NCMB316 LEC PRELIM.pdf

NCMB316 LECTURE: Exam Week 06 BSN 3RD YEAR 2ND SEMESTER PRELIM 2023...

NCMB316 LECTURE: Exam Week 06 BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Bachelor of Science in Nursing 3YB Professor: Dr. Potenciana A. Maroma Prelim Topics: blood vessels, nerve endings, lymph nodules, and Intro to Gastrointestinal System lymphatic vessels. GERD, Gastritis, PUD, Dumping Muscular layer- The muscularis externa is a muscle layer Crohn's Disease, Ulcerative Colitis, Intestinal typically made up of an inner circular layer and an outer Obstruction, etc. longitudinal layer of smooth muscle cells. Hepatitis, Liver Cirrhosis, Esophageal Varice, etc. Serosa - The serosa is the outermost layer of the wall that Endocrine System & Pituitary Disorders consists of a single layer of flat serous fluid-producing cells, the visceral peritoneum. GASTROINTESTINAL SYSTEM Introduction G.I. tract (alimentary canal) - Mouth - Esophagus - Stomach - Intestines (small & large) - Rectum Accessory organs - Salivary glands - Liver - Gallbladder - Pancreas Functions: - Adult G.I. tract is about 25 feet long (mouth to anus) 1) Secretion (HCl, bile, enzymes) 2) Digestion (mechanical & chemical process) – pagdadaanan ng food for further digestion. Enzymes ang tumutulong para mag digest ng mabilis ang pagkain. To speed it up it is known at catalyst. 3) Absorption (CHYME – liquid in nature) – dito na ma absorb ang mga nutrients. 4) Motility 5) Elimination GI System 4 layers Mucosa – The mucosa is the innermost layer, a moist membrane that lines the cavity, or lumen, of the organ; it consists primarily of a surface epithelium, plus a small Blood Supply amount of connective tissue (lamina propria) and a scanty - Blood supply to the GI tract originates from the aorta & smooth muscle layer. branches to the many arteries throughout the length of the Submucosa - The submucosa is found just beneath the tract. mucosa; it is a soft connective tissue layer containing J.A.K.E 1 of 25 NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Oral Cavity Buccal mucosa – mucous membrane lining the inside of the mouth Lips – external to the mouth & are pink-red Tongue – involve in speech, taste & mastication (chewing) Hard & soft palate – forms the roof of the mouth Teeth – 32 permanent teeth in adults; important for speech & mastication Salivary glands – parotid, submandibular, sublingual glands; secretes mucin & salivary amylase (ptyalin) breakdown of CHO; 1 liter of saliva is produced/day Pharynx (Throat) – extends from the soft palate to the esophagus J.A.K.E 2 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 - Guarded at both ends by the cardiac & pyloric sphincters - Rugae (folds of mucosa & submucosa) parietal cells – secretes HCL chief cells – pepsinogen, IF Three Phases of Gastric Secretion 1) Cephalic phase - begins w/ sight, smell & taste of food - vagus & GI nerve plexuses initiates secretory & contractile activities 2) Gastric phase - begins w/ the presence of food in the stomach - Gastric juice (HCL + hormones + enzymes)  FOOD  CHYME - G cells  hormone gastrin  promotes secretion of HCL & pepsinogen - HCL  converts pepsinogen to active pepsin (digestion of CHONS) - Mucus & bicarbonate secretions (protects stomach Esophagus from mechanical & chemical damage - a muscular canal about 10 inches (24cm) long; extends 3) Intestinal phase from the pharynx to the stomach. - begins as the chyme passes from the stomach into the - Function: propel food & fluids from the pharynx to the duodenum stomach & prevent reflux of gastric contents into the - mediated by secretin (inhibits further acid production & esophagus. (reflux – meron syang lower esophageal decreases gastric motility) sphincter, kunwari un food mo nakarating sa stomach, hindi na pwede bumalik sa esophagus) Upper esophageal sphincter (UES) – closed when at rest to prevent air in esophagus. Lower esophageal sphincter (LES) – normally closed when at rest to prevent reflux of gastric contents into the esophagus. Stomach - location: midline & LUQ of the abdomen - anatomic regions of the stomach: Cardia Fundus Corpus or Body Pylorus or Antrum Small Intestine - major organ of absorption of the G.I. system - longest (16-19 feet) - most convoluted portion of GIT - 3 regions: duodenum (12”), jejunum (8’) ileum (8’ – 12’) J.A.K.E 3 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Pancreas - A fish shaped gland that lies retro-peritoneally in the upper abdominal cavity behind the stomach and extends horizontally from the duodenal C-loop to the spleen - Divided into head, body & the tail - Function: Exocrine: 80% of the organ; acinar cells secretes enzymes Endocrine: 20% of the organ; islets of langerhans secretes hormones NOTE: Intestinal cells produce cells that secretes enzymes & hormones Secretin - secreted by duodenum in the presence of HCL - stimulates secretion of pancreatic juice & bile in the liver Pancreozymin - secreted by duodenum in the presence of HCL & peptides - stimulates secretion of pancreatic juice Cholecystokinin - secreted by duodenum in the presence of amino acids & fatty acids - stimulates secretion of pancreatic enzymes & bile in the gallbladder Liver - Largest internal organ in the body located in the RUQ of the Large Intestine abdomen - extends from the ileo-cecal valve to the anus (about 5-6 - 2 major regions: right & left lobe feet) - About 1500 ml of blood flows through the liver q min. - Functions: - Performs more than 400 functions in 3 major categories: Movement Storage (copper, iron, magnesium, Vit.B2, B6, B12, A, D, Absorption (H2O & é) E, K, folic acid) Elimination Protection (phagocytic kupffer cells, detoxifies potentially harmful compounds such as drugs, chemicals & alcohol) Metabolism (breakdown of amino acids forming urea, synthesis of plasma chons, CHO metabolism & Fat metabolism) It produces BILE (for emulsification of fat) J.A.K.E 4 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Gallbladder - Diet history - Pear-shaped bulbous sac that is located in a depression on - Socioeconomic status the inferior surface of the liver - Current health problem: PAIN (common complaint) - It has 3 portions: neck, body, fundus The mnemonic PQRST may be helpful in assisting the - Drained by cystic duct that joins with the hepatic duct to nurse to organize the current problem assessment form the common bile duct Precipitating or palliative - What brings it on? What makes - Function: collects, concentrates & stores bile it better? Quality or quantity - How does it look, feel or sound? How Summary of the Physiology of Digestion & Absorption: intense/ severe is it? 1) Digestion: Physical/Mechanical & Chemical breakdown of Region or radiation - Where is it? Does it spread anywhere? food into absorptive substances Severity scale - How bad is it (on scale of 1 to 10)? 2) Initiated in the mouth where food mixes with saliva and Timing - Onset, duration & frequency starch is broken down Physical Assessment 3) Food then passes into the esophagus where, it is - comprehensive examination of the client’s nutritional propelled into the stomach status, the mouth & pharynx, the abdomen & the 4) In the stomach, food is processed by gastric secretions extremities into a substance called chyme - Anthropometric measurement - evaluates nutritional 5) In the small intestine, CHO are hydrolyzed to status height, weight, BMI monosaccharide, fats to 2-glycerol and fatty acids; and Abdomen proteins to amino acids to complete the digestive process - empty the bladder; lie in a supine position with knees bent, 6) When chyme enters the duodenum, mucus is secreted to keeping the arms at the sides (prevent abdominal muscle neutralize hydrochloric acid; in response to release of tension) secretin, pancreas releases bicarbonate to neutralize acid - RUQ, LUQ, LLQ, RLQ chyme - if areas of pain are noted from the history, this area is 7) Cholecystokinin and pancreozymin (CCK-PZ) are also examined last in the examination sequence to prevent produced by the duodenal mucosa; stimulate contraction abdominal muscle tension of the gallbladder along with relaxation of the sphincter of - Observe the client’s face for signs of distress or pain Oddi (to allow bile to flow from the common bile duct into - 4 techniques used: IAPePa (usual: IPaPeA) – Inspection, the duodenum), and stimulate release of pancreatic Auscultation, Percussion, Palpation enzymes - Cullen’s sign 8) Absorption presence of ecchymosis (bruising) around the a) intestinal cells to absorb nutrient molecules umbilicus indicates intra-abdominal bleeding (monosaccharides, amino acids and fatty acids) - Observe also for abdominal movements b) villi increase the surface area for absorption, most rarely seen on inspection especially in the small intestine indicates intestinal obstruction Auscultation AGING & THE DIGESTIVE SYSTEM High pitched gurgles air & fluid movement - Physiologic changes occur as individuals age, especially - q 5-15 seconds / 5-30 sounds /min when they become 65 years of age or older - Diminished or absent (abdominal surgery, peritonitis, - Overall changes of the digestive system associated with paralytic ileus) Hypoactive- 1-2 sounds in 2 min. aging includes: Hyperactive-> 30 sounds/min. Absent- no sounds in 3- secretory mechanism 5 min. motility of the digestive organs Borborygmus Loss of strength & tone of the muscular tissue & its - loud gurgling sounds due to hypermotility of the bowel supporting structures (diarrhea, gastroenteritis, above a complete intestinal changes in neurosensory feedback regarding enzyme & obstruction) hormone release Bruit “swooshing sounds” - Indicates aneurysm especially if heard over the aorta; if Assessment Techniques heard… DO NOT percuss/palpate abdomen!!! – History mamamatay pasyente mop ag naputok ang aneurysm - Demographic data - age, gender, culture, occupation Percussion - Family history & genetic risk - Determine & estimate the size of solid organs (liver & - Previous G.I. disorders, abdominal surgeries spleen) - Medications - detect presence of masses, fluid, and air aspirin, NSAIDs (PUD, GI bleeding) - Tympanic – high pitched, loud musical sound of an air- laxatives & enemas (causes dependence on such filled intestine stimulation and cause constipation) - Dull – medium pitched, softer, thudlike sound over a solid - Travel history organ (liver) J.A.K.E 5 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Upper GI Series & Small Bowel Series - x-ray visualization from the oral pharynx to the duodenojejunal junction detect disorders of structure or function of esophagus (barium swallow), stomach or duodenum - small bowel follow-through (SBFT) (up to the ileocecal junction) Palpation - Client preparation: - Determine the size & location of abdominal organs & 8° NPO before the procedure assess presence of masses or tenderness withhold opiod analgesics & anticholinergics 24° before - Blumberg’s sign – rebound tenderness (pain felt on the test ( motility) release of fingers pushing & placed at a 90° angle in need to drink around 16 ounces of barium preparation relation to the abdomen) Diagnostic Assessment Blood Tests - CBC – GI bleeding; anemia - Flouroscopy is used to trace the barium through the - PT – liver damage; prolonged PT (liver is the main site of esophagus & stomach all proteins involved in coagulation) - After the procedure: - serum é – GI malabsorption, excessive vomiting or plenty of fluids to eliminate barium diarrhea mild laxative or stool softener can be given - AST, ALT – liver disorders (ex; viral hepatitis) advise client that stool may be chalky white for 24-48° - Serum amylase & lipase – best indicator of acute as barium is excreted pancreatitis if elevated within 24° - 5 days Lower GI Series (Barium Enema) - Bilirubin – important in the evaluation of liver & biliary - radiographic visualization of the large intestine tract functioning - Detect bowel obstruction from the twisting of the colon - Serum ammonia – hepatic function; ammonia is upon itself (volvulus) normally used to rebuild a.a. or is converted to urea for - Contraindication: suspected colon perforation or fistula; excretion cardiac arrest when barium enter venous circulation Urine Tests - Client preparation: - Urine amylase – acute pancreatitis; remains high even clear liquids only 12 -24° before procedure to reduce after serum levels return to normal amount of fecal matter in the bowel but NPO after - Urobilinogen – hepatic & biliary obstruction midnight on the night before the test Stool Tests potent laxatives (Magnesium citrate) or cleansing - FOBT (Fecal Occult Blood Test) – G.I. bleeding enema is performed the evening before the test - Parasitic infection - After the procedure: - Fecal fats (steatorrhea & malabsorption) advise client to drink plenty of water to assist in Plain abdominal X-rayFlat plate of abdomen eliminating the barium (chalky white stool for 24-72° - masses, tumors & strictures or obstructions until all barium is expelled) - no special preparation of the client required laxatives can be given J.A.K.E 6 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Percutaneous Transhepatic Cholangiography (PTC) Before the Procedure - Iodinated dye instilled via a percutaneous needle inserted - Commonly used medications: through the liver into the intrahepatic ducts (needle is Midazolam HCL inserted under x-ray visualization) Meperedine (Demerol) Sedation - Rarely done as a diagnostic procedure anymore Fentanyl - After the procedure: client is placed on the right side; Atropine - dry secretions observe for signs of bleeding, hematoma, ecchymosis or Local anesthetic - sprayed to inactivate gag reflex & bile leakage facilitate passage of tube - Client is place in left lateral decubitus (Sim’s or side-lying) position during the procedure After the procedure - monitor VS q30mins until sedation wears off; put siderails up - NPO until gag reflex returns (usually in 1-2°) to avoid aspiration - monitor for signs of perforation Pain Bleeding Fever Endoscopic Retrograde Cholangiopancreatography (ERCP) - Visual and radiographic examination of the liver, gallbladder, bile ducts & pancreas to identify cause & location of obstruction; after cannula is inserted into the Computed Tomography (CT Scan) common bile duct, radio-opaque dye is inserted followed - Noninvasive cross-sectional x-ray visualization detecting by several x-ray images tissue densities & abnormalities in the abdomen & the - Physician may perform a papillotomy, a small incision in structures in it the sphincter around the ampulla of vater, to remove - performed with (ask about allergies to seafood & iodine!!!) gallstones preparation: same as endoscopy or without contrast medium - No particular follow-up care is needed after a CT scan unless sedatives were administered; monitor VS until client is fully awake Endoscopy - Direct visualization of the GI tract by means of a flexible fiberoptic endoscope - Usually done to evaluate bleeding, ulceration, inflammation, masses, tumors & cancerous lesions Esophagogastroduodenoscopy - Visual examination of the upper GI Colonoscopy - endoscopic examination of the large bowel - use to evaluate the cause of chronic diarrhea, locate the source of bleeding, obtain tissue biopsy specimens or remove polyps - Preparation: liquid diet for 12-24°, NPO 6-8° before the procedure clean the bowel the evening before the procedure (laxatives, suppositories, cleansing enemas) sedation of client Atropine sulfate is kept available in case of bradycardia resulting from vasovagal response - After the procedure: check VS q15mins until stable; siderails up; observe signs of perforation (pain & hemorrhage) J.A.K.E 7 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Proctosigmoidoscopy - Endoscopic examination of the rectum & sigmoid colon using flexible or rigid scope - Purpose: screen for colon cancer, investigate source of GI bleeding, diagnose or monitor inflammatory bowel disease - Preparation: liquid diet for at least 24° before the procedure; laxative (evening), cleansing enema (a.m. Before the procedure) - Position: left side in the knee-chest position - No sedation is required - Inform the client that mild gas pain & flatulence may be experienced from the air instilled into the rectum during the procedure - If biopsy was obtained, a small amount of bleeding may be observed; instruct the client that excessive bleeding should be reported immediately to the health care provider Assessment Findings Gastric Analysis Heartburn - Measures the HCL & pepsin content for evaluation of - substernal or retro- sternal burning sensation aggressive gastric & duodenal disorders (Zollinger-Ellison - pain radiate to the neck, jaw, back (mimic ANGINA or syndrome) MI) - Alcohol, tobacco & medications that may affect gastric Regurgitation secretion are avoided for 24° before the study - warm fluid traveling up the throat (sour or bitter taste) - NGT is inserted & gastric residual contents are aspirated - danger for aspiration (note for crackles in the lungs) Ultrasound Hypersalivation “water brash” - Sound waves are passed through the body via a transducer Dysphagia (Difficulty of swallowing) and echoes are converted into images and photograph for analysis Odynophagia (Painful swallowing) - Commonly used to image soft tissues such as liver, spleen, Barrett’s epithelium the pancreas, gallbladder (biliary system) - change of the normal squamous cell epithelium to - Full bladder is necessary for accurate visualization (1-2 l columnar epithelium of fluid) - more resistant to acid as a result of healing process brought about by the inflammation GERD, GASTRITIS, PUD, DUMPING SYNDROME - considered pre-malignant ( risk of CANCER) in Gastroesophageal Reflux Disease (GERD) clients with prolonged GERD - Backward flow (reflux) of stomach contents into the Other manifestations: esophagus resulting to inflammatory changes of the Chronic cough especially at night (due to position), asthma esophageal mucosa Eructation (belching) - Hallmark of GERD: reflux esophagitis (acute symptoms of Flatulence (gas) inflammation) Bloating after eating Nausea & Vomiting Diagnostic test: - Most accurate method: 24-hour ambulatory pH monitoring - small catheter is placed through the nose into the distal esophagus, pH is continuously monitored & recorded) Endoscopy (esophagogastroduodenoscopy) Esophageal manometry “motility testing” - water-filled catheters are inserted via the client’s nose or mouth & slowly withdrawn while measurements of LES pressure & peristalsis are recorded); not specific enough to establish a diagnosis of GERD Causes Nursing interventions: inappropriate relaxation of the LES/  tone of LES Diet therapy gastric volume or intra-abdominal pressure is elevated - limit or eliminate foods that decrease LES pressure delayed gastric emptying (chocolate, fatty foods, caffeinated beverages such as coffee, tea, & cola, peppermints, alcohol) - restrict spicy & acidic foods (orange juice, tomatoes) - carbonated beverages ’s pressure in the stomach J.A.K.E 8 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Lifestyle changes Gastritis - sleep in the left lateral (side-lying) position to minimize - Gastritis is an inflammation of the gastric mucosa, is the nighttime episodes of reflux classified as either acute or chronic. - Incidence: The incidence of gastritis is highest in the fifth and sixth decades of life; men are more frequently affected than women. The incidence is greater in clients who are heavy drinkers and smokers. Acute Gastritis Etiology and Risk Factors: - It usually stems from ingestion of a corrosive, erosive, or infectious substance. - Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs), chemotherapeutic drugs, steroids, acute alcoholism and food poisoning (typically caused by Staphylococcus organisms) are common causes. - Food substances including excessive amounts of tea, carbonated drinks and pepper can precipitate acute gastritis. Foods with a rough texture or those eaten at an extremely high temperature can also damage the stomach mucosa. - Acute gastritis is usually of short duration unless the gastric mucosa has suffered extensive damage. Pathophysiology - The mucosal lining of the stomach normally protects it from the action of gastric acid. This mucosal barrier is composed of prostaglandins. Due to any cause ↓ This barrier is penetrated ↓ Hydrochloric acid comes into contact with the mucosa ↓ Injury to small vessels Drug therapy ↓ Antacids Edema, hemorrhage, and possible ulcer formation - neutralizes HCL & deactivating pepsin Clinical Manifestation - Aluminum Hydroxide, Magnesium Hydroxide, Maalox, Epigastric discomfort Mylanta Feeling of fullness, early satiety Histamine2 (H2) Receptor Antagonist - ’s acid production of parietal cells Cramping - Famotidine, Ranitidine (Zantac), Cimetidine (Tagamet), Belching Nizatidine Flatulence Proton pump inhibitors (PPI’s): main treatment for GERD Severe nausea and vomiting - inhibition of proton pump of the parietal cell thereby  Hematemesis acid secretion Sometimes GI bleeding is the only manifestation - Omeprazole, Lansoprazole, Rabeprazole, Pantoprazole, When contaminated food is the cause of gastritis, diarrhea Esomeprazole; usually develops within 5 hours of ingestion Metoclopramide (Reglan) Diagnostic Findings -  gastric emptying - Diagnosis is based on a detailed history of food intake, Endoscopic Therapy medications taken, and any disorder related to gastritis. - Stretta procedure – the physician applies - The physician may also perform a gastroscopy. radiofrequency energy through needles placed near Medical Management gastroesophageal junction inhibiting the vagus nerve - Anti – emetic drugs like Inj. Perinorm or Tab, Domperidone thus reducing the discomfort of the client. It will are frequently effective in vomiting. reshape the ring of muscles in the lower esophagus. - Antacids, H2 Blockers like cimetidine, Ranitidine, or Surgical management: Laparoscopic Nissen Famotidine are effective to reduce the pain. Fundoplication - GOLD STANDARD J.A.K.E 9 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 - If ingestion of NSAIDs is a problem, a prostaglandin E1 Complications (PGE1) analog may be prescribed to protect the stomach - Bleeding mucosa and inhibit gastric acid secretion. - Pernicious anemia Diet Therapy - Gastric cancer - Initially foods and fluids are withheld until nausea and Medical Management vomiting subside. - Discomfort may lessen with a bland diet, small frequent - Once the client tolerates food, the diet includes meals, antacids, H2 receptor antagonists, proton pump decaffeinated tea, gelatin, toast, and simple bland foods. inhibitors, and avoidance of food that cause - The client should avoid spicy foods, caffeine and large, manifestations. heavy meals. - If H.pylori bacteria are present, anti-biotics and other - In the continued absence of nausea, vomiting and bloating, medications are administered to eliminate the bacteria. the client can slowly return to a normal diet. - If 1 week of this regimen does not succeed in eliminating Chronic Gastritis the bacteria, the regimen may be repeated for an - 3 forms additional week. - Superficial gastritis, which causes a reddened, edematous - If pernicious anemia develops, intramuscular injections of mucosa with small erosions and hemorrhages. vitamin B12 may be administered monthly for the - Atrophic gastritis, which occurs in all layers of the remainder of the client’s life. stomach, develops frequently in association with gastric Nursing Management ulcer and gastric cancer, and is invariably present in Nursing Diagnosis: pernicious anemia; it is characterized by a decreased 1) Acute pain related to irritated stomach mucosa. number of parietal and chief cells. 2) Imbalanced nutrition, less than body requirement, - Hypertrophic gastritis, which produces a dull and nodular related to inadequate intake of nutrition. mucosa with irregular, thickened, or nodular rugae; 3) Risk for imbalanced fluid volume related to hemorrhages occur frequently. insufficient fluid intake and excessive fluid loss Etiological Factors subsequent to vomiting. - Infection with Helicobacter pylori bacteria or gastric 4) Anxiety related to treatment. surgery may lead to chronic gastritis. 5) Deficient knowledge about dietary management and - After gastric resection with a gastro- jejunostomy, bile and disease process. bile acids may reflux into the remaining stomach, causing gastritis. Peptic Ulcer Disease - H.Pylori infection can lead to chronic atrophic gastritis. - Age is also a risk factor; chronic gastritis is more common in older adults. Pathophysiology The stomach lining first becomes thickened and erythematous and then becomes thin and atrophic. ↓ Continued deterioration and atrophy ↓ Loss of function of the parietal cells ↓ Acid secretion decreases ↓ Inability to absorb vitamin B12 ↓ Causes Development of pernicious anemia - Break in the mucosal barrier Clinical Manifestation o mucus & bicarbonate secretion (1st line of defense in - Manifestations are vague and may be absent because the pH maintenance) problem does not cause an increase in hydrochloric acid. o Gastromucosal PG (’s barrier resistance to Assessment may reveal ulceration) o adequate blood supply o Anorexia o pyloric sphincter dysfunction (bile may enter stomach & o Feeling of fullness cause damage to lipid plasma membrane of gastric o Dyspepsia mucosa) o Belching o delayed gastric emptying o Vague epigastric pain o H. pylori infection o Nausea Note: There is normal gastric acid secretion!!! o Vomiting o Intolerance of spicy and fatty foods J.A.K.E 10 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Complications of PUD Hemorrhage – most serious complications; hematemesis (coffee-ground blood) usually indicates upper GI bleeding Perforation – surgical EMERGENCY!!! Gastroduodenal contents leaks into the surrounding abdomen Sharp pain, client becomes apprehensive assuming knee- chest position, chemical peritonitis occurs, bacterial septicemia & hypovolemic shock follows. Peristalsis diminishes & paralytic ileus develops. Laboratory assessment Duodenal ulcer: causes  Hgb/Hct (indicates bleeding) - rapid emptying of food in the stomach (+) occult blood in stool specimen - acid-bolus delivery, reduce buffering effect of food Endoscopy (EGD) reveals ulceration; BIOPSY is usually to duodenum done to detect H. pylori infection & to rule out -  secretion of acid is triggered also by CHON rich MALIGNANCY!!! food, Ca++, vagal excitation Gastric analysis: normal gastric acidity in gastric ulcer ( - H. pylori produces urease in duodenal ulcer - Urease hydrolyzes urea to ammonia Medical/ Nursing Management - H+ ions are released in response to the presence of - Supportive (rest, bland diet, stress management) ammonia  further gastric mucosal damage Drug therapy: o Antacids o H2-receptor antagonists o Proton pump inhibitors o Anticholinergics (gastric juice secretion) Probanthine, Pirenzepine o Antibiotic for H. pylori infection (Metronidazole (Flagyl), Tetracycline & Pepto-bismol) Surgery: various combinations of gastric resections and anastomosis - Performed when PUD does not respond to medical management Gastroduodenostomy (Billroth I): - distal end of the stomach is removed, and the remainder is anastomosed to the duodenum Gastrojejunostomy (Billroth II): - removal of the antrum and distal portion of the Other factors that contributes PUD: stomach and duodenum with anastomosis of the drugs (aspirin, ibuprofen) remaining portion of the stomach to the jejunum cigarette smoking Vagotomy: chronic anxiety - Transection of vagus nerve that eliminates the acid- Type A personality secreting stimulus to gastric cells & causing a decrease gastric acid secretion Pyloroplasty: performed in conjunction with vagotomy to widen the exit of pylorus to facilitate emptying of stomach contents Subtotal Gastrectomy: removal of 75% - 85% of the stomach Antrectomy: removal of the antrum of the stomach to eliminate the gastric phase of digestion Gastroenterostomy: - creating a passage between the body of the stomach & the jejunum to permit neutralization of gastric acid by regurgitation of alkaline duodenal contents into the stomach Esophagojejunostomy (total gastrectomy) - removal of the entire stomach with a loop of jejunum anastomosed to the esophagus J.A.K.E 11 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Routine preoperative nursing care: - occurs 1½ - 3hrs p.c. - informed consent, NPO, Medications - due to rapid entry of high-CHO food into the jejunum  Postoperative nursing care: Hyperglycemia   insulin release  Rebound - Provide routine post-op care hypoglycemia - Ensure adequate function of NG tube - Symptoms: dizziness, light-headedness, palpitations, - Measure drainage accurately to determine necessity for diaphoresis & confusion fluid and electrolyte replacement; notify physician if there is no drainage. Anticipate frank, red bleeding for 12-24°; Do not manipulate the tube and ensure its patency - Promote adequate pulmonary ventilation - Place client in mid- or high-Fowler’s position to promote chest expansion; Teach client to splint high upper abdominal incision before turning, coughing, and deep breathing Promote adequate nutrition. - After removal of NG tube, provide clear liquids with gradual introduction of small amounts of bland food at frequent intervals; Monitor weight daily. Assess for Dietary Management: regurgitation; if present, instruct client to eat smaller - Decrease the amount of food taken at one time & amounts of food at a slower pace eliminating liquids ingested with meals Provide client teaching and discharge planning - Instruct client to consume a high-CHON ( colloidal concerning osmotic pressure), high-fat, low- to moderate-CHO - Gradually increasing food intake until able to tolerate 3- diet meals/day - Daily monitoring of weight CROHN'S DISEASE, ULCERATIVE COLITIS, INTESTINAL - Stress-reduction measures OBSTRUCTION, PERITONITIS, APPENDICITIS, - Need to report signs of complications to physician DIVERTICULITIS, HEMORRHOIDS immediately (hematemesis, vomiting, diarrhea, pain, melena, weakness, feeling of abdominal fullness/distension) - Methods of controlling symptoms associated with Dumping syndrome Dumping Syndrome - Constellation of vasomotor symptoms after eating, especially following after billroth II procedure - There is rapid gastric emptying into the small intestine causing abdominal distention (shifting of fluids to the GUT) Crohn’s Disease Early manifestation: - occur w/in 30mins - an idiopathic inflammatory disease of the small intestine - Symptoms: vertigo, tachycardia, syncope, sweating, (60%), the colon (20%), or both pallor, palpitations & desire to lie down - terminal ileum: the site most often affected Late dumping syndrome: - Causes J.A.K.E 12 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Unknown, thought to be autoimmune Age/ Peak 15 – 40 years 15 – 25 years M. paratuberculosis incidence 55 – 65 years Genetic predisposition (1st degree & identical twins) ; stool with pus severe; stool with Pathology Bleeding and mucus blood, pus and - Deep fissures & ulceration develops  bowel fistulas  mucus diarrhea & malabsorption Fistulas Common Rare - Chronic pathologic changes include thickening of the Rectal 20% 100% bowel wall  narrowed lumen & strictures  obstruction involvement 5 – 6 soft loose 20 – 30 watery Diarrhea stool/ day stool/ day Abdominal pain + + Weight loss + + TPN Diet, TPN Steroids Steroids Azulfidine Azulfidine Intervention (Sulfasalazine) (Sulfasalazine) Ileostomy Ileostomy Proctocolectomy Assessment Findings Crohn’s Disease VS Ulcerative Colitis Abdominal distention, masses, visible peristalsis Diarrhea (steatorrhea is common & sometimes bloody) constant abdominal pain low-grade fever weight loss (80% of clients) Be aware NURSE!!! to detect clinical manifestations of peritonitis, bowel obstruction & nutritional & fluid imbalances!!! Ulcerative Colitis - Ulcerative and inflammatory condition of affecting the mucosal lining of the colon or rectum - Cause: unknown - Assessment findings: Anorexia Weight loss Fever, Severe diarrhea with Rectal bleeding Anemia Dehydration Abdominal pain and cramping Regional ENTERITIS Ulcerative Colitis (Crohn’s Disease) Transmural Mucous Ulceration Nursing Interventions Characteristic Maintain NPO during the active phase Ileum Rectum/ cecum Unknown Unknown Monitor for complications like severe bleeding, Cause Familial Familial dehydration, electrolyte imbalance Environmental Emotional stress Monitor bowel sounds, stool and blood studies J.A.K.E 13 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Restrict activities Vascular obstructions – interference with the blood Administer IVF, electrolytes and TPN if prescribed supply to a portion of the intestine, resulting in Instruct the patient to avoid gas-forming foods, milk intestinal ischemia and gangrene of the bowel; caused products and foods such as whole grains, nuts, RAW fruits by an embolus, atherosclerosis and vegetables (SPINACH), pepper, alcohol and caffeine Assessment Findings Diet progression- clear liquid LOW residue, high protein high-pitched bowel sounds above the level of the diet obstruction Administer drugs decreased or absent bowel sound below the obstruction - anti-inflammatory Complete Intestinal Obstruction - antibiotics Cardinal Signs and Symptoms - steroids - Abdominal pain - bulk-forming agents and vitamin/iron supplements - Abdominal distention - Vomiting Intestinal Obstruction - Obstipation - It is defined as interference with the forward flow of Other signs/sx intestinal contents. It can be partial or complete & are - Malnutrition classified as mechanical or non-mechanical - Flatulence Mechanical Intestinal Obstruction - Weakness - Physical blockage of the passage of intestinal contents - Electrolyte Imbalances with subsequent distension by fluid and gas - Ascites - Causes: Adhesions (bands of granulation & scar tissue that develop as a result of an inflammatory response encircling the intestines & constricting its lumen) Hernias- protrusion of an organ or structure thru a weakened abdominal muscle, can be congenital or acquired defect volvulus (twisting of the intestine) intussusceptions (telescoping of a segment of the intestine within itself) inflammatory bowel disease, foreign bodies, strictures, neoplasms, fecal impaction Diagnostic Tests Flat-plate & upright abdominal x-rays reveals the presence of gas and fluid  Hgb/Hct, BUN & Creatinine (indicative of dehydration)  serum Na+, Cl-, K+ sigmoidoscopy, colonoscopy, barium enema, CT scan Nursing Interventions Monitor F&E balance, prevent further imbalance; keep client NPO and administer IV fluids as ordered Most clients w/ an obstruction have at least an NGT. Accurately measure the drainage from NG/intestinal tube Non Mechanical Intestinal Obstruction Put in fowler’s position (alleviate pressure on diaphragm) - “paralytic”, “neurogenic” or “adynamic ileus” Encourage nasal breathing to minimize swallowing of air - brought about by interference with the nerve supply to the and further abdominal distension intestine resulting in decreased or absent peristalsis Institute comfort measures associated with NG intubation - Causes: and intestinal decompression handling of the intestine during abdominal surgery Prevent complications Hypokalemia  Measure abdominal girth daily to assess for increasing Peritonitis abdominal distension Shock  Assess for S/Sx of peritonitis  Monitor urinary output J.A.K.E 14 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Drug Therapy/Surgery Management Antiemetic NPO with fluid replacement Antispasmodic Drug therapy: antibiotics to combat infection, analgesics Pain reliever- narcotic analgesic for pain Antibiotic NGT is inserted to relieve abdominal distention Antihelminthic- if caused by bolus of ascaris Peritoneal lavage with warm saline Electrolyte replacement Insertion of drainage tubes Surgery- depends on the cause Fluid, electrolyte and colloid replacement, like albumin, 1) Exploratory Laparotomy dextran, TPN solutions 2) Removal of the tumor- with end to end anastomosis 3) Adhesiolysis Peritonitis Surgery - Local or generalized inflammation of part or all of the 1) Laparotomy: opening made through the abdominal wall parietal and visceral surfaces of the abdominal cavity into the peritoneal cavity to determine the cause of Pathology peritonitis Initial response 2) Depending on cause, bowel resection may be - edema necessary - vascular congestion Nursing interventions - hypermotility of the bowel and outpouring of plasma- Assess respiratory status for possible distress. like fluid from the extracellular Assess characteristics of abdominal pain and changes - vascular over time. - interstitial compartments into the peritoneal space Administer medications as ordered. Later response Perform frequent abdominal assessment - abdominal distension leading to respiratory Monitor and maintain F&E balance; monitor for signs of compromise septic shock. - hypovolemia results in decreased urinary output Maintain patency of NG or intestinal tubes - Intestinal motility gradually decreases and progresses Encourage deep breathing exercises to paralytic ileus Place client in Fowler’s position to localize peritoneal Causes contents - Caused by trauma (blunt or penetrating) Provide routine pre- and post-op care if surgery ordered - Inflammatory conditions - ulcerative colitis, diverticulitis, pelvic inflammatory Appendicitis disease - Inflammation of the vermiform appendix that prevents - Ischemia mucus from passing into the cecum; if untreated, - Ruptured appendix ischemia, gangrene, rupture, and peritonitis occur - Perforated peptic ulcer - Occurs in about 7% of the population and affects males - UTI more often than females - Bowel obstruction (volvulus, intestinal obstruction) - Causes: - Bacterial invasion mechanical obstruction (fecaliths, calcium-phosphate - Peritoneal dialysis rich mucus & inorganic salts, worms, tumors, viral Assessment Findings infection, inflammation) Severe abdominal PAIN, rebound tenderness, muscle may be related to decreased fiber in the diet and high rigidity, absent bowel sounds, abdominal distension intake of refined carbohydrates Anorexia, N&V kinking of appendix Shallow respirations; decreased urinary output; weak, rapid pulse; fever Signs of shock - Tachycardia - Tachypnea - Oliguria - Restlessness - Weakness - Pallor - Diaphoresis Diagnostic Tests WBC elevated WBC (20,000/cu. mm. or higher) Hct elevated (if hemoconcentration) J.A.K.E 15 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Pathophysiology Diagnostic Tests Obstruction of the appendix lumen (mucosa continues to  WBC (above 10,000/cu.mm.) secrete fluids until pressure w/in the lumen exceeds venous Ultrasound & Abdominal x-ray (detection of fecalith) pressure) Nursing Interventions  Administer antibiotics/antipyretics as ordered blood flow to appendix, mucosal Inflammation and bacterial Prevent perforation of the appendix; don’t give enemas or proliferation cathartics or use heating pad  In addition to routine pre-op care for appendectomy gangrene develops w/in 24-36° due to hypoxia - Give support to parents if seeking treatment was  delayed Abscess - Explain necessity of obtaining lab work prior to surgery  Peritonitis Diverticulitis Assessment Findings - Acute inflammation and infection caused by trapped fecal Pain starts at the epigastric or umbilical region & becomes material and bacteria localized in the “Mc Burney’s point” (midway between the - Diverticulum is outpouching of the mucosal lining of the GI umbilicus and the anterior iliac crest) tract commonly in the colon - “Blumberg sign” = Rebound tenderness - Diverticula/ Diverticulosis are multiple outpouchings - “Psoas sign” = pain with extension of right hip - Causes: - “Rovsing’s sign” = right quadrant pain when the left is Low fiber diet palpated - “Obturator sign” = pain on passive internal rotation of chronic constipation the flexed thigh obesity - Nausea & Vomiting Assessment - Anorexia Dull, steady, cramp-like lower left quadrant abdominal - Decreased bowel sounds PAIN worsens with movement, coughing or straining - Fever, low grade (38 – 38.5°C) Low – grade fever - High grade fever = Ruptured!!! Chronic constipation with episodes of diarrhea Nausea and vomiting Abdominal distention and tenderness Occult bleeding, rectal bleeding, change in bowel movement Signs and symptoms of peritonitis due to development of abscess or perforation Diagnostic Test Colonoscopy sigmoidoscopy visualization of diverticula CBC may reveal increased WBC Barium enema is NOT usually ordered in cases of acute inflammation because of possibility of perforation Nursing Management High fiber diet Liberal fluid intake of 2,500 to 3,000 ml/day. Avoid nuts and seeds which can be trapped in the diverticula. Bulk – forming laxatives are ordered to restore normal bowel pattern IVF and medications During an acute episode: - Bed rest - NPO, then clear liquids to rest the bowel - Avoid high fiber foods to prevent further irritation of the mucosa - Gradually increase the fiber when the infection/ inflammation subsides J.A.K.E 16 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Hemorrhoids Avoid constipation by adhering to these practice : - These are dilated blood vessels beneath the lining of the - High – fiber diet, High fluid intake, Regular exercise skin in the anal cana - Regular time for defecation, Use stool softener until - Types: healing is complete 1) External hemorrhoids – occur below the anal sphincter Notify physician for the following: 2) Internal hemorrhoids – occur above the anal sphincter - Rectal bleeding - Causes - Suppurative drainage Chronic constipation - Continued pain on defecation Pregnancy - Continued constipation Obesity Prolonged sitting or standing HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC. Wearing constricting clothing Major Functions of The Liver Disease conditions like liver cirrhosis, RSCHF Bile production and excretion Assessment Excretion of bilirubin, cholesterol, hormones and drugs Constipation in an effort to prevent pain or bleeding Metabolism of CHO, CHON and fats associated with defecation Storage of glycogen, vitamins and minerals Anal PAIN Synthesis of plasma proteins, such as albumin and Rectal bleeding (usually bright red- hematochezia) clotting factors Anal itchiness Detoxification Mucous secretion from the anus Sensation of incomplete evacuation of the rectum Internal hemorrhoids may prolapse, usually painless. External hemorrhoids are usually painful Nursing Management High fiber diet liberal fluid intake Bulk laxatives Hot Sitz bath, warm compress, witch hazel cream can be applied to decrease size Local anesthetic application – Nupercaine Hepatitis Surgery Hemorrhoidectomy Sclerotherapy (5% phenol in oil) Cryosurgery-use cooled gas or liquid to freeze the external hemorrhoid Rubber band ligation (done only if hemorrhoids are INTERNAL) Pre-op Care - Low residue diet to reduce the bulk of stool - Stool softeners Post-op Care Hepatitis A B C D E o Promotion of comfort - Infectious inflammation of the liver parenchyma caused - Analgesics as prescribed by viruses. - Post-op position: Side – lying position or prone - Widespread inflammation of the liver tissue position - Liver cell damage due to hepatic cell degeneration and - Hot sitz bath 12 to 24 hrs. post-op to promote necrosis comfort and hasten healing - Proliferation and enlargement of the kupffer cells o Promotion of elimination - Inflammation of the periportal areas causing interruption of - Stool softeners are given as prescribed bile flow - Analgesic before initial defecation Viral Hepatitis A - Encourage the client to defecate as soon as the urge - RNA virus transmitted via fecal-oral route. occurs - Poor hygiene or contaminated food and shellfish increase - Enema as prescribed, using a small – bore rectal risk of transmission tube - Incubation period: 15 – 45 days Patient Teaching - Practice food hygiene to prevent hepatitis A Clean rectal area thoroughly after each defecation Sitz bath at home especially after defecation J.A.K.E 17 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 - Incubation: 2 weeks - 6 months - High risk of progression to chronic form (70 – 80%) - Associated with extrahepatic manifestations commonly: mixed cryoglobulinemia and polyarteritis nodosa Viral Hepatitis B - DNA virus, identified in all body fluids: blood, saliva, synovial fluid, breast milk, ascites, cerebral spinal fluid, etc. - Transmitted by blood and body fluids (saliva, semen, vaginal secretions): often from contaminated needles among IV drug abusers; intimate/sexual contact - Accounts for 50% of cases of fulminant hepatitis - In an adult who develops acute hepatitis B, there is approximately 10% chance that it will progress into chronic Viral Hepatitis D hepatitis; in the neonate the chance is 90% for chronic - RNA virus that infects either simultaneously with hepatitis hepatitis. B or as a super-infection in a person with chronic hepatitis - Incubation period is very long: 1 - 6 months B - Hepatitis D infection cannot occur unless there is current and ongoing replication of the hepatitis B virus - Overall, this infection carries the highest risk among acute viral hepatitis for fulminant disease; the risk is even greater in super-infection - Predominantly seen in patients exposed to blood products (drug addicts and hemophiliacs). If anti-hbs antibodies are present, then that person is immune to hepatitis B and D Viral Hepatitis E - Similar to Hepatitis A with fecal or oral transmission, there is no chronic form - The risk of fulminant disease has been described mainly in pregnant patients Viral Hepatitis C Assessment findings - RNA virus generally transmitted predominantly by blood Preicteric stage (prodromal phase) = 1 week products - Anorexia (major manifestation), N&V, fatigue, - Currently the most common hepatitis among IV drug constipation or diarrhea, weight loss abusers and in prisons - RUQ discomfort, hepatomegaly, splenomegaly, - Before 1990 it accounted for 90% of transfusion hepatitis lymphadenopathy J.A.K.E 18 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Icteric stage - Fatigue, weight loss, light-colored stools, dark urine - Continued hepatomegaly with tenderness, lymphadenopathy, splenomegaly - Jaundice, pruritus Posticteric stage - Fatigue, but an increased sense of well-being, hepatomegaly gradually decreasing Collaborative Management Promotion of rest to relieve fatigue Maintenance of food and fluid intake 3,000 ml/day of fluids for fever and vomiting; monitor I and O, weight Types Well – balanced diet; encourage fruit juices and non- o Laênnec’s cirrhosis carbonated beverages - associated with alcohol abuse and malnutrition; Fats may need to be restricted characterized by an accumulation of fat in the Alcoholic beverages should be avoided liver cells, progressing to widespread scar formation. Prevention of injury o Postnecrotic cirrhosis advise client to use soft toothbrush or swabs - results in severe inflammation with massive administer Vitamin K as ordered necrosis as a complication of viral hepatitis Provision of comfort measures o Cardiac cirrhosis Relaxing baths, backrubs, fresh linens and quiet dark - occurs as a consequence of RSHF; manifested by environment hepatomegaly with some fibrosis. Relieve pruritus through the following measures: o Biliary cirrhosis - Use of cool, light, non-restrictive clothing - associated with biliary obstruction, usually in the - Use of soft, dry, clean bedding, use of warm baths common bile duct; results in chronic impairment - Application of emollient creams and lotions to dry skin. of bile excretion - Maintenance of a cool environment Assessment - Administration of antihistamines as ordered Anorexia, weakness, weight loss (liver is unable to - Use of diversional activities, e.g. reading, TV and radio metabolize nutrients and store fat-soluble vitamins) Fever (in response to tissue injury) Liver Cirrhosis Jaundice, pruritus, tea colored urine (due to bilirubin in - Chronic, progressive disease characterized by the blood) inflammation, fibrosis, and degeneration of the liver remember!!! bilirubin is conjugated initially before parenchymal cells excretion - Destroyed liver cells are replaced by scar tissue, resulting Increased Bleeding tendencies. (liver is unable to store Vit. in architectural changes & malfunction of the liver K. There is also impaired production of clotting factors) Portal HPN J.A.K.E 19 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Pathology 1) In portal hypertension - plasma shift into interstitial spaces within the liver due to the increase pressure. The collection of fluids shifts out of the Glisson’s capsule and accumulate in the peritoneal cavity 2) The liver is unable to metabolize protein, thereby hypoalbuminemia occurs - result to decreased oncotic pressure, fluids shift out of the IVC, and accumulate in the peritoneal cavity. 3) The liver is unable to excrete adrenal cortex hormone, one of which is aldosterone - Hyperaldosteronism leads to retention of sodium and water 4) Esophageal varices = 2° to backpressure 5) Internal hemorrhoids, leg varicosities, and dependent edema - due to venous stasis, increasing hydrostatic pressure. Males (estrogen) will result to: This leads to shifting of plasma into interstitial space - Decreased libido, Impotence, Fall of body hair, Atrophy Consequences of Portal HPN: of testicles, gynecomastia Hepatomegaly= initially, then the liver shrinks in size as Females (androgen) fibrosis replaces the liver parenchyma - Hirsutism Splenomegaly= due to increased backpressure of the - acne blood - deepening of voice Caput medusae (dilated veins over the abdomen) - Virilism (development or premature development of Spider angioma (telangiectasia / dilated capillaries over male secondary sexual characteristics) the face and anterior trunk)= due to increased estrogen Palmar erythema. This is also due to elevated estrogen Hepatic Encephalopathy level in males. - Accumulation of AMMONIA because the liver cannot convert ammonia into urea that can lead to hepatic coma Ascites (Ammonia is by product of CHON metabolism) - initial manifestations: BEHAVIORAL changes and MENTAL changes - Other findings in advanced stages are: asterixis – flapping tremors of the hands confusion / disorientation delirium / hallucination fetor hepaticus - disagreeable odor from the mouth coma Diagnostic tests SGOT or AST, SGPT, LDH, alkaline phosphatase increased Serum bilirubin increased PT prolonged Serum albumin decreased Hgb/Hct decreased J.A.K.E 20 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 Medical Management may develop higher in the esophagus or extend into Bedrest the stomach Hepatic protector- Essentiale, Godex o Causes: Betablockers - Commonly caused by PORTAL hypertension secondary Blood transfusion to liver cirrhosis Diuretic Vitamin K Antibiotics- Neomycin Paracentesis Albumer infusion Antihistamine Laxative Enema Diet- low sodium, high CHO, Low CHON, Low fat Nursing interventions Provide sufficient rest and comfort - Provide bed rest with bathroom privileges. Assessment Findings - Encourage gradual, progressive, increasing activity with Hematemesis (vomiting of bright red blood) planned rest periods. Melena (passing out of black, tarry stools) - Institute measures to relieve pruritus. Hepatomegaly o Do not use soaps and detergents Splenomegaly o Bathe in tepid water followed by application Jaundice of an emollient lotion. Ascites o Provide cool, light, nonrestrictive clothing. Signs of SHOCK!!! (Tachycardia, Hypotension, Tachypnea, o Keep nails short to avoid skin excoriation Cold clammy skin) from scratching. Diagnostic Evaluation o Apply cool, moist compresses to pruritic Upper GI endoscopy to identify the cause & site of bleeding areas. Serum liver function test Promote nutritional intake Nursing Interventions - Encourage small frequent feedings. Monitor VS strictly (note: signs of shock), LOC - Promote a high-calorie, low- to moderate- protein, high Maintain NPO, Monitor blood studies CHO, low-fat diet, with supplemental vitamin therapy Administer O2, Blood Transfusion, Vasopressin (Pitressin) (vitamins A, B- complex, C, D, K, and folic acid) Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade Prevent infection Prevent skin breakdown by frequent turning and skin care. Provide reverse isolation for clients with severe leukopenia; pay special attention to hand-washing technique. Monitor WBC. Monitor/prevent bleeding. Administer diuretics as ordered Provide client teaching & D/C planning concerning: Avoidance of agents that may be hepatotoxic (sedatives, opiates, or OTC drugs detoxified by the liver) How to assess for weight gain and increased abdominal girth Avoidance of persons with upper respiratory infections Recognition and reporting of signs of recurring illness (liver tenderness, increased jaundice, increased fatigue, Never leave the patient unattended during esophageal anorexia) balloon tamponade Avoidance of all alcohol Closely monitor the lumen pressure Avoidance of straining at stool, vigorous blowing of nose Check VS q30 minutes. Maintain drainage and suction on and coughing, to decrease the incidence of bleeding the suctions ports o Dilated tortuous veins usually found in the Watch for signs of respiratory distress while the tube is in submucosa of the lower esophagus; however they place. If this will happen, call another nurse to notify the J.A.K.E 21 of 25  NCMB 316 LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023 physician and quickly pinch the tube at the patient’s Provide small, frequent meals of modified diet, low fat (if nose and cut it with scissors, remove the tube oral intake allowed) Deflate the esophageal balloon for about 30 minutes every Provide care to relieve pruritus 8-12 hours Provide care for the client with a cholecystectomy or Provide frequent mouth and nose care choledochostomy Surgical Management Medical management Endoscopic sclerotherapy Supportive treatment: NPO with NG intubation and IV fluids - sclerosing agent is injected directly into the varix with Diet modification with administration of fat- soluble a flexible fiberoptic endoscope to promote vitamins thrombosis & sclerosis of bleeding sites Drug therapy Endoscopic Variceal ligation (variceal banding) NSAIDS- Ketorolac Shunt procedures o Narcotic analgesics for pain o Morphine vs Demerol Cholelithiasis o Anticholinergics (atropine) may be used for pain - “gallstones” o Antiemetics - FAT, FEMALE, FORTY, FERTILE Surgery - More common in women after age 40 (estrogen therapy), Cholecystectomy with choledochotomy women taking oral contraceptives, and in the obese - removal of the gallbladder with insertion of a T-tube Cholecystitis into the common bile duct if common bile duct - acute or chronic inflammation of the gallbladder exploration is