1. Pancreatitis:
    What is it?
    What are the normal functions of the pancreas
    What are the two types of pancreatitis & causes
    Auto-digestion of the Pancreas

    • The pancreas has two separate functions:
    • Endocrine = insulin
    • Exocrine = digestive enzymes

    • Two Types:
    • Acute - #1 cause is alcohol, #2 is gallbladder disease
    • Chronic - #1 cause is alcohol
  2. S/S of Pancreatitis:
    1st sign
    changes in abd?
    1st sign is pain - increases with eating

    Abd distention/ascites (losing protein rich fluids like enzymes and blood into the abdomen)

    Abd mass = swollen pancreas

    Bruising around the umbilical area = Cullins sign

    Bruising around flank area = Gray Turner's sign

    • Fever (inflammation)
    • Hypotension = bleeding or acites

    • N/V
    • Jaundice
  3. Diagnoses for Pancreatitis
    • Serum lipase (0-110 U/L) (Most specific)
    • Serum amylase (30-220)

    • WBC increased
    • Blood sugar increased
    • PT, aPTT - longer clotting times

    Serum bilirubin increased

    • Hemoglobin & hematocrit could be up or down:
    • Up is dehydrated, Down is bleeding
  4. Treatment for Pancreatitis
    • Control Pain!
    • Decrease gastric secretions (NPO, NGT to suction, bed rest) - Want the stomach empty and dry
    • PCA narcotics, morphine sulfate, Fentanyl patches

    Steroids to decrease inflammation

    Anticholinergics to dry secretions

    GI protectants (Pantoprazole, antacids)

    Maintain fluid/electrolyte balance

    Will give insulin - Because pancreas is sick. Steriods = increased BS or on TPN = lots of sugar

    Will take daily weights

    Eliminate alcohol!
  5. Normal lab values for AST and ALT
    AST = 8 - 40

    ALT = 10 - 30
  6. Cirrhosis:
    4 major functions of the liver
    What the patho for cirrhosis?
    • 1. Detox the body
    • 2. Helps your blood clot
    • 3. The liver helps to metabolize (break down) drugs
    • 4. The liver synthesizes albumin

    • Patho:
    • Liver cells are destroyed and are replaced with connective/scar tissue = alters the circulation within the liver = the BP in the liver goes up, which is called portal hypertension
  7. If there's a liver problem, what risk should come to mind?

    What do you do with medications?

    What's antidote for Tylenol?

    If liver is sick, decrease the dose of meds!

    • Never give Tylenol to liver pt. 
    • Antidote is Acetylcysteine
  8. S/S of cirrhosis
    • Firm, nodular liver (lumpy, bumpy)
    • Abd pain - liver capsule has stretched
    • Chronic dyspepsia (GI upset)
    • Change in bowel habits

    • Ascites
    • Splenomegaly - immune system has kicked in. *When spleen is enlarged, immune system is involved
    • Decreased serum albumin = causing 3rd spacing
    • Increased ALT & AST
    • Anemia - due to internal bleeding

    *Can progress to hepatic encephalopathy/coma = toxins (ammonia) building up in blood. Ammonia is a sedative
  9. Dx of cirrhosis

    • Liver biopsy: *remember risk for bleeding
    • Clotting studies before procedure and position with right arm on back of head, spine.
    • After procedure, lie on right side.
  10. Treatment of cirrhosis
    What should they avoid?
    What will you monitor (x2)?
    How will we pull fluids?
    What should be avoided?
    • Antacids, vitamins, diuretics (ascites)
    • NO more alcohol
    • I&O + daily weights (ascites = fluid prob)
    • Rest
    • Bleeding precautions
    • Measure abd girth to monitor ascites
    • Paracentesis
    • Avoid Narc's, liver can't metabolize when it's sick.  If you give, it's same a double dosing

    • Diet:
    • Decrease protein. Otherwise ammonia level will continue to go up = LOC down
    • Low sodium!
  11. Hepatic Coma: 
    Normally: When you eat protein, it breaks down into ammonia, and the liver converts is to urea. Urea can be excreted through the kidneys w/o difficulty

    Patho: When the liver becomes impaired, it can't make this conversion. Ammonia then begins to build up in the blood. 

    This causes a decrease in LOC
  12. Hepatic Coma S/S:
    Reflexes and muscle control?
    • Will have minor mental changes/motor problems
    • Difficult to wake up
    • Asterixis = hands shake.  "liver flap"
    • Handwriting changes and reflexes slow down
    • EEG slows
    • Fetor = breath smells like fruit
    • Anything that increases ammonia will aggravate the problem = #1 thing being protein

    Liver people tend to be GI bleeders!!
  13. Hepatic Coma treatment:
    Lactulose = will decrease serum ammonia

    Cleansing enemas to get rid of blood

    Decrease protien in diet - duh

    Monitor serum ammonia
  14. Bleeding Esophageal Varices:

    In the alcoholic client?
    • High BP in the liver (Portal HTN) forces collateral circulation to form.
    • This collateral circulation forms in 3 places: stomach, esophagus, and the rectum.

    When you see an alcoholic client that is GI bleeding, it is usually esophageal varices.  Usually no problem until rupture
  15. Treatment for bleeding esophageal varices
    • Replace blood loss
    • Monitor VS and CVP
    • Oxygen
    • Balloon tamponade
    • Cleansing enema 
    • Saline lavage to get blood out of stomach

    • Octerotide - lowers BP in liver
    • Lactulose
  16. Peptic Ulcers:
    • Patho: Common cause of GI bleed
    • Can be in esophagus, stomach, or duodenum
    • Mainly in males, but increasing for females
    • Erosion is present

    • S/S: Burning pain usually in mid-epigastric area
    • Dyspepsia - (heartburn)

    Dx: Gastroscopy = endoscopy or they look at Upper GI with dye
  17. Instructions with:

    W Dye
    • Endoscopy: NPO pre-procedure, will be sedated
    • NPO until gag reflex returns
    • Watch for perforation by watching for pain, bleeding, or if they are having trouble breathing

    • Upper GI: looks at esophagus and stomach with dye
    • NPO past midnight. This includes chewing gum or mints. Remove nicotine patch and no smoking as it increases stomach motility which will affect the test. Smoking also increases stomach secretions = increased risk for aspiration
  18. Treatment for peptic ulcers:
    • Meds:
    • Antacids - liquid is best to coat the stomach. Take on empty stomach at bedtime when stomach is empty
    • Proton pump inhibitors: decrease acid secretions
    • H2 antagonist: ranitidine (zantac) or famotidine (Pepcid)

    Antibiotics for H. Pylori

    • Teaching: decrease stress
    • Stop smoking
    • Eat what you can tolerate. avoid temp extremes, spicy food, caffeine
    • Need to be followed for one year
  19. Classifications of Peptic ulcer
    Gastric ulcers: malnourished, pain usually 1/2 hour to hour after meals. Food doesn't help, but vomiting does; vomit blood.

    Duodenal ulcers: Well nourished, night time pain common and occurs 2-3 hrs after meals. eating helps, blood in stools
  20. Hiatal Hernia:
    • Patho: This is when the hole in the diaphragm is too large to the stomach moves up into the thoracic cavity. 
    • Main cause is large abd. Other causes include congenital abnormalities, trauma, and straining. 

    • S/S: Heartburn
    • Fullness after eating
    • Regurgitation
    • Dysphagia (difficulty swallowing)

    • Tx: Keep stomach in down position by: eating small frequent meals, sit up 1 hr after eating, elevate HOB
    • May need surgery 

    Teach life style changes and healthy diet
  21. Dumping Syndrome
    Common with?
    Common with gastric bypass

    Path: Stomach empties too quickly after eating and client experiences many uncomfortable to severe side effects... usually secondary to gastic bypass, gasterectomy, or gall bladder disease

    S/S: Fullness, weakness, palpitations, cramping, Diarrhea

    • Tx: Semi-recumbent with meals
    • Lie down after meals
    • NO fluids w meals. Drink in btwn meals
    • Meals should be small and frequent rather than large
    • Avoid foods high in carbs and electrolytes as they empty fast
  22. Ulcerative colitis and Crohns disease:
    S/S on both
    Ulcerative Colitis is ulcerative inflammatory bowel disease = just the LARGE INTESTINE

    Crohn's disease (also called Regional Enteritis) is inflammation and erosion of the ilium but it can be found anywhere in the small or large intestines

    • S/S: diarrhea
    • rectal bleeding
    • weight loss
    • vomiting
    • cramping
    • dehydration
    • rebound tenderness (means there is peritoneal inflammation)
  23. Dx for ulcerative colitis and crohns

    • Colonoscopy: clear liquid for 12-24 hr prior
    • NP 6-8 hrs prior, avoid NSAID
    • Polyethylene glycol (Go Lytely) - serve cold
    • Post op: watch for post-op perf

    Barium enema - done if colonoscopy is incomplete. (involves an xray of intestines)
  24. Tx for ulcerative colitis and Crohns:
    • Diet:
    • low fiber - trying to limit GI motility
    • Avoid cold or hot foods, and NO smoke - they all increase motility

    • Meds:
    • Antidiarrheals - only given with midly symptomatic ulcerative colitis as it doesn't work well in severe cases
    • Antibiotics
    • Sterioids - decrease inflammation

    • Surgery:
    • Ulcerative colitis - Total colectomy (ileostomy formed)
    • Crohn's - may only remove affected area. Pt may end up with ileostomy or colostomy, just depends on area affected
  25. Post Op care:
    Ileostomy care
    • Ileostomy care:
    • It's going to drain liquid stool all the time. Don't have to irrigate
    • Avoid foods hard to digest as it increases motility
    • Gatorade or similar electrolyte replacement in summer
    • At risk for kidney stones, always a little dehydrated
  26. Post op Care: 
    Colostomy care
    As waste moves through colon, water and nutrients are being absorbed and stool is forming. 

    • Colostomy ⇾ ascending and transverse ⇾
    • semi liquid stools

    Colostomy ⇾ descending or sigmoid ⇾ semi-formed or formed.

    • Only irrigate descending or sigmoid for regularity in elimination. Same time everyday, after a meal.
    • When irrigating, pt should lay on same side as if they were getting enema = LEFT side
  27. Appendicitis:
    What's it related it?
    What side should they be placed on?
    What's the place called to test for rebound tenderness?
    Patho: related to a low fiber diet.

    Place pt on RIGHT side. Worried about rupture. 

    Test for rebound tenderness at McBurney's point!

    • Dx: WBC will be up
    • Ultrasound or CT

    Tx: Surgery!!
  28. TPN:
    How is it given?
    How to discontinue it?
    What do we need to monitor?
    Keep refrigerated and warm for administration

    Must be given through central line. It's packed with particales and sugar which will eat up veins.  Must be dedicated line. 

    Have to discontinue gradually to avoid hypoglycemia.

    • Will monitor:
    • daily weights
    • may have to start taking insulin
    • Monitor blood glucose every 6 hrs
    • Check urine for ketones and glucose!

    **Protein can't leak through glomerulus unless there's kidney damage!! 

    IV bag may be covered with dark bag to prevent chemical breakdown from light
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