacy and comfort f. increase activity

i. j.

hard, dry stool abdominal distention decreased frequency of usual patterns straining nausea/anorexia palpable mass hemorrhoids

4.

5.

Diarrhea 1. Definition/etiology - loose stools due to c. fecal impaction d. ulcerative colitis e. intestinal infections f. increased fiber g. medications 2. Finding - loose watery stools 3. Complications - dehydration, electrolyte imbalance 4. Management c. mild diarrhea - oral fluids to replace lost fluid d. moderate diarrhea - drugs that decrease motility (Lomotil, Imodium) e. severe diarrhea - due to infection, antimicrobials and fluid replacement 5. Nursing interventions c. monitor for fluid and electrolyte imbalance d. prevent skin excoriation e. teach client about foods that may affect bowel elimination, e.g., fruits, vegetables Bowel obstruction 1. Definition/etiology c. mechanical: adhesions, hernias, neoplasms, volvulus, intussusception

d.
e. f. 2. g. Findings

nonmechanical: paralytic ileus, occlusion of vascular supply distended abdomen from accumulation of fluid, gas, intestinal contents fluid shifts due to increased venous pressure with hypotension and hypovolemic shock bacteria proliferate

c. d. e.

3.

metabolic acidosis h. bowel necrosis from impaired circulation Complications c. perforation and peritonitis

f. g.

abdominal pain distention (more with large bowel obstruction) nausea/vomiting (more with small bowel obstruction) hypoxia

6.

strangulation of bowel Diagnosis c. upper-GI and lower-GI series d. abdominal X rays show air in bowel e. low fluid volume increases white blood cells, hemoglobin & hematocrit, BUN 5. Management c. decompress the abdomen d. nasointestinal tube e. surgical bowel resection 6. Nursing interventions c. manage pain, but avoid morphine or codeine, which slow bowel motion d. measure abdominal girth e. with nasogastric or nasointestinal tubes, provide oral care f. nasogastric tubes: Salem sump (double lumen), Levin (single lumen) g. nasointestinal tubes i. cantor tube - single lumen, mercury filled weight on tip ii. miller-Abbott - double lumen with mercury weighted tip iii. advance two inches per hour h. maintain fluid and electrolyte balance Colon cancer 1. Definition/etiology c. may develop from adenomatous polyps d. risk factors - low residue diet, high-fat diet, refined foods 2. Pathophysiology c. adenocarcinoma is the most common type d. most common locations are sigmoid rectum and ascending colon e. often metastasizes to the liver f. classification (staging) systems: TNM or Duke's 3. Findings c. rectal bleeding d. change in bowel habits - constipation, diarrhea e. change in shape of stool f. anorexia and weight loss g. abdominal pain, palpable mass 4. Diagnostics c. colonoscopy 4.

d. e.

shock

d.
e.

5. 6.

barium enema CT scan carcinoembryonic antigen (CEA) j. alkaline phosphatase and AST (aspartate aminotransferase) Complications - obstruction Management c. radiation d. chemotherapy e. treatment of choice is surgery - bowel resection, colostomy i. right hemicolectomy - involves ascending colon ii. left hemicolectomy - involves descending colon h. i.

f. g.

sigmoidoscopy digital examination stool for occult blood

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abdominal-perineal resection: removal of sigmoid colon and rectum with formation of a colostomy Nursing interventions c. manage pain d. monitor for complications i. wound infection ii. atelectasis e. f.

iii.

iii. thrombophlebitis maintain fluid and electrolyte balance care of ostomy

2.

Disorders of the Liver 1. Hepatitis 1. Definition/etiology - acute inflammatory disease of the liver caused by viral, bacterial, or toxic ingestion 2. Pathophysiology c. inflammation of liver, enlargement of Kupffer cells, bile stasis d. regeneration of cells with no residual damage e. 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 2. Hepatitis B 1. Risk factors/infection route c. homosexuality d. iv drug use e. health professionals f. hemodialysis g. transmission routes i. infected blood, semen, vaginal secretions or saliva must enter the body h. pathophysiology i. hepatitis B has three distinct antigens • HBsAg - surface antigen • HBcAg - core antigen • HBeAg - e antigen ii. damage to the hepatocytes causes inflammation and necrosis iii. liver function decreased in proportion to damage iv. healing takes three - four months 2. Findings c. jaundice if liver fails to conjugate bilirubin or excrete it

d.

clay-colored stools from lack of urobilin

3.

urine is dark from urobilin excreted in urine rather than stool urine foams when shaken g. pruritus from bile salts excreted through skin h. right upper quadrant pain from edema and inflammation of liver i. anorexia, nausea, vomiting, malaise, weight loss j. prolonged bleeding from impaired absorption of vitamin K k. anemia from decreased RBC lifespan Diagnostics - serologic markers of HBV c. HBsAg - hepatitis B surface antigen d. anti-Hbc - antibodies to B core antigens e. elevated alanine aminotransferase (ALT previously SGPT) f. elevated bilirubin g. elevated aspartate aminotransferase (AST; previously SGOT) h. elevated alkaline phosphatase f.

e.

i. 4.

prolonged prothrombin time

Management - nonspecific and supportive c. symptomatic treatment of pain d. antiemetics as needed

HEPATITIS

• •

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. • Nursing interventions • fatigue - provide rest periods; may require bed rest initially • maintain skin integrity

client will tolerate less activity nutrition needs: • increase carbohydrates and proteins; decrease fat • avoid alcohol • eat frequent, small meals • remedy knowledge deficit • arrange for home care needs • teach infection control • use disposable utensils and dishes or keep separate from others • good handwashing • do not share razors, toothbrush, etc. Prevention • hepatitis B vaccine provides active immunity • hepatitis B immune globulin provides passive immunity • observe Standard and Enteric Precautions • good handwashing

• •

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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. 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 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 Pathophysiology a. nodular liver with fibrosis and scar tissue destroys hepatocytes and kills tissue (necrosis) c. necrosis, nodules, and scar tissue obstruct flow of blood, lymph, and bile d. impaired bilirubin metabolism Findings a. weakness, fatigue, weight loss, hepatomegaly

2.

Cirrhosis

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7.

b.

8.

b.

right upper quadrant pain (illustration

)

c.
d. e.

f. g.
h.

jaundice, pruritus, steatorrhea (decreased absorption of fat and fat-soluble vitamins) clay-colored stools increased bilirubin in urine, producing dark colored urine impaired aldosterone metabolism resulting in edema impaired estrogen metabolism: gynecomastia, menstrual changes, changes in distribution of body hair, vascular changes - spider angiomas, palmar erythema impaired metabolism of protein, carbohydrate, and fat i. produces less plasma protein, resulting in edema and ascites

ii.
iii.

iv.
9.

produces less of proteins needed for clotting (fibrinogen and prothrombin) absorbs less vitamin K, resulting in prolonged bleeding liver fails to convert glycogen to glucose, resulting in hypoglycemia

3.

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 duct f. CTscan of liver g. liver biopsy 10. 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 11. 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 12. Complications a. portal hypertension b. ascites c. hepatic encephalopathy Portal hypertension 6. Definition/etiology - increased pressure in the portal 7. 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. 8. Findings a. prominent abdominal-wall veins (caput medusa) b. hemorrhoids

c.
d. e.

enlarged spleen anemia from increased destruction of RBCs esophageal varices and GI bleeding

9. Diagnostics: endoscopy 10. Management a. sclerotherapy - injection of a sclerosing agent into varices b. balloon tamponade i. sangstaken-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 1. constricts veins and decreases portal blood flow 2. given IV or into superior mesenteric artery 3. 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 1. mesocaval shunt 2. portacaval shunt ii. TIPS (transjugular intrahepatic portosytsemic shunt) - shunt placed between hepatic and portal vein 11. 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

4.
• • • •

Ascites

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

6.
7.

8.

Definition/etiology - accumulation of fluid in the peritoneum 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 Findings a. abdominal distention, protruding umbilicus, dull sound on percussion of abdomen, fluid wave b. bulging flank

2.

c. dyspnea Diagnostics a. abdominal x-ray b. CT scan c. ultrasound 10. 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 11. Nursing interventions a. abdomen will have excess fluid, blood vessels too little b. measure I & O, daily weight, abdominal girth, skin turgor c. restrict fluids d. monitor for ineffective breathing patterns e. semi-Fowler's position f. monitor for impaired skin integrity g. remedy knowledge deficit 5. Hepatic encephalopathy - mental dysfunction associated with severe liver disease 6. Definition/etiology a. impaired ammonia metabolism in liver poisons brain tissue b. ammonia produced in bowel from action of bacteria on protein 7. 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 8. Diagnostics - serum ammonia level 9. 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 10. Nursing interventions a. tremor, confusion can lead to injury: maintain safety b. ascites and low intake decrease fluid volume c. diarrhea from medications Disorders of Pancreas and Gallbladder 1. Acute pancreatitis 6. Definition/etiology - inflammation of the pancreas a. alcohol ingestion b. gall stones c. drug ingestion d. viral infections e. trauma 7. 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 8. Findings a. left upper quadrant abdominal pain b. pain worsens after eating and when lying flat c. nausea and vomiting d. fever, agitation, confusion 9.

9.

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. f.

hypovolemia and shock

e.
f.

hypocalcemia 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.) 5. Complications a. respiratory problems - atelectasis, pneumonia from the immobility imposed by pain b. tetany from decreased calcium levels

c. 6.

abscess or pseudocyst

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 nutrition) ii. NG tube

B.

h2-receptor antagonists 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 Cholecystitis 5. Definition/etiology - inflammation of the gallbladder 7. usually due to gallstones (Cholelithiasis) 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 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 b.

iii. iv.

anticholinergics

a.

6.

7.

8.

9.

d. may scar gallbladder, resulting in less storing of the bile from the liver e. can perforate gall bladder 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 g. extracorporeal shock wave lithotripsy - may have hematuria after procedure, but not longer than 24 hours h. choledocholithotomy - to remove or break up stones

II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV.

cholecystectomy Nursing interventions a. monitor vital signs b. monitor pain and medicate as needed c. teach client - dietary restriction of fatty foods 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. 10.

i. j.

laparoscopic laser cholecystectomy

Appendicitis Borborygmus Cholangiography Cholangitis Cholecystokinin Choledocholithiasis Chvostek's sign Fecalith Flatulence Hematochezia

Parotid gland Pepsin Peristalsis Sitz bath Tenesmus Toxic megacolon Trousseau's sign Valsalva's maneuver Gastrointestinal

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Abdominal quadrants Bile Ducts Colon Digestive system Liver and gallbladder Pancreas and its relationship to the duodenum Stomach

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