CH 22: Gastrointestinal Disorders and Management (p. 426 - 446)

True or False: It is safe to put a nasogastric tube in a person with esophageal varices

False

True or False: The color of blood, bright red representing fresh blood, dark representing old, is the most important assessment finding in a GI bleed

False Rationale: Amount of blood is more important

True or False: Controlling the bleeding from the source is the initial priority in a GI bleed

False Rationale: Restoration of adequate circulating blood volume to treat or prevent shock is the initial priority. Controlling the bleeding is second. (Urden, 2016, p. 429)

True or False: The patient's hemoglobin and hematocrit is a reliable indicators of the severity or rapidity of blood loss.

False Rationale: As whole blood is lost, plasma and RBC are lost in proportion. Hematocrit may be 40 before and after bleeding episode. Resdistribution of plasma to the intravascular space may take up to 72 hours. Dilutional drops in H &H may occur with fluid resuscitation. The trend is important and any H and H that continues to drop significantly with blood administration is indicative of ongoing acute blood loss.

Emergency complication occurring from bleeding in the upper or lower GI tract

GI Hemorrhage

Medical management of the patient at risk for GI hemorrhage should include the administration of what? (hint: If your patient is at risk for DVT, you'd want to take measures to PREVENT that)

Gastric prophylactics (PPI, H2's, Antacids)

Two main causes of Peptic Ulcer Disease

H.pylori NSAIDs

Bleeding from a source above the duodenojejunal junction that appears in vomit

Hematemesis

Occurs from a massive lower GI hemorrhage, appearing as bright red stools

Hematochezia

Doctor orders a nasogastric tube for the nurses patient for abdominal decompression. Why is it important to know this patients history?

If the patient has a history of esophageal varices, an NG tube is contraindicated because of the risk of rupture.

Abnormally high accumulation of bilirubin in the blood causing yellowing of the skin and eyes

Jaundice

Pain from appendicitis, perforated duodenal ulcer, and cecal volvulus. Name the Quadrant.

Right lower quadrant (RLQ)

Pain from liver hepatitis, Cholecystitis (Gallstones), and Perforated peptic ulcer. Name the Quadrant.

Right upper quadrant (RLQ)

The development of acute liver failure or (fulminant hepatic failure) occurs over the course of _ to _ weeks, followed by _________ ______________ within 8 weeks, in a patient with a previously ________ liver. Although uncommon, the mortality rate is __ to __%

1 to 3 hepatic encephelopathy Healthy 40 to 80%

The risk of mortality with each bleeding episode from esophageal varices increases to __% - __%.

20 30

Which of the following medical interventions are appropriate for Fulminant Hepatic Failure (FHF)? (Select all that apply) A. Neomycin reduces bacterial flora of colon which aids in decreasing ammonia formation by the colon and decreases bacterial action on protein in the feces B. Side effects of Neomycin include liver toxicity C. Lactulose creates an acidic environment that decreases bacterial growth D. Lactulose traps ammonia and has a laxative effect that promotes expulsion.

A, C, D Rationale: In addition to controlling ammonia levels, bleeding should be controlled through prevention. Stress ulcer prophylaxis is essential. If bleeding occurs, prepare to administer Vitamin K, fresh-frozen plasma and platelets. Hypoglycemia, metabolic acidosis, hypokalemia, and hyponatremia should be monitored and treated appropriately

Which of the following assessment findings are indicators that hepatic failure is severe? A. Bilirubin >3 B. Albumin >3.5 C. INR <3 D. Mild confusion and slurred speech

A. Bilirubin > 3 Rationale: Stage IV Hepatic encephalopathy- Coma, initally responsive to noxious stimulie, later unresponsive; abnormal EEG. Severe liver failure indicated by presence of ascities, bilirubin >3, albumin <2.8 and INR>6.

Which nursing intervention of the patient with pancreatitis is most important? A. Minimizing pancreatic stimulation to inhibit autodigestion process B. Encourage oral feeding to support nutritional state of patient C. Nasogastric suction D. All of the above

A. Minimizing pancreatic stimulation to inhibit auto-digestion process Rationale: In pancreatitis the normally inactive digestive enzymes become active, in which the pancreas enzymes eat the pancreas itself. Patients with pancreatitis should be kept NPO to rest the inflamed pancreas and prevent further enzyme release. Oral feeding stimulates the pancreas. NG suctioning has not been shown to be beneficial unless the patient is severely vomiting (Urden, 2016, p. 434) Pain management is also crucial in the care of the patient with pancreatitis. While older texts may ask for the preferred opiate Demerol vs Morphine based on sphincter of Oddi argument, evidence-based research reflects that Morphine is the preferred narcotic for parenteral administration.

Which of the following laboratory values is seen in a patient with pancreatitis? A. Hypercalcemia B. Hyperglycemia C. Low triglyceride D. Low serum amylase E. All of the above

B. Hyperglycemia Rationale: Amylase is excreted in the urine, increasing with pancreatitis. Lipase is more of an accurate marker for pancreatitis than Amylase as it is more pancreas specific. Elevated triglycerides and decreased calcium occur. (Urden, 2016, Table 22-2, p. 433)

Your patient has been in the critical care unit for several weeks with acute respiratory failure. The stools become black and tarry and the hemoglobin drops. You suspect: A. Ulcerative colitis B. Stress ulcer C. Pancreatitis D. All of the above

B. Stress ulcer Rationale: Stress ulcers usually occur in the upper GI tract. Melena occurs from digestion of blood from an upper GI hemorrhage, presenting as black, tarry, or dark red stools

Cerebral edema may occur in Acute Liver Failure as a result of what?

Breakdown of the brain blood barrier

Ominous sign that may occur in pancreatitis that is usually present in patients with Peritonitis (inflamed lining of abdominal wall) (hint: Think abdomen)

Rigid or boardlike abdomen

Your patient with long standing cirrhosis and alcoholism has developed esophageal varices. The following statement is TRUE: A. Patients with superficial varices of the legs are more likely to develop esophageal varices B. Control of bleeding can only be accomplished with a Sengstaken Blakemore tube C. A TIPPS procedure creates a channel between the systemic and portal venous system to redirect portal blood and reduce portal hypertension D. The portal hypertension is confined to pressure within the esophageal vessels

C. A TIPPS procedure creates a channel between the systemic and portal venous system to redirect portal blood and reduce portal hypertension Rationale: IV vasopressin, somatostatin and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhage by constricting the splanchnic arteriolar bed.While the use of sclerotherapy is declining, endoscopic variceal band ligation is effective in preventing bleeding esophageal varices. Portal hypertension also leads to hemorrhoids, spleenomegaly as well as increased pressure in peritoneal capillies which causes ascities. Superficial venous varices do not presdispose the patient to esophageal varices-cause is cirrhosis.

Engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension

Esophageal Varices

Select the correct statement about gastric mucosa: A. Stress ulcerations or Stress-related erosive syndrome occurs in less than 5% of patients B. Abnormalities are slow to develop C. Disruption of gastric mucosa resistance with increased acid production and decreased mucosal blood flow occurs in critical illness D. No prophylaxis is indicated as the gastric mucsoa will easily regenerate cell healing

C. Disruption of gastric mucosa resistance with increased acid production and decreased mucosal blood flow occurs in critical illness Rationale: Stress ulceration occurrs in 1-30% of patients, Prophylactic measures such as cytoprotective agents, H2 antagonists, and proton pump inhibitors are often used to prevent. These abnormalities develop rapidly within hours of admission and range from superficial mucosal erosion to deep ulcers.

Which statement regarding fulminant hepatic failure (FHF)/Acute Liver Failure is true? A. Disease usually occurs in patients with long standing liver failure B. Syndrome is characterized by development of acute liver failure over 1-3 months C. Results in impaired bilirubin conjugation, decreased production of clotting factors, depressed glucose synthesis, and decreased lactate clearance. D. All of the above

C. Results in impaired bilirubin conjugation, decreased production of clotting factors, depressed glucose synthesis, and decreased lactate clearance. Rationale: Patients will develop jaundice, coagulopathies, hypoglycemia, and metabolic acidosis. Hepatic encephalopathy results from failure of liver to detoxify. Hypoalbuminemia, fluid /electrolyte imbalnace and acute portal hypertension cause ascities. Patients are usually healthy and the liver failure develops over 1-3 weeks. Many commonly used drugs cause FHF including phenytoin, isoniazid, refampin, tetracycline and Bacrim. Accurate history is important.

Gold standard diagnostic procedure in acute pancreatitis

CT Scan

Complications of acute pancreatitis include which of the following? A. Hypoxemia and ARDS B. Hypotension C. Acute tubular necrosis D. All of the above

D. All of the above Rationale: Pancreatitis is a severe life threatening isorder associated with the escape of activated pancreatic enzymes into the pancreas and surrounding tissue. Onset is usually abrubt and dramatic. Most common initial symptom is severe epigastric and abdominal pain. Loss of a large volume of fluid into the retroperitoneal and peripancreatic spaces contributes to hypotension. Hypocalcemia occurs in 25% of patients (Urden, 2016, p. 434)

Which of the following clinical manifestations is indicative of a class one hemorrhage (<15% blood loss)? A. Pulse rate > 100 beats per minute B. Capillary refill >3 seconds C. Urine output low 25-30cc/hr D. Orthostatic hypotension and apprehension

D. Orthostatic Hypotension and apprehension Rationale: Tachycardia and tachypnea typically do not occur until Class 2 hemorrhage develops which is 15-30% blood loss. Orthostatic BP becomes a useful tool in evaluating patients with suspected GI bleed. (Urden, 2016, Table 22-1, p. 429)

5 Complications of acute liver failure

Decreased clotting factors Increased ammonia Jaundice Hypoglycemia Spider Nevi

Which nursing interventions are appropriate for the patient with GI bleeding? A. Prepare for urgent fiber-optic endoscopy as this examination has a 90-95% accuracy rate B. Hemodynamically stabilize the patient with two large bore IV's and fluid resuscitation C. Monitor coagulation studies carefully including PT, PTT, INR, and platelets especially if patient has cirrhosis or multiple transfusions have been given. D. Prepare for endotracheal intubation if patient is at risk for aspiration or to facilitate gastric lavage. E. All of the above

E. All of the above Rationale: While gastric lavage continues to be used for upper gastrointestinal bleeding, new research demonstrates that iced saline should not be used. Keep accurate records of amount instilled and aspirated. Your goal is to irrigate with normal saline or water until the returned solution is clear.

Pain from ulcerative colitis and colonic diverticulitis. Name the Quadrant.

Left lower quadrant (LLQ)

Pain from splenic trauma, pancreatitis, and pyloric obstruction. Name the Quadrant.

Left upper quadrant (LUQ)

5 causes of Stress-Related Mucosal Disease

Mechanical Ventilation Trauma Burns Acute Neurological Disease Erosisve Gastritis

Occurs from digestion of blood from an upper GI hemorrhage, presenting as black, tarry, or dark red stools

Melena

Antidote to Tylenol

N-acetylcysteine (Mucomyst)

Disease that results from the breakdown of the gastrointestinal lining, leading to 40% of upper GI bleeding

Peptic Ulcer Disease

Cause of Esophageal Varices (hint: Think of what happens in liver failure. What causes those "ports" leaving in and out of it to "tense" up?)

Portal Hypertension

3 Treatment goals for Acute Liver Failure (What do you wanna prevent, remove, or treat?)

Prevent bleeding Remove/Decrease nitrogenous wastes in the large intestine Treat Bleeding

Acute erosive gastritis that covers both types of mucosal lesions often found in critically ill patients; Patients at risk include those in situations of high physiological stress

Stress-Related Mucosal Disease (SRMD)

Vascular lesions caused by dilated blood vessels

Telangiectasia

Why is inspection and auscultation indicated before percussion and palpation?

To prevent stimulation of gastrointestinal activity that may give inaccurate results

Procedure in which a channel between the systemic and portal systems is created and a shunt is placed to redirect portal blood, thereby reducing portal hypertension and decompressing esophageal varices

Transjugular Intrahepatic Portosystemic Shunting (TIPS)

True or False: Two most common causes of acute pancreatitis are biliary disease such as gallstones and alcoholism.

True Rationale: Gallstones are hardened enzyme deposits that get backed up into the bile ducts causing a back up of wastes. Alcohol damages the pancreas.

Two most common causes of Acute Liver Failure in North America

Viral Hepatitis Liver Toxic Medications (Amioderone)