AMS1

Card Set Information

Author:
alyn217
ID:
164549
Filename:
AMS1
Updated:
2012-08-06 11:18:02
Tags:
AMS1T3 GI Upper bleed
Folders:

Description:
GI complications
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user alyn217 on FreezingBlue Flashcards. What would you like to do?


  1. Nursing assessment of the GI
    • Auscultation: present, absent, hypoactive, hyperactive, tinkling,
    • gurgling, rushing

    • Normal: High pitched
    •  clicks or gurgles

    Absent: Rare

    • Borborygmi: loud, high
    • pitched gurgling –indicates
    • hyperperistalsis

    • Obstruction: high pitched
    • tinkling sounds before obstruction;
    • diminished or absent after
  2. Diagnostics and Labs for GI?
    • Radiologic: 
    • Upper GI
    • Lower GI
    • Ultrasound
    • CTMRI
    • Cholangiography
    • Gastric emptying
    • HIDA
    • Endoscopic:
    • Upper GI
    • Colonoscopy
    • ERCP
    • Virtual Colonoscopy
    • Capsule Endoscopy
    • Miscellaneous:
    • Liver Biopsy
    • LFT’s
    • Gastric Analysis
    • Fecal Analysis
    • Stool Culture
  3. Labs for GI assessment
    • Laboratory Studies
    • Serum Albumin to hold fluids in BS
    • Prealbumin
    • Serum Transferrin
    • C-Reactive Protein (CRP)
    • Anthropometric Measurements
    • --Ht/ Wt
    • --Body Mass Index
    • --Skin fold thickness
  4. What are the SnSs of malnutrition?
    • Deficit, excess, or 
    • imbalance in essential
    • components of balanced 
    • diet
    • - dry, scaly skin
    • - brittle nails
    • - decreased muscle mass
    • - fatigue, no endurance
    • - poor wound healing
    • - depressed immune 
    •   system
  5. Assessment for malnutrition?
    • Joint Commission requires screening for all patients
    • within 24 hours of admission
    • MNA - Mini-Nutritional Assessment (older adults)
    • MDS – Minimum Data Set (Long-term care)
    • OASIS – Outcome and Assessment Information Set
    • Obtain accurate Height and Weight
    • Assess weight loss
    • Calculate BMI
  6. What are some risk factors for malnutrition?
    • Dementia
    • Depression
    • Chronic Substance Abuse
    • Swallowing Disorders
    • Decreased Mobility
    • Nutrient loss from malabsorption, dialysis, wounds
    • Drugs w/ antinutrient properties (corticosteriods) 
    • Hypermetabolism (fever, infection, burns, trauma)
    • No oral intake
  7. Nursing intervensions to support nutrtion for the pt w/malnutrition
    • High-Calorie, High-Protein Diet
    • Supplementation
    • Milkshakes
    • Pudding
    • Commercially available products
    • Carnation Instant Breakfast (CIB)
    • Ensure
    • Boost
  8. Indications for enteral nutrition (tube feedings)
    • Nutrition provided through GI tract via a tube, catheter or stoma that delivers nutrients distal to the oralcavity for:
    • Anorexia
    • Orofacial Fractures
    • Head and neck cancer
    • Neurologic problems
    • Psychiatric conditions
    • Critical Illness
    • Considered safer, more physiologically efficient, less expensive than parental nutrition. Obviously, GI system has to work to be able to feed enterally. 
  9. Enteral nutrition 
    types of tubes
    • Types of Tubes
    • Nasogastric Tube (NGT)
    • Percutaneous Endoscopic 
    • Gastrostomy Tube (PEG)
    • Jejunostomy Tube
  10. Nursing management of enteral tube feedings
    • Positioning- HOB 30-45 degrees
    • Tube Patency- Flush before and after
    • Tube Position - Placement check
    • Aspiration Risk - HOB elevation/Residual check
    • Formula- strength/hang time. Do not dilute with water. May -->diarrhea. 
    • Administration – pump/gravity(bolus/intermittent)
    • Medication Administration - crush meds well!
    • General Considerations:
    • --daily weights, glucose checks,
    • --change tubing q24 hrs, free water
    • --label w/ date/time hung, I&O
    • --Gastric residual: check q 4 hrs. for 1st  48 hours then q6-8 hrs for stable patient; q4h critical pts (>200 = gastric intolerance).
  11. What are some complications of enteral feedings?
    • Nausea/Vomiting
    • Diarrhea/Constipation
    • Aspiration: keep HOB 30-45 degrees; hold TF when HOB lowered; check residuals; ambulation; gastric emptying agents, suction for any s/sx aspiration, clear airway!!!!!
    • Clogged Tube: crush meds well; flush before and after meds; dilute viscous solutions; use liquid meds if available; follow hospital protocol for unclogging tube
    • Displacement of tube
    • Dehydration
    • Infection: assess for s/sx infection; clean around site q shift with water initially then soap and water.
    • Skin irritation
    • Thrush: Oral care!!!!!!!
  12. General info about TPN feeding
    • GI tract not functioning properly
    • Administration of nutrition IV:
    • --Total Parental Nutrition (TPN)
    • --Lipids/fat emulsions:
    • --Peripheral Parental Nutrition (PPN)
    • Indications:
    • Severe nausea/vomiting/diarrhea
    • Gastrointestinal obstruction/anomalies
    • Severe injury/trauma
    • Malabsorption/short bowel
    • Pancreatitis
  13. TPN vs. PPN
    • PPN
    • Short term nutritional needs
    • Protein/calorie requirements low
    • CVC Contraindicated-use peripheral IV
    • Supplement inadequate oral intake
    • Hypertonic (Glucose concentration 10%)
    • TPN
    • Long-term nutritional support needed
    • High protein/calorie requirements
    • Must be given in Central Line (CL)
    • Glucose concentration (20-50%)
    • Hypertonic 1600 mOsm/L (blood 280 mOsm/L)
  14. Nursing management of Parenteral nutrition
    • VS q 4-8 hrs.
    • Daily Weight
    • Labs, esp glucose.
    • DSG change according to protocol
    • Change label/bag/tubing/filter q 24 hours no matter how much is left in the bag or even if the condition looks fine. Just do it. 
    • IV site assessment: 
    • Signs of phlebitis: erythema, tenderness or exudate; systemic infxn: fever, chills, N/V, malaise. Cultures (x2) may be performed and line may be D/C’d with tip cultured if no source of infection can be identified. Central line usually not replaced right away r/t risk of seeding new IV with bacteria.
    • Glucose q 6 hrs. risk for hyperglycemia
    • Administer PN ONLY via pump!!!
    • Administration routine


     
  15. Complications of TPN
    • Infection
    • Fungus/ Gram +/ Gram - bacteria
    • Metabolic Problems
    • Hyperglycemia/hypoglycemia
    • Altered Renal Function
    • Electrolyte/vitamin/mineral excess or deficiency
    • Refeeding Syndrome
    • Mechanical Problems
    • Air embolus
    • Pneumothorax
    • Line displacement
    • Thrombosis/phlebitis
  16. Pathophysiology of n/v
  17. preconditions for n/v
    • Etiology
    • Pregnancy
    • Infectious disease
    • CNS disorders
    • CV problems
    • Metabolic disorders
    • SE of drugs
    • Psychologic factors
    • Signs/Symptoms
    • Anorexia
    • Dehydration
    • Electrolyte imbalances
    • Metabolic alkalosis
    • Metabolic acidosis
    • Weight loss

    Aspiration precautions!
  18. assessment and intervensions for n/v
    • HPI
    • Precipitating factors
    • When does it occur
    • Description of contents
    • Drug therapy
    • Antimuscarinics
    • Antihistamines
    • Phenothiazines
    • Dexamethasone
    • Cannibinoids
    • Prokinetics
    • Serotonin antagonists
    • Nutritional therapy
    • BRAT diet
  19. Upper Gastrointestinal Bleeding
    • Most common sites
    • --Esophagus
    • Stomach
    • --Stress Related
    • Duodenum
  20. SnSs of UGI bleed
    • Severity Depends on Origin 
    • Overt
    • --Hematemesis (bright red/coffee ground vomit)
    • --Melena (black/tarry stool)
    • --Hematochezia (maroon colored stool)
    • Occult
    • --Guaic-Positive Stools/Nasogastric Aspirate
  21. Emergency Assessment and management of pt w/UGI bleed.
    • VS (s/sx shock)
    • Abdominal assessment
    • PMH
    • Blood transfusion inquiry
    • Establish IV (x2 large gauge periferal)
    • NGT vs. OGT
    • Foley
    • Labs
  22. Assessment of pt w/UGI bleed
    • LOC
    • VS
    • JVD
    • Abdomen
    • Distention
    • Peristalsis
    • Guarding
  23. Collaborative care with pt/UGI bleed
    • Endoscopic therapy
    • --Hemostasis to coagulate bleeding
    • Drug therapy
    • --Injection therapy with epinephrine
    • --Sclerosant
    • --Vasopressin
    • --H2 blockers or PPI drip via IV
    • --Antacids
    • --Sedatives
    • Angiography
    • Surgical therapy
  24. Possible Nursing Diagnoses
    • Risk for aspiration
    • Decreased cardiac output
    • Deficient fluid volume
    • Ineffective peripheral tissue perfusion
    • Ineffective coping
  25. Pt teaching UGI bleed
    • Avoid alcohol
    • Quit Smoking
    • Reduce Stress
    • Take only prescribed meds
    • Avoid Aspirin, NSAIDS-->GI bleeds, so CX.
    • PPI, H2 Blocker
    • Watch for bleeding
  26. GERD
    • What?
    • Reflux of gastric contents into lower esophagus
    • Who?
    • 14-20% world’s population??
    • Why?
    • Hiatal hernia
    • Incompetent LES
    • Impaired esophageal motility
    • Decreased gastric emptying

What would you like to do?

Home > Flashcards > Print Preview