CCRN - GI

Most GI bleeds are _______. This can be due to peptic ulcer disease, esophageal issues, stress ulcers, and cancer. They have _________ mortality rates.

Upper

Higher

How are upper GIBs treated?

Isotonic fluids

PRBCs/clotting factors

Meds: vasopressin and octreotide reduce splanchic blood flow, lactulose, BBs

What is the primary cause of esophageal varices?

Portal hypertension secondary to liver disease

Liver cirrhosis prevents normal __________ through the liver, so pressure backs into the ____________ vein like a hemorrhoid.

Drainage

Esophageal

Exocrine functions of the pancreas: secrete ____________ and ___________ enzymes

Endocrine functions of the pancreas: alpha cells secrete ___________, beta cells secrete ____________, and delta cells inhibit both

Bicarbonate, digestive

Glucagon, insulin

Acute pancreatitis is ______________ of the pancreas d/t ______________ activation of exocrine enzymes, not usually an infection. This activates inflammatory mediators like ____________, ___________, histamine, and clotting factors, causing SIRS.

Auto-digestion

Premature

Cytokines, kinins

How does acute pancreatitis have respiratory effects?

LLL atelectasis

Left pleural effusion

Bilateral crackles

ARDS

S/s of acute pancreatitis

Pain in all quadrants

NV, rigid abdomen, no rebound tenderness

Decreased bowel sounds

Increased WBC, amylase, lipase

Decreased calcium

__________ is used up for auto-digestion, causing Trousseau’s and Chvostek’s

Calcium

__________ ___ is released in acute pancreatitis, which kills _________ ____ ___________- cells, decreasing surfactant and causing ARDS.

Phospholipase A

Type 2 alveolar

What are signs of hemorrhagic pancreatitis?

Cullen’s sign - bluish discoloration and ecchymosis of the periumbilical area

Great turner’s - bluish discoloration of the flanks

Most common cause of acute hepatic failure is ___________.

Most common cause of chronic hepatic failure is _________ _________.

Acetaminophen

Alcohol abuse

Lab findings in hepatic failure

Decreased serum ___________

Decreased albumin

Increased ________

Coagulopathies; increased ____ and _____

Increased. AST, ALT

Increased serum ___________ and ____________/____

Hyperventilation

Protein

Ammonia

PT, PTT

Bilirubin, creatinine/BUN

S/s of hepatic failure

_____________ is a flapping hand tremor seen in hepatic failure

__________ d/t low albumin and protein

_________ d/t elevated bilirubin

_______ ________ (unknown etiology)

Sepsis

Enlarged liver

AsterixisAsterixis

Ascites

Jaundice

Renal failure

Factors that increase serum ammonia

_____________ triggers ammoniagenesis in the kidneys

Increased _____ and ______

Increased __________ ____________

Hypokalemia

BUN, protein

Lactic acidosis (precipated by LR because it is converted to bicarbonate by a healthy liver)

Hepatic failure tx

Prevent factors that increase serum ammonia

Restrict __________ if hepatic encephalopathy present

_______ factors

___________

Neomycin

____________ for all suspected acetaminophen OD

Protein

Clotting

Lactulose

Acetylcysteine/mucomyst

Pt with a hx of splenectomy has reduced __________ function since the spleen filters blood.

Immune

Signs of splenic rupture include Kehr’s sign (________ ______ _________ pain) and __________ distention with ________ bowel sounds

Sharp left shoulder

Abdominal, absent

Signs of abdominal trauma

LUQ ecchymosis

Cullen’s sign

Grey turner’s sign

Kehr’s sign

Absence of bowel sounds with abdominal distention

Bowel sounds in the chest

Free air in the abdomen

What are some causes of intra-abdominal HTN and abdominal compartment syndrome? Pathophys?

Massive fluid resuscitation

Trauma

Emergent abdominal surgery

Abdominal cavity pressure > capillary pressure that perfuses splanchic organs

IAH = > _____ mmHg

APP = difference between MAP and IAP

• > 60 mmHg r/t improved survival

• < ___ mmHg r/t increased mortality

Abdominal compartment syndrome is a sustained IAP > ___ mmHg

12-15

50

20

How is intraperitoneal pressure measured?

Bladder pressure, transducer at the level of the symphysis pubis

12-15, should be <20

Complications of bariatric surgery

___________, need vitamin supplements (protein, calcium iron, B-12, folate)

Wounds

Enteric leakage from ______________

Gallstones

Bowel obstruction

Malabsorption

Anastomosis

Types and etiologies of bowel obstructions

Paralytic ileus: ______kalemia, abdominal surgery, peritonitis, _________, pancreatitis, sepsis

SBO: _______, volvulus, neoplasm, adhesions

Large bowel: neoplasm, ____________, fecal impaction

Hypo, opiates

Hernia

Diverticulitis

SBO s/s

Sharp, __________ pain

Vomiting

Hypokalemia

______ pitched bowel sounds

Dilated bowel

Episodic

High

LBO s/s

_______ pain

Change in bowel habits

Abdominal distention

_____ pitched bowel sounds

Dilated bowel

Dull

Low

Bowel obstruction tx

NG tube

F/Es

Pain tx

Nutritional support

Surgery

Bowel perforation s/s

NV

Fever, tachypneic/cardic

Abdominal pain that worsens with hip flexion

Rigid abdomen (boardlike)

Rebound tenderness

Free air in peritoneum on KUB

Bowel perf tx

__________ decompression w NG tue

FEs

Pain

____________, blood cultures

Surgery, possible __________

Gastric

ATBs

Diversion

Differentiation of abdominal pain

Gastritis: _________, indigestion, NV, abdominal tenderness

________ ________: epigastric/RUQ, gnawing, burning, abdominal tenderness

Pancreatitis: epigastric/LUQ, may radiate to back/flank/_____ ________, worsened with ________ ______, NV, fever, abdominal tenderness

Cholecystitis: epigastric/RUQ, may refer to _________ ___________, cramping, NV, abdominal tenderness

__________: epigastric/periumbilical, dull to sharp pain, anorexia, nausea, __________, fever, diarrhea, rebound tenderness

SBO: across the abdomen, cramping to sharp pain, ____________, variable bowel sounds

___________ ________: left shoulder (Kehr’s sign), sharp pain, abdominal distension

Peritonitis (___________ ____________): generalized, dull pain, rigid abdomen, rebound tenderness

Epigastric/slightly left

Peptic ulcer

Left shoulder, lying down

Right shoulder

Appendicitis, leukocytosis

Hypokalemia

Ruptured spleen

Acute abdomen

ET cuff pressure should be ____ cm H2O < x < ____ cm H2O to prevent aspiration

20, 30

Gastric residual should be obtained every ___ hours and should be less than ____ mL or a promotility agent should be used.

4

250