MedSurge Exam 2

Saliva and ptyalin (salivary amylase)

Aids in chewing and swallowing, begins the digestion of starches

Hydrochloric acid

Breaks down food for absorption and destroys ingested bacteria

Pepsin

Facilitates protein digestion

Intrinsic factor

Allows vitamin B12 absorption

Amylase

Digests starches

Lipase

Digests fats

Trypsin

Digests proteins

Bile

Aids in emulsifying fats to ease digestion/absorption

Preparation of diagnostic tests

Clear liquid, low residue diet or fasting, ingestion of bowel prep, laxatives/enemas, contrast ingestion

Barium

Contrast agent used to help visualize the GI tract on diagnostic tests, increase fluid and fiber to flush out of the body, or the abdomen can harden and cause constipation, blockage or perforation

CBC

Bleeding, antibodies, inflammation, infection, anemia

CMP

Fluid and electrolytes, albumin protein

Pt, Ptt

Bleeding and clotting

Triglycerides

Fats

LFTs

Liver assessment

Amylase, Lipase

Pancreatic function

Carcinoembryonic antigen CEA/cancer antigen CA

Specific for colorectal cancer

FIT-fecal DNA test

Screening for colorectal cancer, can detect abnormal DNA from cancer or polyps; brand name is Cologuard 

Random collection stool test

Detects various health issues

24-72 hour stool test

Fecal fat analysis, requires refrigeration

gFOBT stool test

Guaiac-based Fecal Occult Blood Testing; Avoid red meat, Nsaids, and vitamin C as they can cause false positive

Hydrogen breath test

Evaluates carb absorption, aids in diagnosis of intestinal bacterial growth; Pt drinks substrate white becomes fermented, gases expelled in breath

Urea breath test

Identifies H. Pylori; Pts ingests capsule, breath sampled 10-20 minutes later

Abdominal ultrasound

Noninvasive, rapid results, no radiation, bone and tissue can hinder imaging, NPO 8-12 hours prior, barium studies are done after, moderate sedation 

CT

Computed Tomography; Uses contrast agent to identify inflammation and structural abnormalities

MRI

Magnetic Resonance Imaging; Useful for soft tissues, abscesses, fistulas, bleeding, no metal in machine

PET

Positron Emission Tomography; Detects metabolism within tissues using radionuclide 

Scinitigraphy

Detects amount of radionuclide collected in tissues

Virtual colonoscopy

Xray exam of colon using low-dose CT

Upper GI tract study

Contrast ingested to aid in viewing ulcer, varices, tumors, malabsorption, gastric emptying, obstruction, etc in the esophagus, stomach, and duodenum; NPO prior, PO meds held the day of, no smoking or gum 

Lower GI tract study

Barium enema used to detect polyps, tumors, lesions, abnormalities or intestinal malfunction in the colon; NPO prior, low residue diet 1-2 days prior, laxative evening before

Gastric motility study

Food is tagged with radionuclide markers, multiple scans taken after ingestion to monitor rate of emptying from stomach

Colonic motility study

Capsule contained 2 radionuclide markers in taken, daily scans after until clean (4-5 days)

Nursing interventions for endoscopy 

NPO for 8 hours, local anesthetic gargle/spray, moderate sedation, assess LOC, VS, SPO2, pain, monitor for perforation 

Esophagogastroduodenoscopy EGD

Visualization of the esophagus and stomach; monitor airway

Colonoscopy

Visualization of the colon for screening, polyp removal and biopsies 

Anoscopy

Visualization of the anus, rectum, sigmoid and descending colon; evaluates chronic diarrhea, fecal incontinence, ischemic colitis, lower GI hemorrhage

Manometry

Measures changes in intraluminal pressure and coordination of muscle activity in the GI tract

Rectal sensory function studies

Evaluates rectal sensory function and neuropathy 

Electrophysiologic studies

Gastric electrical activity recorded for up to 24 hours

Gastric analysis

Small NGT inserted into stomach, gastric contents aspirated, samples collected q15 for 1 hour; NPO 8-12 hours prior, hold meds that affect gastric secretions for 24-48 hours prior, no smoking the day of the procedure

Gastric acid stimulation test

Histamine given to stimulate secretions, specimens are collected q15 mins for 1 hour

pH monitoring

pH sensor inserted via endoscopy, worn for 24 hours with external recording device, evaluation of acid reflux and non reflux events

Gingivitis

Inflammation of the gums

Periodontal disease

May result from prolonged gingival inflammation, extednds for the soft tissue and bone supporting the gums

Dental caries

Tooth decay; Occurs when plaque breaks down tooth enamel; Related to plaque build up, soft drinks, genetics, meds or dry mouth

Candidiasis

Milky white plaque on the tongue

Candidiasis interventions 

Anti fungal meds, promote oral care, ensure adequate food/fluid intake, minimize pain, prevent infection 

Enteral nutrition

Nutrition delivered straight to the GI tract; given when PO intake is inadequate or impossible 

Parenteral nutrition

Nutrition delivered straight to the bloodstream via a vein

Dumping Syndrome

Occurs when food moves too quickly through the stomach to the small intestine

Dumping syndrome s/s

Tachycardia, dizziness, diaphoresis, n/v/d, dehydration

Dumping syndrome interventions

Administer slowly in a smaller volume, place in semi-fowlers position, administer feeds at room temperature

NGT

Large bore, stiffer tubing, sits in the stomach, short term

Dobhoff tube

Small bore, more flexible tubing, sits in the duodenum or jejunum, nosuction, better tolerated but requires frequent monitoring and flushing

Bolus delivery

All at once, 4-6/day per gravity over 15-60 minutes

Intermittent delivery

Start and stop, given over 30 minutes with flow rate controlled by roller clamp

Continuous delivery

Slow infusion over long period via pump (normally 24 hours)

Cyclic delivery

Faster infusion over a shorter period of time (normally less than 24 hours)

Placement of NGT or Dobhoff

Confirmed with Xray before use, pH assessment; flush with water before and after feeds, medication administration, checking residuals, q4hr with continuous feeds and when feeds are discontinued 

Medication administration through NGT or dobhoff

Flush with 15ml water before and administer each medication, never mix medications

Reasoning and interventions for gas, bloating, and cramping when giving NGT feeds

Due to air in the tube or excess fiber; keep tubing free of air

Reasoning and interventions for n/v when giving NGT feeds

Due to change in formula or rate, or gastric emptying; Check residuals, if <200 ml reinstill and recheck, if residual is consistently high report

Reasoning and interventions for aspiration pneumonia when giving NGT feeds

Due to improper placement, vomiting with aspiration in tube feeding or supine position during feeds; Keep HOB >30 degrees and frequently monitor tube placement

Reasoning and interventions for tube displacement when giving NGT feeds

Due to excessive coughing or vomiting, tube tension, tracheal suction or airway intubation; Verify tube placement before use

Reasoning and interventions for dehydration when giving NGT feeds

Due to hyperosmolar feeding and insufficient fluid intake; Provide adequate fluids

Reasoning and interventions for hyperglycemia when giving NGT feeds

Due to glucose intolerance or high carb content of feeding; Monitor blood glucose frequently, dietary consult 

Refeeding syndrome

Occurs when malnourished Pts begin feeds again; The body adapts to being starved of nutrients, causing rapid shifts of electrolytes so food can be metabolized

S/S of refeeding syndrome

Muscle weakness, difficulty breathing, seizures, coma, n/v, arrhthmias, severe constipation, delirium, hypothermia, amnesia, pulmonary edema, kidney dysfunction, blurred vision

Interventions for refeeding syndrome 

Initiate feeds at 25% of the estimated goal, advance slowly, laboratory assessment 

Gastrostomy

Procedure to create opening into the stomach, can be for nutrition, fluids, meds, gastric decompression or intestinal obstruction; can last up to 2 years; device names are PEG, MIC-KEY, Bard Button

Jejunostomy

Opening placed into the jejunum, used when gastric route is not accessible or to decrease risk for aspiration with stomach dysfunction; can lat 6-9 months; device name is PEJ

Hiatal hernia

When a portion of the stomach moves through the diaphragm into the thoracic cavity

Sliding hiatal hernia

When the upper stomach/gastroesophageal junction slides in and out of the thorax, most common hiatal hernia

Causes of sliding hiatal hernia

Repetitive stress, like valsalva maneuvers, positional changes, reflux or vomiting

Paraesophageal/rolling hiatal hernia

Part of all of the stomach pushes through the diaphragm beside the esophagus, may result from anatomical defect

S/S of hiatal hernia

Symptoms often occur after meals; Feeling of suffocation, pyrosis, regurgitation, dysphagia, GERD, food intolerance, n/v, breathlessness, chest pain, hermorrhage; Sliding may be asymptomatic, paraesophageal/rolling increased symptoms while lying flat 

Management of hiatal hernia

Frequent and small meals, elevate HOB, stay upright after eating meals for 1hr, surgery (Nissen fundoplication to relieve GERD symptoms)

Esophageal diverticulum

Out pouching of the mucosa/submucosa through weakened musculature in the esophagus, Zenker is the most common type

S/S of esophageal diverticulum

Dysphagia, regurgitation, neck fullness, belching, gurgling after eating, halitosis

Halitosis

Sour taste in the mouth 

Management of esophageal diverticulum

Endoscopy using barium, NGT, NPO until xray indicates leakage

Esophageal perforation

A hole or tear in the wall of the esophagus, emergency!

Causes of esophageal perforation

Forceful vomiting, severe straining, foreign body or trauma 

S/S of esophageal perforation

Excruciated retrosternal pain, dysphagia, infection, dyspnea

Management of esophageal perforation

NPO, IV fluids, surgical or endoscopic repair

GERD

Backflow of gastric or duodenal contents into the esophagus 

Causes of GERD

Relaxation of LES, obesity, pregnancy, ascites, NGT, constrictive clothing, age, IBS, tobacco/caffeine ingestion, H. Pylori

S/S of GERD

Pyrosis, regurgitation, dyspepsia, dysphagia, chest pain, morning hoarseness, esophagitis

Management of GERD

Low fat diet, avoid caffeine, tobacco, alcohol, milk, peppermint and carbonated beverages, avoid eating and drinking 2 hours before bed, elevate HOB

Barrett Esophagus 

Complication of GERD; When the lining of the esophageal mucosa is altered, premalignant 

Barrett esophagus S/S

Manifestations of GERD, frequent heartburn

Barrett esophagus management

Endoscopic ablation, PPIs to control reflux symptoms

Antacids/Acid neutralizing agents

Neutralize acid, risk of loss of protective flora and increased risk for infection

Antacids/Acid neutralizing agents examples

Calcium carbonate, aluminum hydroxide, magnesium hydroxide

Histamine 2 receptor antagonists

Decrease gastric acid production, risk of loss of protective flora and increased risk for infection, short acting

Histamine 2 receptor antagonists examples

Famotidine, Cimetidine 

Prokinetic agents

Accelerate gastric emptying, short term use

Prokinetic agents example

Metoclopramide 

Proton Pump Inhibitors PPI

Decrease acid production, risk of loss of protective flora and increased risk for infection, may increase risk for hip fracture, common medication interactions, first line of drugs used, long acting