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1 Med/Surg II, Part 3 of 4 Digestion Disorders Malignant Oral and Laryngeal Tumors.

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Presentation on theme: "1 Med/Surg II, Part 3 of 4 Digestion Disorders Malignant Oral and Laryngeal Tumors."— Presentation transcript:

1 1 Med/Surg II, Part 3 of 4 Digestion Disorders Malignant Oral and Laryngeal Tumors

2 2 Pre-Malignant Mouth Lesions Leukoplakia: pre-malignant lesion, especially on tongue or lips; thickened, white, permanently attached patches, slightly raised, sharp edges Erythroplakia: pre-malignant lesion more likely to progress to malignancy than leukoplakia; red, velvety lesion found in floor of mouth, tongue, palate, mandible mucosa

3 3 Risk Factors Increased age Tobacco (chewing or smoking) Treatment Early detection is most important Local excision will be done if possible for biopsy and possible cure. Squamous Cell Mouth Carcinoma

4 4 Direct laryngoscopy CT scan of the head and neck with contrast MRI of head and neck with contrast PET scan: Biopsies Endoscopic biopsy Fine needle aspiration (FNA) biopsy Diagnosis of Laryngeal Cancer

5 5 Total Laryngectomy, Preoperative Care Discuss the informed consent Explain that the procedure will likely be many hours Intensive care unit for airway protection - may be on a ventilator. Alternate forms of communication Prepare the patient for a feeding tube Explain pain control methods: PCA machine. Have the patient practice with one if possible. Tracheostomy will probably be performed - explain this to the patient.

6 6 Postoperative Care Airway Maintenance Flap and reconstructive tissue care Hemorrhage Wound breakdown Pain management Nutrition Speech rehabilitation

7 7 Discharge Teaching Stoma Care Avoid swimming, care with showering or shaving to protect stoma opening Lean slightly forward, cover stoma when coughing or sneezing Wear a stoma guard Clean the stoma with mild soap & water. Lubricate with non-oil-based ointment prn Increase humidity in airway with saline spray, humidifier in room Wear a Med-Alert bracelet & carry emergency care card

8 8 Communication Verify the patient knows how to use his selected communication method Keep backup communication options available Card that explains the patients situation in an emergency:

9 9 Resources Smoking cessation support Speech therapy Dietician Laryngectomy support group Alcoholics Anonymous if needed

10 10 Psychosocial Preparation A visit from a fellow laryngectomee Importance of returning to a normal lifestyle as much as possible Expect changes in smell & taste as well as communication Prepare for mucus with handkerchiefs, tissues or gauze

11 11 Esophageal Problems Gastroesophageal Reflux Disease (GERD) Esophageal Cancer

12 12 Clinical Manifestations of GERD Pyrosis Dyspepsia - may mimic symptoms of a myocardial infarction Regurgitation of food particles or fluid – sour or bitter taste in mouth – high risk aspiration Dysphagia Hypersalivation

13 13 Collaborative Management: Diet Limit or eliminate chocolate, fat, mints, carbonated drinks Limit spicy and acidic foods when symptomatic Eat 4-6 small meals per day Avoid evening snacks, no food 3 hours before sleeping

14 14 Lifestyle Changes Elevate head of bed at least 6 inches to avoid reflux when sleeping Sleep in left lateral decubitus position Smoking and alcohol exacerbate reflux Weight reduction will decrease intra-abdominal pressure Avoid any activity that increases abdominal pressure

15 15 Medication Antacids for occasional episodes raise gastric pH: Gaviscon, Maalox, Mylanta one hour before and 2-3 hours after a meal Histamine receptor antagonists reduce acid secretion: ranitidine (Zantac), famotidine (Pepcid) Proton pump inhibitors are the main treatment for GERD: omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix), esomeprazole (Nexium)

16 16 Esophageal Cancer Risk Factors: Chronic irritation: smoking, alcohol ingestion, GERD Manifestations: progressive and persistent dysphagia (most common), sense of mass in throat, painful swallowing (odynophagia), substernal pain or fullness, regurgitation with foul breath and hiccups and weight loss

17 17 Diagnosis Barium swallow with fluoroscopy Esophagogastroduodenosc opy (EGD) with biopsies (definitive diagnosis) Image Source: National Cancer Society, Public Domain,

18 18 Esophageal Reconstruction Postoperative Nursing Care Highest priority Stress deep breathing Incentive spirometer Early ambulation Semi-fowlers position in bed

19 19 Cardiovascular Monitor closely for: Hypotension from hypovolemia Pulmonary edema from fluid overload Chest tube management if present

20 20 Wound management Multiple incisions and drains Support incision when moving to prevent dehiscence Infection from incision leak Watch for fever, increased fluid from drains, signs of local inflammation, tachycardia

21 21 Nasogastric tube Placed intraoperatively to decompress suture area Do not irrigate or reposition. Drainage bloody early, green-yellow after 24 hours

22 22 Nutrition Jejunal tube placed intraoperatively Start tube feeding after 24 hours, increase slowly When taking oral nutrition, start with liquids and advance slowly to accommodate decreased stomach capacity Teach: always eat in upright position – to protect against reflux Eat 6-8 small meals per day No liquids with meals to prevent diarrhea (dumping syndrome)

23 23 Stomach Disorders Peptic Ulcer Disease (PUD) Gastric Carcinoma

24 24 Peptic Ulcer Disease (PUD) Risk Factors Acute gastritis caused by: Helicobacter pylori, a gram-negative bacterium Medication side effect: Nonsteroidal anti- inflammatory drugs, alcohol, cytotoxic agents, caffeine, corticosteroids

25 25 Prevention Avoid excess alcohol Use caution with inflammatory medications Avoid excess caffeine Stop smoking

26 26 Manifestations Epigastric pain Anorexia, nausea or vomiting Hematemesis Dyspepsia Intolerance of fatty and spicy foods

27 27 Collaborative Treatment Teach: Stress reduction, avoid alcohol and tobacco Diet: Limit any foods or spices that cause symptoms Avoid bedtime snacks (stimulate acid secretion)

28 28 Drugs H. pylori: Treat with 2 antibiotics + bismuth compound (Pepto-Bismol) or proton pump inhibitor Antacids 2 hours after meals to buffer acid secretions. H2- receptor blockers to prevent acid secretions

29 29 Drugs (continued) Mucosal barrier, sucralfate (Carafate) Antisecretory agents Prostaglandin analogues such as misoprostol (Cytotec) to decrease acid secretion and increase mucosal resistance

30 30 Manage Complications Bleeding: Watch for coffee ground vomitus; black, tarry stools (melena) as well as bright red blood Monitor hemoglobin, hematocrit, coagulation studies Monitor vital signs for shock

31 31 Manage Complications Nasogastric lavage: NOTE: use 0.9% saline NOT tap water

32 32 Hypovolemia from Bleeding Isotonic crystalloids (0.9% saline, Ringers lactate), blood products, electrolytes as indicated Watch! for metabolic alkalosis due to acid loss from vomiting.

33 33 Assist physician with EGD Patient preparation: Large-bore IV catheter for conscious sedation Blood products if needed NPO for at least 6 hours, informed consent Post-procedure: monitor vital signs, oxygen

34 34 Surgical Management Vagotomy Pyloroplasty Billroth I (gastroduodenostomy) Billroth II (gastrojejunostomy) Image Source: www.healcentral.rog, Royal College of Surgeons of Ireland, Creative Commons

35 35 Postoperative Management: Nasogastric Tube: Attach securely to maintain position – do not change position without surgeons order Monitor drainage for color, volume of drainage NOTE: report more than scant bloody drainage or minimal drainage; do not irrigate.

36 36 Dumping Syndrome Early manifestations: vertigo, tachycardia, syncope, sweating, pallor, palpitations. Late (90 minutes to 3 hours after eating): excessive insulin release causes dizziness, palpitations, diaphoresis, confusion.

37 37 Management: Dumping Syndrome Eat small amounts Eliminate liquids at meals High-protein, high-fat, low-carbohydrate diet Powdered pectin may prevent symptoms Octreotide (Sandostatin) prescribed in severe cases to inhibit hormones that cause symptoms

38 38 Alkaline Reflux Gastropathy Bile reflux in patients whose pylorus is bypassed or removed (Billroth procedures) Symptoms of early satiety, abdominal discomfort, vomiting.

39 39 Delayed Gastric Emptying Often present after gastric surgery, usually resolves within one week. Continued nasogastric suction relieves symptoms until resolved.

40 40 Afferent Loop Syndrome If duodenal loop is partially obstructed after a Billroth II, pancreatic and biliary secretions fill the loop, distending it. Monitor for abdominal bloating, pain 20-60 minutes after eating followed by nausea and vomiting. Surgical correction is necessary.

41 41 Nutrition Decreased absorption of calcium and vitamin D. At risk for pernicious anemia. Give vitamin B12 injection May need folic or iron replacement.

42 42 Gastric Carcinoma: Risk Factors H. pylori infection, untreated Pernicious anemia Gastric polyps Achlorhydria Chronic atrophic gastritis Cigarette smoking, alcohol consumption are controversial

43 43 Manifestations Early: Indigestion Abdominal discomfort, feeling of fullness Epigastric, back, or retrosternal pain Late: Nausea and vomiting Obstructive symptoms, enlarged lymph nodes Iron deficiency anemia Palpable epigastric mass Enlarged lymph nodes Progressive weight loss

44 44 Surgical Management Subtotal or total gastrectomy: stomach, or portion, is removed and duodenum, or remainder of stomach, is sutured to esophagus

45 45 Postoperative Care Decompress wound: maintain patency and suction from NG tube to keep pressure off sutures and prevent anastomosis leakage Notify surgeon if reposition or irrigation needed.

46 46 Postoperative Care (continued) Assess color, amount, odor of NG drainage: notify surgeon of any changes Color should change from dark red to green- yellow over the first 2-3 days

47 47 Postoperative Care (continued) Replace fluids and electrolytes intravenously: At risk for dehydration, Imbalances of sodium, potassium, chloride Metabolic alkalosis.

48 48 Postoperative Care (continued) Anti-ulcer and antibiotic therapy: prevention of stress ulcers and prophylaxis against any gastric contamination of the abdominal cavity.

49 49 Postoperative Care (continued) Monitor abdomen: listen for bowel sounds, watch for distention – may be third spacing, obstruction or infection. Encourage ambulation to stimulate peristalsis.

50 50 Nutrition Total parenteral nutrition (TPN) Enteral feeding postoperatively Oral feedings: prevent regurgitation from overeating or eating too quickly. Watch for dumping syndrome. Treat anemia, vitamin B12, and folate deficiency. Teach: recurrence of cancer is common – need regular follow-up.

51 51 Disorders of the Intestine Irritable Bowel syndrome (IBS) Hernias Colorectal Cancer

52 52 Irritable Bowel Syndrome (IBS) Typical manifestations: Abdominal pain relieved by defecation or associated with changed stool frequency or consistency Abdominal distention Sensation of incomplete stool evacuation Mucus in stool

53 53 Collaborative Management Identify food intolerances Add fiber to diet (bran) Avoid lactose, fructose or sorbitol (often cause problems) Avoid gas-forming foods Limit caffeinated drinks (GI stimulants) Evacuate promptly Stress and anxiety reduction

54 54 Medications Constipation prominent: GI prokinetics Bulk laxatives at meals with water Diarrhea prominent: loperamide (Imodium) or diphenoxylate (Lomotil) Abdominal pain prominent: Anticholinergic before meals to prevent spasm: dicyclomine (Antispas, Bentyl, Asacol)

55 55 Hiatal Hernia Clinical Manifestations Heartburn (reflux) Dysphagia, belching Feeling of fullness or breathlessness after eating Feeling of suffocation Worsening of symptoms when lying down

56 56 Prevention Remain upright several hours after eating Avoid straining Sleep with head elevated Weight loss to decrease abdominal pressure

57 57 Medical Management Frequent small feedings No reclining for 1 hour after eating Control reflux

58 58 Postoperative Nursing Care NG placed in OR, no moving! Expect temporary dysphagia – gradual increase in diet Gas bloat syndrome – inability to belch – avoid gas producing foods, gum, drinking with straw Aerophagia (air swallowing) habit – retrain or use simethicone to reduce bloating

59 59 Inguinal Hernia Bulge, lump or swelling in groin Sharp pain or dull ache radiating to scrotum or vagina Mass felt with standing or straining Reducible Irreducible (incarcerated) Strangulated

60 60 Prevention Weight control Avoid heavy lifting and straining

61 61 Medical Management A truss is prescribed for inguinal hernias. A firm pad placed over hernia attached to a belt to keep intestine from protruding

62 62 Postoperative Nursing Care Difficulty voiding Scrotal support Ice bags to scrotum or vaginal area Elevate scrotum on soft pillow Teach: avoid heavy lifting, straining for 3 weeks

63 63 Colorectal Cancer Image Source: National Cancer Society, Public Domain,

64 64 Prevention Avoid fat or fatty foods, low-fiber foods, refined carbohydrates Consume fruits and vegetables, especially cabbage family; whole grains, adequate water, baked or poached fish and poultry Avoid chronic bowel inflammation

65 65 Early Detection Genetic testing for familial risk Yearly occult blood testing of stool, -or- Flexible sigmoidoscopy every 5 years, -or- Double-contrast barium enema every 5 years, -or- Colonoscopy every 10 years

66 66 Manifestations Rectal bleeding (hematochezia) with anemia Narrowing of stool, change in bowel habits Signs and symptoms of bowel obstruction: gas pain, cramping, incomplete evacuation, high- pitched tinkling bowel sounds in waves Dull abdominal pain

67 67 Colorectal Cancer Staging Image Source: National Cancer Society, Public Domain,

68 68 Fiberoptic Colonoscopy Colon preparation During procedure Conscious sedation Care after Procedure Watch! Bowel perforation Polyp removal Expect amnesia: written instructions, no driving! Image Source: National Cancer Society, Public Domain,

69 69 Colostomy Image Source: National Cancer Society, Public Domain,

70 70 Preoperative preparation Clear liquids for 1-2 days Mechanical bowel cleansing Prophylactic antibiotics Colostomy placement Instruct in general principles of ostomy care Nasogastric tube

71 71 Postoperative care: Colostomy management Assess stoma color, integrity, drainage Keep periostomal skin clean, dry Place close-fitting pouch over stoma - monitor for leakage Empty pouch frequently, remove gas buildup

72 72 Perineal Wound Care Bulb suction drains: monitor amount, color, odor of drainage Absorbent dressing Rectal pain and itching Teach: use side-lying position, avoid long periods of sitting using soft pillow Do NOT use air ring or donut devices – will cut off circulation to wound

73 73 Discharge Teaching Refer to local ostomy association. Ostomy supplies Instruct Placing a drainage bag Assessing and cleansing the stoma, irrigation Signs of infection Nutrition: avoid odor and gas-causing foods Develop a plan: constipation or diarrhea

74 74 Inflammatory Bowel Disease Ulcerative ColitisPeritonitis Crohns DiseaseDiverticular Disease Appendicitis

75 75 Ulcerative Colitis Begins in rectum, proceeds toward cecum; affects only superficial layers Age 15-25 & 55-65 10-20 liquid, bloody stools per day Stools occult blood positive Very hemoglobin, WBCs sodium, potassium, chloride, albumin Barium enema: incomplete filling, fine ulcerations

76 76 Complications Hemorrhage Bowel perforation Fistulas Nutritional deficiencies

77 77 Crohns Disease Mostly terminal ileum, patchy through all layers of the bowel Age 15-40 5-6 soft, loose stools per day, rarely bloody hemoglobin, WBCs, albumin Upper GI series: string sign of constricted terminal ileum Decreased folic acid, vitamins A, B complex, C

78 78 Complications Fistula Nutritional deficiencies

79 79 Collaborative Management Medication: to rest the bowel Nutrition: Fluids, low-residue, high-protein, high-calorie diet Vitamin and iron supplements Avoid foods that cause diarrhea Avoid cold foods and smoking: increase intestinal motility

80 80 Colectomy Total colectomy with an ileal pouch-anal anastomosis (IPAA). A pouch is formed from the terminal ileum and connected to the anal canal. Continent (Kocks) ileostomy. Image Source: National Cancer Society, Public Domain,

81 81 Preoperative Care Similar to colostomy Fluids, blood & protein if losses severe Low residue diet, frequent small feedings Antibiotics to treat inflammation, cleanse bowel Stoma right lower quadrant about 2 inches below waistline

82 82 Postoperative Care Apply a pouch with meticulous skin care Assess stoma for bleeding, color Monitor stool production Empty pouch when no more than 1/3 full Emphasize fluid and salt intake High potassium, low-residue diet, avoid gas-producing or high fiber foods to prevent blockage Signs of blockage: abdominal cramps, swelling of stoma, no output over 4-6 hours Relieve blockage prn

83 83 Irrigate continent ileostomy (Kock pouch) Insert catheter into pouch, drain every 4-6 hours Irrigate once daily with normal saline. No external pouch is necessary Amount of stool will increase as pouch stretches.

84 84 Appendicitis Epigastric or peri-umbilical cramping Nausea followed by vomiting Pain becomes more steady and severe, migrates to right lower quadrant (McBurneys point) Rebound tenderness Signs of perforation Photo Source: Wikimedia Commons, Creative Commons, pendix_vermiformis.svg

85 85 Peritonitis Rigid, board-like abdomen (classic) Pain: general abdominal, may spread to shoulders or chest Distended abdomen Nausea, vomiting Decreased bowel sounds Rebound abdominal tenderness High fever, tachycardia

86 86 Collaborative Management NPO with intravenous fluids Broad spectrum intravenous antibiotics Nasogastric tube to decompress stomach Oxygen Pain management

87 87 Exploratory Laparotomy Abdomen is flushed with saline and lavaged with antibiotic solution. Postoperative Care: Position Manage wound and drains If wound irrigation ordered, use sterile technique Replace lost fluids and electrolytes

88 88 Diverticular Disease Small outpouchings of the colon, 90% in the sigmoid colon, that can become infected resulting in diverticulitis, or rupture, resulting in peritonitis. Risk Factors: Diet: highly refined, fiber-deficient Decreased physical activity Poor bowel habits with constipation

89 89 Manifestations Episodic left-sided abdominal cramping or steady pain Constipation alternating with diarrhea Narrow stools with bright red blood Diverticulitis: if undigested food and bacteria collect in the diverticula, inflammation results

90 90 Collaborative Management Broad-spectrum antibiotics Pain relief: patient-controlled analgesia with opiate Bulk-forming products: psyllium seed (Metamucil) Bowel rest during acute episode Assess for decreased bowel sounds, abdominal distention, tenderness: peritonitis from bowel rupture Assess for lower GI bleeding

91 91 Teach Avoid laxatives Eat a high-fiber diet Avoid: wheat and corn bran, vegetable and fruit skins, nuts, dry beans

92 92 Liver Disorders Cirrhosis Hepatitis

93 93 Cirrhosis Portal hypertension Ascites Esophageal varices Coagulation defects Jaundice Encephalopathy Hepatorenal syndrome Spontaneous bacterial peritonitis

94 94 Clinical Manifestations Massive ascites: distended abdomen with positive fluid wave, enlarged abdominal girth Hepatomegaly right costal border in early cirrhosis, later hard and small Fetor hepaticus: fruity or musty breath odor Asterixis (liver flap): coarse tremor of wrists and fingers

95 95 Laboratory Assessment Prolonged prothrombin time and INR Serum elevation in: Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Lactate dehydrogenase (LDH) Indirect bilirubin, ammonia Creatinine (hepatorenal syndrome) Serum decrease in: Albumin, Platelet count, Hemoglobin and hematocrit White blood cell count

96 96 Diagnostic Procedures Ultrasound Percutaneous biopsy Esophagogastro-duodenoscopy (EGD)

97 97 Liver Biopsy Pre-procedure: Labs: prothrombin time, CBC, platelet count Fresh frozen plasma and/or platelets Post-procedure: Pressure to site, roll to right side for 1 hour Hemoglobin and hematocrit Chest x-ray to rule out pneumothorax Ultrasound of liver to rule out hematoma Report: BP, heart rate, respiratory distress, change in level of consciousness Report: increased pain, abdominal girth, weakness or dizziness, bleeding

98 98 Esophagogastroduodenoscopy (EGD) Pre-procedure: NPO for 6-8 hours IV access for conscious sedation Remove dentures, assess gag reflex Place in left lateral decubitus position Post-procedure: Frequent vital signs until conscious sedation worn off Keep patient NPO until gag reflex returns Monitor for: pain, bleeding, fever

99 99 Nutrition High calorie, moderate fat Ascites/edema – Low sodium to control fluid retention, limit fluid intake if serum sodium is low High serum ammonia – limit protein Vitamins/minerals – thiamine, folate, multiple vitamins, fat-soluble vitamins (A,D,E,K), magnesium

100 100 Fluids/Electrolytes Monitor intake and output Weigh patient daily Daily electrolytes, BUN, creatinine, protein, hematocrit Monitor for signs of fluid retention Give intravenous fluids and electrolytes as indicated

101 101 Medication Diuretics: Spironolactone (Aldactone)Furosemide (Lasix) Laxatives: lactulose (Cephulac) Anti-infective agents: Neomycin sulfate (aminoglycoside) Metronidazole (Flagyl) Alternative medications: Silymarin (herb milk thistle), Adenosylmethione (SAM-e)

102 102 Paracentesis Patient preparation: Informed consent Weigh patient Assess vital signs Have patient void immediately prior to procedure Supine, seated at edge of bed or in chair with feet supported Obtain vacuum bottle, paracentesis tray May give 25% albumin intravenously

103 103 Post-Paracentesis Bed rest Monitor blood pressure for hypotension Place patient supine, legs elevated if hypotensive Send specimen to laboratory as ordered Place dry dressing over puncture site – expect some fluid leakage Weigh patient

104 104 Esophageal Varices Blood loss leading to shock occurs if these thin- walled varices burst. Teach patient to avoid any activity that increases abdominal pressure: stooping heavy lifting vigorous physical exercise

105 105 Balloon Tamponade Sengstaken-Blakemore tube One larger balloon is inflated in the esophagus to press on the varices Smaller balloon is inflated in the stomach to keep traction on the esophageal balloon. A third lumen opens into the stomach to aspirate blood and stomach contents.

106 106 Band Ligation Endoscopic band ligation of varices: Small O bands placed by physician around base of varices to cut off blood supply. The nurse may give an infusion of octreotide before procedure to reduce blood flow

107 107 Sclerotherapy Injection of an agent into the varices to occlude their blood supply. Performed by an MD during EGD.

108 108 Transjugular intrahepatic portal- systemic shunt (TIPS) enlargement of portal vein with balloon inflation and stent placed to maintain patency. Photo Source: Courtesy of the University of Michigan Health System,

109 109 Shunts Monitor patient for circulatory fluid overload: increased blood pressure, crackles in lung bases. Patient may need a diuretic. Expect decreased ascites: decreased abdominal girth, weight loss, increased urine output.

110 110 Hepatitis A (HAV) Cause: Ingestion of fecal contaminants: water, shellfish, food handlers, oral-anal sex Incubation: 15-50 days Signs: Mild, similar to gastrointestinal illness Prevention: Wash hands, safe water supplies, vaccination; immune globulin after exposure Treatment: Bed rest, frequent small feedings of high- protein high-calorie foods, enteral feedings if unable to eat; avoid alcohol & substances that affect liver function

111 111 Hepatitis B (HBV) Cause: Blood from unprotected sex, sharing needles, accidental needle sticks, unscreened blood transfusion, hemodialysis, maternal-fetal Incubation: 25-180 days Signs: Fatigue, anorexia, nausea & vomiting, fever, RUQ pain, rash, dark urine, light stool, joint pain, jaundice Prevent: Screen donor blood, standard precautions with all blood samples, disposable needles, lancets, needle-less IV systems; vaccination of all newborns, high-risk persons Passive immunity: hepatitis B Immune Globulin (HBIG) after exposure (if not vaccinated); alpha interferon injections for chronic infection; gradually increase activity

112 112 Hepatitis C (HCV) Cause: Sharing needles (highest incidence), needle stick injury, tattoos with dirty equipment, intranasal cocaine sharing Incubation: 21-140 days (average 7 weeks) Signs: gradual chronic inflammation of liver, eventual cirrhosis (leading cause of liver transplants in U.S.), liver cancer possible Prevent: Screen blood transfusions, sterile disposable intravenous equipment; sterilize equipment. No vaccine Treat: Interferon and ribavirin (Rebetol)

113 113 Pancreatic Disorders Pancreatitis Pancreatic Carcinoma

114 114 Pancreatitis Inflammation characterized by release of its enzymes into the pancreas causing hemorrhage and necrosis. Risk Factors Alcohol ingestion Cholelithiasis Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) complication

115 115 Manifestations Abdominal pain localized in epigastrium – most frequent symptom– relieved by fetal position or bending forward Nausea, vomiting, weight loss Generalized jaundice Gray-blue color around umbilicus (Cullens sign) Gray-blue color to the flanks (Turners sign) Respiratory compromise from abdominal pressure Decreased breath sounds, especially at bases

116 116 Diagnosis - Lab Increased serum amylase (nonspecific): remains elevated for 3- 4 days Increased lipase (more specific): remains elevated for 2 weeks Elevated trypsin (most accurate) Elevated bilirubin and alkaline phosphatase if concurrent biliary dysfunction Elevated alanine aminotransfersase (ALT) if biliary obstruction Elevated glucose Decreased calcium, magnesium if fat necrosis present Elevated white blood cell count

117 117 Diagnosis: Radiography Abdominal x-ray: gas-filled duodenum (obstruction) Chest x-ray: elevated left diaphragm, pleural effusion Computed tomography (CT) with contrast Abdominal ultrasound

118 118 Collaborative Management NPO, nasogastric drainage if vomiting with ileus Pain relief Comfort: bed rest, assist to fetal position if pain acute Intravenous fluids and electrolytes Semi-fowlers position, frequent turning, incentive spirometer ERCP to remove gallstones and open sphincter of Oddi

119 119 Monitor for complications: Necrosis: sudden increase in pain Hemorrhagic shock Septic shock Respiratory failure

120 120 Pancreatic Carcinoma Pain: boring pain in mid-back unrelated to position or activity Progressive and severe More severe at night Accentuated when lying supine Relieved by sitting up and leaning forward Jaundice with clay-colored stools, dark urine Gastrointestinal: anorexia, nausea, vomiting, weight loss, flatulence, ascites, glucose intolerance

121 121 Diagnosis Elevated but nonspecific: amylase, lipase, alkaline phosphatase, bilirubin Elevated carcinoembryonic antigen (CEA) levels in 80%-90% Computed tomography (CT) confirms presence of tumor versus cyst ERCP with cystology of aspirate most definitive diagnosis

122 122 Collaborative Management Pain: high dose opioids, usually morphine or hydromorphone (Dilaudid) Chemotherapy Radiation: shrinks tumor cells = pain relief Biliary stent: if biliary drainage system is obstructed Laparoscopic procedures to palliate, debulk or remove tumors Whipple procedure (radical pancreaticoduodenectomy) for extensive metastasis

123 123 Whipple Procedure GI drainage Positioning Pain Watch! Sudden increased pain may be anastomosis leak Fluids and electrolytes Nutrition

124 124 Biliary Disorders Cholecystitis Cholelithiasis

125 125 Cholecystitis/Cholelithiasis Risk Factors Excessive dietary cholesterol intake Obesity Increased age, female Type I diabetes mellitus Low-calorie or liquid protein diets Alcohol abuse Hemolytic blood disorders, such as Crohns disease After gastric bypass surgery

126 126 Manifestations Biliary colic: pain in right upper quadrant of the abdomen, may radiate to back, right scapula, or shoulder Abrupt onset – triggered by high-fat or high-volume meal Severe and constant Lasts 12-18 hours Aggravated by movement, breathing Anorexia, nausea, vomiting are common Fevers and possibly chills Jaundice & icterus Pruritis Clay-colored (light), fatty (steatorrhea) stools Urine is dark and foamy

127 127 Diagnosis Rebound tenderness in right upper quadrant (Blumbergs sign) Pain increases with deep inspiration (Murphys sign) while examiner pushes over gallbladder area (right costal margin). Direct bilirubin rises Indirect bilirubin rises Ultrasonography shows edema of gallbladder wall surrounded by fluid.

128 128 Endoscopic Retrograde Cholangiopancreatography (ERCP) Contrast agent injected into the ducts and x-rays are taken to evaluate their caliber, length and course

129 129 Collaborative Management Teach low-fat diet If calculi are causing obstruction, give fat-soluble vitamins Ursodol (Actigall) or chenodial (Chenix) Cholestyramine (Questran) for pruritis Opiate analgesics Watch! morphine may cause biliary spasm and constrict sphincter of Oddi (outlet). Antispasmodic Antibiotics if infection is suspected Biliary catheter (T-tube)

130 130 Laparoscopic Cholecystectomy Small puncture at umbilicus, carbon dioxide instilled to lift abdominal wall. Laparoscope inserted, attached to a monitor, and abdominal organs are viewed. Several small punctures are made to allow forceps to manipulate the gallbladder, aspirate bile, crush stones and remove all through the umbilical port. Postoperative care: Pain from carbon dioxide retention: Teach early ambulation to promote absorption.

131 131 Open Cholecystectomy Postoperative nursing care Pain relief via patient-control analgesia (may be meperidine instead of morphine if risk of sphincter of Oddi) spasm. Antiemetics – common postoperative nausea. Incision and drain care If drainage is large may give synthetic bile salts such as dehydrocholic acid (Decholin) via NG tube When patient is allowed to eat, clamp tube for 1-2 hours per surgeons order before and after meals

132 132 Home Care of T-tube Report sudden increase in output Inspect for signs of infection Report change in drainage, abdominal pain, nausea or vomiting Clean and change dressing daily Never irrigate, aspirate or clamp the drainage tube without surgeons order Prevent kinks, pulling tension or tangling of tubing– keep drainage bag below tubing Empty drainage bag If ordered, clamp tube for 1-2 hours before and after meals. Otherwise keep unclamped Watch stools

133 133 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.

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