What causes upper GI bleeds?
- Peptic ulcers
When I see a person vomiting bright red blood what do I do first?
ABC...get an airway, probably by intubation and then give the fluids/blood
If BP drops give
If a person has high ammonia levels give.....but then watch for?
a break in the mucosa from it coming in contact with pepsin and hydrochloric acid
pain 1-2 hours after eating
a break in the mucosal barrier at the junction of fundus and pylorus
ulcer pain is relieved by food, but will have pain 2-4 hours after
H pylori #1 cause or.....
from increased acid secretion that is stimulated by rich meals, calcium and vagal stimulation, cuasing a chronic break in the duodenal mucosa
What causes stress ulcers?
- acid hypersecretion from stress (ICU)
- decreased mucosal pH
- pt on long term ventilator support
Complications of ulcers
- UGI hemorrhage
- Mallory-Weiss Tear
- Esophageal Varices
S/S of perforation
- board like abdomen
- have localized pain, until it perforates, then it is generalized pain.
Mallory Weiss tear
Common in bulemics and alcoholics that wretch alot
longitudinal tear in the gastroesophageal mucosa....usually self limiting and resolves itself
Vericose veins in the esophagus from portal hypertension (liver problems)
pressure in the veins cause them to distend with blood and enlarge. They can rupture resulting in massive GI bleeds
Clinical manifestations of ulcers
- Abdominal discomfort
- Hypovolemic shock
vomiting bright red or coffee ground blood
- red= new
- coffee=old or mixed with stomach acids
bright red blood per rectum ....and it will take several days after the GI bleed has stopped for the stool to be cleared of blood
Hemorrhagic ulcers can cause hypovolemic shock...describe s/s of this
- cool/clammy skin
- decreased LOC
- decreased UO
- decreased gastric motility
If a person has been bleeding a lot, how do we determine if they need or CAN GET a blood transfusion?
- What's their cardiac/pulmonary status? Are they compensating
- How are their kidneys? Can they handle a transfusion
When I am assessing a person with a suspected or confirmed ulcer what do I need to find out?
- meds....on steroids, nsaids, aspirin
- pain....where is it?
If you lose this much blood you wont see any major changes in the person
<15%....which is <750cc
If you have lost 1000 cc of blood the person will present with....
- decreased pulse pressure
- cap refill >3
- increased RR
- UO <25
How do you calculate pulse pressure? What is normal?
systolic BP - diastolic BP
If you have lost 1500-2000 cc of blood the person will present with....
- HR >120
- SBP 70-90
- cool pale skin
- change in LOC
- increased RR
- UO 5-15 cc/hr
How can you quickly determine a persons EBL?
if a persons BP drops greater than 10mmHg with a corresponding HR increase of 20bpm.....then they have lost greater than 1,000 mL of blood
- 140/70 to 120/60
- 80 to 110
Diagnostic studies for ulcers
- Electrolytes panel
- Hematology profile
When a person has a bleeding ulcer what lab will I look at serially...q 4-6 hours?
What amount of blood loss means a transfusion is necessary?
Changes seen with the administration of 1 unit of PRBC
- increase in Hgb by 1
- increase in Hct by 3%
**unless they are still bleeding, then you wont see changes
Why would a person with a bleeding ulcer have deceased K?
cuz the have blood in their stomach which makes them nauseous and they are vomiting and losing their K
If a person has a bleeding ulcer what am I expecting to see in the hematology labs? What does this tell me?
prolonged PT and PTT......
tells you they may be in anticoagulants, or they have liver dysfunction
Procedure of choice to look for an ulcer? Why?
- uz it can diagnose and they can correct the problem while they are in there
Initial interventions for a person with a bleeding ulcer
- assess severity of blood loss
- replace fluids/blood
- dx the cause of bleeding with endoscopy
- plan and implement treatment
What fluids are given to a person with a bleeding ulcer?
LR or NS in a 20 gauge catheter
*assess VS continuously as fluids are being replaced
What improves coagulation?
FFP (fresh frozen plasma)...platelets
If give a PPI watch for....
Goal of drug therapy for a person with a bleeding ulcer
- hemodynamic stability
- decrease bleeding
- neutralize the HCL that's present
- get rid of H pylori
- rest the stomach
How do H2 antagonists work?
decreases acid secretion for up to 5 hours
How do antacids work?
they are an alkaline buffer that controls gastric pH....makes less acidic
How do PPI's work?
decrease acid secretion
temporary solution for esophageal varicies...until the bleeding stops or they go to surgery
has 3 ports, positioned in the stomach then slowly withdrawn until the balloon fits snugly against the cardi of the stomach
vagotomy and resection of the antrum and anastamosis of the stomach to the jejunum
How is going to have a problem with dumping syndrome post op?
person who had a Billroth II
Nursing care for the person that had surgical interventions for bleeding ulcers need to be monitored for.....
- risk for fluid volume deficits
- altered nutrition
If the liver isnt working watch for....
increased risk for bleeding
How do you teach a person to manage dumping syndrome?
- 6 small meals/day
- drink before or after meals only
- increase protein intake
- decrease sugar
- **resolves after 6 months
Dumping syndrome puts a person at risk for.....why?
dumping syndrome makes you release increased amounts of insulin
When do you take antacids?
1-2 hours after taking other meds.....cuz antacids interfere with other medicaitons
List H2 Blockers....and what do I need to monitor?
WBC count....will decrease
List PPI's....and what is complication from these meds
Causes C diff
Carafate....what does it do and details on how to take it
coats and protects the stomach...mucosal barrier
take 1 hour before of 2 hours after meals....NEVER with antacids
Never take these 2 meds together
carafate and antacids
Which medication will interfere with the absorption of digoxin, theophylline, coumadin, antibiotics???
carafate....so dont take these meds within 2 hours of taking carafate
What is given for a peptic ulcer related to H pylori?
What do you teach a person about gastric ulcers?
- no caffeine, alcohol, stress
- dont eat at bedtime
- avoid intense physical activity
- avoid OTC meds that contain aspirin/ibuprofen
- recognition of s/s of GI bleeds
If a person has surgery for a GI bleed I need to teach them....
about dumping syndrome and how to avoid it
How do I know if a person understands what I am teaching?
Have them repeat it back in their own words
S/S of GI bleeding
- decreased energy
- decreased exercise intolerance
- dark stool
- easily bruises
2 ways to get pacreatitis
chronic alcohol use
when amylase, lipase, tripsin are released and activated prior to entering the small bowel, these enzymes will eat at the pancreas
#1 causes of pancreatitis in men vs. women
How does alcohol cause pancreatitis?
alcohol causes spasms, causing obstructions not allowing enzymes to reach the small bowel, causing autodigestion of the pacreas
How does a person with pancreatitis end up with ARDS?
severe autodigestion causes the pancreatic enzymes to spillover into the peritoneum and it affects diaphragmatic excursion= ARDS
Where will you feel pain if you have pancreatitis?
upper left quadrant
What happens to a person with pancreatitis after meals?
pain increases cuz of the release of digestive process
Describe pain felt from pancreatitis
- left upper quadrant, radiating towards the back
- begins abruptly following a heavy meal or alcohol consumption
Pncreatitis will cause.....
n/v, but it does not relieve the pain
Bowel sounds with pancreatitis
hypoactive or absent....causing a parlytic ileus
Grey Turner sign
- seen with pancreatitis
- discoloration of the lower abdominal blaniks
gotta "turn around" to see it
seen with pancreatitis
blue discoloration around the umbillical area
What lab will tell you the person with peritonitis has a poor prognosis
Pancreatic specific labs...and what will they look like?
Amylase and lipase....both will be elevated
Amylase and pancreatitis
increase in the first 12-24 hours and stays elevated for 3-4 days
Lipase and pancreatitis
stays elevated for 2-3 weeks
Why do you have hyperglycemia with pancreatitis?
cuz pancreas has endocrine fxn of releasing insulin....with this, insulin isn't released
Best way to dx pancreatitis?
Ranson severity criteria
takes 3-4 days to do and it evaluates a persons chances of dying from pancreatitis.
Mortality rate is 1% for patients with fewer than 3 signs
Mortality is 100% for patients with 7 signs
What is estimated fluid sequestration for pancreatitis....and what is a bad result?
in 48 hours if a patient is given 6L of fluid, their output should match. If it doesnt, then they have significant 3rd spacing volume loss which is a bad sign
If a person has encephalopathy from alcohol I need to watch
for DT's and watch their liver fxn
seizure precautions, lorazapam
How can pancreatitis cause hypotensive shock?
when the pancreas gets ischemic it will release myocardial depressant factors which are negative inotropes and cause decreased force and rate of contractions which causes peripheral vasodilation and hemodynamic instability
Priority management for pancreatitis
- relieve pain
- prevent shock
- decrease pancreatic secretion of enzymes
- monitor for complications and prevent them
How will I know a person with pancreatitis is ready to go from NPO to liquid diet?
amylase and lipase levels will be leveling out and then decreased
we were resting the gut by not letting digesting enzymes be released from pancreas
What does nasograstric suctioning do for a person with pancreatitis?
- manages abdominal distention
- prevents ileus
Persons with pancreatitis can have hypocalcemia....how do I check for this and what do I give if positive
Trousseaus and Chovesk
calcium gluconate....watch for hypotension
How do you replace fluids with pancreatitis?
When your patient is having pancreatic hormone replacement to enhance digestion....when do they take these pills?
Antibiotics to treat H pylori
#1 nursing dx for pancreatitis
- pain....then altered nutrition....
- Ineffective therapeutic regime management (from coffee, alcohol and smoking)
Teach the person with pancreatitis to call the doctor when....
- have acute abdominal pain
- clay colored stools
- dark urine
Mortality is highest when pancreatitis accompanies....
If a person is NPO for pancreatitis for 5+ days, what is the next step?
TPN with OUT lipids.....tube inserted in to jejunum is best