Gastrointestinal System NCLEX Review

Gastrointestinal System:

Common Diagnostic Studies

Stomach/esophagus endoscopy: Visualization of esophagus and stomach through flexible, fiberoptic ube introduced from the mouth to the stomach to determine the presence of tumors, ulcerations, tumors and obtain tissue samples

Preprocedure:

NPO at least 8 hours prior
Verify informed consent.
Notify patient of procedure and that they may feel numbness in throat due to local aesthetic

Postprocedure:

Maintain NPO status till gag reflex returned
Observe for vomiting or bleeding
Let client know they may experience a sore throat for a few days post procedure

Endoscopic retrograde cholangiopancreatography (ERCP): Examination of the hepatobiliary system using a flexible scope, multiple positions needed

Preprocedure

a. Client is NPO for 6 to 8 hours.
b. Inquire about previous exposure to contrast media and any sensitivities or allergies.
c. Moderate sedation is administered (IV and spray anesthesia: remove contact lenses and dentures, monitor closely for signs of respiratory and central nervous system depression, hypotension, oversedation, and vomiting.

Postprocedure
a. Monitor vital signs.
b. Monitor for the return of the gag reflex.
c. Monitor for signs of perforation or peritonitis

Guarding of the abdomen
Increased temperature and chills
Pallor
Progressive abdominal distention and abdominal pain
Restlessness
Tachycardia and tachypnea

Fiberoptic colonoscopy: Direct visual of the colon; biopsies and polypectomies can be performed.

Preprocedure

Adequate cleansing of the colon, as prescribed.
Clear liquid diet on the day before the test. Red, orange, and purple (grape) liquids are to be avoided (maybe mistaken for bleeding)
NPO for 4 to 6 hours prior to the test.
Consult with the HCP regarding medications that must be withheld.
Moderate IV sedation

Postprocedure

Monitor vital signs.
Provide bed rest until alert.
Monitor for signs of bowel perforation and peritonitis or respiratory distress
Passing flatus, abdominal fullness, and mild cramping are expected for several hours.
Instruct the client to report any bleeding to the HCP.

Liver biopsy

Sampling of tissue by needle aspiration

Preprocedure

NPO diet
Administer vitamin K to decrease bleeding risk
Administer sedative
Teach patient they will hold breath for 5-10 seconds
Position supine or left lateral position

Postprocedure

Vital signs
Assess site for bleeding
Monitor for peritonitis
Bedrest for several hours
Position a right side with 2 pillows under the costal margin
Avoid heavy lifting and exercise for 1 week

Paracentesis: transabdominal removal of fluid from the peritoneal cavity

PRIORITY ACTIONS

1. Ensure that the client understands the procedure and that informed consent has been obtained.
2. Obtain vital signs, including weight, abdominal girth, and assist the client to void.
3. Position the client upright.
4. Assist the health care provider (HCP), monitor vital signs, and provide comfort and support during the procedure.
5. Apply a dressing to the site of puncture.
6. Monitor vital signs, especially blood pressure and pulse; weigh the client post procedure, maintain bed rest.
7. Measure the amount of fluid removed.
8. Label and send the fluid for laboratory analysis.
9. Document the event, client’s response, and appearance and amount of fluid removed.

Heart rate and blood pressure must be monitored closely: rapid removal of fluid from the abdominal cavity >decreased abdominal pressure > vasodilation and resultant shock.

Upper gastrointestinal tract study (barium swallow):

Barium is cheaper but contraindicated to bowel perforation, peritonitis, constipation, difficulty swallowing (aspiration risk).
Gastrogafin (water-based) is safer for pre and post op, and obstruction, except for pregnancy, diarrhea, exacerbated colitis, hyperthyroidsm.

Preprocedure:

NPO post midnight (6 to 8 hours before)
Delay feeding (infant)
30 mins duration
Describe consistency (thick, chalk-like), and amount (12-14 oz)
Remove radiopaque objects

Postprocedure:

Laxative
Increase OFI
Monitor stool passage: 24 to 72 hours

Lower gastrointestinal tract studies: Aka barium enema; done before upper GI study

Preprocedure:

NPO post midnight, cleansing enema – morning
Low fiber for 1 to 2 days
Clear liquid and laxative – an evening before

Postprocedure:

Increase OFI
Mild laxative, monitor for stool passage
Notify MD – if no BM after 2 days

Endoscopic retrograde cholangiopancreatography (ERCP): Examination of the hepatobiliary system is performed via a flexible endoscope inserted into the esophagus to the descending duodenum. Multiple positions are required.

Preprocedure:
a. Client is NPO for 6 to 8 hours.
b. Inquire about previous exposure to contrast
media and any sensitivities or allergies.
c. Moderate sedation is administered (monitored closely for signs of respiratory and central nervous system depression, hypotension, oversedation, and vomiting)

Postprocedure:
a. Monitor vital signs.
b. Monitor for the return of the gag reflex.
c. Monitor for signs of perforation or peritonitis

III. Gastrointestinal Disorders of the Adult Client

GERD (gastroesophageal reflux disease): “acid reflux disease”

Complications:

Inflammation of the esophagus (increased risk of cancer from the chronic inflammation)
Narrowing of the esophagus: strictures
Lung problems: asthma, pneumonia, voice changes, wheezing, fluid in the lungs
Barrett’s esophagus: lining of the esophagus is replaced with similar lining that makes up the intestinal lining

Signs and symptoms:

Gastric pain (upper)
Excess regurgitation of food
Dry cough (worse at night)
Nausea
Dysphagia (feels like a lump is in the throat)
Lung Infections

Treatment of GERD: lifestyle changes, medications, surgery such as: fundoplication which is where the fundus of the stomach is placed around the lower part of the esophagus (most severe cases)

Education for GERD

Eat small meals rather than large ones (prevents overeating)
Avoid foods that relax the LES: greasy, fatty, ETOH, soft drinks (increase pressure on the LES and cause regurgitation), and coffee, peppermint/spearmint
Avoid eating right before bed (last meal should be 3 hours before bed)
Sit up after eating for at least 1 hour
Weight loss
Smoking cessation
Watch acidic foods: citrus and tomatoes

Gastritis: Inflammation of the stomach or gastric mucosa (acute or chronic)

Signs and Symptoms:

Abdominal discomfort
Anorexia, nausea, and vomiting
Headache
Hiccupping
Reflux

Interventions

Bland diet
Antacids

Peptic Ulcer Disease: ulcer formation in the lining of the upper GI tract that affects mainly the mucosal lining of the stomach, duodenum or esophagus.

Types of Peptic Ulcers:

Gastric Ulcers: located inside the stomach
Duodenum Ulcer: located inside the duodenum which is the first part of the small intestine

Causes:

Long term use of NSAIDS
Smoking
Alcohol
Stress

Treatment of PUD

Medications: proton pump inhibitors, antibiotics, Histamine receptor blockers, antacids, bismuth subsalicylates
Diagnosis: upper GI series, endoscopy, CT scan
Severe cases due to chronic ulcer formation:
- Gastrectomy: removal of the diseased parts of the stomach. Watch for dumping syndrome post operatively (rapid passing of food from stomach causing diaphoresis, diarrhea and hypotension)
- Vagotomy: cutting the vagus nerve

Signs and symptoms of PUD

Gastric Ulcers

Food makes pain worst (pain 1-2 hours minutes after eating)
Report of pain dull and aching
Weight loss
Severe: vomit blood more common

Duodenal Ulcers

Pain happens when stomach empty
Wake in middle of night with pain
Report of pain gnawing
Weight normal
Severe: tarry, dark stool from GI bleeding

Nursing Interventions of PUD

Goals: assessing, monitor, educate, and administering meds per physician’s order

Assessing:

Assess Bowel sounds
Pain assessment
Dietary modification
Smoking cessation
Reduce stress
Avoid hypermotility in GI tract

Monitoring: for complications of peptic ulcer disease or surgery

GI bleeding
Perforation/Peritonitis
Obstruction in pylorus
Dumping Syndrome

Patient education:

eat many small meals rather than 3 large ones
lie down for 30 minutes after eating
eat without drinking fluids
wait 30 minutes after meals and then consume liquids
avoid sugary food and drinks
eat food high in protein, fiber, and low-carbs

DIET for Ulcers:

Avoid spicy, acidic foods (tomato/citric juices/fruits), foods with caffeine, chocolate, soft drinks, fried foods, alcohol
Consume a low-fiber diet that is bland and eat to digest, eat white rice, bananas etc.

Medications

Proton-pump inhibitors
Histamine-receptor blockers
Bismuth Subsalicylates
Mucosal healing
Antacids
Antibiotics

Hiatal Hernia: also known as esophageal or diaphragmatic hernia.

Herniation results from weakening of the muscles of the diaphragm and is aggravated by factors that increase abdominal pressure such as pregnancy, ascites, obesity, tumors, and heavy lifting.

Assessment:

Heartburn
Regurgitation or vomiting
Dysphagia
Feeling of fullness

Interventions

Provide small frequent meals and limit the amount of liquids taken with meals.
Advise the client not to recline for 1 hour after eating.
Avoid anticholinergics, which delay stomach emptying.

Cholecystitis: Inflammation of the gallbladder that may occur as an acute or chronic process

Acute inflammation is associated with gallstones (cholelithiasis).
Chronic cholecystitis results when inefficient bile emptying and gallbladder muscle wall disease cause a fibrotic and contracted gallbladder.
Acalculous cholecystitis occurs in the absence of gallstones and is caused by bacterial invasion via the lymphatic or vascular system.

Assessment:

Nausea and vomiting, Indigestion, Belching, Flatulence
Epigastric pain that radiates to the right shoulder or scapula
Pain localized in right upper quadrant and triggered by high-fat or high-volume meal
Guarding, rigidity, and rebound tenderness
Mass palpated in the right upper quadrant
Murphy’s sign (cannot take a deep breath when the examiner’s fingers are passed below the hepatic margin because of pain)
Elevated temperature
Tachycardia
Signs of dehydration

Biliary obstruction:

Jaundice
Dark orange and foamy urine
Steatorrhea and clay-colored feces
Pruritus

Interventions

NPO status during nausea and vomiting episodes.
Maintain NG decompression as prescribed for severe vomiting.
Antiemetics as prescribed for nausea and vomiting.
Administer analgesics as prescribed to relieve pain and reduce spasm.
Administer antispasmodics (anticholinergics) as prescribed to relax smooth muscle.
Instruct the client with chronic cholecystitis to eat small, low-fat meals.
Instruct the client to avoid gas-forming foods.
Prepare the client for nonsurgical and surgical procedures as prescribed.

Surgical Interventions

Cholecystectomy is the removal of the gallbladder.
2. Choledocholithotomy requires an incision into the common bile duct to remove the stone.
3. Surgical procedures may be performed by laparoscopy.

Postoperative Interventions

Monitor for respiratory complications caused by pain at the incisional site.
Encourage coughing and deep breathing.
Encourage early ambulation.
Instruct the client about splinting the abdomen to prevent discomfort during coughing.
Administer antiemetics as prescribed for nausea and vomiting.
Administer analgesics as prescribed for pain relief.
Maintain NPO status and NG tube suction as prescribed.
Advance diet from clear liquids to solids when prescribed and as tolerated by the client.
Maintain and monitor drainage from the T-tube if present

Cirrhosis: It’s a liver disease where liver cells become extremely damaged due to long term/severe damage. This leads to the damaged cells being replaced with fibrous tissue, hence, scarring of the liver.

What causes Cirrhosis?

Viral Infection: Hepatitis C*, B
Alcohol Consumption
Too much fat collecting in the liver (nonalcoholic): obese, hyperlipidemia, diabetics
Problems with bile duct (carries bile from liver to small intestine)
Autoimmune

Complications of Cirrhosis

1. Portal Hypertension: the portal vein becomes narrowed due to scar tissue in the liver. This restricts the flow of blood to the liver and increases pressure in the portal vein.

2. Enlarged spleen: splenomegaly

3. Esophageal Varices: due to the increased pressure via the portal vein. This increased pressure causes the veins to become weak, and can cause rupture

4. Fluid overload in legs and abdomen: Ascites

5. Jaundice: yellowing of the sclera of the eyes, mucous membranes, and skin.

6. Hepatic Encephalopathy: the liver is unable to detoxify. Ammonia builds up along with other toxins that collect in the brain. (altered mental status)

7. Renal Failure: In severe cases known as Hepatorenal Syndrome.

Signs and symptoms of Cirrhosis

Remember the mnemonic: “The Liver is Scarred”

Tremors of hands

Hepatic foetor or “fetor hepaticus”: very late in the disease and is a pungent, sweet, musty smell.

Eye and skin yellowing (jaundice)

Loss of appetite

Increased Bilirubin and ammonia

Varices (esophagus and gastric)

Edema in legs (low albumin and congestion of hepatic veins)

Reduced platelets and WBCs (bleeding and infection risk)

Itchy skin (toxins the blood)

Spider angiomas (chest) (increased estrogen in the blood)

Splenomegaly (low platelets and WBCs), stool clay colored (no bilirubin in the stool…should be there not in the urine or blood)

Confusion or coma (high toxin and ammonia level)

Ascites (low albumin and venous congestion)

Redness on the palms of the hands (increased estrogen in the blood)

Renal failure (hepatorenal syndrome)

Enlarged breast in men (decrease metabolism of estrogen so there is more in the blood)

Deficient on vitamins (B12, A, C, D, E, K and iron) (no longer able to store and have bile to help absorb these fat-soluble vitamins)

Diagnosed:

Liver biopsy
Labs: liver enzymes (albumin), platelet levels, PT/INR, hepatitis B or C, bilirubin levels

Nursing Interventions:

Monitor for bleeding (PT and INR)- limit invasive procedures and hold pressure at injection sites for 5 minutes or more, soft tooth brushes, safety, assessing stools, urine, petechiae
Monitor Esophageal varices- Monitor very closely for bleeding, darky tarry stools, vomiting blood, (bleeding is an emergency)
Watch for activities that can increase rupture: coughing, vomiting, drinking ETOH, constipation
Check reflexes, mental status very closely (mental status change, irritability, confusion), hepatic encephalopathy, and for flapping of the hands “asterixis”
Diet: If neuro system is compromised: low protein diet: protein breaks down into ammonia. If neuro system NOT compromised: high lean protein (fish, poultry) NO ETOH, fluid restriction, needs vitamins (administer PO vitamins per MD order)
Monitor blood glucose levels (hyperglycemia and hypoglycemia)
Assessing sclera and skin color for Jaundice along with urine color: very dark
Monitor I’s and O’s very closely, daily weight, and measuring abdominal girth (monitor ascites) and swelling in extremities
Activity intolerance, difficulty breathing (no supine), at risk for skin breakdown (turning every 2 hours), elevating feet
Administering Lactulose per MD order: decreases ammonia levels

Treatment:

Liver transplant
Shunting surgery (helps alleviate the ascites)
Diuretics
beta blockers slows the heart rate and decreases force of contraction and helps with the treatment of esophageal varices to treat portal hypertension
Administer blood products and vitamin K to help with clotting
Lactulose (to decrease ammonia level)
Paracentesis (to remove fluid from abdomen)

Esophageal Varices:

Dilated and tortuous veins in the submucosa of the esophagus.
Cause: portal hypertension, associated with liver cirrhosis; risk for rupture - high portal pressure
Bleeding varices are an emergency.
The goal of treatment is to control bleeding, prevent complications.

Assessment:

Hematemesis
Melena
Ascites
Jaundice
Hepatomegaly and splenomegaly
Dilated abdominal veins

Rupture and resultant hemorrhage is a medical emergency

Nursing Interventions:

Monitor vital signs.
Elevate the head of the bed.
Monitor for orthostatic hypotension.
Monitor lung sounds and for the presence of respiratory distress.
Administer oxygen as prescribed to prevent tissue hypoxia.
Monitor level of consciousness.
Maintain NPO status.
IV fluids as prescribed to restore fluid volume and electrolyte imbalances; monitor I&O
Monitor HGB, HCT, coagulation factors.
BT or clotting factors.
NG tube or a balloon tamponade as prescribed
Medications to induce vasoconstriction and reduce bleeding.
Avoid activities that will initiate vasovagal responses.
Prep for endoscopic procedures or surgical procedures as prescribed.

Endoscopic and surgical procedures:

a. Endoscopic injection (sclerotherapy)

Injection of a sclerosing agent into and around bleeding varices. Injection of a sclerosing agent into and around bleeding varices.
Complications: chest pain, pleural effusion, aspiration pneumonia, esophageal stricture, and perforation of the esophagus.

b. Endoscopic variceal ligation

Ligation of the varices with an elastic rubber band.
Sloughing, followed by superficial ulceration - area of ligation within 3 to 7 days.

Hepatitis: Inflammation of the liver caused by a virus, bacteria, or exposure to medications or hepatotoxins.

Infectious hepatitis (formerly)
At risk: crowded condition, poor sanitation

Hepatitis A

Infectious hepatitis (formerly)
At risk: crowded condition, poor sanitation

Transmission:

Fecal-oral
Person – person contact
Contaminated food and water
Poorly washed utensils
Parenteral

Test: + Anti-HAV, Elevated IgM, IgG

Incubation and Infectious period:

Incubation: 2 to 6 weeks
Infectious: 2 to 3 weeks before and 1 week post Jaundice

Prevention:

Serological screening
Hep A vaccine: 2 doses, 6 mos. apart (full protection)
Immune globulin: for exposed but not vaccinated (given within 2 weeks of incubation)
Hep A Vaccine + IG: household members and sexual contact
IG prophylaxis: traveling countries with poor sanitation/uncertain conditions

Hepatitis B

Nonseasonal
At risk: IV drug user, long-term hemodialysis, healthcare personnel

Transmission: Blood and body fluids

Testing:

+ Anti-HAB,
+ HBsAg (marker for diagnosis)
Anti-HBs – indicates recovery
+ HBeAg – 1 week post HBsAg

Incubation: 6-24 weeks

Prevention:

Hand washing
Screen blood donors
Testing all pregnant women
Needle precaution
Vaccine
Hep IG: exposed individuals and not vaccinated

Hepatitis C

Year around
At risk: An age, IV drug user – post-transfusion hep.

Transmission: Same as HVB, primarily blood

Complications:

Chronic liver disease
Cirrhosis
Primary hepatocellular carcinoma

Prevention

Hand washing
Screen blood donors
Needle precaution

Hepatitis D

Common: Mediterranean, and Middle Eastern areas
Occurs with HBV
At risk: Drug users, receiving hemodialysis, frequent BT

Incubation: 7-8 weeks

Transmission: Same as HBV

Testing: Serological HDV determination is madeby detection of the hepatitis D antigen (HDAg)
early in the course of the infection and by detection of anti-HDV antibody in the later disease
stages.

Complications:

Chronic liver disease
Fulminant hepatitis

Prevention: Because hepatitis D must coexist with hepatitis B, the precautions that help to prevent hepatitis B are also useful in preventing delta hepatitis.

Hepatitis E

Waterborne virus
Risk for infection: same as HAV
High mortality: women in 3rd trimester
At risk: travelers to India, Burma (Myanmar), Afghanistan, Algeria, and Mexico

Transmission: same as HAV

Incubation: 2-9 weeks

Testing: Specific serological tests for HEV include detection of IgM and IgG antibodies to hepatitis E (anti-HEV).

Complications

High mortality rate in pregnant women
Fetal demise

Prevention:

Strict hand washing
Treatment of water supplies, sanitation measures

Pancreatitis

Inflammation of the pancreas that can lead to digestion of the pancreas by its own enzymes and/or irreversible structural damage to the organ.

Assessment:

Blood sugar issues
Ascites
Malabsorption (weight loss problems)
GI issues (diarrhea, pain, oily stools)
Shock (multi-organ failure)
Internal Bleeding or hemorrhage
Structure changes of the pancreas: fibrosis, cysts (filled with infection, rupture, hemorrhage), abscesses, duct changes

Two types of Pancreatitis: Acute and Chronic

Acute Pancreatitis:

Sudden inflammation of the pancreas due to something that has triggered the digestive enzymes to become activated inside the organ (there will be a high amylase and lipase level in the blood). The pancreas starts to digest itself and swell. As the pancreas digests itself, the tissue dies and cysts or abscesses can form out of the dead tissue (which can rupture or hemorrhage).

Most common causes are gallstones and high amount of alcohol consumption.

Chronic Pancreatitis:

Chronic inflammation of the pancreas (can be from repeated episodes of acute pancreatitis but most commonly due to years of alcohol abuse) that has led to irreversible damage to the structure of pancreas which may lead to:

How is pancreatitis diagnosed?

Blood tests: amylase, lipase, electrolytes elevated
CT or ultrasound: imaging of the pancreas
ERCP (Endoscopic Retrograde Cholangio-Pancreatography): use to diagnose and sometimes treat the cause of pancreatitis. It assesses the pancreas, bile ducts, and gallbladder with a small scope. In addition, it can be used to help remove gallstones, dilate the blocked ducts with a stent or balloon, drain cysts etc.

Signs and symptoms:

Acute Pancreatitis:

Sudden Abdominal Pain
Pain worst when lying flat
May report the pain started after consuming greasy/high fat meal or alcohol.
Fever, increased HR, decreased BP
Nausea and vomiting
Hyperglycemia
Increased amylase and lipase
Cullen’s and Grey-Turner’s Sign (seen with SEVERE cases of acute pancreatitis)
- What causes Cullen’s and Grey-Turner’s Sign? They represent retroperitoneal bleeding from the leakage of digestive enzymes into the surrounding tissues which is causing bleeding and it is leaking down into the flanks and umbilicus.
  - Cullen’s Sign: bluish discoloration around the belly button.
  - Grey-Turner’s Sign: bluish discoloration on the flanks

Chronic Pancreatitis

Abdominal pain: Chronic epigastric pain that is persistent (can have no pain because the pancreas is not producing enzymes because of the extent of the damage)
Pain becomes worst after drinking alcohol or eating a greasy/fatty meal
May have a mass and swelling in abdomen due to pseudocyst formation on the pancreas
Diarrhea with stool that is called Steatorrhea: oily/fatty stools due to the lack of pancreatic enzymes to help digest fats
Weight loss: because no enzymes to help digest the food
Signs and symptoms of Jaundice: yellowing of skin and eyes
Dark urine: due to the excessive bile in the body
Signs and symptoms of DM

Nursing Interventions:

Goal: rest the pancreas (prevent it from being stimulated to produce digestive enzymes), control pain, monitor for complications, administer medications per MD order (pancreatic enzymes, antibiotics and stomach acid blockers), diet education

Maintain NPO status to allow for pancreas to rest
Maintain IV hydration (TPN may be ordered)
Insert NG tube and maintain per MD order (used to remove stomach contents and gas)
Monitor blood sugars
Monitor stools
Monitor intake and output
Pain management
Nonpharmacological methods for pain: leaning forward or sitting up (no supine positioning)
Administering PPIs, H2 blockers, antacids per MD order
Education on diet
- AVOID alcohol or greasy/fatty food
- Low fat, bland small meals rather than large, high protein, stay hydrated
- Limit sugar and avoid refined carbs (high fructose corn syrups, breads) but concentrate on complex carbs like fruits, vegetables, grain

Ulcerative Colitis: Inflammation and ulcers in the inner lining of the colon and rectum.

Key points:

No cure
Happens over time or suddenly
Starts in the rectum, move to the large intestine (uniform)
periods of “flare-ups” and remission
Unknown, autoimmune

Severe cases: rupture of bowel, hemorrhage, toxic megacolon

Signs and symptoms: "ULCERS"

Urgent/frequent need to have bowel movements
Loss of weight due to constant diarrhea, low red blood cells (anemia)
Cramps in abdomen (very painful)
Electrolyte imbalances, elevated temperature
Rectal bleeding
Severe diarrhea (pus, blood, mucous)

Nursing Interventions

High-protein, high-calorie, low-fat and low-fiber diet
May require PN for bowel rest
Administer analgesics, corticosteroids, antidiarrheals, antiperistalsis
Maintain fluid and electrolyte imbalance
Promote rest
Ileostomy care

Appendicitis

Causes:

OBSTRUCTION of some form:
- most common fecalith (hard stool that blocks the appendix)
- parasites (worms)
- foreign body that may have been ingested
TRAUMA/Injury

Signs and symptoms: “Appendix”

Abdominal pain (right lower quadrant)

Point of McBurney’s will have the most pain (found one-third distance between the belly button and anterior superior iliac spine)

Poor appetite

Elevated temperature

Nausea/vomiting

Desire to be in the fetal position to relieve pain (side lying with knees bent)

Increased WBC, inability to pass gas or have a bowel movement

eXperiences rebound tenderness

Nursing implementation:

No heating pads, enemas or bowel prep
NPO status with IV fluids
Ice bag to abdomen to alleviate pain
Observe for signs and symptoms related to peritonitis: sudden cessation of pain is a medical emergency
Appendectomy
Position in fowlers to relieve abdominal pain and ease breathing
Antibiotic therapy

B12 Deficiency

Pernicious anemia; deficiency of intrinsic factor: necessary for intestinal absorption of vitamin B12.

Assessment:

Severe pallor
Fatigue
Weight loss
Smooth, beefy red tongue (classic sign)
Slight jaundice
Paresthesia of the hands and feet
Disturbances with gait and balance

Interventions:

Increase vitamin dietary intake
B12 injections

Diverticulosis and Diverticulitis

Diverticulosis refers to the condition of having sacs or pouches in the intestinal wall.
Diverticulitis refers to diverticula that have become inflamed, infected, or obstructed.

Typical signs and symptoms