upper git disorders
TRANSCRIPT
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PEPTIC ULCER
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PEPTIC ULCER
A break in the mucous lining of thegastrointestinal tract when it comes in contact
with gastric juice
peptic ulcer occurs in any area of the
gastrointestinal tract exposed to acid- pepsinsecretions, including esophagus, stomach or
duodenum.
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RISK FACTORS H. pylori infection
Low socioeconomic status
Crowded, unsanitary living conditions
Unclean food or water
Use of NSAIDs
Advance age
History of ulcer
Cigarette smoking
Family history of PUD
Psychological stress, alcohol, caffeine consumption
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PATHOPHYSIOLOGY
MANIFESTATIONS pain- gnawing, burning, aching or hungerlike
located at the epigastric region sometimes
radiating at the back
pain occurs when the stomach is empty 2-3
hours after meals and in the middle of the night
Relieved by eating
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MANIFESTATIONS OF PUD
complicationsHEMORRHAGE Occult or obvious blood in the stool
hematemesis
Weakness, dizziness orthostatic hypotention
hypovolemic shock
OBSTRUCTION sensation of epigastric fullness
nausea and vomiting
electrolyte imbalances
metabolic alkalosis
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PERFORATION
severe upper abdominal pain, radiating to theshoulder
rigid boardlike abdomen
absence of bowel sounds
diaphoresis tachycardia
fever
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DIAGNOSTIC TESTS
Upper GI series using barium as a
contrast can detect 80%- 90% of peptic
ulcers. Gastroscopy- allows visualization of the
esophagus, gastric and duodenal mucosa
and direct inspection of ulcers. Tissue can
be obtained for biopsy
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MEDICATIONS eradication of H. pylori combination of two
antibiotics bismuth or proton pump inhibitors( omeprazole, metronidazole and clarithromycinor bismuth subsalicylate, tetracycline andmetronidazole
medications that decrease gastric acid contentinclude proton pump inhibitors and H2 receptorantagonist
agents that protect mucosa sucralfate,bismuth, antacids and prostaglandin analogs
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TREATMENTS
dietary management
Clients are encourage to maintain good
nutrition, consuming balanced meals at regular
intervals.
alcohol intake
smoking should be discourage as it slows the
rate of healing and increases the frequency of
relapses.
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Nursing diagnoses and Interventions
PAIN typically experienced 2-4 hours after
eating , a high levels of gastric acid and pepsin
irritate the exposed mucosa.
assess pain, including location, type, severity,frequency, and duration and its relationship to food
intake
administer proton- pump inhibitors, H2 receptor
antagonists, antacids. Monitor foe effectiveness and
side effects or adverse reactions.
teach relaxation, stress reduction and lifestyle
management techniques.
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SLEEP PATTERN DISTURBANCES- night time
ulcer pain, typically occurs between 1- 3 am,
may disrupt the sleep cycle and result in
inadequate rest.
the importance of taking the medications as prescribed
( bedtime dose)
instruct the client to limit food intake after the eveningmeal, eliminating bedtime snacks. (stimulate the
production of gastric acid and pepsin)
encourage use of relaxation techniques
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IMBALANCE NUTRITION:LESS THAN BODY
REQUIREMENTS
assess current diet, including pattern of food intake,
eating schedule and food that precipitate pain or being
avoided.
refer to dietician for meal planning and meet nutritional
needs monitor for complaints of anorexia, fullness, nausea,
and vomiting
monitor laboratory values for indications of anemia or
other nutritional deficits.
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DEFICIENT FLUID VOLUME- bleeding canlead to hypovolemia and volume deficit, which
can lead to decrease in cardiac output andimpaired tissue perfusion. monitor stool and gastric drainage ( vomitus or
nasogastric tube)
Bright red with possible clots acute hemorrhage
dark red or coffee ground blood has been in thestomach for a period of time
hematochezia- stool containing blood and clots( acutehemorrhage
melena black tarry stool ( less acute bleeding)
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maintain IVF with volume and electrolyte solutions,
administer whole blood or PRBC as ordered.
insert NGT and maintain its position and patency( if
ordered may irrigate with sterile normal saline until
return flow is clear)
monitor hgb and hct, serum electrolyte BUN and CREA.
( digestion and absorption of blood in the GI tract may
result to elevated BUN and CREA.
assess abdomen, including bowel sounds, distention,
girth and tenderness.
maintain bedrest with the head of bed elevated
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DIVERTICULAR DISEASE
are saclike projections of mucosa through
the muscular layer of the colon.
diverticula may occur anywhere in thegastrointestinal tract
affect the large intestine with 90% - 95%
occurring in the sigmoid colon.
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PATHOPHYSIOLOGY
DIVERTICULOSIS
presence of diverticula
asymptomatic
episodic pain ( usually left- sided), constipation or
diarrhea, abdominal cramping, occult bleeding in the
stools, weakness and fatigue
complications include hemorrhage and diverticulitis
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DIVERTICULITIS- inflammation in and around
the diverticular sac.
undigested food and bacteria collect in the
diverticula , forming a hard mass ( fecalith) that
impairs he mucosal blood supply, allowing
bacterial invasion
mucosal ischemia can lead to perforation,
bacterial contamination and can lead to
abscess formation or peritonitis.
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pain it is usually left- sided and may be mild to
severe and either steady or cramping.
constipation or increase frequency in defecation
nausea, vomiting and fever may occur
abdomen is distended with tenderness and s
palpable mass in the left lower quadrant resulting
from inflammatory response
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Diagnostic tests
WBC count leukocytosis ( increase in
the number of immature wbc) due to
inflammation
hemoccult or guaiac testing
barium enema\abdominal x-ray
CT scan
sigmoidoscopy or colonoscopy
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Dietary Management
a high fiber diet is recommended- increases
stool bulk , decreases intraluminal pressure andmay reduce spasm.
avoid foods with small seeds like popcorn,berries which could obstruct diverticula
bowel rest is prescribed put patient on NPO withIVF and possibly TPN
feeding is resumed initially clear liquid then soft,low roughage diet
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Nursing diagnoses and Interventions
Impaired tissue integrity: gastrointestinalMonitor VS every 4 hours Tachycardia and
tachypnea may be early indications of increase
inflammation and resulting to fluid shift. Fevermay indicate increase or spread of inflammation
assess abdomen every 4 hours, measureabdominal girth, auscultating bowel sounds,palpating for tenderness
assess for lower intestinal bleeding
maintain IVF, TPN and accurate I and O
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painAsk the client to rate the pain using the pain
scale, document level of pain and note for anychanges in location or character of pain
administer prescribed analgesics or PCA, userelaxation, positioning and distractions.
maintain bowel rest and total body rest reintroduce oral foods and fluids slowly,
providing a soft, low fiber diet with bulk formingagents
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anxiety assess and document the level of anxiety
demonstrate empathy and awareness of the perceivedthreat to health
attend to physical care needs
spend as much time as possible to client
encourage supportive family and friends to remain withthe client
assist client to use and identify appropriate copingmechanism
involve the client and family in care decisions
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CHOLELITHIASIS/ CHOLECYSTITIS
CHOLELITHIASIS is the formation of stones within thegallbladder or biliary tract system.
Bile is formed by the liver and stored in the gallbladder. Bilecontains bile salts, bilirubin, water, electrolytes,cholesterol, fatty acids and lecithin. In the gallbladder,some of the water and electrolytes are absorbed, foodentering the intestine stimulates the gallbladder tocontract and release bile through the common bile duct
and sphincter of oddi in the intestine. The bile salts in thebile increases the solubility and absorption of dietaryfats.
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PATHOPHYSIOLOGY
RISK FACTORS
age
family history of gallstones
race
obesity, hyperlipidemia
rapid weight loss female gender
biliary stasis
diseases or conditions
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CHOLECYSTITIS- is the inflammation of thegallbladder.
Acute cholecystitis usually follows obstruction of thecystic duct by a stone. The obstruction increasespressure within the gallbladder leading to ischemia ofthe gallbladder wall and mucosa. Ischemia can lead tonecrosis and perforation of the gallbladder.
biliary colic- pain involves the entire RUQ and may
radiate to the backright scapula or shoulder. movement or deep breathing may aggravate the pain
last longer 12- 18 hours
anorexia, nausea and vomiting are common
fever with chills
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chronic cholecystitis result from repeated
bouts of acute cholecystitis or from persistent
irritation of the gallbladder wall by the stones.
bacteria may be present
asymptomatic
complications include empyema a collection ofinfected fluid in the gallbladder, gangrene and
perforation with resulting peritonitis or abscess
formation
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Diagnostic Tests
serum bilirubin elevated direct bilirubin mayindicate obstructed bile flow in the biliary duct
CBC- elevated may indicate infection and
inflammation abdominal x-ray gall stones with a high
calcium content
serum amylase and lipase- possible
pancreatitis related to common duct obstruction UTZ of the gallbladder- accurately diagnose
cholethiasis
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medications
ursodiol( actigall) and chenodiol (chenix)- reduce the cholesterol content ofgall stones, leading to gradual dissolution
side effects diarrhea and hepatotoxic
disadvantages long duration ( 2 years ormore) and a high incidence of recurrent
stone formation when treatment isdiscontinued.
antibiotics
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treatment
laparoscopic cholecystectomy ( removal
of the gallbladder)
cholecystostomy drain the gallbladder
choledochostomy- remove stones and
position a T tube in the common bile duct
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dietary management
food may be eliminated during an acute attack NGT is inserted to relieve nausea and vomiting
dietary fat intake may be limited
Shock wave lithotripsy
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Nursing diagnoses and Interventions
pain
Discuss the relationship between fat intake and the
pain- fat entering the duodenum initiates gallbladder
contractions causing pain when gallstones are presentin the ducts
withhold oral food and fluid during episodes of acute
pain
administer analgesic or narcotic analgesia morphine
causes spasm of the colon place in fowlers position
monitor vs including temp.
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imbalanced nutrition : less than body requirements assess nutritional status
evaluate laboratory results refer to dietician or nutritionist
risk for infection monitor vs including temp
assess abdomen every 4 hours
assist to cough and deep breath or use of spirometer, splintabdominal incision with blanket or pillow while coughing
place in fowlers position and encourage ambulation
administer antibiotics
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PANCREATITIS
inflammation of the pancreas, that
involves self- destruction of the pancreas
by its own enzymes through autodigestion.
characterized by release of pancreatic
enzymes into the tissue of the pancreas
itself leading to hemorrhage and necrosis.
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interstitial edematous pancreatitis- leads
to inflammation and edema of pancreatictissue.
necrotizing pancreatitis inflammation ,
hemorrhage and ultimately necrosis of
pancreatic tissue.
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PATHOPHYSIOLOGY
MANIFESTATIONS
ACUTEAbrupt onset of severe epigastric pain and LUQ pain, may radiate to
back
nausea and vomiting, fever
decrease bowel sounds, abdominal distention, rigidity
tachycardia, hypotension,cold clammy skin
possible jaundice CHRONIC
recurrent epigastric and LUQ pain, radiates to the back
anorexia, nausea, vomiting, weight loss
Flatulence, constipation
steatorrhea
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Diagnostic Tests
UTZ can identify gallstones, pancreatic mass,pseudocyst( abnormal collection of fluid, deadtissue, pancreatic enzymes and blood that canlead to a painful mass in the pancreas)
CT scan identify pancreatic enlargement, fluidcollections
Endoscopic retrogradecholangiopancreatography ERCP perform todiagnose chronic pancreatitis
endoscopic UTZ
percutaneous fine needle aspiration biopsy-differentiate from cancer
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medications narcotic analgesics
antibiotics
H2 blocker and proton pump inhibitor to neutralize or decrease gastric
secretions
synthetic hormone- octreotide(
sandostatin) suppresses pancreatic
secretion and may relieve pain
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fluid and dietary management
oral food and fluids are withheld duringacute episodes
NGT may be inserted
IVF , TPN
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surgery
endoscopic transduodenalsphincterotomy- performed if the result of
a gallstone lodge in the sphincter of oddi
to remove the stone
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nursing diagnoses and interventions
pain obstruction of pancreatic ducts and inflammation ,
edema and swelling of the pancreas caused bypancreatic autodigestion, severe epigastric pain, leftupper abdominal or midscapular back pain. Nausea andvomiting assess pain using the pain scale, location,radiation,
duration, and character NPO and maintain the patency of NGT- gastric
secretions stimulate hormones that stimulate pancreaticsecretion , aggravating pain. NGT decreases nausea,vomiting, and intestinal distention.
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maintain on bed rest
assist on comfortable position
Imbalanced nutrition: less than body requirements
monitor laboratory values
weigh daily
maintain stool charting
monitor bowel sounds return of bowel soundsindicates return of peristalsis
administer prescribed IVF to maintain hydration, TPN toprovide fluids, electrolytes and kilocalories
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