Health Concepts II Comprehensive Study Guide PDF

Health Concepts II Comprehensive Study Guide Written by Megan Kroll | patreon.com/NursingSchoolStudyNotes St Petersburg College ADN Spring 2024 Revised April 2024 Table of Contents Test 1: Hepatitis | Cirrhosis | Cholecystitis | Diverticulitis | Peptic Ulcer Disease | Appendicitis | Perioperative N...

Health Concepts II Comprehensive Study Guide Written by Megan Kroll | patreon.com/NursingSchoolStudyNotes St Petersburg College ADN Spring 2024 Revised April 2024 Table of Contents Test 1: Hepatitis | Cirrhosis | Cholecystitis | Diverticulitis | Peptic Ulcer Disease | Appendicitis | Perioperative Nursing Care Test 2: Magnesium & Calcium Imbalance | Acid Base Balance | Obstructive Sleep Apnea | Pneumonia | Peripheral Vascular Disease | Venous Thromboembolism | Coronary Artery Disease & Chronic Stable Angina | ECGs: Normal Sinus Rhythm, Sinus Tachycardia, Sinus Bradycardia | Intestinal Obstruction | Benign Prostatic Hyperplasia Test 3: Diabetes Mellitus | Obesity | GERD | Eczema | Glaucoma | Cataracts | Otitis Media | Fractures | Osteoarthritis | Amputation | Tinea (Ringworm) Test 4: Dementia | Delirium | Depression & Anxiety | Suicide | Adjustment Disorder | Ego Defense Mechanisms | Abuse, Violence, and Neglect | Substance Abuse Test 5: Sexually Transmitted Infections | Contraception | Antepartum Nursing Care | Intrapartum Nursing Care | Assessment of the Newborn | Postpartum Nursing Care Skills Nasogastric Intubation & Enteral Nutrition IV Therapy Indwelling Catheter Test 1 Hepatitis Iggy p. 1166 ATI Med Surg p. 395 Background: Hepatitis is the inflammation and infection of liver cells, usually caused by a virus Hepatitis A, B, C, D, & E viruses are most common causes Toxic and drug-induced hepatitis: caused by exposure to certain drugs and chemicals by inhalation, ingestion, or IV administration - NOT caused by a virus Secondary hepatitis: secondary infection due to infection with other viruses such as Epstein-Barr, herpes simplex, varicella-zoster, and cytomegalovirus Pathophysiology: the liver becomes enlarged and congested with inflammatory cells, WBCs, and fluids; the actual shape of the liver becomes distorted by progressive inflammation and necrosis - this causes increased pressure & interferes with the blood flow into the hepatic lobes. Inflammation in the liver’s bile channels causes jaundice. Assessment Cues HBV, HCV, and HDV can be asymptomatic until advanced stages Early signs: ○ Abdominal pain ○ Nausea & vomiting ○ Constipation or diarrhea ○ Joint or muscle pain ○ Fatigue, malaise Later/advanced signs: ○ Jaundice & icterus (yellowing eyes) ○ Dark yellow to brownish urine ○ Fever ○ Anorexia & weight loss ○ Dry skin, pruritus (due to bilirubin deposits in skin) Labs/Diagnostics Elevated ALT, AST, ALP, bilirubin ○ Alanine aminotransferase (ALT): liver enzyme; elevated (>36 units/L) ○ Aspartate aminotransferase (AST): liver enzyme; elevated (>35 units/L) ○ Alkaline phosphatase (ALP): normal or elevated (>120 units/L) ○ Total bilirubin level: elevated (>1.0 mg/dL) Antibody tests: anti-HAV antibody test; hepatitis B surface antigen test (HBsAg); anti-HCV antibody test; anti-HDV antibody test; anti-HEV antibody test Liver biopsy for definitive diagnosis & assessing intensity of infection and degree of liver damage Nursing Interventions Adequate nutrition to combat weight loss (high-cal, high-carb, mod-fat, mod-protein diet with extra vitamins; small, frequent meals) Health Concepts II Comprehensive Course Study Guide | 1  Encourage rest to combat fatigue Avoid unnecessary medications to allow liver rest Pts with hepatitis should avoid crowds or being around sick people (because many meds to treat hepatitis cause immunosuppression) Pts should refrain from sexual activity and should be educated about preventing transmission to others Positive test for ANY type of viral hepatitis must be reported to health department Complications Fulminant hepatitis: severe, acute, and often fatal; caused by acceleration of liver necrosis without cell regeneration; rapid onset of severe liver failure Chronic hepatitis: liver inflammation lasting 6+ months or longer; usually resulting from HBV, HCV, and HDV; increases risk for liver cancer Cirrhosis: extensive liver scarring, can be caused by chronic hepatitis Liver failure: caused by irreversible damage to liver and leads to decreased liver functionality Liver cancer: HBV/HCV increase risk Type of Hepatitis Incubation Mode of Transmission Treatment Virus Period Hepatitis A (HAV) 15-50 days Fecal-oral or via contaminated food or water Immunoglobulin post * Vaccine available (esp shellfish) exposure; supportive care - self-resolves Hepatitis B (HBV) 25-180 days Blood, unprotected sex, during birth from an Antiviral medications; 10% * Vaccine available infected mother, infected needles/drug of cases become chronic paraphernalia Hepatitis C (HCV) 14-180 days Blood, infected needles/drug paraphernalia, Ribavirin & peginterferon unprotected sex alfa-2a; most cases are chronic; some can be cured Hepatitis D (HDV) 14-56 days Coinfection with HBV; infected needles/drug Supportive care paraphernalia, unprotected sex Hepatitis E (HEV) 15-64 days Fecal-oral; ingestion of food or water Supportive care - contaminated with fecal waste; common self-resolves after heavy rains and flooding in countries without adequate sanitation Cirrhosis Iggy p. 1156 Cirrhosis is extensive, irreversible scarring of the liver. Pathophysiology: chronic liver inflammation leads to scarring; nodular tissue develops; nodules can block bile ducts and normal blood flow in the liver; in early stages, liver is enlarged and firm, and in late stages, liver is shrunken and hard Health Concepts II Comprehensive Course Study Guide | 2 Types of Cirrhosis Postnecrotic cirrhosis (caused by hepatitis viruses, especially hepatitis C) Laennec’s/alcoholic cirrhosis (caused by chronic alcoholism) Biliary (cholestatic) cirrhosis (causes by chronic biliary obstruction) Signs & Symptoms Jaundice, icterus (yellowed eyes) Dry skin, pruritus (itchy skin) Rashes Purpuric lesions (petechiae - pinpoint red spots, ecchymoses - large bruises) Warm, bright red palms Spider angiomas (vascular lesions) on face and upper body Ascites Peripheral dependent edema Vitamin deficiency (esp. Fat-soluble vitamins: Vit A, Vit D, Vit E, Vit K) Asterixis: coarse hand tremor, hand flapping Nursing Assessment History: alcohol/drug use, sexual history (hepatitis risk), time in institutions (prison, military) Early signs: fatigue, significant weight changes, GI symptoms, abdominal pain Later signs: GI bleeding, jaundice, ascites, bruising, mental status changes Labs/Diagnostics Labs: ○ Liver enzymes (AST, ALT, LDH, ALP, GGT) - all elevated ○ Bilirubin - elevated ○ Serum proteins (albumin, globulin, total protein) - low ○ Ammonia (high), prothrombin time (PT), INR (prolonged) Diagnostics: ○ Abdominal x-ray ○ CT or MRI ○ Ultrasound of liver Complications of Cirrhosis Portal hypertension: persistent increase in pressure within the portal vein >5mm Hg ○ Caused by blockage or increased resistance to blood flow through the portal vein ○ Blood has nowhere else to go, so it back flows into the spleen and causes splenomegaly (enlarged spleen) - also causes enlarged veins in the esophagus (esophageal varices), prominent abdominal veins, hemorrhoids, and ascites (excessive abdominal fluid) Ascites: collection of free fluid in the peritoneal cavity (third spacing) ○ Plasma protein moves from blood into peritoneal fluid = low serum protein ○ Liver’s ability to produce albumin is also impaired (also contributes to low serum proteins) = feedback loop of more fluid moving into peritoneal cavity and out of circulation Esophageal varices: distention of esophageal veins due to portal hypertension ○ High risk of bleeding; ruptured esophageal varices can result in massive blood loss and death Splenomegaly: enlarged spleen Health Concepts II Comprehensive Course Study Guide | 3  ○ Blood backs up from the liver into the spleen and causes enlargement ○ Spleen destroys platelets = thrombocytopenia (low platelet count) ○ Increased risk for bleeding; may be first clinical sign of liver dysfunction Biliary obstruction: decreased production of bile in liver ○ Prevents absorption of vitamins, especially vitamin K, from intestines ○ Vitamin K is needed for clotting factors; increased risk for bleeding Hepatic encephalopathy (aka portal-system encephalopathy, PSE): a cognitive syndrome caused by liver failure and cirrhosis ○ 4 stages; progression from mild cognitive impairments and personality changes, sleep disturbances, continuing mental impairment, confusion, stupor, disorientation, to unconsciousness and death (see Iggy pg. 1157) ○ Labs: high serum ammonia & GABA Other ○ Hepatorenal syndrome: kidney failure secondary to cirrhosis/liver failure ○ Spontaneous bacterial peritonitis: bowel bacteria migrate through intestinal wall and infiltrate the peritoneal cavity ○ Hepatopulmonary syndrome: excessive volume of fluid from ascites causes trouble breathing due to pressure on lungs and diaphragm Nursing Interventions & Care for Cirrhosis/Ascites/Hepatic Encephalopathy Measure abdominal girth Daily weights, I&O Low sodium diet (1-2g/day) Additional nutritional support (IV vitamins); high-carb, high-protein, mod-fat diet Diuretic (watch for electrolyte imbalances) Respiratory support: semi-Fowler’s position, oxygen prn Observe for confusion, monitor ammonia levels (encephalopathy) Avoid acetaminophen, alcohol, heavy lifting/increased abdominal pressure (esophageal varices) Paracentesis may be needed Cholecystitis Iggy p. 1177 ATI Med Surg p. 383 Background: cholecystitis is inflammation of the gallbladder. It can be acute or chronic. There are two types of acute cholecystitis: calculous (caused by gallstones) or acalculous (not caused by gallstones). Chronic cholecystitis is due to repeated acute episodes and almost always involves calculi. Cholelithiasis is the presence of gallstones without inflammation/infection. Pathophysiology Calculous cholecystitis (caused by gallstones, aka calculi) ○ Gallstones (calculi) cause blockages in the cystic duct, gallbladder neck, or common bile duct Gallstones are caused by impaired gallbladder motility and/or abnormal metabolism of cholesterol Health Concepts II Comprehensive Course Study Guide | 4  ○ Obstruction leads to inflammation, which causes impaired circulation, edema, and distention of gallbladder; inflammation also leads to trapped bile, which is reabsorbed and further damages gallbladder wall ○ Ischemia & infection occur; necrosis and gangrene can follow ○ Perforation of the gallbladder may occur, leading to abscess (if perforation is small) or peritonitis (if perforation is large) Acalculous cholecystitis (not caused by calculi) ○ Caused by biliary stasis due to decreased blood flow to the gallbladder or anatomical problems like twisting/kinking of gallbladder neck or sphincter of Oddi dysfunction (SOD) ○ Pancreatic enzymes reflux into the gallbladder causing inflammation, which causes impaired circulation, edema, and distention This type of cholecystitis occurs in patients with: Sepsis, severe trauma, or burns Long-term TPN Multiple organ dysfunction syndrome (MODS) Major abdominal surgery Hypovolemia Chronic cholecystitis ○ Usually results from repeated episodes of cystic duct obstruction which leads to chronic inflammation, organ atrophy, and fibrosis; calculi are almost always present Some people on long-term low-fat (i.e. vegetarian/vegan) diets who are athletic or thin may experience chronic cholecystitis without calculi ○ Bile backup due to bile obstruction leads to pancreatitis, cholangitis (bile duct inflammation), jaundice, icterus, pruritus and burning skin (due to excess bile salts in skin), clay-colored stools (due to lack of urobilinogen in feces), dark urine Risk Factors for Cholecystitis Female Pregnancy American Indian, Mexican American, Family history Caucasian ethnicity Prolonged use of TPN Obesity Crohn’s disease Rapid weight loss or prolonged fasting Gastric bypass surgery Low-fat diet (long-term) Sickle cell disease High cholesterol/lipids Glucose intolerance/diabetes Women on HRT or oral contraceptives Genetic factors Assessment Cues Episodic or vague upper abdominal pain (may Rebound tenderness (Blumberg sign) radiate to right shoulder) Fever Pain triggered by high-fat foods or large Jaundice, icterus (yellow sclera), clay-colored volumes stools, dark urine (late stage/chronic cases) Anorexia Steatorrhea (fatty stools, common with chronic Nausea and/or vomiting cholecystitis) Dyspepsia (heartburn) In older adults: acute delirium, no pain or fever Eructation (burping) In diabetics: no pain or fever Flatulence (gas) Feeling of abdominal fullness Health Concepts II Comprehensive Course Study Guide | 5 Labs & Diagnostics Yoost p. 764 for values White blood cells High (>10,000 cells/mm3) Alkaline phosphatase (ALP) High (normal range 30-120 units/L) Aspartate aminotransferase (AST) High (normal range 4-36 units/L) Lactate dehydrogenase (LDH) High (normal range 140-280 units/L) Bilirubin High (normal 0.3-1.0 mg/dL) Serum amylase High (normal 40-140 units/L) Serum lipase High (normal 0-160 units/L) Ultrasound of URQ (best initial test) Abdominal x-ray (calcified stones only) Hepatobiliary scan/hepatobiliary iminodiacetic acid (HIDA) scan - nuclear test Endoscopic retrograde cholangiopancreatography (ERCP) - nuclear test Magnetic resonance cholangiopancreatography (MRCP) - nuclear test Nursing Interventions Pain management: ketorolac for moderate pain, opioids for acute biliary pain Nausea and vomiting: antiemetics, IV hydration, withhold food for nausea IV antibiotic therapy Nutrition: avoid excessive intake of high-fat foods, increase fiber intake, avoid “trigger” foods, avoid gas-producing foods, recommend weight reduction program if obese Treatment Ursodiol and chenodiol: medications that can dissolve gallstones (long-term management) Extracorporeal shock wave lithotripsy (ESWL): for patients who have normal weight, cholesterol-based stones, and good gallbladder function; patient lies on a water-filled bed and shock waves break up the stones so they can pass naturally; contraindicated for people with pacemakers or other devices affected by shock waves. Percutaneous transhepatic biliary catheter: aka biliary drain; surgically placed drain for blocked bile ducts Cholecystectomy: surgical removal of gallbladder ○ Laparoscopic (most cases) or open approach (rare) ○ Nursing interventions: pain management, deep breathing exercises, leg exercises to prevent DVT, incision care Complications Biliary colic happens when the cystic duct is blocked or a gallstone is trying to move through a duct and spasms occur as the body tries to rid itself of the blockage. It causes severe pain, tachycardia, pallor, diaphoresis, and prostration (exhaustion). It can lead to shock - contact the PCP or RRT, stay with the patient, and keep the head of the bed flat. Suppurative cholangitis: bacterial accumulation around the stones leading to pus in the ductal system; severe and life-threatening Health Concepts II Comprehensive Course Study Guide | 6  Postcholecystectomy syndrome (PCS): signs/symptoms of cholecystitis which occur after removal of gallbladder; symptoms are abdominal pain, diarrhea, and/or vomiting; various causes Bile peritonitis: caused when too much bile remains undrained from surgical site after a cholecystectomy; report pain, fever, jaundice to PCP ASAP Diverticulitis Iggy p. 1149 ATI Med Surg p. 373 Background: Diverticulosis is the presence of diverticula, pouchlike herniations of the mucosa through the muscular wall of any part of the intestines, usually the sigmoid colon; diverticulosis is a condition without inflammation and usually don’t cause problems. Diverticula are often found via routine colonoscopy. Diverticulitis is the inflammation and/or infection of the diverticula. 10-25% of pts with diverticulosis will have an episode of diverticulitis. Pathophysiology Diverticula usually occur in the sigmoid colon at points of weakness in the intestinal wall Weakness in the intestines is due to advanced age or low-fiber diet Diverticula are like little pouches that can trap undigested food or bacteria, which causes reduced blood flow and allows bad bacteria to invade the area Inflammation and infection result; abscess or peritonitis can develop Lower GI bleeding can also occur Very common in older adults (80+ years old) and in people with low-fiber diets Assessment Cues Abdominal pain, especially in LLQ In peritonitis… Abdominal distention ○ General abdominal pain Localized muscle spasms ○ Fever Guarded movement ○ Chills Rebound tenderness ○ Tachycardia Blood in stool ○ Profound guarding Constipation, diarrhea, flatulence, heartburn ○ Profound rebound tenderness ○ Hypotension ○ Hypovolemic shock ○ Sepsis Labs & Diagnostics WBCs (high) (>10,000 cells/mm3) Hematocrit & hemoglobin (decreased with chronic or severe bleeding) Fecal occult blood test Colonoscopy (most definitive) Abdominal x-ray Abdominal ultrasound CT scan Nursing Interventions Health Concepts II Comprehensive Course Study Guide | 7  Focused GI assessment: bowel sounds (hyperactive) Expect to give antibiotics and analgesics Do not give laxatives or enemas Check stools for occult or frank bleeding Tell pt to rest and specifically avoid straining, bending, coughing, or lifting - anything that increases abdominal pressure Nutrition during an inflammatory episode: IV fluids for dehydration; liquid diet, NG tube, or NPO; progressive low-fiber diet (start low and go up) Diet education: gradually increase fiber once symptoms subside; 25-35g/day; avoid alcohol; avoid anything with seeds or indigestible material (nuts, corn, popcorn, cucumbers, tomatoes, figs); adequate hydration Treatment Colon resection with colostomy for severe/recurrent diverticulitis Nutrition management at home will suffice for the majority of cases Complications Peritonitis (due to perforation) Bowel abscess Bowel obstruction (due to fibrosis or advanced inflammation) Fistula (perforation of bowel into surrounding organs, like bladder) Uncontrolled bleeding (due to perforation) Paralytic ileus Peptic Ulcer Disease Iggy p. 1096 ATI Med-Surg p. 351 Types of Peptic Ulcers Duodenal Ulcer Gastric Ulcer Stress Ulcer Location Occur in upper portion of Usually occur in the antrum Usually occur in the fundus duodenum (lower area) of the stomach (body of stomach) Causes/risk Caused by H. pylori or adverse Caused by H. pylori or adverse Caused by critical/acute factors effects of meds (primarily effects of meds (primarily illness or injury, especially NSAIDs); smoking, alcohol, NSAIDs); smoking, alcohol, sepsis or head trauma genetics, stress increase level genetics, stress increase level of stomach acid of stomach acid Patho- High gastric acid secretion Break in the mucosal barrier Reduced mucosal blood flow, physiology causes excessively low pH in leads to damage to epithelial decreased GI motility, the duodenum for extended tissues from stomach acid reduced bicarbonate periods of time production, and acid Dysfunction of the pyloric back-diffusion during periods sphincter and delayed gastric of critical illness contribute to emptying can also contribute to stress ulcers Health Concepts II Comprehensive Course Study Guide | 8  mucosal inflammation and ulceration Appearance Deep, sharp, penetrating Smooth, round, oval or cone Multiple, superficial erosions lesions through mucosa, shaped lesions submucosa, & muscle layers; necrotic lesions over granulation tissue Signs & Pain 1.5-3 hrs after eating Pain 30-60 mins after eating Bleeding caused by gastric symptoms Awakened by pain at night Nighttime pain uncommon erosion is the main symptom Pain relieved by food or Pain worsened by eating antacids Possible malnourishment Usually well-nourished Hematemesis more likely Melena more likely More common in older pts More common in younger pts (50-70 years old) (20-50 years old) Treatment PPIs, antacids, H2 antagonists, PPIs, antacids, H2 antagonists, Prophylactic proton pump prostaglandin analogs, prostaglandin analogs, mucosal inhibitor (PPI) drugs mucosal barrier fortifiers, barrier fortifiers, antimicrobials antimicrobials (for H. pylori) (for H. pylori) Complications of Peptic Ulcer Disease Hemorrhage (most serious) ○ Occurs most often in older patients and with gastric ulcers ○ Symptoms: Hematemesis (bright red or coffee-ground vomit) Melena (tarry or dark sticky stools) Decreased hemoglobin & hematocrit Hypotension Tachycardia Weak peripheral pulses Acute confusion (in older adults) Vertigo and dizziness Syncope (loss of consciousness) Perforation (also very serious) ○ Occurs when the ulcer eats away at the entire thickness of the stomach or duodenum, causing stomach/intestinal contents to leak into the peritoneal cavity ○ Symptoms: Sudden, sharp pain in the epigastric region Tender, rigid, boardlike abdomen (peritonitis) Patient in fetal position to alleviate pressure in abdomen ○ Bacterial septicemia, hypovolemic shock, and paralytic ileus can develop Pyloric obstruction ○ Caused by blockage in the pylorus due to scarring, edema, and/or inflammation and causes gastric stasis and dilation ○ Symptoms: Vomiting Abdominal bloating Nausea Metabolic alkalosis and hypokalemia from vomiting Health Concepts II Comprehensive Course Study Guide | 9  Intractable disease (recurrence/worsening of symptoms) ○ Intractability may result from complications of ulcers, excessive stress, or inability to adhere to long-term therapy Gastric cancer (rarely) Assessment for Peptic Ulcer Disease Risk factors ○ History of chronic NSAID use, corticosteroids, chemotherapy, radiation therapy ○ History of H. pylori infection ○ Lifestyle factors: alcohol, smoking, stress, caffeine Assessment findings ○ Epigastric tenderness and pain ○ Hyperactive bowel sounds ○ Dyspepsia (heartburn, bloating, nausea, vomiting) ○ Weight loss Assessment actions ○ Take orthostatic blood pressure (to assess for fluid volume deficit) ○ Assess for dehydration ○ Assess for dizziness (secondary to dehydration) Diagnostic Assessment Tests for H. pylori ○ Urea breath test ○ Stool antigen test ○ Serologic (blood) antigen test Other tests ○ Esophagogastroduodenoscopy (EGD) - the most common diagnostic test Visualization of ulcers, ability to take biopsy samples ○ Rapid urease test ○ Nuclear medicine scan (for GI bleeding) Treatment Esophagogastroduodenoscopy (EGD) - cauterize bleeding ulcers Surgical interventions ○ Gastrectomy: removal of all or part of the stomach Antrectomy: removal of antrum (lower part of stomach) Gastrojejunostomy: lower portion of stomach is removed, remaining portion is attached to jejunum, bypassing duodenum ○ Vagotomy (vagus nerve is cut to reduce gastric acid production - last resort therapy) ○ Pyloroplasty (pyloric sphincter is enlarged to speed up gastric emptying) Nursing Interventions/Patient Education Tell pt to keep a food diary to track trigger foods Eat smaller meals Avoid alcohol Reduce stress No food or drink 2 hours before bed Health Concepts II Comprehensive Course Study Guide | 10 Drug Therapies for Peptic Ulcer Disease Iggy p. 1097 Drug Class & Common Side Effects/Adverse Patient Education Examples Effects/Contraindications Antacids Deactivate pepsin and increase pH (alkalinize) of gastric contents Magnesium hydroxide with Side effects: diarrhea, high magnesium Take 2 hrs after meals & at bedtime aluminum hydroxide levels Take in liquid form (not tablets) Don’t take longer than 2 weeks Contraindicated for pts with kidney Do not take other drugs within 1-2 hrs problems of antacids Aluminum hydroxide Side effects: constipation, low Take 1 hr after meals & at bedtime phosphorus/magnesium levels, Take in liquid form (not tablets) electrolyte imbalances Don’t take longer than 2 weeks Do not take other drugs within 1-2 hrs Safe for patients with kidney problems of antacids H2 Antagonists Decrease gastric acid secretions by blocking histamine receptors in parietal cells Famotidine (Pepcid) Side effects: decreased libido, Give single dose at bedtime Nizatidine impotence, lethargy, confusion, Ranitidine depression Mucosal Barrier Fortifiers Protect stomach mucosa Sucralfate Check for medication interactions Give 1 hr before meals & at bedtime Do not give within 30 mins of antacids Bismuth subsalicylate Do not take aspirin while on this drug - (Pepto-bismol) may cause salicylic acid overdose Proton Pump Inhibitors *PPIs are the drug of choice for PUD OTC meds should only be used for 2 weeks (PPI) Slow-release, lasts over 24+ hours Suppress HK-ATPase enzyme Don’t crush/chew ER tabs system of gastric acid secretion to suppress acid Omeprazole (Prilosec) Side effects: rebound acid after abrupt Give 30 min before main meal of the day discontinuation, increased risk of osteoporosis, increased risk of pneumonia in pts w/ COPD Contraindicated w/ lactation Lansoprazole (Prevacid) Side effects: rebound acid after abrupt Give 30 min before main meal of the day discontinuation, increased risk of osteoporosis, increased risk of pneumonia in pts w/ COPD Health Concepts II Comprehensive Course Study Guide | 11  Contraindicated w/ lactation Rabeprazole (AcipHex) Take after morning meal Pantoprazole (Protonix) IV form must be given on a pump with filter and separate line; must not be given with other IV drugs Monitor for adverse reactions for other drugs Esomeprazole (Nexium) Assess for liver impairment Do not give IV with other IV drugs Monitor for adverse reactions for other drugs Prostaglandin Analogs Stimulate mucosal protection and decrease gastric acid secretions Misoprostol Side effects: diarrhea, stomach cramping People of childbearing age should take Abortifacient - do not give to pregnant pregnancy precautions people May be given to patients on NSAID therapy Antimicrobials Used to treat H. pylori infection Clarithromycin Use with caution in pts with renal impairment Amoxicillin Side effects: GI upset Take w/ food Tetracycline Side effects: GI upset, photosensitivity Take at least 1 hr before meals or 2 hrs after; use sun protection Metronidazole Side effects: GI upset Take w/ food MAJOR interaction w/ alcohol, avoid Appendicitis Iggy p. 1135 Appendicitis: acute inflammation of the appendix Pathophysiology: the lumen (opening) of the appendix is obstructed by fecaliths (very hard pieces of feces); when the lumen is blocked, the mucosa secretes fluid which increases the internal pressure and restricts blood flow (causing pain), allowing bacteria to infect the wall of the appendix ○ If inflammation/infection occurs slowly, an abscess may develop ○ If inflammation/infection occurs quickly, this may cause peritonitis Within 24-48 hrs, gangrene, sepsis, and perforation can occur Health Concepts II Comprehensive Course Study Guide | 12  Assessment Cues: ○ Pain in the RLQ at McBurney’s point (between umbilicus and anterior iliac crest, right) ○ Pain at obturator sign (pain with internal rotation of the right hip) ○ Sudden relief of pain may be a sign of appendix rupture ○ Nausea and vomiting ○ Loss of appetite (anorexia) ○ Abdominal pain with coughing or movement ○ Rebound tenderness of abdomen ○ Rigid, boardlike abdomen, abdominal guarding (with peritonitis) Labs/Diagnostics: ○ moderate WBC elevation (10,000-18,000 mm3) with left shift (bandemia) ○ May be elevated: C-reactive protein, AST, ALT, bilirubin ○ ultrasound of appendix ○ CT scan ○ Differential diagnosis: pregnancy test to rule out ruptured ectopic pregnancy Nursing Interventions: ○ Keep pt NPO in prep for surgery ○ IV fluids, opioid analgesics, antibiotics ○ Do not apply heat to the abdomen (can cause increased inflammation/risk of perforation) ○ Do not administer laxatives or enemas (can cause perforation) Treatment: ○ Surgical interventions: Laparoscopic appendectomy (minimally invasive) Exploratory laparotomy (large incision, used for non-definitive diagnosis) Perioperative Nursing Care ATI Med Surg p. 751 Yoost p. 891 Types & Classification of Surgical Procedures Level of Urgency Elective: procedure that is performed to improve quality of life; procedure is planned and scheduled in advance. Example: hysterectomy for uterine fibroids Urgent: procedure that is performed within 24 hours of diagnosis; condition isn’t life-threatening, but delaying or not doing the procedure could result in life-threatening complications or death. Example: pinning or setting a bone after a fracture Emergency: procedure is performed ASAP to preserve the patient’s life, body organs, or body function; mortality and morbidity rates are highest in this category. Examples: control of internal bleeding after a gunshot wound Degree of Risk Minor surgery: low risk, little to no anesthesia or respiratory assistance, usually outpatient. Examples: cataract surgery, breast biopsy, mole removal Major surgery: moderate to high risk, use of anesthesia and respiratory assistance, major alterations to body, often inpatient. Examples: bowel resection, mastectomy, appendectomy Health Concepts II Comprehensive Course Study Guide | 13 By Purpose Diagnostic: establishes or confirms a diagnosis (ex: liver biopsy for hepatitis) Ablative: removal of a part of the body that is diseased (ex: removal of gangrenous toes) Constructive: restores functioning that has been lost or reduced (ex: cleft lip or palate) Reconstructive/restorative: restores function or appearance of traumatized or malnourished tissues (ex: skin graft for burn victim) Transplantation: replaces dysfunctional body part (ex: lung, heart, kidney) Palliative: improves comfort and decreases pain or symptoms but does not cure illness (ex: back surgery to decrease pain and pressure) Cosmetic: improves personal appearance (ex: liposuction, rhinoplasty) Types of Anesthesia Type Method Description Moderate sedation Pain medications, sedatives Pt is awake, maintains their own airway, but may be (conscious sedation) drowsy, have amnesia; may be combined with other types of regional anesthesia General anesthesia Administered via gasses and/or Pt is in drug-induced coma with CNS depression; IV drugs risks of respiratory and circulatory depression; usually has artificial airway Regional anesthesia Types: nerve, spinal, epidural, Blocks pain impulses, no loss of consciousness, no local, topical intubation Nerve block Injection of anesthetic into a Injections given in head, neck, extremities, or trunk particular nerve, group of nerves, or surrounding tissues Bier block Injection of anesthetic into the Can help manage chronic pain, or for use in venous circulation of an surgery on an extremity. * Important to note time extremity, extremity has tourniquet is inflated tourniquet applied Epidural Anesthetic injected into epidural Results in loss of sensory and motor function below space in the lumbar or thoracic level of injection spine Spinal Anesthetic injected into Blocks sensations in lower body; may result in subarachnoid space in spine severe spinal/postspinal headache: blood patch will be placed over dura hole for relief Local Injection or application of Used for small areas of the body for procedures anesthetics subcutaneously to a such as dental or dermatological procedures specific area Topical Anesthetic applied to surface of Can be used to decrease pain or discomfort the skin or mucous membranes for numbing Health Concepts II Comprehensive Course Study Guide | 14 Preoperative Nursing Care Preoperative Assessment ATI Med Surg p. 751 Detailed history Medical and surgical history Tolerance of anesthesia Medication use, including herbal supplements Psychosocial history and cultural considerations Substance use (tobacco, alcohol, illicit drugs) Social/family support systems Genetic history Occupation and level of education Perceptions and knowledge about surgery Possibility of pregnancy Allergies Medications Latex Contrast agents Food products ○ Banana or kiwi allergy: risk for latex allergy ○ Egg or soybean oil allergy: risk of propofol allergy ○ Shellfish allergy: possible risk for iodine based contrast media Anxiety level About the procedure/surgery Anxiety coping mechanisms Support systems Baseline data Head-to-toe assessment Neurologic assessment Vital signs & O2 sats Lab/diagnostic results Clot risk Risk level based on surgical procedure performed (PE/DVT) Patient history & individual risk factors Anticipated time immobilized during and after procedure Risk factors for surgical complications Body system Examples Risks Respiratory Obstructive sleep apnea, COPD, Increased risk of airway obstruction, oxygen disorders pneumonia, asthma desaturation, respiratory depression Cardiovascular Heart failure, myocardial infarction, Increased risk of MI, fatal dysrhythmias, fluid and disorders hypertension, dysrhythmias electrolyte imbalances Coagulation Use of blood thinners, history of clots Increased risk of bleeding, hemorrhage, bloods disorders (stroke, etc), liver diseases clots, shock Renal disorders Acute or chronic renal failure Increased risk of dangerous blood pressure, fluid and electrolyte imbalances, inability to metabolize drugs properly Hepatic disorders Liver disease Increased risk of fluid and electrolyte imbalances, acid-base imbalances, altered excretion/metabolism of drugs Health Concepts II Comprehensive Course Study Guide | 15  Diabetes Diabetes mellitus type 1 or 2 Increased risk of hyperglycemia during surgery, impaired wound healing, impaired circulation, increased risk of infection Pregnancy Especially risky in first trimester Fetal risk with anesthesia (spontaneous abortion, preterm labor) Substance Smoking, illicit drug use Increased risk of anesthetic overdose (with many use/abuse illicit drugs), impaired wound healing (smoking), laryngospasm (smoking), vasoconstriction (smoking) Obesity BMI >30 Pulmonary complications d/t hypoventilation, reduced effect of anesthetic, delayed wound healing Malnutrition BMI