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NURS 6550 / NURS6550 Advanced Practice Care Of Adults In Acute Care Settings I
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NURS 6550 Midterm Exam Study Guide
Gastrointestinal System
Evaluation, differential diagnosis, treatment options, and complications
o Dyspepsia: acute, chronic, or recurrent pain in the upper abdomen
Etiology:
1. Food or drug intolerance, functional with no obvious cause,
luminal GI tract dysfunction, H-pylori infection, pancreatic
disease, biliary tract disease or other conditions such as DM,
thyroid disease, CKD, pregnancy or gastrointestinal ischemia.
Symptoms:
1. Epigastric pain or burning, postprandial fullness, bloating, nausea
or vomiting
2. If there is weight loss, persistent vomiting, severe pain or
hematemesis then endoscopy warranted.
Labs:
1. >50 years – CBC, BMP, LFT, calcium and thyroid function tests
2. <50 years with uncomplicated dyspepsia use noninvasive strategies
1st; H-pylori fecal test
Upper Endoscopy:
1. Use for pts over the age of 50 who have new dyspepsia associated
with weight loss, dysphagia, recurrent vomiting, bleeding or
anemia.
Other tests:
1. Patient with persistent symptoms or progressive weight loss, check
for celiac disease, stool for parasites, or abdominal imaging such as
CT or ultrasound
Treatment:
1. Empiric
, Proton pump inhibitor x 4 weeks, may have to use long
term if symptomatic after stopping
If H-pylori positive, then antibiotic therapy warranted
2. Functional dyspepsia
Life style changes (limiting alcohol and caffeine intake),
small low-fat meals
Pharmacologic
Oral PPI (omeprazole 20 mg or pantoprazole 40mg)
for 4-8 weeks
Low dose antidepressants (desipramine or
nortriptyline) have been effective in some patients
Alternative therapies: hypnotherapy, psychotherapy,
peppermint, caraway
o Nausea / vomiting
Variety of causes
Acute without pain
1. Food poisoning, infectious gastroenteritis, drugs or illness
Acute with pain:
1. Peritoneal irritation, acute gastric or intestinal obstruction, or
pancreaticobiloiary disease
Persistent Vomiting:
1. Pregnancy, gastric outlet obstruction, gastroparesis, intestinal
dysmotility, psychogenic disorders, and central nervous system or
systemic disorders
2. Vomiting undigested food hours later is indicative of gastroparesis
or a gastric outlet obstruction
3. All patients with acute or chronic symptoms need to be asked
about neurological symptoms
Examinations:
1. Serum electrolytes for vomiting: hypokalemia, azotemia, or
metabolic alkalosis
, 2. Abdominal CT for pain
3. Gastroparesis: confirmed by either nuclear scintigraphic studies or
C-octanoic acid breath tests
4. LFT’s for pancreaticobiliary disease
5. CT or MRI for central nervous system cause
Treatment:
1. General:
most cause self-limiting, clear liquids, small quanitities or
dry foods (crackers), ginger.
If severe, may require hospitalization with IV 0.45 with
20mEq potassium. NG tube for obstruction
2. Antiemetic Medications
Serotonin 5-HT receptor agonists: ondansetron,
granisteron, dolasetron
Corticosteriods: dexamethasone
Neurokinin receptor antagonists: Aprepitant and rolapitant
are used with corticosteroids and serotonin antagonists for
prevebtion of acute or delayed nausea and vomiting
Dopamine Antagonists: promethazine, prochlorperazine.
Can have sedative effects
Antihistamines and anticholinergics: meclizine,
dimenhydrinate or transdermal scopolamine. Used in
vertigo, motion sickness and migraines. May induce
drowsiness
Cannabionoids: Dronabinol contains THC used as an
appetite stimulant.
o Constipation: Most common in elderly and in women
Etiology:
1. Primary – structural abnormalities, systemic disease. Normal
colonic transit site is 35 hours
, 2. Secondary – medications (anticholinergics or opioids), colonic
lesions, endocrine disorders, electrolyte abnormalities
(hypercalcemia or hypokalemia)
Signs/Symptoms
1. Digital rectal exam: for anatomic abnormalities
2. Laboratory studies: CBC, BMP, calcium, glucose, thyroid
Special examinations:
1. Those not responding to routine medical management may need to
have a anorectal manometry. This will show if the patient is having
pelvic floor dyssynergia.
Treatment:
1. Dietary and Lifestyle: fluids, fiber, exercise, changing toileting
habits such as timing, or positioning
2. Laxatives:
Osmotic Laxatives: Magnesium hydroxide, lactulose,
polyethylene glycol. Safe for acute and chronic cases.
Increase water into the colon. Generally, work within 24
hours
Stimulant laxatives: Prescribed as a “rescue” agent or used
3-4 times per week. Bowel movement within 6-12 hours for
PO or 15-60 mins rectal. Bisacodyl, senna, cascara
Chloride secretory agents: Lubiprostone or linaclotide
which increase intestinal fluid and accelerate colonic
transit.
Opioid receptor antagonists: Methylnaltrexone
(subcutaneous injection), used for those on chronic opioids
that can inhibit peristalsis
3. Refer: Refer patients with alarm symptom’s and over the age of 50
for a colonoscopy.
o Diarrhea
Acute
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