Medsurg Quiz 10

Nausea & Vomiting

• Nausea is defined as discomfort with the need to vomit.
• Emetic events include forceful ejection of partially digested food and secretions.
• Nausea and vomiting can occur for reasons such as medications, pregnancy, or viral infections.
• Clinical manifestations of these associated conditions include anorexia, weight loss, dehydration, electrolyte imbalance, circulatory failure, and metabolic alkalosis.
• Interprofessional care for nausea and vomiting addresses the underlying cause, type, timing, precipitating factors, and contents.
• Regurgitation is characterized as partially digested and effortless.
• Projectile vomiting involves forceful expulsion without nausea
• The colour of emesis can show presence/source of bleeding, fecal order & bile, and food presence.
• Hematemesis is the vomiting of blood which is bright red.
• “Coffee ground” emesis indicates the interaction of blood with HCL acid.
• Bright red blood in emesis indicates active bleeding above the stomach.

Treatment of Nausea & Vomiting

• Drug therapy includes drugs such as chlorpromazine (Thorazine), prochlorperazine (Compazine), and promethazine (Phenergan.)
• Chlorpromazine acts on the Chemoreceptor Trigger Zone.
• Anticholinergic effects are contraindicated in some conditions like glaucoma and BPH.
• Metoclopramide (Reglan) increases gastric emptying.
• CNS side effects include extrapyramidal side effects.
• Ondansetron (Zofran) blocks serotonin and is used for post-operative nausea.
• Additional interventions include scopolamine, antihistamines, decadron, cannabinoid, and marinol
• Nursing care includes NPO, IV fluid replacements with electrolytes & glucose, and NG tube & suction to decompress the stomach.
• Assess for dehydration and aspiration precautions, monitor intake and output of vitals
• Diet as clear liquids (5-15 ml Q 15-20 mins.)
• Sipping small amounts of water, room temperature, and no carbonation is recommended
• Coffee, spicy and highly acidic foods, and food with strong odours should be avoided
• Diet: advance as tolerated (dry toast, crackers, high carb-low fat next), eat slowly & small amounts
• Causes, treatment & management Acupuncture, relaxation therapy, ginger & peppermint oil patient education.

Enteral Nutrition (Tube Feeding)

• Enteral nutrition involves administering nutritionally balanced liquefied food or formula through a tube.
• Tubes are inserted into the stomach, duodenum, or jejunum.
• Nasogastric tubes are for short-term use, while gastrostomy is for longer-term use.
• Enteral nutrition provides nutrients alone or as a supplement to oral intake.
• There is a variety of formula.
• Special formulas exist for diabetes, liver, kidney, & lung diseases, with concentrations from 1 - 2 cal/mL.
• Osmolarity, the amount of protein, sodium, & fat can vary within the formula.
• Delivery options include continuous infusion or intermittent (bolus) by pump, bolus by gravity, or syringe.
• Type depends on the anticipated length of time EN is needed, patient's clinical status, and adequacy of digestion & absorption
• Nursing considerations for EN include daily weights, assessing bowel sounds before feedings, and accurate intake and output.
• Initial glucose checks, labeling the bag with the date and time started and changing pump tubing are also considerations.

Safety with Enteral Feedings

• Elevate the head of the bed 30 to 45 degrees.
• Elevate the head of the bed for 30 to 60 mins after intermittent delivery.
• Check placement before each feed/drug administration.
• For continuous feeds, check placement every 8 hours.
• Aspirate stomach contents, pH, and x-ray for placement, x-ray is the most accurate (EBP).
• Check for residual regularly every 4 hrs during the first 48 hrs.
• Patency should be flushed with 30mL of water every 4 hrs for continuous feed, before & after each bolus feed, and after drug administration and after residual checks
• Meds can be given per tube, to avoid tubes plugging, try to use all liquids
• Perform site care and ensure you know how to care for skin around the site to avoid misconnections and prevent death.

Hiatal Hernia

• Type I: Sliding (most common), the upper stomach & GE are displaced upward into the thorax.
• Type II: Paraesophageal or Rolling, the GE junction stays below the diaphragm

Gastroesophageal Reflux Disease (GERD)

• Gastroesophageal Reflux Disease (GERD) is the backward flow of GI contents into the esophagus, causing irritation of the lining by stomach acid.
• Causes include a relaxed lower esophageal sphincter (LES) which decreases LES pressure, hiatal hernia, delayed gastric emptying, and increased intra-abdominal pressure.
• GERD is associated with obesity, pregnancy, smoking, excessive intake of caffeine or chocolate, alcohol, and GI irritants.
• Clinical manifestations include heartburn (pyrosis), which is described as a burning, tight sensation in the lower sternum spreading to the throat or jaw.
• Patients also have dyspepsia, sore throat, hoarseness, lump in throat, hypersalivation, and chest pain after eating.
• In severe cases, pain may radiate to the neck, back, or jaw and mimic a cardiac episode, wheezing, coughing, dyspnea, choking, and nocturnal discomfort & coughing with loss of sleep.
• Complications can include esophagitis, ulcerations leading to scar tissue, stricture, and dysphagia.
• Barrett’s esophagus (BE) is metaplasia of cells that increases the risk for cancer.
• Respiratory complications include cough, bronchospasm, laryngospasm, and cricopharyngeal spasm.
• Aspiration into the respiratory system can lead to asthma, chronic bronchitis, and pneumonia.
• Diagnostic measures include determining the response to behavioral & drug therapies, history & physical exam.
• Other diagnostic tests include upper GI endoscopy with biopsy & cytologic analysis, esophagram (barium swallow), motility (manometry) studies, pH monitoring, and radionuclide studies.
• Radiography, abdominal flat plate, simple X-ray is also used for diagnosis.
• Upper GI- barium swallow, requires prep to identify tumors, gas patterns, tumors, fluid collection.
• Lower GI- barium enema, requires prep to identify the esophagus, stomach, duodenum, jejunum, sigmoid colour, and rectum.
• A CT scan (with/without contract) can detect masses, inflammation and abscesses
• Endoscopy should go first to allow for direct visualization of GI mucosa via esophagoscopy, gastroscopy, and esophagogastroduodenoscopy (EGD).
• Gastroscopy –Esophagogastroduodenoscopy- EGD –Proctoscopy.
• Sigmoidoscopy & Colonoscopy are other diagnosis methods that can be utilized.
• ERCP- Endoscopic Retrograde CholangioPancreatography is useful for GI bleed, esophageal injury, inflammatory bowel, gall bladder disease
• Keep patient NPO, administer sedation via IV, and use throat spray anesthesia

Upper Endoscopy Procedure

• Before the procedure, have the patient sign consent, ensure they are NPO after midnight, and assess for loose teeth/dentures.
• During the procedure, place the patient in the left lateral Sims position to prevent aspiration and numb the back of the throat.
• A flexible fiber optic scope is inserted through the mouth, and photos and biopsies are taken.
• After the procedure, check gag reflex before giving oral intake, the gag sensation must return, and throat discomfort is rare.
• Interprofessional care includes lifestyle modifications, patient and caregiver education, low-fat small meals, and avoiding alcohol, caffeine, smoking, carbonated beverages, beer, citrus juice, chocolate, peppermint, and fatty foods.
• Maintain an upright position 2-3 hrs after meals, avoid tight clothing or bending over after eating.
• Avoid eating 3 hrs before bed, elevate HOB 30 degrees, take fluids between meals, chew gum & oral lozenges, lose weight and manage stress.

Medications for GERD

• Antacids like Maalox and Mylanta provide relief in 10-30 minutes by neutralizing gastric acid and soothing the mucosal lining.
• Take 1 hr before meals or 2-3 hrs after meals
• H2 receptor blockers such as famotidine (Pepcid) and ranitidine (Zantac) are taken 1 hr before or after antacids BID, and taper to PRN.
• Proton Pump Inhibitors are the most effective, including omeprazole (Prilosec) and pantoprazole (Protonix), taken 30 minutes before meals
• Proton Pump Inhibitors control acid section, and are antiemetic and cholinergic
• bethanechol (Urecholine) increases LES pressure and gastric emptying for 30-60 minutes before meals
• Antireflux surgical therapy includes Nissen & Toupet fundoplications, which uses a laparoscopic LINX reflux management system

Gastritis

• Inflammation of the gastric mucosa can be caused by drugs (ASA, steroids, NSAID’s), H. pylori, viral or bacterial infections, and smoking, alcohol, or spicy irritating foods.
• Acute gastritis lasts few hours to days with complete healing; chronic gastritis is longer term.
• Symptoms include anorexia, nausea & vomiting, dyspepsia (epigastric pain), feeling of fullness, melena, hematemesis, and hematochezia (bright red blood in stool).
• Interprofessional management of acute gastritis involves identifying and eliminating the cause.
• Supportive care includes rest, NPO, IV fluids, antiemetics, and monitoring for dehydration.
• Severe cases require NGT to monitor for bleeding, lavage, and empty the stomach.
• To assess risk for hemorrhage, monitor VS and heme test vomitus, and have upper GI bleed strategies in place.
• Management of chronic gastritis includes drugs (PPIs or H2 receptor blockers), evaluating & eliminating the cause, antibiotics for H. pylori, cobalamin for pernicious anemia, and lifestyle modifications
• Smoking cessation, 6 small meals/day; nonirritating food and eliminating NSAIDs are other considerations.

GI Bleed

• Assess vomitus & stool for presence of gross or occult blood.
• Assessment & Management of GI Bleed includes assessing for shock
• Signs of shock include tachycardia, weak pulse, hypotension, cool extremities, prolonged cap refill, and apprehension .
• Abdominal exams identify a tense, rigid, or boardlike abdomen that may indicate perforation & peritonitis.
• An indwelling urinary catheter assesses hourly output and hemodynamic monitoring ensures accurate blood pressure assessment by using a central venous pressure line to assess fluid volume status and supplemental oxygen
• Nursing care for GI Bleed includes assessing LOC, VS Q 15-30 min, skin color, cap refill, and abdominal assessment.
• Shock symptoms include low BP, rapid weak pulse, increased thirst, cold clammy skin, and restlessness
• Other interventions include accurate I&O, assessing stools/output for blood, and gradually introducing clear liquids
• Patient teaching: avoidance of GI toxic drugs (NSAIDS, steroids)

Peptic Ulcer Disease (PUD)

• Involves erosion of the GI mucosa.
• 90% are caused by Helicobacter pylori bacteria.
• HELIVAX vaccine (2003).
• ASA & NSAID’s breakdown gastric lining, allowing acids to damage the mucosa.
• Other elements include alcohol, smoking, caffeine & psychologic distress
• Can be acute or chronic and gastric or duodenal
• Patients experience Epigastric discomfort immediately after eating; burning or gaseous pain; food may worsen.
• Perforation is first symptom in some patients
• With duodenal ulcers patients experience burning or cramplike pain in midepigastric or back 2 to 5 hours after a meal, bloating, nausea, vomiting, and early satiety
• May be silent (older adults and NSAIDs)

Diagnostic Studies (PUD)

• Endoscopy is used for direct visualization & to obtain specimens for H. pylori (urease).
• Monitor progress toward healing; noninvasive H. pylori: serology, stool, breath test.
• Other tests: barium contrast, high fasting serum gastrin levels, and secretin stimulation.
• Labs: CBC, liver enzymes, serum amylase, and stool examined for blood.
• Interprofessional care includes rest, medications, avoiding asa, smoking cessation and dietary modification.
• No alcohol and long term follow up.
• Ulcer healing takes many weeks.
• Medications- table 40-3.
• Triple therapy for H Pylori-Clarithromycin (Biaxin) (antibacterial), Amoxicillin (Amoxil) (antibacterial), and Prilosec (proton pump inhibitor).
• H2 receptor blockers, ex. Zantac, Pepcid, etc. can take 24 hours
• Proton Pump Inhibitor (PPI): Prilosec or omeprazole –Antacids (neutralize gastric acid): Mylanta (immediate effect).
• Complications include hemorrhage–most common; duodenal perforation–most lethal
• GI contents spill into peritoneal cavity
• Sudden, severe abdominal pain; radiates to back and shoulders; no relief with food or antacids.
• The abdomen may be rigid/boardlike, bowel sounds absent, N & V, respirations shallow, and pulse increased & weak
• Edema, inflammation, pylorospasm, or scar tissue can cause obstruction distally in the stomach & duodenum
• Nursing Care for GI Ulcers: Nutritional therapy, Avoid foods that cause irritation, caffeine & alcohol
• Manage pain (no ASA, NSAID’s).
• Promote rest & relaxation (lower stress).
• Encourage small frequent meals.
• Teach about causes & prevention and discuss stress reduction. Importance of emergency symptoms of n/v, pain, bloody emesis, or tarry stools.
• Advise patient to discuss with their HCP, to eat between meals, and to take H2 antagonists or antacids.

Gastric Surgery

• Billroth 1: gastroduodenostomy- removal of 2/3 of stomach & anastomosis to duodenum
• Billroth 2: gastrojejunostomy- removal & anastomosis to jejunum.
• Gastrectomy- remove stomach
• Vagotomy- severing of the vagus nerve, decreases gastric acid secretion
• Pyloroplasty- enlargement of pyloric sphincter
• Gastric Surgery Complications include hemorrhage and dumping syndrome
• Dumping syndrome manifests as weakness, sweating, palpitations, dizziness, cramping, borborygmi, & defecation urge that lasts about 1 hour
• Dumping Syndrome is reduced with rest after eating
• Postprandial hypoglycemia is a variant of dumping syndrome Symptoms include sweating, weakness, confusion, palpitations, and tachycardia.
• Patients may experience anxiety (hypoglycemia reaction).
• Bile reflux gastritis occurs after reconstruction or removal or pylorus and causes epigastric distress temporarily relieved with vomiting.
• Administer cholestyramine will bind bile salts
• Nursing Management postoperatively includes maintaining: fluid & electrolyte balance preventing respiratory complications, maintaining comfort, and preventing infection.
• Other interventions include enteral feedings or parenteral nutrition, potassium, Vit. C, D, K & B complex, and addressing pernicious anemia
• Reduced stomach size can lead to reduced meal size

Constipation

• Risk factors include low-fiber diet, immobility, weakness, ignoring the urge, emotions, drugs like opioids and chronic laxative use.
• Clinical manifestations include fewer than 3 bowel movements per week, hard, dry, difficult to pass stool, abdominal distention, bloating, flatulence, rectal pressure, straining, fecal impaction and perforation.
• Interprofessional care involves treating the cause, increasing dietary fiber, increasing fluids and exercise, probiotics, regular defecation time, and not ignoring the urge and considering the patient's position & privacy

Diarrhea

• Diarrhea can be classified as acute, persistent, or chronic.
• Infectious causes- viral- rotavirus (highly contagious), bacterial-E coli, clostridium difficile (C Diff).
• Other causes are noninfectious such as laxatives, food intolerance, malabsorption
• Upper GI: Large-volume, watery stools; cramping, periumbilical pain; nausea & vomiting; low grade or no fever
• Lower GI: Small-volume bloody diarrhea; fever
• Stool may contain leukocytes, blood, or mucus
• Severe diarrhea: Dehydration (life-threatening), electrolyte imbalances, & acid-base imbalances (metabolic acidosis)
• Diagnostic Studies include stool cultures, blood cultures, WBC, and checking for anemia from iron & folate deficiencies
• Interprofessional care includes preventing transmission (hand washing), replacing electrolytes, protecting the skin, and antidiarrheal medication
• Treat anal excoriation and abscesses with a Sitz bath.

Irritable Bowel Syndrome (IBS)

• Psychologic stressors, Gl infections, dietary intolerances, abdominal pain, nausea, flatulence, mucus in stool, and sensation of incomplete evacuation, fatigue, headaches, & sleep disturbance.
• Diagnosis is based on symptoms (Rome IV criteria):
• IBS with constipation, IBS with diarrhea, IBS mixed, IBS unsubtyped
• Treatments involve psychologic support, opioid agonists, antispasmodics, antidepressants, antidiarrheals, laxatives, a FODMAP diet and avoiding alcohol & smoking

Celiac Disease

• Celiac Disease is an autoimmune malabsorption disorder in response to gluten and manifests as Diarrhea, steatorrhea, abdominal pain & distention, flatulence, and weight loss
• Treatment includes refraining from gluten

Acute Abdomen Peritonitis

• Abdominal pain is the most common.
• Universal sign: tenderness over area involved
• Rebound tenderness, muscular rigidity, & spasm is considered peritoneal irritation.
• Other symptoms include abdominal distention, fever, tachycardia, nausea and vomiting, and altered bowel habits
• History Diagnostics include history, CBC, and electrolytes and performing peritoneal aspiration
• ABD x-ray, US, CT scan, and peritoneoscopy
• Preoperative/mild cases or poor surgical risk involves NPO, NG suction, IV fluids, antibiotics, analgesia, and antiemetics.
• Surgery can be performed locate the source, drain purulent fluid, and repair the damaged organ
• Postoperative care includes NPO, IV fluid, NG suction, blood, parenteral nutrition, antibiotics, sedatives, opioids, and antiemetics

Appendicitis

• Initially dull periumbilical pain; anorexia, nausea & vomiting.
• Persistent pain in the RLQ at McBurney’s point.
• Fever, localized tenderness, rigidity, rebound tenderness, and muscle guarding
• Diagnostic Methods: History, WBC, UA, CT scan
• Immediate surgery (appendectomy) to avoid rupture.
• Preoperative Nursing Management: Administer IV fluid & analgesia, Prevent complications and keep NPO and Monitor VS/Antiemetics.
• Postoperative Care involves general postop care (laparotomy) and early ambulation, and diet is advanced as tolerated

Diverticulosis

• Multiple, noninflamed diverticula that are most commonly found in the sigmoid colon.
• Patients are typically asymptomatic
• Some experience abdominal pain, bloating, flatulence, & change in bowel habit and serious: bleeding or diverticulitis.

Diverticulitis

• One or more inflamed diverticula
• Acute pain LLQ, distention, decreased or absent bowel sounds, N & V, and symptoms of infection.
• Complications include erosion of bowel wall & perforation, abscess, peritonitis, & bleeding
• Nursing & Interprofessional Management Prevention: High-fiber diet; lower fat & red meat, and physical activity
• Acute diverticulitis: bowel rest to lower inflammation Clear liquids and analgesia
• Severe symptoms, systemic infection, hospitalization: NPO, NGT, bed rest, IV fluid & antibiotics; advance diet as tolerated
• Reoccurring diverticulitis or complications: Surgical resection with anastomosis or temporary colostomy
• Patient Education: Explain condition & prescribed regimen, encourage a high-fiber diet with soft foods with increased fiber and cooked veggies offer Fluids: at least 2 L/day
• Avoid increased intraabdominal pressure

Intestinal Obstruction

• Diagnosed as either: Small bowel (SBO) or large bowel (LBO), or as Partial, complete, simple or strangulated
• Mechanical obstructions are hernias, strictures, masses volvulus
• Nonmechanical obstructions involve lack of peristalsis (neuro or vascular)
• Patients will manifest abdominal pain, nausea & vomiting, distention, & constipation
• Treatment depends on the cause, emergency surgery (strangulation or perforation) and resection of obstructed segment with anastomosis
• Partial/total colectomy or ileostomy (obstruction or necrosis).
• Colonoscopy- remove polyps, dilate strictures, and perform laser destruction & removal of tumors Supportive measures: NPO, NG, IV fluids & antibiotics, pain management, and oral care

Inflammatory Bowel Disease (IBD)

• Diagnosed as Crohn’s Disease if it involves the GI tract from mouth to anus, or Ulcerative Colitis if it involves only the colon
• It is chronic & recurrent with no known cure Treatment is symptomatic Table 41-5 compare
• Crohn’s Disease involves all layers of the bowel wall and presents as "Skip" lesions, areas of normal tissue between areas of inflammation.
• Cobblestone appearance Strictures- bowel obstruction.
• Leaks- abscess formation in peritoneal cavity Fistulas
• Ulcerative Colitis (UC): Involves mucosa & submucosa Characterized by profuse watery diarrhea with a combination of blood, mucous, & pus.
• Infections cause further inflammation Perforation of the ulcers can lead to peritonitis and increase risk of colon cancer Clinical Manifestations
• Crohn’s disease Diarrhea, cramping Weight loss Abdominal pain Fever Fatigue
• Some rectal bleeding Ulcerative colitis Diarrhea, bloody Mild: fewer than 4 stools/day
• Moderate: up to 10 stools/day Malaise, anemia, and anorexia Severe - 10 to 20 stools/day

Interprofessional Care (Inflammatory Bowel Disease)

• Rest the bowel, control inflammation, treat infection, improve nutrition, and impove quality of life
• Drug theray includes immunosuppressants, (no methotrexate with pregnancy) and biologic therapies (no live vaccines and knowing warning signs and symptoms of infection) and possible surgical therapy
• Ulcerative colitis is curable, while Crohn’s is managed for complications, not curative
• Focus management on nutritional therapy, adequate nutrition, and preventing malnutrition
• Replace fluid & electrolyte losses and prevent weight loss
• Refeeding syndrome- complication that must be monitored and refer to the Complications- table 41-7

Parenteral Nutrition (PN) aka TPN

• Aministration of nutrients directly into the bloodstream
• Used when a patient cannot be fed orally or by tube feeding and are who need long term nutritional support when a GI access is not possible
• PN or TPN solutions are prepared by a pharmacist or trained technician under strict aseptic techniques
• Must be refrigerated until 30 minutes before use.
• Must be labeled with content, time mixed, & date/ time of expiration
• Solutions include Carbohydrates, Fat emulsion, Amino acids, Electrolytes- Na, K, Cl, Minerals- calcium, magnesium, Vitamins, and Trace elements- zinc, copper, manganese
• Nursing Care with TPN involves monitoring vitals Q 4-8 hrs, daily weights, and daily lab work includes: electrolytes, BUN, CBC, and liver enzymes I & O
• Perform Finger stick blood sugars (FSBS): q 4-6 hr.s or as ordered
• Glucose range 140-180 mg/dL.
• Administers a sliding scale of insulin to keep in range Never through peripheral IV Dressing changes sterile tech. & observe for infection.
• Note that IV tubing is changed Q 24hrs.
• Refeeding syndrome- complication that must be monitored Complications
• Refer to table 41-7.