Med Surg Exam #2 Study Guide PDF

Med Surg Exam #2 Study Guide Assessment of GI System § Subjective data - Health history - Medications - Nutritional status o Consider food diary with chronic issues - Overall health perception § Objective data - Lis...

Med Surg Exam #2 Study Guide Assessment of GI System § Subjective data - Health history - Medications - Nutritional status o Consider food diary with chronic issues - Overall health perception § Objective data - Listen to each quad for 5 mins if no sound heard - Abdominal o Inspection o Auscultation o Percussion o Palpation What are the types of diseases and disorders of the lower GI tract? - Constipation - Diarrhea - Diverticulitis - Inflammatory bowel disease (IBS) What is inflammatory bowel disease? - A group of chronic disorders: Crohn’s disease (regional enteritis) and ulcerative colitis that result in inflammation or ulceration (or both) of the bowel Inflammatory bowel disease - Onset typically 15-25 yrs. - Common with Caucasians - Occur at any age - Autoimmune disease o Immune response to intestinal tract o Results in wide-spread inflammation and tissue destruction o Can be influence by genetics and environmental factors - Different pattern for each disease Inflammatory bowel disease (nutritional) - Keep food diary (food that increase symptoms or discomfort) to avoid those foods in the future to help prevent exacerbating the disease - Advised to eat small frequent meals and lie down after eating to prevent dumping syndrome (rapid gastric emptying) - Monitor dehydration and weight loss - During induction therapy, oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet nutritional needs, reduce inflammation, and control pain and diarrhea Inflammatory Bowel Diseases - Corticosteroids are administered for acute inflammation or to control symptoms but do not cure underlying disease processes. - With severe disease, clients often require hospitalization, IV fluids for hydration, and parenteral corticosteroids until symptoms subside. - Often only “cure” will be a proctocolectomy or bowel resection  What medications are used in the treatment of IBS? - combination of 5-aminosalicylates (e.g., sulfasalazine, mesalamine) - glucocorticoids (e.g., dexamethasone, budesonide) - immunosuppressants (e.g., azathioprine, mercaptopurine, infliximab) - immunomodulators (e.g., infliximab, certolizumab) - antibiotics. Aminosalicylates such as sulfasalazine are typically the first pharmacologic agents selected to induce and maintain remission of mild to moderate IBD Sulfa-free aminosalicylates (e.g., mesalamine, olsalazine, balsalazide) are indicated for patients with sulfa allergies; these drugs tend to be better tolerated by most patients, including those without sulfa allergies, and are effective in preventing and treating recurrence of inflammation Aminosalicylates tend to be more effective agents in treating ulcerative colitis than Crohn’s disease, although they are indicated as first-line agents for both types of IBDs Some select patients with perianal fistulas or inflammatory abdominal masses that occur from flare-ups of Crohn’s disease may be prescribed antibiotics as first line agents, rather than aminosalicylates - The most commonly prescribed antibiotics include a combination therapy of both metronidazole and ciprofloxacin, taken orally (drugs are not prescribed long-term) - These antibiotics are associated with adverse effects that include nausea and diarrhea, and increased risk of Clostridium difficile infection What surgery recommended for IBS? - Proctocolectomy (i.e., surgical excision of the colon and rectum) - with ileostomy (i.e., a surgical opening into the ileum by means of a stoma to allow drainage of bowel contents) Management of the Patient with Inflammatory Bowel Disease obtains a health history to identify the onset, duration, and characteristics of abdominal pain the presence of diarrhea, fecal urgency, or tenesmus; nausea, anorexia, or weight loss; and family history of IBD It is important to discuss dietary patterns and smoking habits discuss dietary patterns and smoking habits Assessment The nurse asks about patterns of bowel elimination, including character, frequency, and presence of blood, pus, fat, or mucus Allergies and food intolerance, especially milk (lactose) intolerance, must be noted The patient may identify sleep disturbances if diarrhea or pain occurs at night Based on the assessment data, nursing diagnoses may include the following: Nx diagnosis Diarrhea associated with the inflammatory process  Acute pain associated with increased peristalsis and GI inflammation Diagnosis Hypovolemia associated with anorexia, nausea, and diarrhea Impaired nutritional status associated with dietary restrictions, nausea, and malabsorption Activity intolerance associated with generalized weakness Anxiety associated with impending surgery Difficulty coping associated with repeated episodes of diarrhea Risk for impaired skin integrity associated with malnutrition and diarrhea Lack of knowledge concerning the process and management of the disease COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Electrolyte imbalance Cardiac arrhythmias related to electrolyte imbalances GI bleeding with fluid volume loss Perforation of the bowel Planning And Goal The major goals for the patient include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid volume deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, increased knowledge about the disease process and self-health management, and avoidance of complications. Maintaining normal elimination pattern - It is important to administer antidiarrheal medications as prescribed - Loperamide may be prescribed 30 minutes before meals - The nurse should record the frequency and consistency of stools after therapy is initiated Intervention Relieving pain - The character of the pain is described as dull, burning, or crampy (It is important to ask about its onset) - Does it occur before or after meals, during the night, or before elimination? Is the  pattern constant or intermittent? Is it relieved with medications? - nurse administers analgesic agents as prescribed for pain. Position changes, local application of heat (as prescribed), diversional activities, and prevention of fatigue also are helpful for reducing pain. Maintaining fluid intake - To detect fluid volume deficit, the nurse keeps an accurate record of intake and output - It is important to encourage oral intake of fluids and to monitor the flow rate of any IV fluids. The nurse initiates measure to decrease diarrhea (e.g., dietary restrictions, stress reduction, antidiarrheal agents). MAINTAINING OPTIMAL NUTRITION - The nurse assesses the patient’s nutrition, including usual dietary habits, changes in appetite and body mass index (BMI) and trends in weight loss or gain - Laboratory studies to detect vitamin and mineral deficiencies may help identify the need for supplementation, especially vitamin D and B12 - During the induction therapy, if oral foods are tolerated, small, frequent, low-residue feedings are given to avoid over distending the stomach and stimulating peristalsis Promote rest - The nurse recommends intermittent rest periods during the day and schedules or restricts activities to conserve energy and reduce the metabolic rate What are patients with IBD are at risk for? - Becoming malnourished - Increased morbidity What is the first pharmacologic agent to induce and maintain remission of mild to moderate IBD? - aminosalicylates What is the key to effective treatment of Crohn’s and Ulcerative colitis? - Aimed at decreasing inflammation and implementation and maintenance of remission Crohn’s disease: Chronic inflammation involving all layers of the bowel wall Occurring anywhere in the GI tract “skip” lesions- areas of disease alternating with healthy GI tract - Ulcerations are deep, have a cobblestone appearance - Strictures at areas of inflammation may cause bowel obstruction - Because inflammation goes through the entire wall, microscopic leaks can allow bowel contents to enter the peritoneal cavity  o Peritonitis or abscesses possible (can be life-threatening) Ulcerative Colitis: Ulcerative colitis is a chronic inflammatory bowel disease (IBD) in which abnormal reactions of the immune system cause inflammation and ulcers on the inner lining of your large intestine. - Disease of the mucosal layer of the colon and rectum o Typically starts in the rectum and moves inward - Left lower abdominal pain and bloody diarrhea would indicate ulcerative colitis - Damage to mucosa, breakdown of cells, possible formation of pseudopolyps Signs and symptoms of Crohn’s disease -VS- Ulcerative colitis Crohn’s Disease Ulcerative Colitis Diarrhea (unrelieved by defecation) diarrhea with marked fluid loss, stool Crampy abdominal pain with passage of mucus, pus, or blood especially after meals d/t intestinal left lower quadrant abdominal pain peristalsis intermittent tenesmusm (unable to Weight loss relieve the urge to stool - causes you to Malnourishment (think- small intestine) strain) = constipation Fatigue anemia Secondary anemia pallor Some people may be symptom free most fatigue of their lives, while others can have anorexia severe chronic symptoms that never go weight loss away fever Steatorrhea (EXCESSIVE FAT IN THE vomiting FECES) dehydration Anorexia hypoalbuminemia Malnutrition electrolyte imbalance Ocular disorders (uveitis) skin lesions Oral ulcers eye lesion (uveitis) Skin lesions (erythema nodosum arthritis Prominent RLQ abdominal pain unrelieved liver disease by defecation Crohn’s Disease diagnosis and treatment - MRI - CT Scan (bowel wall thickening & mesenteric edema, obstructions, abscesses, or fistula) - CBC- H&H and WBC - Erythrocyte sedimentation rate (ERS): elevated - Treatment o Cannot be cured o Medications such as steroids and immunosuppressants are used to slow the progression of disease. o If meds aren't effective, a patient may require surgery Why does the CT scan indicate for Chron’s disease? - Bowel wall thickening and mesenteric edema, obstructions, abscesses, fistulas  What does MRI indicate for Crohn’s disease? - Highly sensitive and specific in terms of identifying pelvic and perianal abscesses and fistulas Why is CBC performed in patients who may have Crohn’s disease? - Low hematocrit and hemoglobin - Elevated WBC - Erythrocyte sedimentation rate (ESR) is elevated - Decrease in albumin and protein level What are complications that can arise with Crohn’s disease? - Intestinal obstruction or stricture formation - Perianal disease - Fluid and electrolyte imbalance - Malnutrition for malabsorption - Fistula and abscess formation What is the most common type of small bowel fistula caused by Crohn’s disease? - Enterocutaneous fistula (abnormal opening between the small bowel and the skin) What is a risk of Crohn’s disease? - Colon disease Ulcerative Colitis diagnosis and treatment - Colonoscopy is the definitive screening test that can distinguish ulcerative colitis from other diseases of the colon with similar symptoms. It may reveal friable, inflamed mucosa with exudate and ulcerations - Ulcerative colitis lab test shows what? o Elevated WBC count o Low albumin levels o C-reactive protein levels elevated o Elevated antineutrophil cytoplasmic antibody levels - What us an abdominal x-ray show for ulcerative colitis determine? Free air in the peritoneum and bowel dilation or obstruction - What is used to identify abscesses and perirectal involvement in ulcerative colitis? o CT scan o MRI o Ultrasound studies - Why are biopsies important in ulcerative colitis? To determine histologic characteristics of the colonic tissue and extent of disease - Proctocolectomy-the removal of the rectum and colon cures the disease What are the complications that arise from ulcerative colitis? - Toxic megacolon - Perforation - Bleeding - Fever - Abdominal pain and distention What type of nutritional therapy is induced for patients with Crohn’s disease and ulcerative colitis? - Low residue (fiber) - High protein - High calorie  - Supplemental vitamin therapy and iron replacement What type of surgery is common with patients who have ulcerative colitis or Crohn’s disease? - Laparoscope-guided strictureplasty - Small bowel resection - Proctocolectomy w/ileostomy - Ileostomy - Restorative proctocolectomy w/ IPAA - Continent iileostomy What is GERD? - disorder marked by backflow of gastric or duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus What are some causes GERD? - Any agent that decreases LES pressure - Food & alcohol - Cigarettes - Anticholinergics (atropine, belladonna, propantheline) - Other drugs (morphine, diazepam, and meperidine) - Hiatal hernia (especially in children) Symptoms of GERD - Heartburn o Most common clinical manifestation o Burning, tight sensation felt beneath the lower sternum and spreading upward to throat or jaw o Felt intermittently - Dyspepsia o Pain or discomfort centered in upper abdomen - Regurgitation o Described as hot, bitter, or sour liquid coming into throat or mouth o Hypersalivation may also be reported - dysphagia or odynophagia, - hypersalivation - esophagitis - GERD can result in dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications GERD Nursing Management - Elevation of head of bed at least 30 degrees o Elevate top of mattress 4-8” with blocks or books to elevate head fosters esophageal emptying thereby reducing reflux - Not lying down for 2–3 hours after eating - Avoidance of late-night eating - Eating small, frequent feedings (6 to 8 per day) - The client is instructed to eat a low fat diet; avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, and carbonated beverages. Milk increases gastric acid secretion. GERD Potential Complications -Barrett’s esophagus (esophageal metaplasia)  o BE is a condition in which the lining of the esophageal mucosa is altered o Replacement of normal squamous epithelium with columnar epithelium o Precancerous lesion o Thought to be primarily due to GERD (other causes: smoking, obesity) o Similar symptoms of GERD- frequent pyrosis (aka heartburn) o Signs and symptoms: none to perforation § Perforation can be evidenced by increased temperature o Dx: EGD & biopsy for pathology to check for alterations in epithelial lining o Tx: depends on extent of epithelial damage- possible ablation, surveillance, use of PPI, endoscopic resection o Must be monitored every 2–3 years by endoscopy GERD medication management - Proton pump inhibitors (PPIs) o “-prazole” § Esomeprazole § Lansoprazole § Omeprazole § Pantoprazole § Rabeprazole o Proton pump is activated by food intake o Block the enzyme responsible for secreting Hcl acid in the stomach. o Drugs of choice for short-term therapy of PUD and GERD. o Take 20 to 30 mins before first meal of day. - Histamine-2 receptor (H2R) antagonists o “-tidine” § (Tagamet) cimetidine § (Zantac) ranitidine § (Axid) nizatidine § (Pepcid) famoti o Histamine 2 increases acid secretion in the stomach. H2 antagonists suppress the volume & acidity of parietal cell secretions o Antacids should NOT be taken at the same time because absorption of H2 receptor blockers will be diminished o Once a day dose of H2 RAs should be taken at bedtime - Antacids o Maalox (magnesium hydroxide/aluminum hydrate) § Watch Mg++, especially with patient that have cardiac or renal issues; § S/E- constipation § TUMS (Calcium carbonate) § Sodium bicarbonate o Neutralize stomach acid by raising pH of stomach contents. Does NOT reduce volume. o Acts within10-15 minutes, duration of action is only 2 hours. o Milk-alkali syndrome- Administering calcium carbonate antacids with milk or any items with vitamin D can cause. Early symptoms are like hypercalcemia (H/A, urinary frequency, anorexia, nausea, & fatigue.) o Antacids should be taken one and 3 hours after meals What do histamine 2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) do?  - Decrease gastric acid secretion, sucralfate provides a barrier between mucosal erosions or ulcers and gastric secretions, and misoprostol restores prostaglandin activity Obesity - Who: an abnormal or excessive fat accumulation that impair health - Classification: Overweight or pre-obese have a BMI of 25 to 29.9 kg/m2 - Cause: o Greater access to food w/ poor nutritional quality o Lack of physical exercise o low socioeconomic status - Obesity nursing actions and implementations- surgeries, medications Education for obesity meds? o Bariatric Surgery: Viable and popular option for treating obesity § Currently the only treatment found to have a successful and lasting impact on sustained weight loss for severely obese individuals § Criteria for surgery Ø BMI ≥40 kg/m2 Ø BMI ≥35 kg/m2 with one or more obesity-related complicationsHypertension, type 2 diabetes, heart failure, sleep apnea § Patient Education v Very specific diet- most common reason patients have complications & are not successful long term Ø Small, frequent meals (≤ 1 Cup per meal) Ø Low carb and glucose Ø Nutrient dense foods (protein & fiber) Ø Drinking should be 30min prior or 30-60min after eating Ø Avoid ETOH and carbonation v Benzphetamine (Didrex) Ø Noradrenergic sympathomimetic anorexiants Ø Stimulate the release of norepinephrine and dopamine in the brain Ø Affects the nerve terminals of the hypothalamic feeding center Ø Suppresses appetite v Lorcaserin  Ø Selective serotonergic 5-HT2C receptor agonist Ø Causes appetite suppression Ø Liraglutide (semaglutide) Ø GLP-1 receptor agonist Ø Mimics the effects of incretins, resulting in delayed gastric emptying, thus curbing appetite. v Orlistat (lipase inhibitor) Ø Diminishes intestinal absorption and metabolism of fats Ø Reduces absorption of fat-soluble vitamins Ø Clients taking orlistat should take a multivitamin containing fat-soluble vitamins (A, D, E, and K) daily Ø Orlistat prevents absorption of fat-soluble vitamins from food or multivitamin preparations if taken at the same time – take at least 2 hours before or after taking orlistat. Constipation: Defined as less than 3 bowel movements per weekly or bowel movements that hard, dry, small, or difficulty to pass - Complications: § Anal fissure due to hard stool (require stool softener like docusate) § Hemorrhoids caused by straining § Steatorrhea: fatty, oil stool § Tenesmus: an ineffective and sometimes painful straining and urge to eliminate § megacolon - Which population of people does constipation occur in more likely? § Women § Pregnant women § Recent surgical pt § Older adults § Non-Caucasians § Those of lower socioeconomic status - Constipation is a symptom and not a disease, however, constipation can indicate an underlying disease or motility disorder of the GI tract (True) - Treatment of constipation: § High fiber/residue diet § Establishing healthy bowel habits § Avoiding holding in stool when urge is present § May consider bulk-forming OTC’s § Consider why your patient in constipated (opioids, dietary issues, anatomy concerns, dehydration?) § Laxatives: *Docusate is a fecal softener that can be used safely by clients who should avoid straining, like when having anal fissures. *Methylcellulose and Psyllium are examples of bulk forming laxatives *Bisacodyl is a stimulant laxative that also does not make the stool softer and easier to pass.  * Magnesium hydroxide is a saline agent that will change the consistency of the stool but is not the most appropriate medication for a client with anal fissures over docusate. *Laxative use should be minimized and avoided if possible because they can cause the client to become dependent and further constipation - What medication is used to prevent or treat constipation? § Laxative Diarrhea: an increased frequency of bowel movements (more than 3 per day) with altered consistency (i.e., increased liquidity) of stool - Travel diarrhea: take bismuth (Pepto-Bismol) § People with an allergy to aspirin and aspirin products should not take bismuth subsalicylate as the drug is a salicylate § This salt causes a temporary and harmless darkening of the tongue or stool. - Watch food intake - Long term diarrhea should be monitored for dehydration and electrolyte imbalance - Watch medication to stop diarrhea with abx- associated colitis § Loperamide (Imodium) and Diphenxylate with Atropine (Lomotil) are contraindicated - possibility of C. difficile infection should be considered in all clients with unexplained diarrhea who are taking or have recently taken antibiotics. § client have C. difficile the nurse should maintain contact precautions - Treatment: § Taking a medication to stop diarrhea is not always needed or desirable because diarrhea may mean the body is trying to rid itself of irritants or bacteria § Teaching: Stop antidiarrheal drugs when diarrhea is controlled to avoid adverse effects such as constipation § Try to drink 2 to 3 quarts of fluid daily. This helps prevent dehydration from fluid loss in stools. Water, clear broths, and noncarbonated, caffeine-free beverages are recommended because they are unlikely to cause further diarrhea. § Diphenoxylate and loperamide may cause dizziness or drowsiness and should be used with caution if driving or performing other tasks requiring alertness, coordination, or physical dexterity. - S/S: increased frequency and fluid content of stools § abdominal cramps § distention, borborygmus (i.e., a rumbling noise caused by the movement of gas through the intestines) § anorexia § thirst § Painful spasmodic contractions of the anus and tenesmus may occur with defecation. - Electrolyte imbalances: dehydration, hypokalemia, metabolic acidosis Intestinal obstruction - Small bowel obstruction: a blockage in the small intestine § Increased bowel sounds § Colicky abdominal pain  § Marked distension early on § Hold oral intake- NG tube often used to decompress § MANAGEMENT OF SBO v Maintaining fluid and electrolyte balance is a priority area to monitor in the client with a small bowel obstruction. v Having an NG tube, being NPO puts the client at a higher risk for fluid imbalance. v With a partial SBO an NG tube can be tried for up to 3 days to see if the obstruction will resolve spontaneously. v The nurse should assess the client frequently for manifestations consistent with resolution. v If rest and decompression do not resolve the obstruction the client will require surgical intervention. v Crampy, wavelike pain in the abdomen is seen with a small bowel obstruction. v Vomiting may occur - Large bowel obstruction § Decreased/No bowel sounds § Patient may complain of constipation for weeks in advance § Marked distension later- bowel may be visible or palpated through abdominal wall § The client may experience weakness, weight loss, and anorexia. § Eventually, the abdomen becomes markedly distended, loops of large bowel become visibly outlined through the abdominal wall § A large bowel obstruction is a medical emergency. It occurs when a tumor, scar tissue or something else blocks the large intestine. Enteral Nutrition: tube feeding - Liquefied food or formula through tube inserted into: stomach, duodenum, jejunum - Indication: anorexia, orofacial fractures, head/neck cancer, burns, nutritional deficiencies - Complication: § Vomiting § Diarrhea § Constipation § Hyperglycemia § Skin breakdown § Patient safety (pulling out tube) § Dehydration v More calorically dense, less water formula contained - Jejunostomy: (J-Tube) is a soft, plastic tube placed through the skin of abdomen into midsection of small intestine placed for the purpose of administering nutrition, fluids, and medications and is indicated when the gastric route is not accessible, or to decrease aspiration risk when the stomach is not functioning adequately to process and empty food and fluids. - Dobhoff: enteric feeding tube  § To prevent sludge build-up, or occlusion of the tube the nurse should administer 30 mL of water before and after medication administration (with at least 5 mL of water in between each individual medication) § Monitor respiratory rate and oxygen sat can provide information on aspiration - NG tube: low intermittent suction (fluid electrolytes nutrition) § For feeding, either continuous or bolus, flushing with water is SUPER important § 5 mL in between each med § 30 mL before and after anything is introduced § 30 mL free water flush q 4 hours - NG tube feeding and action § Confirming tube placement v Auscultation (not definitive) v pH strip testing (not definitive) v Chest Xray- gold standard to confirm Parenteral nutrition: Administration of nutrients by route other than GI tract (i.e., bloodstream) - Used when GI tract cannot be used for ingestion, digestion, and absorption of essential nutrients v GI obstruction v GI tract anomalies and fistulae v Malnutrition v Nutrients are given by another route other than the GI tract - Complications: v Metabolic problems- Hyperglycemia, renal alterations (specifically increase in urine), lytes imbalance, hyperlipidemia, mineral deficiency v Monitor for hyperglycemia because parenteral nutrition is high in glucose - monitor q6h Methods of administration- parenteral - Central parenteral nutrition is used for long-term support v Administered through a central line v Cannot be combined with other meds or fluids - Peripheral parenteral nutrition is used for short-term therapy only v Can be used to supplement oral intake - Do not use IV line for anything else - Patient should not be connected without infusion for long periods of time - Sudden discontinuation of TPN while waiting for the pharmacy to deliver the solution can cause hypoglycemia; therefore, it is recommended to infuse 10% dextrose while waiting. - Waiting for TPN? – Hang dextrose! Enteral vs Parenteral? - E: Administration of nutrition through tube - P: administration of nutrition through bloodstream tube feeding method chosen depends on the location of the tube in the GI tract, patient tolerance, convenience, and cost  TPN ONLY GOES THRU A CENTRAL LINE Gallbladder Disease - Certain conditions, such as age, obesity, and estrogen imbalance, cause the liver to secrete bile that’s abnormally high in cholesterol or lacking the proper concentration of bile salts. - If a stone lodges in the common bile duct, the bile flow into the duodenum becomes obstructed. Bilirubin is absorbed into the blood, causing jaundice - Cholelithiasis- Gallstones - Cholecystitis- inflammation of the gallbladder secondary to gallstones Cholecystitis Patho - Cholesterol stones account for almost 75% of cases of gallbladder disease in the United States - The cholesterol-saturated bile predisposes to the formation of gallstones and acts as an irritant that produces inflammatory changes in the mucosa of the gallbladder - Gangrene of the gallbladder with perforation may result. Signs and Symptoms Epigastric distress Abdominal distention RUQ pain following meals with fried or fatty foods Biliary colic- Gallstone obstructs cystic duct Fever RUQ radiating to back or R shoulder Jaundice (bile absorb by blood & give yellow color also itching) Dark urine (r/t bile excreted by kidney) Clay colored stool (chronic cases) (bile doesn’t reach duodenum so stool not brown) Vitamin Deficiency ( no bile interferes with absorption of fat soluble vitamins ADEK Cholecystitis-assessment & diagnostic: - Abdominal X-Ray - Ultrasound – dx procedure of choice, rapid & accurate, no radiation, more accurate if pt NPO overnight so GB distended - Radionuclide Imaging - Oral Cholecystography - Endoscopic Retrograde Cholangiopancreatography (ERCP CHOLECYSTECTOMY- PREOP ASSESSMENT - If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion.  Laparoscopic Cholecystectomy Vs open - LC: Small incisions, including through umbilicus v Can be day surgery - OC: v Needs longer monitoring- don’t forget your surgical assessments v Know baseline assessment v T-tube placement necessary to drain bile from common bile duct v Will need to be clamped prior to and after meals v Any surgery watch for acute postop changes with liver function- especially cholecystostomy Cholecystostomy - a procedure where a stoma is created in the gallbladder, which can facilitate placement of a tube for drainage - Usually, only a small amount of serosanguineous fluid drains in the initial 24 hours after surgery; afterward, the drain is removed. - Empty the drainage bag attached at least every 8 hours and as needed, to prevent reflux back into the bile duct. - After these surgical procedures, the client is observed for indications of infection, leakage of bile into the peritoneal cavity, and obstruction of bile drainage. If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. - Scleral icterus- yellow discoloration sclera of eye, the nurse should assess the color of the sclera Cholecystostomy – postop teaching - Take showers not baths to prevent infection of the incision site. - Returning to work after one week is for a client who had laparoscopic surgery. - Avoid heavy lifting and strenuous exercise after surgery to prevent evisceration for at least 4 to 6 weeks - Low-fat liquid diet - Bile duct injury is a serious complication of cholecystectomy so teach them to watch for yellowing of the skin or sclera, but it occurs less frequently than with the laparoscopic approach, which has largely replaced traditional surgical cholecystectomy. - After laparoscopic surgery - If pain occurs in the right shoulder or scapular area (from migration of the carbon dioxide used to insufflate the abdominal cavity during the procedure), the nurse may recommend a heating pad for 15 to 20 minutes hourly or for the client to ambulate frequently to reduce the bloating. Peptic ulcer Disease - Pain commonly occurs immediately after eating - Medications: v Sucralfate (Carafate) for coating protection prior to meals v H2 Blockers are used for treatment only if H Pylori is NOT present Can be taken long term QHS - Dietary management v Individualize plan of care for what types of foods can be tolerated v Goal: avoid over secretion of acid and hypermotility in the GI tract v Instruct patients to avoid extremes of temperature in food and beverages v Avoid overstimulation from:  Consumption of alcohol, Coffee (including decaffeinated coffee, which also stimulates acid secretion) Other caffeinated beverages v Neutralize acid by eating three regular meals a day v Small, frequent feedings are not necessary as long as an antacid or an H2 blocker is taken v Diet compatibility becomes an individual matter: The patient eats foods that are tolerated and avoids those that produce pain. - Nursing intervention v Monitor the client’s laboratory results to watch for anemia which could indicate that the client has a bleeding ulcer v Tachycardia and hypotension may indicate bleeding as well v Avoid NSAIDs like ibuprofen, and aspirin v Use sucralfate (Carafate) as a barrier to protect from stomach acid and helps heal the ulcer - Treatment v The most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and sometimes bismuth salts that suppress or eradicate H. pylori - Teaching v Because most clients become symptom free within a week, the nurse stresses to the client the importance of following the prescribed regimen so that the healing process can continue uninterrupted and the return of chronic ulcer symptoms can be prevented. v H2 receptor antagonists are taken at bedtime if prescribed once per day. Maintenance dosages of H2 blockers are usually recommended for 1 year but healing occurs in 6 to 8 weeks. v The client is advised to adhere to and complete the medication regimen to ensure complete healing of the ulcer Duodenal ulcers - Dull, gnawing, or burning upper abdominal pain (mid-epigastrium or the back) - Pain commonly occurs 2-3 hours after eating - Both PPI’s or H2 blockers can be used to manage long-term - Similar dietary considerations as Peptic ulcer - commonly occurs 2 to 3 hours after meals. Esophageal ulcers: - Occur as a result of the backward flow of acid from the stomach into the esophagus (gastroesophageal reflux disease [GERD]). - In the past, stress and anxiety were thought to be causes of peptic ulcers, but research has documented that most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired through ingestion of food and water Appendicitis: An inflammation of the appendix - Most common reason for emergency abdominal surgery - Once obstructed, becomes ischemic - caused by bacteria or an abscess - not treated promptly, rupture may occur - Can lead to peritonitis (inflammation of entire abdominal cavity) - Surgical removal is treatment  Laparoscopic when possible (very common - Signs and symptoms: v Vague periumbilical pain with anorexia v Progresses to sharp right lower quadrant pain v Nausea & Vomiting v Low-grade fever v Rebound tenderness- McBurney point v Diarrhea or Constipation may occur v If appendix ruptures - abdomen is typically distended from a paralytic ileus - Nursing Care v Replacing fluids to prevent dehydration, providing pain medication and keeping the client on bedrest are appropriate prescriptions when a client is suspected of having appendicitis. v Clients with acute appendicitis prefer to lie still often with their right leg flexed to alleviate discomfort. v Pre-op… patient will likely be NPO since immediate surgery is imminent - Assessment and diagnostic v CBC- Elevated WBC (elevated neutrophils) v C-reactive protein- elevated v CT scan v Pregnancy test - before radiology r/o ectopic pregnancy v Urinalysis v Diagnostic laparoscopy - Medical management v Appendectomy v IVF - correct fluid & electrolyte imbalances, dehydration v Antibiotics - Postop v High Fowler position - reduces tension on incision & abdominal organs (help reduce pain), promotes thoracic expansion v Incentive spirometer v Auscultate bowel sounds v Monitor urinary output v Encourage ambulation v Pt. may eat when bowel sounds return v IVF – encourage PO fluids v Morphine - IV meds changed to PO when tolerate v Client may resume normal activity in 4-6 weeks v Discharge- Instruct f/u appt in 5-7 days suture removal; inspect wound Peritonitis: Inflammation of the membrane lining the abdominal wall and covering the abdominal organs. - It's caused by leakage or a hole in the intestines, such as from a burst appendix. Even if the fluid is sterile, inflammation can occur - S/S: Symptoms usually include pain, tenderness, rigid abdominal muscles, fever, nausea, and vomiting - Antibiotics are almost always needed, along with surgery or drainage Diverticulosis  - a condition that occurs when small pouches, or sacs, form and push outward through weak spots in the wall of your colon. Diverticulitis: Acute inflammation of an outpouching (diverticula) in the colon - Can be found with acute left lower quadrant pain - c/o pain and nausea and vomiting - Watch high roughage foods (nuts, seeds, corn, celery), could get stuck in diverticula and create inflammation - Changes in bowel movements are a main characteristic - Manage the fluid and electrolyte imbalances, dehydration, and sepsis risks - Antibiotic therapy- usually broad spectrum - Laxatives should not be used because of the risks of perforation