Transcript Nursing of Adult Patients with Medical & Surgical Conditions

Nursing of Adult Patients
with
Medical & Surgical Conditions
Gastrointestinal
Accessory Organ
Disorders
Diagnostic Studies
• Serum Bilirubin Test
– Normal Values
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Direct bilirubin: 0.1 to 0.3 mg/dl
Indirect bilirubin: 0.2 to 0.8 mg/dl
Total bilirubin:
0.1 to 1.0 mg/dl
Total bilirubin
in newborns:
1 to 12 mg/dl
– Rationale
• Used to diagnose liver disease, biliary obstruction,
erythroblastosis fetalis, and hemolytic anemia
– Nursing Interventions
• NPO
Diagnostic Studies
• Liver Enzyme Tests
– Normal Values
• AST (SGOT): 5-40 IU/L
– elevated with MI, hepatitis, cirrhosis, hepatic necrosis, hepatic
tumor, acute pancreatitis, acute renal failure, and acute hemolytic
anemia
• ALT (SGPT): 5-35 IU/L
– elevated with hepatitis, cirrhosis, hepatic necrosis, hepatic
tumors, and hepatotoxic drugs.
• LDH:
45-90 U/L
– elevated with MI, pulmonary infarction, hepatic disease,
pacreatitis, hemolytic anemia, and skeletal muscle disease.
Diagnostic Studies
• Alkaline Phosphatase: 30-85 ImU/L
– elevated in obstructive disorders of the biliary tract,
hepatic tumors, cirrhosis, primary and metastatic tumors,
hyperparathyroidism, metastatic tumor in bones and
healing fractures
• Gamma GT:
4-38 U/L
– elevated with hepatitis, cirrhosis, hepatic tumors,
hepatotoxic drugs, MI (4-10 days after), CHF, and alcohol
ingestion
– Rationale
• Liver is storehouse for many enzymes
• Injury or diseases affecting the liver will cause
release of these enzymes into the bloodstream
Diagnostic Studies
• Serum Protein Test
– Normal Values
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Total Protein: 6-8 g/dl
Albumin:
3.2-4.5 g/dl
Globulin:
2.3 to 3.4 g/dl
Albumin globulin (A/G ratio): 1.2 to 2.2 g/dl
– Rationale
• The liver metabolizes protein, esp. albumin. If the
liver is diseased it loses the ability to metabolize the
albumin and the serum albumin level is decreased
Diagnostic Studies
• Oral Cholecystography (Gallbladder Series)
– Rationale
• Provides x-ray visualization of the gallbladder after
ingestion of a radiopaque dye.
• The following factors are necessary for adequate
dye concentration:
– Ingestion fo correct number of dye tablets
– Adequate absorption of the dye from the GI tract; no
vomiting or diarrhea
– Abstinence from food the morning of the test
– Patency of the cystic duct
– Concentration of the cye within the gallbladder
Diagnostic Studies
– Nursing Interventions
• Assess for allergies to iodine
• Administer 6 Telepaque tablets orally, after the
evening meal
• NPO after midnight
Diagnostic Studies
• Intravenous Cholangiography (IV Cholangiogram)
– Rationale
• Radiographic dye is administered IV
• Allows visualization of the hepatic and common bile ducts and
also the gallbladder if the cystic duct is patent
• Used to visualize stones, strictures, or tumors of the hepatic
duct, common bile duct, and gallbladder.
Diagnostic Studies
• Operative Cholangiography
– Rationale
• Common bile duct is injected directly with
radiopaque dye.
• Visualization of stones or other obstructions during
surgery to prevent unneccessary common bile duct
exploration
Diagnostic Studies
• T-Tube Cholangiogram
– Rationale
• Demonstrates good flow of contrast into the
duodenum
• Diagnose retained ductal stones and/or leaks in
ducts
– Nursing Interventions
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T-tube to closed drainage system
Cover site with sterile dressing, if t-tube removed
Assess for allergies to iodine
NPO after midnight
Diagnostic Studies
• Ultrasound of the Liver, Gallbladder, and
Biliary System
– Rationale
• Visualization of deep structures by recording the
reflections of ultrasonic waves directed in to the
tissue
– Nursing Interventions
• NPO after midnight
• Should be done before barium studies or after all
barium has been expelled
Diagnostic Studies
• Gallbladder Scanning
– Rationale
• Injection of technetium 99 is given and scan is done
to visualize the gallbladder and biliary tract
• Used to diagnose acute cholecystitis
– Nursing Interventions
• NPO after midnight
Diagnostic Studies
• Liver Biopsy
– Rationale
• Needle is inserted through the abdominal wall into
the liver to remove a piece of liver tissue
• Used to diagnose cirrhosis, hepatitis, drug-related
reactions, granuloma, and tumors
– Nursing Interventions
• Informed consent
• NPO for 4-8 hours
• Assess lab results for normal platelet count and
prothrombin time
Diagnostic Studies
• After biopsy
– Assess for s/s of bleeding
– Vital signs every 15 min x 1hr, every 30 min x 4 hrs, then
every 4 hrs
– Assess for s/s of pneumothorax
– Bed rest for 24 hrs
Diagnostic Studies
• Liver Scanning
– Rationale
• Radionuclide is given IV
• Geiger counter is used to record the distribution of
radioactive particles in the liver
– Nursing Interventions
• NPO after midnight
Diagnostic Studies
• Blood Ammonia
– Normal Value
• 15 to 110 micrograms/dl
– Rationale
• Ammonia is normally converted into urea and then
excreted by the kidneys
• Liver dysfunction or altered blood flow to the liver
causes blood ammonia levels to rise and BUN
(blood urea nitrogen) to decrease
– Nursing Interventions
• Notify lab if patient is currently taking Neomycin;
can cause decreased ammonia levels
Diagnostic Studies
• Hepatitis Virus Studies
– Rationale
• Diagnose specific virus causing hepatitis
– A, B, C, D, and E
Diagnostic Studies
• Serum Amylase Test
– Normal Value
• 25 to 125 U/L
– Rationale
• Damage to pancreas cells or obstruction to the pancreatic
ductal flow will cause an outporing of this enzyme and
absorption into the bloodstream
• Levels will rise within 12 hours of onset of pancreatic disease.
• Rapidly cleared by the kidneys; levels may return to normal
within 48-72 hrs
– Nursing Interventions
• Note administration of any IV dextrose; can cause a falsenegative result
Diagnostic Studies
• Urine Amylase Test
– Normal Value
• 3-35 IU/hr
– Rationale
• Disorders affecting the pancreas will cause elevated
amylase levels in the urine because the kidneys
rapidly clear amylase
• Levels remain elevated in the urine for 7-10 days
• Used to diagnose pancreatitis in patients who have
had symptoms for 3 days or longer
Diagnostic Studies
– Nursing Interventions
• Urine collection may be 2 hr spot urine, 6 hr, 12 hr,
or 24 hr collection.
– Record exact time collection is begun
– Discard first urine specimen
– Collect all subsequent urine, including the last urine
voided exactly 2, 6, 12, or 24 hrs after collection began
– Urine should be kept on ice during collection period
Diagnostic Studies
• Ultrasound of Pancreas
– Rationale
• Provides diagnostic information with the use of
ultrasonography of the pancreas
• Used to diagnose carcinoma, pseudocyst,
pancreatitis, and pancreatic abcess
– Nursing Interventions
• NPO for 8 hours before test
• Gas or barium will interfere with sound wave
transmission
Diagnostic Studies
• Computerized Tomography of the Abdomen
– Rationale
• Cross-sectional image
• Used to diagnose inflammation, tumors, cysts, ascites,
aneurysm, and cirrhosis of the liver
– Nursing Interventions
• NPO after midnight
• Some patients may experience claustrophobia
Diagnostic Studies
• Endoscopic Retrograde Cholangiopancreatography
of the Pancreatic Duct (ERCP)
– Rationale
• A fiberoptic duodenoscope is inserted through the oral
pharynx, through the esophagus and stomach, and into the
duodenum. Dye is injected for radiographic visualization of
the CBD and pancreatic duct.
• Used to diagnose obstructive jaundice, remove common bile
duct stones, and place biliary and pancreatic duct stents to
bypass obstructions
Diagnostic Studies
– Nursing Interventions
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NPO for 8 hours before test
Informed consent
Must remain still for 1-2 hours
After procedure
– NPO until gag reflex returns
– Assess for abdominal pain, tenderness and guarding
– Assess for s/s of pancreatitis
• abd. pain, nausea, vomiting, and diminished or absent
bowel sounds
Cirrhosis
• Etiology/Pathophysiology
– Chronic, degenerative disease of the liver
– Scar tissue restricts the flow of blood to the liver
– Types of cirrhosis
• Laennec’s cirrhosis
– history of chronic ingestion of alcohol
• Postnecrotic cirrhosis
– viral hepatitis, exposure to hepatotoxins, or infection
• Primary biliary cirrhosis
– destruction of the bile ducts
• Secondary biliary cirrhosis
– chronic biliary tree obstruction (gallstones, tumor, etc.)
Cirrhosis
– Alteration of liver function
• Reduced ability to metabolize albumin
• Obstruction of portal vein
• Increased pressure in the veins that drain the GI tract
• Complications
– Portal Hypertension
• increased venous pressure in the portal circulation
caused by compression or occlusion in the portal or
hepatic vascular system
– Ascites
• accumulation of fluid and albumin in the
peritoneal cavity
• Esophageal Varicosities
– veins in the upper part of the body distend, including the
esophageal veins due to portal hypertension. They may
rupture causing severe hemorrhage
Cirrhosis
• Hepatic Encephalopathy
– Brain damage due to elevated ammonia levels
– Inaapropriate behavior, disorientation, flapping hand
tremors, twitching of the extremities, stupor, and coma
Cirrhosis
• Signs & Symptoms
– Early stages
• Abdominal pain
• Liver is firm and easy to palpate
– Late stages
• dyspepsia
• changes in bowel habits
– constipation or diarrhea
• Nausea and vomiting
• gradual weight loss
Cirrhosis
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ascites
enlarged spleen
spider angiomas
anemia
bleeding tendencies
– cannot absorb vitamin K, or produce clotting factors
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epistaxis
purpura
hematuria
bleeding gums
Cirrhosis
• jaundice
– yellow discoloration of the skin, mucous
membranes and sclerae or the eyes
– caused by abnormal amounts of bilirubin in the
blood
• mental disorientation
Cirrhosis
• Treatment
– Eliminate the cause
• alcohol, hepatotoxins, environmental exposure to
harmful chemicals
– Diet
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Well balanced
High-calorie (2500 to 3000 cal/day)
Moderate protein (75 g/day)
Low fat
Low sodium (1000 to 2000 mg/day)
Supplemental vitamins and folic acid
– Antiemetics
Cirrhosis
• Benadryl & Dramamine
• Contraindicated: Vistaril, Compazine, and Atarax
– Treatment of Complications
• Ascites
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Bedrest
Strict I&O
Restrict fluids to 500 -1000 cc/day
Restrict sodium to 1000-2000 mg/day
Diuretics: Aldactone, Lasix, HCTZ
Vitamin Supplements: Vitamin K, Vitamin C and folic
acid
– LeVeen Peritoneal-Jugular Shunt
– Paracentesis
LeVeen Peritoneal Jugular Shunt
Paracentesis
Cirrhosis
• Ruptured Esophageal Varices
– Maintain airway
– Establish IV
– Vasopressin drip to control bleeding
• IV or directly into the superior vena cava
– Sengstaken-Blakemore tube
– Endoscopic sclerotherapy
– Portacaval shunt
• divert blood from the portal vein to the inferior vena cava
– Blood transfusion
Sengstaken-Blakemore Tube
Cirrhosis
• Hepatic Encephalopathy
– Decrease protein in diet
– Avoid drugs which are detoxified by the liver
– Lactulose
• Oral or retention enema
• decreases the pH of the bowel which decreases the
production of ammonia
– Neomycin
• inhibits protein synthesis in bacteria, therefore
decreasing the production of ammonia
Hepatitis
• Etiology/Pathophysiology
– Inflammation of the liver resulting from several
types of viral agents or exposure to toxic
substances
– Hepatitis A
• Most common
• Incubation 10-40 days
• Oral-fecal trasmission
Hepatitis
– Hepatitis B
• Incubation 28-160 days
• Transmission by contaminated serum; blood
transfusion, contaminated needles, dialysis, or direct
contact with infected body fluids
– Hepatitis C
• Incubation 2 weeks to 6 months (usually 6-9 weeks)
• Transmitted through contaminated needles and
blood transfusions
– Hepatitis D
• Coinfection with hepatitis B
• Incubation 2-10 weeks
Hepatitis
– Hepatitis E
• Fecal contamination of water
• Rare in the U.S.; usually in developing countries
• Incubation 15-64 days
Hepatitis
• Signs & Symptoms
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General malaise
Aching muscles
Photophobia
Headaches
Chills
Abdominal pain
Dyspepsia
Nausea
Hepatitis
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Diarrhea
Constipation
Pruritus
Hepatomegaly
Enlarged lymph nodes
Weight loss
Jaundice
Dark amber urine
Clay colored stools
Hepatitis
• Treatment
– Treat signs and symptoms
– Small frequent meals
• low-fat, high carbohydrate
– IV fluids for dehydration
• Vitamin C for healing
• Vitamin B-complex for absorption of fat soluble vitamins
• Vitamin K for coagulation
– Avoid unnecessary medications, esp seditives
Hepatitis
– Gamma globulin or immune serum globulin
• should be given to anyone exposed to Hepatitis A
• may be given 2 weeks before and 1 week after onset of
symptoms
– Hepatitis B imune globulin (HBIG)
• should be given to anyone exposed to Hepatitis B
– Hepatitis B Vaccine
• should be given to persons identified as high risk for
developing Hepatitis B
– healthcare personnel
– high-risk lifestyle (drug users, homosexual men, prostitutes)
– infants born to mothers who are Hepatitis B positive
Liver Abscesses
• Etiology/Pathophysiology
– May be single of multiple
– Abscess forms in the liver due to an invading
bacteria
Liver Abscesses
• Signs & Symptoms
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Fever
Chills
Abdominal pain and tenderness in the RUQ
Hepatomegaly
Jaundice
Anemia
Liver Abscesses
• Treatment
– IV antibiotics
– Percutaneous drainage of liver abscess
– Open surgical drainage
Cholecystitis & Cholelithiasis
• Etiology/Pathophysiology
– An obstruction, gallstone, or tumor prevents bile from
leaving the gallbladder and the trapped bile acts as an
irritant causing inflammation.
– Risk factors:
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Female
Native American or white
Obesity
Pregnancy
Diabetes
Multiparous women
Use of birth control
Cholelithiasis
Cholelithiasis
Cholecystitis & Cholelithiasis
• Signs & Symptoms
– Indigestion after eating foods high in fat
– Severe, colicky pain in the right upper quadrant
• may radiate around the midtorso to the right scapular area
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Anorexia
Nausea & vomiting
Flatulence
Increased heart & respiratory rates
Diaphoresis
Cholecystitis & Cholelithiasis
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Low grade fever
Elevated WBC
Mild jaundice
Steatorrhea (fatty stool)
Dark amber urine
Cholecystitis & Cholelithiasis
• Treatment
– Mild attacks
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Bedrest
NG tube to suction
NPO
IV fluids
Antispasmodic/Analgesic
– Demerol: decreases incidence of spasms of the sphincter
of Oddi
• Antibiotics
• Avoid spicy foods when allowed PO intake
Cholecystitis & Cholelithiasis
– Lithtripsy
• A machine discharges a series of shock waves through water or
a cushion that breaks the stone into fragments
– Cholecystectomy (Removal of the gallbladder)
• Laparoscopic
– Oral liquids post-op
– Outpatient or discharged next day
– Resume moderate activity in 48-72 hrs
• Open
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Jackson-Pratt drain
T-tube
NG tube
Routine post-op care
T-Tube
Pancreatitis
• Etiology/Pathophysiology
– Inflammation of the pancreas
• Acute or Chronic
– Predisposing Factors
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Alcohol
Trauma
Infectious disease
Certain drugs
– Obstruction of the pancreatic duct may cause a
rupture and enzymes digest the pancreas
Pancreatitis
Pancreatitis
• Signs & Symptoms
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Abdominal pain
Anorexia
Nausea & vomiting
Malaise
Restlessness
Low-grade fever
Jaundice
Weight loss
Steatorrhea
Tachycardia
Pancreatitis
• Treatment
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NPO
IV fluids
NG tube
Antiemetics
Demerol 75 -100 mg q 3-4 hrs
• Avoid morphine; causes spasms of the sphincter of Oddi
– Anticholinergics
– atropine or Pro-Banthine
– Antacids or Tagamet (prevent ulcers)
Pancreatitis
– Hyperalimentation
• may be required to maintain nutrition
– Prevention
• bland, low-fat, high-protein, high-carbohydrate diet
• no alcohol or gastric stimulants (coffee)
• may need oral hypoglycemic agents if destruction or
the islets of Langerhans
Cancer of the Pancreas
• Etiology/Pathophysiology
– Unknown
– Risk factors
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cigarette smoking
exposure to chemical carcinogens
diabetes mellitus
pancreatitis
diet high in meat, fat and coffee
– May be metastisis form the lung, stomach,
duodenum or CBD
– May live only 4-8 months after diagnosis
Cancer of the Pancreas
Cancer of the Pancreas
• Signs & Symptoms
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Anorexia
Fatigue
Nausea
Flatulence
Change in stools
Steady, dull aching pain in the epigastic area
Weight loss
Jaundice
Onset of diabetes mellitus
Cancer of the Pancreas
• Treatment
– Surgery
• Whipple procedure
– resection of the antrum of the stomach, duodenum, and part of
the pancreas
– anastomosis between the stomach, CBD, and pancreatic ducts
and the jejunum
• Total pancreatectomy with resection of parts of the GI
tract
– Chemotherapy
– 5-FU and BCNU
– Gemzar
– Radiation
Whipple Procedure