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Nursing of Adult Patients with Medical & Surgical Conditions Gastrointestinal Accessory Organ Disorders.

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Presentation on theme: "Nursing of Adult Patients with Medical & Surgical Conditions Gastrointestinal Accessory Organ Disorders."— Presentation transcript:

1 Nursing of Adult Patients with Medical & Surgical Conditions Gastrointestinal Accessory Organ Disorders

2 Diagnostic Studies Serum Bilirubin Test –Normal Values Direct bilirubin: 0.1 to 0.3 mg/dl Indirect bilirubin: 0.2 to 0.8 mg/dl Total bilirubin: 0.1 to 1.0 mg/dl Total bilirubin in newborns: 1 to 12 mg/dl –Rationale Used to diagnose liver disease, biliary obstruction, erythroblastosis fetalis, and hemolytic anemia –Nursing Interventions NPO

3 Diagnostic Studies Liver Enzyme Tests –Normal Values AST (SGOT): 5-40 IU/L –elevated with MI, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute pancreatitis, acute renal failure, and acute hemolytic anemia ALT (SGPT): 5-35 IU/L –elevated with hepatitis, cirrhosis, hepatic necrosis, hepatic tumors, and hepatotoxic drugs. LDH: 45-90 U/L –elevated with MI, pulmonary infarction, hepatic disease, pacreatitis, hemolytic anemia, and skeletal muscle disease.

4 Diagnostic Studies Alkaline Phosphatase: 30-85 ImU/L –elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, metastatic tumor in bones and healing fractures Gamma GT: 4-38 U/L –elevated with hepatitis, cirrhosis, hepatic tumors, hepatotoxic drugs, MI (4-10 days after), CHF, and alcohol ingestion –Rationale Liver is storehouse for many enzymes Injury or diseases affecting the liver will cause release of these enzymes into the bloodstream

5 Diagnostic Studies Serum Protein Test –Normal Values Total Protein: 6-8 g/dl Albumin: 3.2-4.5 g/dl Globulin: 2.3 to 3.4 g/dl Albumin globulin (A/G ratio): 1.2 to 2.2 g/dl –Rationale The liver metabolizes protein, esp. albumin. If the liver is diseased it loses the ability to metabolize the albumin and the serum albumin level is decreased

6 Diagnostic Studies Oral Cholecystography (Gallbladder Series) –Rationale Provides x-ray visualization of the gallbladder after ingestion of a radiopaque dye. The following factors are necessary for adequate dye concentration: –Ingestion fo correct number of dye tablets –Adequate absorption of the dye from the GI tract; no vomiting or diarrhea –Abstinence from food the morning of the test –Patency of the cystic duct –Concentration of the cye within the gallbladder

7 Diagnostic Studies –Nursing Interventions Assess for allergies to iodine Administer 6 Telepaque tablets orally, after the evening meal NPO after midnight

8 Diagnostic Studies Intravenous Cholangiography (IV Cholangiogram) –Rationale Radiographic dye is administered IV Allows visualization of the hepatic and common bile ducts and also the gallbladder if the cystic duct is patent Used to visualize stones, strictures, or tumors of the hepatic duct, common bile duct, and gallbladder.

9 Diagnostic Studies Operative Cholangiography –Rationale Common bile duct is injected directly with radiopaque dye. Visualization of stones or other obstructions during surgery to prevent unneccessary common bile duct exploration

10 Diagnostic Studies T-Tube Cholangiogram –Rationale Demonstrates good flow of contrast into the duodenum Diagnose retained ductal stones and/or leaks in ducts –Nursing Interventions T-tube to closed drainage system Cover site with sterile dressing, if t-tube removed Assess for allergies to iodine NPO after midnight

11 Diagnostic Studies Ultrasound of the Liver, Gallbladder, and Biliary System –Rationale Visualization of deep structures by recording the reflections of ultrasonic waves directed in to the tissue –Nursing Interventions NPO after midnight Should be done before barium studies or after all barium has been expelled

12 Diagnostic Studies Gallbladder Scanning –Rationale Injection of technetium 99 is given and scan is done to visualize the gallbladder and biliary tract Used to diagnose acute cholecystitis –Nursing Interventions NPO after midnight

13 Diagnostic Studies Liver Biopsy –Rationale Needle is inserted through the abdominal wall into the liver to remove a piece of liver tissue Used to diagnose cirrhosis, hepatitis, drug-related reactions, granuloma, and tumors –Nursing Interventions Informed consent NPO for 4-8 hours Assess lab results for normal platelet count and prothrombin time

14 Diagnostic Studies After biopsy –Assess for s/s of bleeding –Vital signs every 15 min x 1hr, every 30 min x 4 hrs, then every 4 hrs –Assess for s/s of pneumothorax –Bed rest for 24 hrs

15 Diagnostic Studies Liver Scanning –Rationale Radionuclide is given IV Geiger counter is used to record the distribution of radioactive particles in the liver –Nursing Interventions NPO after midnight

16 Diagnostic Studies Blood Ammonia –Normal Value 15 to 110 micrograms/dl –Rationale Ammonia is normally converted into urea and then excreted by the kidneys Liver dysfunction or altered blood flow to the liver causes blood ammonia levels to rise and BUN (blood urea nitrogen) to decrease –Nursing Interventions Notify lab if patient is currently taking Neomycin; can cause decreased ammonia levels

17 Diagnostic Studies Hepatitis Virus Studies –Rationale Diagnose specific virus causing hepatitis –A, B, C, D, and E

18 Diagnostic Studies Serum Amylase Test –Normal Value 25 to 125 U/L –Rationale Damage to pancreas cells or obstruction to the pancreatic ductal flow will cause an outporing of this enzyme and absorption into the bloodstream Levels will rise within 12 hours of onset of pancreatic disease. Rapidly cleared by the kidneys; levels may return to normal within 48-72 hrs –Nursing Interventions Note administration of any IV dextrose; can cause a false- negative result

19 Diagnostic Studies Urine Amylase Test –Normal Value 3-35 IU/hr –Rationale Disorders affecting the pancreas will cause elevated amylase levels in the urine because the kidneys rapidly clear amylase Levels remain elevated in the urine for 7-10 days Used to diagnose pancreatitis in patients who have had symptoms for 3 days or longer

20 Diagnostic Studies –Nursing Interventions Urine collection may be 2 hr spot urine, 6 hr, 12 hr, or 24 hr collection. –Record exact time collection is begun –Discard first urine specimen –Collect all subsequent urine, including the last urine voided exactly 2, 6, 12, or 24 hrs after collection began –Urine should be kept on ice during collection period

21 Diagnostic Studies Ultrasound of Pancreas –Rationale Provides diagnostic information with the use of ultrasonography of the pancreas Used to diagnose carcinoma, pseudocyst, pancreatitis, and pancreatic abcess –Nursing Interventions NPO for 8 hours before test Gas or barium will interfere with sound wave transmission

22 Diagnostic Studies Computerized Tomography of the Abdomen –Rationale Cross-sectional image Used to diagnose inflammation, tumors, cysts, ascites, aneurysm, and cirrhosis of the liver –Nursing Interventions NPO after midnight Some patients may experience claustrophobia

23 Diagnostic Studies Endoscopic Retrograde Cholangiopancreatography of the Pancreatic Duct (ERCP) –Rationale A fiberoptic duodenoscope is inserted through the oral pharynx, through the esophagus and stomach, and into the duodenum. Dye is injected for radiographic visualization of the CBD and pancreatic duct. Used to diagnose obstructive jaundice, remove common bile duct stones, and place biliary and pancreatic duct stents to bypass obstructions

24 Diagnostic Studies –Nursing Interventions NPO for 8 hours before test Informed consent Must remain still for 1-2 hours After procedure –NPO until gag reflex returns –Assess for abdominal pain, tenderness and guarding –Assess for s/s of pancreatitis abd. pain, nausea, vomiting, and diminished or absent bowel sounds

25 Cirrhosis Etiology/Pathophysiology –Chronic, degenerative disease of the liver –Scar tissue restricts the flow of blood to the liver –Types of cirrhosis Laennec’s cirrhosis –history of chronic ingestion of alcohol Postnecrotic cirrhosis –viral hepatitis, exposure to hepatotoxins, or infection Primary biliary cirrhosis –destruction of the bile ducts Secondary biliary cirrhosis –chronic biliary tree obstruction (gallstones, tumor, etc.)


27 Cirrhosis –Alteration of liver function Reduced ability to metabolize albumin Obstruction of portal vein Increased pressure in the veins that drain the GI tract

28 Complications –Portal Hypertension increased venous pressure in the portal circulation caused by compression or occlusion in the portal or hepatic vascular system

29 –Ascites accumulation of fluid and albumin in the peritoneal cavity

30 Esophageal Varicosities –veins in the upper part of the body distend, including the esophageal veins due to portal hypertension. They may rupture causing severe hemorrhage

31 Cirrhosis Hepatic Encephalopathy –Brain damage due to elevated ammonia levels –Inaapropriate behavior, disorientation, flapping hand tremors, twitching of the extremities, stupor, and coma

32 Cirrhosis Signs & Symptoms –Early stages Abdominal pain Liver is firm and easy to palpate –Late stages dyspepsia changes in bowel habits –constipation or diarrhea Nausea and vomiting gradual weight loss

33 Cirrhosis ascites enlarged spleen spider angiomas anemia bleeding tendencies –cannot absorb vitamin K, or produce clotting factors epistaxis purpura hematuria bleeding gums

34 Cirrhosis jaundice –yellow discoloration of the skin, mucous membranes and sclerae or the eyes –caused by abnormal amounts of bilirubin in the blood mental disorientation

35 Cirrhosis Treatment –Eliminate the cause alcohol, hepatotoxins, environmental exposure to harmful chemicals –Diet Well balanced High-calorie (2500 to 3000 cal/day) Moderate protein (75 g/day) Low fat Low sodium (1000 to 2000 mg/day) Supplemental vitamins and folic acid

36 Cirrhosis –Antiemetics Benadryl & Dramamine Contraindicated: Vistaril, Compazine, and Atarax –Treatment of Complications Ascites –Bedrest –Strict I&O –Restrict fluids to 500 -1000 cc/day –Restrict sodium to 1000-2000 mg/day –Diuretics: Aldactone, Lasix, HCTZ –Vitamin Supplements: Vitamin K, Vitamin C and folic acid –LeVeen Peritoneal-Jugular Shunt –Paracentesis

37 LeVeen Peritoneal Jugular ShuntParacentesis

38 Cirrhosis Ruptured Esophageal Varices –Maintain airway –Establish IV –Vasopressin drip to control bleeding IV or directly into the superior vena cava –Sengstaken-Blakemore tube –Endoscopic sclerotherapy –Portacaval shunt divert blood from the portal vein to the inferior vena cava –Blood transfusion

39 Sengstaken-Blakemore Tube

40 Cirrhosis Hepatic Encephalopathy –Decrease protein in diet –Avoid drugs which are detoxified by the liver –Lactulose Oral or retention enema decreases the pH of the bowel which decreases the production of ammonia –Neomycin inhibits protein synthesis in bacteria, therefore decreasing the production of ammonia

41 Hepatitis Etiology/Pathophysiology –Inflammation of the liver resulting from several types of viral agents or exposure to toxic substances –Hepatitis A Most common Incubation 10-40 days Oral-fecal trasmission

42 Hepatitis –Hepatitis B Incubation 28-160 days Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids –Hepatitis C Incubation 2 weeks to 6 months (usually 6-9 weeks) Transmitted through contaminated needles and blood transfusions –Hepatitis D Coinfection with hepatitis B Incubation 2-10 weeks

43 Hepatitis –Hepatitis E Fecal contamination of water Rare in the U.S.; usually in developing countries Incubation 15-64 days

44 Hepatitis Signs & Symptoms –General malaise –Aching muscles –Photophobia –Headaches –Chills –Abdominal pain –Dyspepsia –Nausea

45 Hepatitis –Diarrhea –Constipation –Pruritus –Hepatomegaly –Enlarged lymph nodes –Weight loss –Jaundice –Dark amber urine –Clay colored stools

46 Hepatitis Treatment –Treat signs and symptoms –Small frequent meals low-fat, high carbohydrate –IV fluids for dehydration Vitamin C for healing Vitamin B-complex for absorption of fat soluble vitamins Vitamin K for coagulation –Avoid unnecessary medications, esp seditives

47 Hepatitis –Gamma globulin or immune serum globulin should be given to anyone exposed to Hepatitis A may be given 2 weeks before and 1 week after onset of symptoms –Hepatitis B imune globulin (HBIG) should be given to anyone exposed to Hepatitis B –Hepatitis B Vaccine should be given to persons identified as high risk for developing Hepatitis B –healthcare personnel –high-risk lifestyle (drug users, homosexual men, prostitutes) –infants born to mothers who are Hepatitis B positive

48 Liver Abscesses Etiology/Pathophysiology –May be single of multiple –Abscess forms in the liver due to an invading bacteria

49 Liver Abscesses Signs & Symptoms –Fever –Chills –Abdominal pain and tenderness in the RUQ –Hepatomegaly –Jaundice –Anemia

50 Liver Abscesses Treatment –IV antibiotics –Percutaneous drainage of liver abscess –Open surgical drainage

51 Cholecystitis & Cholelithiasis Etiology/Pathophysiology –An obstruction, gallstone, or tumor prevents bile from leaving the gallbladder and the trapped bile acts as an irritant causing inflammation. –Risk factors: Female Native American or white Obesity Pregnancy Diabetes Multiparous women Use of birth control

52 Cholelithiasis


54 Cholecystitis & Cholelithiasis Signs & Symptoms –Indigestion after eating foods high in fat –Severe, colicky pain in the right upper quadrant may radiate around the midtorso to the right scapular area –Anorexia –Nausea & vomiting –Flatulence –Increased heart & respiratory rates –Diaphoresis

55 Cholecystitis & Cholelithiasis –Low grade fever –Elevated WBC –Mild jaundice –Steatorrhea (fatty stool) –Dark amber urine

56 Cholecystitis & Cholelithiasis Treatment –Mild attacks Bedrest NG tube to suction NPO IV fluids Antispasmodic/Analgesic –Demerol: decreases incidence of spasms of the sphincter of Oddi Antibiotics Avoid spicy foods when allowed PO intake

57 Cholecystitis & Cholelithiasis –Lithtripsy A machine discharges a series of shock waves through water or a cushion that breaks the stone into fragments –Cholecystectomy ( Removal of the gallbladder) Laparoscopic –Oral liquids post-op –Outpatient or discharged next day –Resume moderate activity in 48-72 hrs Open –Jackson-Pratt drain –T-tube –NG tube –Routine post-op care

58 T-Tube

59 Pancreatitis Etiology/Pathophysiology –Inflammation of the pancreas Acute or Chronic –Predisposing Factors Alcohol Trauma Infectious disease Certain drugs –Obstruction of the pancreatic duct may cause a rupture and enzymes digest the pancreas

60 Pancreatitis

61 Signs & Symptoms –Abdominal pain –Anorexia –Nausea & vomiting –Malaise –Restlessness –Low-grade fever –Jaundice –Weight loss –Steatorrhea –Tachycardia

62 Pancreatitis Treatment –NPO –IV fluids –NG tube –Antiemetics –Demerol 75 -100 mg q 3-4 hrs Avoid morphine; causes spasms of the sphincter of Oddi –Anticholinergics –atropine or Pro-Banthine –Antacids or Tagamet (prevent ulcers)

63 Pancreatitis –Hyperalimentation may be required to maintain nutrition –Prevention bland, low-fat, high-protein, high-carbohydrate diet no alcohol or gastric stimulants (coffee) may need oral hypoglycemic agents if destruction or the islets of Langerhans

64 Cancer of the Pancreas Etiology/Pathophysiology –Unknown –Risk factors cigarette smoking exposure to chemical carcinogens diabetes mellitus pancreatitis diet high in meat, fat and coffee –May be metastisis form the lung, stomach, duodenum or CBD –May live only 4-8 months after diagnosis

65 Cancer of the Pancreas

66 Signs & Symptoms –Anorexia –Fatigue –Nausea –Flatulence –Change in stools –Steady, dull aching pain in the epigastic area –Weight loss –Jaundice –Onset of diabetes mellitus

67 Cancer of the Pancreas Treatment –Surgery Whipple procedure –resection of the antrum of the stomach, duodenum, and part of the pancreas –anastomosis between the stomach, CBD, and pancreatic ducts and the jejunum Total pancreatectomy with resection of parts of the GI tract –Chemotherapy –5-FU and BCNU –Gemzar –Radiation

68 Whipple Procedure

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