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PANCREATITIS

ACUTE: A mild self-limited disorder to a severe, rapidly fatal disease that is characterized by edema and inflammation confined in the pancreas. Return to normal function in 6 months.

CHRONIC: Progressive anatomic and functional destruction of the pancreas.

Alcohol consumption is the major cause..

ASSESSMENTS:

●Severe abdominal pain-LUQ (24-48 hours after heavy meal/alcohol ingestion). ●Nausea and vomiting. ●Rigid or board-like abdomen (warning sign!). ●Turner’s sign (bluish discoloration of the left flank). ●Cullen’s sign (bluish discoloration of the periumbilical area). ●Hypotension, tachycardia, cyanosis, and cold clammy skin. ●Respiratory distress. ●Increase serum amylase and lipase level (3x than normal). ●Weight loss (chronic pancreatitis). ●Jaundice – d/t common bile duct obstruction cause by common bile duct edema (gallstone associated pancreatitis).

ACUTE INTERVENTIONS:

●NPO (to inhibit stimulation of pancreatic enzyme). ●Monitor vital signs. ●H2 blockers as ordered (cimetidine, ranitidine) and PPI – decreased pancreatic activity by inhibiting the secretion of hydrogen chloride. ●Manage pain: Meperidine (Demerol) or Morphine as ordered and positioning. ●Fluid volume replacement (fluid, blood, albumin). ●Respiratory care. ●Surgical intervention: Biliary drainage (wound care).

PATIENT TEACHINGS:

●Abstinence from alcohol. ●Avoid irritants such as caffeine and smoking. ●Avoid stressful situations. ●Encourage carbohydrates and restrict fat on the diet. ●Avoid crash dieting and bingeing. ●Instruct patient and family in recognizing and reporting symptoms of infection, DM, steatorrhea.

NOTE: If:

  • Taking pancreatic enzymes: should be taken with meal or snack. – assess for steatorrhea to determine effectiveness of the enzymes.

  • DM develops – teach patient regarding BG testing and diabetes medications.

  • On antacids – must be taken after meals.

  • Alcohol consumption – refer to agencies or resources (AA).

APPENDICITIS

Inflammation of the vermiform appendix d/t obstruction such as fecalith, tumor or foreign body, adhesion or parasitic infection.

ASSESSMENTS:

●Local tenderness at McBurney’s point (between the umbilicus and the right anterior superior iliac spine). ●(+) Rebound tenderness. ●(+) Rovsing’s sign (palpation of the LLQ causes pain in the RLQ). ●Low grade fever. ●Nausea and vomiting. ●Anorexia. ●Increase WBC.

COMPLICATION: ●PERFORATION which can lead to PERITONITIS. ●Abscess.

MANAGEMENT:

●NPO patient. ● No laxative and enemas to relieve constipation – can cause appendix to burst. ●Avoid taking pain medications that could MASK the symptoms. ●Never apply heat. ●Assess S/S of peritonitis. ●APPENDECTOMY (asap) – post-op care after.

PEPTIC ULCER DISEASE

A condition characterized by erosion of the GI mucosa resulting from the digestive action of HCL and pepsin.

Risk factors: ●Helicobacter Pylori. ●Cigarette smoking. ●Alcoholism. ●Caffeine. ●Stress. ●NSAIDS or aspirin etc…

GASTRIC

Location: Antrum of the stomach, also in body and fundus.

Incidence: ●Older age (50-60 y/o). ●Greater in women. ●Lower socioeconomic status. ●↑with smoking, drug and alcohol use.

Clinical manifestations: ●Pain 1-2 hours after meal (aggravated by eating, if penetrating ulcer. Burning or gaseous pressure in high left epigastrium and back and upper abdomen. ●Occasional nausea and vomiting. ●Weight loss.

Interventions:

  • Continuous vomiting: ●NPO the patient. ●NGT as ordered for gastric drainage. (Monitor discharge-COCA).

  • IV fluids as ordered.

  • Monitor vital signs and laboratory status (especially hgb. &hct.).

  • Monitor s/s of bleeding (hematemesis, melena (tarry stools), abdominal pain) and shock (hypotension, tachycardia, dyspnea, cyanosis, cold and clammy skin etc.).

  • Give pain medication as ordered.

DUODENAL

Location: Proximal part of duodenum.

Incidence: ●Greater in men. ●Middle age (35-45 y/o). ●Stress. ●↑with smoking, drug and alcohol use. ●Associated with other diseases.

Clinical manifestations: ●Pain 2-4 hours after meals, common in midmorning, midafternoon, and middle night. Relieved by food (sphincter closes after eating) and antacids. Burning, cramping, pressure like pain across midepigastrium, and upper abdomen. ●Occasional nausea and vomiting.

Management:

  • Diet: Avoid foods that are spicy and increase acidity (soft drinks, coffee etc.), small frequent meals, and BLAND diet (↓ spices).

  • Lifestyle changes: Stop smoking, stress management, mental and physical rest (relaxation techniques).

  • Pharmacologic management: H2 antagonist, Antacids, PPI, sucralfate. (Avoid OTC drugs i.e. NSAID and aspirin).

  • Surgical management: Sub-total gastrectomy (billroth I and II), Total gastrectomy, Antrectomy, Pylorosplasty, Vagotomy.

POST-OPERATIVE COMPLICATIONS: Dumping syndrome, postprandial hypoglycemia, and bile reflux gastritis.

DUMPING SYNDROME: Rapid passage of food and fluids into the intestine. Common in gastric resections. Occur during meals or up to 30 mins after meals lasting for 30 minutes to one hour.

Signs and symptoms:

●Early: Feeling of fullness, weakness, faintness, palpitations, nausea, diaphoresis, cramping pain, diarrhea and HYPOGLYCEMIA.

●Late: 10-90 mins after eating: Pallor, perspiration, palpitations, h/a. Feeling of warmth, dizziness and drowsiness.

Prevention:

  • Provide a small frequent meal (6 meals) to avoid overloading the intestine.

  • Avoid fluids at least 30-45 mins before and after meals; helps to prevent distension and feeling of fullness.

  • Avoid concentrated sweets (honey, sugar, jelly, jam, candies etc.); may cause dizziness, diarrhea, and feeling of fullness.

  • Avoid large meals, high salts, and carbohydrates.

  • Increase protein and fats to promote rebuilding of body tissue to meet energy needs.

  • Rest after meals and avoid stress.

INFLAMMATORY BOWEL DISEASE

CHRON’S DISEASE (Regional enteritis): Chronic, inflammatory disorder of unknown origin that can affect any part of the GI tract from mouth to anus. Subacute and Chronic transmural (all layers) inflammation of the GIT.

Course: Prolonged and variable.

Transmural thickening interrupted lesions “cobblestone” appearance.

Deep penetrating granulomas.

Common location: Ileum, ascending colon etc…

Diarrhea: Less severe.

Bleeding: Mild, usually none.

Fistula: Common.

Rectal involvement: About 20%.

Dx test: Barium study (determine string sign, cobblestoning, fistulas).

Complications:

● Intestinal obstruction/stricture formation.

●Perianal disease.

●Fluid electrolyte imbalance.

●Malnutrition from malabsorption.

●Fistula and abscess formation.

ULCERATIVE COLITIS: Recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum.

Course: Exacerbation and remissions.

Mucosal ulceration, continuous lesions.

Minute mucosal ulceration.

Common location: Rectum and descending colon.

Diarrhea: Severe diarrhea with mucoid blood.

Streaked stool. Intermittent tenesmus and abdominal pain.

Bleeding: Severe, common.

Fistula: Rare.

Rectal involvement: Almost 100%.

Dx test: Sigmoidoscopy/colonoscopy and barium enema.

Complications:

●Toxic megacolon.

●Perforation.

●Bleeding.

●Malignant neoplasm.

MANAGEMENT:

  • DRUGS: ●Corticosteroids. ●Antidiarrheal, antispasmodics and sedatives - ↓ peristalsis to rest the inflamed bowel. ●Sulfasalazine (Azulfidine) - ↓ inflammation. ●Antibiotics – metronidazole (Flagyl).

  • DIET: ●Low residue, roughage, and fat but high in calories and in protein. ●Supplemental vitamin and iron supplement. ●No milk in the diet.● B12 injection. ●Parenteral nutrition may be given for severe disease, small bowel fistula, and in before and after surgery.

  • SURGICAL INTERVENTION: If symptoms are unresponsive to treatment (anastomosis). For ulcerative colitis-proctocolectomy.

EXTRA: NURSING CONSIDERATIONS/INTERVENTIONS/TEACHINGS: ULCERATIVE COLITIS

●I&O (24h fluid balance). ●Assess for dehydration (dry mouth, lethargy, low or no urine output, sunken eyes, poor skin turgor, dry mucous membrane, dark urine, increased specific gravity, increased hematocrit, infant – sunken fontanels,  no tears) – Fluid replacement, weight pt. daily, I&O, check SG. ●Assess stool – usually 10-20/day (assess frequency, appearance, and colour of stool-COCA). ●Assess electrolytes – hypokalemia. ●Corticosteroids – full dose taken in the morning so that it coincides with the body’s natural rhythm of cortisol secretion.  Do not interrupt treatment – must be d/c gradually with decreasing dose – to prevent adrenal failure.

OSTOMY CARE

1. Nurse responsibilities: ●Explain how to contact the enterostomal therapy nurse (ET nurse). ●Explain how to obtain additional supplies or accessories. ●Ensure access to home health services.

2. How to prevent offensive odours: ●Change the appliance q 5 days or as needed if it leaks or if it smells. ●Empty the bag when it is 1/3 full. ●Put a drop of oil in the bag when it is new to make it easier to empty. ●Use a bag with filter. ●Avoid foods those are likely to produce a foul smell or gas as they decompose. ●Take care of the ostomy bag before breakfast. ●Add a product to the bag that will reduce odours (e.g. M9, mouthwash or toothpaste). ●Bismuth subcarbonate tablets (3-4xs) daily to reduce odours.

3. Teach the following dietary and fluid intake guidelines: ●Identify a well-balanced diet and dietary supplements if necessary to prevent nutritional deficiencies. ●Drink at least 1500-2000 mL/d of fluid to prevent dehydration (unless contraindicated). ●Increase fluid intake during hot weather and if there is excessive perspiration or diarrhea to replace losses and prevent dehydration. ●Provide information about S/S of DHN. ●Explain how to contact a registered dietitian.

Foods:

  • Combat odours: Spinach, parsley, buttermilk, yogurt, and cranberry juice.

  • Increase odours: Onions, fish, eggs, garlic, asparagus, broccoli, cauliflower, alcohol, and spicy foods, cabbage.

  • Gas forming: Beans and legumes, cabbage, onions, beer, carbonated beverages, cheeses.

  • Diarrhea causing: Alcohol, beer, cabbage, spinach, green beans, coffee, spicy foods, fruits and vegetables (raw).

  • Potential obstruction: Nuts, raisins, popcorn, seeds, fruits and vegetables (raw).

        Lomotil (diphenoxylate) – improve stool consistency.

4. Discuss potential resources to assist with emotional and psychological adjustment.

●Identify persons available to provide emotional support. (Family-husband/wife, yourself).

●Identify community resources for psychosocial support.

 I.e. Montréal Ileostomy and Colostomy Association, Montréal Youth Chapter, and Sherbrooke Association des Personnes Stomisées de L’Estrie.

●Contact local ostomy support groups for information and peer support. (Ostomate).

5. Explain the importance of follow-up care. Report signs and symptoms of the following:

●Fluid and electrolytes deficits (dehydration). ●Fever. ●Diarrhea. ●Constipation.

Other stoma problems: 

Including change in appearance of the stoma or its functions, a change in the peristomal skin, tenderness, erythema, or pain.

NURSING DIAGNOSES

Body image: ●Encourage to verbalize feelings. ●Instruct patient how to control odour. ●Offer support groups. ●Educate self-care of ostomy.

Loss of sexuality: ●Arrange a visit with person of same sex and condition to discuss sexual concern (support groups). ●Discuss ways to secure and conceal appliance during intimate relations (using stoma caps, cleaning appliance before sex etc.). ●Encourage discussion of meaning of sexuality to patient and significant others. ●Assess patient attitude about impact of ostomy on sexual functioning.

Other: SKIN IRRITATION, NUTRITIONAL IMBALANCE, AND DEHYDRATION.

POST-OPERATIVE CHARACTERISTICS OF STOMA

BLEEDING

●Small amount: Oozing from the stomal mucosa when touched or cleansed is normal because of its high vascularity.

●Moderate to large amount: Coagulation factor deficiency. Trauma to the stoma.

Could indicate lower gastrointestinal bleeding.

COLOR

●Pink, rose – to brick – red: Viable stoma mucosa.

● Pale pink: May indicate anemia.

● Blanching, dark red to purple: May indicate inadequate blood supply to the stoma.

EDEMA

●Mild to moderate: Normal in the initial postoperative period.

Trauma to the stoma.

●Moderate to severe: Obstruction proximal to the stoma.

COLOSTOMY: Stool consistency:

●Transverse: Semi-liquid to semi-formed. ●Sigmoid: Formed (patient may have regular bowel pattern). ●Ileostomy: Liquid to pasty.

HEPATITIS

Liver inflammation commonly caused by a virus, termed hepatitis A, B, C, D, E and G.

AtE:  transmitted through fecal-oral route

BlooD C: transmitted by percutaneous (IV) drug use, accidental needle stick punctures, tattoos, permucosal exposure to infectious blood, blood products, or other body fluids (semen, vaginal secretions, saliva).

HOW CAN YOU CONTACT HEPA.  A OR HEPA. B

HEPATITIS A

  • Eating food handled by an infected worker who did not wash his/her hands properly after using the washroom.

  • Eating raw or undercooked seafood and shellfish from sewage-polluted water.

  • Eating produce (e.g. salad) that has been rinsed in contaminated water.

  • Swimming in contaminated water.

HEPATITIS B

  • Getting a manicure, pedicure, tattoo, piercing or acupuncture with improperly sterilized tools.

  • Having sexual contact with an infected partner.

  • Giving first aid to, or receiving it from, an infected person.

  • Having a medical or dental procedure with contaminated equipment.

  • Sharing personal grooming items (e.g. nail clippers) with an infected person

PREVENTIONS

Hepatitis:

A – Immunization before and after exposure.

B – Immunization before and after exposure.

C – Blood donor screening, risk behaviour modification.

D – Immunization for HBV prevents HDV infection.

E – Ensure safe drinking water.

Jaundice: Assess hard palate, plantar or palmar surfaces if patient has dark skin.

SIGNS AND SYMPTOMS: ●Fever. ●Fatigue. ●Nausea and vomiting. ●Loss of appetite. ●Jaundice. ●Abdominal pain. ●Dark urine. ●Joint pain.

●Treatment for Hepatitis A: No effective treatment, the patient will recover in 4-6 weeks.

●Treatment for Hepatitis B:  Treated with interferon (Intron).  Infected person will be lifelong “carriers”.

●There is available vaccine for A and B together - Twinrix.

HOSPITAL SETTING PREVENTIONS

GENERAL PREVENTIVE MEASURES

HEPATITIS A

●Maintain good personal hygiene.

●Wash hands after contact with patient or removal of gloves.

●Use infection control precautions.

HEPATITIS B

●Use infection control precautions.

●Wash hands.

●Reduce contact with blood or blood-containing secretions.

●Handle blood of patients as potentially infective and handle it accordingly.

●Dispose needles properly.

●Administer HBV vaccine to all HCP.

●Use needleless IV access device if available.

HEPATITIS A

●Handwashing.

●Proper personal hygiene.

●Environmental sanitation.

●Control and screening (S/S) of food handlers.

●Serological screening while carrying virus.

●Active immunization:  HAV vaccine to anyone over age 2.

●Use of Immune Globulin – early administration (1-2 weeks after exposure).

●Prophylaxis for travellers to areas where hepatitis A is common if not vaccinated.

HEPATITIS B

Percutaneous transmission:

●Screening of donated blood.

●Use of disposable needles and syringes.

Sexual transmission:

●HBIG administration to sexual partner who is infected.

●HBV vaccine to uninfected individual.

●Use condom.

General measures:

●Handwashing.

●Avoid sharing toothbrush and razors.

●HBIG administration for one time exposure (needle stick, contact to mucus membranes)

●HBV vaccine.

LIVER CIRRHOSIS

Chronic progressive disease of the liver characterized by extensive degeneration and destruction of the liver parenchymal cells. 

CLINICAL MANIFESTATIONS

EARLY:

●Anorexia. ●Dyspepsia. ●Flatulence. ●Nausea and vomiting. ●Change in bowel habits (diarrhea and constipation). ●Abdominal pain – dull, heavy feeling at the RUQ. ●Fever. ●Lassitude. ●Slight weight loss. ●Hepatomegaly and spleenomegaly

LATE:

●Jaundice. ●Skin lesions – spider angiomas. ●Hematological problems – thrombocytopenia, leucopenia, and anemia.● Endocrine disturbance – gynocomastia, impotence, amenorrhea, testicular atrophy. ●Peripheral neuropathy – d/t deficiency of thiamine, folic acid, and cobalamin.

COMPLICATIONS

●Portal hypertension.

●Esophageal varices.

●Peripheral edema.

●Ascites.

●Hepatic encephalopathy.

COLLABORATIVE CARE

Hepatic Encephalopathy:

●Lactulose: Acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

●Neomycin sulfate: Decrease bacterial flora, decreasing formation of ammonia.

Ascites:

●Diuretics as ordered.

●Abdominal paracentesis if indicated.

 

Esophageal varices:

●Endoscopic sclerotherapy or ligation.

●Balloon tamponade.

●Beta blockers:  Reduction of portal venous pressure, reduction of portal varices bleeding.

●Vasopressin:  Hemostasis and control bleeding in esophageal varices.

PATIENT AND FAMILY TEACHINGS

  • Teach the patient and family about the disease and the importance of follow-up care.

  • Teach them when to seek medical help.

  • Teach the proper diet.

  • Teach to avoid hepatotoxic OTC medications.

  • Abstain from alcohol.

  • Avoid ASA and NSAID and control coughing.

  • Avoid spicy and rough foods and activities that increase portal pressure, such as straining at stool, coughing, sneezing, and retching and vomiting. Hemorrhage is dangerous because of the inability of the liver to produce clotting factors.

Nutritional therapy:

●Low protein diet: Limit protein to 20g per day at onset of hepatic failure or as ordered.

●High in calories or carbohydrates.

●Fat is limited.

●Sodium restriction, especially when edema and ascites are present.

●Fluid is limited.

Conservative therapy:

●Administration of B-complex.

●Rest.

●Avoidance of alcohol, aspirin, and NSAIDS.

REFERENCES:

 

Preparation guide for professional examination of the OIIQ, PRN comprendre pour intervenir guide d'evaluation, de surveillance clinique, et d'intervention infermieres, Fundamentals of nursing potter-perry, Ultimate learning guide nursing review, The ABC's of passing philippine nursing exam, Medical-surgical nursing assessment and management of clinical problem, Saunders Comprehensive review for the NCLEX-RN examination, Mosby drug guide for nurses, Critical thinking in nursing Winningham & Pressure

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