GI Recitation Complex Care training .pptx

GI Recitation Complex Care slideshow for nursing training

1. GI Recitation Patti E. Landerfelt Complex Care

2. An RN is the leader of a team caring for clients with gastrointestinal (GI) disorders on a medical-surgical unit. The team includes a newly graduated RN who has recently completed hospital orientation, an experienced unlicensed assistive personnel (UAP), and a nursing student. The following information about the four assigned clients is included in the hand—off report. Mr. R, a 57-year-old man, has periumbilical pain. The pain is very severe, despite medication, and radiates to the back. Mr. R was admitted with acute pancreatitis. He is nothing by mouth and has an NG tube and IV line. He is belligerent and confused. The white blood cell (WBC) count and blood glucose level are increased.

3. When the nurse goes in to assess Mr. R, he is complaining of severe left upper quadrant pain radiating to his back. While the nurse goes to the Pyxis to retrieve pain medication for Mr. R, what instructions will she give to the UAP about how to reposition Mr. R to relieve his abdominal pain related to acute pancreatitis? A. Place him in a high Fowler position. B. Help him to lie in a side-lying "fetal" position. C. Lay the bed flat and put Mr. R’s legs on a pillow D. Help him to sit on edge of bed and dangle his legs.

4. When the nurse goes in to assess Mr. R, he is complaining of severe left upper quadrant pain radiating to his back. While the nurse goes to the Pyxis to retrieve pain medication for Mr. R, what instructions will she give to the UAP about how to reposition Mr. R to relieve his abdominal pain related to acute pancreatitis? A. Place him in a high Fowler position. B. Help him to lie in a side-lying "fetal" position. C. Lay the bed flat and put Mr. R’s legs on a pillow D. Help him to sit on edge of bed and dangle his legs. Rationale: For patients with pancreatitis, the fetal position or sitting up and holding the knees to the chest will open the retroperitoneal space, which helps to decrease discomfort. For Mr. R, having him lie down is preferable to having him sit because of his mental status and condition.

5. Mr. R demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and shortness of breath. He also has a low-grade fever. Which potential complication does the nurse suspect? A. Hypovolemic shock B. Pleural effusion C. Paralytic ileus D. Acute respiratory distress syndrome

6. Mr. R demonstrates a dry cough. He reports left-sided chest pain when breathing deeply and shortness of breath. He also has a low-grade fever. Which potential complication does the nurse suspect? A. Hypovolemic shock B. Pleural effusion C. Paralytic ileus D. Acute respiratory distress syndrome Rationale: A dry cough, left-sided chest pain when breathing deeply, shortness of breath, and low-grade fever are signs and symptoms of pleural effusion. Clients with acute pancreatitis can develop many complications: pancreatic infection that can lead to septic shock, hemorrhage secondary to necrotizing hemorrhagic pancreatitis, acute kidney failure, paralytic ileus, hypovolemic shock, pleural effusion, acute respiratory distress syndrome, atelectasis, pneumonia, multiorgan system failure, disseminated intravascular coagulation, and type 2 diabetes mellitus.

7. The nurse notes that Mr. R has a small amount of blood oozing from the IV insertion site, and there is a palm-shaped bruise on his anterior lateral humerus. What action should the nurse take first? A. Remove the IV line and restart it at a different site. B. Remind the UAP to handle Mr. R very gently. C. Assess for other signs of obvious or occult bleeding D. Obtain an order for coagulation studies.

8. The nurse notes that Mr. R has a small amount of blood oozing from the IV insertion site, and there is a palm-shaped bruise on his anterior lateral humerus. What action should the nurse take first? A. Remove the IV line and restart it at a different site. B. Remind the UAP to handle Mr. R very gently. C. Assess for other signs of obvious or occult bleeding D. Obtain an order for coagulation studies. Rationale: First, the nurse would assess for additional evidence of bleeding. Findings would be immediately reported to the HCP, because clients with acute pancreatitis have an increased risk for coagulation disorders, such as disseminated intravascular coagulation. If there is a coagulation disorder, the new insertion site will also bleed. It would be appropriate to initiate interventions for bleeding precautions, such as gently handling. The nurse anticipates that the HCP will want coagulation studies after assessment findings are reported.

9. What information regarding Mr. R is appropriate to report to the HCP? Select all that apply. A. Hematocrit is decreased by more than 10%. B. Calcium level is < 9 mg/dL (2.25 mmoVL ). C. Partial oxygen pressure (Pa0 2 ) is less than 60 mm Hg. D. Pain is unrelieved by medication. E. Blood type is O positive. F. NG tube and IV line are intact.

10. What information regarding Mr. R is appropriate to report to the HCP? Select all that apply. Hematocrit is decreased by more than 10%. Calcium level is < 9 mg/dL (2.25 mmoVL ). C. Partial oxygen pressure (PaO 2 ) is less than 60 mm Hg. D. Pain is unrelieved by medication. E. Blood type is O positive. F. NG tube and IV line are intact. Rationale: The low calcium level and the falling hematocrit and PaO 2 , in combination with the elevated WBC count and his age, are indicators of a high mortality risk. High level of pain is not a prognostic factor, but severe unrelieved pain should always be reported. Blood type will not affect the HCP's decisions about therapy. Reporting on the NG tube and IV line would be appropriate for hand-over report to the oncoming RN, but information about equipment is not reported to the HCP unless there is a specific problem that requires an order or a change of therapy.

11. The HCP has been paged and is enroute to see Mr. R for complications related to acute pancreatitis. The client is increasingly agitated and confused. He pulls out his IV line and NG tube and removes the oxygen nasal cannula. His skin is pale and clammy. His pulse rate is 140 beats/min, and his blood pressure is 140/60 mm Hg. List the following steps, in order of priority, in caring for Mr. R with 1 being the first and 6 being the last. A. Restart the IV line B. Stay with the client and call for assistance C. Replace the nasal cannula for supplemental 0 2 . D. Have a colleague gather IV supplies, glucometer, pulse oximeter, and nonrebreather mask. E. Check the blood glucose level. F. Delegate UAP to take vital signs every 15 minutes.

12. The HCP has been paged and is enroute to see Mr. R for complications related to acute pancreatitis. The client is increasingly agitated and confused. He pulls out his IV line and NG tube and removes the oxygen nasal cannula. His skin is pale and clammy. His pulse rate is 140 beats/min, and his blood pressure is 140/60 mm Hg. List the following steps, in order of priority, in caring for Mr. R with 1 being the first and 6 being the last. A. Restart the IV line B. Stay with the client and call for assistance C. Replace the nasal cannula for supplemental 0 2 . D. Have a colleague gather IV supplies, glucometer, pulse oximeter, and nonrebreather mask. E. Check the blood glucose level. F. Delegate UAP to take vital signs every 15 minutes. Ans: B, C, D, A, E, F Rationale: Stay with the client, but call for assistance; reestablish oxygen per nasal cannula, and have a colleague gather equipment. (Note: Check oxygen saturation with nasal cannula in place and replace with nonrebreather mask as needed.) Restart the IV infusion so that emergency fluids or drugs can be given. Check the blood glucose level to rule out a hypoglycemic reaction. Continuously monitor vistal signs. If at all possible, reinsert the NG tube, however, this is not a lifesaving priority.

13. The HCP arrives while the RN team leader is caring for Mr. R. Because of Mr. R's deteriorating status, the team leader would advocate for which intervention?. A. Perform additional laboratory tests and continue monitoring. B. Prepare Mar. R for emergency surgery. C. Prepare Mr. R for transfer to the intensive care unit (ICU). D. Reestablish NG suction and apply restraints or use

14. The HCP arrives while the RN team leader is caring for Mr. R. Because of Mr. R's deteriorating status, the team leader would advocate for which intervention?. A. Perform additional laboratory tests and continue monitoring. B. Prepare Mar. R for emergency surgery. C . Prepare Mr. R for transfer to the intensive care unit (ICU). D. Reestablish NG suction and apply restraints or use Rationale: Mr. R has severe life-threatening problems that warrant intensive care. The HCP is responsible for the decision to transfer Mr. R; however, the nurse must recognize and advocate for clients who are decompensating. Ordering laboratory and other diagnostic tests may be needed, and restraints or one-on-one observation could be suggested to prevent dislodging equipment, but ultimately the client should be transferred to the ICU. Surgery is unlikely until aggressive medical management measures are exhausted.

15. A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? a. Pain in right upper quadrant radiating to right shoulder b. Report of pain being worse when sitting upright c. Pain relieved with defecation d. Epigastric pain radiating to the left shoulder

16. A nurse is completing an admission assessment of a client who has pancreatitis. Which of the following findings should the nurse expect? a. Pain in right upper quadrant radiating to right shoulder b. Report of pain being worse when sitting upright c. Pain relieved with defecation d. Epigastric pain radiating to the left shoulder A. A client who has cholecystitis will report pain in the right upper quadrant radiating to the right shoulder. B. A client who has pancreatitis will report pain being worse when lying down. C. A client who has pancreatitis will report that pain is relieved by assuming the fetal position. D. CORRECT: A client who has pancreatitis will report severe, boring epigastric pain that radiates to the back, left flank, or left shoulder.

17. A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Decreased blood lipase level B. Decreased blood amylase level C. Increased blood calcium level D. Increased blood glucose

18. A nurse is reviewing the admission laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Decreased blood lipase level B. Decreased blood amylase level C. Increased blood calcium level D. Increased blood glucose Rationale: A. The client will experience an elevated blood lipase level due to pancreatic cell injury. B. The client will experience an elevated blood amylase level due to pancreatic cell injury. C. The client will experience a decreased blood calcium level due to fat necrosis. D. CORRECT: The client will experience an increased blood glucose level due to pancreatic cell injury, which results in impaired metabolism of carbohydrates due to a decrease in the release of insulin.

19. A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis? a. Generalized cyanosis b. Hyperactive bowel sounds c. Gray-blue discoloration of the skin around the umbilicus d. Wheezing in the lower lung fields

20. A nurse is assessing a client who has pancreatitis. Which of the following findings should the nurse identify as a manifestation of pancreatitis? a. Generalized cyanosis b. Hyperactive bowel sounds c. Gray-blue discoloration of the skin around the umbilicus d. Wheezing in the lower lung fields A. Expect to find generalized jaundice. B. Expect to find absent or decreased bowel sounds. C. CORRECT: A gray-blue discoloration in the periumbilical area is a manifestation of pancreatitis. D. Expect to find diminished breath sounds as well as dyspnea or orthopnea.

21. A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) a. “I plan to eat small, frequent meals.” b. “I will eat easy-to-digest foods with limited spice.” c. “I will use skim milk when cooking.” d. “I plan to drink regular cola.” e. “I will limit alcohol intake to two drinks per day.”

22. A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.) a. “I plan to eat small, frequent meals.” b. “I will eat easy-to-digest foods with limited spice.” c. “I will use skim milk when cooking.” d. “I plan to drink regular cola.” e. “I will limit alcohol intake to two drinks per day.” A. CORRECT: Small, frequent meals are recommended for the client who has pancreatitis. B. CORRECT: Bland, easy-to-digest foods are recommended for the client who has pancreatitis. C. CORRECT: Low-fat foods are recommended for the client who has pancreatitis. D. Caffeine-free beverages are recommended for the client who has pancreatitis. Regular cola contains caffeine. E. The client who has pancreatitis should avoid any alcohol intake.

23. A nurse is admitting a client who has bleeding esophageal varices. The nurse should expect a prescription for which of the following medications? Propranolol B. Metoclopramide C. Ranitidine D. Vasopressin

24. A nurse is admitting a client who has bleeding esophageal varices. The nurse should expect a prescription for which of the following medications? Propranolol B. Metoclopramide C. Ranitidine D. Vasopressin A. Propranolol is not used for clients who are actively bleeding. It can be given prophylactically to decrease portal hypertension. B. Metoclopramide decreases motility of the esophagus and stomach. C. Histamine2-receptor antagonists are administered following surgical procedures for bleeding esophageal varices. D. CORRECT: Vasopressin constricts blood vessels and is used to treat bleeding esophageal varices.

25. A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply.) a. Anorexia b. Change in orientation c. Asterixis d. Ascites e. Fetor hepaticus

26. A nurse is assessing a client who has advanced cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (Select all that apply.) a. Anorexia b. Change in orientation c. Asterixis d. Ascites e. Fetor hepaticus A. Anorexia is present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. B. CORRECT: A change in orientation indicates hepatic encephalopathy in a client who has advanced cirrhosis. C. CORRECT: Asterixis, a coarse tremor of the wrists and fingers, is observed as a late complication in a client who has cirrhosis and hepatic encephalopathy. D. Ascites can be present in a client who has liver dysfunction, but it is not an indication of hepatic encephalopathy. E. CORRECT: Fetor hepaticus (a fruity, musty breath odor) is a finding of hepatic encephalopathy in the client who has advanced cirrhosis

27. A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? ( Select all that apply.) A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose E. Sedative

28. A nurse is caring for a client who has cirrhosis. Which of the following medications can the nurse expect to administer to this client? ( Select all that apply.) A. Diuretic B. Beta-blocking agent C. Opioid analgesic D. Lactulose E. Sedative A. CORRECT: Diuretics facilitate excretion of excess fluid from the body in a client who has cirrhosis. B. CORRECT: Beta-blocking agents are prescribed for a client who has cirrhosis to prevent bleeding from varices. C. Opioid analgesics are metabolized in the liver. They should not be administered to a client who has cirrhosis. D. CORRECT: Lactulose is prescribed for a client who has cirrhosis to aid in the elimination of ammonia in the stool. E. Sedatives are metabolized in the liver. They should not be administered to a client who has cirrhosis.

29. The nurse is reviewing the laboratory results of a client with cirrhosis and notes the ammonia level is 85 mcg/dL. which dietary selection does the nurse suggest to the client? a. Roast pork b. Cheese omelet c. Pasta with sauce d. Tuna fish sandwich

30. The nurse is reviewing the laboratory results of a client with cirrhosis and notes the ammonia level is 85 mcg/dL. which dietary selection does the nurse suggest to the client? a. Roast pork b. Cheese omelet c. Pasta with sauce d. Tuna fish sandwich Rationale: Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The serum ammonia level assesses the ability of the liver to deaminate protein byproducts. Normal reference range is 10 – 80 mcg/dL. Most of the ammonia in the body is found in the GI tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein which results in the formation of ammonia. Foods high in protein should be avoided since the client’s ammonia level is elevated above the normal range. Therefore, pasta with sauce would be the best selection.

31. The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? Elevated level of pepsin Decreased level of lactase Elevated level of amylase Decreased level of enterokinase

32. The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results? Elevated level of pepsin Decreased level of lactase Elevated level of amylase Decreased level of enterokinase Rationale: The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.

33. The nurse provides teaching on the medication Sucralfate to be taken four times daily. Which statement by the client indicates teaching was effective? "I can stop the medication if my pain is relieved." "I may get terrible diarrhea from the medication, and if I do I need to stop taking it." "Side effects are minimal and I need to take it an hour before meals and at bedtime." "I need to take the medication halfway between meals and at bedtime on an empty stomach."

34. The nurse provides teaching on the medication Sucralfate to be taken four times daily. Which statement by the client indicates teaching was effective? "I can stop the medication if my pain is relieved." "I may get terrible diarrhea from the medication, and if I do I need to stop taking it." "Side effects are minimal and I need to take it an hour before meals and at bedtime." "I need to take the medication halfway between meals and at bedtime on an empty stomach.” Rationale: Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is scheduled so that it has time to bind to the base of ulcers and erosions and form a protective coating before food intake stimulates chemical and mechanical irritation in the stomach. Medication should not be stopped. Side effects are minimal, and diarrhea is not associated with the medication.

35. While on tour, a 32-year-old male musician has presented to the emergency department of a hospital after a concert complaining of severe and sudden abdominal pain. He admits to a history of copious alcohol use in recent years, and his vital signs include temperature 38.8°C (101.8°F), blood pressure 89/48 mm Hg and heart rate 116 beats per minute. Blood work indicates that his serum levels of C-reactive protein, amylase, and lipase are all elevated. Which diagnosis would the care team suspect first ? A. Hepatitis C B. Cholecystitis C. Liver cirrhosis D. Acute pancreatitis

36. Answer: D. Acute pancreatitis Alcohol use, fever, hypotension and tachycardia are often associated with pancreatitis, as are elevated serum amylase and lipase levels. These enzymes would be unlikely to rise in cases of hepatitis, cholecystitis , or cirrhosis. The precise mechanisms whereby alcohol exerts its action are largely unknown. The capacity for oxidative and nonoxidative metabolism of ethanol by the pancreas and the harmful byproducts that result have been related to the disease process. Cirrhosis represents the end stage of chronic liver disease. The end result is liver failure that affects many organs. The patients usually have anemia, thrombocytopenia, endocrine disorders, skin lesions, azotemia and renal failure, and hepatic encephalopathy.

37. Key clues: While on tour, a 32-year-old male musician has presented to the emergency department of a hospital after a concert complaining of severe and sudden abdominal pain . He admits to a history of copious alcohol use in recent years, and his vital signs include temperature 38.8°C ( 101.8°F ), blood pressure 89/48 mm Hg and heart rate 116 beats per minute. Blood work indicates that his serum levels of C-reactive protein, amylase, and lipase are all elevated.

38. A major factor in the development of hepatic encephalopathy is: A. Hypersplenism B. High sodium level C. Neurotoxin accumulation D. Steroid hormone deficiency

39. A major factor in the development of hepatic encephalopathy is: A. Hypersplenism B. High sodium level C. Neurotoxin accumulation D. Steroid hormone deficiency Rationale: In hepatic encephalopathy there is accumulation of neurotoxins, particularly ammonia , because the liver has lost its detoxifying capacity. The liver metabolizes the steroid hormones; therefore, these hormones are often elevated in persons with liver failure. Hypersplenism associated with liver failure is a factor in the development of anemia, thrombocytopenia, and leukopenia. Several factors contribute to fluid accumulation in ascites, including salt and water retention by the kidney and increase in capillary pressure due to portal hypertension and obstruction of venous flow through the liver.

40. A patient with pancreatic cancer is admitted for portal hypertension and is symptomatic with ascites. Following paracentesis and removal of 7.5 L of ascitic fluid, the nurse should anticipate that the physician will order which medication to assist in maintaining an effective circulating fluid volume? A. Bumetanide B. Furosemide C. Albumin (Human) 5% D. Epoetin alfa

41. A patient with pancreatic cancer is admitted for portal hypertension and is symptomatic with ascites. Following paracentesis and removal of 7.5 L of ascitic fluid, the nurse should anticipate that the physician will order which medication to assist in maintaining an effective circulating fluid volume? A. Bumetanide B. Furosemide C. Albumin (Human) 5% D. Epoetin alfa Explanation: Complications of portal hypertension include ascites, splenomegaly, and hepatic encephalopathy. Following paracentesis to remove ascitic fluid, a volume expander such as albumin is usually administered to maintain the effective circulating volume. Furosemide and bumetanide are diuretics which decrease circulating fluid volume. Epoetin alfa stimulates red blood cell production and ultimately increases O 2 carrying capacity.

42. A 29 year-old female has been admitted to the emergency department following a suicide attempt by overdose of acetaminophen. What physiologic changes in the patient's liver and accompanying altered diagnostic results does the nurse anticipate? A. Hepatocellular necrosis evidenced by increased ALT and AST levels. B. Allergic inflammation accompanied by an increase in serum IgE and basophils. C. Cholestatic reaction with increased bilirubin count D. Rapid onset of viral hepatitis and increased GGT, ALT, and bilirubin

43. A 29 year-old female has been admitted to the emergency department following a suicide attempt by overdose of acetaminophen. What physiologic changes in the patient's liver and accompanying altered diagnostic results does the nurse anticipate? A. Hepatocellular necrosis evidenced by increased ALT and AST levels. B. Allergic inflammation accompanied by an increase in serum IgE and basophils. C. Cholestatic reaction with increased bilirubin count D. Rapid onset of viral hepatitis and increased GGT, ALT, and bilirubin Explanation: Acetaminophen is commonly implicated in cases of direct hepatotoxicity, a situation that is characterized by hepatocellular necrosis and increased ALT and AST levels. An allergic-type reaction is associated with idiosyncratic drug reactions and cholestatic reactions and development of viral hepatitis are not noted to be associated with acetaminophen. GGT (gamma-glutamyl transpeptidase) test can diagnose liver damage, but it can’t determine the cause.