Unit 5-GI Bleeds & Gastric Carcinoma

GI bleed interventions

-monitoring & early recognition of complications

-preventing/managing bleeding, perforation & gastric outlet obstruction

-possible surgical tx

GI bleed

-upper or lower

-acute >1000mL or discrete of 100mL

-chronic over a period of weeks or months

GI bleed types

-occult- hidden (x3)

-melena - black, tarry & sticky (upper)

-hematochezia -bloody stool (lower)

-rectorrhagia -passage of blood, no feces

-hematemesis

GI bleed management

-assess blood loss (vitals & H&H)

-IV - NS or LR

-NG tube

-transfusions (PRBC, albumin)

-tx varies with dx & amount of blood loss

hypovolemic management

-monitor vitals & observe for fluid loss from bleeding & vomiting

-monitor electrolytes

-insert 2 large bore IV (20 GA)

-O2

-I& O monitoring (foley)

-volume replacement should be started immediately

-blood products to expand volume & correct abnormalities

*assess for orthostatic hypotension

bleeding reduction

-endoscopic therapy

-acid suppressive agents to stabilize the clot by raising pH of gastric contents

-NG

-saline lavage w/ large bore NG

perforation nonsurgical management

replacing fluids, blood & electrolytes

-ABX

-keep pt NPO

preop care

insertion of NG

Operative procedures

-gastroenterostomy

-vagotomy

-pylorplasty

gastroenterostomy

permits neutralization of gastric acid.

vagotomy

eliminates the acid secreting stimulus to gastric cells & decrease the response of parietal cells

pyloroplasty

facilitated emptying of stomach contents

gastric surgery nursing care

-ally preop fears & anxiety, teaching

-monitor for complications (peritonitis, obstruction & bleeding)

-NG tube

-pain relief & position for comfort

-nutrition (parenteral initially & advance to 6 small meals)

-monitor for dumping syndrome

Billroth I

Gastroduodenostomy

Attaches remaining stomach to the duodenum

Billroth II

remove of distal segment of stomach and antrum

anastomosis with jejunum

nutritional management

-Deficiencies of vitamin B12, folic acid, and iron

-impaired calcium metabolism

-reduced absorption of calcium and vitamin D develop as a result of partial removal of the stomach.

*These problems are caused by a shortage of intrinsic factor.

*Monitor CBC for signs of megaloblastic anemia and leukopenia.

postoperative care

-monitor NG

-monitor for complications (dumping syndrome & reflux gastroplasty)

perforation

erosion through to gastric serosa into peritoneal cavity

perforation s/s

-sudden severe pain

-pain may refer to R shoulder

-vomiting

-faint

-severe tender, rigid abdomen

-hypotension, tachycardia, shock

penetration

erosion through serosa & into adjacent structures (pancreas, biliary tract, omentum)

penetration s/s

unrelieved back and epigastric pain

gastric carcinoma

adenocarcinoma is most common

-Dx w/ endoscopy & biopsy, barium swallow, CT

gastric cancer risk factors

-age over 40

-smoked foods

-low veggie & fruit intake

-chronic inflammation of stomach

-smoking

-NSAIDs

-H. Pyloric infection

gastric cancer early s/s

usually absent & may resemble ulcer symptoms for a month

gastirc cancer later s/s

-indigestion

-anorexia

-dyspepsia

-weight loss

-abd pain

-constipation

-anemia

-NV

signs of matastisis

-Virchow's node

-sister Mary Joseph nodes

-Blumer's shelf

-Krukenberg's tumor

CA non surgical management

-combination drug therapy

-radiation

CA surgical management

subtotal & total gastrectomy

anastomotic leak

leak of luminal contents from a surgical joining

surgical complications

-hemorrhage

-reflux aspiration

-wound infection

-sepsis

-reflux gastritis

-paralytic ileus

-bowel obstruction

-dumping syndrome

paralytic ileus

paralysis of intestinal peristalsis

*nonmechanical obstruction

dumping syndrome

pt gets a sudden vasomotor response & GI symptoms

-occurs when the stomach empties too fast into the jejunum

-occurs 15-30mins after eating

-epigastric fullness

*occurs after the billiroth II

dumping syndrome s/s

-Fullness

-faintness

-diaphoresis

-tachycardia

-palpitations

-hypotension

-nausea

-abdominal distinction

-cramping

-diarrhea

-weakness

-syncope

achlorhydria

lack of hydrochloric acid in the stomach

pancytopenia

deficiency of all types of blood cells

CEA

carcinoembryonic antigen

colectomy

excision of the colon

obstipation

no poop