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Symptoms of GERD
- Heartburn (dyspepsia)
- Regurgitation (lead to aspiration/bronchitits)
- Coughing, hoarseness or wheezing at night
- Dysphagia
- Pyrosis
- Globus
- Belching, Flatulence
- Epigastric or retrosternal pain
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Diagnosic test for GERD
- 24hours gastric pH monitoring
- Esohageal manometry (rarely used)
- Endoscopy:
- requires conscious sedation
- Informed consent
- NPO prior to procedure
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Medical management for GERD
Goals
Diet therapy
Lifestyle changes
- Goal:
- Relief of symptoms and prevent complications
- DT:
- Restrict caffine, tomatoe, chocolate, fatty foods, and spicy
- DO NOT eat before bedtime
- Limit amount ( volume) of food eaten at each meal
- LC:
- Elevate head of bed, sleep on left side
- Avoid smoking, alcohol
- Weight reduction program
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Drug therapy for GERD
- Histamine receptor antagonists (h2 blockers)
- Reduces acid secretions, promote healing of infamed esophagus, control symptoms titrate
- Tagamet, Pepcid, Zantac
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- Proton Pump inhibitor (PPI)
- MAIN drugs used for effective long term use by inhibiting proton pump of parietal cells thus reducing acid
- Prilosec, Nexium, Prevacid, Protonix
- Acid protectives- Carafate
- -cytoprotective properties
- Cholinergic- Urecholine
- -increases LES pressure
- Prokinetic drugs- Reglan
- - Mobility enhanceing
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GERD surgical interventions
- Endoscopic therapy and surgery
- -BESS procedure, stretta procedure or enteryx procedure
- Delivers radiofrequency energy to smooth musle of LES
- -Induces collagen contration: forms a barrier against reflux
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Cause:
High gastric acid secretion, rapid empty of food reduces buffering- allows large acid bolus into the duodenum- penetrates the mocosa and into the muscle layer.
H. pylori
Chronic renal failure
Smoking and alcohol use
Duodenal ulcer
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Cause:
Unknown mechanism but there is apresence of elevated levels of hydrocoric acid, ischemia, and erosive gastritis seen.
Stress Ulcer
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Examples of destryers of mucosal barrier
- Aspirin and nsaids
- H. pylori
- Corticosteroids
- Lipid-soluble cytotoxic drugs
- Increased vagal nerve stimulation
- Chronic alcohol abuse
- Bile reflux
- Nicotine
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Symptoms of Gastric ulcer
- Intermittent dull, gnawing pain
- Burning epigastric
- Pyrosis (heartburn)
- Pain occurs 1-2 hours post meal
- rare @ night
- Weight loss
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Symptoms of doudenal ulcer
- Pain improves after eating but returns a few hours later or in the middle of the night
- A change in appetite with weight gain
- Mid-epigastric pain
- Back pain
- 2-4 hours after meals
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Diagnostic tests for ulcers
- History and physical especially with family
- Upper GI
- Endoscopy (EGD)
- Stool for occulet blood
- H pylori test (carbon urea breath test)
- Gastric secretion studies
- Biopsy
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Laboratory analysis for ulcers
- CBC
- *anemia
- Urinalysis
- Liver enzyme studies
- Serum amylase determination
- *pancreatic function
- Stool examination
- *positive blood
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Medical management for ulcers
- Drug thereapy: goals to prevent recurrence, heal ulcers, treat infection and provide pain relief
- Diet therapy: aimed at decrease acid and increase motility. Bland non-irritating diet
- Eat small frequent meals
- No smoking, alcohol, caffeine
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Surgical intervention for ulcers
- Removal of ulcer
- Pyloroplasty and vagotomy (V/P)
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Drug therapy for Ulcer
- H2 blockers
- Cytoprotective
- Proton pump inhibitors
- Antibiotic for H pylori
- Antiacids
- Anticholinergics
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Tagamet
Pepcid
Zantac
H2 blockers
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Cytotec
- Antisecretory and cytoprotective
- -given to prevent gastric ulcers in chronic nsaid users
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Carafate
Peptobismol
Cytoprotective
- - give 30 min before or after an antiacid
- - if mixed with cimetidine, digoxin, coumadin, dilantin, and tetracyclin, it binds with them and reduced bioavailibitlty
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Prevacid
nexium
protonix
prilosec
generic names all end with -zole
- Proton pump inhibitors
- -more effective than h2 blockers
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amocicillin
metroniadzole (flagyl)
tetracycline
clarithromycin (biaxin)
- Antiboiotics for h. pylori
- -use concurrently with h2 blockers or ppi
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Baselijel
amphojel
tums
rolaids
riopan
mag-ox
alka seltzer
- Antiacids
- -increase pH neutralizing acid
- -titralac ( higher sodium) caution in older patient or with liver cirrosis, hypertension, heart failure, and renal disease
- -magnesium preparations should not be prescribed for patient with renal faiulre becuase risk of mag. toxticity.
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signs and symptoms of mag toxitcity?
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Nursing interventions with Ulcers
- Assessment of symptoms and family history
- Encourage smoking and alcohol cessation
- medication education
- assess for complications
- monitor labs (CBC)
- Monitor pain management
- monitor nutritiional status
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Signs of Gastrointestinal bleeding
Coffee ground emesis, bright red emesis, melena, signs of hypotension, decreased HCT and HgB, confusion, syncope, vertigo
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Signs of Gastric perphoration
- Ulcer is so deep entire thickness is wore out
- Sudden, shrarp pain midepigastric and spreads all over abdomen
- Abdomen is tender and rigid "board like"
- Client assumes the fetal postition
- Absent bowl sounds
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Signs of pyloric obstruction
- caused by scarring, edema, inflammation
- vomiting and abdominal distention
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Complication treatments
GI bleed
- find the cause intitially thru endoscopy
- monitor amoutn and frequency of bleeding
- fluid management: IVF's and blood transfusions
- Monitor serial CBC , bleeding studies
- Endoscpic ablation, clot stabilizer (somatostatin)
- NGT with pt NPO, may lavage if ordered with cool salin to eliminate clots
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Treatment fo perforation
- NPO
- pain monitoring
- surgical intervention to prevent peritonitis
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Treatment fo pyloric obstruction
- NGT compression
- fluid volume replacement
- surgical intervent if needed
- NPO until no vomiting
- IVF's
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Treatment of duodenal ulcers: eliminates acid secreting stimulus to gastric cells and dcreases responsiveness of parietal cells
Vagotomy
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Widens the exit of pylorus, facilitates stomach emptying
Pyloroplasty
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Partial resections of the stomach
Gastrectomy
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Billroth I:
- Gastroduodenostomy
- Distal stomach removed, remainder anastomosed to duodenum
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Bilroth II
- Gastrojejunostomy
- Lower stomach removed, remainder anastomosed to jejunum.
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Post operative management fixing ulcers
- Assess vitals- will be hypotensive, increased heartrate
- Monitor pain
- Monitor gastric decompression and output
- Monitor labs (CBCand electroyltes)
- Montior for coninued illeus
- monitor for gastric empty delay and recurrent ulcerations
- make sure they deep breath
- Replacement therapy: for every ml put out will replace half every 4 hours in addition to regular maintence IV fluids
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Normal Hematocrit
Woman:
Man:
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Dumping syndrome
Early manifestations
- Vertigo
- tachcardia
- syncope
- sweating
- pallor
- desire to lay down
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Dumping syndrome
Late manifestations
- intestinal manifestations
- dixxiness
- lightheadedness
- palpitations
- diaphoresis
- confusion
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Treatment for dumping syndrome
- Decreasing amount of food eaten at one time
- Decrease eating time
- Sit up when eating
- NO LIQUIDS WITH MEALS
- High protein, low to moderate carbs, and high fat diet
- Administer Sandostatin (may prevent syndrome)
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What can you expect patients to have to have once stomach take once stomach surgery?
- B12 shots
- because no longer has intrensic factor
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Diverticula
Congenital pouch like mucosal herniations of small intestins or colon
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Diverticulosis:
Many pouches (herniations) in the wall of the intestins
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Divericulitis:
Inflammation of one or more diverticula/ results when diverticulum perforates and local abscess form
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Symptoms of diverticulitis
- Typically not seen until problem arises
- abdominal pain, tenderess to palpation
- elevated temperature > 101, may have chills
- Abdominal guarding, rebound tenderness
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How is diverticulitis confirmed
- CT scan
- Flat plate of abdomen
- EGD (endoscopy)
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What must you not adminster to a patient with active untreated diverticulitis
Barium enema (will turn into cement and cause a rupture
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Nonsurgical medical management of diverticulites
- Broad spectrum antibiotics (flagyl, zipro)
- IVF's ( watch k+)
- Anticholinergics- slow down
- NPO until able to tolerate clear liquids then increase
- stop fiber therapy until attack is limited
- NO enemas or laxatives
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Surgical medical management for diverticulitis
Done for rupture with peritonitis, fistula formation, bleeding, bowel obstruction, or unresponsive to medical management
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Nursing interventions for diverticulitis
- Healthy teaching:
- Diet:A high fiber diet, mainly fruits and vegetable and decreased intake of fat and red meat
- Weight reduction
- Avoid strating at stool, vomiting, bending, lifting, and tight restrictive clothes.
- symptom recognition,
- activity
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Post operative management
Nursing interventions
- monitor colostomy is present
- monitor vitals, urine output, wound condition
- Ambulation- the sooner the better, that day or next
- Psychosocial adjustment to stoma
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stool from colostomy
formed mushy stool with regular bowel movements
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stool for iliostomy
- liquid drainage always draining
- green/brown
- at risk for skin breakdown
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Chronic inflammatory process affection mucosal lining of colon or rectum
Ulcerative colitis
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Diffuse inflammation fo intestinal mucosa, loss of surface epithelium causing ulcerations and abscess formations
ulcerative colitis
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Starts normally at the rectuma dn progresses towards cecum (bowel can become shorter and narrower due to fibrosis)
ulcerative colitis
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Inflammatory diseas of small intestins or colon or both, terminal ileum is the most common site
Crohn's disease
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Chronic nonspecific inflammation of entire intestinal tract, formation of deep fissures and ulcerations thru ALL layers
Crohn's disease
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Causing thickening of boewl wall resulting in narrowing of lumen and strictures
Crohn's disease
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Crohn's disease late disease
Granulomas form with ulcerations which may become cancer
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Symptoms of Ulcerative colitis
- 10-20 liquid blood stools per day
- Tenesmus (straining uncontrolled)
- Low grade fever (late)
- Anemia
- fatigue
- LLQ pain/ cramping
- Weight loss
- Rebound tenderness
- guarding
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Symptoms of Crohn's
- 5-10 fatty stools per day (steatorrhea)
- Flatulence
- malabsorption
- weight loss
- diffuse bilateral lower quadrant pain
- fever with perforation or fistula
- fluid and electrolyte and vitamin dficits- high
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Diagnostic tests for ulcerative colitis
- CBC
- electoylte panels
- Stools for O&P, occult blood and C&S
- Colonoscopy or sigmoidoscopy
- Barium studies - only if not in acute phase
- CT scans
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Diagnostic test for crohns
- CBC
- electrolyte anels
- viatmin, folic acid levels
- ALBUMIN and nutritional labs
- barium studies
- Colonoscopy
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TPN contents
who is it for?
Things to remember
- dextrose and amino acids (protein)
- Massive deficency
- Only in picc or central (diluted if in peripheral)
- everything changed every 24 hours
- Filtered
- check every component in the bag
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Medical Management of Ulcerative colitis
Drug therapy
- Aminosalicylates Inhibits prostaglandins to reduce inflammation
- Corticosteriods Suppress immune system
- Reduce inflammation
- Immunomodulators Help reduce amount of steriod use
- Overrides body immune system
- Antibiotics Use with acute flair ups that may be prone to infections
- Antidiarrheals Symptomatic relief of severe diarrhea
- GIVE CAUTIOUSLY
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Medical Management of Crohn's
Drug therapy
- Aminosalicylates- inhibits prostaglandins to reduce inflammation
- Corticosteriods- Suppress immune system, reduce inflammation
- Inmmunomodulators- Help reduce amount of steriod use, overrides body immune system
- Biologic therapy- Given to those who have not responded to conventional therapy, reduces number of fistulas, works with tumor necrosis factor alpha
- Antibiotics- common for abscess
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Diet therapy for ulcerative colitis
- NPO if severe symptoms
- TPN for long NPO
- Elemental formula
- Low fiber foods
- Lactose free products
- No caffeine, spices, alcohol, smoking
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Diet therapy Crohns
- TPN for long term use
- Nutritional supplements
- elemental supplements
- NO caffeine or carbonated beverages
- No alchohol
- Probiotics (non-digestive food ingredients)
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Surgical Management for ulcerative colitis
- "Curable"
- Total colectomy with permanent ileostomy
- -colon, rectum and anus removed
- Total colectomy with contient ileostomy
- -kock's pouch
- -J pouch- removes the colon and rectum but sutures the ileum to anal canal-forms a ileoanal reservoir NO STOMA
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Surgical management for crohns
- surgery isnt a cure
- repair of fistulas
- release of intestinal obstructions
- partial resection with primary anastomosis
- ileostomy- most end up with one
- Remember crohns can come back in the unaffected part of the bowel
- May require many surgeries
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Nursing interventions for uc and crohns
- Nutritional assesssment
- monitoring fluid and electroytes
- monitoring lab valures
- monitor for complications
- montior weight
- psychological assessment
- post op care
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nurisng care for uc and crohns
- Adminster and monitor tpn and ppn
- provide adequate nutrition: pre-medicate as ordered
- Assess stools: quality, frequency, amount , and pain issure with stooling
- assess vitals
- teach relaxation techniques
- Educate for ileostomy and colostomy for both client and family
- eliminate factors that cause diarrhea and pain
- chronic pain management
- Provide small frequent meal with specific dietary preferences
- detailed adominal assessment
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Complications of Ulcerative colitis
- coagulation problems
- hemorrage
- bowel perforation
- colon cancer
- toxic megacolon
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Complications for crohns
- intestinal obstruction
- fistulas (can be extraintestinal)
- malabsorption sydrome
- liver and biliary disease
- kidney stones
- arthritis
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Characterized by intermittent and recurrent abdominal pain and stool pattern irregularities
altered intestinal colonic motility
alteredd responce to stress
may be due to alterations in the enteric nervous system and/or autonomic nervous system
Irritable bowel syndrome
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Diagnostic test for IBS
- Review signs and symptoms
- screening and colonscopy
- lab tests and stool testing -rule out physilogic cause
- stress evaluation
- lifestyle evaluation
- get what pattern they are doing? Constipated or diahrrea?
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Symptoms of IBS
- Diarrhea
- Constipation
- Alternating diarrhea/constipation
- abdominal distention
- excessive flatulence
- bloating
- continual defecation urge, urgency
- sensation of incomplete evacuation
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Medical management of IBS
- Diet
- Fiber therapy (20 g/day)
- Antispasmodics
- -Dicyclomine (Bentyl)
- -Laxatives
- -Serotonergic agents
- -5-HT3 receptor blockers
- *Alosetron (Lotronex)
- -Antidepressants
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Dicyclomine (Bentyl)
- -Dicyclomine (Bentyl)
- -reduce colonic motility after meals
- -take before meals
- -side effects
- *dry mouth, urinaty retention, tachycardia
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Over use of laxatives
will deplete k+, Na+ and decreased Magnesisum
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5-HT3 receptor blockers
- Decrease urgency, pain, and diarrhea in diarrhea-prominent women
- -Alosertron (Lotronex)
- *FDA approved for WOMEN only
- *Must be monitored due to potential side effects
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Nursing Management of IBS
- Establish a trusting relationship
- Monitor nutrition
- Monitor stress levels
- Teach relaxation techniques
- Medication education and compliance
- Herbal and alternative thereapies
- Finding the causative factor
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