Nursing review - Adult health 1 - GI, GU systems + diabetes PDF

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Summary

This document has all the necessary information about GI, GU system as well as diabetes to pass your exam....

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Assessment of the GI system ● ●

It goes from the mouth to the anus Pain (PQRST mnemonic) ○ P. stands for palliative or precipitating factors ○ Q for quality of pain, ○ R for region or radiation of pain, ○ S for subjective descriptions of pain ○ T for temporal nature of pain (the time the pain occurs). ○

GI changes associated with aging ● ● ● ● ● ●

Important

Gastric mucosa atrophy Decreased peristalsis Dulled nerve impulses Distention and dilation of pancreatic ducts Decrease in number and size of hepatic cells Disruption of microbial balance of good anaerobic and aerobic flora

Assessing the abdomen ● ●

Starting at RUQ - LUQ - LLQ - RLQ Inspection, auscultation and palpation (depending of the condition)

Stool tests ●

Blood in the stool → gFOBT and FIT

Urea breath test → test the presence of H. pylori Diagnostic procedures ●

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Endoscopy ○ Direct visualization using an endoscopy ○ NPO 6-8 hours before procedure ○ NPO until gag reflex returns (usually 1-2 hours) Esophagogastroduodenoscopy (EGD) (duodenum and up) ○ Direct visualization to evaluate bleeding, ulceration, inflammation, tumors and cancer. Endoscopic retrograde cholangiopancreatography (ERCP) ○ NPO 6-8 hours before ○ Sedatives as prescribed ○ Assess for return of gag reflex Colonoscopy (below the duodenum) ○ Adequate cleansing of colon before procedure (laxative with water?) ○ NPO ○ Sedation ○ Need someone to take him home ○ Screening → risk for cancer colon, chrons, ulcerative colitis, polyps, diverticulitis ○ After a colonoscopy ■ Gas is good ■ Bowel perforation is bad → emergency ■ Some blood is “okay” Laparoscopy ○ No special interventions ○ Usually a drain afterward Liver biopsy ○ Assess results of coagulation studies before procedure ○ Before procedure → place client supine or in left lateral position

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After procedure → bedrest for several hours with client on right side, with pillow under costal margin

Cholecystitis ● ● ●

Gallstones within the gallbladder and obstructing the common bile and cystic bile ducts Common cause: stones Calculous ○ Most common ○ Gallstones ○ Obstruct either cystic duct, gallbladder neck or common bile duct ● Acalculous ○ Without gallstones ○ Caused by changes in the regular filling or emptying of the gallbladder Assessment Do not do deep palpation Mass and pain radiates to the right shoulder or scapula Pain in the RUQ Rigidity and rebound tenderness Murphy’s sign Place the hand firmly to the RUQ and ask the patient to breathe deeply Biliary obstruction Jaundice → most common in chronic cholecystitis Dark orange and foamy urine Steatorrhea (fat in stool) Clay-colored (pale) Pruritis Labs increased WBC alkaline phosphatase AST LDH Serum bilirubin levels Diagnostic assessment x*ray Ultrasonography HIDA scan ERCP MRCP Risk factors Women (20-60) Obesity Female, Forty, Fat and Fertile Signs/Symptoms Blumberg’s sign (rebound tenderness - indicative of peritonitis) Pallor Diaphoresis Interventions/Treatment Avoid rapid weight loss, maintain ideal weight Opioid analgesia (morphine or Dilaudid) Surgery Extracorporeal shock wave lithotripsy Laparoscopy

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Cholelithiasis ●

The formation of gallstones

Interventions/Treatment NPO during nausea or vomiting episodes Surgery Cholecystectomy - Laparoscopic Choledocholithotomy Teach about PCS (postcholecystectomy syndrome) A large intake of fatty foods may result in abdominal pain and diarrhea Administer analgesics as prescribed Instruct client to : Eat small, low-fat meals, avoiding gas-forming foods Pre-operative interventions Postoperative care Monitor airway Encourage coughing and deep-breathing NPO, NG tube suction as prescribed Opioids (PCA pump) T-tube Antiemetics Wound care Clear liquids to solids as prescribed Splinting abdomen → hold a pillow firmly over the incision when coughing Evaluation Control of abdominal pain Adequate nutrition Procedure: Laparoscopic Cholecystectomy Minimally invasive Complications are not common Quick recovery They need to move because if they don’t, the radiation pain will come back -

High fiber, low fat Small, frequent meals Drug therapy Lithotripsy (destruction of hardened masses)

Acute Pancreatitis ● ● ●

Inflammation of the pancreas with the escape of pancreatic enzymes Can be life-threatening Autodigestion and fibrosis of the pancreas

Assessment Watch for weight loss Ask about alcohol (CAGE) Jaundice Sudden abdominal pain Mid-epigastric region Radiating to back Pain aggravated by fatty meal or alcohol Cullen’s sign Edema and bruising in the subcutaneous fatty tissue around the umbilicus Turner’s sign Bruising of the flank “Turn to see the flank” Absent or decreased bowel sounds

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Labs Elevated phosphatase, urinary amylase, elevated serum lipase, amylase Amylase (increased between 12-24 hours and remain elevated 3-4 days) Serum bilirubin ALT WBC ESR Diagnosis Abdominal ultrasound (most sensitive) CT (more reliable) NPO 4 hours before Abdominal x-ray Risk factors “Attacks” during holidays (a lot of food and alcohol) Cholethisiasis and biliary tract problems if triglycerides are high Signs/Symptoms Interventions/Treatment Relieving symptoms, decrease inflammation, anticipate or treat complications Opiates as prescribed Hydration IV fluids NPO IV calcium and magnesium Complication Necrotizing hemorrhagic pancreatitis (NHP) → diffusely bleeding pancreatic tissue with fibrosis and tissue death Jaundice Calculi or pancreatic pseudocyst Hyperglycemia Pleural effusions (listen to lungs) Hypovolemia (monitor B/P and pulse) Paralytic ileus (bowel sounds) Diabetes mellitus Evaluation Notify if dark-colored stools or urine develop

Chronic pancreatitis ● Characterized by remissions and exacerbations ● Develops after repeated episodes of alcohol or chronic obstruction of common bile duct Assessment May be associated with SPINK1 and CFTR gene mutations Tenderness Ascites LUQ mass Dark urine Polyuria, polydipsia and polyphagia Interventions/Treatment Administer pancreatic enzymes as prescribed Fat and protein intake → limited Insulin or oral as prescribed Analgesics Refer patients to AA TPN Complications Diabetes mellitus Pancreatic abscess Always fatal if untreated -

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Blood cultures Drainage or laparoscopy

Evaluation Notify if steatorrhea, abdominal distention, cramping occur.

Pancreatic pseudocyst Risk factors Acute/Chronic pancreatitis Trauma Signs/Symptoms Epigastric pain radiating to the back Interventions/Treatment External drainage Complications Hemorrhage Infection Bowel obstruction Abscess Fistula formation Pancreatic ascites

Pancreatic Cancer ● ●

Difficult to diagnose early 5 years survival rates

Assessment Assess bowel movement and how the stool is Slow, vague presentation Jaundice/Icterus Weight loss Anorexia, nausea, vomiting Labs Elevated CEA in most patients (carcinoembryonic antigen) CT scan MRI Endoscopic ultrasonography Risk factors Signs/Symptoms Jaundice (late sign) Fatigue Pain: vague, constant dullness in the Upper abdomen Intervention/Treatment Glucose monitoring Palliative care GI drainage monitoring Drug, chemotherapy, radiation Biliary stent insertion Surgery (Whipple procedure) NG tube TPN Complication VTE Evaluation

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Oral cavity and esophageal problems ● ● ●

Brush and floss twice daily Avoid alcohol-based mouthwashes Esophagous problems are very similar to an MI

Stomatitis ● ● ●

Inflammation of the oral cavity Ulceration → most common Primary and secondary ○ Primary→ aphthous stomatitis, herpes simplex stomatitis, traumatic ulcers ○ Secondary → results from infection or chemotherapy drugs

Assessment ● Recent infections ● oral truma ● stress ● drug history ● Ask about frequency of outbreaks and how they affect nutrition and communication ● Usually dry painful mouth Risk factors ● Females ● Smoking ● Infection ● Trauma ● Chemotherapy ● Spicy, salty, or acidic (like tomatoes and oranges), Interventions/Treatment ● Proper oral hygiene ● Decrease stress level ● Preserve tissue integrity ● Rinse mouth every 2-3 hours with a sodium bicarbonate solution or warm saline that may be mixed with hydrogen peroxide ○ To produce saliva and keep the oral cavity moist ● Avoid mouth washed high in alcohol content ● Drug therapy ● Assess for dysphagia ● GENTLE oral care

Leukoplakia ● ● ●

Most common oral lesion Thick, white, firmly attached patches Results from mechanical factors causing irritation → poor fitting dentures, chronic cheek nibbling, or damaged teeth

Care of ef esophageal disorders ● ● ● ● ● ●

Remain with dysphasic patient during meals Teach oral exercises and position Elevate HOB Sleep in the right side-lying position Monitor body weight ○ Notify of a loss of 5 pounds or greater No

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alcohol, smoking, carbonated beverages, gas-producing foods, chewing gum or drinking with a straw

Gastroesophageal reflux disease (GERD) ● Most common UPPER GI disorder ● Caused as a result of backward flow off gastric and duodenal content into esophagus Assessment ● History of heartburn, chest pain (from the acid reflux), hoarseness (morning), hypersalivation, epigastric pain ● coughing or wheezing at night Signs and Symptoms ● Dyspepsia - indigestion ● Regurgitation ● Eructation, flatulence ● Dysphagia ● Crackles Risk factors ● 31% heritability ● Middle-ages 30-39 ● Hiatal hernias Diagnosis ● Ordered an EKG to reject the possibility of a MI ● Barium swallow ● EGD ● Ambulatory esophageal pH monitoring ● Esophageal manometry Interventions/Treatment ● Nutrition therapy ○ Decrease peppermint, chocolate, alcohol, fatty foods, caffeine, carbonated beverages, spicy and acidic foods (orange and tomatoes) ○ Low fat high fiber ● Do not eat 2-3 hours before bed ● Elevate HOB ● Weight loss ● Do not wear constrictive clothing ● Avoid heavy lifting ● Straining or working in a bent over position ● Avoid liquids with food ● Sit upright for one hour after eating ● Medication ○ Antacids → Maalox, Mylanta, Gaviscon ■ Increase pH of gastric content ■ Take 1 hour before and 2 to 3 hours after each meal ○ Histamine blockers ■ Reduce gastric secretion ■ Famotidine (Pepcid) ○ Proton Pump Inhibitors ■ Inhibitor of gastric secretion (long-acting) ■ Omeprazole, rabeprazole, pantoprazole, esomeprazole Complications ● During healing, barrett's epithelium and esophageal stricture are concerns ● Barret’s esophagus → Risk of cancer with prolonged GERD

Hiatal/Diaphragmatic Hernias ● ●

Similar symptoms to GERD Deductible/Non Deductible types

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Assessment ● Many people are asymptomatic ● GERD like symptoms ● Nutrition status Signs/Symptoms ● Heartburn ● Regurgitation or vomiting ● Pain ● Dysphagia ● Eructation ● Feeling of fullness Diagnosis ● Barium swallow study with fluoroscopy ● Manometry with esophageal pressure topography Risk factors ● Smoked/pickled foods ● appetite or taste changes ● weight loss ● Dysphagia ● Odynophagia (swallowing feels painful) Interventions/Treatment ● Weight loss if surgery not urgent ● Small frequent meals ● Limit liquids with meal ● Not to recline for 1 hour after eating ● After surgery: ○ HOB 30º ○ Assist the patient getting out of bed and ambulate ○ Support the incision with a pillow when coughing ● Avoid ill people ● Stool softeners or bulk laxatives Complications ● Strangulation ● Potential to compromised nutrition

Stomach disorders ●

EGD → gold standard diagnostic stool for gastritis

Peptic ulcer ● ● ●

Occurs when mucosal defenses become impaired Three types: gastric ulcers, duodenal ulcers, and stress ulcers (less common) H,pylori (bacteria) is a common cause

Assessment ● History of H.pylori, GI surgeries ● Dyspepsia ● Gastric versus duodenal ulcer pain ● Assess for fluid volume deficit Signs and symptoms ● Epigastric tenderness and pain ● Rigid, board-like abdomen with rebound tenderness and pain = peritonitis Diagnosis ● Testing for H.pylori → urea breath test ● Hemoglobin and hematocrit

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● Occult blood in stool ● Chest, abdomen x-ray ● EGD ● Nuclear medicine test (if GI bleeding is suspected) Risk factors ● H.pylori ○ Diagnosis exam for it → urea breath test ● NSAIDs (ibuprofen) ● Other substances that alter gastric secretion ● Aspirin ● Alcohol ● Tobacco ● Increased stress ● Dietary habits Interventions/Treatment ● If H.pylori is the cause → Antibiotic with a minimum of 2 weeks Complications ● Hemorrhage (most serious) ● Perforation ○ If it occurs → patient will have rigid boardlike abdomen accompanied by rebound tenderness (EMERGENCY) ● Pyloric obstruction ● Intractable disease

Gastric ulcers Assessment ● Gnawing (persistently worrying or distressing) ● Sharp pain in or left of midepigastric region 1 to 2 hours after eating ● Hematemesis (vomiting of blood) ● Nausea and vomiting ● If actively bleeding → Life-threatening ○ Signs of dehydration ○ Hypovolemic shock ○ Sepsis ○ Respiratory insufficiency Intervention/Treatment ● Administer mucosal barrier protectants 1 hour before each meal ● Surgery ○ Post op ■ Fowler’s position ■ Do not irrigate or remove NG tube ■ NPO until peristalsis occur ■ Monitor for hemorrhage, dumping syndrome, diarrhea, hypoglycemia, vitamin B12 deficiency

Dumping syndrome ● Rapid emptying of gastric contents into small intestine ● Usually 30 min after eating ● Prevent dumping syndrome → lie on the left side Assessment ● Nausea and vomiting ● Abdominal cramping ● Diarrhea ● Diaphoresis ● Tachycardia

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Borborygmi (rumbling or gurgling noise made by the movement of fluid and gas in the intestines)

Sign and symptoms ● Light headed, weak, fatigue, dizzy ● Tachycardia ● Abdominal cramping ● Diarrhea Interventions/Treatment ● Eat high-protein high-fat, low-carb diet ● Small frequent meals ● lie down after meals

Duodenal ulcers Interventions ● Eat bland diet ● Small frequent meals ● Avoid alcohol, caffeine, aspiring, corticosteroids, nonsteroidal anti-inflammatory medications

Care for noninflammatory intestinal disorders ●

Older adults are more likely to have bowel obstructions

Mechanical obstruction disease ●

Physically blocked by problems outside intestines, in the bowel wall (Crohns’ disease), appendicitis complications hernia, fecal impactions

Assessment ● Pain ● Elimination habits ● Obstipation (severe or complete constipation) Risk factors ● Intussusception ● Volvulus ● Older adults ● Bowel surgery ● Intestinal tumors Labs ● WBC ● Hemoglobin and hematocrit ● Creatinine ● BUN ● Serum sodium, chloride, potassium ● Serum amylase Diagnosis ● CT ● Abdominal ultrasound ● Endoscopy Signs and symptoms ● Acute pain due to obstruction ● Peristaltic waves ● Abdominal distention ● Borborygmi Interventions/Treatment ● NG tube ● IV fluid replacement and maintenance

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● Surgery → exploratory laparotomy Complications ● Fluid and electrolyte imbalance ● Perforation ● Sepsis ● Bleeding Evaluation ● Report normal bowel habits

Colorectal cancer ●

Colon + rectum → large intestine

Assessment ● Bleeding and change in stool (most common signs) ● Pain or cramping ● Incomplete evacuation Lab ● FOBT if over 50 ● FIT ● Carcinoembryonic antigen (CEA) ● Sigmoidoscopy ● CT Diagnosis ● Colonoscopy (definitive test) Risk factors ● >50 years ● genetics ● history of cancer ○ Screening earlier and more frequently to “prevent it” ● Crohn's ● Ulcerative colitis ● Long-term smoking, high body fat, physical inactivity, high-fat diet and alcohol Interventions/treatment ● Stop smoking ● Exercise ● Modify diet ● Radiation therapy ● Adjuvant chemotherapy ● Colon resection ● colectomy ● colostomy

Colostomies ● ● ● ●

Ascending → right-sided tumors Transverse → intestinal obstruction or perforation Descending → left-sided tumors Sigmoid → rectal tumors

Colostomy care ● ● ● ●

Measurement of stoma Appropriate appliance and care to cover stoma Diet modification to control gas and odor Ileostomy (small intestine) → normal stool is liquid ○ Monitor for dehydration and electrolyte imbalance ○ No suppositories administered through ileostomy ○ No beans or broccoli

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Care of Inflammatory Intestinal disorders Peritonitis ● ●

Often caused by bacteria or leakage of bile, pancreatic enzymes, gastric acid Dominant cause of death from surgical infections

Assessment ● Abdominal pain, tenderness and distension ● Pain (type and location) ● Edema ● Movement may be guarded ● Fever (Do not choose fever with geriqatric patients, choose cognitive changes and dehydration) Signs and symptoms ● Increased fever, chills, pallor, abdominal distention, right guarding abdomen Lab ● WBC → over 20K mm3 ● Hemoglobin and hematocrit ● Blood culture (both arms, 15 min apart) ● BUN, creatinine ● ABG, oxygen saturation Diagnosis ● Abdominal x-ray or ultrasound Interventions/Treatment ● Decrease potential for infection ● Restore fluid volume balance ● manage pain Complication ● Infection ● Fluid volume shift ○ Fluid moving into interstitial or peritoneal space

Appendicitis ● ● ●

McBurney’s point ○ Half way between the umbilicus and the anterior iliac crest RLQ Rebound tenderness

Assessment ● Pain in RLQ, McBurney’s point ● Nausea, vomiting ● Constipation or diarrhea ● Peritonitis ● Client in side-lying position, with abdominal guarding Risk factors Interventions/Treatment ● NPO ● Appendectomy ○ Preop ■ monitor for peritonitis ■ Position the client in right side-lying or low semi-fowler’s ■ Apply ice for 20-30 min every hour ■ Avoid laxatives, enemas ○ Postop ■ NPO until bowel function returns ■ Drain

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■ Leg flexed to facilitate drainage NO heat over RLQ No deep palpation

Gastroenteritis ● ●

Watch for weakness and cardiac dysrhythmias ○ Diarrhea → secreting potassium Handwashing

Crohn’s Disease ● Cobblestone appearance of the intestine ● Inflammation that causes a thickened bowel wall ● Severe diarrhea and malabsorption of vital nutrients ● Most often affects terminal ileum Assessment ● Unintentional weight loss ● Assess for distention, masses, visible peristalsis ● Anemia ● Cramp-like, colicky pain after meals ● Diarrhea (mucus or pus) ● Dehydration, electrolyte imbalances, malnutrition Intervention/Treatment ● Meds → Glucocorticoids ○ Caution because can cause → hyperglycemia, osteoporosis, infection, epigastric discomfort ● Surgery avoided if possible Complications ● Hemorrhage ● Severe malabsorption ● Malnourishment ● Debilitation ● Cancer (rare)

Diverticulosis and diverticulitis ● ● ● ●

Outpaching or herniation of the intestinal mucosa Occur in any part of the small or large intestine Diverticulosis (poaching) becomes diverticulitis (inflammation) with inflammation of one or more diverticula Abscess can develop

Assessment ● May have no symptoms ● Left, lower abdominal pain (descending colon) increasing with coughing, straining, lifting ● Abdominal distention, tenderness ● Palpable, tender rectal mass ● Blood in stool Risk factors Interventions/Treatment ● High fiber → diverticulosis ● Low fiber → diverticulitis ○ Avoid nuts, foods with seeds and GI stimulants ● Acute phase ○ NPO ○ Clear fluids

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Avoid gas-forming foods, foods containing indigestible roughage corn, seeds, nuts, high-fiber foods (when inflammation occurs) ● Colon resection ● Colostomy ○ Takes 48-72 h to form stool ● Monitor for stool formation ○ RIght→ ascend, transverse ○ Left → more like normal, descending Complication ● Peritonitis ● Hemorrhage ● Perforation ● Físt...