NR511 Midterm Study Guide Worksheet

Disease Risk Subjective Finding Objective Findings Diagnostics Treatment Education

GI DISORDERS

Appendicitis -Most common

between 10-30yrs; but

can occur at any age;

rare in infants and older

adults

-men more at risk

- Diets low in fiber, high

in fat, refined sugars, &

other carbs at increased

risk.

- Obstruction of

appendix is cause of

majority of appendicitis

- contributing factors:

Intra-abdominal

tumors, positive family

hx

- Recent roundworm

infection or viral GI

infection

-Dx made clinically,

based primarily on

H&P exam

- Classic presentation

includes acute onset of

mild to severe colicky,

epigastric, or

periumbilical pain

- Pain is vague at first

then localizes within

24hrs to RLQ

- Pain exacerbated by

walking\coughing

- Men may feel

radiated pain in testes

- Abd muscle rigidity,

N\V, anorexia

- Mildly elevated temp

99-100F common

- If RLQ accompanied

by shaking chills,

perforation should be

suspected

- Older adults may

present with

weakness, anorexia,

abd distention, mild

pain leading to delayed

dx and increased

morbidity.

-May have HTN\tachy

proportional to pain\

symptoms

-When lying flat, may

flex R knee to relieve

tension in abd muscle

-Pain with palpation in

abd, diffuse in early

stages. Localized to

RLQ later

-Positive for rebound

pain; ask pt to cough

to localize pain

location

-Sudden cessation of

pain means

perforation and is ER

-Labs are not

diagnostic and

nonspecific

-Women should have

urine human

chorionic

gonadotrophin to r\o

ectopic pregnancy

- +Rovsing’s Signdeep palpation &

release in LLQ causes

rebound pain in RLQ

- +Psoas Sign- lift R

leg against gentle

pressure causes pain

- +Obturator Signflex R hip & knee and

slowly rotate

internally causes pain

- +McBurney’s Signpain with pressure

applied to point

between umbilicus &

ilium

- x-ray\CT helpful

when paired with

positive H&P findings

-Surgical; preoperative

care, NPO, correction of

fluid\electrolyte

imbalances

-Avoid narcotics

-Atb with 3rd gen

cephalosporin; Ex:

ampicillin, gentamycin,

flagyl

-F\U with surgeon

-Ambulation after

surgery

-Adv diet when

bowel sounds

return

-Return to hosp

with s\s of infection

-Avoid heavy lifting

for at least 2 wks

Celiac disease **

(autoimmune

disorder caused by an

immunologic

response to gluten)

Mostly diagnosed in

adulthood.

A family member with

celiac disease or

dermatitis herpetiformis

Type 1 diabetes

Many asymptomatic.

May complain of

diarrhea, gas,

dyspepsia, wt loss.

Atypical symptoms:

fatigue,

bone or joint pain,

arthritis,

osteoporosis, or

Muscle wasting

(anemia), reduces

subcutaneous fat,

ataxia, & peripheral

neuropathy (vitamin

B12 deficiencies)

osteoporosis or

osteopenia (bone

loss)

Serologic testing for

anti-tTG IgA antibody

Total IgA (2% of pts

have IgA deficiency

and will falsely test

negative)

duodenal biopsies

lifelong adherence to a

strict gluten-free diet.

Referral to a dietician to

help.

Some pts may need

treatment with

immunomodulating

teaching related to

gluten free diet.

Some people with

celiac disease have

vitamin or nutrient

deficiencies that do

not cause them to

feel ill, such as

anemia due to iron

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NR511 Midterm Study Guide Worksheet

Down syndrome or

Turner syndrome

Autoimmune thyroid

disease

Microscopic colitis

(lymphocytic or

collagenous colitis)

Addison's disease

osteopenia (bone loss)

liver and biliary tract

disorders

(transaminitis, fatty

liver, primary

sclerosing cholangitis,

depression or anxiety

peripheral neuropathy

seizures or migraines

missed menstrual

periods

infertility or recurrent

miscarriage

canker sores inside the

mouth

dermatitis

herpetiformis (itchy

skin rash)

hypothyroidism

Pts with dermatitis

herpetiformis found

to have signs of celiac

disease on intestinal

biopsy.

Test for nutritional

deficiencies

associated with

malabsorption of C.D.

(hemoglobin, iron,

folate, vit B12,

Calcium, and Vitamin

D.)

agents. deficiency or bone

loss due to vitamin

D deficiency.

However, these

deficiencies can

cause problems

over the long term.

Untreated

celiac/developing

certain types of

gastrointestinal

cancer. This risk can

be reduced by

eating a gluten-free

diet.

Cholelithiasis is the formation of

gallstones and is found

in 90% of patients with

cholecystitis.

--Risk factors--2 types of

stones (cholesterol and

pigmented)

a. Cholesterol (most

common form): female,

obesity, pregnancy,

increased age, druginduced (oral

contraceptives and

clofibrates: cholesterol

lowering agent), cystic

fibrosis, rapid weight

loss, spinal cord injury,

Ileal disease with

extensive resection,

Diabetes mellitus, sickle

cell anemia.

b. Pigmented: hemolytic

diseases, increasing age,

hyperalimentation

Patient complaint of

indigestion, nausea,

vomiting (after

consuming meal high

in fat), and pain in RUG

or epigastrium that

may radiate to the

middle of the back,

infrascapular area or

right shoulder.

Right side involuntary

guarding of

abdominal muscles,

Positive Murphy's

sign, possible palpable

gallbladder, Low

grade fever between

99-101 degrees.

Possible jaundice

from common bile

duct edema and

diminished bowel

sounds.

Mild elevation of

WBC up to 15, 000

Abdominal Xray:

Quick, noninvasive,

reliable, and costeffective means of

identifying the

presence of

cholelithiasis.

a. Initial management--

begins with definitive

diagnosis. When

asymptomatic (normally

an incidental finding while

exploring another

problem) require no

further treatment except

teaching s/sx of

"gallbladder attack".

Nonsurgical candidate can

be treated with dissolution

therapy or lithotripsy.

Acute includes hydration

(IV fluids), antibiotics,

analgesics, GI rest.

b. Treatment of choice for

Acute cholecystitis is early

surgical intervention after

stabilization. Poor surgical

risk may benefit from

cholecystectomy

operatively or

percutaneously.

Nonsurgical

intervention: weight

loss, avoidance of

fatty foods to

decrease attacks,

alternative birth

control for persons

taking oral

contraceptives,

menopausal women

taking estrogen

informed about

alternative sources

of phytoestrogens

(soy products).

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NR511 Midterm Study Guide Worksheet

(artificial supply of

nutrients, typically IV),

cirrhosis, biliary stasis,

chronic biliary

infections.

Crohn’s ** Ages 15-25 of onset and

then again at 50-80.

Familial tendency,

smoker

Carcinoma less common

in patients with CD due

to treatment sometimes

colectomy

Mild-Four or fewer

loose bowel

movements per day,

can have small

amounts of blood and

mucus in the stool,

and cramping in the

rectum. Moderate-4-6

loose bowel

movements per day

containing more blood

and mucus and other

sx such as tachycardia,

weight loss, fever, mild

edema. Severefrequent bloody bowel

movements (6-10),

abd pain and

tenderness, sx of

anemia, hypovolemia,

impaired nutrition.

Most common sx are

abd

cramping/tenderness,

fever, anorexia, wt

loss, spasm, flatulence,

RLQ pain or mass

Tenderness in LLQ or

across entire abd with

guarding and abd

distension. DRE

performed to look for

anal and perianal

inflammation, rectal

tenderness, and blood

in stool. S/Sx of

peritonitis and ileus

may be found

depending on severity

of crohns. Tender

mass in RLQ, anal

fissure, perianal

fissure, edematous

pale skin tags. Extra

intestinal finding may

be episcleritis,

erythema nodosum,

nondeforming

peripheral arthritis,

and axial arthropathy

Stool analysis to r/o

bacterial, fungal, or

parasitic infection for

cause of diarrhea.

CBC to check for

anemia, eval for

hypocalcemia, vit D

deficiency.,

hypoalbuminemia,

and steatorrhea. LFT

to screen for primary

sclerosis cholangitis,

and other liver

problems assoc with

IBD. Check fluid and

electrolytes. May

have elevated WBC

count and sed rate

and prolonged

prothrombin time.

Barium upper GI

series, colonoscopy,

and CT to determine

bowel wall thickening

or abscess formation

Glucocorticoids, there is

no cure for CD and

treatment is aimed at

suppressing inflammation

and symptomatic relief of

complications. Initially

oral prednisone 40-60

mg/d, tapered over 2-4

months, then can have

daily maintenance dose of

5-10mg/d. Sulfasalazine

for mild to moderate CD

500 mg BID, increased to

3-4 g/d. Clinical

improvement in 3-4 wks,

and then tapered to 2-3

g/d for 3-6 months, this

medication interferes with

folid acid absorption and

patient must take

supplements.

Metronidazole effective in

tx perianal disease and in

controlling crohns colitis,

other ABT’s such as Cipro,

Ampicillin, and

Tetracycline effective in

controlling CD ileitis, and

ileocolitis.

Immunosuppressive meds

when unresponsive to

other treatments.

Pt educated on

disease process,

diet and lifestyle

changes. Stress

reduction, adequate

rest to decrease

bowel motility and

promote healing.

Low residue diet

when obstructive sx

present such as

canned fruits,

vegetables and

white bread

Diverticulitis ** -Uncommon under

40yrs; risk rises after

-Rare in pediatric; equal

in men\women

-More common in

-25% develop

symptoms

-LLQ abd pain, worsens

after eating

-Pain sometimes

-LLQ abd tenderness

with possible Firm,

fixed mass may be

identified in area of

diverticula

-Abd x-ray can reveal

free air, ileus,

obstruction

-Barium studies show

sinus tracts, fistulas,

-Asymptomatic cases

managed with high fiber

diet or fiber supplement

with psyllium

-Mild symptoms managed

-Increase fiber in

diet to avoid

constipation and

straining

-H2O intake of at

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NR511 Midterm Study Guide Worksheet

developed countries

-High in low fiber, high

fat\red meat diets

-Obesity, chronic

constipation, h\o

diverticulitis, & number

of diverticula which

occur in sigmoid colon.

relieved with BM or

flatus

-BM may alternate

between diarrhea\

constipation

-May present with

bleeding w\o pain or

discomfort

-Fever, chills, tachy;

LLQ with anorexia, N\V

-Fistula may form

causing dysuria,

pneumaturia, fecaluria

-May have rebound

tenderness with

guarding\rigidity

-Tender rectal exam;

stool usually + for

occult blood

obstruction

-Colonoscopy to r\o

Ca, but less sensitive

than barium for

diverticula

-CT with contrast

outpatient with clear

liquid diet and rest

-Atb should not be

routinely used but can be

with diverticula abscess

culture

-Amoxicillin\clavulanate K

(or) flagyl with bactrim

-Symptoms usually subside

quickly and diet can be

advanced slowly

-Pain managed with

antispasmotics Ex; Levsin,

Bentyl, BuSpar

-Avoid morphine

-NG for ileus or intractable

N\V

-Pt can be D\C’d from

hosp once able to

maintain adequate

nutrition\ hydration if

acute phase resolved

-Colon resection may be

necessary if no

improvement or

deterioration after 72hrs

of treatment

least 8\8oz glasses

to promote bowel

regularity

-Bulk-forming

laxative may be

needed Ex: psyllium,

FiberCon,

Metamucil

GERD ** -Can occur at any age

-Risk increases with age,

then decreases after

69yrs

-Prevalence equal

across gender, ethnic,

cultural

-Obesity, alcohol,

caffeinated beverages,

chocolate, fruit, decaf

coffee, fatty foods,

onions, peppermint\

spearmint, tomato

products

Anticholinergics, beta-

-Heartburn; mild to

severe

-Regurgitation, water

brash, dysphagia, sour

taste in AM, belching,

coughing, odynophagia

(painful swallow),

hoarseness or

wheezing at night

-Substernal\

retrosternal pain

-Worsens if reclined

after eating, eating

large meals,

constrictive clothing

-H&P usually normal

-May be + for occult

blood in stool

-Usually Hx alone

diagnoses

-May manifest with

atypical symptoms

such as adult-onset

asthma, chronic

cough, chronic

laryngitis, sore throat,

noncardiac chest pain

-If pt fails to respond

to 4-8wks PPI, EGD is

ordered

-EGD warranted over

empiric treatment

when heartburn &

-8wk trial of PPI; weight

loss, avoiding triggers

-If unresponsive to once

daily dosing; can increase

to twice daily; if no relief

EGD needed

-PPI and H2-RA should not

be taken together

-Pt’s on long term therapy

should be re-eval’d q6mos

-Weight loss, med

compliance and

avoidance of

triggers

-Small frequent

meals; main meal

mid-day, avoid

eating 4hrs before

bed, avoid straining,

sleep with HOB

elevated, smoking

cessation, stress

mgmt

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