Gastrointestinal Disorders- Fin
Pt teaching
-Avoiding NSAID's (e.g., cough mixtures), alcohol, antibiotics, or antacids containing salt. -Weighing self-daily
Esophageal varices
-Esophageal varices are dilated, tortuous veins that are usually found in the submucosa of the lower esophagus but may develop higher in the esophagus or extend into the stomach. -Almost always caused by portal hypertension, which results from obstruction of the portal venous circulation within the damaged liver. -Prone to rupture: massive hemorrhage in upper GI tract & rectum (straining, coughing, vomiting, reflux, poorly chewed food, heavy lifting, aspirin) -S/s: hematemesis, melana, ↓ mental status, shock, frequent BM (blood is natural cathartic) -Assess w endoscopy (and band varices-stop bleeding. band falls off by itself), & CT angiogram (withhold fluids after exam when gag reflex return) -High mortality rate Varices are varicosities that develop from elevated pressure in the veins that drain into the portal system. They are prone to rupture and often are the source of massive hemorrhages from the upper GI tract and the rectum.
Manifestation of Esophageal varices
-Hematemesis (vomiting blood) -Melana -Deterioration of mental status -Symptoms of shock Assessment: -Endoscopy (banding- rubberband the varices which stop them from bleeding. Eventually the bands fall off and dissolve when it's healed -CT, angeiogram
What meds to give?
-Lactulose -Lowers ammonium level -Causes loose stools
Treatment for esophageal varices
-Monitor VS, volume status, CBC, electrolytes -Have blood type & screen available -Lactulose to ↓ ammonia, give every 4 hrs until pt has 3-4 loose stools/day. Anything more than that should speak to provider. -BB to ↓ BP -Sandostatin for splenic vasoconstriction to ↓ BP in hepatic system & ↓ bleeding from varices (active bleeding) -Vasopressin: natural astringent (don't use w CAD- lead to MI)- emergent situation used. -Vitamin K for clotting -Beta blockers to lower BP and prevent initial bleeding Blakemore tube: nasal gastric tube inserted through nose- 2 balloons on it-1 sits in stomach, other inflates and push against varices. Note: DO NOT TOUCH TUBE- bleed out. Provide oral hygiene. Give them tissues so they can spite- impair swallowing. -Epinephrine: IV for bleeding. Given cautiously- should be avoided if they have a cardiac history -BE AWARE OF OVERHYDRATING PT- varices might pop
Variceal band therapy
-Varices are banded to constrict & ↓ swelling -Bands will fall off or be sclerosed w drugs -Effective in controlling acute bleeding. -Complications include superficial ulceration and dysphagia, transient chest discomfort, and, rarely, esophageal strictures
TIPS (Transjugular Intrahepatic Portosystemic Shunt) Treatment of an acute episode
-Wire goes from IJ → hepatic vein → portal vein for stent placement to ↓ pressure in portal system -Risk of: bleeding, perforation, HF, sepsis -Potential complications of TIPS include bleeding, sepsis, heart failure, organ perforation, shunt thrombosis, and progressive liver failure.
14. When assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the patient toa. stand on one foot.b. ambulate with the eyes closed.c. extend both arms.d. perform the Valsalva maneuver. a. stand on one foot. b. ambulate with the eyes closed. c. extend both arms. d. perform the Valsalva maneuver.
-c. extend both arms. Rationale: Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests might also be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.
Procedures to control hemorrhage
1) Double balloon tamponade 2) Variceal banding therapy 3) Transjugular intrahepatic portosystemic shunting (TIPS)
Levels of hepatic encephalopathy
1) Normal consciousness, periods of lethargy 2) Drowsiness, disoriented, inappropriate behavior, mood swings, asterixis (hold hand out but then it flaps) 3) Difficult to arouse (stuporous), asterixis, sleep, increase deep tendon reflex 4) Comatose- no asterixis, no dependent reflexes, flaccid
Pancreatic cancer
4th leading cause of death in men, 5th in women -80% cases occur in head of pancreas (can be in head, body, or tail) -Most pts aren't dx until later stages (asymptomatic) -High rate of metastasis (liver, lungs, bones) -S/s: pain, jaundice, weight loss, clay stool, dark urine, obstructed common bile duct, ascites -Dx: ERCP (endoscopy), spiral CT (reliable), biopsy -Cannot perform total excision: (1) extensive growth of tumor before diagnosis and (2) probable widespread metastases (especially to the liver, lungs, and bones). -7% of pts survive >5 yrs -Treatment is limited to palliative measures: Pain management, nutritional requirements -Asymptomatic until its in it's late stage
Double balloon tamponade -Temporarily control hemorrhage and to stabilize a patient with massive bleeding prior to other definitive management
AKA blakemore -1 balloon holds tube in stomach, the other compresses the varices -Priority is to make sure tube doesn't move -Frequent oral & nasal care -Rule out gastric or esophageal aspiration -Displacement of the tube and the inflated balloon into the oropharynx can cause life-threatening obstruction of the airway and asphyxiation -Rupture of the gastric balloon causes esophageal balloon to move into the oropharynx. -Sudden rupture of the balloon causes airway obstruction and aspiration of gastric contents into the lungs -Aspiration of blood and secretions into the lungs is frequently associated with balloon tamponade, especially in the stuporous or comatose patient. -Endotracheal intubation before insertion of the tube protects the airway and minimizes the risk of aspiration -Most of these people are alcoholics- challenged to managed. -Delirium tremens: alcohol, benzos, methadone CANNOT ABRUPTLY STOP ALCOHOL- they can die. If these people are in the hospital and they haven't drank in 48-72 hours- look for delirium tremenes: tachycardia at rest, tremors- ADMIN ATIVAN OR VALIUM
Whipple procedure
AKA pancreaticoduodenectomy -Removal of gallbladder, portion of stomach, duodenum, proximal jejunum, head of pancreas, & distal common bile duct and piece them all back together. -Pain relieved -Fluid resuscitation -Dietitian consult -Risk for bleeding -Risk for further complication of diabetes
Cant abruptly stop the following drugs or they will die
Alchohol Benzodiapines If they don't get these meds they can go into delirium tremens -> vital signs will increase Give ativan, valium or some sort of benzo
C1 protocol
Assess current state of withdrawals Evaluate 10 different things ex: Tremors sweats anxiety hallucination nausea vomiting visual disturbance agitation Go in q 1 hr- assess these symptoms (1-7= 7 being profound)
A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor a. prothrombin time. b. bilirubin levels. c. ammonia levels. d. potassium levels.
C. ammonia levels. Rationale: The blood in the GI tract will be absorbed as protein and may result in an increase in ammonia level since the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels should also be monitored, but these will not be affected by the bleeding episode.
Esophageal Varices
Cause by liver malfunction, often: Cirrhosis Elevated pressure in the veins Prone to rupture -massive hemorrhage in upper GI, rectum Blood clotting abnormalities (liver- produces clotting factors) High mortality rate
Factors that contribute to hemorrhage
Muscular exertion from lifting heavy objects; -straining at stool -sneezing, coughing -vomiting; esophagitis -irritation of vessels by poorly chewed foods or irritating fluids -reflux of stomach contents (especially alcohol).
Hepatic encephalopathy Liver: metabolize ammonium (waste product of protein) into urea goes to the kidney to get excreted. Liver broke-> ammonium stays in bloodstream and goes to brain. Causes LOC -Low/no protein diet -Skin: Increase risk for bleeding (no coagulation produced anymore- pressure injuries in bed/bruising from moving a lot. Yellow skin- liver failing- bilirubin. ) Pruritus: inflammation of skin
Neuropsychiatric manifestations of liver failure -Life threatening -Associated w portal HTN & shunting of blood away from portal venous system into circulatory system (esophageal varices) -Causes minor mental health changes & motor disturbances -S/s: confusion, unkempt, altered mood & sleep, asterixis (floppy hand) - One to one observation. -Dx w EEG -Tx w lactulose via enema, PO, or NG tube (Lactulose scopes up ammonium and excrete it as stool)
Delirium tremens (DTs)
Severe alcohol withdrawal that occurs 3-5 days after last drink -Dangerous to suddenly stop drinking, have to wean off -Alcohol suppresses sympathetic nervous system, which suddenly increases when an alcoholic d/c drinking -S/s: agitation, confusion, ↑BP & HR, tremors, sweating, hallucinations -Can cause stroke or MI -Tx w sedative (ativan, valium)
During treatment of a patient with a Minnesota balloon tamponade for bleeding esophageal varices, which nursing action will be included in the plan of care? a. Encourage the patient to cough and deep breathe. b. Insert the tube and verify its position q4hr. c. Monitor the patient for shortness of breath. d. Deflate the gastric balloon q8-12hr.
c. Monitor the patient for shortness of breath. Rationale: The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. The health care provider inserts the tube and verifies the position. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.
