Nur242
Medsurg Exam 3 (chapters: 48, 49, 50, 51, 52, 53, 54, 55; Chapters 24, 25, 26, 27, 28)
Prof Milhome
Chapter48 Assessment of Gi system aka Alimentary canal
Labs to know
ALT= 3-36 units/L
Albumin= 3.5-5.0
Alkaline phosphate 30-120 units/L
Ammonia= 10-80 mg/dL
AST= 0-35 units
Bilirubin= 0.3-1.0
Calcium= 9.0-10.5
Cholesterol= less than 200 mg/dL
Potassium= 3.5-5.0
Amylase= 30-220
Lipase= 0-160
4 layers of the GI tract= Mucosa, Submucosa, Muscularis, Serosa
Small intestine = absorbs nutrients
Large intestines = absorbs water
Page 1059 Esophagus- Lower esophageal sphincter (LES) does not work in GERD
Page 1064 Location of Body structures in Abdomen
LRQ=appendix, cecum, right ureter, right ovary , fallopian tube, right spermatic cord
URQ= liver, gallbladder, Duodenum, hepatic fixture of colon,
ULQ= spleen, stomach, pancreas, splenic ficture of colon
LLQ= small intestine( illeum), sigmoid colon,left ureter, left ovary fallopian tube, left spermic cord
Page 1061 GI changes in older adults
-atrophy of HI mucosa = decreased hydrochloric acid levels (Hypochlorhydria=lower iron and B12 and atrophic gastritis
-peristalsis decrease = decreased sensation to defecate= constipation and impaction
-decrease lipase- decreased fat and digestion= Steatorrhea fatty stools
-decreased rx metabolism= toxic levels
-dysfunction = obesity, inflammatory disease, reduced immunity
Physical assessment of GI> IAPePa= Inspect, Auscultate, Percuss, Palpate
-Normal Auscultation= high pitched, irregular gurgles frequency of 5-10 per min (not normal BORBORYMUS= hyperactive bowels/ diarrhea)
-After surgery ask assess return of peristalsis ask patient if they have passed flatus within past 8 hours or stool within 12-24 hours
-BRUIT OVER ABDOMINAL AORTA= ANEURSYM; if sound is heard DO NOT PERCUS OR PALPATE; Tell HCP ASAP
-light Palpitation-depress abd depth ½ -1 inch;
- Deep palpitations by physicians, physician's assistant, and advance practice nurses
Page 1063 Action alert: PERISTALIC MOVEMENTS ARE RALEY SEEN UNLESS THE PATIENT IS THIN AND HAS INCREASED PERSISALISIS. IF THESE
MOVEMENTS ARE OBSERVED, NOTE THE QUADRANT OF ORGIN AND DIRECTION OF PERSITALIC FLOW. REPORT THIS FINDING TO HEALTH CARE
PROVIDER BECAUSE IT MAY INDICATE AN INSTESTIAL OBSTRUCTION
IF BULGING MASS IS PRESENT DURING ASSESSMENT OF ABDOMEN DO NOT TOUCH Area because patient may have an ABDOMINAL AORTIC
ANEURSYM. A life-threatening problem. Notify the health care provider of this finding immediately.
GI labs- H&H, CBC, CMP, ASL, AST, (elevated in liver disorders) Bilirubin, PT, serum level of ammonia (hepatic function) Urine (amylase= pancreatitis), Guaiac fecal
occult
Page 1067 Endoscopy used to evaluate bleeding, ulceration, inflammation, tumors, cancer of esophagus, stomach, biliary system, bowel
Page 1068 Teaching EGD=avoid anticoagulants, aspirin, NSAIDS before procedure, can take other daily meds, remain NPO 4/6 or 6-8hrs before,
remove dentures, Midazolam, fentylal, proprafol sedative(depress rate and depth of respirations), gag reflex inactivated (numbing spray; HOB
elevated, bite block ; takes 20-30 mins; NEED CONSENT
POST EGD = check VS every 15-30 mins til sedative wears off, side rails up, NPO til gag refex returns, someone must drive them home, (don’t drive
12-18 hrs after), throat may hurt 12-18 hr after take lozenges
IF RESPIRATION IN BELOW 10 breath PER/MIN OR CO2 IS BELOW 20% USE STERNAL RUB to encourage deep / fast respiration.
PRIORTY AFTER EGD PREVENT ASPIRATION. DO NOT OFFER DFLUIDS OR FOOD PO UNTIL YOU ARE SURE GAG REFLEX IS INTACT . MONITOR SIGNS
OF PERFORATION SUCH AS PAIN, BLEEDING, FEVER.
Page 1068 Teaching ERCP= removes gallstones; avoid anticoagulants', aspirin, NSAID prior to procedure. NPO 6-8 hours before, remove dentures,
CONTRAST USED; IV needed , deactivate defibrillators;
DURING once cannula is placed patient in prone position; last 30 mins to 1 hour.
POST ERCP= Assess VS every 15-30 mins; check gag reflex,
1
, TEACH PATIENT AND FAMILY TO MONITOR FOR SEVERE POST PROCEDURECOMPLICATIONS AT HOME, INCLUDING CHOLECYSTITIS, CHOLANGITIS
(GALLBLADDER INFLAMMATIONOR INFECTION.), BLEEDING PERFORATION, SEPSIS AND PANCREATITIS. THE PATIENT WILL HAVE SEVERE PAIN IF
ANY FO THESE COMPLICATIONS OCCUR. FEVER IS PRESENT IN SEPSIS. THESE PROBLEMS DO NOT OCCUR IMMEDIATELY AFTER PROCEDURE THEY
MAKE TAKE SEVERAL HOURSTO 2 DAYS TO DEVELOP
Page 1069 Teaching colonoscopy=(should be done at age 45 and then every 10 years) Avoid aspirin and NSAIDS, several days before; clean liquid
diet before (have Gatorade available for electrolytes), avoid orange red, purple drinks or jello, NPO several hrs before, bowel prep diarrhea is
expected
DURING= lay left side knees to chest; air instilled lasts 30-60 mins, (have ATROPINE SULFATE (antidote)
POST colonoscopy= VS every 15-20 mins til alert, NPO status til sedation off, remain on left lateral position, fluid given after flatus, rails up, expected
abd cramping ; rails up tila lert, assess rectal bleeding or severe pain; Signs of perforation( severe abd pain, guarding), signs of hypovolemic shock
( dizzy, light head, bp down, tachycardia, pallor, Altered loc ( first sign in elderly); arrange for another person to drive patient home, advise patient
not to work, drive, make legal decisions for the rest of the day
IF SEVERE PAIN OR BLEEDING REPORT TO HCP
IF RESPIRATORY RATE BELOW 10BREATHS/MIN CO@ below @ 20%= STERNAL RUB
Teaching CT= NPO for 4hrs, IV acess needed contrast, contrast metalic taste, clausterphobia mild sedative, hold breath while taking
images, 10 mins tops
Teaching MRI-/ MRCP= no radiation, no metals
-After surgery ask client HAVE you passed flatus within the past 8 hours or stool within past 12-24 hours
- -STOOL =gFOBT (every 3 years, avoid NSAID 7 days, avoid red meat, citrus foods, juices, vitamin C excess 250mg per day)
-IMAGES older than 45- flexible sigmoidoscopy ( every 5 years)CT colonography ( every 5 years ) colonoscopy every 10 years; EGD
-nutriention affected, Anorexia( loss of appetite,
Nasogastric tube –Measure from Tip nose to ear to zyphoid process, insert while as swallowing, ( prevent from going into airway) assess placement
Xray and ph. 5)
Chapter 49 GERD, Hiatal Hernia (page 1081-1085, 1085-1088)
Page 1081 GERD- (backward flow of stomach contents into esophagus) lower esophageal sphincter, teeth erosion, lining will thicken complication
( barius epithelium pre cancerous; lumen smaller – difficulty swallow, (burns normal epithelium, regrown thicker= barrett esophagus) sour taste in
mouth, dispepsia ( indigestion) pyrosis (heartburn)
Page 1082 S/S = dyspepsia ( indigestion) regurgitation (leading to aspiration), water brash (hypersalivation), dysphagia, coughing, hoarseness,
globus (feeling something back of throat), pyrosis (heartburn), pharyngitis, regurgitation, coughing, hoarseness, belching, odynophagia (painful
swallowing), dental caries, chest pain, generalized abd pain, flatulence, nausea
Risk factors diet (caffeinated beverages, coffee, soda, chocolate, nitrates, citrus, tomatoes, alcohol, peppermint, smoking, calcium channel blockers;
anticholinergic, high estrogen, high progesterone, NG tube (doesn’t let LES close, truckle obesity, overeating, pregnancy, abdominal binders,
bending over, ascites,
Dx- EGD, endoscopy, oh monitoring, barium swallow, ph monitoring, usually signs and symptoms, 24 ph monitor test
Drugs- antacids (metabolic alkalosis CA hyper calcium), histamine blockers DINES decrease aids in stomach right before meal, Proton pump
inhibitor ZOLES (take once a day empty stomach), h2 antagonists DINES (right before a meals), (same as peptic ulcer disease)
Teaching- diet modification, avoid alcohol, tobacco cola, citrus, nitrates, peppermint, stop smoking, sit up after eating 1 hr, don’t eat 3 hours before
bed, do not lay flat to sleep,4- 6 small meals, avoid meds that can cause GERD= oral contraception, NSAIDS ( motrin, advil, toradol, ketoralac,
uprught 1-2 hours after eating, limit fried food, fatty, spicey food; eat slowly , chew thouroughly, sleep propped up (promote gas exchange),
discourage heavy lifting, non restrictive clothing,
Complication- barrett esophagus (thickening of epithelium), stricture (narrowing), asthma, laryngitis, dental decay, cardiac disease, aspiration
pneumonia
Treatment- Stretta Procedure, LNF surgery with LINX, tums , hr antagonis DINES, PPI,
Page 1084 WHEN CARING FOR PATIENT W/ LINX DEVICE INSERTION, EMPHASIZE IMPORTANCE OF TELLING HCP ABOUT PROCEDURE AND DATE
OF INSERTION; IF MRI IS RECOMENDED, ONLY CERTAIN PATIENTS W/ MORE RECENT LINX DEVICES MAY BE ELIGIBLE TO UNDERGO MRI SCAN.
PATIENT W/ OLDER LINX SHOULD NEVER UNDERGO MRI SCANNING (CONTAINS MAGNETS)
Page 1085 Hiatal Hernia- protrusion stomach thru opening-sliding or rolling ???
S/S= asymptomatic, GERD-like symptoms- regurgitation, chest pain, dysphagia, belching
DX= barium swallow w/ fluoroscopy, EGD, HRM, EPT
Risk factors- pg , obesity, heavy lifting, strain in toilet
Page 1086 WHEN CARING FOR PATIENT W/ HAITAL HERNIA , EDUCATION IS VERY IMPORTANT. FOLLOW HEALTH TEACHING AS DESCRIBED FOR
GERD.
Teaching- diet modification, avoid alcohol, tobacco cola, citrus, nitrates, peppermint, stop smoking, sit up after eating 1 hr, don’t eat 3 hours before
bed, do not lay flat to sleep,4- 6 small meals, avoid meds that can cause GERD= oral contraception, NSAIDS ( Motrin, Advil, Toradol, ketorolac,
upright 1-2 hours after eating, limit fried food, fatty, spicey food; eat slowly , chew thoroughly, sleep propped up (promote gas exchange),
discourage heavy lifting, non restrictive clothing
2
Medsurg Exam 3 (chapters: 48, 49, 50, 51, 52, 53, 54, 55; Chapters 24, 25, 26, 27, 28)
Prof Milhome
Chapter48 Assessment of Gi system aka Alimentary canal
Labs to know
ALT= 3-36 units/L
Albumin= 3.5-5.0
Alkaline phosphate 30-120 units/L
Ammonia= 10-80 mg/dL
AST= 0-35 units
Bilirubin= 0.3-1.0
Calcium= 9.0-10.5
Cholesterol= less than 200 mg/dL
Potassium= 3.5-5.0
Amylase= 30-220
Lipase= 0-160
4 layers of the GI tract= Mucosa, Submucosa, Muscularis, Serosa
Small intestine = absorbs nutrients
Large intestines = absorbs water
Page 1059 Esophagus- Lower esophageal sphincter (LES) does not work in GERD
Page 1064 Location of Body structures in Abdomen
LRQ=appendix, cecum, right ureter, right ovary , fallopian tube, right spermatic cord
URQ= liver, gallbladder, Duodenum, hepatic fixture of colon,
ULQ= spleen, stomach, pancreas, splenic ficture of colon
LLQ= small intestine( illeum), sigmoid colon,left ureter, left ovary fallopian tube, left spermic cord
Page 1061 GI changes in older adults
-atrophy of HI mucosa = decreased hydrochloric acid levels (Hypochlorhydria=lower iron and B12 and atrophic gastritis
-peristalsis decrease = decreased sensation to defecate= constipation and impaction
-decrease lipase- decreased fat and digestion= Steatorrhea fatty stools
-decreased rx metabolism= toxic levels
-dysfunction = obesity, inflammatory disease, reduced immunity
Physical assessment of GI> IAPePa= Inspect, Auscultate, Percuss, Palpate
-Normal Auscultation= high pitched, irregular gurgles frequency of 5-10 per min (not normal BORBORYMUS= hyperactive bowels/ diarrhea)
-After surgery ask assess return of peristalsis ask patient if they have passed flatus within past 8 hours or stool within 12-24 hours
-BRUIT OVER ABDOMINAL AORTA= ANEURSYM; if sound is heard DO NOT PERCUS OR PALPATE; Tell HCP ASAP
-light Palpitation-depress abd depth ½ -1 inch;
- Deep palpitations by physicians, physician's assistant, and advance practice nurses
Page 1063 Action alert: PERISTALIC MOVEMENTS ARE RALEY SEEN UNLESS THE PATIENT IS THIN AND HAS INCREASED PERSISALISIS. IF THESE
MOVEMENTS ARE OBSERVED, NOTE THE QUADRANT OF ORGIN AND DIRECTION OF PERSITALIC FLOW. REPORT THIS FINDING TO HEALTH CARE
PROVIDER BECAUSE IT MAY INDICATE AN INSTESTIAL OBSTRUCTION
IF BULGING MASS IS PRESENT DURING ASSESSMENT OF ABDOMEN DO NOT TOUCH Area because patient may have an ABDOMINAL AORTIC
ANEURSYM. A life-threatening problem. Notify the health care provider of this finding immediately.
GI labs- H&H, CBC, CMP, ASL, AST, (elevated in liver disorders) Bilirubin, PT, serum level of ammonia (hepatic function) Urine (amylase= pancreatitis), Guaiac fecal
occult
Page 1067 Endoscopy used to evaluate bleeding, ulceration, inflammation, tumors, cancer of esophagus, stomach, biliary system, bowel
Page 1068 Teaching EGD=avoid anticoagulants, aspirin, NSAIDS before procedure, can take other daily meds, remain NPO 4/6 or 6-8hrs before,
remove dentures, Midazolam, fentylal, proprafol sedative(depress rate and depth of respirations), gag reflex inactivated (numbing spray; HOB
elevated, bite block ; takes 20-30 mins; NEED CONSENT
POST EGD = check VS every 15-30 mins til sedative wears off, side rails up, NPO til gag refex returns, someone must drive them home, (don’t drive
12-18 hrs after), throat may hurt 12-18 hr after take lozenges
IF RESPIRATION IN BELOW 10 breath PER/MIN OR CO2 IS BELOW 20% USE STERNAL RUB to encourage deep / fast respiration.
PRIORTY AFTER EGD PREVENT ASPIRATION. DO NOT OFFER DFLUIDS OR FOOD PO UNTIL YOU ARE SURE GAG REFLEX IS INTACT . MONITOR SIGNS
OF PERFORATION SUCH AS PAIN, BLEEDING, FEVER.
Page 1068 Teaching ERCP= removes gallstones; avoid anticoagulants', aspirin, NSAID prior to procedure. NPO 6-8 hours before, remove dentures,
CONTRAST USED; IV needed , deactivate defibrillators;
DURING once cannula is placed patient in prone position; last 30 mins to 1 hour.
POST ERCP= Assess VS every 15-30 mins; check gag reflex,
1
, TEACH PATIENT AND FAMILY TO MONITOR FOR SEVERE POST PROCEDURECOMPLICATIONS AT HOME, INCLUDING CHOLECYSTITIS, CHOLANGITIS
(GALLBLADDER INFLAMMATIONOR INFECTION.), BLEEDING PERFORATION, SEPSIS AND PANCREATITIS. THE PATIENT WILL HAVE SEVERE PAIN IF
ANY FO THESE COMPLICATIONS OCCUR. FEVER IS PRESENT IN SEPSIS. THESE PROBLEMS DO NOT OCCUR IMMEDIATELY AFTER PROCEDURE THEY
MAKE TAKE SEVERAL HOURSTO 2 DAYS TO DEVELOP
Page 1069 Teaching colonoscopy=(should be done at age 45 and then every 10 years) Avoid aspirin and NSAIDS, several days before; clean liquid
diet before (have Gatorade available for electrolytes), avoid orange red, purple drinks or jello, NPO several hrs before, bowel prep diarrhea is
expected
DURING= lay left side knees to chest; air instilled lasts 30-60 mins, (have ATROPINE SULFATE (antidote)
POST colonoscopy= VS every 15-20 mins til alert, NPO status til sedation off, remain on left lateral position, fluid given after flatus, rails up, expected
abd cramping ; rails up tila lert, assess rectal bleeding or severe pain; Signs of perforation( severe abd pain, guarding), signs of hypovolemic shock
( dizzy, light head, bp down, tachycardia, pallor, Altered loc ( first sign in elderly); arrange for another person to drive patient home, advise patient
not to work, drive, make legal decisions for the rest of the day
IF SEVERE PAIN OR BLEEDING REPORT TO HCP
IF RESPIRATORY RATE BELOW 10BREATHS/MIN CO@ below @ 20%= STERNAL RUB
Teaching CT= NPO for 4hrs, IV acess needed contrast, contrast metalic taste, clausterphobia mild sedative, hold breath while taking
images, 10 mins tops
Teaching MRI-/ MRCP= no radiation, no metals
-After surgery ask client HAVE you passed flatus within the past 8 hours or stool within past 12-24 hours
- -STOOL =gFOBT (every 3 years, avoid NSAID 7 days, avoid red meat, citrus foods, juices, vitamin C excess 250mg per day)
-IMAGES older than 45- flexible sigmoidoscopy ( every 5 years)CT colonography ( every 5 years ) colonoscopy every 10 years; EGD
-nutriention affected, Anorexia( loss of appetite,
Nasogastric tube –Measure from Tip nose to ear to zyphoid process, insert while as swallowing, ( prevent from going into airway) assess placement
Xray and ph. 5)
Chapter 49 GERD, Hiatal Hernia (page 1081-1085, 1085-1088)
Page 1081 GERD- (backward flow of stomach contents into esophagus) lower esophageal sphincter, teeth erosion, lining will thicken complication
( barius epithelium pre cancerous; lumen smaller – difficulty swallow, (burns normal epithelium, regrown thicker= barrett esophagus) sour taste in
mouth, dispepsia ( indigestion) pyrosis (heartburn)
Page 1082 S/S = dyspepsia ( indigestion) regurgitation (leading to aspiration), water brash (hypersalivation), dysphagia, coughing, hoarseness,
globus (feeling something back of throat), pyrosis (heartburn), pharyngitis, regurgitation, coughing, hoarseness, belching, odynophagia (painful
swallowing), dental caries, chest pain, generalized abd pain, flatulence, nausea
Risk factors diet (caffeinated beverages, coffee, soda, chocolate, nitrates, citrus, tomatoes, alcohol, peppermint, smoking, calcium channel blockers;
anticholinergic, high estrogen, high progesterone, NG tube (doesn’t let LES close, truckle obesity, overeating, pregnancy, abdominal binders,
bending over, ascites,
Dx- EGD, endoscopy, oh monitoring, barium swallow, ph monitoring, usually signs and symptoms, 24 ph monitor test
Drugs- antacids (metabolic alkalosis CA hyper calcium), histamine blockers DINES decrease aids in stomach right before meal, Proton pump
inhibitor ZOLES (take once a day empty stomach), h2 antagonists DINES (right before a meals), (same as peptic ulcer disease)
Teaching- diet modification, avoid alcohol, tobacco cola, citrus, nitrates, peppermint, stop smoking, sit up after eating 1 hr, don’t eat 3 hours before
bed, do not lay flat to sleep,4- 6 small meals, avoid meds that can cause GERD= oral contraception, NSAIDS ( motrin, advil, toradol, ketoralac,
uprught 1-2 hours after eating, limit fried food, fatty, spicey food; eat slowly , chew thouroughly, sleep propped up (promote gas exchange),
discourage heavy lifting, non restrictive clothing,
Complication- barrett esophagus (thickening of epithelium), stricture (narrowing), asthma, laryngitis, dental decay, cardiac disease, aspiration
pneumonia
Treatment- Stretta Procedure, LNF surgery with LINX, tums , hr antagonis DINES, PPI,
Page 1084 WHEN CARING FOR PATIENT W/ LINX DEVICE INSERTION, EMPHASIZE IMPORTANCE OF TELLING HCP ABOUT PROCEDURE AND DATE
OF INSERTION; IF MRI IS RECOMENDED, ONLY CERTAIN PATIENTS W/ MORE RECENT LINX DEVICES MAY BE ELIGIBLE TO UNDERGO MRI SCAN.
PATIENT W/ OLDER LINX SHOULD NEVER UNDERGO MRI SCANNING (CONTAINS MAGNETS)
Page 1085 Hiatal Hernia- protrusion stomach thru opening-sliding or rolling ???
S/S= asymptomatic, GERD-like symptoms- regurgitation, chest pain, dysphagia, belching
DX= barium swallow w/ fluoroscopy, EGD, HRM, EPT
Risk factors- pg , obesity, heavy lifting, strain in toilet
Page 1086 WHEN CARING FOR PATIENT W/ HAITAL HERNIA , EDUCATION IS VERY IMPORTANT. FOLLOW HEALTH TEACHING AS DESCRIBED FOR
GERD.
Teaching- diet modification, avoid alcohol, tobacco cola, citrus, nitrates, peppermint, stop smoking, sit up after eating 1 hr, don’t eat 3 hours before
bed, do not lay flat to sleep,4- 6 small meals, avoid meds that can cause GERD= oral contraception, NSAIDS ( Motrin, Advil, Toradol, ketorolac,
upright 1-2 hours after eating, limit fried food, fatty, spicey food; eat slowly , chew thoroughly, sleep propped up (promote gas exchange),
discourage heavy lifting, non restrictive clothing
2
