Download File - Emergency Assessment Skills

Acute GI
Part 1 and 2
Statistics
• What percentage of patients presenting to
emergency departments offer abdominal pain
as their chief complaint?
• 31.8% or 5.8 million people (1999-2000)
• This number increased to 7 million (20072008)
• Of the 7 million cases between 2007 and 2008
what percent arrived by ambulance?
• 26.9%
CDC.gov
Breakdown
Absorb
Eliminate
Map Quest
• Breakdown
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start = mouth
On ramp = esophagus
Round about = stomach
Exit = pyloris
• Absorb
– Enter Country road = Small intestine
• Duodenum
• Jejunum
• Ileum
• Eliminate
– Enter Parkway to large intestine
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Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Digestion
• Mouth
– Chewing and swallowing (CNS)
• Stomach
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Hydrochloric Acid
Pepsin
Intrinsic Factor  B12 absorption
Peristalsis outward
• Small intestine
– Duodenal secretions
• Amylase, Lipase  pancreatic enzymes (bicarbonate)
• Bile from liver to gallbladder via common bile duct
– Fat/protein/carbohydrates
– Nutrients & Vitamins absorbed
• Large intestine
– Ileocecal valve colon
– Bacteria breakdown remaining waste
– Slow peristalsis water and electrolytes reabsorbed
Case Study
• “After every time I eat a meal within 20 minutes I
have the immediately go to the bathroom. I also
become very bloated and "gassy" almost
nauseous, but never threw up, only go to the
bathroom and it goes away until I eat again. At
first I thought I was lactose-intolerant (because
my sister 22, just developed a severe case out of
no where) but it isn't just dairy that causes this, it
is with any food. My brother of 25 also suffers
from very similar symptoms.”
WebMD Forum
Case Study
• A 67 year old male involved in an MVC. Witnesses say he drifted
into oncoming traffic on Ridge Road and struck another vehicle
head-on.
• He was a restrained driver, there was significant passenger side
compartment intrusion. The passenger, an elderly woman, remains
trapped in the vehicle, Mercy Flight is en route to the scene
• The patient is hypotensive with 2 BP readings in the 70’s. His HR is
140. He is still awake, moaning in pain.
– Based on Trauma Activation Criteria and Level I Trauma Alert is issued
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An OR is prepped
A cooler of type O negative is prepared
A CT scanner is held
The Trauma Team Assembles
• The patient arrives to ED.
– What is you first priority?
• There is no history available
– You hang 2 liters of NS via rapid infuser
• You cut his clothing off…
– A bedside ultrasound is preformed
• There is “free fluid”
• He vomits
• His airway is compromised
• He is intubated
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BP= 60/40
You give 2 units of blood
BP: 70/40
You give 2 more units of blood
– The CT tech yells out “we’re ready”
• You suction emesis out of his mouth and then insert an OG tube
• Social work enters the room: “I got a hold of his daughter she said
he’s on blood thinners for his DVTs”
• BP: 80/60 HR: 130
• You take the patient to CT
Group Work
• The CT scan reveals a liver laceration. The
patient is taken to the OR. The surgery went well
and the damage was repaired. The patient was
extubated and is hemodynamically stable. He
was transferred to a floor. His sister, the elderly
passenger, is still in the ICU.
• You are the nurse assigned to this patient
Before and After
Triage
• Anticipate/Coordinate/Evaluate (ACE)
– Is this new or old?
– Is this expected or unexpected?
– What is the patients “normal”?
– Is this life threatening?
– Can the cause long-term harm?
– Is this time sensitive?
• BP/HR/RR/Sat/T + pain score
• What are the physiological signs of pain?
Subjective Data
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OLDCART
Onset
Location
Duration
Characteristics
Aggravating Factors
Relieving Factors
Treatments
• Focused History
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Abdominal Pain
Dyspepsia
Gas
Nausea
Vomiting
Diarrhea
Constipation
Fecal incontinence
Jaundice
Previous GI disease
• http://www.youtube.com/
watch?v=UM-HWkbnDfg
Objective: Inspection
Inspection
Surface/contour/movement
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Scars
– Describe (length/location/character)
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Striae
– Pink-purple = Cushings
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Dilated veins
– Cirrhosis or inferior vena cava obstruction
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Rashes/Lesions
Contour
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Flat/rounded/protuberant
ascites
pregnancy
hernia
distended bladder
AAA
Mass
Peristalsis
– Observe for several minutes if you suspect obstruction
– Increased waves with obstruction
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Pulsations
– Aortic aneurysm (AAA)
Objective: Auscultation
Auscultation
• Listen prior to percussion/palpation
• Bowel sounds – one spot RLQ is usually sufficient – 5 to 34 per
minute normal
– Altered with diarrhea, intestinal obstruction, paralytic ileus, and
peritonitis
• Bruits
– Suggest vascular occlusive disease
– Listen over aorta, iliac arteries, femoral arteries
– May be heard in systole normally, having a bruit in diastole is more
indicative of arterial insufficiency/partial occlusion
• Borborygmi
– “stomach grumble” normal in transient waves
• Listen for friction rubs over the liver and spleen
– Tumor/infection/infarction
Objective: Percussion
Percussion
• Helps determine the amount and distribution of
gas
• Identifies masses (solid or fluid filled)
• Liver/spleen boarders
• Tympany + dullness
– Check all 4 quadrants
– Tympany = gas
– Typanitic = intestinal obstruction
• Dullness = fluid/feces
– Can be related to a mass in the abdomen
Objective: Palpation
Palpation
• Light palpation
– Superficial, relaxes patient, identify areas of pain
• Deep palpation
– Can delineate abdominal masses
• Peritoneal Inflammation
– Have the patient cough, ask where it hurts, use one
finger to touch
– Rebound tenderness = peritoneal inflammation
• “does it hurt more when I push down or let go?”
• “did the pain get worse with the bumps in the road”
• Be aware of referred pain
Specialty Exams
• Percussing to establish the liver boarders
• Palpating the liver boarders
– Hooking technique
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Percussing the spleen
Palpating the spleen
Palpating the kidneys
CVA (costal vertebral angle) tenderness
Referred Pain
Acute GI
Part 2
Jason Morgan RN, BS
Roberts Wesleyan
Inspection
Surface/contour/movement
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Scars
– Describe (length/location/character)
•
Striae
– Pink-purple = Cushings
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Dilated veins
– Cirrhosis or inferior vena cava obstruction
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Rashes/Lesions
Contour
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•
Flat/rounded/protuberant
ascites
pregnancy
hernia
distended bladder
AAA
Mass
Peristalsis
– Observe for several minutes if you suspect obstruction
– Increased waves with obstruction
•
Pulsations
– Aortic aneurysm (AAA)
Auscultation
• Listen prior to percussion/palpation
• Bowel sounds – one spot RLQ is usually sufficient – 5 to 34 per
minute normal
– Altered with diarrhea, intestinal obstruction, paralytic ileus, and
peritonitis
• Bruits
– Suggest vascular occlusive disease
– Listen over aorta, iliac arteries, femoral arteries
– May be heard in systole normally, having a bruit in diastole is more
indicative of arterial insufficiency/partial occlusion
• Borborygmi
– “stomach grumble” normal in transient waves
• Listen for friction rubs over the liver and spleen
– Tumor/infection/infarction
Percussion
• Helps determine the amount and distribution of
gas
• Identifies masses (solid or fluid filled)
• Liver/spleen boarders
• Tympany + dullness
– Check all 4 quadrants
– Tympany = gas
– Typanitic = intestinal obstruction
• Dullness = fluid/feces
– Can be related to a mass in the abdomen
Palpation
• Light palpation
– Superficial, relaxes patient, identify areas of pain
• Deep palpation
– Can delineate abdominal masses
• Peritoneal Inflammation
– Have the patient cough, ask where it hurts, use one
finger to touch
– Rebound tenderness = peritoneal inflammation
• “does it hurt more when I push down or let go?”
• “did the pain get worse with the bumps in the road”
• Be aware of referred pain
Nursing Process
• Define this condition
• What physical exam findings would you
expect?
• What subjective data/complaints would you
expect?
• What’s the plan for your patient?
• What are your nursing diagnoses?
• What would you teach your patient?
Content Overview
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Appendicitis
Intestinal Obstruction
Esophageal varices
Peptic ulcers
Pancreatitis
Upper/lower GIB
Peritonitis/NG tubes
Diverticulitis
http://www.youtube.com/watch?v=9RFYqH4DnHU
Acute Abdomen
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Severe pain
Rigid, board-like on exam
Muscle spasms r/t peritoneal irritation
DX problem
– Peritonitis
– Bowel rupture
– Bleeding
• Testing
• Aggressive pain management - OR
Assessment findings of common
disorders
• Right lower quadrant
(RLQ)
– Appendicitis
– Perforated duodenal
ulcer
• Cecal volvulus
• Strangulated hernia
– Left lower quadrant
(LLQ)
• Ulcerative colitis
• Colonic diverticulitis
– Right upper quadrant
(RUQ)
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Liver hepatitis
Acute hepatic congestion
Biliary stones, colic
Acute cholecystitis
Perforated peptic ulcer
– Left upper quadrant
(LUQ)
• Splenic trauma
• Pancreatitis
• Pyloric obstruction
Appendicitis
Appendicitis
• Assessment:
– Severe sudden epigastric pain
– Pain increases w/ movement,
breathing
– Pain may radiate to shoulder or
back
– Indigestion
– Acute Abdomen
– Psoas sign
– Obturator sign
• Vital signs?
• Testing
– Lab work (WBC)
– X-ray (free air series)
– CT scan – contrast
• Treatment
– Surgery (endoscopic)
• Complications
– Rupture – SBP
• Nursing Care
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PIV
IVF
NPO
OR prep
NG
Intestinal Obstruction
Intestinal Obstruction
• Partial or complete obstruction in
the small or large intestine
• Impairs absorption
– Electrolyte abnormalities
• Cause
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Hernia
Adhesions
Tumor
Paralytic ileus
Neuromuscular disease
• Assessment
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Distended ABD
N/V, constipation
Pain
Hyperactive bowel sounds or
absent
• Testing
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Labs
X-ray
CT scan
U/S
• Treatment
– Can be conservative such as bowel
rest
– Surgical option
• Nursing Care
– IV/IVF/NPO/NG/Pain medications
Obstruction
SBO = copious vomiting/ hyperactive BS
Large Intestine = uncommon emesis /decrease or absent BS
Esophageal Varices
Esophageal Varices
• Risk
– Liver disease
• Portal hypertension
– Portal system engorged
• Rupture
– High mortality
– Vomiting bright red
blood
– Hemodynamic
monitoring
– Banding via endoscope
• Treatment
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Gastric decompression
Sclerotherapy
Endoscopic band ligation
Esophogogastric balloon
tamponade
– ETOH withdrawl
– Transjugular intrahepatic
portosystemic shunting
(TIPS)
Peptic Ulcer
Peptic Ulcer
• HPI
– Severe sudden epigastric
pain
– Pain increases w/
movement, breathing
– Pain may radiate to
shoulder or back
– Indigestion
– Acute Abdomen
• PMH?
• Medications?
• Objective Data
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X rays - Free air series
CT
Endoscopy
CBC
Coagulation studies
• PT/PTT
• INR
• Treatment
– PPI/H2 blocker
Gastric Surgery
Gastric Surgery
• Open vs. closed
(laparoscopic)
– Indication related to
diagnosis
– Maintain NPO status
– ABX on-call to OR
– Lab work
• CBC
• Chemistry panel
• Coags
• Type and screen
– Pre-op EKG (cardiology
clearance)
• POST-OP considerations
Complications
◦ Include typical post-op
complications (bleeding, infection,
pain, ileus)
◦ Dumping syndrome
 Rapid emptying into small intestine
 Water rushes into intestine causing
nausea, diarrhea, sweating, palpitations,
syncope
 May result in malnutrition, weight loss,
inability to travel from home
• With in 30 minutes of eating
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Tachycardia
Palpitations
N-V
Dizziness
May be delayed up to 90 minutes
after a meal.
Abdominal Trauma
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Blunt force trauma
Sheering injuries
Rapid deceleration
Penetrating wounds
MVC and pregnancy
Seat Belt sign
Liver/spleen/kidney laceration
Hemodynamic monitoring
Pancreatitis
Pancreatitis
• Acute inflammation resulting in auto-digestion
– Inflammation delays enzyme release which damages the organ
• Gallstones and alcohol abuse account for 80 to 90% of cases
• Assessment
– Sudden onset of sharp, twisting, deep ,upper abdominal pain
– Symptoms include anorexia, hypoactive bowel sounds, abdominal distention,
as well as nausea and vomiting.
• Management
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IVF
Pain management
NPO (block stimulation of enzymes)
3 days to 7 weeks for recovery
• ERCP (endoscopic retrograde cholangiopancreatography)
– Endoscopic approach to view structures such as the bile duct
• Gallstones can be removed this way
• MRCP – MRI to see biliary tree and pancreatic ducts
GI Bleed
Upper GI Bleed
 Causes
◦ Ulcers, varices, trauma, Mallory-Weiss tears, ingestion of foreign
bodies
◦ Only 5% GIBs originate in small bowel
 Nursing considerations
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NPO
Isotonic IVF, blood products
Gastric and airway suction
Left lateral (side) decubitus (lying) position
Endoscopy within 24h
Post endoscopy complications:
 Spasm, perforation
 Decreased BS, abd distension
 Mediastinis, fever
Lower GI Bleed
Causes
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Ulcerative colitis
Diverticulitis
Hemorrhoids
Colon polyps
Cancerous tumors
Crohn's disease
Trauma
Foreign object insertion /
ingestion
Nursing considerations
– NPO
– Isotonic IVF, blood
products
– Guiaic stools until LGIB
confirmed
– Prep for colonoscopy
• Oral prep
• Enemas contraindicated
– Post colonoscopy
complications:
• Perforation
• Decreased BS, abd
distension
• Infection, fever
Peritonitis
Peritonitis
• Inflammation of the peritoneum
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Usually related to bacterial exposure
May be from an injury or trauma
Appendicitis
Perforated ulcer
Diverticulitis
Bowel perforation
Remedy problem (above)
Watch hemodynamics (shock?)
IVF/ABX
Improvement
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Decrease in temp/HR
ABD softens
(+) BM/flatus
(+)BS
Diverticulitis
Diverticulitis
• A diverticulum is a saclike
herniation that extends
through the muscle wall of
the bowel
• 95% are in the sigmoid
colon
• When food or bacteria are
retained in the pouches
inflammation occurs
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Perforation
Abscess formation
Peritonitis
Obstruction
• Typical DX occurs through
colonoscopy
• CT scans
• X-ray (free-air series)
• Labs
– CBC
– ESR
• Treatment
– PERC drain for abscess
– Resection
– Colectomy
Review:
Nasogastric and Nasointestinal tubes
• Know why the tube is placed
• Know how to check placement
– What are the gold standards?
– What have you been taught in clinical?
• Know the common complications
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Nasal breakdown
Low intermittent vs. continuous suction
Aspiration
Discomfort