Unit IX Gastrointestinal Disorders

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Unit IXGastrointestinal Disorders

• Wendy DuFour, RN, MN, CCRN
• Assistant Professor of Nursing
• Los Angeles Valley College

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Jaundice

• A yellowish discoloration of body tissues such as
  skin, sclera, urine and feces, from an alteration
  in normal bilirubin metabolism or flow of bile
  into the hepatic or biliary duct systems.
• Symptom, not a disease!!
• Body can handle some elevated levels, but
  jaundice appears when gt 3x normal levels.
• Breakdown of hemoglobin forms bilirubin.
• Normally stored on Gallbladder.

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Types of Jaundice

• Hemolytic- increased breakdown of RBCs which
  produces ? in uncojugated bilirubin in the blood.
• Causes include
• Transfusion reactions
• Sickle cell crisis
• Hemolytic anemia
• Hepatocellular- due to impaired liver function.
• Causes include hepatitis, cirrhosis, and hepatic
  carcinoma.
• Obstructive- due to impede or blocked flow of
  bile either from the bile duct or the liver.

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Hepatitis

• Inflammation/infection of the liver causing liver
  cell death. Remember the liver can regenerate.
  Some cell replication may be normal. When its
  not, you have scaring and cirrhosis.
• Most common cause is viral.
• Types of viral infections include A, B, C, D, E,
  G
• Can be caused by drugs
• Alcohol, Tylenol
• Can be autoimmune
• Can be from a bacterial infection- rare

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Hepatitis

• Hepatitis B has infected gt 300 million people
  worldwide.
• of cases is decreasing due to vaccination.
• Hepatitic C has infected gt 170 million people
  worldwide.
• Most common liver disease in the US.
• 20 of Hep C individuals will progress to
  cirrhosis
• Takes 15-20 years to see overall effect.
• High prevalence of co-infection of HIV and HCV
• 40 of HIV patients also have HCV
• See Lewis pg. 1106, table 42-2

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Hepatitis

• Collaborative Care-
• Medication/drug therapy to alleviate symptoms
• Goal is to ? viral load ? drug resistant HBV,
  ? liver damage (cirrhosis and
  hepatocellular cancer)
• Rest and good nutrition for liver regeneration.
• Prevention
• Hep A B have vaccines.
• Hep C ?-interferon may help prevent liver CA.

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Hepatitis

• Nursing Assessment
• Subjective Data
• Past health history!!
• Hx of high risk behaviors- such as_________
• Travel history
• Medication usage
• Objective Data
• Skin Color
• Lethargic, low grade fever
• Lab tests- ? serum total bilirubin,
  hypoalbuminemia, anemia, prolonged coagulations
  studies.

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Hepatitis

• Nursing Diagnoses
• Impaired metabolic function
• Infection
• Altered fluid volume gt body requirements
• Ineffective therapeutic management
• Risk for injury -bleeding r/t
• Coagulopathy
• Esophageal Varices
• Activity intolerance
• Impaired physical mobility
• Impaired gas exchange
• Self-care deficit
• Spiritual distress
• Caregiver role strain

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Hepatitis

• Plan of care
• Primary and secondary prevention
• Prevent further deterioration
• Promote healing
• Prevent spread of infection
• Safety

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Cirrhosis

• A chronic progressive disease of the liver.
• Characterized by extensive degeneration
  destruction of the parenchymal cells.
• Loss of ability to regenerated normal cells
  resulting in abnormally shaped blood vessels and
  scaring of common bile duct.
• Blood flow impeded ?venous congestion.
• Bile backup into liver jaundice.

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Cirrhosis

• Types
• Alcoholic- An accumulation of fatty deposits in
  the liver that eventually cause scaring. Can be
  reversed early if alcohol consumption ceases.
• Postnecrotic- Broad bands of scar tissue form as
  a result of viral, bacterial or idiopathic
  infections.
• Biliary- Chronic obstruction and infection leads
  to scar tissue formation.
• Cardiac- Results from long-standing severe R
  sided heart failure.

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Cirrhosis - early signs

• Subjective- c/o nausea and vomiting, fatigue
• Objective- may be insidious, due to altered
  metabolism of carbohydrates, fats, and proteins.
• Pain- due to stretching, swelling or spasm of the
  liver, common bile ducts or vasculature.
• Anorexia- think about where protein metabolism
  occurs.
• Dyspepsia
• Change in bowel habits- constipation or diarrhea

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Cirrhosis- physical late signs Due to liver
failure and portal hypertension

• Encephalopathy
• Peripheral neuropathy
• Varices
• Esophageal
• Rectal
• Jaundice
• Spider angiomas

• Petechiae
• Bruising
• Ascites
• Peripheral edema
• Gynecomastia
• Amenorrhea
• Impotence

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Cirrhosis medications

• Vasopressin- vasoconstriction of varices to
  prevent bleeding.
• ? blockers to vasodilate smooth muscle of the
  veins and ? portal venous pressure.
• Lactulose traps ammonia in the bowel causing its
  elimination.
• Antibiotics (neomycin) prevent ammonia buildup.
• Diuretics
• Vitamin K

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Ascites

• Accumulation of serous fluid into the peritoneal
  cavity due to overflow of fluid and proteins out
  of the vascular system into the lymphatic system
  and then overflows again into the belly.
• Remember OSMOSIS- movement from a lesser
  concentration to a greater concentration.

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Nursing Assessment

• Subjective Data
• The jaundice will push them to seek medical
  attention
• Objective Data
• You just saw it! See previous slide.
• Others include
• Asterixis- flapping movements, extension and
  flexion
• Fetor hepaticus - musty sweet breath
• Hepatorenal syndrome- functional renal failure
  causing more fluid overload.

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Esophageal Varices

• Prevention of rupture and bleeding is the goal!
• No alcohol, aspirin, irritating foods.
• Avoidance of upper respiratory infections
  coughing
• If bleeding occurs, goal is stabilization and
  maintaining patent airway ABCs
• Treatments
• Endoscopic sclerotherapy causes thrombosis and
  obliterates varices.
• Endoscopic ligation
• Balloon tamponade- Sengstaken-Blakemore tube.

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Liver transplantation

• Another treatment for cirrhosis.
• Reinfection of HBV or HBC is almost certain.
• 20-30 will develop cirrhosis again within 5
  years.
• Rejection, secondary infection and cancer common.
• Medications present another set of problems.

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Acute Pancreatitis

• Acute inflammation of the pancreas that activates
  digestive enzymes causing autodigestion of
  pancreatic cells. The pancreas eats itself.
• PAIN- Radiating retroperitoneal to back pain.
• Aggravated by eating.
• Onset is sudden.
• Positioning does not help.
• Complications-
• Pseudocyst- contains necrotic material
• Abcess- fluid can become infected and perforate
  other organs.

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Acute Pancreatitis

• Medical Diagnosis-
• Elevated serum amylase!!!!
• Elevated serum lipase
• Hyperglycemia
• Hypocalcemia
• Radiating PAIN!!!!!!!
• Electrolyte imbalance

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Acute Pancreatitis

• Nursing diagnoses-
• Alteration in comfort Acute PAIN
• Infection
• Imbalanced nutrition, lt body requirements
• Altered metabolism d/t insulin production failure
  and digestive enzyme over secretion
• Decreased fluid volume

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Acute Pancreatitis

• Nursing care-
• Pain medication and evaluation
• Fluid replacement
• Monitoring of electrolytes and blood sugars
• Anti-emetic administration /or NGT insertion
• Monitoring for s/s of secondary infection

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Chronic Pancreatitis

• Goal is Prevention of further attacks
• Supplemental pancreatic enzymes
• Dietary control
• Patient education
• Glucose monitoring and possible medication
  administration

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Upper GI Bleeding (UGI)

• Sudden onset of insidious bleeding from artery,
  capillary or vein.
• Types include
• Hematemesis- bright red or coffee ground emesis.
• Melena- FOUL smelling, tarry, black stools.
  Color is due to iron.
• Occult bleeding- small amounts of blood not
  detectible by random visualization but test
  positive by guaiac test.
• Common sites
• Esophageal- Mallory-Weiss tear junction of the
  esophagus and stomach.
• Stomach
• Duodenum

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Upper GI Bleeding (UGI) cont.

• Goal is to stabilize the patient and monitor for
  further bleeding.
• 80-85 of bleeds will stop spontaneously, but can
  restart so finding cause and site is very
  important.
• Prioritization is ABCs
• What will you do??
• Fluid volume deficit!! So Cardiac Output is low.
• Impaired tissue perfusion
• Altered gas exchange
• Altered mental status
• Potential for injury
• Potential for ineffective airway clearance

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Upper GI Bleeding (UGI) cont.

• Collaborative care includes-
• Endoscopy - Ligation or thrombosis of bleeding
  artery.
• Surgical repair- Considered absolutely necessary
  is the bleed continues after gt 2000 cc blood
  transfused.
• Drug therapy-
• H2 receptor blockers
• Proton pump inhibitors
• Vasopressin
• Sandostatin- ? release of gastrin