Gastrointestinal Part 3

Gastrointestinal Pancreatitis Causes: obstruction of pancreatic ducts (gallstones, infections), alcoholism, drug toxicity (cyclosporine, steroids, thiazides, tetracyclines), trauma *auto-digestion of the pancreas- pancreas eats itself, the pancreas is fatty, needs calcium → uses up calcium to eat itself so pts with pancreatitis have hypocalcemia, also doesn't have the time to put out the right amount of insulin pts also get HHNK -when pancreas is eating itself, lifts the diaphragm up → left sided atelectasis, left sided pleaural effusions (left sided lung mess), BILATERAL rales (sympathetic rales → right side feels bad for the left and gets rales too) -complications of pancreatitis = HHNK, hypocalcemia, bilateral rales, left lung affected, ARDS -bleeding → Cullen's sign = black and blue umbilicus (belly button) Grey-Turner's sign = black and blue flank and groin ex. what is the electrolyte abnormality found in people with pancreatitis? Hypocalcemia (NOT hyperglycemia because glucose is NOT an electrolyte), but people with pancreatitis are very hyperglycemic *ARDS is the most common cause of death resulting from pancreatitis! -pancreas releases an enzyme phospholipase A → travels to lungs and kills type 2 alveolar cells that make surfactant, alveoli cannot open, no gas exchange → ARDS -elevated amylase levels **NO morphine because causes sphincter of odi to spasm (give demerol instead) Bowel Obstruction Large bowel = large distention -nothing is coming out! Small bowel = small distention, diarrhea, vomiting -small distention because everything is coming up and out! *I'll take the large bowel! Liver Kupper cells- detoxify blood Makes Bile Synthesizes amino acids makes albumin, prothrombin and fibrinogen (clotting) → people with liver disease don't clot well (bleed easily), people with liver disease have low albumin levels so they get ascites -blood drains from the esophagus and stomach, spleen, intestines and goes to liver to be detoxified -1500 cc goes to liver each minute to detoxify -if liver is diseased, unable to accept blood coming in → back pressure of blood to esophagus causes varices, back pressure to stomach causes gastritis, back pressure to spleen causes splenomegaly, back flow to intestines causes hemorrhoids → it doesn't pay to drink! -Liver converts glycogen to glucose -Liver converts ammonia into urea -if your liver doesn't work, you can't detoxify blood, can't clot, hypoglycemic because can't convert glycogen into glucose, high ammonia levels → hepatic encephalopathy **NEVER WANT ANYONE WITH LIVER DISEASE TO HAVE A LOW K LEVEL -when you have a low K, your kidneys hold on to K → when kidneys hold on to K, they hold on to ammonia → puts you into a worse state of liver disease **always give aldactone = K sparing diuretic **NO lasix! Because decreases K **NEVER want anyone with liver disease to become dehydrated (have a high BUN/Cr), never want them to have a high fever *NO protein → NO food OR blood! -blood is a protein (difficult if they have a GI bleed because they need blood- but blood is a protein and breaks down which increases ammonia which worsens their condition and eventually causes hepatic encephalopathy) *DO NOT want them to have high acids (ex. Prevent hypotension because do not want them to develop lactic acidosis), never give ringer's lactate (LR) because lactate converts into bicarb by liver -LR is converted to bicarb by a healthy liver, but a diseased liver is unable to convert it to bicarb so it stays in your body as lactate, which kidneys convert to lactic acid → hepatic encephalopathy *Causes of hepatic encephalopathy: things that increase ammonia level (low K, increased BUN/dehydration, increased protein, increased acids) ex. think of the story with the post-op pt getting LR for 5 days in a coma (it wasn't anesthesia, it was the LR!), as soon as they switched LR to NS, clinical picture improved and mental status improved → very high ammonia level when labs drawn (480) → tx. Lactulose – loose stools *Complication of Neomycin therapy?? stays in the gut, affects gut bacteria, bacteria in the bowels make vitamins like folic acid and riboflavin, synthesizes vitamin K → neomycin stays in the bowel and kills all the bacteria -bacteria normally make vitamins which produce ammonia → hepatic encephalopathy -so give neomycin to people with liver disease because it kills the bacteria that make the vitamins so that they don't get hepatic encephalopathy -NOT ototoxicity, or nephrotoxicity -SO a complication of neomycin therapy is??? VITAMIN DEFICIENCY! Bowel Sounds 5-34 rumbles per minute Listen in each quadrant for 5 minutes (20 minutes total) Jaundice Your patient is jaundiced... is it hepatic (liver) failure or gallbladder disease (biliary tract disease)? -jaundice is either a problem with liver or gallbladder -bilirubin and albumin are unconjugated through blood (indirect, not married), when they get to the liver they become conjugated (married), once conjugated, go to the gallbladder to live happily ever after -so, if high levels of indirect, or unconjugated bilirubin → problem is liver (hepatic disease) -if high levels of direct, or conjugated → problem is gallbladder (gallbladder/biliary tract disease) Ruptured Spleen -abdominal trauma, 55% of people have left shoulder pain (Kehr's sign) -often misdiagnosed, especially if multiple trauma -can look like cardiac due to shoulder pain and hypovolemia -lady in ER with RBBB (V1, MCL 1, not V2) and tachy at 150, BP 70, diaphoretic, no UOP, tachypneac → can be misdiagnosed as MI or cardiogenic shock, but was splenic rupture (fell off the stairs and hit the bannister), so these VS changes were a result of hypovolemic shock -when you have a LBBB, can't see an MI, but can see one when you have a RBBB -MI and cardiogenic shock → pulmonary edema -inferior wall MI infarct = clear lungs Practice Questions 1) In order to most accurately establish that your patient has no bowel sounds, you must listen to each quadrant for at least: -2-5 minutes 2) The usual order for carrying out physical assessment of the abdomen is: -Inspection, auscultation, percussion, palpation 3) The function of the liver includes all of the following except: -Formation of ammonia to remove urea from the blood (liver makes urea to get rid of ammonia) 4) Nursing interventions for the patient with hepatic failure include: -Restrict protein in the diet, avoid narcotics, sedatives and tranquilizers, administer lactulose and neomycin as prescribed 5) The underlying cause of most bleeding esophageal varices is: -portal hypertension due to liver disease 6) The rationale for the use of neomycin in the setting of liver failure is to: -Inhibit the production of ammonia by intestinal bacteria 7) The administration of vasopressin should be most carefully monitored in patients who have: -coronary artery disease (because it is a vasopressor and water hormone) 8) Urea is formed by the liver to rid the body of: -Ammonia 9) The inability of the liver to conjugate what substance is a primary contributor to hepatic coma? -Ammonia (ammonia gives you hepatic coma), not bilirubin (that causes jaundice, not coma) 10) Which of the following may precipitate the onset of hepatic encephalopathy in patients with severe liver dysfunction? -Diuretics (low K- kidneys hold on to ammonia), acute infection (raises BUN which causes increased ammonia), GI bleeding (blood in GI tract breaking down is a protein and causes increased ammonia) 11) Which of the following may contribute to the preciptation of encephalopathy in the patient with liver failure? -GI bleeding (blood = protein), hypokalemia (low K- kidneys hold on to K and ammonia), hypotension (build up of lactic acid causes hepatic encephalopathy) 12) Ecchymosis around the umbilicus indicative of peritoneal bleeding is called: -Cullen's sign FYI: Chvostek = cheek twitching, hypocalcemia Trousseau's sign = hypocalcemia, inflate BP cuff 13) Pulmonary complications of acute pancreatitis may include: -ARDS, elevation of diaphragm and bilateral basilar rales, atelectasis (especially left base) 14) A bluish-green, brown discoloration in the flank and groin due to retroperitoneal bleeding is called: -Grey-Turners sign 15) Patient assessment findings indicative of a bowel infarction would include: -Hypoactive bowel sounds and leukocytosis, hyperresonance and abdominal tenderness, absense of dullness in the liver area