1
Q
– refers to any bleeding that starts in the GI tract
* Bleeding may come from any site along the GI tract, but is often
divided into:
o Upper GI Bleeding – The upper GI includes the esophagus
(tube from mouth to stomach), stomach, and first part of the
small intestine
o Lower GI Bleeding – the lower GI includes much of the small
intestine, large intestine or bowels, rectum, and anus
A
ACUTE GI BLEEDING
2
Q
ACUTE GI BLEEDING ETIOLOGY
A
Upper GIT disorders
* Peptic ulcer disease
* Duodenal ulcer (20-30%)
* Gastric ulcer (10-20%)
* Gastric or duodenal
erosions (20-30%)
* Gastroesophageal varices
(15-20%)
Lower GIT disorders
* Anal fissures
* Colitis; Radiation,
ischemic, infectious
* Colonic sarcoma
* Colonic polyps
* Diverticular disease
* IBD (ulcerative colitis,
Crohn’s disease)
* Internal hemorrhoids
3
Q
ACUTE GI BLEEDING
Signs and Symptoms/ Clinical Presentation
A
- Hematemesis
- Melena – black stools; old blood; upper GIT bleeding
- Hematochezia – red stools; fresh blood; lower GIT bleeding
- Syncope
- Dyspepsia (indigestion)
- Epigastric pain
- Heartburn
- Diffuse abdominal pain
- Dysphagia
- Weight loss
- Signs of shock
o Hypotension
o Decreased pulses
o Decreased urine output - Jaundice
4
Q
ACUTE GI BLEEDING
Diagnostic Exams
A
- Endoscopy – considered the GOLD STANDARD for diagnosis of GI bleeding
- EGD
- Colonoscopy
- Radiographic procedures
- Serum blood studies
5
Q
ACUTE GI BLEEDING
TREATMENT:
A
Treatment: Fluid resuscitation
* Adequate resuscitation and stabilization is essential
* Px with active bleeding should receive IVF (e.g. 500 mL of NS or
RL over 30 minutes) while being crossmatched for blood
transfusion
* Blood transfusion
o Must be individualized
o Approach is to initiate BT if hemoglobin is <7 g/dL (70 mg/L)
* Hemostasis
o Early intervention to control bleeding is important to
minimize mortality, particularly in elderly px
* Airway
o Endotracheal intubation should be considered in px who
have inadequate gag reflexes or are obtunded or
unconscious, particularly if they will be undergoing upper
endoscopy
* Active variceal bleeding
o Can be treated with endoscopic banding, injection
sclerotherapy, or transjugular intrahepatic portosystemic
shunting (TIPS) procedure
* General support
o Supplemental oxygen via nasal cannula
o NPO
o PIVC (16G / 18G) or a central venous line should be inserted
o Placement of a pulmonary artery catheter
o Elective endotracheal intubation
6
Q
ACUTE GI BLEEDING
Nursing Management
A
- All critically ill px should be considered at risk for stress ulcers
and therefore GI hemorrhage. - Maintaining gastric fluid pH 3.5-4.5 is a goal of prophylactic
therapy - Major nursing interventions are:
o Administering volume replacement
o Controlling bleeding
o Maintaining surveillance for complications (i.e. hemorrhagic
shock)
o Educating family and px
7
Q
- Intrabdominal pressure – pressure concealed within the
abdominal cavity
o Sustained pathological elevation of IAP greater than or equal
to 12 mmHg:
Grade I - IAP between 12-15 mmHg
Grade II - IAP between 16-20 mmHg
Grade III - IAP between 21-25 mmHg
Grade IV - IAP >25 mmHg
A
Intraabdominal hypertension (IAH)
8
Q
o Organ dysfunction caused by intraabdominal pressure >20
mmHg
o This is a MEDICAL EMERGENCY
- Prevalence
o IAH and ACS are not only r/t trauma
▪ IAH and ACS are equally prevalent in medical px
▪ Can be found in every critical care population
A
Abdominal Compartment Syndrome (ACS)
9
Q
Effects of Increase IAP
A
- Renal
o Compression of renal veins and collecting systems
o Oliguria, activation of RAA system, acute tubular necrosis,
and renal failure (if prolonged) - Neurological
o ↑ ICP
o ↓ Cerebral perfusion pressure (CPP) - Gastrointestinal
o Edema
o Necrosis
10
Q
- The gold standard for diagnosing intra-abdominal hypertension
- Measure IAP at least q 4-6 hours
- IAP is measured by measuring bladder pressure
o Requires placement of indwelling urinary catheter
o Drainage bag clamped
o Px in flat supine position (recommended)
▪ If not tolerated, may place in supine 30-degree reverse
Trendelenburg
▪ Note px position at the time of pressure measurement
in medical record
o Instill 25 mL of sterile 0.9% normal saline thru catheter
o Transducer attached to catheter sample port (transducer
zeroes to mid axillary line, at the level of the iliac crest)
o Obtain pressure reading during end-expiration
o Subtract instilled volume from urine output
o Monitor for trends and signs of organ dysfunction
A
Intra-abdominal Pressure Monitoring
11
Q
TREATMENT FOR IAP
A
- Titrate therapies for IAP <= 15 mmHg
- Optimize fluid status
- Optimize systemic perfusion
o Goal abdominal perfusion pressure (AP) of >= 60 mmHg
o APP = MAP – IAP - Evacuate intraintestinal contents
- Evacuate intra-abdominal lesions
- Improve abdominal wall compliance
- Consider emergent abdominal decompression
o Percutaneous drain to remove fluid
o Decompressive Celiotomy
o Bedside laparotomy
12
Q
- An uncommon condition in which rapid deterioration of liver
function results in coagulopathy and alteration in mental status - Liver failure indicated that liver has sustained injury
A
LIVER FAILURE
13
Q
Types of Liver Failure
A
- Fulminant Hepatic Failure
o Encephalopathy starts within 8 weeks - Non Fulminant Hepatic Failure
o Encephalopathy starts between 8-26 weeks
14
Q
- Is a rare condition characterized by the ABRUPT onset of severe
liver injury - Loss of liver function that occurs rapidly—in days or weeks—
usually in a person who has no pre-existing liver disease - It’s a MEDICAL EMERGENCY that requires hospitalization
A
Acute Liver Failure
15
Q
LIVER FAILURE
Signs and Symptoms
A
- Jaundice
- Hepatic encephalopathy
o Mental confusion
o Difficulty concentrating
o Disorientation - Pain and tenderness in the upper right side of the stomach
- Electrolyte imbalances
o Hypoglycemia
o Hypokalemia
o Hypomagnesemia
o Hypocalcemia
o Hypophosphatemia - Melena
- Ascites
- Ankle edema
- Malaise, drowsiness, and muscle tremors
- Bleeding, cerebral edema, hematemesis, coma
16
Q
LIVER FAILURE
Pharmacological Management
A
- Treatment of acute liver failure consists of drugs and liver
transplantation - Pharmacological management includes certain antidotes to
reverse the effects of ALF and various medication to reduce ICP
o Penicillin G
o Activated charcoal
o N-acetylcysteine
o Osmotic diuretics
o Barbiturate
o Benzodiazepine
o Anesthetic agents
17
Q
LIVER FAILURE
Nursing Managements
A
- Assess, report, and record S/S and reactions to treatment
- Monitor fluids I&O closely
- Provide adequate diet with high proteins, CHO, and vitamins
(carefully in encephalopathy) - Monitor for signs of possible bleeding
- For coagulopathy / GIT bleeding
o Vit. K can be given to treat abnormal PT - Hypotension should be treated with fluids
- Pulmonary complications – mechanical ventilation may be
required - HOB should elevated to 30 degrees
- Monitor neurologic status
o Goal is to maintain ICP below 20 mmHg, and CPP above 50-
60 mmHg
o Judicious administration of sedation and analgesia for px
experiencing agitation during certain stages of hepatic
encephalopathy
18
Q
- Occurs suddenly as 1 attack or can be recurrent with resolutions
- Can be a medical emergency
- Due to self-digestion of pancreas by its own proteolytic enzymes
A
ACUTE PANCREATITIS
19
Q
ACUTE PANCREATITIS
Assessment
A
- Acute steady and severe epigastric pain that occur in the
umbilical area and may radiate into the back - Associated with ingestion of alcohol or fatty meal (cardinal sign)
- Pain is usually the main symptom in pancreatitis and is
aggravated when lying down - Nausea & vomiting worsens with oral intake and does not relieve
the pain - Vital signs:
o Fever
o Hypotension
o Tachycardia - Abdominal rigidity,
tenderness, distention, and
decreased bowel sounds - Grey Turner’s Sign
o Reddish-brown to bluish discoloration along the flanks and
represents accumulation of blood in the area; a sign of
severe necrotizing pancreatitis - Cullen Sign
o Bluish discoloration around the umbilicus
o Also a sign of severe necrotizing pancreatitis - Steatorrhea
o Fat content increase in volume as pancreatic insufficiency
worsens
20
Q
ACUTE PANCREATITIS
Diagnostic Exams
A
- ↑ Serum lipase, amylase levels
- ↑ urine amylase
- Leukocytosis
- Hyperglycemia
- Hypocalcemia
- Increase C-reactive protein
- Increase bilirubin and liver function test (indicates hepatic
involvement) - Imaging studies (Abdominal x-ray, UTZ, CT Scan)
21
Q
ACUTE PANCREATITIS
Medical Management
A
- Narcotic analgesics
o Drug of choice: Meperidine (Demerol) - Antiemetics, antispasmodics, and anticholinergics
- Somatostatin – a treatment for acute pancreatitis, inhibits the
release of pancreatic enzymes
o Known to inhibit GI, endocrine, exocrine, pancreatic, and
pituitary secretions, as well as modify neurotransmission and
memory formulation in the CNS - Fluid resuscitation and electrolyte replacement
- Insulin administration as prescribed
- Antibiotics
22
Q
ACUTE PANCREATITIS
Therapeutic Management
A
- NPO with NGT
- IV and TPN
- Peritoneal lavage
- Cholecystectomy after acute pancreatitis is resolved
23
Q
ACUTE PANCREATITIS
Nursing Management
A
- Administer pain management as ordered
- Keep NPO with gastric decompression
- Monitor lab results, v/s, I&O, bowel sounds
- Maintain bed rest and may increase activity as tolerated
- Place px in knee-chest position
- Oral feeding is resumed when amylase levels return to normal
and when pain is relieved - Small, frequent, low fat, feedings with no alcohol after acute
phase
24
Q
- Medical term describing an abnormally high blood glucose level
- Hallmark sign of diabetes (both type 1 and 2 DM)
A
HYPERGLYCEMIA
25
HYPERGLYCEMIA
Signs and Symptoms
* 3 Ps
o Polyuria
o Polydipsia
o Polyphagia
* Viscous blood – poor circulation
* Altered sensation
* Glycosuria
* Diabetic foot
* Risk for infection and dehydration
* Hot and dry skin
* HTN (with headache)
* Fatigue, blurred vision, slurring of speech
26
HYPERGLYCEMIA
Precautionary Measures
* Follow diabetes meal plan, exercise program, and medication
routine
* If blood sugar levels are above target range, drink extra liquids
* Monitor blood sugar often
27
HYPERGLYCEMIA
Treatment
* Control of high glucose level
o Raise insulin dose as prescribed
o Recommend dietary changes
o Recommend more exercise (at least 3 times/week)
o Recommend closer glucose monitoring
28
* A life-threatening complication of DM that develops when
severe insulin deficiency occurs
DIABETIC KETOACIDOSIS (DKA)
29
DIABETIC KETOACIDOSIS (DKA)
The main clinical manifestations:
o Hyperglycemia
o Dehydration and electrolyte loss
o Acidosis
* Occurs in px with Type I DM
* Causes:
o Decreased or missed dose of insulin
o Illness or infection
30
DIABETIC KETOACIDOSIS (DKA)
Assessment
* Elevated blood glucose level: 300-800 mg/dL
* Decreased serum bicarbonate and pH
* Sodium and potassium may be low
* Glycosuria; polyuria; dehydration
* Metabolic acidosis: Kussmaul’s breathing
* Sweet breath odor
* When to CALL physician
o Decreased consciousness
o Difficulty breathing
o Fruity breath
31
DIABETIC KETOACIDOSIS (DKA)
Implementation
* Restore circulating blood volume
* Treat dehydration with rapid IV infusions (e.g. bolus PNSS to
promote circulation and dilute sugar)
* Treat hyperglycemia with IV regular insulin
* Cardiac monitoring & electrolyte replacement
* Treat acidosis according to cause (check ABG)
o Antacid: Sodium bicarbonate
32
DIABETIC KETOACIDOSIS (DKA)
Prevention
* Restore circulating blood volume
* Educate px in recognizing early s/s of DKA
* Emphasize not to eliminate insulin doses when nausea and
vomiting occur
* Should have available foods for use on a “sick day”
* Drink fluids q hour to prevent dehydration
* In people with infections or who are on insulin pump therapy,
measuring urine ketones can give more information than glucose
measurements alone
33
* AKA Hyperosmolar hyperglycemic state
* Extreme hyperglycemia without ketosis and acidosis
* Characterized by hyperglycemia, hyperosmolarity, and
dehydration without ketosis
* Occurs in px with Type II DM
* Onset is usually slow and takes hours or days to develop
* Causes
o Leading cause: inadequate fluid replacement
o Insufficient insulin
o Major stresses
HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
34
HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
Signs and Symptoms
* Blood glucose is from 600-1200 mg/dL
* Hypotension
* Dehydration
* Tachycardia
* Mental status changes and neurological deficits
* Seizures
* Polydipsia, polyuria, increased plasma osmolality
o (> 320 mosm/kg)
o (NV: 275-295 mOsm/kg),
o high urine specific gravity (>1.010)
35
HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
Implementation
* volume restoration
36
MEDICAL-SURGICAL MANAGEMENT
1. NASOGASTRIC SUCTION TUBES
2. ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
3. BILLROTH I AND II
4. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
5. LIVER TRANSPLANTATION
6. BARIATRIC SURGERY
7. REVERSE HYDRATION
8. REVERSE KETOACIDOSIS
9. ELECTROLYTE REPLACEMENT
10. RAPID HYDRATION
37
primarily inserted for decompression of stomach
Nasogastric tubes
38
Nasogastric tubes types:
a. LEVIN (Single lumen) Pump
b. SALEM (Double Lumen) Pump
39
o (channel within a tube or catheter) and is made of
plastic/rubber. This is tube is connected to low intermittent
suction (30-40 mmHg) to avoid erosion or tearing of the
stomach lining
LEVIN (Single lumen) Pump
40
o radiopaque (easily seen on x-ray), clear plastic, doublelumen gastric tube. The blue port vent is always open to air for continuous atmospheric irrigation; prevent reflux by having the blue vent port above patient’s waist
SALEM (Double Lumen) Pump
41
* Done via placement of Sengstaken-blakemore or Minnesota tube which are multi-lumen gastric tubes, placed nasally & extended into the stomach;
ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
42
2 balloons in ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
o Esophageal balloon – at the esophageal area, when inflated,
tamponades the bleeding in the esophagus
o Gastric balloon - serves as anchor
a. Sengstaken-Blakemore tube
* triple lumen gastric tube (one lumen allows inflation of
esophageal balloon, the other allows inflation of gastric balloon
while third lumen allows for gastric aspiration)
b. Minnesota tube
* quadruple lumen gastric tube; a modified Sengstakenblakemore tube with an additional lumen for aspirating
esophagopharyngeal secretions
43
ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
Nursing Considerations:
* Closely monitor patient’s condition and lumen pressure
* Careful surveillance of patient’s vital signs, oxygen saturation,
and cardiac rhythm (a change may indicate new bleeding)
* Monitor respiratory status and observe for respiratory distress
o If respiratory distress= CUT balloon ports and REMOVE tube.
o Keep scissors at bedside
* Provide support for patient
* Deflate esophageal balloon for about 30 minutes every 12 hours
or according to hospital policy/procedure
44
a generic term referring to any surgery that involves partial removal of the stomach, may be
accomplished by either a Billroth I or a Billroth II procedure.
Subtotal Gastrectomy
45
* Surgeon removes part of the distal portion of the stomach,
including the antrum.
* The remainder of the stomach is anastomosed to the duodenum
* This combined procedure is more properly called
gastroduodenostomy
* It decreases the incidence of dumping syndrome that often
occurs after a Billroth II procedure.
Billroth I
46
* Billroth II resection involves reanastomosis of the proximal
remnant of the stomach to the proximal jejunum
* Pancreatic secretions and bile continue to be secreted into the
duodenum, even after gastrectomy
* Surgeons prefer the Billroth II technique for treatment of
duodenal ulcer because recurrent ulceration develops less
frequently after this surgery.
Billroth II
47
WOF in BILLROTH I AND II
Dumping Syndrome – rapid gastric emptying in which your
food moves too quickly from the stomach to the duodenum = let
patient lie on the LEFT SIDE
48
* Involves the threading of a cannula into the portal vein via the
transjugular route
* an expandable stent is inserted & serves as an intrahepatic shunt
between the portal circulation & hepatic vein, reducing portal
hypertension.
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
49
* Surgery to remove a diseased liver and replace it with a healthy
one.
LIVER TRANSPLANTATION
50
LIVER TRANSPLANTATION
Indications:
* Liver transplantations is needed for patients who are likely to die
because of liver failure
* Common conditions requiring liver transplant include:
o Noncholestatic cirrhosis
o Biliary atresia
o Acute hepatic necrosis
51
Where does a liver for a transplant come from?
Two types:
a. Living donor transplantation
b. Cadaveric transplantation
* Liver transplant surgery takes between 6 and 12 hours
52
LIVER TRANSPLANTATION
POST-OP
Patient is advised to stay in the hospital for an average of 1-3
weeks to ensure that new liver is
working
* Patient is required to take lifetime medicines (e.g. immunosuppressive medications) to prevent rejection and
infections
53
LIVER TRANSPLANTATION
Complications
a. Rejection
* Immune system works to destroy foreign substances that
invades the body. The immune system, however, can’t
distinguish between transplanted liver and unwanted invaders,
such as viruses and bacteria.
* Therefore, immune system may attempt to attack and destroy
the new liver. This is called rejection episode
* Antirejection medications are given to ward off the immune
attack
b. Infection
* Because antirejection drugs that suppress immune system are
needed to prevent the liver from being rejected, it places patient
at increased risk for infections
54
Liver Transplant Guidelines:
1. Monitor prothrombin time, partial thromboplastin time, fibrinogen,
and factor V levels as ordered.
2. Monitor blood pressure: hypertension is common.
3. GI assessment: Monitor for ascites, bowel sounds, tenderness,
nausea, vomiting and distention.
4. Do not reposition or irrigate the nasogastric tube without orders.
5. Measure abdominal girth every 12 hours
6. Monitor for biliary leak: Fever, jaundice, shoulder, sepsis.
7. Monitor for biliary stricture: Jaundice, itching, abnormal bilirubin/
alkaline phosphatase.
55
* Gastric bypass and other weight-loss surgeries—known
collectively as bariatric surgery—involves making changes to the
digestive system to help lose weight.
* Done when diet and exercise haven’t worked or when you have
serious health problems because of your weight
BARIATRIC SURGERY
56
BARIATRIC SURGERY
Types:
a. Biliopancreatic diversion with duodenal switch
b. Roux-en Y Gastric bypass
c. Sleeve gastrectomy
57
BARIATRIC SURGERY
Indications:
* Done to help lose excess weight and reduce risk of potentially
life-threatening weight-related health problems, including:
* Heart disease and stroke
* High blood pressure
* Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic
steatohepatitis (NASH)
* Sleep apnea
* Type 2 diabetes
* In general, bariatric surgery could be an option if:
o Body mass index (BMI) is 40 or higher (extreme obesity)
o BMI is 35-39.9 (obesity), and patients who have serious
weight-related health problems threatening complication which would lead to sepsis if left
untreated)
* NPO for at least 1-2 days
* Diet: Liquids → pureed, very soft foods → regular foods
* Frequent medical checkups to monitor health in first several
months after surgery
58
PHARMACOLOGIC MANAGEMENT
COMPLIMENTARY/ALTERNATIVE THERAPY
Medicinal uses of Ginger:
* Ginger has been used to treat problems such as vomiting,
diarrhea, coughing, inflammatory joint diseases including
rheumatism and arthritis.
* Ginger may lower cholesterol and help prevent blood from
clotting.
* Other studies suggest that ginger may help improve blood sugar
control among people with type 2 diabetes
How to take it:
Pediatric:
* DO NOT give ginger to children under 2
* Children over 2 may take ginger to treat nausea, stomach
cramping, and headaches. However, a consult with a physician is
recommended to find the right dose
Adult:
* In general, DO NOT take more than 4g of ginger per day,
including food sources.
* Pregnant women should not take more than 1g/day.
Possible Interactions:
* Blood-thinning medications
o Warfarin (Coumadin), clopidogrel (Plavix), aspirin
o Ginger may increase risk of bleeding
* Diabetes medications
o Ginger may lower blood sugar. That can raise the risk of
developing hypoglycemia or low blood sugar
* High blood pressure medications
o Ginger may lower blood pressure, thereby raising the risk of
hypotension or irregular heartbeat
2. BITTER GOURD OR BITTER MELON (AMPALAYA)
* Scientific name: Momordica charantia
* A climbing vine with tendrils that grow up to 20 cms long
* Fruits have ribbed and wrinkled surface that are fleshy green
with pointed end at length and has a bitter taste
Uses:
* Lowers blood sugar levels
* Diabetes Mellitus (Mild-non insulin dependent)
Preparation:
* Gather and wash young leaves very well.
* Chop.
* Boil 6 tablespoons in two glassfuls of water for 15 minutes under
low fire.
* Do not cover pot.
* Cool and strain.
* Take one third cup 3 times a day after meals
V. CLIENT EDUCATION
VI. EVALUATION OF OUTCOME OF CARE
VII. REPORTING AND DOCUMENTATION OF CARE
Critical Care Nursing
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