Critical Care -- GI Disorders
TIPS procedure
A channel between the systemic and portal venous systems is created to redirect portal blood this reducing portal hypertension and decompressing the varices to control bleeding
B, C, E, F Calcium and potassium decrease with acute pancreatitis.
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 triglycerides
B -- Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.
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."
Whipple procedure
Standard operation for pancreatic cancer
Pain management LR for initial fluid resuscitation No NG tube!!!!!!! No prophylactic antibiotics!!!
What is the treatment for acute pancreatitis?
- jaundice - portal HTN - hepatocellular failure' - thrombocytopenia
What are the clinical manifestations of cirrhosis?
Lipase
What lab is specific for acute pancreatitis?
C -- 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.
A Salem sump NG tube has 2 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 the tube from adhering to the gastric wall d. prevents the tube from advancing
A, B, E, F Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, Grey-Turner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent.
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. N/V c. diaphoresis d. hyperactive bowel sounds e. fever f. jaundice
D -- The results of physical assessment of a patient with pancreatitis usually reveal hypoactive bowel sounds and abdominal tenderness, guarding, distention, and tympany. Findings that may indicate pancreatic hemorrhage include Grey Turner sign (gray-blue discoloration of the flanks) and Cullen sign (discoloration of the umbilical region); however, they are rare and usually seen several days into the illness.
A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds, abdominal guarding, and a discoloration around the umbilicus. The nurse suspects the patient may have which condition? a. PUD b. esophageal varices c. acute liver failure d. acute pancreatitis
A -- Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids. Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood from areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach.
A patient is admitted with a GI hemorrhage due to esophageal varices. The nurse knows that varices are caused by which pathophysiologic mechanism? a. portal HTN resulting in diversion of blood from a high-pressure area to a low-pressure area b. superficial mucosal erosions as a result of increased stress levels c. loss of protective mechanisms resulting in the breakdown of mucosa d. inflammation and ulceration secondary to NSAID use
B -- In acute variceal hemorrhage, control of bleeding can be accomplished through the use of pharmacologic agents. Intravenous vasopressin, somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed.
A patient is admitted with a GI hemorrhage due to esophageal varices. What medication would the nurse expect the PCP to order for this patient? a. H2 antagonist b. vasopressin c. heparin d. antacids
C -- A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension, acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident. These side effects can be offset with concurrent administration of nitroglycerin. Other complications include bradycardia and fluid retention.
A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. The nurse would monitor the patient for which side effect of the medication? a. constipation b. diarrrhea c. chest pain d. bleeding
D -- The initial clinical presentation of the patient with acute GI hemorrhage is that of a patient in hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee ground emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.
A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for GI hemorrhage due to stress-related mucosal disease. The nurse should 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
C -- Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure.
A patient was admitted after a Roux-en-Y gastric bypass. A nursing student asks the nurse what type of surgery this is. What would be an appropriate response? a. "It is an esophagectomy performed using a 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 -- In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.
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 released of insulin b. Loss of storage capacity for senescent RBCs c. premature activation of inactive digestive enzymes, resulting in autodigestion d. release of glycogen into the serum, resulting in hyperglycemia
B -- As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program.
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
A -- 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.
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 NG tube is placed d. place the patient on a fluid restriction to avoid the fluid sequestration
B -- 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. However, the patient's pain needs to be addressed first.
A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1-10 pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the plan of care? 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
pancreatitis
Cullen's sign is an indication of ...
B -- Sucralfate should not be crushed but may be dissolved in 10 mL of water to form a slurry. It is also available as a suspension.
How would the nurse administer sucralfate through a gastric tube? a. crushed and mixed with 10 mL of water b. dissolved in 10 mL of water to form a slurry c. mixed in 15 mL of water to form a solution d. administered as a whole pill with a 35 mL water flush
B
The nurse has been caring for a patient with liver dysfunction. The PCP has just performed a liver biopsy at the bedside. Following a liver biopsy, how would the nurse position the patient? a. left side for 2 hours b. right side for 2 hours c. left side for 6-8 hours d. right side for 6-8 hours
B
The nurse is caring for a patient after an esoophagectomy. The nurse knows that 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 bowel sounds
B -- It is imperative to appropriately manage the patient's pain after gastrointestinal (GI) surgery. Adequate analgesia is necessary to promote the mobility of the patient and decrease pulmonary complications. Initial pain management may be accomplished by intravenous opioid (morphine, hydromorphone) administration by means of a patient-controlled analgesia (PCA) pump or through continuous epidural infusion of an opioid and local anesthetic (bupivacaine).
The nurse is caring for a patient after an esophagectomy. In the immediate post-operative period, which intervention would have the highest priority? a. preventing atelectasis b. managing pain c. promoting ambulation d. preventing infection
C -- 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. The result is the creation of an acidic environment that results in ammonia being drawn out of the portal circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding. Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with acute liver failure because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.
The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the PCP to order? a. insulin b. vitamin K c. lactulose d. lorazepam
C -- The patient should be evaluated for the presence of asterixis, or "liver flap," best described as the inability to voluntarily sustain a fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists.
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 BP 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
Pruritis due to excess bile salts, jaundice, hypoglycemia, metabolic acidosis, portal HTN leading to ascites, hepatic encephalopathy (increased ammonia levels), palmar erythema, spider nevi, asterixis
What are signs and symptoms of liver failure?
jaundice hepatocellular dysfunction
What are the LATE signs of liver failure?
Gallstone migration, alcoholism, toxins, meds, infection, ischemia
What are the causes of acute pancreatitis?
1. Viral hepatitis (B, C, D) 2. Med induced (tyenol) 3. Metabolic disorders 4. Hypoperfusion 5. IV drug use 6. Toxins
What are the causes of cirrhosis leading to acute liver failure?
Dylan can invite izzy and her ass. Diverticulitis Cancers or polyps IBD, Crohn's, UC Infectious diarrhea Angiodysplasia Hemorrhoids Anal fissure
What are the most common causes of lower GI bleeds?
Severe abdominal pain, N/V, elevated amylase and lipase, hyperglycemia, decrease in all electrolytes, grey turner, Cullen
What are the signs and symptoms of acute pancreatitis?
Liver disease, malnutrition, IBD, celiac disease
What does decreased albumin and/or protein indicate?
Liver damage
What does elevated ALKP indicate?
Hepatitis, cirrhosis
What does elevated AST and ALT indicate?
Elevations without anticoagulant use indicates liver damage
What does elevated PT, PTT, and INR indicate?
Tissue damage
What does lactate dehydrogenase LDH elevations indicate?
- acute erosive gastritis - increased acid production, decreased mucosal blood flow results in ischemia and degeneration of mucosal lining
What is SRMD?
Inflammation of the pancreas the causes endocrine and exocrine dysfunction Inactive enzymes become prematurely activated leading to auto digestion of the pancreas
What is acute pancreatitis?
Amylase and lipase
What is elevated in acute pancreatitis?
- engorged and distended blood vessels of esophagus and proximal stomach as a result of portal HTN caused by hepatic cirrhosis - blood shunted to areas of lower pressure, such as the esophagus - can result to rupture or hemorrhage
What is esophageal varies?
diverts portal blood away from the liver in order to decrease portal hypertension
What is the TIPS procedure?
Low to no protein diet
What is the diet for liver failure?
Lactulose given orally or through retention enema
What is the gold Standard for treating acute liver failure?
H-pylori and NSAIDs
What is the most common causes of PUD?
Position patient on right side Strict bed rest for 6-8 hours
What is the nursing care after a percutaneous liver biopsy?
Whipple procedure
What is the surgical resection of pancreatic cancer called?
Vagotomy - reduces acid production Pyloroplasty - produces gastric emptying
What is the treatment for PUD and SRMD?
TIPS procedure
What is the treatment for esophageal varices?
- Bilirubin - PT - PTT - INR - Ammonia - Lactic Acid
What labs are increased in liver disease?
1. PPIs (prazoles) 2. H2 blockers (tidine) 3. Sucralfate 4. Octreotide 5. Vasopressin 6. Somastatin
What meds are used for acute GI hemorrhage?
A, B, C, D, E Diabetes is not a primary cause of acute liver failure but is associated with pancreatitis.
Which disorders or conditions are potential causes of acute liver failure? Select all that apply. a. ischemia b. Hepatitis A, B, C, D, E, non-A, non-B, non-C c. Acetaminophen toxicity d. Wilson Disease e. Reye Syndrome f. Diabetes
B -- Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of comorbid conditions (eg, coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding.
Which nursing intervention is a priority for a patient with GI hemorrhage? a. positioning the patient in a high-fowler position b. ensuring the patient has a patent airway c. irrigating the NG tube with iced saline d. maintaining venous access so that fluids and blood can be administered
- perforation - hemorrhage - vasovagal stimulation with bradycardia - aspiration (due to sedation effects) - over-sedation
What are the complications of an endoscopy?
1.) PUD (40%) 2.) SRMD 3.) esophageal varices 4.) cancers
What are the most common causes of an upper GI bleed?
A -- Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastro mucosal lining, is the leading cause of upper gastrointestinal (GI) hemorrhage, accounting for approximately 21% of cases.
A patient is admitted with an upper GI bleed. Which disorder is the leading cause of upper GI hemorrhage? a. peptic ulcers b. stress ulcers c. nonspecific erosive gastritis d. esophageal varices
C -- Side effects of histamine antagonists include central nervous system (CNS) toxicity (confusion or delirium) and thrombocytopenia.
An older patient reports taking cimetidine for several years. The nurse knows that this medication can cause CNS side effects. For what side effect would the nurse monitor the patient? a. tremors b. dizziness c. confusion d. hallucinations
6-12 hrs
Any procedure of upper GI —> must be NPO for how long before?
Chronic alcohol use disorder, chronic viral hepatitis (B, C, D), liver damage caused by meds or toxins, chronic bile duct obstruction
What are risk factors for cirrhosis?
