Chapter 21 Gastrointestinal Disorders and Therapeutic Management

What causes the mucosal lining to be penetrated?

Gastric secretions autodigest the layers of the stomach or duodenum.

What are the main causes of peptic ulcer disease?

Helicobacter pylori and NSAIDs.

Hallmarks of GI Bleeding

Hematemesis: Bright RED or BROWN "coffee grounds" emesis: usually bleeding above duodenojejunal junction. color depends on time of bleeding and contact with gastric secretions. Hematochezia: Bright RED stools from massive lower GI bleeding, but it's from upper GIB when it is rapid Melena: Black, tarry, or DARK RED stools from upper GI, several days to be clear

Acute GI bleeding medical management

1st priority: Hemodynamic stabilization •The initial treatment priority is the restoration of adequate circulating blood volume to treat or prevent shock (patient stabilization). This is accomplished with the administration of intravenous infusions of crystalloids(N/S, Ringer's Lactate), (colloids) blood, and blood products. 2nd priority: controlling the bleeding •In the patient with GI hemorrhage related to peptic ulcer disease(PUD), bleeding hemostasis may be accomplished by endoscopic injection therapy in conjunction with thermal or hemostatic clips. •In the patient with GI hemorrhage caused by SRMD, bleeding hemostasis may be accomplished by intraarterial infusion of vasopressin and intraarterial embolization. •In acute variceal hemorrhage, control of bleeding may be initially accomplished through the use of pharmacologic agents and endoscopic therapies. •If these initial therapies fail, transjugular intrahepatic portosystemic shunting (TIPS) may be necessary.

Acute pancreatitis Hallmark symptoms

Acute onset of abdominal pain, nausea, and vomiting are Other: • fever, diaphoresis, weakness, tachypnea, hypotension, and tachycardia. The patient may also exhibit signs of hypovolemic shock. CT contrast: Gold standard for diagnosing pancreatitis & overall degree of pancreatic inflammation & necrosis

Bright red or brown "coffee grounds" emesis is called by which term? a. melena b. hematamesis c. hematochezia

B. Hematamesis

What happens when peptic ulceration occurs?

Body's protective mechanisms cease to function, allowing gastroduodenal mucosal breakdown.

What is peptic ulcer disease?

Breakdown of the gastromucosal lining.

Acute Liver Failure

Causes: •Common: Viral hepatitis & Medication-induced liver damage in US •infections, medications, toxins, hypoperfusion, metabolic disorders, & surgery •Thorough meds & health Hx are needed: environmental toxins, hepatitis, intravenous drug use, sexual history, viral hepatitis, medication toxicity, poisoning, vascular causes, & metabolic disorders Prevent Complications: •Hemodynamic instability is a common complication necessitating fluid administration and vasoactive medications to prevent prolonged episodes of hypotension. If ALF continues and the patient shows no immediate signs of improvement, the patient should be considered for a liver transplant. Nursing Management: AVOID SEDATIVES •Use of benzodiazepines and other sedatives is discouraged in the patient with ALF, because pertinent neurologic changes may be masked and hepatic encephalopathy may be exacerbated. These patients may become agitated and combative. Physical restraint may be necessary to prevent injury to the patient. As the neurologic condition worsens, respiratory depression and arrest can occur quickly.

A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? Select all that apply. a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice e. Hyperactive bowel sounds f. Fever

a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice f. Fever Pain • Location: left upper quadrant or midepigastrium radiating to the back • Onset: sudden • Quality: severe, deep, continuous • Aggravating factors: food and alcohol • Nausea and vomiting • Flushing and diaphoresis • Dyspnea • Low-grade fever • Abdominal distention • Abdominal tenderness and guarding • Abdominal tympany • Hypoactive or absent bowel sounds • Jaundice • Palpable abdominal mass • Ecchymoses or bluish discoloration of the flanks (Grey Turner sign) and/or the umbilical area (Cullen sign) • Basilar crackles • Tachypnea • Tachycardia • Hypotension

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care? a. Monitor the patient for hypovolemic shock from plasma volume depletion. b. Observe the patient for hypoglycemia and hypercalcemia. c. Initiate enteral feedings after the nasogastric tube is placed. d. Place the patient on a fluid restriction to avoid the fluid sequestration.

a. Monitor the patient for hypovolemic shock from plasma volume depletion. Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected.If hyperglycemia develops, exogenous insulin may be required. Nutrition support too.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. Portal hypertension b. Superficial mucosal erosions c. Breakdown the mucosal resistanced d. Inflammation and ulceration

a. Portal hypertension Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension caused by hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids.

The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention would have the highest priority? a. Preventing atelectasis b. Managing pain c. Promoting ambulation d. Preventing infection

a. Preventing atelectasis

A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What would be an appropriate response from the nurse? a. "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction." b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." c. "This procedure is usually performed for cancer of the pancreatic head." d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."

b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction." Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction. The technically difficult procedure involves the removal of part or all of the esophagus, part of the stomach, and lymph nodes in the surrounding area. The stomach is then pulled up into the chest and connected to the remaining part of the esophagus. If the entire esophagus and stomach must be removed, part of the bowel may be used to form the esophageal replacement. Two approaches may be used for esophageal resection: transhiatal or transthoracic. Transhiatal: Neck Transthoracic: chest

A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control? a. Administer analgesics only as needed. b. Administer analgesics around the clock. c. Educate the patient and family on lifestyle changes. d. Teach relaxation and distraction techniques.

b. Administer analgesics around the clock. Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the knee-chest position can also assist in pain control.

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan? a. Diabetes management b. Alcohol cessation c. Occult blood testing d. Anticoagulation management

b. Alcohol cessation Before the patient's discharge, the patient should be able to teach back the following topics: • Pancreatitis • Specific cause • Precipitating factor modification • Interventions to reduce further episodes • Importance of taking medications • Lifestyle changes • Diet modification • Stress management • Alcohol cessation • Diabetes management, if needed

Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage? a. Positioning the patient in a high-Fowler's position b. Ensuring the patient has a patent airway c. Irrigating the nasogastric tube with iced saline d. Maintaining venous access so that fluids and blood can be administered

b. Ensuring the patient has a patent airway

A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? Select all that apply. a. Administer benzodiazepines for agitation. b. Monitor oxygen saturation. c. Initiate an insulin drip for hyperglycemia. d. Monitor serum electrolyte levels. e. Assess for signs of cerebral edema.

b. Monitor oxygen saturation. d. Monitor serum electrolyte levels. e. Assess for signs of cerebral edema. • Diminished Gas Exchange due to ventilation-perfusion mismatching or intrapulmonary shunting • Low Cardiac Output due to alterations in preload • Impaired Intracranial Regulation due to failure of normal compensatory mechanisms • Nutritional Deficient due to lack of exogenous nutrients or increased metabolic demand • Body Image Disturbance due to actual change in body structure, function, or appearance • Need for Patient Education due to lack of previous exposure to information

A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage? a. Stress ulcers b. Peptic ulcers c. Nonspecific erosive gastritis d. Esophageal varices

b. Peptic ulcers (leading cause of upper gastrointestinal bleeding)

A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? Select all that apply. a. Calcium b. Serum amylase c. Serum glucose d. Potassium e. WBC f. Serum lipase

b. Serum amylase c. Serum glucose e. WBC f. Serum lipase LABS Serum Amylase: Elevated Urine Amylase: Elevated Serum Lipase: Elevated Serum Triglycerides: Elevated Cross-reactive protein: Elevated Glucose: Elevate WBC: Elevated Calcium: Low Mag: Low K+: Low Bili: may be elevated liver enzymes: may be elevated prothrombin time: prolonged ABGs: hypoxemia/metabolic acidosis

The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence? a. Crackles in the lung bases b. Subcutaneous emphysema c. Incisional bleeding d. Absent of bowel sounds

b. Subcutaneous emphysema The clinical signs and symptoms of a leak can be subtle and often go unrecognized. They include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the practitioner to order for this patient? Select all that apply. a. Histamine2 (H2) antagonists b. Vasopressin c. Heparin d. Antacids e. Somatostatin f. Octreotide

b. Vasopressin e. Somatostatin f. Octreotide Control bleeding. • Endoscopic interventions • Vasopressin, somatostatin, octreotide • Transjugular intrahepatic portosystemic shunt • Surgery (last resort)

A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery is a RYGBP. What would be an appropriate response from the nurse? a. "It is an esophagectomy performed using the transthoracic approach." b. "It is an esophagectomy performed using a transhiatal approach." c. "It is a combination of restrictive and malabsorption types of bariatric surgery. d. "It is a standard operation for pancreatic cancer."

c. "It is a combination of restrictive and malabsorption types of bariatric surgery." Bariatric surgery refers to surgical procedures of the GI tract that are performed to induce weight loss. Bariatric procedures are divided into three broad types: (1) restrictive (Restrictive procedures such as adjustable gastric banding), (2) malabsorptive (biliopancreatic diversion), and (3) combined restrictive and malabsorptive (reating a small gastric pouch and anastomosing the jejunum to the pouch).

The nurse is caring for a patient with acute liver failure. The practitioner asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom? a. Inflate a blood pressure cuff on the patient's arm. b. Have the patient bring the knees to the chest. c. Have the patient extend the arms and dorsiflex the wrists. d. Dorsiflex the patient's foot.

c. Have the patient extend the arms and dorsiflex the wrists. on GI hemorrhage Diagram Priorities in Medical Management 1. ID those at risk for GI hemorrhage 2. Airway protection 3. Fluid resuscitation to achieve hemodynamic stability 4. correction of co morbid conditions 5. therapeutic procedures to determine exact cause 6. administer drugs that neutralize gastric acids.

The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the practitioner to order for this patient? a. Insulin b. Vitamin K c. Lactulose d. Lorazepam

c. Lactulose Antibiotics such as neomycin, metronidazole, and rifaximin and lactulose, which is the gold standard, are administered to remove or decrease production of nitrogenous wastes in the large intestine. Antibiotics reduce bacterial flora of the colon; this aids in decreasing ammonia formation by decreasing bacterial action on the protein in feces. Side effects include renal toxicity and hearing impairment. Lactulose, a synthetic ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a nasogastric tube or as a retention enema.

A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs as a result of what pathophysiologic mechanism? a. Uncontrolled hypoglycemia caused by an increased release of insulin b. Loss of storage capacity for senescent red blood cells c. Premature activation of inactive digestive enzymes, resulting in autodigestion d. Release of glycogen into the serum, resulting in hyperglycemia

c. Premature activation of inactive digestive enzymes, resulting in autodigestion Acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, leading to autodigestion of pancreatic tissue. The enzymes become activated through various mechanisms, including obstruction of or damage to the pancreatic duct system, alterations in the secretory processes of the acinar cells, infection, ischemia, and other unknown factors.

A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen? a. Allows for administration of tube feeding. b. Allows for testing of gastric secretions. c. Prevents tube from adhering to the gastric wall. d. Prevents the tube from advancing.

c. Prevents tube from adhering to the gastric wall. The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa. The tube is passed through the nose or mouth into the nasopharynx and then down through the pharynx into the esophagus and stomach.

A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms? a. Metabolic acidosis and hypovolemia b. Decreasing hemoglobin and hematocrit c. Hyperkalemia and hypernatremia d. Hematemesis and melena

d. Hematemesis and melena In a patient with GI hemorrhage caused by SRMD, bleeding hemostasis may be accomplished by intraarterial infusion of vasopressin and intraarterial embolization. Endoscopic therapies provide minimal benefit because of the diffuse nature of the disease. In the past, several operative procedures were used to control bleeding from SRMD. Because of the advent of stress ulcer prophylaxis, the incidence of hemorrhage from SRMD is markedly decreased.

Stress-related mucosal disease (SRMD)

is an acute erosive gastritis that covers mucosal lesions often found in the critically ill patient: stress-related injury and discrete stress ulcers. SRMD is caused by increased acid production and decreased mucosal blood flow, resulting in ischemia and degeneration of the mucosal lining. Patients at risk include those with high levels of physiologic stress

Acute Pancreatitis

•In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, leading to autodigestion of pancreatic tissue. The enzymes become activated through various mechanisms, including obstruction of or damage to the pancreatic duct system, alterations in the secretory processes of the acinar cells, infection, ischemia, and other unknown factors. Trypsin is the enzyme that becomes activated first. It initiates the autodigestion process by triggering the secretion of proteolytic enzymes such as kallikrein, chymotrypsin, elastase, phospholipase A, and lipase.

Nursing Management

•Nursing management of a patient experiencing acute GI hemorrhage incorporates a variety of patient problems. Nursing priorities are directed toward: (1) administering volume replacement, (2) initiating gastric lavage, (3) providing comfort and emotional support, 4) maintaining surveillance for complications, and (5) educating the patient and family. •Measures to facilitate volume replacement include obtaining intravenous access and administering prescribed fluids and blood products. •One measure to prepare the patient for endoscopy is the initiation of gastric lavage. It is used to evacuate blood from the stomach and improve visualization during endoscopy. Gastric lavage is performed by inserting a large-bore nasogastric tube into the stomach and irrigating it with normal saline until the returned solution is clear. It is important to keep accurate records of the amount of fluid instilled and aspirated to ascertain the true amount of bleeding. However this practice has recently been called into question as unnecessary and is no longer routinely recommended. •Although a rare complication, gastric perforation constitutes a surgical emergency. Signs and symptoms include sudden, severe, generalized abdominal pain with significant rebound tenderness and rigidity. •Early in the hospital stay, teaching should focus on acute GI hemorrhage and its causes and treatments. Toward discharge, teaching should focus on preventing a recurrence.