UNIT V EXAM STUDY GUIDE

BE FAMILIAR WITH THE ANATOMY AND PHYSIOLOGY OF THE DIGESTIVE TRACT. 1. Mouth 2. Esophagus 3. Stomach 4. Pyloric sphincter 5. Small intestine a. duodenum b. jejunum c. ileum 6. Cecum 7. Large intestine a. ascending b. transverse c. descending d. sigmoid colons 8. Rectum 9. Anus 10. Ancillary organs a. appendix b. liver c. gall bladder d. pancreas pH of gastric normal range is 3.5 to 8.

EXPLAIN HOW TO PERFORM AN ASSESSMENT OF THE GI TRACT. During interview: P: provocative questions: what causes it? what makes it better? ect. Q: quality/ quality R: region S: Severity T: Timing. when does it begin, how long does it last? ect. 1. Inspection a. Tongue b. Buccal Mucosa c. Pharynx d. Abdomen 2. Auscultation. normal: sound every 5 - 30 seconds. hypoactive: sound every 1 - 2 minutes. hyperactive: 5 or 6 sounds or more every 30 seconds. four quadrants: RUQ include: right lobe of liver, gallblader, right kidney, small/large intestine LUQ include: left lobe of liver, stomach, pancrease, left kidney, spleen, small/intestines RLQ include: cecum, appendix, small/large intestines, reproductive organs LLQ include: most of small intestine, portions of large, left ureter, reproductive organs 3. Palpation (palpate tender area last) a. shallow b. deep. (rebound tenderness: when letting go of palpation causes pain, common in appendicitis)

4. Percussion of abdomen a. four quadrants b. tone: dullness: over organ. tympanic: over air filled area. bloody stool: occult blood. Could be caused by iron, pepto, medications, spinach, blueberries clay/grey color: liver failure coffee ground vomit: has been in contact with blood in stomach. EXPLAIN THE PURPOSE OF PRE-AND POST-TEST NURSING CARE FOR DIAGNOSTIC TESTS OF THE GI TRACT, FROM EGD TO COLONOSCOPIES, TO MRI/CT, MRCP/ERCP. Type of Blood test Aspartate aminotransferase (AST) Alanine aminotransferase Alkaline phosphatase (ALP) Amylase Lipase Total bilirubin Normal values 5 - 40 units/L 8 - 20 units/L or 3 - 35 IU/L 42 - 128 units/L, 30 - 85 IU/L 56 - 90 IU/L 0 - 110 units/L 0 - 1.0 mg/dl Reason why test may be elevated hepatitis or cirrhosis hepatitis or cirrhosis Liver damage Pancreatitis Pancreatitis Altered liver functioning, bile duct obstruction, hepatobiliary disorder Altered liver functioning, bile duct obstruction, hepatobiliary disorder Altered liver functioning, bile duct obstruction, hepatobiliary disorder Decrease may indicate hepatic disorder Liver Cancer Liver disease

Direct (conjugated) bilirubin

0.1 - 0.3 mg/dl

Indirect (unconjugated) bilirubin

0.1 - 1.0 mg/dl

Albumin Alpha -fetoprotein Ammonia

3.5 - 5.0 g/dl less than 40 mcg/L 15 - 110 mg/dl

Urine Bilirubin: positive finding indicated possible liver disorder (cirrhosis, hepatitis) or biliary obstruction Endoscopy: allows direct visualization of body cavities, tissues, organs through a flexible, lighted tube, Contrast medium used to allow visualization (see chart below) 1. Colonoscopy: visualization of anus, rectum, colon (sigmoid, descending, transverse, ascending) 2. Esophagogastroduodenoscopy: visualization of orpharynx, esophagus, stomach, duodenum 3. Endoscopic retrograde cholangiopancreatography: visualization of liver, gallbladder, bile ducts 4. Sigmoidoscopy: visualization of anus, rectum, sigmoid colon

Procedure Colonoscopy

Anesthesia Moderate sedation: midazolam (Versed) with opiate analgesic

Preparation bowel prep: laxatives such as dulcolax, clear liquid diet, NPO after midnight

Positioning Left side with knees to chest

Postprocedure Monitor for bleeding, encourage fluids, increased flatulence is normal due to increased air respiratory status, without fluids until return of gag reflex Respiratory status, without fluids until gag reflex is restored Bleeding encourage fluids, increased flatulence

EGD

Moderate sedation: topical anesthetic conscious sedation: topical anesthetic None

NPO 6 - 12 hours

left side lying

ERCP

NPO 6 - 8 hours

Semi Prone, repositioning throughout procedure On left side

Sigmoidoscopy

Laxatives such as dulcolax, clear liquid died, NPO after midnight

GI series: radiographic studies done with or without contrast that help define anatomic or functional abnormalities. 1. Upper GI: patient drinks radiopaque liquid a. clear liquid, low residue diet, NPO after midnight, avoid chewing gum or smoking due to increased peristalsis. 2. Lower GI: barium enema is done by instilling radiopaque liquid into patients rectum and colon Nursing actions: a. bowel prep: laxatives and enemas for lower GI, clear diet day before, NPO after midnight c. Barium enema scheduled before upper GI d. possible stool softeners post op due to constipation from barium Abdominal Ultrasound: noninvasive, can be done at bed side, images can be compromised due to increased abdominal fat MRI: NPO 6 hours before test, consider claustrophobia, with or without contrast CT: combines xrays with computers to produce cross sectional images, with or without contrast

4.

RELATE KNOWLEDGE OF THE GI, LIVER, DIVERTICULITIS, GALLBLADDER DISORDERS , HEMORRHIODS, FISTULAS/FISSURES AND OBESITY GIVEN IN THE SYLLABUS/CLASS. 1. GERD: characterized by gastric content leaking into esophagus a. primary treatement is diet and and lifestyle changes and antacids, H2 receptor antagonists, proton pump inhibitors. b. Risk factors: obesity, older age, sleep apnea, NG tube, c. EGD, 24 hour ambulatory pH monitoring, Barium swallow can diagnose 2. Esophageal Varices: swollen, fragile blood vessels in esophagus resulting from liver damage a. risk factors: portal hypertension, alcohol cirrhosis, viral hepatitis b. Medications: betablockers, vasoconstrictors (vasopessin) c. procedures: -endoscopic injection or varical band ligation,

-transjugular intrahepatic portal systemic shunt (relieves portal hypertension) -esophagogastric ballon tamponade 3. Esophageal Cancer: fast growing metastasizing type of cancer a. risk factors: smoking, alcohol abuse, nitrites, GERD, Barretts esophagus b. Procedures for diagnoses : barium swallow, EGD, CT or PET, Esophageal ultrasound c. Medications: chemotherapy, Angiogenesis inhibitors, tyrosine kinase inhibitors d. procedures for treatment: radiation, photodynamic therapy (injection of agent that remains in cancer cells, shrinking them.), esophagectomy/ esophagogastrostomy 4. Peptic Ulcer disease: erosion of the mucosal lining of the stomach or duodenum, mucous membranes can become eroded to the point where epithelium is exposed to gastric acid and pepsin a. risk factors: H. pylori infection, NSAID use, stress, hypersecretory states, type O blood, alcohol ingestion, pulmonary/renal disease\ b. procedures for diagnoses: H. pylori testing, hemoglobin/ hematocrit, stool sample for occult blood, EGD c. Medications: antibiotics, H2 receptor antagonists, Proton pump inhibitors, antacids, mucosal protectants d. procedures for treatment: gastric surgery (gastrectomy, antrectomy, gastrojejunostomy, vagotomy, pyloroplasty) 5. Acute and chronic gastritis: inflammation in the lining of the stomach, a result from irritation to the stomach mucosa a. risk factors: bacterial infection, family history, excessive alcohol use, bile reflux disease, autoimmune diseases, advanced age, smoking, caffeine, excessive stress b. procedures for diagnoses: CBC to check for anemia, serum/stool antibody test, upper endoscopy c. Medications: H2 antagonists, antacids, proton pump inhibitors, prostaglandins, mucosal barriers, antibiotics d. procedures for treatment: vagotomy (in order to decrease gastric acid), pyloroplasty(to increase gastric emptying 6. Appendicitis: the projected portion of the appendix becomes trapped with hard material that leads to bacterial infection, most common reason for emergency abdominal surgery, rebound tenderness occurs in right lower quadrant a. risk factors: often in people between 10 and 30, rare among older adults b. procedures for diagnoses: WBC count elevation, ultrasound of abdomen may show enlarged appendix, CT may show fecal material in appendix, c. procedures for treatment: appendectomy 7. Intestinal obstruction: can result from mechanical or nonmechanical causes, usually requires surgery. Higher level obstructino have colicky intermittent pain with vomiting. Lower level obstructions have vague, diffused pain with distention a. risk factors: intesting adhesions, tumors, fibrosis, crohns disease, twisting of bowel segments, hernia, fecal impactions b. procedures for diagnoses: labs may reveal dehydration, metabolic alkalosis with high obstruction (due to vomiting), metabolic acidosis with low obstruction (due to alkaline fluids not reabsorbed) X-ray, endoscopy, CT c. Nonmechanical: nothing by mouth with bowel rest, ambulation d. mechanical: surgery e. procedures for treatment: NG tube to decompress bowel, exploratory laparotomy 8. Ulcerative colitis: edema and inflammation of the rectum, usually begins in the rectum and distal colon involving the mucosa and submucosa a. bowel obstruction may occur, mucosal cell changes may cause colon cancer, poor absorption of B12 leads to pernicious anemia 9. Crohns disease: inflammation and ulceration of GI tract, fistulas are common a. can involve the entire GI tract b. malaborption and malnutrition may develop when jejunum and ileum are involved, B12 injections may be necessary 10. Diverticulitis: inflammation of diverticula, hernia in intestinal wall a. only about 10 percent of patient who have diverticula develop diverticulitis 11. Irritable bowel syndrome: disorder of GI system, differs from ulcerative colitis and Crohns disease in that it

does not cause structural damage to tract and does NOT involve inflammatory process. a. risk factors: female, stress, eating large meals with large amounts of fat, caffeine, alcohol b. procedures for diagnosis: CBC, serum albumin, erythrocyte sedimentation rate, occult stools, difficult to diagnose with specific test, diagnoses typically made with symptoms: change in bowel patterns, abdominal distension, mucus in stools. c. Medications: Lotronex (blocks receptors that innervate viscera), IBS specific drug, indicated for IBS in women that has last more than 6 months that is resistant to conventional management. Amititiza: IBS med that is used for IBS with constipation 12. Cholecystitis: inflammation of gallbladder wall. Cholelithiasis: presence of stones in gall bladder. a. risk factors: females, high fat diet, obesity, genetic predisposition, older than 60, DM1, low calorie liquid protein diets, rapid weight loss. b. symptoms: right upper quadrant pain, radiating to right shoulder, rebound tenderness, pain with deep inspiration c. procedure for diagnosis: elevations in WBC, serum bilirubin, amylase, lipase, and other liver enzymes. Right upper quadrant ultrasound, xray, CT, heptobiliary scan to assess patency of biliary duct system, ERCP d. Medications: Demerol, Dilaudid for pain, anticholinergics to decrease ductal tone and biliary spasms, Bile acid to dissolve gall stones e. procedures for treatment: extracorporeal shock wave lithotripsy (break up gall stones), cholecystectomy