`Digestion and Absorption Part I

NUR 433 Adult Health II; MCUSON; Mrs. Owen

what is the backward flow of stomach acid up the esophagus

gastroesophageal reflux disease (GERD)

what is the most common health problem in all age groups

gastroesophageal reflux disease (GERD)

list some symptoms of gastroesophageal reflux disease (GERD)

• heartburn after eating

• fullness/discomfort after eating

• nocturnal coughing/wheezing

lit some lifestyle modifications for gastroesophageal reflux disease (GERD)

• stop smoking

• weight loss

• small, frequent meals - avoid fried, fatty foods, caffeine, citrus/tomatoes, alcohol

• sit up after eating

what is the drug class for medications such as omeprazole, esomeprazole, pantoprazole

proton pump inhibitors

list some common side effects of proton pump inhibitors

• headache

• diarrhea/constipation

• vitamin B12 deficiency

• increased fractures

• increased C. diff risk

• hypomagnesemia

list some major teaching points for proton pump inhibitors

• take 30-60 minutes before eating in the AM

• s/s of B12 deficiency

• hypomagnesemia

what is the drug class for medications such as famotidine, cimetidine, nizatidine

H2 (histamine) receptor antagonists

list some common side effects for H2 (histamine) receptor antagonists

• headache/dizziness

• gynecomastia with long-term use

list some major teaching points for H2 (histamine) receptor antagonists

significant drug interactions with warfarin, phenytoin, and theophylline

what is the drug class for medications such as calcium carbonate, aluminum hydroxide, and magnesium hydroxide

antacids

list some common side effects for antacids

• constipation

• diarrhea

list some major teaching points for antacids

• can interfere with absorption of meds so give 2 hours apart

• calcium carbonate has a risk of alkali syndrome (especially renal)

what is the drug class for medications such as metoclopramide

prokinetics (for GERD caused by delayed emptying)

what is the black box warning for prokinetics

• extrapyramidal symptoms

• tardive dyskinesia

list some major teaching points for prokinetics

• watch for facial tics, tongue movements, and tremors

• avoid other CNS depressants

what is the drug class for medications such as sucralfate

mucosal protectant

what is a common side effect for a mucosal protectant

constipation

list a major teaching point for a mucosal protectant

• give on an empty stomach, 1 hour before meals, and at bedtime

• give 2 hours apart from meds

what is the universal red flag for potential signs of ischemia/necrosis

pain out of proportion to physical findings

list the 4 types of bowel obstructions

• herniation

• adhesions

• volvulus

• intussusception

*initial obstruction can occur from them

***an initial bowel obstruction can also occur from distension due to fluid and gas and intestinal content build-up

bowel obstructions can also be caused by fluid and electrolytes. fluid builds up in the _____ _____, causing electrolyte disturbances

intestinal lumen

bowel obstructions can also be cause by fluid and electrolytes. for example, _____ when content can’t move through the obstruction

vomiting

bowel obstructions can also occur when _____ fatigues and stops, creating more pressure, edema, and ischemia

peristalsis

Finding	What does it mean?	Nursing Priority
Pain out of proportion to exam	Hallmark of mesenteric ischemia — often underdiagnosed until late	Advocate strongly if exam looks "benign" but pain is severe
Bloody or "currant jelly" stools	Mucosal sloughing from ischemia	Report immediately, correlate with lactate
Elevated lactate	Marker of tissue hypoperfusion/necrosis	Trend serially, correlates with severity
Fever, distension, rigidity together	Suggests progression to necrosis/perforation	Emergent surgical evaluation

one complication of a bowel obstruction occurs when there is increased fluid retention in the abdomen which then decreases circulating _____

blood

Then, a decrease in circulating blood leads to …

hypovolemia

Then hypovolemia leads to …

decreased tissue perfusion

then decreased tissue perfusion leads to ….

ischemia

then ischemia leads to …

necrosis

then necrosis leads to …

perforation

finally, perforation leads to …

• gut contents in the abdomen

• infection

• sepsis

• and death

what does the additional assessment of high pitched, tinkling bowel sounds indicate

early bowel obstruction

what does the additional assessment of diminished or absent bowel sounds

late bowel obstructions

list some nursing interventions for a patient with a bowel obstruction

o    Fluids and electrolyte management: I’s & O’s, lab values

o    NG tube to low suction: GI decompression, decrease vomiting

o    NPO until otherwise noted, monitor for flatus

o    Pain medication/nausea medication

o    IMMEDIATELY REPORT: Changes in vitals, bowel sounds, UOP, distention, pain, S/S of shock

The nurse is reassessing a patient with a bowel obstruction. Which changes should be reported to the health care provider? Select all that apply.

A.      Documented passage of flatus

B.      Changes in bowel sounds

C.      Increased abdominal distention

D.      Stable abdominal girth with no change from the previous measurement

E.       No change in the patient's reported abdominal pain

F.       Changes in vital signs

B, C, F

list the 6 functions of the liver

1. stores glycogen for energy

2. metabolizes fat for energy

3. processes proteins (_____, prothrombin, and other factors for blood clotting) and amino acids

4. vitamin storage and activation

5. secretion of bile (water, salts, lipids, bilirubin, electrolytes)

6. detoxification (including ammonia)

what is extensive degeneration and destruction of liver cells which is then replaced by scar tissue

cirrhosis (which is a result of end-stage liver disease)

what are 5 factors that can cause cirrhosis

• chronic liver disease

• hepatitis C virus (HCV) infection

• NASH

• alcohol-induced

• extreme dieting

list some symptoms of cirrhosis

• RUQ pain

• asterixis

• dark-colored urine

• hepatic encephalopathy

• jaundice

• palmer erythema

• clay-colored stools

• weight loss

• fruity/musty breath

• ascites

• pruritis

what may need to be performed for large-volume ascites to relieve fluid and pressure

paracentesis

what is a complication of paracentesis defined by increased pressure in liver circulation from obstruction of blood flow in and out of the liver

portal hypertension

portal hypertension causes _____ _____ which leads to alternate circulation pathways causing esophageal varices

collateral circulation

_____ _____ are fragile veins as a result of collateral blood flow in portal hypertension; these varices bleed easily

esophageal varices

patients with esophageal varices may present with _____ or _____

melena; hematemesis

ruptured varices are the most life-threatening complication of _____ and considered a medical emergency!

cirrhosis

what is a neurological disorder that is majorly from the build-up of ammonia

hepatic encephalopathy

what are some symptoms of hepatic encephalopathy

• impaired consciousness

• mental status changes

what medication traps ammonia in the gut, reduces ammonia formation, and causes diarrhea

lactulose

acute liver failure/end stage liver failure is _____ _____ and is severe liver dysfunction

rapidly progressive

acute liver failure is usually from what medication use and/or an autoimmune/viral hepatitis

Acetaminophen

list some manifestations of acute liver failure/end stage liver failure

• hepatic encephalopathy

• coagulation problems

• cerebral edema

• renal failure

• hypoglycemia

• metabolic acidosis

• sepsis

• multiorgan failure

list some nursing interventions for acute liver failure/end stage liver failure

• ICU transfer and transplant planning

• Neuro monitoring

• renal monitoring

• lab monitoring

list some ways to monitor/manage neuro symptoms for acute liver failure/end stage liver failure

• avoid stimulation

• avoid increasing ICP

list some ways to monitor/manage renal monitoring for acute liver failure/end stage liver failure

• hepatorenal syndrome

• dehydration

• acute tubular necrosis

• avoid nephrotoxic agents (NSAIDs, -mycins)

what are some labs to monitor for acute liver failure/end stage liver failure

• bilirubin

• prothrombin

• bleeding times

• electrolytes

• CBC

• ammonia

a normal gallbladder stores and concentrates _____ produced by liver, and then releases it to aid in fat digestion

bile

_____ typically develops when a gallstone becomes lodged in the cystic duct, obstructing bile flow and causing distension and inflammation

cholecystitis

cholecystitis can also be caused by “_____” from bile stasis (especially in ICU patients)

calculus

in acute cholecystitis, the _____ becomes edematous and hyperemic distending with bile or pus

gallbladder

what does hyperemic mean

fills with blood

***acute cholecystitis = distension → pressure → decreased blood flow → ischemia, necrosis, gangrenous changes, perforation → EMERGENCY

list some manifestation for acute cholecystitis

• fever and leukocytosis

• RUQ pain (biliary colic)

• rebound tenderness and abdominal muscle guarding

• elevated serum bilirubin and alkaline phosphatase levels

***remember, sudden pain relief after severe pain could be a sign of acute cholecystitis

***remember, acute cholecystitis may indicate perforation (pressure released), not improvement

***remember, reassess immediately, do not reassure falsely

_____ of the bile duct can be caused from obstructed bile flow which then causes infection

cholangitis

cholangitis could be a complication of coexisting conditions of or totally separate from _____

cholecystitis

what are the 3 factors of Charcot’s triad which is a finding for cholangitis

• fever

• jaundice

• RUQ pain

Charcot’s triad is a classic finding for _____ cholangitis

ascending

list some nursing priorities for Charcot’s triad which is a finding of cholangitis

• blood cultures

• early antibiotics

• prep for biliary drainage

• address obstruction

Reynolds’ pentad (+ hypotension, AMS) is a finding of _____ cholangitis which is septic and critical

suppurative

list some nursing priorities for Reynolds’ pentad

• sepsis bundle

• likely ICU-level care

what means that the normal pancreas secretes pancreatic enzymes into the duodenum required for the metabolism of carbohydrates, fats, and proteins

exocrine

list the pancreatic enzymes

• trypsin

• chymotrypsin

• elastase

• amylase

• lipase

pancreatic enzymes remain inactive until they get to the _____

duodenum

what means Islet cells produce hormones for glucose regulation and maintaining a normal glucose

endocrine

_____ occurs when some sort of injury or disruption to pancreatic cells cause pancreatic enzymes to leak into the pancreatic tissues instead of the duodenum, triggering early activation and autodigestion

pancreatitis

***local effects of pancreatitis: enzymes break down tissues → edema, vascular damage, hemorrhage, necrosis, fibrosis → make pseudocysts → edema causes ischemia and necrosis

what are walled off sections of pancreatic secretions called

pseudocysts

***systemic effects of pancreatitis includes toxic enzymes and inflammatory mediators which cause widespread damage

list some specific, systemic effects of pancreatitis

• injury to vessels and organ systems (hepatic, renal)

• development of systemic inflammatory response syndrome (SIRS)

• potential for ___?___

list some general complications for pancreatitis

• ARDS
  heart failure

• renal failure

• coagulopathies

• shock

• sepsis

list some specific GI complications for pancreatitis

• paralytic ileus and bleeding

list some manifestations for pancreatitis

o    Severe epigastric/midabdominal pain, patient may describe as “twisting/knifelike,” may be in fetal position

o    GI – nausea/vomiting

o    Fever, weakness, diaphoresis, hypotension, tachycardia, tachypnea (Shock?)

o    hypocalcemia symptoms! – autodigestion of enzymes releases free fatty acids, which bind with calcium to form calcium salts

Cullen’s/Grey Turner’s sign is a finding of pancreatitis which indicates a _____ _____ and is a late, ominous finding

retroperitoneal hemorrhage

list some nursing priorities for pancreatitis

• report immediately

• anticipate ICU transfer

hypocalcemia is a finding of pancreatitis and indicates fat saponification which is a marker of severity. What are the two main signs of hypocalcemia

• Chvostek’s sign

• Trousseau’s sign

list some nursing priorities for hypocalcemia in pancreatitis

• monitor for tetany

• seizure precautions

tachypnea and hypoxia are some more findings of pancreatitis and indicate a risk of _____ from systemic inflammatory response

ARDS

list some nursing priorities for tachypnea and hypoxia with pancreatitis

• monitor SPO2 closely

• anticipate escalation of O2 support

oliguria and hypotension are also findings of pancreatitis and indicates third-spacing and massive fluid shifts. This leads to _____ and acute kidney injury (AKI)

hypovolemia

list some nursing priorities for oliguria and hypotension in pancreatitis

• aggressive fluid resuscitation per protocol

• strict I&Os

list some nursing priorities for pancreatitis

o    Hemodynamic monitoring for SIRS/shock: hypotension, fever, tachypnea

§  Volume, volume, volume

o    Hypocalcemia S/S

o    Hyperglycemia monitoring

o    Pain relief – pancreatitis HURTS!

§  Also NPO à stop digestive processes to stop further autodigestion