med surg

  1. gastrointestinal system
    • upper GI- mouth ends @ jejunum
    • lower GI- ileum eands @ anus

    accessory structures include peritoneum, liver, gallbadder, & pancreas

    primary function- digestion & distrubution of food
  2. mouth, esophagus, stomach
    mouth: contains enzyme salivary amylase which os secreted by salivary gland (moisten food), adds ptyalin enzyme 4 digestion of starched foods

    • esophagus: starts @ pharynx & ends opening of stomach, has straied muscle @ proximal ends, straided & smooth muscle @ mid, & smooth muscle @ lower esophagus
    • upper esphageal & hypopharyngeal sphincter prevents fluids from re-enterin pharynx

    • stomach:
    • lower esophageal/cardiac sphincter- between esophagus & stomach
    • pyloric sphincter- between stomach & duodenum
    • both are circular bands of muscle fibers

    Gastric secretions: acidic b/c contain hydrochloric acid(HCI), this mixture with food is call chyme, & move by peristalisis 2 sm. intestine
  3. Sm. intestine
    • primary function is 2 absorb nutrients from chyme, type of nutrient depends on site of sm. intestine (see pg 636, TBL-44-3)
    • divided to 3 parts:
    • duodenum- 10 in. long, 1st part of sm. intestine & where bile & pancreatic enzymes enter, which promote chemical breakdown of food, from chyme 2 a alkalin state
    • jejunum & ileum- 23ft 2gether

    • ileocecal valve- @ distal end, regulates flow of liquid content 2 lrg. intestine
    • if any part diseased or removed absorption is reduced or lost
  4. lrg. intestine
    • 4-5in long, 2inches in diameter
    • recieves waste & sends it to anus
    • absorbs water, eletrolytes, & bile acids

    • parts of lrg intestine
    • cecum- pouch-like, begining of lrg. intestine, appendix- narrow blind tube @ tip of cecum, no known use
    • colon (3 parts)
    • ascending, transverse, descending, sigmoid & rectum
    • In colon unabsorbed material becomes fecal matter (water, food residue, microorganism, digestive secretion, & mucus), water reabsorbed by diffusion, when mixture reaches descending itz already a formed mass
    • internal & external anal sphincters holds feces, when accumulates urge to defecate occurs, & sphincters are relaxed

    if any part diseased/removed absorption is reduced/lost, leadin 2 loss stool, potential fuid & electrolyte imbalance, passage of stool that has bile salts lead to risk of skin breakdown, & if stool stays in lrg intestine too long it leads 2 constipation
  5. Accessory structures
    • peritoneum:
    • lines inner abd., encloses viscera & serous fluid it secretes, allows abd. organs 2 move w/o friction
    • walls prevent gastric & intestinal content from escaping into peritoneal cavity
    • peritonitis- when the content escape thru a perforation of wall

    • live:
    • largest glandular organ, weighs 1-1.5kg, in R upper abd. under diaphragm which serperates from R lung
    • forms & releases bile, processes vit. proteins, fats, & carbs, stores glycogen, for blood coagulation, metabolizes & biotransforms chemical, bacteria & foreign matter, from antibodies & immunizing substances (gamma globulin)

    • Gallbladder:
    • attached to mid-portion in under surface of liver, has thin wall & holds 60ml of bile
    • water & minerals absorbed
    • triggered by ingested food (especially fats), causes bile to b released 1st by cystic duct then by common bile duct into duodenum where absorption of fats, fat-soluble vit., iron & calcium
    • bile activates pancreas to release digestive enzymes & alkalin fluid that nuetralizes stomach acid that reach duodenum

    • Pancreas:
    • exocrine gland- releases secretions into duct or channel
    • endocrine gland- releases substances directly to bloodstream
    • endocrine organ releases insuline & glucagon
    • exodrine organ- produces fats, protein, carb-digested enzymes
    • panceatic emzyme- released in inactive form & transported to duodenum where activated
  6. HX Assessment
    • b/c of GI disorders disturbances in ingestion, digestion, absorption, & elimination
    • pt HX- c/o, focus on nutrition, metabolic & elimination patterns
    • why pt needs tx & current symptoms, how long & cause
    • foods that produce distress & when symptoms likely 2 occur
    • ? pt does to releive symptoms
    • pt appetite, problems w/ chewing/swallowing, ?/how much pt eats, any discomfort around consumption, any nutritional supplements
    • wt gain/loss
    • hx of medical/surgical procedures
    • family health/death hx, family hx of digestive disorders
    • work hx 2 exposure if chemical/toxins/radioactive materials
    • allergy/med hx
  7. Physical assessment
    • v/s, breathing pattern
    • appearance w/ regard to age & body size
    • hygiene
    • energy
    • emotional attitude, mental status

    • skin:
    • abnormal color (jaundice) in well lit room
    • if dark skinned pt. inspect hard palate, gums, conjunctiva, & surroundng tissue 4 discoloration
    • if jaundice, inspect sclera
    • inspect skin of abd. & face (looking 4 spider angiomas- superficial red discoloration from blood vessels
    • distended abd. veins (caput medusae), & scars
    • oral dryness & skin turgor

    • mouth:
    • inspect lips 4 sores, cracks, lesions, abnormalities
    • using tongue blade check 4 inflammation, discoloration
    • quality of oral care, lookin 4 missin teeth, partial plates, dentures & ask if well fittin & if pt could eat reg. food

    • abd: discribed in quads
    • pt supine, knees flexed (helps 2 relax abd muscles)
    • whether flat, round, concave, distended, & effort when breathing, (distention could cause dyspnea from upward pressue on diaphragm
    • auscultation before palpation lower liver margin if tender liver may be enlarged (R lower rib cage) suggest liver disorder, gallbladder/intestinal disease or pancreatic disorder , mesurement of abd. girth
    • percuss 4 changes in dullness over solid mass like liver

    • Anus:
    • hemorrhoid
    • skin tags
    • fissures (sm. tears), breaks, lesions, rash, inflammation, drainage
    • stool characteristics
    • (see pg 639 TBL. 44-4)
  8. barium swallow or upper GI series
    used interchangeably

    • barium swallow: flouroscopic observation
    • faciliates identification of abnormalities of esophagus, swallowing dyfunctins & oral aspirations

    • upper GI series: radiographic observation
    • barium moving from stomach to 1st part of sm. intestine

    • abnormalities in esophagus include tumors, peptic ulcers, gastric disorders
    • if only barium swallow done takes 20min, but if stomach filling & emptyin then takes 1hr

    • nurse teaching:
    • pt needs to be on low-residue diet, NPO for 8-12hr before
    • laxative given
    • no smoking b/c it stimulates gastric mobility
    • sometimes meds held like insuline & anticonvulsives
    • barium is very constipating so after procedure pt needs fluids
    • advise that stool may look white, streaky, clay color, of pt doesnt have bowel movement notify DR. b/c barium may cause blockage
  9. sm. bowel series
    • flouroscope in sm. intestine after ingestion of contrast medium
    • 2 identify inflammation/obstruction in jejunum or ileum
    • like GI series but pt swallow more barium so sm. intestine could be well visualized
    • if fissure or obstruction suspected substitute a water-soluble contrast medium like methylglucamine(gastrografin)
    • takes 5hr till reaches lower portion of sm. intestine
    • if series fails enteroclysis done
  10. enteroclysis/ sm. bowel enema
    • nasal/oral placement of feedig tube, tip positioned @ proximal jejunum
    • uses 2 contrast- 1st 750-1000ml of thin barium, then 750-1000ml of methylcellulose, both pass thru intestinal loop, DR. observes continuosly by flouroscopy & take some x-ray in sections
    • takes up to 6hr

    • nurse:
    • if sedation ensure pt comfortable & monitor
    • risk 4 aspiration especially if pt vomits while sedation
    • position pt on side & have suction available
  11. barium enema or lower GI series
    • 2 identify polyps, tumors, inflammation, strictures, abnormalities in colon
    • radiographic tech, rectally instills 1000-1500ml barium
    • observes rectum, sigmoid colon, & desending colon flouroscopically during fillin
    • to facilitate process instruct to have multiple postion changes
    • pt needs to retain bariun during test which takes 30 min
    • pt may have abd. cramping & urge to defecate, nurse ensures pt thatmost pt could retain barium throughout test
    • radiographs taken again after pt expels barium
    • sometimes air instilled to compress barium residue against wall to help detect mucosal defect
    • stool specimens not collected till barium expelled completely

    • pt teaching to reduce formation of stool & remove residual stool:
    • restrictions & process 24-48hr before barium enema
    • low-residue diet 1-2 days before
    • clear liquid diet evening before
    • laxative evening before
    • NPO after mid-night
    • cleansing enema morning of (if not contraindicated b/c inflammation/active bleeding
  12. oral cholecytography or gallbladder series
    • checks 4 stone, tummors, obstruction in gallbladder or common duct
    • also checks gallbladders ability 2 concentrate/store dyelike iodine-based radiopaque contrast, after dye absorbed goes 2 liver excreted into the bile & passes into gallbladder makin it radiographic visible
    • radiography should be done before GI exam w/ barium b/c it obscures image of gallbladder/ducts

    • Nurse teaching:
    • eat fat-free meal night before
    • allergy to iodine, pt swallow 6 iodine tabs 1q5min after evenin meal bight before w/ 250ml of water, then pt needs to be NPO after mid-night
    • if nausea/vomiting tell DR. so more tabs ordered or test rescheduled
    • once radiography done, a fatty-test meal/fatty synthetic substance given 2 stimulate gallbladder contraction & emptying, checked by more radiography
  13. cholangiography
    • performed in radiology or during surgery
    • determines patency of ducys from liver & gallbladder
    • used when gallbladder not seen w/ oral cholecystogram, vomite interferes w/ w/ retention of dye

    • endoscopic retrograde cholangiopanceatography (ERCP):
    • dye injected thru cath into pancreatic duct & common bile duct

    • intraoperative cholangiography:
    • contrast injected directly to bile dict during gallbladder surgery

    • magnetic resonance cholangiopancreatography(MRCP):
    • sees bile/pancreatic duct & gallbladder w/ no dye uses MRI, gives clear & detailed view

    • percutaneous transhepatic cholangiogrphy:
    • ultrasound used to guide needle into bile duct & directl injected

    • no matter of dye given it travels into biliary system, x-ray taken to see narrowing/blackage
    • nurse teaching:
    • pt must sign consent
    • ask about allergy to iodine/shellfish
    • check orders for enema, & any food restrictions
    • inform pt that warm feelng & nausea may happen when instilling dye
    • pt may eat after procedure
    • promote fluids for excretion of dye
  14. radionuclide imaging
    • checks 4 lesions of liver or pancreas, & checks gastric emptying
    • natural/synthetic, given IV or orally
    • scanner used over body organ
    • shows size of organ, & tumors, identifies site 4 bleeding/inflammation in GI tract
    • have shorter half-lives lasting hr-days

    dosed by wt, preg
  15. CT reffered to colonography
    • tube inserted & air introduced & images done
    • detect structual abnormalities of GI tract
    • detect metastic lesions
    • oral barium sulfate or IV calcium phosphate 4 contrast
    • pt NPO 6-8hr before
    • bowel cleansed
    • med may be given to lower paristalisis or improve gastric motility
  16. MRI
    • if test not good MRI done:
    • check soft tissueGI disorders- abscess/bleeding

    • Nurse:
    • pt NPO 6-8 before
    • remove metal objects
    • pt w/ pacemakers need cardiologist consult 1st
    • IV fluids, if req., by gravity
    • inform that tunnel like maccin that makes load noises
    • if claustrophobic- sedation needed
  17. magnetic resonance elastrography (MRE)
    • low frequency sound waves (shear waves)
    • checks firmness of liver , leads to prediction of fibrosis (scar tissue) & eventually cirrhosis (hardeni of liver)
    • great promise like breast, muscle. & brain tissue
  18. ultrasound
    • high frequency sound waves
    • liver & pancreas
    • shows size & location of orgns outlines stuctures & abnormalities like cholecytitis, cholelithiasis, pyloric stenosis, & disorders of billary system
    • pt could have fluids but instructed not too, also no smoking chewing gum, they may swallow air distort sound waves
  19. percutanous liver biopsy
    • checkin 4 malignant changes infectious & inflammatory process, liver damage (cirrhosis), & signs of liver rejection if transplant
    • coagulation test done b/c biopsy could lead to bleeding, if @ risk give vit. k 2 promote coagulation
    • CT 4 correct site of biopsy
    • sedation & anesthics give 4 comfort & cooperation, monitor pt closley
  20. GI endoscopy
    • visual exam of lumen
    • flexible endoscope
    • detects lesions

    • nurse teaching:
    • NPO
    • bowel preps
    • pt needs to spray & gargle anesthetic
    • pt given anxiolytic 4 sedation
    • monitor v/s, including pain, LOC, abd symptoms
    • monitor signs of perforation like fever, abd distention, abd/chest pain vomiting blood, rectal bleeding
    • pt may eat when gag reflex returns
    • if sore throat gargle saline, ice chips, & cool drinks
  21. LABS
    • CBC, urinalysis, serum bilirubin, cholesterol, ammonia level, PT, protein electrophorisis, & enzyme (amylase, lipase, aspertate aminotransferase, lactic acid dehydrogenase
    • common tumor markers carcinoembryonic antigen & alpha-feto-protein

    gastric analysis- activitiy of gastric mucosa, retention, NPO 8-12hr, nasogastric tube into stomach, content aspirated q15min for 1hr, checkin ph, volume, cytology

    • H-pylori- 4 peptic ulcers,
    • blood test, urea breath test, stool,
    • more invasive biopsy could be done;
    • raid ureas test (enzyme), histology (actual bacteria), culture(growing bacteria in tussue sample)

    hydrogen brething test- collecting breath before & after ingestion of cardohydrate solution, detect types of malabsorption of lactose (most common)

    • stool analysis- check WBC(inflammation), RBC(GI blood loss), fat(malabsorption), infection
    • detects bacteria, parasites, ova
    • hemocult test (blood)
    • false + include red meat, iodine having antiseptic prep, asprin, & NSAIDS, alcohol
    • false - include ascorbic acid (vit. C), iron supplements
Card Set
med surg
ch 44