Week 13 / Test 4 - GI / GU

GERD Health Promo & Disease Prev

- BMI <30 - Stop smoking, limit alcohol & tobacco. - Eat low-fat - Avoid foods that lower LESpressure - Avoid eating or drinking 2h before bed - Avoid tight-fitting clothes - Elevate HOB 6-7 inches

GERD Dx Procedures - EGD

- Mod sedation to observe tissue dmg & dilate strictures - Esophageal lining should be pink but often red w persistent GERD. Biopsies may be done to determine if high-grade dysplasia (HGD) present - HGD: Squamous mucosa of esophagus replaced by columnar epithelium (seen in stomache/intestines). When found, 30% ^ risk of cancer. - EGD allows visualization of esophagus, revealing esophagitis or Barrett's epithelium (premalignant cells) Verify gag refelx returned prior to oral fluids or food following proc to reduce risk aspiration. Monitor pt for maniefstations esophageal perf (fever, pain, dysp, bleed)

GERD - Expected Findings

- Report of dyspepsia (indigestion) after eating an offending food or fluid, & regurgitation - Radiating pain (neck, jaw, back) - Feeling of having heart attack - Pyrosis (burning in esophagus) - Odynophagia (pain w swallow) - Pain worsens w position (bending, straining, laying) - Pain that occurs after eating & lasts 20 min to 2 hr - Throat irritation (chronic cough, laryngitis), hypersalivation, bitter taste. Chronic GERD can lead to dysphagia - Increased flatus & eructation (burping) - Pain relieved by drinking water, sitting up, antacids - Occurs 4-5x/wk on consistent basis is diagnostic - Dental caries - Chest congestion & wheezing due to reflux material entering tracheobronchial tree

Lipase blood test - Range & Interpretation

0-160 units/L Elevation occurs with pancreatitis

Aspartate aminotransferase (AST) blood test - Range & Interpretation

0-35 units/L Elevation occurs with hepatitis or cirrhosis

Ammonia blood test - Range & Interpretation

10-80 mcg/dL Elevated in liver disease

Albumin blood test - Range & Interpretation

3.5-5 g/dL Decrease can indicate hepatic disease

Alkaline phosphatase (ALP) blood test - Range & Interpretation

30-120 units/L Elevation indicates liver damage

Amylase blood test - Range & Interpretation

30-220 units/L Elevation occurs with pancreatitis

Alanine aminotransferase (ALT) blood test - Range & Interpretation

4-36 units/L Elevation occurs with hepatitis or cirrhosis

Alpha-Fetoprotein blood test - Range & Interpretation

<40 mcg/L Elevated in liver cancer, cirrhosis, hepatitis

A nurse is caring for a client who si receiving TPN solution. The current bag of solution was hung 24 hr ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? A) Remove the current bag and hang a new bag B) Infuse the remaining solution at the current rate and then hang a new bag C) Increase the infusion rate so the remaining solution is administered withn the house and hang a new bag D) Remove the current bag and hag a bag of lactated ringers

A >24 H = Risk of infection

A nurse is caring for a client who has a new diagnosis of GERD. The nurse should expect prescriptions for which of the following meds? Select all that apply. A) Antacids B) Histamine 2 Receptor Antagonists C) Opioid analgesics D) Fiber laxatives E) Proton Pump Inhibitors

A, B, E

A nurse is planning care for a client who has a new prescription for TPN. Which of the following interventions should be included in the plan of care? Select all that apply. A) Obtain capillary blood glucose four times daily B) Admin prescribed meds through seondary port on TPN IV tubing C) Monitor vitals 3 times per 12-hr shift D) Change TPN tubing Q 24 H E) Ensure daily aPTT obtained

A, C, D

Esophages Varices Interprof Care & Complications

Alcohol recovery program (varices secondary to alc use disorder) Hypovolemic shock due to hemorrhage from varices - Observe for manifestations of hemorrhage & shoc (tachy, hypotension) - Monitor vitals, hgb, hct, coag studies - Replace losses & support therapeutic proc to stop & control bleeding

Urine bilirubin

Also known as urobilinogen, this is a urine test to determine presence of bilirubin in urine Indications: suspected liver or biliary tract disorder Preprocedure nursing actions: Can be performed using dipstick (urine bilirubin) or 24-hr urine collection (urobilinogen) Pt education: Collect urine using provided proper container Interpretation of findings: Positive or elevated finding indicates possible live disorder (cirrhosis, hepatitis), biliary obstruction, hemolytic anema, or pernicious anemia (bilirubin released from liver when rbcs break down)

A nurse is having difficulty arousing a pt following an EGD. Which of the following is the priority action by the nurse? A) Assess the patient's airway B) Allow the patient to sleep C) Prepare to admin an antidote to the sedative D) Evaluate preprocedure lab findings

Answer: A ABCs!

A nurse is reviewing bowel prep using polyethylene glycol with a pt scheduled for a colonoscopy. Which of the following instructions should the nurse include? A) Check with the provider about taking current meds when consuming bowel prep B) Consume normal diet until starting bowel prep C) Expect bowel prep to not begin acting until day after all prep consumed D) Discontinue bowel prep once all feces expelled

Answer: A Some meds can be wittheld when taking polyethylene glycol due to their lack of absorption

A nurse in a clinic is instructing a pt about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the patient indicated understanding? A) "I will continue taking my warfarin while I complete these tests." B) "I'm glad I don't have to follow any special diet at this time" C) "This test determines if I have parasites in my bowel" D) "This is an easy way to screen for colon cancer"

Answer: D

A nurse is teaching a patient who will undergo a sigmoidoscopy. Which of the following information about the procedure should the nurse include? Select all that apply. A) Increased flatulence can occur following the procedure B) NPO status should be maintained prior to procedure C) Conscious sedation is used D) Repositioning will occur throughout procedure E) Fluid intake is limited the day after the procedure

Answers: A, B

A nurse is reviewing the health record of a pt who has a suspected tumor of the jejunum. The nurse should exect a prescription for which of the following tests? Select all that apply. A) Bood alpha-fetoprotein B) ERCP C) GI x-ray with contrast D) Small bowel capsule endoscopy (M2A) E) Colonoscopy

Answers: C, D

Peptic Ulcer Disease Meds

Antibiotics H2 receptor antagonists PPIs Antacids Mucosal protectants

GERD Complications

Aspiration of Gastric Secretion - Esoph aspirations can be aspirated into trachea Risks assoc w aspiration: - Asthma exacerbation from inhaled aerosolized acid - Frequent upper resp, sinus, or ear infec - Aspiration pneumonia Barrett's Epithelium (premalignant) & Esophageal Adenocarcinoma - Reflux of gastric fluids leads to esophagitis. In chronic esophagitis, body continuously heals inflamed tissue, eventually replacing normal esoph epithelium w premalignant tissue (Barrett's epithelium) or malignant adenocarcinoma. Nursing actions: - Determine cause of GERD w pt & review lifestyle changes. Monitor nutrition.

Esophageal Varices Health Promo & Disease Prev

Avoid alcohol Avoid heavy lifting Avoid straining w BMs Chew food completely, as poorly-chewed foods can irritate area Avoid salicylates & other meds that can irritate esophagus

Peptic Ulcer Disease Nursing

Avoid foods that cause distress (coffee, tea, carbonation) Monitor for othostatis changes in vitals & tachy as these suggest GI bleed or perf Admin saline lavage via NG tube Admin meds as prescribed Decreased envtl stress Encourage rest periods Encourage smoking cessation & avoiding alcohol cons Monitor labs

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? A) Absence of saliva B) Painful swallowing C) Sweet taste in mouth D) Absence of eructation

B

A nurse is providing care to a client who is 1 day postop following a paracentesis The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? A) Place a clean towel near the drainage site B) Apply a dry, sterile dressing C) Apply direct pressure on the site D) Placec the client in a supine position

B

A nurse is teaching a client who has a hiatal hernia. Which of the following client statements indicates an understanding of the teaching? A) "I can take my medications with soda" B) "Peppermint tea will increase my indigestion" C) "Wearing an abominal binder will imit my manifestations" D) "I will drink hot chocolate at bedtime to help me sleep" E) "I can lift weights a a way to exercise"

B

Hiatal Hernia Dx Procedures

Barium Swallow with Fluoroscopy: - Allows visualization of esophagus Nursing: - Intruct pt to use cathartics to evac barium from GI tract or fecal impaction may occur EGD: - Allows visualization of gastric lining Nursing: - verify gag reflex has returned prior to food or fluids CT Scan of Chest w Contrast: - Allow visualization of esophagus & stomach Nursing: - Assess for iodine allergies if IV contrast is to be used. - Encourage fluids following proc to promote dye excretion & min risk of renal injury - Monitor BUN & creatinine

A nurse is completing discharge teaching with a client who is 3 days postop following a transverse colostomy. Which of the following should the nurse include in the teaching? A) Mucus will be present in stool for 5-7 days after surgery B) Expect 500-1,000 mL of semi-liquid stool after 2 wks C) Stoma should be moist & pink D) Change hte stomy bag when it is 3/4 full

C

A nurse is completing discharge teaching with a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding of the teaching? A) "When sitting in my lounge chair after a meal, I will lower the back of it" B) "I will try to eat three large meals a day" C) "I will elevate the head of my bed on blocks" D) "I will avoid eating within 1 hour before bedtime"

C

Endoscopy Findings

Can indicate need for med or surgical removal of lesion

A nurse is caring for a pt following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? A) Client report of upper chest pain B) Decreased urine output C) Pallor D) Temperature elevation

D

A nurse is admitting a client who has bleeding esophageal varices. The nurse should expect a prescription for which oft he following medications? A) Propranolol B) Metoclopramide C) Ranitidine D) Vasopressin

D Vasopressin constricts BVs & treats bleeding

Bariatric Surgery Complications

Dehydration - Warn pt excessive thirst or concentrated urine should be comm to surgeion - Establish goals for intake Malabsorption/malnutrition: - Fewer nutrients ingested/absorbed - Monitor pt tolerance of ^ amt of food & fluid - Refer to diety mgmt - Encourage meals in low-Fowler's & remain in this pos for 30 min after eating to delay stomach emptying & minimize dumping syndrome Pt education: - Eat 2 serving protein daily - Eat only nutrition-dense foods. Avoid empty calories (juice, soda)

Hiatal Hernia Expected Findings

Depend of type & are typically worse after meal Sliding: - Heartburn - Reflux - Chest pain - Dysphagia - Belching Paraesophageal: - Fullness after eating - Sense of breathlessness/suffocation - Chest pain - Worsens when reclining Both: Pharyngitis & Insp/exp wheezes

Fecal Occult Blood Test & Stool Samples

Done with unexplained diarrhea & GI bleeding 3 repeats of positive guaiac FOBT confirms GI bleed Positive finding for blood is indicative of GI beed (ulcer, colitis, cancer) Positive finding for ova (parasite eggs) & parasites is indicative of GI parasitic infection Positive C.diff indicative of this opportunistic infection, which usually becomes established secondary to use of broad spectrum antibiotics Change in vimentin gene can be indicator of colorectal cancer

Peptic Ulcer Disease - Health Promo & Disease Prev

Drink alcohol in moderation Stop smoking & use of tobacco prods Use stress mgmt techs Avoid NSAIDs as indicated Limit caffeine-containing beverages Consume balanced diet Engage regularly in exercise

Peptic Ulcer Disease Complications - Pernicious Anemia

Due to deficiency of instrinsic factor normally secreted by GI mucosa Pallor, glossitis, fatigue, paresthesias Pt education: Life long monthly B12 injections necessary

Peptic Ulcer Disease Expected Findings

Dyspepsia: Heartburn, bloating, N/V (vom is rare but can be caused by gastric outlet obstruction)/ Can be perceived as uncomfortable fullness or hunger. Dull, gnawing pain or burning sensation at midepigastrium or back - Pain or epigastric tenderness or abdominal distention - Blood emesis, stools (melena) - Weight loss

Dx / Therapeutic Procedures Peptic Ulcer Disease

EGD - definitive dx test NPO 6-8 hr prior to EGD Surgical interventions used when ulcers don't heal after 12-16 wks med trmt, hemorrhage, perf, or obst Gastrectomy: All stomach removed Antrectomy: Antrum (lower) stomach removed Gastrojejunostomy (Billroth II): Lower stomach excised, remaining stomach anastomosed to jejunum, & remaining duodenum closed Vagotomy: vagus nerve cut to decrease gastric acid prod in stomach. Pyloroplasty: Opening between stom & small intestine enlarged to ^ rate of gastric emptying NURSING: - Monitor incision for infec - Place pt in semi-fowler's - Monitor NG tube drainage (scant blood may be seen first 12-24h) - Notify provider before repos or irrigating NG (disruption of sutures) - Monitor bowel sounds - Advance diet as tolerated to avoid ab dist & diarrhea - Admin meds as prescribed (analgesics, stool softeners) Pt teaching: - tak evits & mins due to decreased abs afer gastrectomy (B12, D, calcium, iron, folate) - Consume small frequent meals while avoiding large qtys of carbs as directed

Peptic Ulcer Disease Complications - Perforation/Hemorrhage

Emergency Perf: Severe, epigastric pain spreading across ab. Can radiate to shoulders, esp right shoulder due to irritation of phrenic nerve. Ab can become tender & rigid (boardlike). Hyperactive to diminished bowel sounds can be auscultated & there is rebound tenderness. Pt will display manifestations of shock, hypotension, & tachy. Perf is surgical emergency. GI Bleed: Hematemesis or melena can cause shock (hypotension, tachy dizz, conf) & decreased hgb NURSING: - Frequent pain assmt & vitals - O2 & vent support prn - start 2 large-bore IV lines for replacement of blood & fluids - NG tube - Saline lavages

Esophageal Varices Therapeutic Procedures

Endoscopic Variceal Ligation (EVL): - Banding therapy for acute bleeding - Complications: Superficial ulceration, dysphagia, temp chest discomfort, esophageal strictures (rare) - Admin preproc sedation. Post proc, mon vitals & prevent aspiration Endoscopic Sclerotherapy: - Sclerosing agent injected into varices, resulting in thrombosis of varicosity - Complications: Bleeding, perf of esophagus, aspiration pneumonia, esophageal stricture - Admin preproc sedation. Post proc, mon vitals & prevent aspiration - Antacids, H2RBs, or PPIs can be admin'd after proc to protect esoph from reflux, often caused by sclerotherapy Transjugular Instrahepatic Portal-Systemic Shunt (TIPS) - Used to treate acute bleeding when EVL & pharm measures don't control it. Costly, so only used when other measures don't work. Lowers portal pressure rapidly. - Cath placed into liver via jugular vein in neck. Stent then placed between portal & hepatic veins bypassing the liver. Portal htn is subsequently relieved. - Complications: Bleeding, sepsis, HF, organ perf, liver failure - Monitor vitals & keep HOB elevated

Esophageal Varices Dx Procedures

Endoscopy Nursing interventions: - Admin preproc sedation - Monitor vitals & prevent aspiration (confirm gag reflex before fluids) postop

Colonoscopy

Enters through anus to visualize rectum & colon Anesthesia: Moderate sedation. Midazolam, or opiates such as fentanyl and/or propofol are commonly used. Positioning: Left side with knees to chest Prep: - Bowel prep. Can include laxatives such as bisacodyl or polyethylene glycol (miralax) - Polyethylene glycol not rec for older adults because can cause F&E imbalance. - PG can also inhibit absorption of some meds so review pt med list & consult provider - Clear liquid diet (avoid red, purple, orange fluids). NPO after midnight. - Pt must avoids meds indicated by provider (aspirin, anticoags, antiplatelets) Postprocedure: - Notify provider of severe pain (possible perf) or indication of hemorrhage - Monitor for rectal bleed - Monitor vitals & resp status. Maintain open airway until pt awake. - Resume normal diet as prescribed - Encourage increased fluid intake - Can be ^ flatulence due to air instillation during proc - Instruct pt not to drive or use equip for 12-18 hr after proc

Esophageal Varices Therapeutic Procedures cont.

Esophagogastric Balloon Tamponade: - Rarely used but can be used temporarily control bleeding until another measure can be implemented - Risks: Tube migration, which can lead to airway obstruction; aspiration of gastric contents into lungss - Pts often intubated to protect airway - Can cause necrosis if left in place for extended time. Balloon should be in place no longer than 12 hrs. - Check balloons for leaks prior to insertion - Monitor placemnt of tube & poss obstruction of airway - Monitor for asp into lungs & secretions or blood from esophagus - Oral suction as needed - Maintain balloon pressure at prescribed pressure for prescribed time to decrease risk esoph or gastric necrosis from ischemia - Monitor pt who might pull tube Surgical interventions: - Last resort. TIPS has replaced many surgical measures. High morbidity & mortality. - Bypasses establish venous shunt that bypasses liver, decreasing portal htn. Splenorenal, mesocaval, portacaval. - Commonly NG tube inserted to monitor for hemorrhage - Monitor for liver dysfunction & encephalpathy - Monitor NG tube for bleeding - Monitor clotting factors & platelets

Nasogastric Decompression Complications

F&E Imbalance: - Monitor for imbalance (metabolic acidosis: low obstruction. metabolic alkalosis: high obstruction.) Skin breakdown

Ostomies Patient Education

Foods that cause odor: Fish, eggs, asparagus, garlic, beans, dark leafy veg. Foods that decrease odor: Buttermilk, cran juice, parsley, yogurt Cause gas: Dark leafy veg, beer, carbonate beverages, dairy, corn, chewing gum, skipping meals, smoking Decrease gas: Yogurt, crackers, toast After small intestine ostomy placed: Avoid high-fiber foods first 2 mo, chew food well, ^ fluid intake, eval evidence of blockage when slowly adding high-fiber foods to diet Proper appliance fit & maintenace prevent odor when pouch is not open. Filters, deoderizers, or a breath mint can be placed in pouch to minimize odor when pouch open.

Enteral Feedings

For pt with functioning GI tract but inability to swallow. Can't take in adequate protein/cals orally. Can be supplemental or the only source of nutrition. Potential Diagnoses: - Inability to eat due to medical condition (comatose, intubated) - Pathologies that cause difficulty swallowing or ^ risk of aspiration (stroke, advanced Parkinson's, MS) - Inability to maintain adequate oral nutritional intake & need for supplementation due to ^ metabolic demands (cancer therapy, burns, sepsis) Pt Presentation: - Malnutrition - Aspiration pneumonia

Hiatal Hernia Therapeutic Procedures

Fundoplication: Reinforcement of LES by wrapping portion of fundus of stomach around distal esophagus Laparoscopic Nissen fundoplication: Minimally invasive with fewer complications - Elevate HOB to promote lung expansion - Instruct pt to support incision during mvmt & coughing - Teach pt to consume soft diet first wk postop. Avoid carbonation. Ambulate, but avoid heavy lifting - Complications are temporary dysphagia, gas bloat syndrome (diff burping & distention), atelectasis/pneumonia

Gastroesophageal Reflux Disease (GERD)

Gastric content & enzyme backflow into esophagus. Some backflow of stomach contents is normal. When reflux excessive due to conditions (incompitent LES, pyloric stenosis, hiatal hernia, excessive intra-abdominal or intragastric pressure, motility probems) the corrosive fluids irritate esophageal tissue, causing delay in their clearance. This exposes esophagus to more fluids causing more irritation. Primary treatment of GERD: - Diet & lifestyle changes - Advancing to med use (antacids, H2-receptor antagonists, proton pump inhibitors) - Surgery Untreated, leads to: - inflamm - breakdown - LT complications: Barrett's esophagus or adenocarcinoma of the esophagus.

Labs tests

H. Pylori Urea breath testing (if HP present, CO2 will come out), stool sample (hp & occult blood), endoscopy, Hct & Hgb

Peptic Ulcer Disease Risk Factors (Causes of PUs)

H. pylori infection NSAID & corticosteroid use Severe stress Familial tendency Hypersecretory states Gastrin-secreting benign or malignant tumors of the pancreas Type O blood Excess alcohol consumption Chronic pulm or kidney disease Zollinger-Ellison syndrome (combo of peptic ulcers, hypersecretion of gastric acid, & gastrin-secreting tumors) Pernicious anemia

Total Parenteral Nutrition

Hypertonic IV bolus solution. Used to prevent or correct nutritional deficiencies & minimize adverse effects of malnourishment. - Through central line (tunneled triple lumen cath, or single/double lumen PICC) - Complete nurition, incl cals in high concentraion (10-50%) of dextrose, lipids, protein, electrolytes, vits, & trace elements. Standard IV bolus no more than 700 cal/day Partial PN or Peripheral PN (PPN): Less hypertonic, for ST use, admin'd in large peripheral vein. Usual dextrose concentration is 10% or <. Risks include phlebitis.

Complications of Paracentesis

Hypovolemia: Albumin levels can drop because peritoneal fluid removed contains large amt of protein. Removal of this protein-rich fluid can cause shifting of intravascular vol. Prevention: - Slow drainage & admin of plasma expanders (albumin) to counter losses - Montior for evience of hypovolemia (tachy, hypotension, pallor, diaphoresis, dizziness)

GERD Dx Procedures - Barium Swallow

Identified Hiatal hernia, strictures, or structural abnormalities. Instruct pt to use cathartics to evacuate barium from GI after proc. Failure to elim barium may cause fecal impaction.

Esophageal Varices Nursing Care

If bleeding suspected, establish IV access w large bore needle, monitor vitals & hct, type & cross match for possible blood transfusions, monitor for overt & occult bleeding

TPN - Indications, Dx, Pt Presentation

Indications: Any condition that.. - Affects abiliy to absorb nutrition - has prolonged recovery - Creates hypermetabolic state - Creates chronic malnutrition Potential Dx: - Chronic pancreatitis - Diffuse peritonitis (peritoneum = abdominal lining) - Short bowel syndrome - Gastric paresis from DM - Severe burns (can change bacterial makeup for GI tract) Patient Presentation: - Weight loss >10% body weight & NPO or unable to eat or drink for > 5 days - Muscle wasting, poor tissue healing, burns, bowel disease disorders, acute kidney failure

Paracentesis

Inserting needle or trocar through ab wall into peritoneal cavity. Goal is to relieve ab ascites pressure. Usually done w ultrasound as safety precaution Abdominal ascites: - Abnormal accumulation of protein-rch fluid in ab cavity most often caused by cirrhosis of liver. - Result is ^ abdominal girth & distention. - Resp distress is the determining factor in use of paracentesis & in eval of treatment effectiveness Pt presentation: - Compromised lung expansion, increased ab girth, rapid weight gain

EGD

Insertion through mouth into esophagus, stomach, & duodenum to identify or treat bleeding, dilate esophageal stricture, or diagnose gastric lesions or celiac Anesthesia: Moderate sedation per IV access. Topical anesthetic to depress gag reflex, atropine to decrease secretions. Positioning: Left side-lying with HOB elevated Prep: NPO 6-8 hr. Remove dentures. Prostproc: - Monitor vitals & resp status. Maintain open airway until pt awake - Notify provider of bleeding, ab or chest pain, evidence of infec - Withhold fluids until return of gag reflex - D/C IV fluid therapy when pt tolerates oral fluids without n/v - Instruct pt not to drive or use equip for 12-18 hr after proc - Teach pt to use throat lozenges if sore throat or hoarse voice persists following proc

Nasogastric Decompression

Intestinal obstruction Obstruction can be mechanical or functional Indications: - Any disorder that causes mechanical (tumors, adhesions, impaction), or functional (surgery, trauma, GI infec, absent peristalsis) intestinal obstruction Pt presentation: - Vomiting (stomach contents --> fecal matter) - Bowel sounds absent (paralytic ileus) or hyperactive & high-pitched (obstruction) - Intermitent, colicky abdominal pain & distention - Hiccups - Abdominal distention Nursing: - Incorporate NG tube flushes & drainage into I&O - Assess bowel sounds, abdominal girth, return of flatus - Monitor for tube displacement (decreased drainaged, nausea, vom, distention) - Assess electrolytes & hct - Frequent oral & nares care - Maintain NPO status - Pt should respos when in bed & get out of bed as able to promote mvmt of intestines

Liver Function Tests & Other Blood Tests

LFTs are: - aspartate aminotransferase (AST) - alanine aminotransferase (ALT) - alkaline phosphatase (ALP) * AST, ALT, & ALP are released into blood when liver tissue damage occurs - billirubin (occurs when liver breaks down old RBCs) - albumin (protein made by liver) Other Blood Tests that provide info about GI function: - amylase (enzyme in saliva & pancreatic fluid that convert glycogen into sugar) - lipase (pancreatic enzyme that catalyzes the breakdown of fats to fatty acids and glycerol or other alcohols) - alpha-fetoprotein - ammonia (waste buildup in bs when kidneys or liver not working properly to filter) Tests indicated in anyone with suspected liver, pancreative, or biliary tract disorder. Preprocedure, explain to pt how blood obtained & what info this provides

Esophageal Varices Lab Tests

LFTs: Indicate liver disorder Hgb & Hct: Anemia secondary to occult bleeding or overt bleeding Elevated blood ammonia level: Indicates increased nitrogen load from bleeding varices

TPN Complications

Metabolic: Hyperglycemia, hypoglycemia, vitamin deficiencies - Review daily labs & monitor for hyperglycemia - Fluid needs replaced w separate IV to prevent fluid vol excess Air Embolism: Pressure change during tubing change - Monitor for: Sudden dyspnea, chest pain, anxiety, hypoxia - Clamp cath immediately & place pt on left side in Trendelenburg to trap air. Admin O2 & notify provider so trapped air can be aspirated. Infection: Concentrated glucose is medium for bacteria - Observe for local or systemic infec - CHange steril dressing on central line Q 48-72 H - Change IV tubing Q 24 H Fluid Imbalance: Hyperosmotic solution poses rissk for fluid shifts & fluid vol excess - Older adults more vulnerable to imbalance - Assess for crackles & resp distress - Monitor daily weight & I&O - Use controlled infusion pump to admin TPN at prescribed rate - Do not speed up infusion to catch up - Gradually increase flow rate until prescribed rate acheived

Esophageal Varices Meds

Nonselective Beta-Blockers: - Decrease HR & reduce hepatic venous pressure - Prophylactic Vasoconstrictors: - Decreases bleeding from varices but does not effect BP - Constriction of esoph & proximal gastric veins & reduces portal pressure

Expected output for ileostomy

Normal postop output: - > 1,000 mL/day - Can be bile-colored & liquid Postop changes in output: - After several days to wks, output decreases approx 500-1,000 mL/day. - Becomes more paste-like as small intestine assumes absorptive function of large intestine Pattern of output: - Continuous

Expected output for Transverse Colostomy

Normal postop output: - Small semi-liqudi with somemucus 2-3 days after surgery - Blood can be present in first few days after surgery Postop changes in output: - After several days to wks, output becomes more stool-like, semi-formed, or formed Pattern of output: - Resumes pattern similar to preop pattern

Expected output for Sigmoid Colostomy

Normal postop output: - Small to mod amt of mucus with semi-formed stool 4-5 days after surgery Postop changes in output: - After several days to wks, output resembles semi-formed stool Pattern of output: - Resues pattern similar to preop pattern

Interprofessional care

Nutrition consultant Diet that restricts acid-prod foods: milk prods, caffeine, decaf coffee, spicy, meds (NSAIDs)

Duodenal Ulcer Pain

Occurs 1.5-3 H after a meal Awakening w pain during night Pain relieved by ingestion of food or antacid Well-nourished Melena

Bariatric Surgeries

Only used when other methods failed. Meds to try before surgery: - Orlistat: Prevents fat digestion. - Lorcaserin: Stimulates serotonin receptors in hypothalamus in brain to curb appetite. - Phentermine-topiramate: Suppresses appetite & induces feeling of satiety Bariatric surgeries include gastric restrictive & malabsorption - Restrictive surgeries: Laproscopic adjustable gastric band & Laparoscopic sleeve gastrectomy. These reduce stomach capacity & limit amt of food pt can eat at one time. Weight loss often regained unless pt adheres to protocols & lifestyle mods. - Vertical Banded Gastroplasty: Creation of new smaller stomach pouch using staples to decrease functional size - Malabsorption surgeries: Roux-en-Y gastric bypass (or simply gastric bypass). Interferes w absorption of food & nutrients from GI. Most pts maintain 60-70% weight loss. Pt likely has BMI >40 or BMI >35 with comorbidities

Enteral feeding complications

Overfeeding: Ab distention, N/V - Residual check Q 4-6 H - Slowing or wittholding feedings for excess residual vol (100-200 mL) then restart at lower rate after rest period - Check rate of infusion & for proper pump operation Diarrhea: Secondary to concentration of feeding or its constituents - Slow rate of feed & notify prov - Confer w dietitian - Skin care & protection - Eval for C. diff, esp if prolonged or very fowl odor Aspiration pneumonia: Secondary to aspiration of feeding. Life-threatening. Tube displacement i primary cause of aspiration of feeding. - Prevention: Confirm tube placement before feeding - Prevention: Elevate HOB at least 30 degrees during feed & 1 hr after - Stop the feeding - Turn pt on side & suction airway. Admin O2 if indicated. - Monitor vitals for ^ temp - Auscultate breath sounds for ^ congestion & diminishing breath sounds - Notify prov & obtain chest x-ray is prescribed Refeeding Syndrome: Life-threatening. Occurs when enteral feeding started in pt who is in starvation state & whose body has begun to catabolize protein & fat for energy. - Monitor for new onset of confusion/seizures - Assess for shallow resps - Monitor for ^ musc weakness - Notify prov & obtain blood electrolytes if needed

Endoscopy Complications

Oversedation: Difficult to arouse, poor resp effort, evidence of hypoxemia, tachycardia, high or low BP - Admin antidotes, admin O2, notify provider Hemorrhage: Bleeding, cool & clammy skin, hypotension, tachycardia, dizziness, tachypnea - Assess for hemorrhage from site, monitor vits, monitor diagnostics (Hb, Hct), notify provider Aspiration: Dyspnea, tachypnea, adventitious breath sounds, tachycardia, fever - Keep pt NPO until gag reflex returns. Ensure pt awake/alert prior to consuming fluid/food. Encourage to deep breathe & cough for secretion removal. Notify provider if delay in gag reflex return. Perforation of GI: Chest or ab pain, fever, N/V, ab distention - Monitor diagnostic for evidence of infection (^ WBC), notify hc provider

Gastric Ulcer pain

Pain most commonly occurs 30-60 min after a meal Less often pain at night (30-40% of pts) Pain exacerbated by ingestion of food Malnourishment Hematemesis

Esophageal Varices Risk Factors

Portal htn (elevated BP in veins that carry blood from intestines to liver) - Caused by mpaired circulation of blood through liver. Collateral circulation subsequently develops, creating varices in upper stomach & esophagus. - Primary risk factor for development of esophageal varices Alcohol cirrhosis Viral hepatitis Older adult pts: Frequently have depressed immune func, decreased liver func, & cardiac disorders that make them esp vulnerable to bleeding.

TPN Considerations

Prep: - Determine pt readiness - Daily lab vals (incl electrolytes). Solutions customized. Ongoing care: - Flow rate gradually ^ & gradually decreased to allow body adjustment (no more than 10% hrly increase) - NEVER abruptly stop TPN! Speeding up/slowing down rate is contraindicated. Abrupt rate change can alter BG levels significantly! - Assess vitals Q4-8H & weights daily - Follow sterile procedures to minimize risk of sepsis ( TPN sol is prepared by pharmacy using aseptic technique w laminar flow hood. Change tubing & solution bag Q 24 h even if not empty. Ensure tubing has filter. Do not use line for other IV boluses - prevents contam & interruption of flow rate. Do not add anything to solution - contam & incompatibility risk. Sterile technique & mask when changing central line dressing!) Interventions: - Check cap glucose Q 4-6 H for first 24 h - Pts frequently need supp R insulin until pancreas can ^ prod - Keep dextrose 10% in water at bedside in case solution ruined or next bag not avail. Minimize risk hypoglycemia w abrupt dextrose concentration changes. - If bag unavailable & administered late, do not attempt to catch up by ^ infusion rate because pts can develop hyperglycemia - Older adult pts have ^ incidence glucose intolerance.

Ostomies - Nursing Actions

Preproc: - Referral to wound ostomy care nurse WOCN & collab with WOCN - Pt should perform care & mgmt of ostomy Postproc: - Fit ostomy appliance based on: Type & location of ostomy; Viual acuity & manual dexterity of pt - Stoma should be pink & moist - Apply skin barriers & creams (adhesive paste) to peristomal skin & allow to dry before applying new appliance - Output should be more liquid & acidic the closer the ostomy is proximal to small intestine - Empty ostomy bag when 1/3 - 1/2 full - F&E imbalances esp w new ileostomy - Eval pt ability & support system

Bariatric Surgery Nursing Actions

Preprocedure: - Get bariatric bed & mechanical lifting device - Assess labs: CBC, electrolytes, BUN, creatinine, HbA1C, iron, B12, thiamine, folate - SCD to prevent DVT Postprocedure: - Monitor for leak of anastomosis (^ back, shoulder, ab pain. Restlessness. Tachycardia. Oliguria.) Life threatening. Notify prov ASAP. - Do not reporsition NG tube if pt has, as can disrupt sutures. - Monitor for complications: Atelectasis, thromboemboli, skin fold breakdown, incisional hernia, peritonitis - Airway & O2 sat! Semi fowlers - Bowel sounds & measure abdominal girth - Abdominal binder to prevent dehiscence - Ambulate pt ASAP - Resume fluids as prescribed: Can be 30 mL at a time, up to 120 mL/day first few days with gradual increase - 6 small meals/day when pt can have oral nutrients - Observe for indications of dumping syndrome: Cramps, diarrhea, tachycardia, dizziness, fatigue - Interprof care for LT behavior mod Teach pt: - Adhere to ltd diet of liquids & purees first 6 wks, as well as vol that can be consumed (often no more than 1 cup) - Walk daily at least 30 min - Overating can dilate surgically created pouch causing weight regain - Vit & mineral supplements

Paracentesis Nursing Actions

Preprocedure: - Position pt upright, either on edge of bed with feet supported, or high-Fowler's (pts with ascites are more comfortable sitting up) - Measure abdominal girth - Admin sedation / local anesthetic. Can be pressure or pain with needle insertion. - Admin IV bolus fluids or albumin before or after to restore fluid balance Intraprocedure: - 4-6 L fluid slowly drained from abdomen by gravity. Monitor amt of drainage & notify provider of evidence of complications. Postprocedure: - Pressure on insertion site for several mins & apply dressing - If continues to leak after pressure held for several mins, apply sterile gauze dressings & change as often as needed - Measure abdominal girth - Monitor temp Q 4 H for 48 H. Fever can indicate bowel perforation. - Assess I&O Q 4H - Admin diuretic to control fluid vol (w potassium supp w loop diuretic) - Admin IV bolus fluids or albumin - HOB elevated - Color, odor, consistency, amt of fluid drained, loc of insertion site, evidence of leakage, manifestations of hypovolemia, & change in mental status - Continue to monitor labs Teach pt: - Avoid alcohol, maintian low-sodium diet, monitor puncture site - Report mental/cognitive changes (F&E balance) - Change pos slowly to decrease risk of falls caused by hypovolemia from acscites fluid removed

Hiatal Hernia Meds

Proton Pump Inhibitors: - Reduce gastric acid by inhbiting cellular pump of gastric parietal cells necessary for gastric acid secretion Antacids: - Neutralize excess acid & increase LES pressure

GERD Meds

Proton Pump Inhibitors: Reduce gastric acid by inhibiting cellular pump of gastric parietal cells necessary for gastric acid secretion Antacids: Neutralize excess acid & ^ LES pressure Histamine 2 Receptor Antagonists: Reduce secreation of acid. Onset longer than antacids, but effect longer Prokinetics: ^ motility of esophagus & stomach

Hiatal Hernia

Protrusion of stomach above diaphragm into thoracic cavity through hiatus (opening in diaphragm). Two types: 1) Sliding (more common): Portion of stomach & gastroesophageal junction move above diaphragm. Generally occurs w increases in intra-abdominal pressure or while pt is supine. 2) Paraesophageal (rolling): Part of fundus of stomach moves above diaphragm, although gastroesophageal junction remains below diaphragm.

Esophageal Varices Expected Findings

Pt may experience no manifestations until varices begin to bleed. Hematemesis (vomiting blood), melena (black, tarry stools), and general deterioration of pt's physical & mental status. Activities that precipitate bleeding: - Valsalva maneuver - Lifting heavy objects - Coughing - Sneezing - Alcohol consumption Physical Assessment Findings: - Shock - Hypotension - Tachycardia - Cool, clammy skin

GERD Dx Procedures - Esophageal Manometry

Record LES pressure & peristaltic activity of esophagus. Pt swallows 3 sm tubes & pressure readings & pH levels are tested.

GERD Risk Factors

Risk Factors: Obesity, older age, sleep apnea, nasogastric tube Contributing Factors: - Foods that relax LES: fatty/fried foods, chocolate, caffeinated beverages, peppermint, spicy foods, tomatoes, citrus fruits, alcohol - Prolonged or frequent abdominal distention (overeating, delayed emptying) - ^ abdominal pressure from obesity, pregnancy, bending at the waist, ascites, or tight cothing at the waist. - Meds that relax LES (theophylline, nitrates, CCBs, anticholinergics, diazepam) - ^ gastric pressure caused by meds (NSAIDs) or stress (environmental) - Debilitation resulting in weakened LES tone - Hiatal hernia (LES displacement into thora with delayed esophageal clearance) - Gastritis due to helicobacter pylori can cause reflux - Lying flat

Hiatal Hernia Health Promo & Disease Prev

Same as GERD - Avoid eating immediately before bed - Avoid foods & bevs that decrease LES pressure (fatty/fried, choc, coff, peppermint, spicy, tomatoes, citrus, alcohol) - Exercise reg & maintain healthy weight - Evelate HOB on 6" blocks - Avoid straining or excessive vigorous exercise - Avoid wearing cothing tight around ab

Sigmoidoscopy

Scope shorter than colonoscopy, allowing visualization of anus, rectum, & sigmoid colon to test for colon cancer, investigate for GI bleed, and diagnose or monitor inflammatory bowel disease. Anesthesia: None Positioning: Left side Prep: - Bowel prep, which can incl. laxatives (bisacodyl), cleansing enema, or sodium biphosphate enema. - Clear liquid diet at leat 24h before - NPO after midnight - Pt must avoid meds as indicated by provider Postproc: - Monitor vitals & resp status - Monitor for rectal bleed - Resume normal diet as prescribed - Encourage increased fluid intake - Instruct pt there can be increased flatulence due to air instillation during proc

GERD Dx Procedures - Esophageal pH Monitoring

Small cath through nose into distal esophagus. Or small capsule attached to esophageal wall during endoscopy. pH readings are taken in relation to food, position, & activity for 24-48 h. - MOST ACCURATE method of dx GERD - Esp helpful for pts w atypical manifestations Instruct pt to keep food/bev/manifestations/activity journal during 24h test period

Changing Ostomy Device

Step 1: Empty Step 2: Remove Step 3: Replace disk Step 4: Replace bag

Ostomy Complications

Stoma ischemia/necrosis: - Stoma should be pink & moist - Manifestations of stomal ischemia: Pale pink or bluish purple & dry appearance - If black or purple, indicates serious impairment of blood flow. Immediate attn required. - Obtain vitals, O2 sat, current labs Intestinal Obstruction: - Monitor & record output from stoma - Assess for manifestation of obstruction: Abdominal pain, hypoactive/absent bowel sounds, distention, nausea, vom

GERD Therapeutic Procedures

Strettaprocedure: Radiofrequency energy applied by endoscope. Dereases vagus nerve activity. Causes LES muscle to contract & tighten. Postop pt education: - Clear liquids first 24h then advance to soft diet - No NSAIDs 10 days - Report chest/ab pain, bleeding, difficulty swallowing, dyspnea, nausea, vom ASAP --- Fundoplication: For pts who fail to respond to other trmts. Fundus of stomach wrapped around & behind esophagus through laparoscope to create physical barrier. Nursing: - Complications incl temporary dyspagia (mon for asp), gas bloat syndrome (diff belching or relieve distention), atelectasis/pneumonia (mon resp func) - Monitor bowel sounds ---- Postop Patient Education: - Soft diet 1 wk postproc - Avoid offending foods, avoid large meals, avoid carbonated bev - Remain upright after eating - Avoid eating before bedtime - 4-6 sm meals/day - Avoid clothing tight around abdomen - Lose weight if applic - Elevate HOB 6-8 in w blocks - Avoid lifting heavy objects - Walk daily - Report fever, n/v, severe pain, dysphagia, or persistent bloating to surgeon

GI Series

Studies done w or w/o constrast & help define anatomic or functional abnormalities - Radiographic imaging of esophagus, stomach, entire intestinal tract - Upper GI imaging done by having pt drink radiopaque liquid (barium). For small bowel (sm intestine) follow-through, barium, traced through small intestine to ileocecal junction - Barium enema done by instilling radiopaque liquid into rectum & colon (large bowel) Potential Dx: Gastric ulcers, peristaltic disorders, tumors, varices (swollen veins), intestinal enlargements or constrictions Pt presentation: Ab pain, altered elim habits (const/diarr), GI bleed Preproc: - Med, food, fluid restrictions (clear liquid or low-residue diet, NPO after midnight), & avoiding smoking or chewing gum (^ peristalsis) - Assess pt understanding of bowel prep so image not distorted by feces - Barium enema studies must be scheduled PRIOR to upper GI studies - Assess contraindications to bowel prep (poss bowel perf or obstruction, inflamm disease) Postproc: - monitor elim of contrast & admin lax if presc - Increase fluid intake to promote elim of contrast - OTC med can be needed to prevent constipation from barium - Stools will be white 24-72 h until barium clears. Report ab fullness, pain, or delay to brown stool return Interpretation of findings: Altered bowel shape & size, increased motility, obstruction

Ostomies

Surgical opening from inside of body to outside. Can be located in various areas of body. Can be permanent or temporary. Stoma: Artificial opening created during ostomy surgery Main types of ostomies eprformed in abdominal area: - Ileostomy: Opening into ileum to drain stool. Frequent & lquid because large intestine is bypassed. - Colostomy: Opening into larger intestine to drain stool, with ascending colon producing more liquid stools, transverse colon producing more formed stools, Sigmoid colon producing near-normal stools. Indications: - Ileostomy: When entire colon mustbe removed due to disease (Chron's, Ulcerative Colitis) - Colostomy: When portion of bowel must be removed (cancer, ischemic injury) or requires rest for healing (diverticulitis, trauma)

M2A

Swallow capsule with glass of water for video enteroscopy to visualize entire small bowel over 8 hr period. Capsule not used to view colon. Anesthesia: None Positioning: Normal activity Prep: - Fast (water only) 8-10h. NPO first 2 h testing. Normal eating 4 h after swallowing capsule. - Abdomen marked for loc of sensor. Eight-lead sensors placed & connected to data recorder, which captures images of small intestine Postproc: - After 8 h, client returns recorder for image download - Pt will evacuate cap in stool

Esophageal Varices

Swollen, fragile BVs generally found in submucosa of lower esoph, but can develop higher in esophagus or extend into stomach. Occur as result of portal htn, usually due to cirrhosis of liver. When esophageal varices hemorrhage, often med emergency assoc w high mortality rate. Recurrence of esophageal bleedding is common.

Total bilirubin Direct conjugated bilirubin Indirect unconjugated bilirubin blood test - Range & Interpretation

TB: 0.3-1 mg/dL DB: 0.1-0.3 mg/dL IB: 0.2-90.8 mg/dL Elevations indicated altered liver function, bile duct obstruction, or other hepatobiliary disorder

ECRP

Through mouth into biliary tree via duodenum. Allows visualization of biliary ducts, gall bladder, liver, pancreas. X-rays taken after contrast injected. Anesthesia: Moderate sedation per IV access. Topical anesthetic to depress gag reflex, atropine to decrease secretions. Positioning: Initially semi-prone with repos throughout procedure SAME PREP & POSTPROC AS EGD Prep: - NPO 6-8 hr. Remove dentures. - Explain proc & need to change positions during. Prostproc: - Monitor vitals & resp status. Maintain open airway until pt awake - Notify provider of bleeding, abdominal or chest pain, evidence of infec - Withhold fluids until return of gag reflex - D/c IV fluid therapy when pt tolerates oral fluids without n/v - Instruct pt not to drive or use quip for 12-18 hr after proc - Teach pt to use throat lozenges if sore throat or hoarse voice persists following proc

Endoscopy

Visual examination of a body cavity or canal using a specialized lighted instrument called an endoscope. Provider can perform biopsies, remove abnormal tissue, & perform minor surgery. This makes it diagnostic & therapeutic GI Scope Procedures: - Colonoscopy - Esophago-gastro-duoden-oscopy (EGD) - Endoscopic retrograde cholangiopancreatography (ERCP) - Small bowel capsule endoscopy (M2A) - Sigmoidoscopy Indications: Suspected GI bleed, ulcerations, inflammation, polyps, malignant tumors. Pt Presensation: Anemia, ab discomfort, ab distention or mass If a biopsy was performed, postprocedure food restrictions may be prescribed

Hiatal Hernia Complications

Volvulus: Twisting of esophagus and/or stomach Obstruction (paraesophageal hernia): Blockage of food in herniated portion of stomach Strangulation (paraesophageal hernia): Compression of blood vessels to herniated portion of stomach Iron-deficiency anemia (paraesophageal hernia): Result of bleeding into gastric mucosa due to obstruction

Peptic Ulcer Disease

erosion of mucosal lining of stomach, esophagus, or duodenum. Most often duodenum. Membranes can become eroded to point that epithelium is exposed to gastric acid & pepsin, which can cause bleeding & perf. Perf that extends through all stomach or duodenum layers can cause peritonitis. Person with peptic ulcer has peptic ulcer disease Cause by gram neg H. pylori. Contact through food, water, body fluids (saliva). HP does not always cause ulcers. Stress ulcer occurs from acute period of physiological stressful events (burns, shock, sepsis, mult organ trauma). These are diff from peptic ulcers & can be present in a ventilated pt in the ICU. Bleeding is primary manifestation. - Curling's ulcer is seen in pts w burns - Cushing's ulcer is seen in pts w head/brain trauma Pts w trauma may rec proton pump inhibitor prophylaxis to prevent stress ulcers