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 • 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 • 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 • 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 false negative 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 • 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
• ascites • enlarged spleen • spider angiomas • anemia • bleeding tendencies – cannot absorb vitamin K, or produce clotting factors • 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 • 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
Cirrhosis
– Antiemetics • Benadryl & Dramamine • Contraindicated: Vistaril, Compazine, and Atarax – Treatment of Complications • Ascites – 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 – General malaise – Aching muscles – Photophobia – Headaches – Chills – Abdominal pain – Dyspepsia – Nausea
Hepatitis
– 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 – 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: • 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 – Anorexia – Nausea & vomiting – Flatulence – Increased heart & respiratory rates – Diaphoresis
Cholecystitis & Cholelithiasis
– Low grade fever – Elevated WBC – Mild jaundice – Steatorrhea (fatty stool) – Dark amber urine
Cholecystitis & Cholelithiasis
• Treatment – Mild attacks • 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 – 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 • Alcohol • Trauma • Infectious disease • Certain drugs – Obstruction of the pancreatic duct may cause a rupture and enzymes digest the pancreas
Pancreatitis
Pancreatitis
• Signs & Symptoms – Abdominal pain – Anorexia – Nausea & vomiting – Malaise – Restlessness – Low-grade fever – Jaundice – Weight loss – Steatorrhea – Tachycardia
Pancreatitis
• Treatment – 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 • 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 – 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