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137 Cards in this Set
- Front
- Back
Acute abdominal pain results from
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- abdominal structures
- pelvic structures - Ischemia of blood vessels - may be a life-threatening illness (hemorrhage, obstruction, rupture) |
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Causes of Acute abdominal pain
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- appendicitis
- bowel obstruction - cholecystitis - Diverticulitis - gastroenteritis - renal calculi - UTI - pelvic inflammatory disease - perfortaed ulcer - peritonitis - ruptured AAA - ischemic bowel - ruptured ectopic pregnancy - testicular disorders |
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Best way to assess abdominal pain
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OLDCART
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OLDCART
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- onset
- location - duration - characteristic - associated sx - relieving and exacerbating factors - temporal issues |
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h/H for dehydration and occult bleeding
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up for dehydration, down for occult bleeding
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urinalysis
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- looking for protine, blood backteria, UTI, urobiligen would be up, ketones up if dehydrated
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why do an ECG?
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pain is cardiac pain unless it is ruled out, so ECGs always done
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Ultrasound and CT
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US: push fluids, must have full bladder
CT: may be NPO |
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Goals for acute abdominal pain
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- identify cause
- treat cause - monitor and treat complications (hypovolemia, shock) - pain management (don't treat unless know what it is, need pain to determine what it is!) - exploratory laparotomy |
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things that may accompany pain
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N/V (what color?)
bowel patterns (color?) Change in (clay colored?) |
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Vital signs with acute abdominal pain
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- increased pulse
- decreased BP (hypovolemia) - increased temperature (infection, inflammation) - intake and output must also be assessed |
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Order of GI assessment
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Inspection
Auscultation Palpation (gentle) Rectal (defer if appendicitis suspected) |
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GI sounds for bowel obstruction
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hyperactive proximal (before)
absent distal the obstruction (After) |
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Initial management of acute abdominal pain
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- assess
- ensure airway - oxygen if hypoxic - large bore IV (may need rapid fluid resuscitation) - labs/dx - Type/Crossmath, Type/Screen - NPO - Possible NG insertion - Prepare for emergency surgery |
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Gi post op care
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- fluid volume and electrolyte management
- NG tube (if upper Gi surgery will have 12 hours of dark red, dark brown, then will become more bile green/yellow) - N/V management - pain control - early ambulation - gradual advancement of diet - risk for clots, wound problems, pain management |
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Blunt Abdominal trauma examples
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- may not have visual evidence of injury
- falls - MVC - pedestrian event - assault with blunt object - crush injury - explosions |
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Penetrating abdominal trauma examples
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- knife
- gunshot wounds - other projectiles/missiles ***do not pull out objects!!! support them |
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Clinical manifestations of abdominal trauam
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- guarding and splinting of abdominal wall
- hard, distended abdomen (looks like peritonitits) - decreased or absent bowel sounds - contusions, abrasions, or bruising - Abdominal pain **pain over scapula (irritation of splenic nerve) - hematemesis - hematuria - S/S of hypovolemic shock - ecchymosis |
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S/S of hypovolemic shock
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- tachycardia
- orthostasis (do a tilt test if not dangerous for pt) ... |
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Pain over scapula or shoulder pain
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scapula- irritation of splenic nerve
shoulder- ectopic pregnancy |
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Cullen's sign
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ecchymosis around umbilicus
- abdominal trauma possible |
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If pt is vomiting or has stool or anything...
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do occult blood testing on them!!
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Bowel sounds with peritonitis
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absent
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Bowel sounds with ruptured diaphragm
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- bowel sounds can be heard in the chest
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Why do a follow up H/H from very first one
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- it takes a while for the H/H to drop so it make show normal in ER arrival, but will change later, look at serial H/H, takes like 24 hours
- H/H may also drop with fluid resuscitation (due to hemodilution not necessarily bleeding) be aware of this |
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What dx study can be done at bedside
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abdominal ultrasound
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What is peritoneal lavage looking for?
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- RBC > 100,000
- WBC > 500/uL - high amylase level - bacteria - bile (hepatic injury) - fecal matter (bowel perforation) |
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Nursing management of abdominal trauma
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- ensure patent airway
- maintain oxygenation - Apply pressure to external bleeding - 2 large bore IV catheters with WARM NS or LR (cold will make them hypothermic) - prepare for blood or volume expanders - Stabalize bulking dressing - don't remove penetrating objects - cover protruding organs or tissue with sterile saline - urinary catheter (with temp regulator) - NG if evidence of facial trauma - prepare for diagnostic peritoneal lavage (results will determine if pt needs emergent surgery) - ongoing assessment of vital signs, LOC, oxygen saturation, urine output - monitor temp, maintain warmth - pain management - nutrition - potentially complex wound care |
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Peritonitis
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local or systemic inflammation of peritoneum
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Primary causes of peritonitis
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- blood borne organisms (like blood sepsis)
- genital tract organisms (women that come in for pelvic inflammatory disease and STDs) - cirrhosis with ascites |
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Secondary causes of peritonitis
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- ruptured appendix
- blunt or penetrating trauma - ruptured diverticulitis - ischemic bowel - GI obstruction - Pancreatitis - Perforated ulcer - Peritoneal ulcer - Peritoneal dialysis - Post operative (belly opened up) |
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Clinical presentation of Peritonitis
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- Tenderness in infection area
- Rebound tenderness - Abdominal rigidity - Abdominal pain - Distention or ascites - N/V - increased temp - increased pulse and respirations - bowel changes |
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Complications of Peritonitis
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- hypovolemic shock
- sepsis - intraabdominal abcess - paralytic ileus - Acute respiratory distress syndrome - death (multi-organ dysfunction syndrome) |
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CTs and cat scans can see what?
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ascites and abscess
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Treatment of peritonitis
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surgical drainage and repair
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Preoperative care for peritonitis surgery
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- NPO
- IV and electrolyte replacement - NG placement - Antibx - Analgesics - Respiratory support - Surgical preparation |
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Post operative management of peritonitis surgical pt
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- NPO
- NG low intermittent suction - Semi-fowler's position - Vital sign assessment - IV replacement - I&O - TPN - Antibx (C-dif risk) - prn blood replacement - pain mangement - antiemetics - prn oxygen and pulmonary toliet/prevention - DVT prophylaxis - complex wound care if open procedure (drains, can't close belly if there is an infection in there) |
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Acute Peptic ulcer disease (PUD)
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superficial erosion
minimal inflammtion short duration resolves quickly when cause is removed |
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Chronic PUD
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erodes through muscular wall and forms scarring
- long duration, many months or intermittently - more common than acute (4x more) |
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Gastric ulcers
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- any portion of stomach
- most common in lesser curvature close to antral junction - in western countries duodenal are more common - older, women, <50yo |
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Causes of gastric ulcers
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- Aspirin, NSAIDS, corticosteroids
- chronic alcohol abuse - chronic gastritis - bile reflux - nicotine * majority present with H. Pylori |
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Secretions in gastric and duodenal ulcers
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Gastric acid is normal to low in gastric ulcers and higher in duodenal
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H. Pylori
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produces urease to buffer ammonia and mediate inflammation (which is why is survives for along time in GI tract)
- more destructive when combines with drugs and smoking |
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Duodenal ulcers
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- anyone, any age, usually 35-45 increased risk
- more common of peptic ulcers - famililal (O blood) - increased HCl secretion - H. Pylori infection is #1 cause of duodenal ulcers |
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Medical conditions that increase risk for duodenal ulcers
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- COPD (corticosteroids)
- liver cirrhosis - chronic pancreatitis - hyperparathyroidism - chronic renal disease - smoking and alcohol |
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Zollinger-Ellison syndrome
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rare condition
severe peptic ulceration gastric acid hypersecretion elevated serum gastrin |
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Stress-related mucosal Disease
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"physiologic stress ulcer"
- develop after major physiologic insult (trauma, surgery, mechanical ventilation) |
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Prophylaxis of stress related mucosal disease (SRMD)
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prophylactic H2 blockers
-----tidine Tagamet, Zantac, Pepcid, Axid OR Proton pump inhibitors - ---Prazole - Nexium, Prevacid, Aciphex, Protonix, Dexilant |
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Clinical Manifestations of peptic ulcer
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- common to have no pain or other symptoms (lack of sensory pain fibers)
- If there is pain it depends on gastric or duodenum |
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Gastric ulcer pain
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high in epigastrium
1-2 hours after meals Gastric acid pain is burning or gaseous |
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Duodenal ulcer pain
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mid epigastric region beneath xyphoid process
- back pain if posterior aspect - 2-4 hours after meals - tendency to occur, disappear and occur again |
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3 main Aims of treatment of non-complicated PUD
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- reduce gastric acid
- enhance mucosal defense - minimize harm on mucosa |
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Medical regimen for PUD
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- adequate rest
- dietary modification (not very good cause its just "don't eat what hurts you") - Drug therapy - eliminate smoking and alcohol - long term follow-up care - stress management - generally treated in ambulatory care settings - healing requires many weeks of therapy - pain subsides after 3-6 days |
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Healing of PUD non complicated
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complete healing 3-9 weeks
- assessed by xray or endoscopic exam - may stop aspirin and nonselective NSAIDS *very improtant for pts to finished PUD meds or it can become chronic! |
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Meds for PUD
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H2 blockers
Proton pump inhibitors Antibiotics Antacids Anticholinergics Cytoprotective |
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Improtant thing about protin pump inhibitors
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only for temporary use! not long term!
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Antibiotics for PUD
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amox, Biaxin, Flagyl (use multple antibx because of resistance)
- 7-14 days - multiple agents - lots of antibx cause nausea **Don't combine flagyl with alcohol |
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Antacids
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use with caution, used as adjunct therapy
- increase gastric pH bu neutralizing HCl - effects on empty stomach take 20-30 min - after meals may wait 3-4 hours |
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Anticholinergics
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to control acid secretions
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Cytoprotective
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Carafate, Cytotec (not to be used with pregnant pts unless inducing labor!)
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Nutritional therapy for PUD
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- bland diet during actue phase is controversial
- 6 small meals during symptomatic phase - individual for pt |
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Acute exacerbation of PUD complications
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perforation
hemorrhage Obstruction ** All considered emergencies! - treatment is same for all major GI complications |
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S/S of PUD exacerbation
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bleeding
increased pain and discomfort N/V |
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Management of PUD exacerbation
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- similar to upper GI bleed
- endoscopic eval to reveal amount of inflammation or bleeding and ulcer location (may cauterize or take samples) - 5 year follow-up plan recommended for acute exacerbation ***H pylori increases risk of gastric cancer*** |
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GI obstruction causes
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- ulcers in antrum and prepyloric and pyloric areas of stomach
- duodenum - edema - inflammation - pylorospasm - fibrous scare tissue formation - all contribute to narrowing of pylorus |
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hematemesis
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coffee grounds appearance
or bright red |
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hematochezia
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maroon colored stool
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3 meds that cause diruption of gastric mucosa
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aspirin, nsaids, corticosteroirds
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Early phase of GI obstruction
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gastric emptying is normal but over time more contractual force to empty stomach is needed and stomach wall hypertrophies
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After long standing obstruction the stomach
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dilates and becomes atonic
- most common near pyloris - symptoms are gradual |
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Clinical manifestations of GI obstruction from ulcer or other GI obstructions
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- usually long standing ulcer pain
- pain progresses to generalized upper abdominal pain - pain worse toward end of day as stomach fills and dilates - relief from belching or vomiting ***Hallmark of GI obstruction is projectile vomiting!*** - Constipation - Dehydration - swelling in stomach and upper abdomen - loud peristalsis, hyperactive bowel sounds (proximal) - no bowel sounds distal to obstruction - visible peristaltic wave (esp on thin person) - stomach may be palpable |
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Borborygmi
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hyperactive bowel sounds
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Clinical priority for Gi obstruction
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Decompress the stomach
- NG tube with intermittent suction for about 24-48 hours - continuous decompression |
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Continuous decompression allows for-
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- stomach to regain its normal muscle tone
- ulcer to begin to heal - inflammation and edema to subside |
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After several days of suction...
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- clamp NG and residual volumes checked periodically
- may start pt on fluids first to make sure they can tolerate that before pulling tube - common to clamp tube overnight for 8-12 hours and measure residual in morning |
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Healthy residual amount
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under 200mL
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If pt has healthy residual then can...
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clamp tube and can start on oral fluids at 30mL/hour and gradually increase
**assess pt for signs of distress and vomiting** as residual decreases solid foods are added and tube removed |
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2nd Clinical priority for GI obstruction
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Fluid electrolyte management
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How much fluids to administer?
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according to degree of dehydration, vomiting, and electrolyte imbalance
- correct any existing fluid and electrolyte imbalances - fluids and electrolytes are replaced by IV infusion until pt is able to tolerate oral feeding without distress |
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3rd clinical priority for GI obstruction
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Treatment of pyloric obstruction
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How to treat pyloric obstruction?
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endoscopically treated with balloon dilations
surgery may be required to remove scar tissue surgery if bowel rest, reintroduction of foods, etc. doesn't work |
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Mechanical GI obstruction
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- generally small intestines
- surgical adhesion (scar tissue, intestines stick together) - hernia - tumor/carcinoma (inside of bowel or pushing on it from outside) - strangulation/incarceration of bowel, torsion, twisting (***BOWEL EMERGENCY!***) |
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Non-mechanical GI obstruction causes
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- usually from failure of peristalsis
- neuromuscular or vascular disorders - neuropathy (gastroparesis to any part of the GI tract) - anything that can cause paralytic ileus (post op, peritonitis, inflammation, acute pancreatitis, appendicitis, hypokalemia, thoracic or spinal fractures, neuromuscular diseases) |
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Pseudo obstruction
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apparent mechanical obstruction without x-ray demonstration
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Vascular obstruction
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- emboli or mesenteric artery athersclerosis
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Medication causes of obstruction
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- opiods, antidepressants, psych meds (anti-SLUD, SSRI, TCA)
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Clinical manifestations of SMALL intestine obstruction
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- rapid onset
- frequent, copious vomiting (projectile, contains bile) - intermittent, colicky, crampy abdominal pain - will produce stool for short amount of time - greatly increased abdominal distention hyperactive bowel sounds above obstruction |
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Clinical manifestations of LARGE intestine obstruction
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- gradual onset
- vomiting is rare (if so, orange brown, smells like stool) - low, grade cramping abdominal pain - absolute constipation- no stool - increased abdominal distention both will have hyperactive sounds above area of obstruction - temp rarely goes above 100 unless strangulation or peritonitis occurred |
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Conservative management of lower GI obstruction
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- NPO
- NG tube - IV resuscitation (NS or LR) - Analgesics (which will slow bowel even more) - parenteral nutrition |
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When surgical management for lower GI obstruction?
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- Emergent of bowel strangulation suspected
- if no response to conservative mgt in 1-2 days |
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When should you immediately report what urine output?
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less than 0.5 mL/kg of body weight
-risk for renal failure! |
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high intestinal obstruction metabolic ______
low intestinal obstruction, metabolic______ |
alkalosis
acidosis |
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NG tube care
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oral care
nose care (wash and dry area, apply water soluble lubricant, chack nose for irritation, retape tube) check NG tube for patency q 4h |
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What is the most common complication of PUD
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hemorrhage
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Hemorrhage develops from
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- granulation tissue found at base of ulcer during healing
- ulcer through a major blood vessel - esophogeal varices - esophagitis - Mallory-weiss tear - gastric cancer - blood dyscracias - anticoagulants - renal failure |
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Younger age disease for polyps
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Familial Adenomatous Polyposis
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Lower GI hemorrhage causes
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polyps
Inflammatory bowel disease Diverticulitis (can lose liters!) cx vascular abnormalities hemorrhoids |
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Clinical presentation of GI hemorrhage
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- hematemesis (bright red or coffee grounds)
- Melena (lower Gi bleed) - Bright red stools (hematochezia) - Changes in vital signs (assess q 15 min) - S/S of shock - look for presence or absence of bowel sounds |
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CBC/Hgb and HCt of Gi bleed
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provide a baseline, may take 4-5 hours to reflect loss
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Management of Gi bleed first priority
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Restore Fluid volume
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Restoring fluid volume of GI bleed
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- 2 large bore IV lines
- Intially isotonic crystalloid replacement (LR) - Blood replacement (more blood someone gets the more chance for reaction) |
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Nursing assessment during fluid resuscitation
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- assessment of fluid overload (CVP or hemodynamic monitoring)
- I&O - urinary catheter with UROMETER q 1 hour - BUN/Creatinine (At risk for renal failure) - Cardiac monitoring - Pulmonary assessment - Monitor serial HgB/Hct |
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blood transfusion and hgb/hct monitoring
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- pre and post transfusion
- 1 unit of blood = i gram of Hgb increase - so may need more than 1 unit of blood |
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Next priority for management of GI hemorrhage
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- gastric decompression
- NG with possible lavage - may have to have iced saline |
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Medication used for Arterial GI bleeding (especially varices)
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Pitressin (ADH, Vasopressin)
* acts as vasoconstriction on V1 receptors **watch for hypotension and SIADH |
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More signs and symptoms of shock
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- low BP
- rapid - weak pulse - increased thirst - cold, clammy skin - restlessness - for GI bleed monitor vitals q 15-30 min and inform MD of major changes, also obtain orthostatic vitals |
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Control anxiety with GI bleed
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use anxiolytics with care because restlessness is one of the warning signs of shock
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Clinical presentation of GI hemorrhage
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- change in vital signs (assess q 15min)
- Increase in amount and redness of aspirate (signal for massive upper GI bleed) - increase in amount of gastric contents - decreased pain because blood neutralizes acidic gastric contents |
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IF pt has a venous pressure line or pulmonary artery catheter in place, record every...
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1-2 hours
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What is the most lethal complication of PUD?
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Perforation because it leads to peritonitis, sepsis, and shock from multiorgan dysfunction
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Mortality rates are high in what location of gastric ulcers?
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gastric ulcers because lots of organs are by the stomach and acidic pH of 1 leaks around these organs.
however, most common perforation is duodenal ulcers |
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smaller vs. larger ulcer healing
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small perforation may seal itself
large perforations need immediate surgical closure |
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Clinical manifestations of perforation
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- sudden, dramatic onset
- severe abdominal pain spreads throughout abdomen - possible referral pain to shoulder - rigid, board-like abdominal muscles - shallow, rapid respirations - bowel sounds absent - N/V - Hx/reporting symptoms of indigestion or previous ulcer - hard to tell with symptoms where location of perforation is (gastric or intestinal ulcer) |
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With perforation, the peritoneal cavity may contain...
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- air
- HCl - Bacteria - Bile, pancreatic fluid, enzymes |
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With perforation, what can occur within 6-12 hours
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Bacterial peritonitis (that's quick!!)
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Immediate focus of perforation
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stop spillage of gastric or duodenal contents into peritoneal cavity
**early recognition and assess appropriately! ** Make sure pt gets proper care! |
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2nd focus for perforation
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- assess hemodynamic status q 15 min
- monitor for shock - central venous pressure line inserted and monitored hourly - ECG monitoring |
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Treatment for perforation
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- Restore circulating volume with LR, NS, or albumin
- Packed red blood cells may be becessary - continuous gastric decompression with NG tube (place by perforation helps reduce inflammation) - may require irrigation with order and repositioning. DO NOT IRRIGATE WITHOUT AN ORDER!! - NPO - broad spectrum antibx - pain meds - prepare for emergency surgery (open or laproscopic) |
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Indications for Surgical therapy for PUD
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- uncommon because antisecretory agents are used instead
- unresponsive to medical management - concern about gastric cx - drug induced but can't withdraw from drugs |
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Billroth I
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surgical procedure
- gastroduodenostomy - removal of distal 2/3 of stomach and anastomiosis of gastric stump to duodenum |
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Billroth II
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- surgical procedure for PUD
- gastroieiunostomy - removal of distal 2/3 of stomach and anastomiosis of gastric stump to jejunum *Preferred procedure |
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Vagotomy
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severeing the vagus nerve (to stomach), will decreased acid production in stomach. Don't like have to do this unless needed.
- done in conjunction with gastrectomy (vagus=parasympathetic system--> SLUD) |
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Pyloroplasty
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- surgical enlargement of pyloric sphincter
- commonly done with vagotomy - decrease gastric motility and gastric emptying - if accompanying vagotomy, increases gastric emptying |
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Preop care for PUD surgeries
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- educate pt about what type of surgery, what wound will be like (may not know before hand whether it will be laparoscopic or open)
- surgeon should educate pt/family on surgical procedure and nurse can clarify questions - Give instructions on comfort measures - pain relief - coughing and deep breathing - NG tube - IV fluids |
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Post op care
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- NG placed with suction to relieve suture pressure
** MUST be patent, DO NOT REMOVE TUBE!!!! if there is a lot of blood or clotting, call MD!!** - assess gastric aspirate (yellow green in 48 hours) - observe for signs of decreased peristalsis and lower abdominal discomfort (intestinal obstruction) - I&O - vitals q4h - pain control - pulmonary toileting - splinting of incisions - frequent position changes - assess dressing and drain output - IV therapy - Infection signs - long term complication (pernicious anemia) |
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Post op complications of PUD surgical procedures
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- similar to gastric bypass
- dumping syndrome - post prandial hypoglycemia - bile reflux gastritis |
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Dumping syndrome
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decreased ability of stomach to control amount of gastric chyme entering small instestine
- large bolus of hypertonic fluid enters intestine--> increase of fluid drawn into bowel lumen - symptoms are a result in lowered plasma fluid because fluid was drawn into GI |
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When does dumping syndrome occur and what are S/S
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- 15-30 minutes after eating
- weakness - sweating - palpations - dizziness - abdominal cramps - borborygmi - urge to defecare - lasts no longer than an hour |
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Post prandial hypoglycemia
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- a variant of dumping syndrome
- a result of uncontrolled gastric emptying of a bolus of high carbs into small intestine --> increased blood sugar--> excessive insulin release into circulation |
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When does postprandial hypoglycemia occur and S/S
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- 2 hours after meals
- sweating - weakness - mental confusion - palpitations - tachycardia - anxiety |
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Symptoms of post pandreal hypoglycemia are relieved by
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immediate ingestion of sugared fluids or candy
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Bile reflux gastritis
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- reflux of bile onto gastric mucosa
- causes damage to mucosa - may result in back-diffucion of H= ions through gastric mucosa --> PUD |
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S/S of bile refluc gastritis
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continuous epigastric distress that increases after meals
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Treatment for Bile reflux gastritis
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- cholestyramine (Questran) relieves irritation
- alluminum hydroxide antacids also used |
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Post operatively, aspirate is observed for...
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- color, amount odor
** bright red at first then darkening within first 24 hours ** color changes to yellow-green within 36-48 hours |
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Post operative general info about nutritional therapy
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- start immediately after post op period is successfully passed
- reduce drinking to 4 oz/none or less with meals |
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Post op diet should consists of
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- small, dry feedings daily
- low in carbs - restrict sugar with meals - moderate amounts of protein and fat - 30 minutes of rest after each meal |