Nursing Lectures, #1 Free Online Nursing Topics Website: March 2009

Nursing Lecture about the Endocrine System: Altered Metabolic Function

Altered Metabolic Function

- Lack (<) Endocrine Gland Over (>)
- Pineal –behind lateral ventricles
- Diabetes Insipidus Pituitary - SIADH
- Hypothyroidism Thyroid - Hyperthyroidism
- pedia: Cretinism Basedow’s/Parry’s
- adult: Myxedema Coma Grave’s Disease
- Hypoparathyroidism Parathyroid - Hyperparathyroidism
- Thymus
- DM Pancreas
- Addison’s Disease Adrenals - Cushing’s/Conn’s
- Gonads (testes / ovaries)
- Interaction of endocrine system with aging are inconclusive, however, changes in endocrine glands & target organs occur
- Loss of self-regulation (autoimmune or immunodeficiency disorders)
- Target organs lose ability to respond to hormones
- Hypothalamus & pituitary functions may be altered by changes in neurotransmitter levels
- Wear out of body structures in time are no longer able to adapt to stressors (theory of stress adaptation)
- Inspection:
- Palpation:
- Auscultation
- Vital signs & history taking
- “ diabetes” – going through; “mellitus” – honey/sweet
- Metabolic disorder characterized by glucose intolerance resulting from an imbalance between insulin supply & demand
- Involves β -cells if Islet of Langerhans (pancreas) – source of insulin
- Insulin Functions:
- Types:
- Type I
- Juvenile onset
- Abrupt onset
- Little or no insulin produced
- within ideal body weight / thin
- Tx:
- Type II
- Maturity onset
- Insidious onset
- Below normal or normal insulin production (but high demand for it)
- 80% of clients are obese
- Tx:
Genetic predisposition Environmental agents inciting an immune response Autoimmune destruction of β cells Insulin resistance Inability of pancreas to release insulin ↓ glucose utilization Stimulates insulin secretion initially Increased insulin demand Fat & protein mobilization Blood glucose accumulation Uncontrolled increased in blood sugar Diabetes mellitus ↓ insulin response due to exhaustion
- Hyperglycemia – increased blood sugar levels (normal = 80-120mg/dL)
- Glycosuria – (+) glucose in urine
- Polyuria – excessive urination
- Polydypsia – excessive thirst
- Polyphagia – excessive hunger
- Weight loss despite normal or increased appetite (type I)
- Blurring of vision
- Fatigue / weakness
- Skin infections
- Pruritus (candidal infections common among women)
- Blood Tests
- priority = correct deficiency
- D iet: 50-60%CHO, 10-20%CHON, 20-30%fats (unsaturated)
- I nsulin
- A nti-diabetic agents
- B lood sugar monitoring
- E xercise
- T ransplant of pancreas (if indicated)
- I nsure adequate food intake
- S crupulous foot care – cut toenails straight
- - do not use sandpaper or stones
- - socks = cotton
- - shoes = snugly
- - water = tepid
- - foot powder
- - dry between toes (after bath)
- - do not walk on barefoot
- Oral Hypoglycemic agents – for type II only
- Insulin – must be stored in cold (not freezing) temp
- Preparation Onset Duration Peak Route
- Subcutaneous injections are absorbed fastest at the abdomen
- Watch out for signs of hypoglycemia – cold, clammy skin & diaphoresis
- Lipodystrophy – loss of fatty tissues
- Diabetic Ketoacidosis (DKA) – liver ketone production exceeds cellular use & renal excretion
- Function – synthesis of thyroxin (T4) and triiodothyronine (T3)
- Bound to thyroid hormone-binding globulin (TBG) for transport in blood
- T3 = triiodothyronine (active form)
- T4 = thyroxin (needs to be converted to T3 before manifestation of physiologic action)
- Secretion is regulated by hypothalamic-pituitary-thyroid feedback (release of thyroid stimulating hormones –TSH)
- RDA of iodine is 40-50 mcg (infants), 70-120 mcg (children), and 150 mcg (adolescents and adults)
Sleep, cold temp, stress hypothalamus Thyroid-releasing hormone (TRH) Anterior pituitary (TSH) Thyroid gland (T3 & T4) Target organs Inhibition
- Basal Metabolic Rate – measures O 2 consumption of the body at a given time
- Thyroid Function Test – immunoassays measuring T 3 , T 4 , & TSH levels
- Thyroid scan – used to detect nodules & determine functional activity of thyroid glands
- CT Scan & MRI – used to demonstrate tracheal compression on neighboring structures
- too little thyroid hormone produced, when there is decreased conversion from T4 to T3 , or from Tx of hyperthyroidism
- Primary – intrinsic disorder in the thyroid gland
- Secondary – insufficient stimulation of thyroid hormone by TSH from anterior pituitary gland
- Tertiary – hypothalamus fails to produce TRH
- Dx: detailed Hx & physical assessment;
- Tx/Nursing Management: Replacement T3 or T4 therapy – FOR LIFE (caution use with MI, HPN, DM, pregnant & elderly)
- Myxedema Coma – life-threatening end stage expression of the disease
- Excessive delivery of thyroid hormones
- Common cause: Grave’s disease (autoimmune) & goiter
- Grave’s – abnormal stimulation of thyroid gland by thyroid stimulating antibodies
- Dx: increased serum T4
- Tx/ Nursing Management: Anti-thyroids = 2-3wks before effects are seen
- Thyroid storm/crisis – life-threatening
- Hypothyroidism
- Decreased BMR
- Myxedematous features
- Deep voice
- Impaired growth (child)
- ↑ cholesterol levels
- Behavior: mental & physical fatigability; mental retardation (infant)
- Bradycardia
- Decreased appetite
- Weight gain
- Cold intolerance
- Hyperthyroidism
- Increased BMR
- Exophthalmus
- Lid lag
- Fine hand tremors
- Decreased blinking
- ↓ cholesterol levels
- Behavior: restlessness, wakefulness, irritability, anxiety
- Tachycardia & palpitations
- Increased appetite
- Weight loss
- Heat intolerance
- Pre-op: achieve euthyroid state by Lugol’s solution & antithyroid drugs (2-3wks); rest
- Post-op Care:
- also called Radioiodine I-131 therapy
- for hyperthyroidism
- I-131(small dose) is swallowed, it is absorbed into the bloodstream in the GI tract and concentrated from the blood by the thyroid gland, where it begins destroying the gland’s cells
- client simply swallows a single dose (a prepared dose), in capsule or liquid form, and is quickly absorbed
- effect of this treatment on the thyroid gland usually takes between one and three months to develop, with maximum benefit occurring three to six months after treatment
- Nearly all the radioactive iodine leaves the body during the first two days following the treatment, primarily through the urine (Small amounts will also be excreted in saliva, sweat, tears, vaginal secretions, and feces)
- Client will be able to go home after treatment
- Clients who need to travel immediately after treatment are advised to carry a letter of explanation from physician
- Use private toilet facilities, if possible, and flush twice after each use.
- Bathe daily and wash hands frequently.
- Drink a normal amount of fluids.
- Use disposable eating utensils or wash your utensils separately from others.
- Sleep alone and avoid prolonged intimate contact.
- Avoid prolonged contacts esp. with pregnant women, infants, & children
- Launder your linens, towels, and clothes daily at home, separately.
- Do not prepare food for others that requires prolonged handling with bare hands.
- C/I: pregnancy (can damage the baby's thyroid gland)
- Pregnancy should be delayed until at least 6-12months after treatment (treatment exposes the ovaries to radiation)
- Women who have not yet reached menopause should fully discuss the use of I-131 with their physician.
- Inform client that it is highly likely that the entire thyroid gland will be destroyed with this procedure (most clients will need to take thyroid pills for the rest of their life following the procedure.
- There are essentially no other permanent side effects from the procedure
- Parathyroid hormone (PTH) - major regulator of serum calcium & phosphate
- Parathyroid gland –secretes the hormone
↓ serum Ca PTH Kidney- ↓ Ca Elimination & ↑ phosphate elimination ↑ serum Ca Intestine-↑ Ca absorption Bone-release of Ca Activated Vit.D
- Blood tests:
- Urine calcium & phosphate level determination (PO 4 -3 lost in urine is directly related to PO 4 -3 blood concentrations)
- Parathyroid hormone by radioimmunoassay
- Hypoparathyroidism Hyperparathyroidism
- Main Problem: - deficiency of Ca +2 in blood - excess Ca +2 in blood ↓Ca +2 in bones
- S/Sx: - Early = tingling - Recklin-Hensen’s Disease (↑Ca +2 in blood)
- = Chvostek’s sign - bone pain & destruction
- = Trousseau's sign
- Lab: - Ca +2 <>
- Mgt: - priority = Ca +2 - priority = safety
- replacement
- - diet: Broccoli - diet: ↓Ca +2
- Sardines - ↑oral fluids to prevent stone Spinach formation
- Tuna - strain urine
- Meds: - Fosamax - Paracalcitriol – suppress PTH
- Ca +2 gluconate IV (for acute)
- Adrenal glands – found retroperitoneally at the apex of kidneys
- Dx:
- CUSHING’S SYNDROME
- Overproduction of ACTH
- Cortisol
- Aldosterone
- Androgen (hirsutism)
- Mgt: correct electrolyte imbalance = priority
- ADDISON’S DISEASE
- Inadequate production of ACTH
- Cortisol:
- Aldosterone
- Androgen (lesser pubic hair)
- Mgt: correct electrolyte imbalance
- Addisonian Crisis – severe hypotension (coma & shock)

Nursing Care plan about Cholecystitis and Cholelithiasis

A comprehensive nursing care plan guide for Cholecystitis and Cholelithiasis

CHOLECYSTITIS WITH CHOLELITHIASIS
Cholecystitis is an acute or chronic inflammation of the gallbladder, usually associated with gallstone(s) impacted in the cystic duct, causing distension of the gallbladder.
Stones (calculi) are made up of cholesterol, calcium bilirubinate, or a mixture caused by changes in the bile composition. Gallstones can develop in the common bile duct, the cystic duct, hepatic duct, small bile duct, and pancreatic duct.
Crystals can also form in the submucosa of the gallbladder causing widespread inflammation. Acute cholecystitis with cholelithiasis is usually treated by surgery, although several other treatment methods (fragmentation and dissolution of stones) are now being used.
CARE SETTING Severe acute attacks may require brief hospitalization on a medical unit. This plan of care deals with the acutely ill, hospitalized patient.
RELATED CONCERNS Cholecystectomy Fluid and electrolyte imbalances,Psychosocial aspects of care Total nutritional support: parenteral/enteral feeding Patient Assessment Database
ACTIVITY/REST May report: Fatigue May exhibit: Restlessness
CIRCULATION May exhibit: Tachycardia, diaphoresis, lightheadedness
ELIMINATION May report: Change in color of urine and stools May exhibit: Abdominal distension Palpable mass in right upper quadrant (RUQ) Dark, concentrated urine Clay-colored stool, steatorrhea
FOOD/FLUID May report: Anorexia, nausea/vomiting Intolerance of fatty and “gas-forming” foods; recurrent regurgitation, heartburn, indigestion, flatulence, bloating (dyspepsia) Belching (eructation) May exhibit: Obesity; recent weight loss Normal to hypoactive bowel sounds
PAIN/DISCOMFORT May report: Severe epigastric and right upper abdominal pain, may radiate to mid-back, right shoulder/scapula, or to front of chest Midepigastric colicky pain associated with eating, especially after meals rich in fats Pain severe/ongoing, starting suddenly, sometimes at night, and usually peaking in 30 min, often increases with movement Recurring episodes of similar pain May exhibit: Rebound tenderness, muscle guarding, or abdominal rigidity when RUQ is palpated; positive Murphy’s sign
RESPIRATION
May exhibit: Increased respiratory rate Splinted respiration marked by short, shallow breathing
SAFETY May exhibit: Low-grade fever; high-grade fever and chills (septic complications) Jaundice, with dry, itching skin (pruritus) Bleeding tendencies (vitamin K deficiency) TEACHING/LEARNING May report: Familial tendency for gallstones Recent pregnancy/delivery; history of diabetes mellitus (DM), IBD, blood dyscrasias Discharge plan DRG projected mean length of inpatient stay: 4.3 days considerations: May require support with dietary changes/weight reduction Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES Biliary ultrasound: Reveals calculi, with gallbladder and/or bile duct distension (frequently the initial diagnostic procedure). Oral cholecystography (OCG): Preferred method of visualizing general appearance and function of gallbladder, including presence of filling defects, structural defects, and/or stone in ducts/biliary tree. Can be done IV (IVC) when nausea/vomiting prevent oral intake, when the gallbladder cannot be visualized during OCG, or when symptoms persist following cholecystectomy. IVC may also be done perioperatively to assess structure and function of ducts, detect remaining stones after lithotripsy or cholecystectomy, and/or to detect surgical complications. Dye can also be injected via T-tube drain postoperatively. Endoscopic retrograde cholangiopancreatography (ERCP): Visualizes biliary tree by cannulation of the common bile duct through the duodenum. Percutaneous transhepatic cholangiography (PTC): Fluoroscopic imaging distinguishes between gallbladder disease and cancer of the pancreas (when jaundice is present); supports the diagnosis of obstructive jaundice and reveals calculi in ducts. Cholecystograms (for chronic cholecystitis): Reveals stones in the biliary system. Note: Contraindicated in acute cholecystitis because patient is too ill to take the dye by mouth. Nonnuclear CT scan: May reveal gallbladder cysts, dilation of bile ducts, and distinguish between obstructive/nonobstructive jaundice. Hepatobiliary (HIDA, PIPIDA) scan: May be done to confirm diagnosis of cholecystitis, especially when barium studies are contraindicated. Scan may be combined with cholecystokinin injection to demonstrate abnormal gallbladder ejection. Abdominal x-ray films (multipositional): Radiopaque (calcified) gallstones present in 10%–15% of cases; calcification of the wall or enlargement of the gallbladder. Chest x-ray: Rule out respiratory causes of referred pain. CBC: Moderate leukocytosis (acute). Serum bilirubin and amylase: Elevated. Serum liver enzymes—AST; ALT; ALP; LDH: Slight elevation; alkaline phosphatase and 5-nucleotidase are markedly elevated in biliary obstruction. Prothrombin levels: Reduced when obstruction to the flow of bile into the intestine decreases absorption of vitamin K. NURSING PRIORITIES 1. Relieve pain and promote rest. 2. Maintain fluid and electrolyte balance. 3. Prevent complications. 4. Provide information about disease process, prognosis, and treatment needs. DISCHARGE GOALS 1. Pain relieved. 2. Homeostasis achieved. 3. Complications prevented/minimized. 4. Disease process, prognosis, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge NURSING DIAGNOSIS: Pain, acute May be related to Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis
ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Collaborative Maintain NPO status, insert/maintain NG suction as Removes gastric secretions that stimulate release of indicated. cholecystokinin and gallbladder contractions. Administer medications as indicated: Anticholinergics, e.g., atropine, propantheline (Pro- Relieves reflex spasm/smooth muscle contraction and Banthı-ne); assists with pain management. Sedatives, e.g., phenobarbital; Promotes rest and relaxes smooth muscle, relieving pain. Narcotics, e.g., meperidine hydrochloride (Demerol), Given to reduce severe pain. Morphine is used with caution morphine sulfate; because it may increase spasms of the sphincter of Oddi, although nitroglycerin may be given to reduce morphine- induced spasms if they occur. Monoctanoin (Moctanin); This medication may be used after a cholecystectomy for retained stones or for newly formed large stones in the bile duct. It is a lengthy treatment (1–3 wk) and is administered via a nasal-biliary tube.
A cholangiogram is done periodically to monitor stone dissolution. Smooth muscle relaxants, e.g., papaverine (Pavabid), Relieves ductal spasm. nitroglycerin, amyl nitrite; Chenodeoxycholic acid (Chenix), ursodeoxycholic
These natural bile acids decrease cholesterol synthesis, acid (Urso, Actigall); dissolving gallstones. Success of this treatment depends on the number and size of gallstones (preferably three or fewer stones smaller than 20 min in diameter) floating in a functioning gallbladder. Antibiotics. To treat infectious process, reducing inflammation.
Prepare for procedures, e.g.: Endoscopic papillotomy (removal of ductal stone); Choice of procedure is dictated by individual situation. Extracorporeal shock wave lithotripsy (ESWL); Shock wave treatment is indicated when patient has mild or moderate symptoms, cholesterol stones in gallbladder are 0.5 mm or larger, and there is no biliary tract obstruction. Depending on the machine being used, the patient may sit in a tank of water or lie prone on a water-filled cushion.
Treatment takes about 1–2 hr and is 75%–95% successful.
Note: This procedure is contraindicated in patients with pacemakers or implantable defibrillators. Procedure done to widen the mouth of the common bile Endoscopic sphincterotomy; duct where it empties into the duodenum. This procedure may also include the manual retrieval of stones from the duct by means of a tiny basket or balloon on the end of the endoscope. Stones must be smaller than 15 mm.
Fluid/Electrolyte Management (NIC) Independent Assess for unusual bleeding, e.g., oozing from injection sites, epistaxis, bleeding gums, ecchymosis, petechiae, hematemesis/melena. Prothrombin is reduced and coagulation time prolonged Collaborative when bile flow is obstructed, increasing risk of bleeding/hemorrhage. Keep patient NPO as necessary. Insert NG tube, connect to suction, and maintain patency as Decreases GI secretions and motility. indicated. Provides rest for GI tract. Administer antiemetics, e.g., prochlorperazine (Compazine). Reduces nausea and prevents vomiting. Review laboratory studies, e.g., Hb/Hct, electrolytes, ABGs (pH), clotting times. Aids in evaluating circulating volume, identifies deficits, and influences choice of intervention for Administer IV fluids, electrolytes, and vitamin K. replacement/correction. Maintains circulating volume and corrects imbalances.
NURSING DIAGNOSIS: Nutrition: imbalanced, risk for less than body requirements Risk factors may include Self-imposed or prescribed dietary restrictions, nausea/vomiting, dyspepsia, pain Loss of nutrients; impaired fat digestion due to obstruction of bile flow Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Nutritional Status (NOC) Report relief of nausea/vomiting. Demonstrate progression toward desired weight gain or maintain weight as individually appropriate.
ACTIONS/INTERVENTIONS RATIONALE Nutrition Management (NIC) Independent Estimate/calculate caloric intake. Keep comments about Identifies nutritional deficiencies/needs. Focusing on appetite to a minimum. problem creates a negative atmosphere and may interfere with intake.
ACTIONS/INTERVENTIONS RATIONALE Nutrition Management (NIC) Independent Weigh as indicated. Monitors effectiveness of dietary plan. Consult with patient about likes/dislikes, foods that cause Involving patient in planning enables patient to have a distress, and preferred meal schedule. sense of control and encourages eating. Provide a pleasant atmosphere at mealtime; remove Useful in promoting appetite/reducing nausea. noxious stimuli. Provide oral hygiene before meals. A clean mouth enhances appetite. Offer effervescent drinks with meals, if tolerated. May lessen nausea and relieve gas. Note: May be contraindicated if beverage causes gas formation/gastric discomfort. Assess for abdominal distension, frequent belching, Nonverbal signs of discomfort associated with impaired guarding, reluctance to move. digestion, gas pain. Ambulate and increase activity as tolerated. Helpful in expulsion of flatus, reduction of abdominal distension. Contributes to overall recovery and sense of well-being and decreases possibility of secondary problems related to immobility 9e.g., pneumonia, thrombophlebitis).
Collaborative Useful in establishing individual nutritional needs and most Consult with dietitian/nutritional support team as indicated. appropriate route. Begin low-fat liquid diet after NG tube is removed. Limiting fat content reduces stimulation of gallbladder and pain associated with incomplete fat digestion and is helpful in preventing recurrence. Advance diet as tolerated, usually low-fat, high-fiber. Meets nutritional requirements while minimizing Restrict gas-producing foods (e.g., onions, cabbage, stimulation of the gallbladder. popcorn) and foods/fluids high in fats (e.g., butter, fried foods, nuts). Administer bile salts, e.g., Bilron, Zanchol, dehydrocholic Promotes digestion and absorption of fats, fat-soluble acid (Decholin), as indicated. vitamins, cholesterol. Useful in chronic cholecystitis. Monitor laboratory studies, e.g., BUN, prealbumin, Provides information about nutritional albumin, total protein, transferrin levels. deficits/effectiveness of therapy. Provide parenteral/enteral feedings as needed. Alternative feeding may be required depending on degree of disability/gallbladder involvement and need for prolonged gastric rest.
NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs May be related to Lack of knowledge/recall Information misinterpretation Unfamiliarity with information resources Possibly evidenced by Questions; request for information Statement of misconception Inaccurate follow-through of instruction Development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Illness Care (NOC) Verbalize understanding of disease process, prognosis, potential complications. Verbalize understanding of therapeutic needs. Initiate necessary lifestyle changes and participate in treatment regimen. ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Provide explanations of/reasons for test procedures and Information can decrease anxiety, thereby reducing preparation needed. sympathetic stimulation. Review disease process/prognosis. Discuss hospitalization Provides knowledge base from which patient can make and prospective treatment as indicated. Encourage informed choices. Effective communication and support at questions, expression of concern. this time can diminish anxiety and promote healing. Review drug regimen, possible side effects. Gallstones often recur, necessitating long-term therapy. Development of diarrhea/cramps during chenodiol therapy may be dose-related/correctable. Note: Women of childbearing age should be counseled regarding birth control to prevent pregnancy and risk of fetal hepatic damage. Discuss weight reduction programs if indicated Obesity is a risk factor associated with cholecystitis, and weight loss is beneficial in medical management of chronic condition. Instruct patient to avoid food/fluids high in fats (e.g., Prevents/limits recurrence of gallbladder attacks. whole milk, ice cream, butter, fried foods, nuts, gravies, pork), gas producers (e.g., cabbage, beans, onions, carbonated beverages), or gastric irritants (e.g., spicy foods, caffeine, citrus).
ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Review signs/symptoms requiring medical intervention, Indicative of progression of disease process/development e.g., recurrent fever; persistent nausea/vomiting, or pain; of complications requiring further intervention. jaundice of skin or eyes, itching; dark urine; clay-colored stools; blood in urine, stools, vomitus; or bleeding from mucous membranes. Recommend resting in semi-Fowler’s position after meals. Promotes flow of bile and general relaxation during initial digestive process. Suggest patient limit gum chewing, sucking on straw/hard candy, or smoking. Promotes gas formation, which can increase gastric distension/discomfort. Discuss avoidance of aspirin-containing products, forceful Reduces risk of bleeding related to changes in coagulation blowing of nose, straining for bowel movement, contact sports. Recommend use of soft toothbrush, electric razor. time, mucosal irritation, and trauma.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities) Pain, acute—recurrence of obstruction/ductal spasm; inflammation, tissue ischemia.

Nursing Care plan about Cholecystectomy

A Comprehensive Nursing care plan guide for Cholecystectomy

Nursing Lecture about Alterations in Fluids and Electrolytes

Alterations in Fluids and Electrolytes

Fluids and Electrolytes in the Newborn

Nursing Lecture about Altered Nutrition:Gastrointestinal System

Altered Nutrition: Gastrointestinal System and Biliary Disorders

- Group of ulcerative disorders in the upper GI tract caused by resistance of mucosa to acid-pepsin injury
- Common site: 1 st part of duodenum
- Risk factors:
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- Gastric Ulcer Duodenal Ulcer
- Site - antrum of stomach - duodenum (proximal)
- Problem - weakened mucosa - ↑in HCl
- Pain - gnawing epigastric pain - gnawing epigastric pain
- - occurs 1hr after eating - occurs 2hrs after eating
- - aggravated by eating - relieved by food (closure
- (increase acid secretion) of pyloric sphincter)
- - relieved by vomiting
- (acid is expelled)
- - no pain at hours of sleep - pain at hours of sleep
- ( decreased HCl production) (continuous gastric emptying)
- Bleeding - commonly hematemesis - commonly melena
- (anemia, weight loss)
- Demographics
- - common in older people - middle-age people
- - females with familial history - males with no significant familial history (stress- related)
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- History taking – include use of NSAIDs & ASA
- Lab findings: occult blood
- Barium contrast / Barium Swallow – radiologic visualization of upper GI
- Endoscopy (gastroscopy or duodenoscopy) – direct visualization of the GI system by means of lighted flexible tube
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- Primary objective: provide stomach rest
- Small frequent meals
- Avoid foods that increases acidity (eg. caffeine, alcohol, milk)
- Bland diet
- Lifestyle changes: stop smoking
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- Bismuth subsalicylate (Pepto-Bismol) for H.pylori
- Sucralfate (Caralfate) & prostaglandin analogs; Misoprostol (Cytotec)
- Antacids: - given 1-3hrs after meals & at bedtime (empty stomach; ↓ pain
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- Gastrectomy
- Antrectomy – removal of lower portion of stomach (entire antrum)
- Vagotomy – interruption of vagus nerve to decrease gastric secretion
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- Backward movement of gastric contents into the esophagus (causes heartburn)
- Causes:
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- Heartburn (pyrosis) – occurs 30-60mins after eating; usually at night
- Belching (water brash)
- Pain – epigastric or retrosternal area (pain may be confused with angina)
- Dysphagia – resulting from edema
- wheezing
- Chronic cough
- hoarseness
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- Esopha goscopy – passage of flexible fiber optic endoscope into the esophagus
- 24-hour pH Monitoring – small tube with pH electrode is passed through the nose into the esophagus
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- Instruct client to:
- Have small frequent feedings (4-6x/day) but NPO 3h rs before sleep
- Avoid caffeine, fats, chocolates in the diet (reduces esophageal sphincter tone)
- Avoid alcohol & smoking
- Eat meals sitting up rather (avoid recumbent position for several hours after eating)
- Avoid bending for long periods – increases intra-abdominal pressure
- Sleep with head elevated
- Weight loss for overweight / obese clients
- Meds:
- Antacids
- H 2 blockers: Cimetidine, Ranitidine, Famotidine
- Proton-pump inhibitors: Omeprazole, pantoprazole
- Motility agents: Meteclopramide – increases lower esophageal pressure & enhance esophageal clearance
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- Nissen fundoplication – most frequently used & involves gastric wraparound (fundus around lower esophagus)
- Hill’s operation – narrows the esophageal opening
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- Esophageal diverticulum – out-pouching of the esophageal wall due to weakness of mucularis layer
- Achalasia – failure of lower esophageal sphincter to relax & swallowed food has difficulty passing into the stomach (“something stuck in the throat”)
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- Hiatal hernia – barium swallow (confirmatory)
- Esophageal cancer – more common among 50 years of age
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- Presence of gallstones
- Possible causes: gallbladder stasis, infection, genetics
- Risk factors:
- Manifestations: colicky pain, jaundice, nausea & vomiting
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- inflammation of the gallbladder
- inflammation believed to be caused by chemical irritation from the concentrated bile, mucosal swelling, ischemia from venous congestion & lymphatic stasis, gallstones
- Risk factors: sedentary lifestyle & obesity
- Types:
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- Pain often precipitated by a fatty meal commonly at RUQ
- Tenderness on RUQ
- Vomiting – bilious in character
- Fever
- High WBC count
- Elevated total serum bilirubin, AST / ALT
- Intolerance to fatty food
- belching
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- Ultrasound – can detect wall thickening (inflammation)
- - can detect small (1-2cm) gallstones
- Cholescintigraphy – gallbladder scan
- - relies on the ability of the liver to extract rapidly injected radionuclide (technetium-99) that is excreted into the bile ducts
- - reading every 10-15mins of the hour
- - highly accurate
- Oral cholecystography – radiologic technique that uses oral tablets containing radiopaque contrast medium
- - fat-free diet 1-2days prior
- - dye is taken 10-14hrs prior
- -may produce nausea & vomiting or diarrhea
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- Low-cholesterol diet
- Laparoscopic cholecystectomy – treatment of choice for symptomatic gallbladder disease
- - longer duration of operation shorter hospital stay (1 day after OR)
- - client can resume work 1-2wks after
- ESWL (Extracorporeal Shock-wave Lithotripsy) – uses soundwaves to pulverize gallstones (30-40mins)
- - suitable only for radiolucent stones
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- TPN contents:
- monitoring of the following is vital:
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- Condition characterized by excess body fat (BMI ≥ 30)
- May be seen as a sign of lack of self-control
- Causes:
- Basic energy imbalance – more energy intake (food) than energy expanded for basal metabolic needs & exercise = weight gain
- Genetic & family factor – genetic control regulates differences in body fat & sex differences in weight; family food patterns add to genetic factor = social pressure, habits & attitudes toward food
- Physiological factor – amount of body fat is related to the number & size of fat cells in the body
- Psychosocial factor – eating under emotional stress; using food for comfort
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- Hypertension
- Cardiovascular & pulmonary diseases
- Gallbladder diseases
- Glucose intolerance / insulin resistance
- Stroke
- Arthritis
- Infertility
- Cancer (prostate, colon, breast)
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- Focused on lifestyle modification
- Determine client’s motivation & goal/s to lose weight (organizations: eg. TOPS, Weight Watchers, Overeater anonymous)
- Physical activity – prevention of weight gain
- Dietary therapy – individually prescribed based on client’s weight status & risk profile (usually calorie-restricted)
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- Criteria for Evaluating Weight-reduction Diet
- Realistic goals – promote 1-2lbs/wk weight loss; easily adapted to lifestyle; based on individual’s calorie requirement
- Reduce caloric intake (Food consumption)
- - use food to meet nutritional requirements rather than vitamins & minerals supplement
- - encourage food from major food groups
- - decrease fat consumption
- - increase fruits, vegetables, grains, & fiber
- Behavior Modification – control of eating behaviors & promotes physical activity
- Exercise – encourage exercise plan that is acceptable & enjoyable to the client
- Culturally acceptable – offer a maintenance plan after achievement of weight loss; re-educating of eating habits
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- Sibutramine – inhibits serotonin, dopamine, norepinephrine re-uptake; decreasing appetite
- Orlistat – lipase inhibitor; decreases fat absorption in the intestine
- Surgery: Bariatric Surgery
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- Bariatric Surgery – also known as Gastric banding, O besity surgery (group of various procedures)
- usually for men who are at least 100 pounds overweight and women who are at least 80 pounds overweight
- limits the amount of food you can take in
- reduce the size of the stomach
- stomach is divided into two sections reducing the size of the new pouch from approximately two quarts to two ounces
- drastic reduction in the size limits its capacity to hold food causing client to feel full after eating only a small amount;
- also causes the food to bypass part of the digestive system, reducing the amount of calories the body absorbs
- after surgery, client will find it hard to eat foods high in sugars and fats
- emphasize that procedure is in no way to be considered cosmetic surgery

Biliary Disorders of the GIT system

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