Medsurg Certification Prep

GI System

Non-sterile "tube system"

Function to supply nutrients to body cells through ingestion, digestion and absorption.

Accessory organs

Liver

Biliary system

Pancreas

Salivary glands

GI Nursing Assessment

History- Family history, Medications, Eating habits, Social history, Surgeries. Symptoms- Pain, Food intolerance, Weight loss, Nausea, Bowel habits, Vomiting

Right upper quadrant Pain

Gallbladder

Right lower quadrant Pain

appendix

Left upper quadrant Pain

stomach

Left lower quadrant Pain

inflammatory bowel disease

Flank Pain

kidneys

GI assessment

Inspection- Skin appearance- Contour, Auscultation- Bowel sounds, Palpation, Percussion

GI Labs

Bilirubin: conjugated and unconjugated

Liver enzymes: AST (SGOT), ALT (SGPT)

albumin

PT

Pancreatic enzymes: lipase, amylase, protease

H. pylori

stool

GI Contrast studies

upper and lower GI tract with small bowel follow through Nursing considerations: assess for allergy, adequate prep, NPO

GI Angiography

Assess perfusion

Nursing considerations: assess for bleeding

GI Scopes

upper endoscopy, colonoscopy, sigmoidoscopy, ERCP Nursing considerations: sedation considerations, return of swallow, need for biopsy

Acid Neutralizers

Contain aluminum hydroxide and/or magnesium hydroxide

Common: Maalox, Amphogel, TUMS

Side effects: diarrhea (magnesium), constipation (aluminum) Nursing considerations: patients should take at least 1-2 hours after other medications

Proton Pump Inhibitors

Blocks the H+K+ pump, which is the final pathway of HCL production

Common: Prilosec®, Prevacid®, Protonix®

Side effects: increases risk for gastric cancer, GI infections, and C. diff

Nursing considerations: PPIs can potentiate warfarin and may also interact with antibiotics

Gastric Motility Stimulants

Prokinetic agents that stimulate peristalsis to prevent HCL reflux into the esophagus

Common: Reglan®• Side effects: CNS changes, dry mouth, hypotension, tachycardia

Nursing considerations: administer 30 minutes before meals

H2 Receptor Antagonists

Acts on histamine receptors and decreases hydrogen ion production, which increases stomach pH (less acidic)

Common: Tagamet, Zantac, Pepcid

Few side effects

Considerations: may increase absorption of drugs that break down in the stomach (digoxin, theophylline, Dilantin)

Concerns for toxicity

Stomach

Three lobes- Fundus, body, pylorus

Absorption is minimal in the stomach but it does absord carbohydrates, digoxin, alcohol, and ASA

Secretes HCL and enzymes

GERD Patho

Reflux of gastric contents into esophagus which leads to inflammation. Risk factors: Hiatal hernia, Incompetent lower esophageal sphincter, Delayed gastric emptying, Smoking and pregnancy.

GERD: Clinical Manifestations

Heartburn

Dyspepsia

Hypersalivation

Substernal pain that worsens when lying down

Increase pain with high fat meals and increased caffeine

GERD: Therapeutic Modalities

Diagnostics: Thorough patient history, barium swallow, and EGD

Treatments: Antacids, H2 Blocker, Proton Pump Inhibitors, Prokinetic agents to promote gastric emptying

GERD: Nursing Considerations

Encourage small meals

Avoid lying down after meals

Decrease consumption of caffeine and alcohol

Avoid over-distending the stomach with fluids

Adhere to a low-fat diet

Peptic Ulcer Disease (PUD) Patho

Erosion of any portion of the GI tract. Results from an imbalance between defense resources- Mucus lining, Bicarbonate secretion, Prostaglandins, Factors that cause injury to mucosal lining (gastric acid, pepsin, and bile acids) Classified as gastric or duodena

Contributing Factors- increased HCL production, Chronic use of NSAIDs, Aspirin-containing products, Alcohol, caffeine- Family history, Consistent stress, H. pylori

PUD: Clinical Manifestations

Duodenal (80%)- More prevalent in younger population, Pain occurs 2-4 hours after meal and at night, Usually do not suffer from anorexia.

Gastric (20%)- Higher mortality rate, Pain immediately after meals, Anorexia common

PUD: Diagnostics

Barium swallow, EGD, Breath test - to determine presence of urea, Stool examination

PUD: Therapeutic Modalities

Lifestyle changes: diet, smoking, stress reduction, avoid NSAIDS.

Antacids

H2 Blockers

PPI

Antibiotics for H. pylori- Metronidazole (Flagyl®), Clarithromycin (Biaxin®)

Bismuth subsalicylate (Kaopectate®)

Peptic Ulcer Complications

Bleeding- More common with duodenal ulcers

Perforation- Emergent: manage with antibiotics, fluids, NGT, pain medications. May require surgical repair if conservative interventions are unsuccessful

PUD Surgical Interventions/Complications

Gastric resection, Dumping syndrome, Rapid gastric emptying into the duodenum

Vagotomy with pyloroplasty. Complications are Pyloric obstruction due to edema- Perforation

GI Bleed Patho

Acute blood loss anywhere in the GI tract

Upper GI bleed- Esophagus to duodenum, Erosive ulcerations or lesions, Varices

Lower GI bleed- Cecum to rectum-,Hemorrhoids, diverticulitis, polyps, colitis, CA

GI Bleed: Clinical Manifestations

Symptoms- Frank blood in stool or melena, Coffee ground emesis, Volume loss: HR, BP, H&H

Management- Fluid/blood replacement, Correct the cause, Pain control

Inflammatory Bowel Disease Patho

Equal prevalence in men and women, Commonly occurs during adolescent years, Risk factors: family history, altered immune response, environmental factors. Includes several different disorders- Spastic colon, colitis, Crohn's disease, ulcerative colitis

Crohn's Disease Clinical Manifestations

Chronic diarrhea

Abdominal pain

Undesired weight loss

Anorexia

Fatigue and malaise

Nausea and vomiting

Fever and chills

dyspepsia

Ulcerative Colitis Clinical Manifestations

Urgency and frequency of bowel movements

Rectal bleeding

Mucus discharge

Fever

Tenesmus

Malaise

Crampy abdominal pain

Anemia

IBD: Diagnostic Studies

CBC: check for anemia and leukocytosis

Electrolytes: may see hypoalbuminemia

Stool for occult blood

Barium studies

EGD, colonoscopy, and biopsy

CT and MRI

IBD: Therapeutic Modalities

In the acute phase: Bowel rest, Maximize nutrition, Manage symptoms, No scopes in the acute phase due to the risk of perforation.

Pharmacologic- Antispasmodics (Bentyl®), Aminosalicylates (Sulfasalazine, Mesalamine), Corticosteroids, Immunosuppressants (Methotrexate, Imuran®), Biological therapies (Humira®)

Interventional: Surgery- Colectomy/Ileostomy

IBD: Nursing Considerations

Nursing care- Accurate I&Os, stool count, Frequent and smaller meals, Enteral and parenteral nutrition may be instituted for patients with Crohn's disease, Stoma should be pink and may be edematous for 5-7 days (for surgical patients) Patient education- Lifestyle modifications: stress management. Diet modifications: high calorie, vitamin & mineral supplements, high protein, low residue, Important vaccines: Hep A & B, flu, MMR, varicella

IBD: Complications

Ulcerative colitis- Toxic megacolon, bleeding, hemorrhoids, absorption problems, malignancy

Crohn's disease- Fistulas, strictures, malabsorption problems

Colon cancer

C. difficile infection

Bowel Obstruction: Patho

Blockage anywhere in GI tract

May be mechanical, vascular, or neurologic

Risk factors: advanced age, previous abdominal surgery, IBD, diabetes, laxative abuse

Clinical Manifestations: Small Bowel Obstruction

#1 cause is adhesions

Acute onset

Frequent vomiting

Pain colicky and intermittent

Continue having bowel movements for a short time

Clinical Manifestations: Large Bowel Obstruction

#1 cause is a tumor

Gradual onset

Vomiting rare

Pain low-grade and diffuse

Absolute constipation

Bowel Obstruction: Therapeutic Modalities

IV fluids

Insert NG tube

Analgesics

Electrolyte replacement

Surgery

Bowel Obstruction: Nursing Considerations

Fluid and electrolyte monitoring

Pain management

Assess intake and output

Monitor stool for occult blood

Prepare patient for possible surgery and possible ostomy

Diverticulitis

Sac-like herniations in the large bowel

Fecal matter trapped

Leads to inflammation and infection

Fluids, bowel rest, antibiotics

Cholecystitis

Gall bladder inflammation

Causes: Gall stone, bile stasis• Signs and symptoms:- URQ pain, N&V, fever, biliary colic, Murphy's sign

Management: Low fat diet, cholecystectomy

What is appendicitis?

Inflammation of the appendix

What are common causes of appendicitis?

Fecalith, strictures, cancer, Crohn's disease

What are the clinical manifestations of appendicitis?

Umbilicus-RLQ acute pain, rebound tenderness, fever, N&V, anorexia, elevated WBC, gas, and bloating

What are the therapeutic modalities for appendicitis?

Pain control, IVF, NGT, appendectomy, antibiotics if perforated

Pancreatitis Patho

Caused from premature activation of enzymes within the acinar cells leading to autodigestion of the pancreas. Most common triggers are gallstones and alcohol (80%).

Pancreatitis: Clinical Manifestations

Epigastric to mid-abdominal pain. Twisting or knifelike sensation that radiates to the low dorsal region of the back. N&V, fever, diaphoresis, weakness. Tachypnea, hypotension, tachycardia. Grey-Turner and Cullen's sign. Elevated WBC, amylase, lipase, protease, CRP. Decrease calcium, magnesium

Pancreatitis: Therapeutic Modalities

NPO/IV Fluids

Analgesics

Anti-emetics

Calcium and magnesium replacements

Positioning: knee-chest; HOB 45o

Surgery- Cholecystectomy, drainage of pancreatic enzymes, pancreatic resection

Pancreatitis: Nursing Considerations

Consider nutritional needs- NPO/enteral Feeding, Low fat diet once able to eat

Monitor fluids and electrolytes

Monitor for complications- Hemorrhage, ARDS, Sepsis

Liver Functions

Production of antibodies and clotting factors, Metabolism, Bilirubin metabolism, Gluconeogenesis, Produces and secretes bile, Detoxifies noxious agents (drugs and ETOH)

Hepatitis: Patho

Inflammation of the liver..

Causes: Viral (Types A-G), Bacteria, Drugs or ETOH, Unknown (NASH)

Hepatits A

Spread via the fecal/oral route- Abrupt onset

Hepatitis B

Spread via body fluids, blood and semen; maternal-fetal, IV drug abuse

Hepatitis C

Blood and body fluids, Slow onset, Most common reason for liver transplant

Liver Failure: Patho

Acute- Drug toxicity (acetaminophen), viral hepatitis (B or E), sepsis, autoimmune- 50% mortality

Chronic- ETOH abuse, cirrhosis, biliary disease, cardiac disease

Liver Failure: Clinical Manifestations

Decreased appetite, Nausea, Jaundice, Fatigue, Asterixis (flapping tremor), Peripheral edema, Dark urine, Bleeding and esophageal varice, Hepatic encephalopathy

Liver Failure: Nursing Considerations

High carbohydrate, moderate protein, low sodium diet

Avoid alcohol

Monitor liver enzymes

Keep HOB elevated at least 30°

Monitor for S & S of infection

Strict glucose monitoring

Nutritional support

Liver Failure: Complications

Metabolic alkalosis

Electrolyte imbalances

Hypoglycemia

Coagulation disorders

Sepsis

Renal failure

Cerebral edema

Cirrhosis

End stage of any chronic liver failure

Characterized by fibrosis of normal liver architecture

Progressive and irreversible

Clinical Manifestations- Ascites, Portal hypertension- Esophageal varices, spider angiomas. Encephalopathy. Temporal and proximal muscle wasting. Increased jugular venous pressure

Cirrhosis: Therapeutic Modalities

Pharmacologic- Diuretics, Neomycin, lactulose, Xifaxin®,Beta-blockers, Ferrous sulfate, folic acid, vitamin K

Non-pharmacologic- Sodium restriction, parental nutrition- Paracentesis

Cirrhosis: Nursing Considerations

Assess respiratory status

Manage excessive fluid volume

Support nutritional needs- High calorie; moderate fats

Monitor for increased risk of bleeding• Supportive care

Fat soluble vitamins (A, D, E, K), thiamin, folate, B12

Alcohol Abuse: Patho

8 million alcohol dependent people is US

Alcohol is a CNS depressant

Affects GABA receptors in brain

Withdrawal can develop 6-72 hours after last drink

Alcohol Withdrawal: Clinical Manifestations

Assessment- N&V, sweats, Presence of tremors, anxiety, agitation, Tactile, auditory, visual disturbances, Clouding of sensorium, headache, Vital signs

Score- 0-9 minimal withdrawal- 10-19 moderate withdrawal- > 20 severe withdrawal

Alcohol Withdrawal: Therapeutic Modalities

Benzodiazepines

Banana bag

Thiamine and folic acid

Fixed dosing versus symptom Triggered

Anti-seizure medications: phenobarbital

Coors light TID???

Obesity

Bariatrics is the medical specialty dealing with obesity

Morbid obesity is body weight of more that 100% over ideal body weight

- Class I-Obesity BMI 30 - 34.99

- Class II-Obesity BMI 35 - 39.99

- Class III-Obesity BMI > 40

Obesity: Therapeutic Modalities

Lifestyle changes- Physical activity, support, sleep habits, goal setting

Dietary changes- Decrease caloric intake

Medications- FDA approved, avoid OTC due to side effects

Surgery

Obesity: Nursing Considerations

Post-operative care:

Bed, chair, aids to accommodate obese patient

Frequent repositioning, HOB 30 - 40o

Skin assessment to prevent pressure damage

Incision protection

Incentive spirometry

Diet high in protein and nutrients

Small amounts of fluids frequently

DVT prevention

Early recognition of anastomotic leak

Bariatric Surgery Options

Reserved for the morbidly obese

Procedures To restrict stomach capacity- Banding, vertical sleeve gastrectomy

Those that affect nutrient absorption. Gastric bypass, Roux-en-Y, biliopancreatic diversion with duodenal switch. Risk of iron and calcium decencies.

Bariatric Surgery: Complications

Anastomotic leak

Dumping syndrome

Malnutrition

Anemia

Peptic ulcer disease

Pain Management

Patient's self-report is the "gold standard"

Adequacy of pain management is directly related to frequency of assessment- Site, intensity, quality, patient's view of pain

Visual analogues as tools for assessment- Number scale 1 - 10, Baker/Baker Faces

Documentation as "fifth vital sign"

Re-evaluation of pain interventions effectiveness

60 minutes after PO, 15 - 30 min after IV- Teaching and understanding the patient's pain management expectations

What is the first-line treatment for mild pain?

Acetaminophen or NSAIDs (PO)

What are the options for moderate pain management?

Weak opioids (IM or IV), codeine, hydrocodone, tramadol

What are the strong opioids used for severe pain?

Meperidine, morphine, hydromorphone, fentanyl (IM or IV)

Are short acting opioids recommended for chronic non-cancer pain?

No, short acting opioids are not recommended for chronic non-cancer pain.

What are some adjuvant medications for pain management?

Tricyclic antidepressants (amitriptyline), anticonvulsants (gabapentin, Lyrica), anxiolytics (lorazepam), steroids (prednisone)

Non-pharmacologic Pain Management

Cutaneous stimulation:-Heat, cold, massage, transcutaneous nerve stimulation

Distraction: Humor, music, TV

Relaxation: Guided imagery, quiet environment, rhythmic breathing

Nerve blocks- Invasive

Pain Management: Nursing Considerations

Side effects: Constipation, nausea, vomiting, drowsiness, confusion, respiratory depression (Narcan)

Patient education: Pain scales, side effects, plan

Timing: PRN vs. around the clock, de-escalation (IV-PO)

Patient advocate: Accept patient's report of pain, collaborate with provider/care team

Enteral Nutrition

Indications: Functional GI tract, inadequate intake 3-5 days, inability to increase PO intake

Benefits: Maintains mucosal barrier of GI tract, maintains GI function and structure

Contraindications:- Complete GI obstruction, lack of access, intractable vomiting, ileus, GI bleed, fistula, GI ischemia

Access: NGT, gastrostomy, or jejunostomy tube• Complications:- Tube obstruction or displacement, aspiration pneumonia, diarrhea, constipation, metabolic complications

Parenteral Nutrition

Indications: Support for > 10 days, increased nutrient needs, GI tract disorders

Benefits:- Avoids issues related to GI feeding, full intake of nutrients for short period of time, flexible composition, easy to individualize

Contraindications:- Functional GI tract, no venous access

Access: Non-tunneled, tunneled, implanted

Complications:- Infection, pneumothorax, arrhythmias, occlusion, phlebitis, air embolism, metabolic complications

Pulmonary Anatomy and Physiology

Upper Airway-Nose, Sinuses, Pharynx, Oropharynx, Laryngopharynx, Trachea.

Lower Airway- Right Bronchus, Left Bronchus, 5 Lobar Bronchi, Bronchioles, Alveoli

Pulmonary Nursing Assessment

Subjective- Listen to the patient as they describe their symptoms, Ask about smoking, Increased SOB? Decreased levels of activity, Ask about sputum, Ask about health, nutrition, and occupation.

Objective- Assess for SOB, coughing, Inspect, palpate, percuss, auscultate, Examine posterior approach first, Examine color, neurological status, signs of chronic hypoxia (clubbing)

Pulmonary Diagnostic Studies

CXR, CT, MRI, Pulmonary function test (PFTs), V/Q scan, Arterial blood gases, Bronchoscopy, thoracentesis, Angiography, Sputum specimen

Arterial Blood Gas

ABGs evaluate gas exchange in the lungs. They also measure acid base balance. Ventilation is reflected by the PCO2. Acid base regulation is reflected by the pH and HCO3. The respiratory system and the renal system are considered buffers.

ABG Analysis

Acid-Base balance- pH

Oxygenation PaO2 - SaO2

Buffers- Respiratory and Renal

Normal ABG Values

pH: 7.35-7.45

PCO2: 35-45

PO2: 80-100

Bicarb: 22-28

Respiratory Acidosis

Major factor: Hypoventilation. Overdose of opioids or other drugs. Pulmonary disease. Atelectasis, pneumonia, embolus, pulmonary edema. Head trauma. CNS lesions

Respiratory Alkalosis

Major factor: Hyperventilation. Psychological stress, anxiety- CNS disorders. Dysfunction of the respiratory center. CNS infection or lesion. Unresolved pain. Increased metabolic demands. Fever, thyrotoxicosis. Severe anemia

Metabolic Acidosis

Major factor: Acid gained or base lost. Renal failure. Excessive acid intake (drugs). Excessive accumulation of acid. Ketoacidosis, Lactic acidosis. GI bicarbonate loss. Diarrhea

Metabolic Alkalosis

Major factor: Losing acid OR gaining base. Loss of gastric acid. Vomiting. Excessive GI suctioning. Renal bicarbonate loss. Excessive diuretics. Bicarbonate retention. Administration of NaHCO3. Massive blood transfusion

What is pneumonia?

Acute infection of the lung parenchyma that impairs gas exchange.

What are common clinical manifestations of pneumonia?

Productive cough, chest pain, fever, shortness of breath, night sweats, rhonchi, crackles, weight loss, increased respiratory rate, flu-like symptoms such as headache, joint pain, and malaise.

What does a chest X-ray (CXR) show in pneumonia?

An area of consolidation.

Pneumonia: Therapeutic Modalities

Appropriate antibiotics

Fluids

Oxygen therapy

Fever control

Bronchodilators

Pneumonia: Nursing Considerations

Pulmonary toilet- Lung flute

Cough and deep breathing techniques

Frequent respiratory assessment- Pulse ox, Respiratory rate, Lung sounds

Aspiration Pneumonia

The key is early identification!!

What to look for: Coughing and choking while eating/drinking, Drooling, Gurgling while speaking, Evidence of right upper infiltrate on CXR

Tuberculosis

Infection caused by various strains mycobacterium tuberculosis organism- Attacks the lungs but can also affect brain, kidneys, and other organs- Spread by airborne

Risk factors- Immunocompromised state, Poorly ventilated living quarters, Prolonged exposure to person with TB