IX. GASTROINTESTINAL A. Pancreatitis: 1. Pathophysiology: a.

The pancreas has two separate functions: 1) Endocrine- INSULIN 2) Exocrine- DIGESTIVE enzymes b. Two types of pancreatitis: 1) Acute: #1 cause = ALCOHOL #2 cause = gallbladder disease 2) Chronic: #1 cause = PANCREATITIS 2. S/S: a. Pain- Does the pain increase or decrease with eating? INCREASE b. Abdominal distention/ascites (losing protein rich fluids like enzymes and blood into the abdomen) ascites c. Abdominal mass- swollen PANCREAS d. Rigid board-like abdomen (guarded) What does it mean? PERITONITIS e. Bruising around umbilical area CULLEN sign; flank area GREY TURNERS sign. f. Fever (inflammation) g. N/V h. Jaundice i. Hypotension = BLEEDING or ASCITIS Hurst Review Services 125 3. Dx: a. Serum lipase and amylase INCREASE b. WBCs INCREASE c. Blood sugar INCREASE d. ALT, AST-liver enzymes INCREASE e. PT, PTT PROLONGED. (BLEEDING) f. Serum bilirubin INCREASE g. H/H (Hemoglobin & Hematocrit) UP or DOWN Why down BLEEDING , up DEHYDRATED. ***Please note that all normal ranges for blood test depend on the lab performing the test. The values listed in this book are only to be used as a reference.

4. Tx: a. Goal: Control pain 1) Decrease gastric secretions (KEEP NPO, NGT to suction, bed rest) Want the stomach empty and dry 2) Pain Medications: PCA narcotics morphine sulfate(Morphine), hydromorphone (Dilaudid) Fentanyl patches 3) Steroids, why? DECREASE INFLAMMATION 4) Anticholinergics, why? DRY UP THE STOMACH ACIDS Benzotropine (Cogentin)Diphenoxylate/Atropi ne (Lonox) 5) Pantoprazole (Protonix) (proton pump inhibitor) 6) Ranitidine HCI (Zantac), Famotidine (Pepcid) (H2 receptor antagonist) 7) Antacids 8) Maintain fluid and electrolyte balance 9) Maintain nutritional status ease into a diet 10) Insulin WHY? PANCREAS IS SICK STEROIDS MAKE IT GO UP GETTING A TPN Normal Lab Values AST=8-40 U/L ALT= 10-30 U/L Normal Lab Values Hemoglobin: Male: 14-18 g/dl Female: 12-16 g/dl Hematocrit: Male: 40-54% Female: 38-47% Normal Lab Values Amylase: 45-200 U/L (dye) Lipase: 0-110 U/L *TESTING STRATEGY* Pancreas client = Keep stomach empty and dry. 126 Hurst Review Services 11) Daily weights 12) Eliminate alcohol

13) Refer to AA if this is the cause. B. Cirrhosis: Liver DETOXIFYING the body. Helps your blood to CLOT The liver helps to metabolize (break down) DRUGS, DECREASE THE DOSE. NEVER GIVE ASPIRIN. The liver synthesizes ALBUMIN 1. Pathophysiology: Liver cells are destroyed and are replaced with connective/scar tissue alters the CIRCULATION within the liver the BP in the liver goes UP, this is called portal HYPERTENTION 2. S/S: a. FIRM, nodular liver b. Abdominal pain liver capsule has stretched c. Chronic dyspepsia (GI upset) d. Change in BOWEL habits e. Ascites f. Splenomegaly g. DECREASED serum albumin HOLD ON THE FLUID IN THE VASCULAR SPACE h. INCREASED ALT & AST LIVER ENZYMES i. Anemia j. Can progress to hepatic encephalopathy/coma *TESTING STRATEGY* If your liver is sick your #1 concern = Bleeding. *TESTING STRATEGY* Never give Tylenol to liver people. *TESTING STRATEGY* When spleen is enlarged the immune system is involved. Hurst Review Services 127 3. Dx: a. Ultrasound b. CT, MRI c. Liver biopsy Clotting studies pre- PT and PTT Vital signs pre-procedure How do you position this client? SUPINE WITH RIGHT ARM BEHIND THE HEAD

Exhale and hold DIAPHRAM Why? To get the DIAPHRAM out of the way. Post: Lie on RIGHT side Vital signs, worried about HEMORRHAGE. 4. Tx: a. Antacids, vitamins, diuretics b. No more ALCOHOL (dont need more damage) c. I & O and daily WEIGHT (Any time you have ascites you have a fluid volume problem) d. Rest e. Prevent bleeding (bleeding precautions) f. Measure abdominal girth, why? ASCITIS g. Paracentesis: Removal of fluid from the PERITONAL cavity (ascites) Have client void Position SITTING UP/FOWLERS Vital signs h. Monitor jaundice good SKIN care, CUT FINGERNAILS. i. Avoid NARCOTICS - liver cant metabolize drugs well when its sick *TESTING STRATEGY* Anytime you are pulling fluids throw them into shock. 128 Hurst Review Services j. Diet: Decrease protein Low Na diet C. Hepatic Coma: 1. Pathophysiology: a. When you eat protein, it transforms into AMMONIA, and the liver converts it to urea. Urea can be excreted through the kidneys without difficulty. b. When the liver becomes impaired then it cant make this conversion, so what chemical builds up in the blood? AMMONIA c. What does this chemical do to the LOC? AMMONIA 2. S/S:

a. Minor mental changes/motor problems b. Difficult to AWAKE. c. Asterixis- FLAPPING FINGERS d. HANDWRITING changes e. Reflexes will decreases. f. EEG SLOWS DOWN. g. What is Fetor? Breath smells like AMMONIA.VERY STONG BREATH SMELL. h. Anything that increases the ammonia level will aggravate the problem. i. Liver people tend to be GI bleeders. 3. Tx: a. Lactulose (Lactulax, Duphalac) (decrease serum ammonia) b. Cleaning enemas c. Decrease PROTEIN in the diet d. Monitor serum ammonia Lets Get Normal Straight First! Protein Breaks down to ammonia The Liver converts ammonia to urea Kidneys excrete the urea *TESTING STRATEGY* If you give liver client narcotics its the same thing as double dosing them. Hurst Review Services 129 D. Bleeding Esophageal Varices 1. Pathophysiology: a. High BP in the liver (PORTAL HTN) forces collateral circulation to form. This circulation forms in 3 different places stomach, esophagus, rectum b. When you see an alcoholic client that is GI bleeding it is usually esophageal varices. Usually no problem until RUPTURES. 2. Tx: a. Replace BLOOD b. VS c. CVP d. Oxygen (any time someone is ANEMIC, Oxygen is needed)

e. Octreotide (Sandostatin) lowers BP in the liver. f. Sengstaken Blakemore Tube What is the purpose? To hold PRESSURE on bleeding varices g. Cleansing enema to get rid of h. Lactulose (Neo-Fradin) (decrease ammonia) i. Saline lavage to get blood out of STOMACH 130 Hurst Review Services E. Peptic Ulcers: 1. Pathophysiology: a. Common cause of GI BLEEDING b. Can be in the esophagus, stomach, duodenum c. Mainly in males or females? MALES, BUT INCREASING IN FEMALES d. Erosion is present 2. S/S: a. Burning PAIN usually on the mid-epigastric area/back b. Heartburn (dyspepsia) 3. Dx: a. Gastroscopy (EGD, endoscopy): 1) NPO pre 2) Sedated 3) NPO until what returns? GAG REFLEX 4) Watch for perforation by watching for PERFORATION, bleeding, or SWALLOWING. b. Upper GI: 1) Looks at the esophagus and stomach with dye 2) NPO past midnight 3) No smoking, chewing gum, or mints. Remove the nicotine patch, too. Smoking INCREASE stomach SECRETIONS which will affect the test. Smoking INCREASE stomach SECRETIONS Hurst Review Services 131 4. Tx: a. Medications: 1) Antacids: Liquids or tablets? LIQUIDS (to ____________stomach)

Take when stomach is empty and at bedtime when stomach is empty acid can get on ulcer take antacid to protect ulcer. 2) Proton Pump Inhibitors: (decrease acid secretions) Omeprazole (Prilosec), Lansoprazole (Prevacid), Pantoprazole (Protonix), Esomeprazole (Nexium) 3) H2 antagonist: Ranitidine (Zantac), Famotidine (Pepcid) GI Cocktail (donnatel, viscous lidocaine, Mylanta II) Antibiotics for H. Pylori: Clarithromycin (Biaxin), Amoxicillin (Amoxil), Tetracycline (Panmycin), Metronidazole (Flagyl) Sucrafata (Carafate): forms a barrier over wound so acid cant get on the ulcer b. Client Teaching: Decrease STRESS Stop SMOKING Eat what you can tolerate; avoid temperature extremes and extra spicy foods; avoid CAFFEINE (irritant). Need to be followed for one year 5. Classifications: a. Gastric ulcers: laboring person; malnourished, pain is usually half hour to 1 hour after meals; food doesnt help, but VOMITTING does; vomit blood b. Duodenal ulcers: executives; well-nourished; night time pain is common and 2-3 hours after meals; FOOD helps; blood in stools F. Hiatal Hernia: 1. Pathophysiology: a. This is when the hole in the diaphragm is too large so the STOMACH moves up into the thoracic cavity. b. Other causes of hiatal hernia: congenital

abnormalities, trauma, and SURGET 132 Hurst Review Services 2. S/S: a. Heartburn b. FULLNESS after eating c. Regurgitation d. Dysphagia (difficulty SWALLOWING) 3. Tx: a. Small frequent meals b. Sit up 1 hour after eating Keep the stomach in down position. c. Elevate HOB d. Surgery e. Teach life style changes and healthy diet G. Dumping Syndrome: 1. Pathophysiology: The stomach empties too quickly and the client experiences many uncomfortable to severe side effects usually secondary to gastric bypass, gastrectomy, or gall bladder disease. 2. S/S: a. Fullness b. Palpitations c. Faintness 3. Tx: d. Weakness e. Cramping f. Diarrhea a. Semi-recumbent with meals b. Lie down after meals c. No FLUIDS with meals (drink in between meals) d. Decrease CARBS (carbs empty fast) *TESTING STRATEGY* Lay on left side to keep food in the stomach. Hurst Review Services 133 H. Ulcerative Colitis and Crohns Disease: 1. Pathophsiology: a. Ulcerative Colitis ulcerative inflammatory bowel disease Just in the large intestine

b. Crohns Disease also called Regional Enteritis; inflammation and erosion of the ILEUM *can be found anywhere 2. S/S: a. Diarrhea b. Rectal bleeding c. Weight loss f. Dehydration g. Blood in stools h. Anemia d. Vomiting i. Rebound tenderness e. Cramping j. Fever What is rebound tenderness? Push in let go HURTS What does it mean? Peritoneal INFLAMMATION 3. Dx: a. CT b. Colonoscopy CLEAR liquid diet for 12-24 hours. NPO 6-8 hours pre Avoid NSAIDs Laxatives or enemas until CLEAR Go-LYTELY Sedated for procedure Post op watch for ANTIEMETIC. We are going to assume the WORST! c. Barium Enema BE or lower GI Done if colonoscopy was incomplete 134 Hurst Review Services 4. Tx: a. Diet: High fiber or low fiber? LOW FIBER Trying to limit motility to help save fluid. Avoid cold foods or hot foods and smoking All of these can INCREASE motility. b. Medications: Anti-diarrheals Only given with mildly symptomatic ulcerative colitis clients; does not work well in severe cases.

Antibiotics Steroids (decrease INFLAMMATION) c. Surgery: 1) Ulcerative Colitis: Total Colectomy (ilesostomy formed) Kocks ileostomy or a J Pouch (no external bag) A Kocks Pouch has a nipple valve that opens and closes to EMPTY intestines The J Pouch procedure removes the colon and attaches the ileum into the rectum. 2) Crohns: (try not to do surgery) May remove only the ILEUM area. The client may end up with an ileostomy or a colostomy. It just depends on the area affected. d. Post op Care: 1) Ileostomy Care: Its going to drain LIQUID all the time. Avoid foods hard to digest; rough foods INCREASE motility. Gatorade in the summer At risk for kidney stones (always a little DEHYDRATED) Hurst Review Services 135 2) Colostomy Care: What happens as waste moves through the colon? Water and nutrients are being absorbed and the STOOL is forming. Colostomy ascending and transverse semi LIQUID stools Colostomy descending or sigmoid semi formed or FORMED. Which one do you irrigate? SIGMOID & DECENDING Why regulate? FOR REGULARITY OF STOOLS When is the best time to irrigate? Same TIME everyday After a MEAL

The further down the colon the stoma is, the more formed the stool will be because WATER is being drawn out. The stool is more normal. 136 Hurst Review Services I. Appendicitis: 1. Pathophysiology: Related to a LOW fiber diet 2. S/S: Generalized pain initially Eventually localizes in the right lower quadrant (McBurneys POINT) Rebound tenderness Nausea and vomiting Get good history (abdominal pain 1st then N & V) Anorexia 3. Dx: WBC INCREASE Ultrasound CT Do not do enemas because you are worried about what? RUPTURE 4. Tx: Surgery Most done via laparoscope unless perforated. After any major abdominal surgery, what is the position of choice? SITTING ON THE RIGHT SIDE *TESTING STRATEGY* #1 thing to worry about is rupture. *TESTING STRATEGY* Positioning is very important to learn as a brand new nurse. *TESTING STRATEGY* Never want pressure on a suture line. Hurst Review Services 137 J. Hyperalimentation (total parental nutrition) (TPN): 1. Nursing Considerations: Keep refrigerated; warm for administration; let sit out for a few minutes prior to hanging. Central line needed Filter needed

Nothing else should go through this line (dedicated line) Discontinued gradually to avoid HYPOGLYCEMIA Daily WEIGHTS May have to start taking INSULIN Accu-checks q6 hours Check URINE (for GLUCOSE & KETONES) Do not mix ahead- mixture changes everyday according to electrolytes. Can only be hung 24 hours Change tubing with each new bag. IV bag may be covered with dark bag to prevent chemical breakdown. Needs to be on a pump Home TPN-emphasize hand washing Most frequent complication INFECTION *TESTING STRATEGY* Protein cant leak through the glomerulus unless there is kidney damage. 138 Hurst Review Services 2. Assisting the MD insert a central line: Have saline available for flush; do not start fluids until positive confirmation of placement (CXR). (3) 10cc syringe Position? TRENDELENBURG to distend veins. If air gets in the line what position do you put the client in? LEFT SIDE TREDELENBURG When you are changing the tubing, how can you avoid getting air in the line? Clamp it off Valsalva Take a deep BREATH and HUMMMMMM Why is an x-ray done postinsertion? Check for PLACEMENT Make sure your client does not have a PNEUMOTHORAX.

NCLEX Critical Thinking Exercise: A nurse is assisting a physician inserting a central line, for a client diagnosed with sepsis. After inserting the central line. Which of the following options would be most appropriate? 1. Start the ordered antibiotics. 2. Allow the physician to start the antibiotics as ordered. 3. Check for blood return and if present start the antibiotics ordered. 4. Administer the stat antibiotics after you have confirmation of placement of the central line.