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NURS 40563 EXAM 3 STUDY GUIDE
GI Disorders
GI BLEEDING
o Acute or chronic (acute = more concerning) o Blood in GI tract that is not visible is occult ▪ Occult checking for presence of blood ▪ + occult colonoscopy ▪ Great screen for colon cancer o Upper GI bleed ▪ Often arterial (gut) o Lower GI bleed ▪ Often venous ▪ Bright red blood
- Biggest concern is internal bleeding!!! ▪ Dark red blood
- Diagnostic Evaluation of GI System o Health history & clinical manifestations ▪ Pain: OLDCART it ▪ Indigestion ▪ Intestinal gas ▪ Nausea & vomiting ▪ Change in bowel habits & stool characteristics & smell (bloody stools stink) o Lab values ▪ H&H • BUN: INCR when blood products are breaking down o Stool tests: occult or visual of red bloody stools o Abdominal ultrasonography o Radiographic imaging: upper & lower GI ▪ CT scan • MRI o Endoscopic procedures: EGD/colonoscopy
▪ Provide volume replacement : FLUIDS (tx like hypovolemic shock) ▪ Monitor results of lab & diagnostic procedures ▪ Support & educate patient and significant others
- Collaborative Care o Endoscopic therapy (Propofol = ideal: dosnt affect BP, fast acting) ▪ First-line therapy ▪ Cauterize bleeding artery o Surgical approach: only done if bleeding continues regardless of therapy. It’s invasive ▪ Vagostomy: cut the vagal nerve DECR gastric secretions o Pharmacologic therapy: DECR bleeding & DECR/neutralize acid ▪ Antacids - PPI: proton pump inhibitors - H2 blockers ▪ Mucosal protectant (Sucralfate): coats the lining of stomach (dissolves in H2O) ▪ Prostaglandins ▪ Vasoconstrictors (Vasopressin) ▪ Sandostatin (somatostatin analog) ▪ Blood Products & Volume Replacement o Mechanical tamponade: Blakmore tube (+TRACTION) ▪ Large bore NG tube with balloons pressure on the esophagus o TEACH to avoid further bleeding! ▪ Avoid disease, drugs/alcohol, liver/resp disease ▪ Avoid drugs that lead to bleeding o Blood products
- BLOOD PRODUCT ADMINISTRATION
- Resuscitation principles o 2 large-bore IV’s: 18 gage or bigger is ideal (settle for 20 gage) o Goal of care: ▪ Maintain sBP above 90 ▪ Maintain Hct>28- - Crystalloids: NS only approved saline to give with blood
- Blood products o PRBC (Packed RBC’s): most common type given o Platelets o Fresh Frozen Plasma (FFP): has all clotting factors ▪ For warfarin/Coumadin toxicity o Albumin: INCR intravascular space by pulling fluid from extravascular space ▪ Temporary fix only! o Cryoprecipitate: clotting factors only used in extreme/unusual circumstances
- Steps o Consent signed (2 signatures if pt refuse) o Inspection of blood product ▪ Type/cross matching - Type: AB, A, B, O, ± - Cross: no antibodies that lead to transfusion reactions ▪ Time limit: 30 min from labinfusion started - RN: make sure there is a GOOD/BIG IV: flushes well, 20+ gage o Check blood with 2 RNs: check armband, computer & bag of blood products
▪ If any number is wrong anywhere… it must be returned to the lab
o VS: know baseline to monitor for transfusion reactions
▪ Closest hub to the IV ▪ Flush IV & have it available for emergency meds (resp/cardiac arrest) o Monitor VS o Notify physician and blood bank ▪ Lab/blood bank
- Draw pt blood & take blood & tubing back
- Lab will look at cross match again! ▪ Doc:
- Steroids (methalprednisone) IV
- Benadryl IV
- Acetaminophen o Recheck ID o Monitor UO, obtain labs/specimens PRN ▪ Urine Analysis test for blood (sign of true reaction) o Treat symptoms **o Return blood AND tubing to blood bank
- Autologous-transfusion** : elective o The patient donates blood 6-weeks before surgery to have for themselves - Auto-transfusion : reserved for those in an emergency o Collect blood from chest tube, filter it & transfuse back into pt – emerbency
- Electrolytes after massive transfusion o K o Ca : may choose to replace o Always do routine electrolyte checks after a transfusion o BUT… esp with massive transfusions, they will have bigger shifts ▪
▪ PEPTIC ULCER
- Duodenal & gastric ulcers most common
- PATHO: Associated with INCR: o Acid-pepsin production o sensitivity of parietal cells to stimuli of HCl secretion o permeability of epithelial lining of the stomach to H+ ions o H. pylori: tx with triple series of ABX to treat it o NSAID’s : VERY common
- Treatment o Stress management o Dietary management o Meds ▪ H2 receptor antagonists ▪ Antacids ▪ Mucosal protective agents (Carafate) o Surgery (last resort)
- Clinical Manifestations o Epigastric pain with empty stomach o Epigastric tenderness o Pain relieved by food / antacids
- Complications o Hemorrhage o Obstruction o perforation ▪
o Kidney Stones o Gallstones ▪ H&P ▪ CBC & CMP (chemistries) ▪ Stool analysis (occult) ▪ Barium enema ▪ Sigmoidoscopy/colonoscopy/endoscopy with biopsy
▪ INFLAMMATORY BOWEL DISEASE
- Goals of Treatment o REST ▪ Resting the bowel ▪ Rest ▪ DECR inflammatory response o Improving quality of life
- Therapeutic Management o NTDT o Pharm therapy ▪ Aminosalicylates (Azulfidine) ▪ Corticosteroids ▪ Immunosuppressant agents ▪ Antibiotics ▪ Biologic therapy: TNF inhibitors - infliximab (Remicade) - adalimumab (Humira) o Symptom relief
- Fight infection
- Improve nutrition (malnutrition) o Dietary consults o TPN feeds?
- DECR stress
- Pharmacologic Therapy
- Supportive meds o Analgesics o Anticholinergics o Antidiarrheals o Antibiotics o Vitamins o Minerals
- Surgical Therapy (last resort) ▪ Failure to respond to medical treatment ▪ Frequent exacerbation
- Nutritional & fluid status ▪ Diagnosis based on assessment findings ▪ Goals for patient: **- DECR in exacerbations
- Maintain F&E balance** o K: paresthesia, muscle weakness, fatigue (worse than usual)
- Be free from discomfort: symptom management - Maintain nutritional balance
- Adhere to treatment plan
- Improve quality of life o Nursing Care: SUPPORTIVE CARE ▪ Promote rest (patient & gut)
▪ Stool assessment
▪ Administer meds & monitor for effectiveness ▪ Comfort measures ▪ Skin care ▪ I&O, especially for someone with an ileostomy : INCR risk of F&E imbalance (2L/day) o Teach S/S of dehydration & electrolyte imbalance (esp K & Na) ▪ Daily weight ▪ Monitor for complications ▪ Stoma care ▪ Nutritional therapy
- PO & Enteral o Long-term diet: calorie, protein, residue (low fiber, EBP may be change)
- TPN ▪ Assist with coping: potential referral for counseling or support ▪ Education
- Disease process
- Symptom management
- Nutritional support
- Complications ▪ ▪
▪ NUTRITION
- Enteral Therapy ▪ Gut has 75% of the immune tissue in the body ▪ Dysfunction edema DECR peristalsis - Give metoclopramide (Reglan) Diarrhea/Tardive dyskinesia - 7 days of fasting gut mass DECR by 50% o FEED THE GUT!!!!!!! ▪ PO intake is insufficient ▪ Functioning GI tract: stomach, distal duodenum, proximal jejunum
- Regardless of BS/not feed slow & EARLY promote bowl activity INCR rate
- Stomach isn’t working… get G-J tube in + NG to LIWS o GJ-Tube: don’t check residuals ▪ Complications may be GI, mechanical, or metabolic FIX UNDERLYING CAUSE
o Ambulate
- Parenteral Nutrition: TPN/Clinamix ▪ Avoid at all possibilities o May be peripheral or central o Indications ▪ 10% deficit in body weight (from preillness) ▪ Inability to take PO fluids/food for extended time ▪ Hypercatabolism o Complications.;
▪ Infection
- Tubing is changed q24hr
- Tubing often comes with a filter ▪ Hyperglycemia ▪ Rebound hypoglycemia : without having some D10W on board ▪ Fluid overload ▪ Pneumothorax ▪ Emboli ▪ ▪
o Hematemesis / hematuria o HYPOVOLEMIC SHOCK o Cullen’s sign (umbilical ecchymosis) o Grey Turner’s sign (flank eccymosis)
FAST study: Focused Assessment with Sonography/CT for Trauma o A quick ultrasound to look for bleeding in/around: ▪ Heart ▪ Liver ▪ Spleen ▪ Pelvis o Intraabdominal bleeding = EMERGENCY! SURGERY (regardless of stability)
Interventions o Ensure patent airway o Administer oxygen o Control external bleeding o IV access (large bore) X2 – or IO line o NS fluid resuscitation (challenge) ▪ LR may be used: contains electrolytes o FAST o CBC, Type & Cross for blood o Stabilize impaled objects (DO NOT REMOVE) o Cover protruding organs with sterile saline soaked dressing ▪ Keep organs moist o Urinary Catheter (if no blood at meatus, pelvic fx, boggy prostate) ▪ BUT… may be risky if ruptured bladder o Urinalysis o NG tube (if no facial trauma) o Possible peritoneal lavage
Volume Resuscitation o Crystalloids-NS or RL (LR)-to keep systolic above 90 through at least 2 large bore IVs o Monitor CVP : don’t need an order CVP o Blood products-PRBC
