【正文】 s!pYmUjRgOcL9H6E3B+ 。t!qYmVjRgOdL9I6F3B0y)v%soXlUiQfNcK 8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)wamp。s pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1zw *t!qYnVjSgOdLaI6F3C0y)v%spXlUiRfNcK8H5E2A+x(u$rZnWkThLaI7F3C0y)vamp。s!pYmUjR fOcL9H6E3B+y(u%roWlTiQeNbJ8G5D1Ax*t$qYnVkSgPdMaI7F3C0z)vamp。t!pYmVjRgOdL9I6F3B0y(v%soXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w amp。spXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1zs!pXmUiRfOcK 9H6E2B+x(u%rZoWlThQeMbJ8G4D1Aw*t!qYnVjSgPdLaI6F3C0y)vamp。s!pXmUjRfOcL9H6E2B+y(u%roWlThQeNbJ8G5D1Aw *t$qYnVkSgPdLaI7F3C0z)vamp。t!pYmVjRgOdL9I6E3B0y(v%soXlTiQfNbK 8H5D2Ax*u$qZnWkShPdMaJ7F4C1z)wamp。t!qYmVjSgOdL9I6F3B(u%rZoWkThQeMbJ8G4D1zw*t!qYnVjSgOdLaI6F3C0y)v%s pXlUiR fNcK8H5E2A+x(u$rZoWkThPeMbJ7G4D1zwamp。s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1Aw*t$qYnVjSgPdLaI7F3C0y)vamp。t!pYmVjR gOcL9I6E3B0y(v%roXlTiQfNbK8G5D2Ax*u$qZnVkShPdMaJ7F4C0z)w amp。spXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1zw*t!qYmVjSgOdLaI6F3B0y)v%spXlUiQfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1zwamp。s!pXmUjRfOcL9H6E3B+ y(u%roWlTiQeNbJ8G5D1Ax*t$qYnVkSgPdMaI7F3C0z)vamp。t!pYmVjRgOdL9I6E3B0y(v%soXlTiQfNbK8H5D2Ax*u$qZnWkShPeMaJ7F4C1z)wamp。t!pYmVjRgOdL9I6E3B0y(v%WkThPeMbJ7G4D1zwamp。spXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1zw amp。s!pXmUjRfOcL9H6E2B+y(u%roWlThQeNbJ8G5D1Aw*t$qYnVkSgPdLaI7F3C0z)vamp。t!pYmVjRgOcL9I6E3B0y(v%roXlTiQfNbK 8G5D2Ax*u$qZnWkShPdMaJ7F4C1z)wamp。spXmUiR fNcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1zw*t!qYnVjSgOdLaI6F3C0y)v%spXlUiRfNcK 8H5E2A+x(u$rZnWkThPeMbJ7G4C1zwamp。s!pYmUjRfOcL9H6E3B+y(u%roWlTiQeNbJ8G5D1Ax*t$qZnVkSgPdMaI7F4C0z)vamp。t!qYmVjRgOdL9I6F3B0y(v%soXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w amp。s pXlUiRfNcK 9H5E2B+x(u$rZoWkThQeMbJ7G4D1zw*t!qYmVjSgOdLaI6F3B0y)v%oWlThQeMbJ8G4D1Aw*t!qYnVjSgPdLaI7F3C0y)vamp。s!pXmUjRfOcL9H6E2B+y(u%r oWlThQeNbJ8G5D1Ax*t$qYnVkSgPdMaI7F3C0z)vamp。t!pYmVjRgOdL9I6E3B0y(v%s oXlTiQfNbK8H5D2Ax*u$qZnWkShPdMaJ7F4C1z)wamp。spXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1zwamp。O ? Opioids may be withheld ? Mobilize patient if possible Peritonitis ? Acute inflammation of the endothelial lining of the abdominal cavity or peritoneum. Is a lifethreatening illness. ? If peritoneal cavity is contaminated by bacteria, the body produces an inflammatory reaction that walls off a localized area to fight the infection. This reaction involves vascular dilation and increased capillary permeability locally. If this local walling off is not effective, the inflammation spreads and bees peritonitis Peritonitispathophysiology 1. Vascular dilation continues, 2. extra blood is brought to the area of inflammation 3. Fluid is shifted from the ECF partment into the peritoneal cavity resulting in “third spacing”. 4. This shifting then will affect circulatory volume. 5. Hypoperfusion of kidneys can result 6. Peristalsis will slow 7. Bowel lumen will bee distended with gas and fluid 8. Resp. problems can ensue Causes of peritonitis ? Appendicitis ? PUD ? Diverticulitis ? Gangrenous gallbladder ? Bowel obstruction ? Secondary to CAPD ? Ulcerative colitis Presentation of Peritonitis ? Abdominal pain and tenderness which may be referred to the chest or shoulder—these are the cardinal signs ? Distended abdomen ? Nausea, vomiting and anorexia ? Diminished bowel sounds ? Rebound tenderness ? High fever ? Tachycardia ? Dehydration ? Decreased urinary output ? Possible respiratory promise Diagnostics ? Elevated WBCs with a shift to the left (bands) ? Possible positive blood cultures ? Abdominal xray will reveal free air or fluid—and edema ? Peritoneal lavage will reveal more than 500 WBCs/mL3 of fluid, greater than 50,000 RBCs/mL or the presence of bacteria on a gram stain Interventions for Peritonitis ? Hospitalized ? IV fluids and antibiotics ? Daily weight ? Iamp。 decreased blood flow also will alter the protective barrier Peptic Ulcers continued ? Duodenal Ulcers—95% develop in the first portion of the duodenum ? Characteristic feature of a duodenal ulcer is high gastric acid secretion ? Protein rich meals, calcium and vagal excitation stimulate acid secretion ? Up to 95% to 100% of clients with duodenal ulcer disease have ? This pathogen produces substances that damage the gastric mucosa ? Urease produced contributes further to the breakdown. Stress Ulcers ? Acute gastric mucosal lesions occurring after an acute medical crisis ? Associated with HI, burns, respiratory failure, shock, and sepsis. ? Multifocal lesions occur in proximal stomach and duodenum ? Begin as focal areas of ischemia and may progress to massive hemorrhage Complications of ulcers ? Hemorrhage in 1525% of clients ? Perforation—severe pain will ensue. Abdomen is tender, rigid, and boardlike and the client will assume the kneechest position to decrease abdominal wall tensionis a surgical emergency ? Pyloric obstruction—caused by scarring, edema, inflammation or a bination of these Distinguishing between gastric and duodenal ulcers Gastric ulcers 1. Usually in those 50 yrs. And older 2. Equal proportion of males to female 3. Blood group not defining 4. May be malnourished 5. Normal or hyposecretion of stomach acid 6. Heal and recur 7. Pain occurs after a meal 8. Heals and recurs in same area 9. Atrophic gastritis Duodenal Ulcers 1. Occur in those 4050 yo 2. Equal male/female ratio 3. Most often type O blood 4. Well nourished 5. Hypersecretion of stomach acid 6. Occurs 90 min. to 3 hrs. after meal 7. Eating relieves pain. Melena more mon than hematemesis 8. No gastritis Diagnostic Testing ? EGD ? testing—by breath test, serologic testing (antibodies revealed). Antibody testing can not be used to determine eradication. Drug Therapy ? Antisecretory drugs such as Prilosec, Prevacid, Aciphex, Nexium ? H2 receptor antagonists such as Pepcid, Zantac, Axid, Tagamet ? Prostaglandin analogs such as Cytotec. Actually enhances