NCLEX RN GUIDE                                                                                   the best of NCLEX

Gastrointestinal 5

  1. Management
  2. sclerotherapy - injection of a sclerosing agent into varices
  3. balloon tamponade
    1. sangstaken-Blakemore tube is inserted into the stomach
    2. gastric balloon is inflated and presses on lower esophagus while allowing suctioning
    3. esophageal balloon places pressure on varices
    4. pressure is released as ordered to prevent necrosis
    5. traction for increased pressure added by attaching tube to football helmet
    6. assess for bleeding and signs of shock
    7. assess for respiratory distress - aspiration or displacement of tube, suction PRN
    8. keep head of bed elevated
  4. medications
    1. vasopressin
    2. nitroglycerin will decrease myocardial effects
    3. beta-adrenergic neuron-blocking agentsmay decrease risk of recurrent bleeding by decreasing pressure in portal system
    4. cathartics to remove blood from GI tract and decrease absorption of ammonia
  5. surgical intervention
    1. shunt to decrease blood flow to liver and therefore pressure Splenorenalshunt
    2. TIPS (transjugular intrahepatic portosytsemic shunt) - shunt placed between hepatic and portal vein
  6. Nursing interventions
  7. prevent bleeding
  8. avoid intake of alcohol, irritating or rough food
  9. avoid increased pressure in abdomen
  10. if bleeding occurs - administer transfusions, fresh frozen plasma, vitamin K
  11. monitor for infection
  12. Ascites
  13. Definition/etiology - accumulation of fluid in the peritoneum
  14. Pathophysiology
    1. portal hypertension causes increased plasma and lymphatic hydrostaticpressure in portal system
    2. hypoalbuminemia causes decreased colloid osmotic pressure
    3. hyperaldosteronism due to liver's inability to metabolize aldosteronecauses body to retain sodium and water
  15. Findings
    1. abdominal distention, protruding umbilicus, dull sound on percussionof abdomen, fluid wave
    2. bulging flank
    3. dyspnea
  16. Diagnostics
    1. abdominal x-ray
    2. CT scan
    3. ultrasound
  17. Medical management
    1. diuretics - spirnolactone (Aldactone) - aldosterone antagonist, spares potassium
    2. iv albumin
    3. paracentesisto remove fluid
    4. diet low in sodium
    5. peritoneal venous shunt - allows drainage of fluid from the peritoneum to superior vena cava
  18. Nursing interventions
    1. abdomen will have excess fluid, blood vessels too little
    2. measure I & O, daily weight, abdominal girth, skin turgor
    3. restrict fluids
    4. monitor for ineffective breathing patterns
    5. semi-Fowler's position
    6. monitor for impaired skin integrity
    7. remedy knowledge deficit
  19. Hepatic encephalopathy - mental dysfunction associated with severe liver disease
  20. Definition/etiology
    1. impaired ammonia metabolism in liver poisons brain tissue
    2. ammonia produced in bowel from action of bacteria on protein
  21. Findings
    1. changes in LOC from confusion to coma
    2. changes in sleep pattern
    3. memory loss
    4. asterixis - flapping tremor
    5. impaired handwriting
    6. hyperventilationwith respiratory alkalosis
    7. fetor hepaticus - musty, sweet odor to breath
  22. Diagnostics - serum ammonia level
  23. Management
    1. neomycin sulfate (Mycifradin) - inhibits action of intestinal bacteria
    2. lactulose (Cephulac) - absorbs ammonia and produces evacuation of the bowel
    3. low protein diet
  24. Nursing interventions
    1. tremor, confusion can lead to injury: maintain safety
    2. ascites and low intake decrease fluid volume
    3. diarrhea from medications
  25. Disorders of Pancreas and Gallbladder
  26. Acute pancreatitis
    1. Definition/etiology - inflammation of the pancreas
      1. alcohol ingestion
      2. gall stones
      3. drug ingestion
      4. viral infections
      5. trauma
    2. Pathophysiology
      1. autodigestion from premature activation of pancreatic enzymes
      2. proteases and lipases, normally active in small intestine, are activated in the pancreas
      3. phospholipase A digests adiposeand parenchymal tissues
      4. elastase digests elastic fibers of blood vessels, producing bleeding
      5. amylase digests carbohydrates
      6. inflammation response occurs from enzyme release
    3. Findings
      1. left upper quadrant abdominal pain
      2. pain worsens after eating and when lying flat
      3. nausea and vomiting
      4. fever, agitation, confusion
      5. hypovolemiaand shock
      6. hemorrhage into retroperitonealspace may produce ecchymosisin flank or around umbilicus
      7. tachypnea, pulmonary infiltrates, atelectasisfrom circulating enzymes