GI Test

4/25/2011 2:11:00 PM

GI Terminologies y Visceral pain; dull poorly localized pain y Somatic pain; sharp pain, well localized y Referred pain; pain experience at a distance from disease process y Fetor hepaticus; sweet fecal odor caused by hepatic failure y Feculent breath; foul fecal odor caused by severe bowel obstruction y Severe halitosis; foul breath odor can be caused by poor dental hygience or neoplasms or esophagus and stomach y Jaundice; yellowish discoloration of skin caused by high bilirubin level associated with liver disease, biliary obstruction, excessive hemolysis y Grey turners sign; ecchymosis to flanks indicative of retroperitoneal bleeding y Ascitis; intraperitoneal fluid infrequently associated with y Anasarca; entire body edema seen in end stage renal disease y Diastasis recti abdominis; abnormal separation of two abdominal muscles by raising his or her head from bed y Ballottment; technique of examining a fluid filled part of body to detect floating object. y Cullens sig; ecchymosis around umbilicus indicative in intraparanteal bleeding y Mcburney's sign: is a sign of acute appendicitis y Rovsing Salivary glands y 1000-1500 ml/day y Enzymes pityalin (amylase) and lysozyme y Initiates carb metabolism, destroy bacterial protects muscus membrane, and tooth decay Stomach 2500 ml/day y Enzyme pesin y Converts proteins into proteoses and peptones Liver bile 500-100 ml/day y No enzymes y Emulsifies fat Pancrease 1000-1500 ml/day

y Enzymes trypsin , amylase, mylase y Digest major components of chime Differntation of abd pain y Gastritis; epigastric or slightly left midline, maybe described as indigestion, nausea vomiting, hematamesis, abd tenderness y Peptic ulcer, epigastric or RUQ, gnawing or burning, abd tenderness, hematemesis or melena y Pancreatitis; epigastric or LUQ may radiate to back, flanks or left shoulder, boring worsen by lying down, nausea or vomiting, jaundice maybe present if common bile duct is obstructed. y Cholecystitis; epigastric PR RUQ area, cramping, maybe referred to below right scapula, murphys sign; nausea vomiting, abd tenderness in RUQ y Appendicitis; epigastric or periumbilical pain, later localizes in RLQ, mcburneys sign, rovsing sing, dull to sharp pain, anorexia, fever, diarrhea, leukocytosis, rebound tenderness, indicates peritoneal irriation y Intestinal obstruction, epigastric or umbilical, spastic to dull, change in bowel habits, melena or hematochezia, hyperactive to hypoactive bowel sounds y Steps o Inspection  Inspection;  Landmarks  General survey  Mouth  Skin  Contour of abd  Abd girth  Weakness of abd wall  Movement of abd o Auscultation  Put pillow under knees to relax abd muscle  Bowel sounds  Succussion splash  Vascular sounds; use bell

 Peritoneal friction rub; presence of peritoneal fluid o Percussion  Percussion tones normally heard are  Dull liver, full sigmoid colon, full bladder, flute tone, tympani gastric bulle (drum like sound)  When testing for ascitis (fluid like, shifting dullness, midline dullness)  Organ borders (spleen, liver, stomach, bladder, intestine) o Palpation  Method  Light palpation 1-2 cm  Deep palpation 4-5 cm only physician  Ballottement Laboratory and Diagnostic exams y Upper GI study y series of radiographys of lower esophagus, stomach, duodenum, using barium sulfate as contrast medium y Detects any abnormal conditions of GI tract y Tumors y Other ulcerative lesions y Prep o NPO post midnight o No smoking night before study o Explain importance of expelling barium solution o Stools will be whitish or light in color until all solution expelled out (72) hrs o Eventual absorption of fecal water may cause hardened barium impaction o Advice increase fluid intake o Administer MOM after exam to promote expulsion of solution unless contraindicated y Tube Gastric analysis o Stomach contents aspirated to determine amount of acid produced by parietal cells in stomach

o Analysis helps determine completeness of vagotomy, confirm hypersecretions of achlohydria, estimate acid secretory capacity or test for intrinsic factor.(vitamin B12) o Nursing interventions  No anti cholinergic for 24 hrs prior to test  NPO after midnight  No smoking  Label specimens properly and send to lab asap  Remove NG tube as soon as specimens collected. E GD o Evaluates esophagus, stomach and duodenum. o Nursing care o NPO PMN o Consent o Pre op check list o Pt usually given midazolam IV o Spraying of pharynx with lidocaine hydrochloride o NPO until further order or until gag reflex returned o Assess for any S/S of perforation; abd pain, tenderness, guarding, oral bleeding, melena (black stool), hypovolemic shock. Capsule Endoscopy o Pt swallows capsule with camera o Collect about 57000 images o Visualizes small intestine o Use to diagnose Chrons disease o Celiac disease o Malabsorption o Helps identify possible sources of GI bleeding o Capsule relays images to a data recorder that pt wears on belt. o Nursing intervention  Diet prep is similar to colonoscopy  Pt swallows video capsule and kept 4-6 hrs later  Device is removed after 8 hrs  Peristalsis causes capsule to pass in bowel movement.

Barium swallow o More thorough barium contrast study of esophagus provided by most UGI exam o Defects in luminal filling and narrowing of barium column indicate tumors, scarred stricture or esophageal varices o Allows easy recognition of anatomical abnormalities o Left atrial dilation, aortic aneurysm, and para-esophageal tumor may cause extrinsic compression of barium column within esophagus. o If barium leaks from GI tract, its not absorbed and can cause complications. Gastrografin studies o Gastrografin:  water soluble and rapidly absorbed o Preferable when perforation is suspected o It facilitates imaging through radiographs o If product escapes from GI tract it is absorbed by the surrounding tissue Diatrizoate o Use in place of barium o Interventions  Maintain NPO after midnight  Explain importance of rectally expelling barium  Stools will be light colored until complete expelling occurs  Increase fluid intake  Give MOM after barium swallow exam unless contraindicated. Esophageal function test o Acid perfusion test, attempt to reproduce symptoms of gastroesophageal reflux o Helps differentiate esophageal pain from angina pectoris o If pt suffers pain within instillation of hydrochloric acid into esophagus, test is positive and indicates reflux esophagitis o Interventions  Avoid sedating pt

 NPO for 8 hrs prior exam  Withhold antacid and analgesics Stool for occult blood, guaiac, hemoccult, hematest! o Stool specimen free from tissue and urine o Diet free from organ mean 24-48 hrs before test Sigmoidoscopy o Lower segment of large intestine! o Nursing care  NPO  Admin enema night before  Consent  Observe for signs of bowel perforation Abd pain Bleeding Tenderness Distention Barium enema study o AKA lower GI series o Consists of series of xrays of colon o Used to diagnose presence of :  polyps , tumors, diverticula, positional abnormalities o Can be used to detect intussusceptions in children o Nursing care  Administer cathartics such as magnesium citrate  Cleansing enema evening before  MOM evacuation of barium  NPO  Retained barium equals hard stools! Colonoscopy o Requires sedation o Camera to view entire colon o GOLYTELY night before o More accurate o Requires bowel preparation night before Virtual colonoscopy o Uses MRI or CT to take pictures of entire colon

o o o o Stool o o o o o

y y

y y y y y

Needs sedation but no consent less invasive Same prep as conventional colon Needs GOLYTELY night before GOLYTELY bowel prep (pg 183 box 5-2 AHN) culture Exam of stool for presence of bacteria, ova, parasites Many physicians may order stool for ova and parasites (o&P) Usually done to detect enteropathogens aka, shigella, c diff. Usually 3 stool series are collected on subsequent days. Nursing interventions  If enema ordered use only saline or tap water  Soap suds enema could affect viability of organisms collected  Stool samples obtained before barium exam instruct pt not to mix specimen with feces  Don gloves , make sure specimen taken to lab within 30 min Obstruction series o AKA flat plate abd Group of xray series performed on abdomen for pts who have suspected bowel obstruction , perforated viscus, paralytic ilius, or abdabcess Consists of at least 2 radiographic studies First shot is erect abdxray that allows visualization of diaphragm Radiographs are examined for evidence of free air under the diaphragm- which is pathognomonic sign of obstruction Detects air fluid levels within intestine Nursing care o Ensure study is scheduled before barium studies for adequate visualization.

GI Pharm.

4/25/2011 2:11:00 PM

Pharmacology Notes 4/15/11-For Test 4 Pharmacology Hydrochloric acid production Stomach-acid production Rugae-big folds in the stomach Gastric pits-smaller folds in the stomach where we find the parietal cells Parietal cells Hydrochloric acid Parietal cells--> HCL Potassium goes out, Hydrogen goes in produces Hydrochloric acid H2 Blockers (dine) y Ranitidine (Zantac) works in less than 1 hour (Long acting) y Cimetidine (Tagament) y Decrease acid in stomach PPI Proton Pump Inhibitors -(ZOLE) y Reduce acid secretions of the stomach y Esomeprazole (Nexium) y Omeprazole -Long acting (Starts in 1-3 hours but lasts 24 hours) Short Acting- Antacids y Aluminum Hydroxide (Amphojel) y Side effects fecal impaction, intestinal obstruction y Maalox-short acting Vomiting y Nausea and vomiting-defense of the GI system and are signs of altered body function y Nausea-unpleasant sensation of the need to vomit y Vomiting-(emesis) the forcing of the stomach contents up through the espophagus and out to the mouth y Phases of vomiting o Nausea o Retches (gagging) o Vomiting y Vestibular system-when balance is or sense of position is upset, vomiting occurs

Receptors in the GI tract mechanoreceptors and chemoreceptors o Mechanoreceptors-distention and contraction in bowel obstruction, vomiting occurs o Chemoreceptor-sensory verve cells in response to chemical stimuli such as poisonous substances in the intestines

Vomiting Center of the brain-located in the medulla is responsible for initiating the vomiting reflex. y It combines the input from the GI tract, vestibular apparatus and higher brain pressure centers for activation. y Once activated, the vomiting center causes vomiting by stimulating the salivary and respiratory centers and the throat (pharyngeal), GI and abdominal muscles y Causes of nausea and vomiting o Unpleasant sights, smells, memories, side effects of chemotherapy, medical disorders o Drug or treatment induced---agents antibiotics, cancer chemo, opiate drugs, radiation therapy o Labyrinth disorders-----menier's disease, motion o Endocrine system infection---pregnancy, gastroenteritis, viral laybrinthitis o Increased intracranial pressure-hemorrhage, meningitis o Postoperative-analgesics, anesthetics, procedural o Central Nervous System---Anticipatory, bulimia nervosa, migraine Antiemetic Drugs y Intended responses for antiemetic agents: y -vomiting reflex inhibited y -vomiting reflex pathways are interrupted y -Pt is sedated y -Nausea is relieved y -Vomiting is prevented y Nursing Diagnosis: o Risk for fluid & electrolyte imbalance o Nausea r/t distention & contraction in the intestinal tract o Nausea r/t poisonous substance in the stomach y

Common side effects of antiemetic drugs vary with the prescribed drug.

Anticholinergicsy Primary antimuscarinic (anti-parkinson) agents that act by binding to and blocking acetylcholine receptors o thus, preventing the nauseous stimuli from being transmitted y -limits the stimulation of the emetic center from the vestibular system. y -has minimal effect on vestibular stimulation (vestibular and serotonin) y Scopolamine Hcl (transderm-Scop, scopace, maldemar) Antihistaminesy it inhibits the same pathways as anticholinergic drugs and depress inner ear excitability, reducing vestibular stimulation y -Decreases allergic response by blocking histamine y -also acts on chemoreceptor trigger zone to decrease vomiting y -increases CNS stimulation, has anticholinergic response y -because of this it inhibits one or more of the vomiting reflex pathways y -sedating effects help control the sensation of nausea Promethazine (phenergan) Dipenhydramine (benadryl) Meclizine (bonamine, antivert) Cyclizine (Marezine) 5HT3-Receptor Antagonist/serotonin blockersy Blocks serotonin receptors in the GI tract and the chemotrigger zone in the brain y -by blocking the receptors in both of these sites at least two pathways of the v omiting reflex are interrupted y - most commonly used agents to prevent and treat nausea and vomiting associated with chemotherapy Serotonin Blockers

y y y y

Dolasetronmesylate Granisetron HCL Ordansetron HCL Palonosetron HCL

Dopamine receptor antagonist or neuroleptic agentsy Directly block dopamine from binding to the receptors in the chemotrigger zone and the intestinal tract y -foods in the intestinal tract moves along more quickly and is less likely to stimulate responses that trigger the vomiting reflex, used after surgery to promote peristalsis, prevents nausea and vomiting Dopamine Receptor Antagonist Agents y Metoclopromide (Reglan, Emex, Maxeran) y Chlorpromazine (Thorazine) y Perphenazine y Prochlorperazine (Compazine) y Trimethobenzamide (Tigan) Drugs Common Side Effects y Cyclizine o drowsiness, dry mouth, hypotension-Antihistamine y Meclizine (Antivert) o Drowsiness-Antihistamine y Prochlorperazine o blurred vision, constipation, dizziness, involuntary msucle spasms, jitteriness, mouth puckering-Domamine receptor y Metochlopromide (reglan) o drowsiness, fatigue, increased depression, restlessnessantiemetic, (dopamine receptor antagonist) y Promethazine (phenergan) o confusion, disorientation, dizziness, dry mouth, nausea, vomiting rash, sedation-antihistamine y Ondansetron o abdominal pain, constipation, fatigue, headache-Serotonin y Granisetron

o headache, constipation loss of energy-Serotonin Scopolamine (L-Hyoscine) o Blurred vision, constipation, dilated pupils, dizziness, drowsiness, dry mouth, light-headedness, rash, urinary retention-anticholinergic Trimethobenzamide (Tigan) o blurred vision, diarrhea, drowsiness, muscle cramps, headache, hypotension, rectal irritation-Dopamine Receptor Antagonist

Adverse y y y y y

Effects Also varies with the prescribed drugs Prochlorperazine promethazine (phenergen) Metochlopromide (reglan)-cause tardive dyskinesia Neuroleptic malignant syndrome-rare and life threatening side effects in which dangerously high body temperature y Trimethobenzamide-may cause coma, seizure

GASTROINTESTINAL DISORDERS
4/25/2011 2:11:00 PM GASTROESOPHAGEAL REFLUX DISEASE (GERD) y DESCRIPTION o The backflow of gastric and duodenal contents into the esophagus y Caused by an incompetent lower esophageal sphincter, pyloric stenosis, or a motility disorder y Symptoms may mimic those of a heart attack y ASSESSMENT o Pyrosis o Dyspepsia o Regurgitation o Pain and difficulty with swallowing o Hypersalivation y IMPLEMENTATION o Instruct the client to avoid factors that decrease lower esophageal sphincter pressure or cause esophageal irritation o Instruct the client to eat a low-fat, high-fiber diet; avoid caffeine, tobacco, and carbonated beverages; avoid eating and drinking 2 hours before bedtime; avoid wearing tight clothes; and to elevate the head of the bed on 6- to 8- inch blocks o Avoid the use of anticholinergics, which delay stomach emptying o Instruct the client regarding prescribed medications, such as antacids, histamine H2-receptor antagonists, or gastric acid pump inhibitors o Instruct the client regarding the administration of prokinetic medications if prescribed, which accelerate gastric emptying o If medical management is unsuccessful, surgery may be required and involves a fundoplication (wrapping a portion of the gastric fundus around the sphincter area of the esophagus); may be performed by laparoscopy HIATAL HERNIA y DESCRIPTION o Also known as esophageal or diaphragmatic hernia

o A portion of the stomach herniates through the diaphragm and into the thorax y It results from weakening of the muscles of the diaphragm and is aggravated by factors that increase abdominal pressure such as pregnancy, ascites, obesity, tumors, and heavy lifting y Complications include: o ulceration, hemorrhage, regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with possible necrosis, peritonitis, and mediastinitis y ASSESSMENT o Heartburn o Regurgitation or vomiting o Dysphagia o Feeling of fullness y IMPLEMENTATION o Medical and surgical management is similar to that for GER o Provide small, frequent meals and minimize the amount of liquids o Advise the client not to recline for 1 hour after eating o Avoid anticholinergics, which delay stomach emptying GASTRITIS y DESCRIPTION o Inflammation of the stomach or gastric mucosa y Can be acute or chronic y ACUTE o Caused by the ingestion of food contaminated with diseasecausing microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin or other nonsteroidalantiinflammatory drugs (NSAIDs), excessive alcohol intake, bile reflux, or radiation therapy o ASSESSMENT  Abdominal discomfort  Headache  Anorexia, nausea, and vomiting  Hiccuping

PEPTIC y

y y

CHRONIC o Caused by benign or malignant ulcers, or by the bacteria Helicobacter pylori; may also be caused by autoimmune diseases, dietary factors, medications, alcohol, smoking, or reflux o ASSESSMENT  Anorexia, nausea, and vomiting  Heartburn after eating  Belching  Sour taste in the mouth  Vitamin B12 deficiency  ACUTE EROSIVE GASTRITIS o IMPLEMENTATION  Acute: Food and fluids may be withheld until symptoms subside; then ice chips followed by clear liquids and then solid food is introduced  Monitor for signs of hemorrhagic gastritis such as hematemesis, tachycardia, and hypotension, and notify the physician if these signs occur  Instruct the client to avoid irritating foods, fluids, and other substances such as spicy and highly seasoned foods, caffeine, alcohol, and nicotine  Instruct the client in the use of prescribed medications, such as antibiotics and bismuth salts (Pepto-Bismol)  Provide the client with information about the importance of vitamin B12 injections, if a deficiency is present ULCER DISEASE DESCRIPTION o An ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus, in portions that are accessible to gastric secretions; erosion may extend through the muscle May be referred to as gastric, duodenal, or esophageal ulcer depending on location The most common peptic ulcers are gastric ulcers and duodenal ulcers

GASTRIC ULCERS y DESCRIPTION o Involves ulceration of the mucosal lining that extends to the submucosal layer of the stomach y Predisposing factors include stress, smoking, the use of corticosteroids, nonsteroidalantiinflammatory drugs (NSAIDs), alcohol, a history of gastritis, a family history of gastric ulcers, or infection with Helicobacter pylori y Complications include: o hemorrhage, perforation, and pyloric obstruction y ASSESSMENT o Gnawing, sharp pain in or left of the midepigastric region 1 to 2 hours after eating o Nausea and vomiting o Hematemesis y IMPLEMENTATION o Monitor vital signs and for signs of bleeding o Administer small, frequent, bland feedings during the active phase o Administer histamine H2-receptor antagonists as prescribed to decrease the secretion of gastric acid o Administer antacids as prescribed to neutralize gastric secretions o Administer anticholinergics as prescribed to reduce gastric motility o Administer mucosal barrier protectants as prescribed 1 hour before each meal o Administer prostaglandins as prescribed for their protective and antisecretory actions y CLIENT EDUCATION o Avoid consuming alcohol and substances that contain caffeine or chocolate o Avoid smoking o Avoid aspirin or NSAIDs o Obtain adequate rest and reduce stress y IMPLEMENTATION: ACTIVE BLEEDING

o Monitor vital signs closely o Assess for signs of dehydration, hypovolemic shock, sepsis, and respiratory insufficiency o Maintain NPO status and administer IV fluid replacement as prescribed; monitor I&O o Monitor hemoglobin and hematocrit GASTRIC ULCERS y IMPLEMENTATION: ACTIVE BLEEDING o Administer blood transfusions as prescribed o Assist with the insertion of a nasogastric (NG) tube for decompression and for lavage access o Assist with normal saline or tap water lavage at room temperature to reduce active bleeding o Prepare to assist with administering vasopressin (Pitressin) by IV as prescribed to induce vasoconstriction and reduce bleeding y SURGICAL IMPLEMENTATION o TOTAL GASTRECTOMY  Also called esophagojejunostomy  Removal of the stomach with attachment of the esophagus to the jejunum or duodenum o VAGOTOMY  Surgical division of the vagus nerve to eliminate the vagal impulses that stimulate hydrochloric acid secretion in the stomach GASTRIC RESECTION Also called antrectomy Involves removal of the lower half of the stomach and usually includes a vagotomy GASTRIC ULCERS SURGICAL IMPLEMENTATION BILLROTH I Also called gastroduodenostomy; partial gastrectomy, with remaining segment anastomosed to duodenum BILLROTH II

Also called gastrojejunostomy; partial gastrectomy, with remaining segment anastomosed to jejunum PYLOROPLASTY Enlarges the pylorus to prevent or decrease pyloric obstruction, thereby enhancing gastric emptying TOTAL GASTRECTOMY TYPES OF VAGOTOMIES BILLROTH I BILLROTH II PYLOROPLASTY GASTRIC ULCERS POSTOPERATIVE IMPLEMENTATION Monitor vital signs Position in Fowler's for comfort and to promote drainage Administer fluids and electrolyte replacements by IV as prescribed; monitor I&O Assess bowel sounds Monitor NG suction as prescribed GASTRIC ULCERS POSTOPERATIVE IMPLEMENTATION Do not irrigate or remove the NG tube; assist the physician with irrigation or removal Maintain NPO status as prescribed for 1 to 3 days until peristalsis returns Progress the diet from NPO to sips of clear water to 6 small, bland meals a day as prescribed when bowel sounds return Monitor for postoperative complications of hemorrhage, dumping syndrome, diarrhea, hypoglycemia, and vitamin B12 deficiency DUODENAL ULCERS DESCRIPTION A break in the mucosa of the duodenum Risk factors and causes include alcohol intake, smoking, stress, caffeine, the use of aspirin, corticosteroids, and NSAIDs, and infection with Helicobacter pylori Complications include bleeding, perforation, gastric outlet obstruction, and intractable disease

Surgery is performed only if the ulcer is unresponsive to medications or if hemorrhage, obstruction, or perforation occurs DEVELOPMENT OF A DUODENAL ULCER DUODENAL ULCERS PERFORATION OF A DUODENAL ULCER DUODENAL ULCERS ASSESSMENT Burning pain in the midepigastric area 2 to 4 hours after eating and during the night Pain that is often relieved by eating Melena DUODENAL ULCERS IMPLEMENTATION Monitor vital signs Perform abdominal assessment Instruct the client in a bland diet with small, frequent meals Provide for adequate rest Encourage the cessation of smoking DUODENAL ULCERS IMPLEMENTATION Instruct the client to avoid alcohol intake, caffeine, the use of aspirin, corticosteroids, and NSAIDs Administer antacids as prescribed to neutralize acid secretions Administer histamine H2-receptor antagonists as prescribed to block the secretion of acid DUMPING SYNDROME DESCRIPTION Rapid emptying of the gastric contents into the small intestine Occurs following gastric resection DUMPING SYNDROME ASSESSMENT Symptoms occurring 30 minutes after eating Nausea and vomiting Feelings of abdominal fullness and abdominal cramping Diarrhea Palpitations and tachycardia

Perspiration Weakness and dizziness Borborygmi DUMPING SYNDROME CLIENT EDUCATION Eat a high-protein, high-fat, low-carbohydrate diet Eat small meals and avoid consuming fluids with meals Avoid sugar and salt Lie down after meals Take antispasmodic medications as prescribed to delay gastric emptying VITAMIN B12 DEFICIENCY DESCRIPTION Results from either an inadequate intake of vitamin B12 or a lack of absorption of ingested vitamin B12 from the intestinal tract Pernicious anemia results from a deficiency of intrinsic factor, which is necessary for intestinal absorption of vitamin B12 VITAMIN B12 DEFICIENCY ASSESSMENT Severe pallor Fatigue Weight loss Smooth, beefy, red tongue Slight jaundice Paresthesias of the hands and feet Disturbances with gait and balance VITAMIN B12 DEFICIENCY IMPLEMENTATION Increase dietary intake of foods rich in vitamin B12 if the anemia is the result of a dietary deficiency Administer vitamin B12 injections as prescribed on a weekly basis initially, and then monthly for maintenance (lifelong) if the anemia is the result of a deficiency of the intrinsic factor ESOPHAGEAL VARICES DESCRIPTION Dilated and tortuous veins in the submucosa of the esophagus

Caused by portal hypertension, often associated with liver cirrhosis, and high risk for rupture if portal circulation pressure rises Bleeding varices is an emergency The goal of treatment is to control bleeding, prevent complications, and prevent the reoccurrence of bleeding ESOPHAGEAL VARICES ESOPHAGEAL VARICES ASSESSMENT Hematemesis Tarry stools, melena Ascites Jaundice Hepatomegaly and splenomegaly Dilated abdominal veins Hemorrhoids Signs of shock ESOPHAGEAL VARICES IMPLEMENTATION Monitor vital signs Elevate the head of the bed Monitor for orthostatic hypotension Monitor lung sounds and for the presence of respiratory distress Administer oxygen as prescribed to prevent tissue hypoxia Monitor level of consciousness (LOC) ESOPHAGEAL VARICES IMPLEMENTATION Maintain NPO status Administer IV fluids as prescribed to restore fluid volume and correct electrolyte imbalances; monitor I&O Monitor hemoglobin, hematocrit, and coagulation factors Administer blood transfusions or clotting factors as prescribed ESOPHAGEAL VARICES IMPLEMENTATION Assist in inserting an NG tube or a balloon tamponade as prescribed Assist with the administration of iced saline irrigations to achieve vasoconstriction of the varices

Prepare to assist with administering vasopressin (Pitressin) by IV or intraarterial infusion as prescribed to induce vasoconstriction and reduce bleeding ESOPHAGEAL VARICES IMPLEMENTATION Prepare to assist with administering nitroglycerin (Tridil) with vasopressin (Pitressin) to prevent vasoconstriction of the coronary arteries Instruct the client to avoid activities that will initiate vasovagal responses Prepare the client for endoscopic procedures or surgical procedures as prescribed ESOPHAGEAL VARICES ENDOSCOPIC INJECTION (SCLEROTHERAPY) Injection of a sclerosing agent into and around bleeding varices Complications include chest pain, pleural effusion, aspiration pneumonia, esophageal stricture, and perforation of the esophagus INJECTION SCLEROTHERAPY ESOPHAGEAL VARICES ENDOSCOPIC VARICEAL LIGATION Ligation of the varices with an elastic rubber band Sloughing, followed by superficial ulceration, occurs in the area of ligation within 3 to 7 days ESOPHAGEAL VARICES SURGICAL SHUNT PROCEDURES SPLENORENAL Involves splenectomy, with anastomosis of the splenic vein to the left renal vein PORTACAVAL Shunting of the blood from the portal vein to the inferior vena cava MESOCAVAL Involves a side anastomosis of the superior mesenteric vein to the proximal end of the inferior vena cava SHUNTING PROCEDURES ESOPHAGEAL VARICES SURGICAL SHUNT PROCEDURES TRANSJUGULAR INTRAHEPATIC PORTAL/SYSTEMIC Uses the normal vascular anatomy of the liver to create a shunt with the use of a metallic stent

The shunt is between the portal and systemic venous system within the liver and is aimed at relieving portal hypertension ULCERATIVE COLITIS DESCRIPTION Ulcerative and inflammatory disease of the bowel that results in poor absorption of nutrients Commonly begins in the rectum and spreads upward toward the cecum Characterized by various periods of remissions and exacerbations The colon becomes edematous and may develop bleeding lesions and ulcers; the ulcers may lead to perforation ULCERATIVE COLITIS DESCRIPTION Scar tissue develops and causes loss of elasticity and loss of ability to absorb nutrients Acute ulcerative colitis results in vascular congestion, hemorrhage, edema, and ulceration of the bowel mucosa Chronic ulcerative colitis causes muscular hypertrophy; fat deposits; and fibrous tissue with bowel thickening, shortening, and narrowing ULCERATIVE COLITIS DESCRIPTION Surgical intervention involves creation of an ostomy; the ostomy can be created within the ileum or at various sites within the large bowel An ileostomy is the surgical creation of an opening into the ileum or small intestine that allows for drainage of fecal matter from the ileum to the outside of the body A colostomy is the surgical creation of an opening into the colon that allows for drainage of fecal matter from the colon to the outside of the body ULCERATIVE COLITIS ACUTE ULCERATIVE COLITIS ULCERATIVE COLITIS ASSESSMENT Anorexia Weight loss Malaise Abdominal tenderness and cramping Severe diarrhea that may contain blood and mucus

Dehydration and electrolyte imbalances Anemia Vitamin K deficiency ULCERATIVE COLITIS IMPLEMENTATION Acute phase: Maintain NPO status, administer IVs and electrolytes, or total parenteral nutrition (TPN) as prescribed Restrict the clients activity to reduce intestinal activity Monitor bowel sounds and for abdominal tenderness and cramping Monitor stools, noting color, consistency, and the presence or absence of blood ULCERATIVE COLITIS IMPLEMENTATION Monitor for perforation, peritonitis, and hemorrhage Following the acute phase, the diet progresses from clear liquids to lowresidue as tolerated Instruct client to consume a low-residue, high-protein diet; vitamins and iron supplements may be prescribed Instruct client to avoid gas-forming foods and milk products and foods such as whole-wheat breads, nuts, raw fruits and vegetables, pepper, alcohol, and caffeine-containing products ULCERATIVE COLITIS IMPLEMENTATION Instruct the client to avoid smoking Administer bulk-forming agents such as bran, psyllium, or methylcellulose, to decrease diarrhea and relieve symptoms Administer antimicrobial, corticosteroids, and immunosuppressants as prescribed to prevent infection and reduce inflammation ULCERATIVE COLITIS SURGICAL IMPLEMENTATION TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY Curative and involves the removal of the entire colon (colon, rectum, and anus with anal closure) The end of the terminal ileum forms the stoma, which is located in the right lower quadrant TOTAL PROCTOCOLECTOMY WITH PERMANENT ILEOSTOMY

ULCERATIVE COLITIS SURGICAL IMPLEMENTATION KOCK ILEOSTOMY (CONTINENT ILEOSTOMY) An intra-abdominal pouch (stores the feces) is constructed from the terminal ileum The pouch is connected to the stoma with a nipple-like valve constructed from a portion of the ileum; the stoma is flush with the skin A catheter is used to empty the pouch, and a small dressing or adhesive bandage is worn over the stoma between emptyings KOCK ILEOSTOMY (CONTINENT ILEOSTOMY) ULCERATIVE COLITIS SURGICAL IMPLEMENTATION ILEOANAL RESERVOIR A two-stage procedure that involves the excision of the rectal mucosa, an abdominal colectomy, construction of a reservoir to the anal canal, and a temporary loop ileostomy The ileostomy is closed in approximately 3 to 4 months after the capacity of the reservoir is increased CREATION OF AN ILEOANAL RESERVOIR ULCERATIVE COLITIS SURGICAL IMPLEMENTATION ILEOANAL ANASTOMOSIS (ILEORECTOSTOMY) Does not require an ileostomy A 12- to 15-cm rectal stump is left after the colon is removed and the small intestine is inserted into this rectal sleeve and anastomosed Requires a large, compliant rectum ILEOANAL ANASTOMOSIS ULCERATIVE COLITIS PREOPERATIVE COLOSTOMY AND ILEOSTOMY Consult with enterostomal therapist to assist in identifying optimal placement of the ostomy Instruct the client to eat a low-residue diet for a day or two prior to surgery as prescribed Administer intestinal antiseptics and antibiotics as prescribed to cleanse the bowel and to decrease the bacterial content of the colon Administer laxatives and enemas as prescribed

ULCERATIVE COLITIS POSTOPERATIVE COLOSTOMY Place a petrolatum gauze over the stoma as prescribed to keep it moist, followed by a dry sterile dressing if a pouch (external) system is not in place Place a pouch system on the stoma as soon as possible Monitor the stoma for size, unusual bleeding, or necrotic tissue ULCERATIVE COLITIS POSTOPERATIVE COLOSTOMY Monitor for color changes in the stoma The normal stoma color is pink to bright red and shiny, indicating high vascularity A pale pink stoma indicates low hemoglobin and hematocrit levels A purple-black stoma indicates compromised circulation, requiring physician notification ULCERATIVE COLITIS POSTOPERATIVE COLOSTOMY Assess the functioning of the colostomy Expect that stool is liquid in the immediate postoperative period, but becomes more solid depending on the area of the colostomy Ascending colon - liquid Transverse colon - loose to semi-formed Descending colon - close to normal LOCATIONS OF COLOSTOMIES ULCERATIVE COLITIS POSTOPERATIVE COLOSTOMY Monitor the pouch system for proper fit and signs of leakage Empty the pouch when it is one-third full Fecal matter should not be allowed to remain on the skin Administer analgesics and antibiotics as prescribed