Gastrointestinal Emergencies PDF

NCMB 418- Care of patients with life threatening conditions Gastrointestinal Emergencies Gastrointestinal Emergencies Alcohol Withdrawal Liver Cirrhosis Pancreatitis Gastrointestinal Bleeding Review of Anatomy and Physiology Alcohol withdrawal Alcohol is the...

NCMB 418- Care of patients with life threatening conditions Gastrointestinal Emergencies Gastrointestinal Emergencies Alcohol Withdrawal Liver Cirrhosis Pancreatitis Gastrointestinal Bleeding Review of Anatomy and Physiology Alcohol withdrawal Alcohol is the most commonly abused substance in the United States. Alcohol withdrawal syndrome (AWS), the constellation of symptoms that may develop in individuals with habitual alcohol intake who stop or significantly decrease their alcohol consumption, occurs in as many as 20% of critical care patients (Riddle, Bush, Tittle, & Dilkhush, 2010). Alcohol Withdrawal Syndrome When exposed to repeated doses of alcohol, the central nervous system (CNS) becomes accustomed to the depressant effects of the alcohol and produces adaptive changes in an attempt to function normally. In the absence of alcohol or with a significant decrease in the amount of alcohol, chaos erupts within the CNS. When alcohol is no longer acting as a depressant, the compensatory actions cause excessive CNS excitability. Alcohol Withdrawal Syndrome Stages of withdrawal are described chronologically as early and late, or according to severity in terms of minor and major or mild, moderate, or severe. Severity is evaluated by the degree of autonomic hyperactivity and neuropsychiatric behavior and the occurrence of complications. Having a history of previous withdrawals also suggests that subsequent withdrawals can be progressively more severe- Kindling Effect Majority of patients- Minor Withdrawal symptoms Others may progress to major withdrawal and experience the most severe manifestations, including withdrawal seizures, alcoholic hallucinosis, withdrawal delirium, or delirium tremens (DTs). Associated problems Liver Deterioration Gastrointestinal Disturbances Pancreatitis Wernicke’s Encephalopathy- inflammatory hemorrhagic and degenerative condition of the brain is caused by a thiamine deficiency. Korsakoff’s Psychosis - Both thiamine and B12 deficiencies contribute to the degeneration of the brain and peripheral nervous system. Cardiovascular Disturbances Fetal Alcohol Syndrome Assessment and Management of the Patient with Alcohol Withdrawal Syndrome Goals of management are to: Identify patients at risk for AWS Establish severity Decrease agitation and prevent withdrawal progression Provide supportive care Maintain fluid and electrolyte balance Provide a safe and dignified environment Minimize effects on acute and chronic comorbid illnesses Prevent complications Initiate case management services for future rehabilitation treatment Severe Alcohol Withdrawal Alcohol Withdrawal Seizures commonly occur and can manifest anytime during withdrawal often appear early, within 6 to 48 hours of the last alcohol ingestion. Patients with a chronic heavy drinking history who have experienced previous episodes of withdrawal have an increased incidence of seizures. are likely to be brief, single, generalized, and tonic-clonic. The nurse monitors for fluid and electrolyte abnormalities and hypoglycemia, which may be associated with seizures. Severe Alcohol Withdrawal Alcoholic Hallucinosis can manifest from 12 to 24 hours after the last alcohol ingestion. patient experiences perceptual disturbances, usually visual, auditory, or tactile phenomena, without sensorial alterations. patient is fully conscious, aware of the environment, and acknowledging that the hallucinations are related to the substance dependence and withdrawal. usually resolve in 24 to 48 hours. The nurse assesses the characteristics of the hallucinations along with orientation status to distinguish hallucinosis from the hallucinations characteristic of the DTs Severe Alcohol Withdrawal Delirium Tremens also called alcohol withdrawal delirium the most severe complication of withdrawal Often it is the result of under treatment or lack of treatment. is seen in approximately 5% of the cases Mortality is up to 1-4% and death is often caused by arrhythmias and associated critical illnesses (Schuckit, 2014) Severe Alcohol Withdrawal Delirium Tremens Risk factors include older age, preexisting lung disease, coexisting liver disease, concurrent illnesses, a previous history of DTs, and/or a history of sustained drinking autonomic and neuropsychological manifestations are profoundly exaggerated most characteristic distinction of the DTs is the disorientation and global confusion The nurse must assess for marked agitation, hallucinations, and distractibility with accentuated response to external stimuli, and increases in heart rate, blood pressure, respiratory rate, and temperature. Stages of Withdrawal Alcohol withdrawal has three stages: Stage 1 (minor withdrawal) includes restlessness, anxiety, sleeping problems, agitation, and tremors; other signs include low-grade fever, tachycardia, diaphoresis, and hypertension Stage 2 (major withdrawal) includes stage 1 signs and symptoms plus visual and auditory hallucinations, whole-body tremors, pulse.100 beats/min, diastolic BP.100 mm Hg, pronounced diaphoresis, and possibly vomiting. Stage 3 (delirium tremens) includes a temperature.100°F (37.8°C); disorientation to time, place, and person; global confusion; and inability to recognize familiar objects or persons. This is a medical emergency with a mortality rate of 1% to 5% (Kasser, Geller, Howell, & Wartenberg, 2004). Treatment/Rehabilitation Detoxification goal of detoxification (DETOX) is to halt or control the neuronal overactivity that occurs when the alcohol level is reduced or alcohol is no longer present in the client’s body. done by substituting a pharmacologically similar drug and gradually reducing the dose given. The benzodiazepine drugs, chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan), and clorazepate dipotassium (Tranxene), are the most commonly used. A client with hypoglycemia should be given thiamine before administering dextrose to prevent Wernicke’s encephalopathy. Treatment/Rehabilitation Psychological Intervention Johnsonian intervention, which is a confrontational approach to a client with a substance problem that lessens the chance of denial and encourages treatment before the client “hits bottom.” This technique can also be used for substances other than alcohol Treatment/Rehabilitation Education abuse of or dependence on alcohol is a maladaptive way to cope with life stressors Learning basic life skills to improve personal competence and provide adaptive coping mechanisms helps the individual resist the use of alcohol. Assist clients to become active in an exercise program and encourage them to participate. Exercise helps relieve feelings of stress and promotes feelings of well-being. Teach clients about the MyPlate food guidelines for an adequate, balanced diet. Treatment/Rehabilitation Self-Help Groups Alcoholics Anonymous (AA), begun in 1935, is the model for other self-help groups such as AL-ANON for adults, ALATEEN for teenage children, and AL-ATOT for younger children in the family of an individual with alcoholism. Treatment/Rehabilitation Disulfiram Disulfiram (Antabuse) may be given to some alcohol abusers as a deterrent to drinking. It produces a sensitivity to alcohol that results in highly unpleasant symptoms Drinking alcohol with disulfiram in the body causes flushing of the neck and face, blurred vision, nausea, vertigo, anxiety, palpitations, tachycardia, and hypotension. Clients must be instructed not to use products made with alcohol. Garlic-like breath occurs frequently and is sometimes used as an indicator of compliance in taking the disulfiram Contraindicated in clients with cardiovascular disease, hypothyroidism, or suicide ideation and in clients receiving antihypertensives or monoamine oxidase inhibitors Medical-Surgical Management Medical Treatment focuses on preserving normal pancreatic function, providing supportive care, and preventing pancreatic necrosis and complications. Treatment depends on the cause of the pancreatitis and removing it if possible. NG tube may be inserted to rest the bowel and relieve abdominal distention. Lab tests are ordered and monitored such as blood glucose, triglycerides, electrolytes, CBC and WBC count, platelets, liver function tests, amylase, lipase, and renal function studies. Medical-Surgical Management Surgical Surgery to relieve the pancreatic duct obstruction An ERCP with stone removal or a cholecystectomy is performed if the pancreatitis is caused by structural changes, such as gallstones. Surgery may be necessary to repair fistulas, drain cysts, resect portions of the pancreas, debride necrotic areas, or repair other damage Medical-Surgical Management Pharmacological Insulin if there is pancreatic insufficiency Opioids for pain control Antiemetics if with N/V Anticholinergics to decrease pancreatic activity Antacids to prevent stress ulcers Replacement enzymes if warranted Medical Surgical Management Diet - NPO>Clear liquids>SFF of bland, low fat, high protein, high carbohydrate diet Activity- bed rest to decrease metabolic rate until serum amylase decreases Nursing Management Monitor and maintain NG tube Weigh client daily and maintain client on bed rest. Assess pain, administer analgesic as ordered, and assess effectiveness Monitor vital signs Provide personal hygiene. Assess and maintain IV hydration, enteral feeding, and TPN, if ordered Accurately record I&O Monitor laboratory results Gastrointestinal (GI) bleeding a common, costly, and potentially life-threatening medical condition Upper gastrointestinal (UGI) bleeding originates proximal to the ligament of Treitz. UGI bleeding is classified as variceal or nonvariceal Lower gastrointestinal (LGI) bleeding refers to bleeding originating distal to the ligament of Treitz, and is differentiated into bleeding from the small bowel or mid-GI bleeding, and bleeding from the colon, or lower GI bleeding Predisposing Factors and Causes of Gastrointestinal Hemorrhage Peptic Ulcer Disease typically refers to ulcers in the stomach and the first part of the duodenum, also called the duodenal bulb Risk factors: Age, NSAID and aspirin use, stress-related mucosal damage Predisposing Factors and Causes of Gastrointestinal Hemorrhage Diverticular Disease results from weak points on the intestinal wall that herniate to form a saclike projection called diverticula most often found in the descending and sigmoid colon, but they can be throughout the colon. Bleeding results from rupture of submucosal arterial vessels at the neck or the dome of the diverticulum Manifestations Manifestations Hypotension Narrowed pulse pressure Orthostatic hypotension Tachycardia ECG Changes Chest pain Poor capillary refill(>3 sec) Dry mucous membranes, poor skin turgor, and flat jugular veins Decreased urine output Mental status changes Coronary Artery Diseases Brief Review Heart Structure Blood Oxygenation & Blood Flow  Physiologic Changes of Aging Aorta & arteries tend to become less distensible Heart becomes less responsive to catecholamines Maximal exercise heart rate declines Decreased rate of diastolic relaxation (↑in BP is more pronounced for systolic BP than diastolic BP) – Note that hypertension is NOT a normal age- related process Compensatory mechanism are delayed/insufficient = orthostatic hypotension is common Thickness of LV wall may increase with age due to blood vessel changes  CORONARY ARTERY DISEASE (CAD) Also known as coronary HEART disease (CHD) Describes heart disease caused by impaired coronary blood flow Common cause: atherosclerosis CAD can cause the following: – Angina – Myocardial Infarction (MI) = heart attack – Cardiac dysrhythmias – Conduction defects – Heart failure – Sudden death Men are more often affected than women Approximately 80% who die of CHD are 65+ y/o  Physical Assessment Inspection: – Skin color – Neck vein distention (jugular vein) – Respiration – Peripheral edema Palpation: – Peripheral pulses  Cont… Auscultation: – Heart sounds (presence of S3 in adults & S4) – Murmurs – audible vibrations of the heart & great vessels produced by turbulent blood flow – Pericardial friction rub – extra heart sound originating from the pericardial sac - may be a sign of inflammation, infection, or infiltration - described as a short, high-pitched scratchy sound  Common Clinical Manifestations Dyspnea – Dyspnea on exertion – may indicate decreased cardiac reserve – Orthopnea – a symptom of more advanced heart failure – Paroxysmal nocturnal dyspnea – severe SOB that usually occurs 2-5hrs after onset of sleep Chest Pain – may be due to decreased coronary tissue perfusion or compression & irritation of nerve endings Edema – increased hydrostatic pressure in venous system causes shifting of plasma resulting to interstitial fluid accumulation Syncope – due to decreased cerebral perfusion Palpitations Fatigue  Diagnostics ❖ ECG (Electrocardiography) – graphical recording of the heart’s electrical activities; 1st diagnostic test done when cardiovascular disorder is suspected – Waves: P wave – atrial depolarization (contraction/stimulation) QRS complex – ventricular depolarization (changes are irreversible) ST segment – ventricular repolarization (changes are reversible) U wave – hypokalemia – PR interval (time for impulse to travel) = 0.12-0.20s (3-5 squares) √ for AV block – QRS = 0.10s or (