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Gastrointestinal 4

  1. Complications - obstruction
  2. Management
    1. radiation
    2. chemotherapy
    3. treatment of choice is surgery - bowel resection, colostomy
      1. right hemicolectomy - involves ascending colon
      2. left hemicolectomy - involves descending colon
      3. abdominal-perineal resection: removal of sigmoid colon and rectum with formation of a colostomy
  3. Nursing interventions
    1. manage pain
    2. monitor for complications
      1. wound infection
      2. atelectasis
      3. thrombophlebitis
    3. maintain fluid and electrolyte balance
    4. care of ostomy
  4. Disorders of the Liver
  5. Hepatitis
    1. Definition/etiology - acute inflammatory disease of the liver caused by viral, bacterial, or toxic ingestion
    2. Pathophysiology
      1. inflammation of liver, enlargement of Kupffer cells, bile stasis
      2. regeneration of cells with no residual damage
      3. types
        1. hepatitis A
          • transmitted from infected food, water, milk, shellfish
          • fecal-oral route of infection common in poor sanitation/overcrowding
          • higher incidence in fall and winter
          • new vaccine available
        2. hepatitis B
          • blood-borne and sexually transmitted
          • may become a carrier
        3. hepatitis C
          • transmitted parenterally (post-transfusion hepatitis) and possibly fecal-oral route
          • may become a carrier
        4. hepatitis D
          • blood borne
          • coexists with hepatitis B
        5. hepatitis E
          • water borne
          • contaminated food or water; rare in the United States
  6. Hepatitis B
    1. Risk factors/infection route
      1. homosexuality
      2. iv drug use
      3. health professionals
      4. hemodialysis
      5. transmission routes
        1. infected blood, semen, vaginal secretions or saliva must enter the body
      6. pathophysiology
        1. hepatitis B has three distinct antigens
          • HBsAg - surface antigen
          • HBcAg - core antigen
          • HBeAg - e antigen
        2. damage to the hepatocytescauses inflammation and necrosis
        3. liver function decreased in proportion to damage
        4. healing takes three - four months
    1. Findings
      1. jaundiceif liver fails to conjugate bilirubin or excrete it
      2. clay-colored stools from lack of urobilin
      3. urine is dark from urobilinexcreted in urine rather than stool
      4. urine foams when shaken
      5. pruritusfrom bile saltsexcreted through skin
      6. right upper quadrant pain from edema and inflammation of liver
      7. anorexia, nausea, vomiting, malaise, weight loss
      8. prolonged bleeding from impaired absorption of vitamin K
      9. anemiafrom decreased RBC lifespan
    2. Diagnostics - serologic markers of HBV
      1. HBsAg - hepatitis B surface antigen
      2. anti-Hbc - antibodies to B core antigens
      3. elevated alanine aminotransferase(ALT previously SGPT)
      4. elevated bilirubin
      5. elevated aspartate aminotransferase (AST; previously SGOT)
      6. elevated alkaline phosphatase
      7. prolonged prothrombin time
    3. Management- nonspecific and supportive
      1. symptomatic treatment of pain
      2. antiemetics as needed
    1. Nursing interventions
      1. fatigue - provide rest periods; may require bed rest initially
      2. maintain skin integrity
      3. client will tolerate less activity
      4. nutrition needs:
        1. increase carbohydrates and proteins; decrease fat
        2. avoid alcohol
        3. eat frequent, small meals
      5. remedy knowledge deficit
      6. arrange for home care needs
      7. teach infection control
        1. use disposable utensils and dishes or keep separate from others
        2. good handwashing
        3. do not share razors, toothbrush, etc.
    2. Prevention
      1. hepatitis B vaccine provides active immunity
      2. hepatitis B immune globulin provides passive immunity
      3. observe Standard and Enteric Precautions
      4. good handwashing
  7. Cirrhosis
    1. Definition/etiology - irreversible, chronic, progressive degeneration of the liver, with fibrosisand areas of nodular regeneration
      1. types
        1. Laennec's cirrhosis - related to alcohol abuse
        2. post-necrotic - associated with viral hepatitis or exposure to hepatotoxin
        3. biliary cirrhosis - associated with inflammation or obstruction of gallbladder or bile duct
        4. cardiac cirrhosis - associated with congestive heart failure
    2. Pathophysiology
      1. nodular liver with fibrosisand scar tissue
      2. destroys hepatocytesand kills tissue (necrosis)
      3. necrosis, nodules, and scar tissue obstruct flow of blood, lymph, and bile
      4. impaired bilirubin metabolism
    1. Findings
      1. weakness, fatigue, weight loss, hepatomegaly
      2. right upper quadrant pain (illustration)
      3. jaundice, pruritus, steatorrhea(decreased absorption of fat and fat-soluble vitamins)
      4. clay-colored stools
      5. increased bilirubin in urine, producing dark colored urine
      6. impaired aldosteronemetabolism resulting in edema
      7. impaired estrogen metabolism: gynecomastia, menstrual changes, changes in distribution of body hair, vascular changes - spider angiomas, palmar erythema
      8. impaired metabolism of protein, carbohydrate, and fat
        1. produces less plasma protein, resulting in edemaand ascites
        2. produces less of proteins needed for clotting (fibrinogenand prothrombin)
        3. absorbs less vitamin K, resulting in prolonged bleeding
        4. liver fails to convert glycogen to glucose, resulting in hypoglycemia
    1. Diagnostics
      1. liver function studies - ALT, AST, alkaline phosphatase
      2. prothrombintime, CBC
      3. decreased cholesterol because liver synthesis impaired
      4. elevated serum bilirubin and urine bilirubin
      5. ERCPto examine bile duct
      6. CTscan of liver
      7. liver biopsy
    2. Management
      1. steroidsfor post-necrotic cirrhosis
      2. replace B vitamins and fat-soluble vitamins
      3. diet
        1. increased carbohydrates
        2. protein may be restricted, depending on amount of damage and symptoms
        3. no alcohol
    1. Nursing interventions
      1. monitor for bleeding
      2. alteration in nutrition
        1. 2,000-3,000 calories daily
        2. low fat
      3. provide rest periods; client will not tolerate strenuous activities
      4. remedy any knowledge deficit about cirrhosis and its therapies
      5. changes in LOC
        1. confusion
        2. avoid sedation
      6. impaired skin integrity, from edema and pruritus
      7. monitor fluid balance
      8. measure abdominal girth daily
      9. weigh daily
      10. measure I & O
    2. Complications
      1. portal hypertension
      2. ascites
      3. hepatic encephalopathy
  8. Portal hypertension
    1. Definition/etiology - increased pressure in the portal
    2. Pathophysiology: normal blood flow is altered producing an increased resistance to flow through the liver. Congestion in the portal system dilates veins, especially in esophagus and rectum.
    3. Findings
      1. prominent abdominal-wall veins (caput medusa)
      2. hemorrhoids
      3. enlarged spleen
      4. anemia from increased destruction of RBCs
      5. esophageal varices and GI bleeding
    4. Diagnostics: endoscopy