GI

Question 0

Pancreatitis signs and symptoms

Answer 0

1. Pain increases with eating
2. Abdominal distention/ascites (losing protein rich fluids like enzymes and blood into the abdomen) → ascites
3. Abdominal mass-swollen pancreas
4. Rigid board-like abdomen (guarding or bleeding) > peritonitis
5. Bruising around umbilical area Culling sign; flank area Gray Turner’s sign.
6. Fever (inflammation)
7. N/V
8. Jaundice
9. Hypotension = bleeding or ascites

Question 1

Patho pancreatitis

Answer 1

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 = alcohol

Question 2

Pancreatitis diagnosis and labs

Answer 2

Normal Lab Values 
Amylase: 45-200 U/L (dye) 
Lipase: 0-110 U/L
AST=8-40 U/L 
ALT= 10-30 U/L
Hemoglobin: Male: 14-18 g/dl 
Female: 12-16 g/dl 
Hematocrit: Male: 40-54% 
Female: 38-47%
a. Serum lipase and amylase increase
b. WBCs increase
c. Blood sugar increases
d. ALT, AST-liver enzymes increases
e. PT, PTT longer
f. Serum bilirubin increased
g. H/H (Hemoglobin & Hematocrit) up or down
 • down if bleeding, up if dehydrated

Question 3

Pancreatitis treatment

Answer 3

***Pancreas client = Keep stomach empty and dry.
a. Goal: Control pain
1) Decrease gastric secretions (NPO, NGT to suction, bed rest) • Want the stomach empty and dry
2) Pain Medications:
• PCA narcotics morphine sulfate(Morphine®), hydromorphone
(Dilaudid®)
• Fentanyl patches(Duragesic®)
3) steroids to decrease inflammation
4) Anticholinergics, dry up
• Benztropine (Cogentin®), Diphenoxylate/Atropine (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?
• pancrease not producing enough
• steroids increase sugar
• TPN
11) Daily weights
12) Eliminate alcohol
13) Refer to AA if this is the cause

Question 4

Cirrhosis patho

Answer 4

TESTING STRATEGY
If your liver is sick your #1 concern = Bleeding.
Never give Tylenol to liver people.

• Liver detoxifies the body.
• Helps your blood to clot
• The liver helps to metabolize (break down) medications
• The liver synthesizes/makes 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 HTN

Question 5

Cirrhosis S/S

Answer 5

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 (unexplained swelling, check albumin)
h. Increaded ALT & AST
I. Anemia from bleeding
j. Can progress to hepatic encephalopathy/coma build up of ammonia (also caused by rye syndrome and Tylenol overdose)

TESTING STRATEGY
When spleen is enlarged the immune system is involved.

Question 6

Cirrhosis dx

Answer 6

a. Ultrasound
b. CT, MRI
c. Liver biopsy
• Clotting studies pre- PT and PTT
• Vital signs pre-procedure
• position supine, r arm behind head
• Exhale and hold breath for few seconds
Why? To get the diaphragm out of the way.
• Post: Lie on R side
Vital signs, worried about hemorrhage

Question 7

Cirrhosis treatment

Answer 7

a. Antacids, vitamins, diuretics
b. No more alcohol (don’t need more damage)
c. I&O and daily weights
d. Rest
e. Prevent bleeding(bleeding precautions)
f. Measure abdominal girth for ascites
g. Paracentesis:
• Removal of fluid from the peritoneal cavity (ascites)
• Have client void
• Position sitting up so that fluid settles
• Vital signs for shock
h. Monitor jaundice – good skin care
i. Avoid narcotics- liver can’t metabolize drugs well when it’s sick
j. Diet:
• Decrease protein
• Low Na diet

TESTING STRATEGY
Anytime you are pulling fluids→ worry about throwing them into shock.
If you give liver client narcotics it’s the same thing as double dosing them.

Let’s Get Normal Straight First!
Protein→ Breaks down to ammonia→ The Liver converts ammonia to urea→ Kidneys excrete the urea

Question 8

Hepatic coma

Patho

Answer 8

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 can’t make this conversion, so what chemical builds up in the blood? Ammonia
c. What does this chemical do to the LOC? Decreases

Question 9

Hepatic coma

S/S

Answer 9

A. Minor mental changes/motor problems
b. Difficult to awaken
c. Asterixis hand tremors, handwriting changes d. Reflexes will decrease
e. EEG slow
f What is Fetor? Breath smells like ammonia.
g. Anything that increases the ammonia level will aggravate the problem.
h. Liver people tend to be GI bleeders.

Question 10

Hepatic coma treatment

Answer 10

a. Lactulose (Lactulax®, Duphalac®) (decreases serum ammonia)
b. Cleansing enemas-get fat out of GI tract
c. Decrease protein in the diet
d. Monitor serum ammonia daily

Question 11

Bleeding Esophageal varices

Answer 11

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 it 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 varice
   g. Cleansing enema to get rid of blood
   h. Lactulose (Neo-Fradin®) (decreases ammonia)
   i. Saline lavage to get blood out of stomach

EVL: Esophageal Variceal Ligation
Also an option. In this procedure a rubber- band like Ligature is slipped over the varices via an endoscope, necrosis results and the varices eventually slough off.

Question 12

Peptic ulcers

pathophysiology and signs and symptoms

Answer 12

1. Pathophysiology:
   a. Common cause of GI bleeding
   b. Can be in the esophagus, stomach, duodenum
   c. Mainly in males
   d. Erosion is present
2. S/S:
   a. Burning pain usually on the mid-epigastric area/back
   b. Heartburn (dyspepsia)

Question 13

Peptic ulcers diagnosis

Answer 13

a. Gastroscopy (EGD, endoscopy):
1) NPO preop
2) Sedated
3) NPO until gag reflex returns
4) Watch for perforation by watching for pain,bleeding, or trouble swallowing.

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 increases stomach motility which will affect the test.
• Smoking increases stomach secretions.

Question 14

Peptic ulcers treatment

Answer 14

Tx:
a. Medications:
1) Antacids: Liquids (to coat 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 (donnatal, viscous lidocaine, Mylanta II®)
• Antibiotics for H. Pylori: Clarithromycin (Biaxin®), Amoxicillin (Amoxil®), Tetracycline (Panmycin®), Metronidazole (Flagyl®)
• Sucralfate (Carafate®): forms a barrier over the wound so acid can’t 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

Question 15

Classification of peptic ulcers

Answer 15

a. Gastric ulcers: laboring person; malnourished, pain is usually half hour to 1 hour after meals; food doesn’t help, but vomiting 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

Question 16

Hiatal hernia

Answer 16

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 surgery
2. S/S:
   a. Heartburn
   b. fullness after eating
   c. Regurgitation
   d. Dysphagia (difficulty swallowing)
3. TX:
   a. Small frequent meals; sit up one hour after eating; elevate head of bed to keep the stomach in a down position
   b. surgery
   c. teach lifestyle changes and healthy diet

Question 17

Dumping syndrome

Answer 17

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:
Fullness 
palpitations 
faintness 
weakness 
cramping 
diarrhea

3. TX:
   Semi-recumbent with meals
   Lie down after meals
   No fluids with meals (drink in between meals) Decrease carbs (carbs empty fast)
   TESTING STRATEGY
   Lay on left side to keep food in the stomach.

Question 18

Ulcerative colitis and Crohn’s disease
Patho
S/S

Answer 18

1. Pathophysiology:
   a. Ulcerative Colitis→ ulcerative inflammatory bowel disease • Just in the large intestine
   b. Crohn’s Disease→ also called Regional Enteritis; inflammation and erosion of the ileum (small intestine) *can be found anywhere
2. S/S:
   a. Diarrhea
   b. Rectal bleeding
   c. Weight loss
   d. Vomiting
   e. Cramping
   f. Dehydration
   g. Blood in stools
   h. Anemia
   i. Rebound tenderness
   j. Fever
   • What is rebound tenderness? Push in → let go→ pain
   • What does it mean? Peritoneal inflammation

Question 19

Ulcerative colitis DX

Answer 19

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® (8oz glass q 10 min, give icy cold, anti nausea meds also)
   • Sedated for procedure
   • Post op watch for perforation . We are going to assume the WORST! Pain or discomfort
   c. Barium Enema
   • BE or lower GI
   • Done if colonoscopy is incomplete.

Question 20

Ulcerative colitis treatment

Answer 20

a. Diet:
• low fiber > Trying to limit GI motility to help save fluid.
• Avoid cold foods or hot foods and smoking
All of these can increase motility.
b. Medications:
• Antidiarrheals
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)
• Kock’s ileostomy or a J Pouch (no external bag)
A Kock’s Pouch has a nipple valve that opens and closes to empty intestines
The J Pouch procedure removes the colon and attaches the ileum to the rectum.
2) Crohn’s: (try not to do surgery)
• May remove only the affected 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:
• It’s 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)
2) colostomy care

Question 21

Colostomy care

Answer 21

• What happens as waste moves through the colon?
Water and nutrients are being absorbed and the stool is forming.
Cecum>ascending> transverse>descending>sigmoid>rectum

• Colostomy → ascending and transverse→ semi liquid stools
• Colostomy→ descending or sigmoid→ semi formed or formed.
• Which one do you irrigate? Descending & sigmoid to establish regularity
• 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.

Question 22

Appendicitis

Answer 22

1. Pathophysiology:
• Related to a low fiber diet
2. S/S:
• Generalized pain initially
Eventually localizes in the right lower quadrant (McBurney’s point)
• Rebound tenderness
• Nausea and vomiting
• Get good history (abdominal pain 1st then N & V)
• Anorexia

3.  DX:
Increased WBC 
ultrasound 
CT 
do not do enemas because you are worried about rupture

4. TX:
   Surgery is usually done laparoscopically unless perforated. After any major abdominal surgery elevate the head of the bed to decrease pressure on the suture line.

Question 23

TPN/hyperalimentation

Answer 23

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 weight
   • May have to start taking insulin
   • Blood glucose monitoring q6 hours
   • Check urine (for glucose & ketones)
   • Do not mix ahead- mixture changes everyday according to electrolytes.
   • Can only be hung for 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 can’t leak through the glomerulus unless there is kidney damage.

Question 24

Assisting with central line insertion

Answer 24

*Have saline available for flush; do not start fluids until positive confirmation of placement (CXR). *Position trendelenburg to distend veins. If air gets in the line position L/side trendenlenburg. When an air embolus is suspected in the heart the client may be taken to the cath lab for removal of the air. *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 post-insertion? Check for placement Make sure your client does not have a pneumothorax