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Lemone and Burke Chapters 21,23-25

ATI – M/S Unit 7

Objectives� Review A&P

� Identify diagnostic exams

� Discuss etiology, pathophysiology, clinical manifestation, and collaborative management of:

� PUD

� Hernias

� Cholecystitis and cholelithiasis

GI - A & P Review� Mouth

� Pharynx

� Esophagus

� Stomach

� Small Intestines

� Large Intestines

� Liver and Gallbladder

� Pancreas

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Peptic Ulcer Disease (PUD)�Objectives:� Identify different types

� Gastric Ulcer

� Duodenal Ulcer

� Stress Ulcer

� Etiology and pathophysiology

� Clinical manifestation

� Collaborative management

� Nursing diagnosis

PUD

� Breakdown mucous lining in GI tract

� Duodenal ulcers

� Gastric ulcers

PUD Etiology and Patho� Pathophysiology

� Gastric mucosa protects epithelium

� Bicarbonates

� Adequate blood supply

� Risk factors

� H. pylori infections, NSAID, Age,

� Hx of ulcers, family hx of ulcers

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PUD Manifestation� Pain

� Gnawing, burning, aching

� Epigastric region – radiates to back

� Dyspepsia

� Weight loss

� Anemia

PUD Complications� Hemorrhage

� Hematemesis, blood in stool

� Fatigue, weakness, dizziness

� Orthostatic hypotension

� Hypovolemic shock

� Narrowing and obstruction (pyloric)� Epigastric fullness

� N/V - Electrolyte imbalance, metabolic alkalosis

� Perforation� Severe pain

� Rigid abdomen

� No bowel sounds

� Peritonitis

PUD Diagnosis� EGD

� Visualize erosion

� Take biopsies

� UGI series

� Lab tests

� IgG

� Urea breath test

� Fecal test

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PUD - Collaborative Management� H & P

� Medication

� PPI

� H2 receptor blocker

� Antacids

� Antibiotics

� Nutrition

� Surgery

� Tx of complications

PUD surgeries

� Pyloriplasty Billroth I

PUD surgeries

� Antrectomy

� Removal of lower third of stomach

� Vagotomy

� Resection of the vagus nerve –reduce acid secretion

� Gastrectomy

� Removal of part or all of stomach

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PUD – Nursing Diagnosis� Acute Pain

� Imbalanced nutrition < body requirement

� Fluid volume deficit

� Disturbed sleep pattern

Hernias�Objectives:� Identify different types

� Hiatal

� Umbilical

� Femoral

� Ventral/incisional

� Direct/indirect inguinal

� Identify etiology and pathophysiology, clinical manifestation, and complications

� Discuss collaborative management

� Discuss nursing diagnosis and interventions

Hiatal Hernia� Stomach protrudes

through esophageal hiatus into thoracic cavity

� Usually asymptomatic

� Incidence increased w age

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Sliding Hiatal Hernia� Gastroesophageal

junction and fundus of stomach slide upward into esophageal hiatus

� Symptoms:

� Dysphagia

� Chest pain

� Heartburn

� Belching

� Regurgitation

Paraesophageal Hiatal Hernia

� Fundus and possibly portions of the stomach’s greater curvature, rolls through the esophageal hiatus and into the thorax beside the esophagus

A Comparison of the normal stomach, sliding hiatal

hernia and rolling hiatal hernia

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Hiatal Hernia - Diagnosis� Barium Swallow

� CXR

� Endoscopy with biopsy

� CBC

� Stool for guaiac

Hiatal Hernia - Medical Treatment� Goals

� Aimed at relieving symptoms and prevent complications

� Bleeding

� Sliding hiatal hernia treatment medically,

� Large paraesophageal hernia treatment - surgery

� Reduce regurgitation of stomach contents into esophagus

� Medications

� Includes antacids, PPI, and histamine receptor antagonists (Protonix, Pepcid and Reglan)

� Neutralizes stomach acidity

� Decrease acid production

� Indirect inguinal

� Direct inguinal

� Femoral

� Umbilical

� Incisional

Types of Abdominal Hernias

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� Peritoneal sac w intestine or omentum pushes down into inguinal canal

� Affect males

� May descend into the scrotum

� S/S: pain with straining

� Soft swelling increases w intra-abdominal pressure, may decrease when lying down

Indirect Inguinal Hernia

� In contrast, this type of hernia passes through a weak point in the abdominal wall

� Rarely enters the scrotum

� Most common in men older than 40; rare in women

� S/S: usually painless, round swelling close to pubis, which is easily reduced when supine

Direct Inguinal Hernia

� Protrusion of bowel into umbilical ring

� Most common in women

� Congenital� Infancy

� Acquired� Obesity

� Multiple pregnancies

� Ascities

� Large tumors

Umbilical Hernia

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Incisional or ventral Hernias� Occur at previous surgical incision

� Results from inadequate healing of incision

� Bulge at incision

� Risk of incarceration is low

� Contributing factors:

� Poor wound closure

� Age

� Obesity

� Poor nutrition

� Protrude through the femoral ring

� More common in women than men

� S/S: lump in groin; severe pain, may become strangulated

Femoral Hernia

Types of Hernias

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Hernia –

Collaborative Management� Diagnosis

� H & P

� Surgical repair

� herniorrhaphy

� Nursing interventions

� H & P

� Post – op care� Assess incisions

� Bowel sounds

� Encourage TCDB + I/S

� Teaching� Muscle strengthen

exercise

� Good body mechanics

Hernia – Nursing Diagnosis� Acute Pain

� Risk of ineffective tissue perfusion - gastrointestinal

� Knowledge deficit

Gallbladder Disorders�Objectives:� Identify etiology, pathophysiology, and clinical

manifestations of:

� Cholelithiasis

� Cholecystitis

� Discuss nursing care and interventions of these diseases

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Function on Biliary System� Create, store, transport,

and release bile into the duodenum to aid in digestion

� Liver,

� Gallbladder,

� Bile ducts

Cholelithiasis� Most common problem within biliary duct system

� Risk factors:

� Age

� Family history

� Race/ethnicity

� Obesity/hyperlipidemia

� Rapid weight loss

� Female

� Biliary stasis

Cholelithiasis - patho� Gallstones

� Abnormal bile composition

� Biliary stasis

� Increased cholesterol

� inflammation

� Manifestation

� Mild distress

� Biliary colic w obstruction

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Cholecystitis - Manifestations� Acute or chronic disorder resulting in distention and

inflammation of gallbladder

� Most often in association with cholelithiasis (gallstones) obstructing the cystic duct

� Obstruction can lead to ischemia of gallbladder wall and mucosa

� Can lead to necrosis

� Pain

� RUQ, may radiate to back and right shoulder

� Chronic disorder results from repeated bouts of acute disease

Cholecystitis - Diagnosis� LFT

� BMP

� CBC

� Serum bilirubin

� Serum lipase and amylase if pancreas involved

� Ultrasound of right upper quadrant

� Abdominal x-ray

� HIDA SCAN

Cholecystitis – Nursing Care� H & P

� Diagnostic tests

� Pain management

� Teaching

� Nutrition

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Cholecystitis - Interventions� Non surgical management

�Asymptomatic, manage conservatively

�Low fat diet

�Medication – ursodiol or chenodiol

�Acute pain - gallstones obstruct cystic or common bile duct

�Opioid analgesia (Demerol, as morphine can cause biliary spasm)

�Anti-emetics to control nausea and vomiting

�Anti-spasmodics to relax smooth muscle (Bentyl, Lomine)

�NPO, IV fluids, IV ANTIBIOTICS

�No surgery until acute infection is resolved

Cholecytitis –

Surgical Management� Laparoscopic

cholecystectomy: � Minimally invasive

� Usually home within 24 hours

� Most common complication

� Injury to bile duct

� “Free air pain” from carbon dioxide retention

� May settle on phrenic nerve and cause shoulder pain

Cholecystitis – surgical

Management (cont)

� Traditional cholecystectoy

� Removes gallbladder and stones

� 4-6 inch incision made into the abdomen

� Usually home in 1-3 days

� Back to work in 4-6 weeks

� May have t-tube placed for drainage of bile

� (If common bile duct is explored)

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Cholecystectomy

Cholecystectomy:

Pre-op Nursing Diagnosis

� Acute pain

� Alteration in bowel elimination

� Alteration in comfort

� Alteration in nutrition

� Fluid volume deficit

� Self-care deficit

� Risk for injury

Cholecystectomy

Pre-op nursing interventions� Patient teaching

� Make sure there is order for consent and it is signed by patient or family (informed)

� Make patient comfortable

� IV - Hydration

� NPO

� Lab work done and in chart

� Pre-op check list completed

� Teaching

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Post-op nursing interventions

� Prevent pulmonary complications: TCDB, I/S w splinting

� Prevent pain, PCA � Care for the incision, surgical drain � NPO - clear liquids - advances to regular as tolerated� Monitor bowel sounds, watch for post-op ileus� Monitor urinary output� Prevent DVT’s, early ambulation is best

Cholecystectomy :

Post-op Nursing Diagnosis

� Acute pain

� Knowledge deficit

� Activity intolerance

� Ineffective breathing pattern

� Risk for infection

� Risk for injury

� Alteration in nutrition

Case Studies� 35 y/o nursing student, working PT, heart burn for

years and takes Prilosec for after dx – dudenal ulcer. Now weak, lightheaded, pale admitted for r/o UGIB

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Case Studies� Juanita, 49 y/o married mother with 3 children, native

of Yucatan region of Mexico works as a checker at a local supermarket.

� Recently she started to notice a dull pain over her upper abdomen after meals – especially on Sundays when all her children come to visit with their families