GI concerns in CC

what are the clinical presentations of GI bleeds? (upper and lower)

hematemesis (can be bright red or coffee grounds), melena (dark, smelly stool where blood has been digested), hematochezia (bright red blood in stool), pale mucus membranes, abdominal tenderness, bright red blood/melena on rectal exam

what determines if it’s an upper or lower GI bleed?

if it’s above or below the ligament of teritz → upper: esophagus to upper part of small intestine, lower: below this point usually in the colon and rectum

what are some vital signs of one experiencing a GI bleed?

tachycardia, hypotension, orthostatic changes → BP might initially appear normal dt compensatory mechanisms; want to watch for changes of 20 mmHg or more with orthostatic vitals

what are some lab studies used to dx GI bleeds?

CBC with diff (shows hgb/hct), coagulation studies like PT/INR, PTT, liver function (liver produces many clotting factors), BUN/creatinine (elevated BUN with normal creatinine can indicate GI bleed)

what are some ways to medically manage GI bleeds?

IV fluid resuscitation (first priority; need large bore IV access), blood product administration, PPIs, octreotide for variceal bleeding (reduces portal pressure and helps control bleeding from these vessels)

what are some interventional treatments to manage GI bleeds?

minnesota/sengstaken-blakemore tube, banding/clipping, embolization, TIPS (liver procedure)

what is a TIPS procedure?

connecting a branch of the portal vein in the liver to a branch of the hepatic vein → people with cirrhosis have hardened livers which compresses down on the portal vein causing backup of pressure and esophageal varices 

what are some nursing management things for GI bleeds?

establish two large bore IV access, frequent vital sign monitoring, serial HGB/HCT checks, strict I&Os, NG tube management if ordered, administer meds as ordered, monitor for re-bleeding, prepare for potential procedures

what is the key concept of pancreatitis?

auto-digestion: pancreatic enzymes digest the pancreas and surrounding tissue, inflammation of the pancreas can be mild to severe, mechanism of release isn’t well known → can be acute (usually resolves) or chronic (persistent inflammation causing scarring)

what are some acute causes of pancreatitis?

gallstones/blockage in bile duct, heavy alcohol use, certain meds, high triglyceride & calcium levels in the blood, pancreatic cancer, injuries from trauma/surgery

what are some causes of chronic pancreatitis?

damage from repeated acute pancreatitis, heavy alcohol use (leading cause), inherited genes linked to pancreatitis, high triglyceride & calcium levels in blood

what are the clinical manifestations of pancreatitis?

sudden onset of epigastric pain in LUQ or mid-abdomen, pain radiates to back or shoulder blades, deep/sharp pain, worse when lying flat or bending forward, NV, anorexia

what are the physical assessment signs of pancreatitis?

tender abdomen with localized guarding, cullen’s sign (periumbilical bruising), grey turner’s sign (flank bruising) → usually takes 24-48 hrs to develop; worse after eating high fat foods

what does both a cullen’s sign and grey turner’s sign indicate?

retroperitoneal hemorrhage associated with severe pancreatitis

what are some lab tests to dx pancreatitis?

serum amylase and lipase (elevated; lipase most specific lab test as pancreas produces this), CBC, metabolic panel, liver enzymes (elevated), calcium (decreased dt fat necrosis)

how to medically manage patients w pancreatitis?

NPO status (new evidence supports early enteral feeding), IV hydration. pain management → opioids, anticholinergics (decr secretions), histamine blockers, pancreatic enzymes, abx for infected necrosis

what are some nursing management things for pancreatitis?

vital signs (tachy, hypoten, fever), pain, signs of hypocalcemia (chvostek/trousseau’s sign), respiratory status (hypoxia common), fluid & electrolyte status

what are some nursing interventions for pancreatitis?

maintain NPO status as prescribed, NG tube management, pain management, coughing/deep breathing, monitor I&Os carefully

what are some pancreatitis complications?

necrotizing pancreatitis (in 20% of pts, most serious, high mortality rate), pancreatic hemorrhage (rare), pancreatic pseudocysts, pancreatic abscess, pleural effusion, MODS, SIRS, ARDS → key takeaway: lots of deadly complications

what is a whipple procedure?

major/high-risk sx to remove part of the pancreas when cancer is present; performed when pancreatic cancer is found in the head of the pancreas → removes multiple organs (head of pancreas, part of stomach, gallbladder, part of small intestine

what is important to know about an NG tube post-whipple procedure?

do NOT take out, adjust, irrigate, check for placement, anything → call surgeon if anything happens to the tube

what is anastomotic leak?

intestinal leakage → signs: tachy, hypoten, severe abd pain, fever

what are some post-op whipple procedure considerations?

don’t mess w NG tube, watch for signs of anastomotic leak, blood glucose problems (may become diabetic dt removal of part of pancreas), respiratory compromise, DVT risk, infection, peritonitis, intestinal obstruction

what are some nursing management things for post-whipple procedure?

monitor vitals q15-30mins initially, check BG q 2-4 hours, document NGT output without manipulating tube → keep pt NPO until bowel sounds return, encourage deep breathing and coughing, early ambulation when cleared, pain management with PCA, dietary restrictions & pancreatic enzymes, possible DM management

characteristics of bariatric sx?

sx used for weight loss when diet/exercise have failed, need BMI over 40 or BMI 35+ with health issues, medical tx for obesity NOT cosmetic → sleeve gastrectomy most common but also gastric bypass with shared goal of weight loss

what are some post-bariatric sx considerations?

keep HOB to 30-45 degrees to prevent breathing issues, need larger BP cuffs, beds, and chairs → watch for dumping syndrome, anastomotic leak, blood clots

what is dumping syndrome?

rapid gastric emptying occurring when concentrated chyme enters the small bowel rapidly causing abd distention, inappropriate gut hormone release, and rapid glucose absorption → dt complications following gastric sx (bariatric procedures, whipple, pyloroplasty)

what are some nursing management things for bariatric sx patients?

vital signs w accurate cuff sizes, daily weights at same time and same scale, check skin folds for breakdown/infection, assess for signs of anastomotic leak, assess surgical sites for bleeding/infection

what are some nursing interventions for post-bariatric sx patients?

encourage early ambulation as tolerated, never reposition or manipulate NGT if present, start w clear liquids and advance slowly, teach small frequent meals, education about NOT drinking fluids w meals

what are the two types of dumping syndrome?

early (15-30 mins after eating): dizziness, tachy, pallor, sweating, diarrhea, palpitations & late (1-3 hours after eating): symptoms of hypoglycemia like weakness, sweating, dizziness → both can be life threatening

how to manage dumping syndrome?

dietary modifications (small more frequent meals, liquids and solids taken separately), medical management (octreotide and anti-diarrheals), nursing interventions (education, monitoring symptoms, glucose monitoring, prevention strategies)

characteristics of small bowel obstruction?

mechanical blockage like adhesions, hernia, tumor → causes abd pain (sharp, cramping, intermittent), vomiting (may be bilious), abd distention, hyperactive bowel sounds

characteristics of ileus?

neurogenic (non-mechanical), occurs after surgery/manipulation of bowel causing peritoneal irritation or intestinal ischemia → decreased or absent BS present, abd distention, inability to pass gas or stool

characteristics of abdominal compartment syndrome?

sustained intra-abdominal pressure > 20 mmHg with evidence of organ dysfunction → caused by trauma, hemorrhage, massive fluid resuscitation, abdominal surgery, severe pancreatitis, burns

what are some s/s of abdominal compartment syndrome?

tense/distended abdomen, decr urine output, incr peak airway pressures, hypoxemia, hypotension, decr cardiac output, organ dysfunction → can be dx with intra-abd pressure measurement via bladder pressure, CT scan, and lab studies showing organ dysfunction

how to medically manage abdominal compartment syndrome?

mild: NG decompression, sedation/paralysis (blocks abd muscles), diuretics, fluid removal; severe: decompressive laparotomy, temporary abd closure techniques