Nursing Management of Inflammation – Flashcards
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What is inflammation? What are some signs and symptoms?
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Something that has been triggered by the inflammatory response such as an infection, irritant, or foreign body. Pain, tenderness, swelling that could lead to tissue integrity problems and possibly cellular death.
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For any GI test the patient should be?
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NPO
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Diagnostics for inflammation
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-ESR: erythrocyte sedimentation rate- elevated -CRP (SED): C reactive protein- elevated -CBC: WBC-elevated -Ultrasound -CT scan -ERCP -FOBT -Nuclear studies -Biopsy -Colonoscopy: look for cause of lower GI problem -Barium Enema
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CT nursing care
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-Check allergies- Patient may be allergic to contrast dye if it is used. -If contrast dye is used patient needs IV! -Check kidney function
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ERCP nursing care
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Contrast medium is used through an IV, then the use a scope to visualize area: exam liver, gallbladder, bile ducts, and pancreas to look for obstruction; pt. sedated; complication pancreatitis
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FOBT nursing care
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Fecal Occult Blood Test checks for blood in stool; Take 2 separate samples on 3 consecutive days -Avoid: meats, asprin, or anthing red that could effect test
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Nuclear Studies
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look at size, shape, or organ; Radionuclear is injected -liver-spleen scan
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Biopsy nursing care
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**AT RISK FOR HEMORRHAGE! **Position pt. on R side to minimize risk for bleeding -Look at platelets- thrombocytopenia? May be risk for bleeding- ask patient if they are taking any anticoagulants. -Liver dysfunction? May be at risk for bleeding. May have anticoagulation problem; Notify HCP; may not be the best time
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Colonoscopy nursing care
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-Patient is moderately sedated -Risk for hemorrhage and infection -HCP will usually order a prep go lightly (laxative) or enema the night before. If patient has a period of exaggeration (inflammation) do NOT give enema, it could cause perforation
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Should we ever place a heating pad on the abdomen if a patient presents with abdominal pain?
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NO! Do NOT put a heating pad on the abdomen. Heat causes vasodilation, and cause rupture of perforation.
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What action should the nurse take if a person presents with abdominal pain?
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-NPO may need surgery -Do not give pain medicine until clear by hcp (surgeon). They will usually want to know the cause of problem bc it might mask symptoms.
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Nursing care after any GI procedure
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-Monitor VS every 15 min -Abdominal pain due to air in stomach -Complication= pancreatitis
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What is Aterixis
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"liver flap or flapping tremor" in wrist and fingers; seen with liver disease
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What is pancreatitis
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inflammation of the pancreas. Can be acute or chronic. Culprit = gall stones/alcohol
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What is cirrhosis
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scaring of the liver usually caused by chronic hepatic inflammation. May result in hepatic encephalopathy
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What is hepatic encephalopathy
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Brain damage from the toxins that build up that the liver cannot process, which results in ammonia *S&S neuro related: altered LOC, confusion, agitation, to coma *Give meds to get rid of ammonia in system= lactulose
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Amylase & Lipase
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Produced by pancreas Levels increased with pancreatitis; Lipase elevated longer- up to a couple weeks
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What is portal Hypertension
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Increase pressure in the portal system (liver veins) resulting in obstruction of flow of blood through the portal veins. Can back up into other systemic circulation= fluid overload -engorgement of liver, spleen, abdomen (Ascities) -esophageal varicies
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What is Ascites
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When fluid shifts into abdomen from portal hypertension; Might affect breathing; -TX: abdominal tap (paracentesis)* If this is done once, more than likely need it again bc fluid will come back -Will try to give meds (diuredics) first to avoid abdominal tap (paracentesis) * Look at labs first!
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esophageal varicies
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From pressure (PH) Lesions that could bleed and cause hemorrhage to death. May need procedure to stabilize EV and keep down hemorrhage. Surg and medications to decrease portal systemic pressure **May put in balloon tampanod= decrease pressure and cut down risk for bleeding in Ev; Risk for compromised airway, infection
