H&H PN3 Midterm PDF

Module 2 Nursing Management: Intraoperative & Postoperative Health, Healing and the Nursing Process 3 Chapter 21 Nursing Management: Intraoperative Care Agenda Introduction Activity Module 2 Part I: Intraoperative Care Break Module 2 Part II: Postoperative Care Looking ah...

Module 2 Nursing Management: Intraoperative & Postoperative Health, Healing and the Nursing Process 3 Chapter 21 Nursing Management: Intraoperative Care Agenda Introduction Activity Module 2 Part I: Intraoperative Care Break Module 2 Part II: Postoperative Care Looking ahead 21-3 Learning Outcomes Examine the role and responsibilities of a nurse caring for a client in the intraoperative and postoperative phase Describe the roles and responsibilities of other healthcare team members in the intraoperative and postoperative phase Examine the role of the nurse and the interventions in place to promote client safety in the intraoperative and postoperative phase Learning Outcomes (Cont.) Analyze key differences in the surgical care of patients in all life stages Differentiate between regional and general anesthesia Describe postoperative nursing assessments and interventions Describe the etiology, pathophysiology, risk factors, clinical manifestations, assessment, diagnostic studies, nursing interventions, and interprofessional management of common post operative complications. Intraoperative Care Historically, took place in operating room (OR) Current trend to decrease in-hospital Shorter procedures surgery and increase ambulatory Faster recovery procedures 21-6 Nursing Management Before surgery Chart review Health record Consent documentation Admit Patient Proper identification Pre-op medications Surgery checklist Personal belongings, last known intake of food 21-7  Nursing Management (Cont.) Room preparation Surgical attire worn by all persons entering OR suite Electrical and mechanical equipment checked for proper function Aseptic technique practised when placing instruments Counts Functions of team members delineated 21-8 Nursing Management (Cont.) Transferring patient Patient transported into OR after preparation Sufficient number of staff to lift, guide, and prevent patient falls, as well as injury to staff Straps across patient Caution with monitor leads, IVs, and catheters Wheels locked 21-9 Nursing Management (Cont.) Scrubbing, gowning, and gloving Disinfect hands and arms by using a surgical hand antiseptic or scrub agent Kills microorganisms on contact Decreases microbes Inhibits rapid microbial reproduction Standard procedure for personnel Sterile gown and gloves are put on after scrub 21-10 Nursing Management (Cont.) Basic aseptic technique Only sterilized items in sterile field Protective equipment Face shields, caps, gloves, aprons, and eyewear Enhanced precautions for aerosolized procedures for individuals with COVID-19 Table 21.3 Maintaining A Sterile Field In The Operating Room 21-11  PN Lab 3, Module 2: Surgical asepsis (“Sterile technique”) Reminder: Aim: prevent or remove all microbes/pathogens Kill all microbes including spores surgical Ex. Use of sterile supplies, sterilizing equipment, sterile gloves, surgical caps etc asepsis STERILE TECHNIQUE GOVERNING PRINCIPLES apply! 11 principles Nursing Management (Cont.) Positioning of patient Accessibility of operative site Administration and monitoring of anaesthetic agents Maintenance of airway Correct anatomical alignment 21-13 Nursing Management (Cont.) Preparing surgical site Scrubbing or cleaning around the surgical site with antimicrobial agents Circular motion from clean to dirty area Hair may be removed with clippers 21-14  Classification of Anaesthesia General anaesthesia: reversible loss of consciousness, skeletal muscle relaxation, amnesia, and analgesia (loss of sensation) Technique of choice for surgeries with significant duration or that require relaxation or uncomfortable position Primarily administered intravenously or by inhalation Table 21.4 and 21.5 for specific medications used Multiple medications used for analgesia, amnesia, and muscle relaxation Adjunct with reversal agents upon wakening Adjunct with antiemetics to prevent nausea and vomiting Moderate sedation (or procedural sedation; formerly conscious sedation): mild depression of consciousness so client can tolerate minor procedures while maintaining airway control Minimizes cardiopulmonary complications Reduces the patient’s anxiety and discomfort when undergoing a noninvasive or minimally invasive procedure Administration of IV sedatives, analgesics, or both Common drugs: ketamine, propofol, and midazolam 21-15 Classification of Anaesthesia (Cont.) Local anaesthesia Loss of sensation without loss of consciousness Recovery is rapid, and the duration of action of the local anaesthetic frequently carries over into the postoperative period, providing continued analgesia. Provides an alternative to general anaesthetic in a physiologically compromised patient. Types (Table 21.6): Topical Local infiltration Regional nerve block IV regional nerve block Spinal and epidural blocks 21-16 Age-Related Considerations Anaesthetic medications should be carefully titrated. Physiological deficits due to aging Skin integrity 21-17 Exceptional Clinical Events in the OR Anaphylactic reactions Life-threatening pulmonary and circulatory complications Anaphylactic reaction causes hypotension, tachycardia, bronchospasm, and possibly pulmonary edema. Antibiotics and latex are responsible for many perioperative allergic reactions Manifestation may be masked by anaesthesia. Vigilance and rapid intervention are essential. 21-20 Exceptional Clinical Events in the OR (Cont.) Malignant hyperthermia Rare potentially fatal metabolic disease affecting genetically susceptible patients Triggered by commonly administered anaesthetic drugs, particularly succinylcholine First sign is usually severe masseter muscle rigidity Other signs: rise in end-tidal carbon dioxide (CO2), tachycardia, and elevated body temperature To prevent MH, important for the nurse to obtain a careful family history. The patient known or suspected to be at risk can be anaesthetized with minimal risk if appropriate precautions are taken. 21-21 Exceptional Clinical Events in the OR (Cont.) Major blood loss: hemorrhage (hypovolemia) Vital that the surgical team monitor the patient’s hemodynamic response and changes in fluid status Early signs: increased heart rate and changes in oxygen saturation Other signs: decreased blood pressure, tachypnea, decreased urine output, and cyanosis. If major blood loss occurs during surgery, fluid replacement is needed.  Chapter 22 Nursing Management: Postoperative Care Postoperative Period Begins immediately after surgery Continues until patient is discharged from medical care or until patient makes a complete recovery  Potential complications in the postoperative period Potential Alterations in Respiratory Function  Potential Alterations in Respiratory Function Patients at particular risk include those who Receive general anaesthesia Are older Have a smoking history or lung disease Are obese Are undergoing thoracic, airway, or abdominal surgery Table 22.3: clinical manifestations of inadequate oxygenation Hypertension, hypotension, tachycardia, bradycardia, restlessness, agitation, muscle twitching, cyanosis, delayed capillary refill, use of accessory muscles, decreased urine output etc. Any sign of respiratory distress needs prompt intervention 22-27  Nursing Assessment: Respiratory Regular monitoring of vital signs and pulse oximetry in conjunction with respiratory assessment Assess airway patency, chest symmetry, and the depth, rate, and character of respirations Slow breathing or diminished chest and abdominal movement during the respiratory cycle may indicate impaired ventilation. Respiratory distress: abdominal or accessory muscle use Breath sounds auscultated anteriorly, laterally, and posteriorly. Decreased or absent breath sounds, or presence of crackles or wheezes necessitates notifying the health care provider. Assess for hypoxemia: rapid breathing, gasping, apprehension, restlessness, and a rapid or thready pulse Assess presence and characteristics of sputum or mucus 22-28  Nursing Management: Respiratory Complications PACU Prevent and treat respiratory conditions: proper positioning Lateral recovery position until conscious; then supine with head of bed elevated unless contraindicated Clinical unit Deep breathing and coughing: deep breaths every 5-10 minutes Incentive spirometer Diaphragmatic breathing Reposition every 1–2 hours Ambulation as soon as possible unless contraindicated Adequate pain medication and splinting of incision site if needed Adequate hydration 22-29 Potential Alterations in Cardiovascular Function Immediate postanaesthetic period: common complications include hypotension, hypertension, and dysrhythmias Greatest risk for persons with altered respiratory function or a cardiac history, older persons, and critically ill patients 22-30  Potential Alterations in Cardiovascular Function Clinical unit complications: Postoperative fluid and electrolyte imbalances contribute to alterations in cardiovascular function Stress response Excessive fluid losses/fluid deficit Fluid retention/fluid overload Hypokalemia Deep vein thrombosis (DVT) Pulmonary embolism Syncope (fainting) 22-31  Nursing Assessment: Cardiovascular Frequently monitor vital signs, every 15 minutes until stable Compare to baseline Cardiac monitoring for patients with Hx of cardiac disease and for all older patients regardless of whether they have cardiac conditions. Assess: skin temperature, colour and moisture. Assess: Peripheral circulation, dressing, and drains. Assess: apical–radial pulse carefully and report irregularities Hypotension with normal pulse and warm, dry, pink skin usually residual vasodilation effects of anaesthesia – continue to monitor. Hypotension with rapid pulse and cold, clammy, pale skin may be impending hypovolemic shock and necessitates immediate treatment. 22-32 Nursing Management: Cardiovascular The anaesthesiologist or surgeon should be notified if any of the following occur: 1. Systolic BP is less than 90 mm Hg or greater than 160 mm Hg. 2. Pulse rate is less than 60 beats per minute (bpm) or greater than 120 bpm. 3. Pulse pressure (difference between systolic and diastolic pressures) narrows. 4. BP gradually decreases during several consecutive readings. 5. An irregular cardiac rhythm develops. 6. There is a significant variation from preoperative readings. 22-33 Nursing Management: Cardiovascular Conditions Nursing implementation: PACU Oxygen therapy, IV fluid boluses, medication administration, re-warming Nursing implementation: Clinical unit Accurate intake and output Monitor laboratory findings IV management and monitoring: assessment of infusion rate of fluid replacement and infusion site Adequate mouth care: thirst and drying effect of mucosa common Leg exercises every 1-2hrs when confined to bed Elastic stockings or compressive devices Unfractionated or low-molecular-weight heparin if needed Ambulation: slow progression, monitor pulse, assess for feelings of faintness 22-34  Potential Alterations in Neurological Function Immediate postanaesthetic period: Emergence delirium Reversible Can include restlessness, agitation, disorientation, thrashing, and shouting Caused by anaesthetic agent, hypoxia, bladder distension, pain, sensory and cognitive impairments, electrolyte abnormalities, or anxiety Primarily pediatric and geriatric patients are affected Immediate postanaesthetic period: delayed awakening From prolonged drug action 22-35 Nursing Assessment: Neurological Level of consciousness Orientation Ability to follow commands Size, reactivity, and equality of pupils Sensory and motor status If the patient had a regional anaesthetic, the level of anaesthetic effect should also be determined by assessing the level of numbness. If the neurological status is altered, possible causes should be determined. Ex. hypoxia, electrolyte imbalance (hyponatremia and hypocalcemia), pharmaceutical agent, emotional disturbance etc. 22-36 Nursing Management: Neurological Complications Potential alterations: Pain and Discomfort Etiology (PACU) Can be result of surgical manipulation, positioning, or presence of internal device Etiology (Clinical unit) Trauma to skin and underlying tissues during surgery Reflex muscle spasms around the incision Tension and muscle spasm due to anxiety or fear Deep breathing, coughing, and changing position Pressure in the internal viscera (deep visceral pain may signal complications) 22-38  Nursing Assessment: Pain and discomfort PACU: Pain assessment difficult since self-report is not possible until patient is conscious Physiological indicators such as vital signs not good indicators of pain Observe for behavioural clues of pain: crying, restlessness, wrinkling face or brow, or moaning. Clinical Unit: Postoperative pain is usually most severe within the first 48 hours and subsides thereafter. Observe for indications of pain PQRSTU pain assessment (refer back to Semester 1 Lab) Measure pain before and after treatment is administered Comfort–function goal (e.g., pain control needed to to deep-breathe, turn, ambulate, perform dressing changes etc.)  Nursing Management: Pain and discomfort PACU: interprofessional approach IV opioids (administered slowly and titrated) Additional interventions: epidurals, PCAs, regional anaesthetic blocks Patient-controlled analgesia (PCA): allows for self-administration of a bolus dose of analgesia by patient. Provides immediate analgesia and maintains a constant, steady blood level Epidural analgesia: infusion of pain-relieving medications through a catheter in the spinal cord. Non-pharmacological interventions 22-40 Nursing Management: Pain and discomfort Clinical unit: Postoperative pain relief Nursing responsibility During the first 48+ hours, opioid analgesics (e.g., morphine) required to relieve moderate to severe pain. Afterward, non-narcotic analgesics may be sufficient as pain decreases. When pain is stabilized, pain should be assessed every 2 hours postoperatively Effective pain management promotes optimal healing and prevents complications Allows patients to participate in necessary activities Should be timed to ensure it is in effect during painful activities (e.g., ambulating, dressing change etc. ) Nursing Management: Pain (Cont.) Nursing implementation: Clinical unit Before administering analgesic, nurse should assess nature of patient’s pain (location, quality, intensity etc.): Incisional pain = analgesic administration is appropriate Chest or leg pain may indicate a complication that must be reported and documented Gas pain could be aggravated by opioids Notify physician and request a change in the order if the analgesic Fails to relieve the pain Makes the patient excessively lethargic or somnolent 22-42 Potential Alterations in Temperature PACU: Hypothermia most common Can result from heat loss during long, open surgical procedures due to the low ambient temperature in the OR, the use of cold irrigation fluids, or both Patients predisposed: older persons, children under 2 (especially infants), burn patients, females, and patients under general anaesthesia Complications: prolonged emergence from anaesthesia, increased likelihood of impaired wound healing and surgical site infection, bleeding, and cardiac incidences Active re-warming is needed Oxygen therapy via nasal prongs used to treat the increased demand for oxygen that accompanies the increase in body temperature. 22-43 Nursing Management: Potential Alterations in Temperature (Cont.) Clinical unit: fever more common; Fever can occur any time during postoperative period Temperature elevation provides information about patient’s status Mild elevation (up to 38°C) in first 48 hours result from a surgical stress response. Moderate to marked elevation (>38°C) is usually caused by respiratory congestion or atelectasis After 48 hours, a moderate to marked elevation (higher than 37.7°C) usually indicates infection (wound infection, pneumonia, urinary infection secondary to catheterization etc.) IV site superficial thrombophlebitis (temperature elevation 7 and 10 days after surgery) Other infections: Hospital-associated diarrhea caused by Clostridium difficile; Septicemia 22-44 Nursing assessment: Temperature complications Nursing Management: Temperature Complications Nursing implementation: Clinical unit Measure temperature q4h for first 48 hours postoperatively and then less frequently if no complications develop Asepsis with wound and IV sites Encourage airway clearance to prevent atelectasis If infection suspected: Chest X-rays Wound, sputum, urine, or blood cultures Antibiotics are started AFTER cultures are obtained Antipyretics Body cooling measures for fever over 39.4°C 22-46 Potential Gastrointestinal Conditions Nausea and vomiting are common in immediate postoperative period; increase patient discomfort, delays in discharge, and dissatisfaction with surgical experience Often the reason for unanticipated hospital admission of day-surgery patients Caused by medications, delayed gastric emptying, slowed peristalsis, or resumption of oral intake too soon postoperatively Slowed GI motility and altered patterns of food intake can cause distressing postoperative symptoms in clients with abdominal surgery Postoperative Ileus and Paralytic Ileus potential complicaitons 22-47 Nursing Assessment: Gastrointestinal Conditions Postoperative Nausea and Vomiting: Occurs in about 30% of all surgical patients and 89% of high-risk patients Risk factors: age < 50 years, female gender, history of motion sickness, non- smoker, use of nitrous oxide, opioid use postoperatively, duration of surgery >1hr, type of surgery Prophylaxis medication (Zofran/ondansetron) to minimize PONV in high-risk patients Nonpharmacological interventions: acupuncture, aromatherapy (alcohol and peppermint), TENS, acupressure etc. Nurses should document the quantity and characteristics (including colour) of the emesis 22-48 Nursing Assessment: Gastrointestinal Conditions Postoperative Ileus: delay in return of normal peristalsis after GI surgery Transient cessation of bowel motility that prevents effective passage of intestinal contents and may affect the patient’s tolerance of oral intake Causes abdominal distension, tenderness, and pain. Stomach motility returns in 1–2 days, and bowel motility in 3–5 days. Abdominal distension may require nasogastric (NG) tube for symptomatic relief Lower opioid doses also helps Use nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation 22-49 Nursing Assessment: Gastrointestinal Conditions Paralytic ileus: postoperative ileus lasts for more than 2 to 3 days. Not a mechanical obstruction; peristalsis stops Bowel lumen remains patent, but contents of intestine are not propelled forward, producing severe pain, distention, nausea, vomiting, and poor appetite Usually seen on the clinical unit postoperatively GI assessment: assess for abdominal distension and bowel sounds. Measure abdominal girth Bowel sounds are frequently absent or diminished, and the abdomen will sound tympanic to percussion. Full return of bowel function is indicated by the passage of flatus or stool, not presence of bowel sounds 22-50  Nursing Management: Potential Gastrointestinal Conditions Nursing implementation: Clinical unit IV fluids provide hydration until the patient is able to tolerate oral fluids May resume intake upon return of gag reflex NPO until return of bowel sounds for patient with abdominal surgery Clear liquids (advance as tolerated) and titrate IV as intake increases If oral intake is well tolerated, IV is discontinued and the diet is advanced progressively until a regular diet is tolerated Care should be taken to prevent aspiration if vomiting is occurring Nausea and vomiting: Antiemetics; placing the patient in the upright position; encouraging slow, deep breathing; doing mouth care; using distraction; and providing emotional support as needed Relief of gas pains by frequent ambulation and repositioning Encourage patient to expel flatus and explain it is necessary and desirable 22-51 Potential Alterations in Urinary Function Low urinary output (30 mL/hr) may be expected in the first 24 hours after surgery, regardless of intake. By the second or third day, urinary output should return to normal (60 mL/hr) Persistent low urinary output (oliguria) can indicate inadequate renal perfusion and pending renal failure. Restoring renal blood flow and urine production can prevent renal failure. Acute urinary retention: from genitourinary surgery, anaesthetic, spasms or guarding, pain, lack of skeletal muscle activity, or positioning. 22-52 Nursing Assessment: Potential Urinary Conditions Urine examined for quantity and quality Note colour, amount, consistency, and odour Assess in-dwelling catheters for patency Urine output should be at least 60 mL/hour If no catheter, patient should be able to void 200 mL within 6–8 hours after surgery If no voiding, abdominal inspection and bladder palpation; use of bladder scanner to detect bladder volume 22-53 Nursing Management: Potential Urinary Conditions Nursing implementation: May be postoperative order to catheterize patient in 8-12hrs if not voiding; however, nurse should also facilitate voiding Position patient for normal voiding Ambulating Reassure patient of ability to void Use bedside commode if needed Use techniques such as running water, drinking water, pouring water over perineum, etc. Before catheterization: assess need for catheterization and only catheterize when absolutely necessary; catheter should be removed as soon as possible. 22-54 Potential Integumentary Alterations Incision disrupts skin barrier and healing is a major concern during postoperative period Despite advancements, surgical site infections still a major concern and SSIs are the most common health care associated infection experienced by surgical patients (77% of patient deaths reported to be related to infection) Surgical site infections occur within 30 days after surgery or within 1 year of implant surgery. Characterized by: A combination of purulent discharge The isolation of organisms from wound fluid or tissue Pain, tenderness, local edema, warmth Health care provider diagnosis 22-55 Nursing Management: Surgical Wounds Refer to PN Lab 3 for care, assessment, and management of surgical wounds. 22-56 Potential Alterations in Psychological Function Anxiety and depression can occur in postoperative patients More pronounced in the patient who has had radical surgery (e.g., colostomy, amputation) or who has received a poor prognosis (e.g., inoperable tumour History of neurotic or psychotic disorder Responses may be part of grief process Risks with lack of knowledge, assistance, or resources (ex. client who lives alone or requires rehabilitation after surgery) Confusion and delirium may result from psychological and physiological sources. Fluid and electrolyte imbalances, hypoxemia, medication effects, sleep deprivation, sensory alteration or overload Delirium tremens (DTs) from alcohol withdrawal Older adults: increase incidence of delirium, dementia, and depression 22-57 Nursing Management: Potential Alterations in Psychological Function Nursing implementation: Observe and evaluate the patient’s behaviour Supportive interventions Listen and talk with patient, offer explanations, reassure, and work collaboratively with patient and family Discuss expectation of activity and assistance needed after discharge. Patient must be included in discharge planning and provided with information and support to make informed decisions about continuing care. Recognition of alcohol withdrawal syndrome Report any unusual behaviour for immediate diagnosis and treatment 22-58 Planning for Discharge and Follow-up Care Ambulatory surgery discharge Difficult to do all required teaching due to short time frame; important need for ++ teaching in pre-operative period Patient must be mobile and alert and able to provide a degree of self-care Pain must be controlled Patient must be stable and near preoperative level of functioning Patient cannot drive and must be accompanied by responsible adult Home needs of individuals should be considered 22-59 Planning for Discharge and Follow-up Care Inpatient surgery discharge: Health teaching needs: Preparation should begin in pre-operative period Care requirements for wound site and dressings Arrangements for home care nurses and Bathing recommendations community resources need to be in place Medications: when to take them, how to take Patient must be mobile and alert and able to them, adverse effects, etc. provide a degree of self-care Activities allowed and prohibited, including Pain must be controlled timing of when activities can be resumed Patient must be stable and near preoperative Dietary restrictions or modifications level of functioning Symptoms to be reported and who to call Patient cannot drive and must be accompanied Where and when to return for follow-up care by responsible adult Answers to any individual questions, concerns, Home needs of individuals should be considered or needs All discharge instructions should be documented 22-60 Age related considerations Normal aging and chronic disease can affect surgical outcomes Older person has decreased respiratory function and ability to cough Pneumonia and atelectasis is more common Cardiac function is more compromised, so body less able to compensate for changes in fluid volume, cardiac output etc. Drug toxicity is a higher concern Postoperative delirium a concern Older patients at greater risk for undertreated pain Next Steps Next week's topic: Acute & Surgical Renal & Urological Conditions Upcoming assignments: Group contract (end of Week 3) First group collaborative learning activity (Week 4) Complete: Pediatric post-op simulation before seminar to contribute to the relevant activities 62 ACUTE AND SURGICAL RENAL AND UROLOGICAL CONDITIONS Module #3 Mohawk College Practical Nursing Semester 3 LEARNING OUTCOMES Describe the etiology, pathophysiology, and clinical manifestations of: oInfectious urinary and renal disorders oInflammatory disorders of the urinary and renal systems oStructural disorders of the urinary and renal systems oObstructive disorders of the urinary and renal systems oGenetic disorders of the urinary and renal systems 2 LEARNING OUTCOMES (CONT.) Describe common nursing assessments, diagnostics, interventions, rationales, and expected outcomes related to: Infectious urinary and renal disorders Inflammatory disorders of the urinary and renal systems Structural disorders of the urinary and renal systems Obstructive disorders of the urinary and renal systems Genetic disorders of the urinary and renal systems Explain the nursing and interprofessional management of a client undergoing a urinary or renal surgical procedure 3 INFECTIOUS AND INFLAMMATORY DISORDERS OF THE URINARY SYSTEM Urinary tract infection (UTI) Acute pyelonephritis Chronic pyelonephritis Urethritis 48-4 URINARY TRACT INFECTION Second most common bacterial disease and the most common bacterial infection in women oRecurrent UTIs are one of the most common bacterial infections in women oAntibiotic resistance makes treatment and prevention of UTIs challenging Escherichia coli (E. coli) is the most common pathogen causing UTI oFungal and parasitic infections are less common 48-5 URINARY TRACT INFECTION ◦ Classification Systems: ◦ According to the location within the urinary system ◦ Upper or Lower UTI ◦ Ex. Pyelonephritis, Cystitis, Urethritis ◦ Complicated or uncomplicated infections ◦ According to their natural history ◦ Initial infection, recurrent UTI, unresolved bacteriuria, or bacterial persistence 48-6 Etiology and pathophysiology oAlteration to a person's physiological and mechanical defense mechanisms that normally prevent UTIs oUrological instrumentation ex. catheterization, cystoscopic examinations URINARY TRACT oHealth care–acquired, or health care–associated, infection INFECTION (CONT.) 48-7 Clinical manifestations Lower urinary tract symptoms (LUTS): symptoms seen in both the lower and upper urinary tracts ▪ Dysuria, frequency of urination (greater than every 2 hours), urgency, and suprapubic discomfort or pressure ▪ Hematuria or sediment in urine (cloudy appearance) URINARY TRACT Upper urinary tract (pyelonephritis): ▪ Flank pain, chills, and fever INFECTION (CONT.) Characteristic UTI symptoms often absent in older persons ▪ Nonlocalized abdominal discomfort 48-8 Diagnostic studies oDipstick and microscopic urinalysis oUrine culture ▪ Voided midstream technique = clean-catch urine sample ▪ Catheterization or suprapubic needle aspiration oIntravenous pyelogram (IVP) or abdominal computed tomographic (CT) URINARY TRACT Interprofessional care and medication INFECTION (CONT.) therapy Antimicrobial therapy Adequate fluid intake 48-9 Nursing assessment  Subjective – previous UTIs; pregnancy; recent urological instrumentation, urinary frequency, urgency, or hesitancy; nocturia; suprapubic or low back pain; chills  Objective – hematuria; foul-smelling urine; NURSING urinalysis positive for bacteria; pyuria, RBCs and WBCs; positive urine culture MANAGEMENT: Nursing diagnosis URINARY TRACT  Ex. Inadequate urinary elimination resulting from INFECTION multiple causality (effects of UTI) 48-10 Planning (Goals)  Client will have relief of LUTS  Prevention of upper urinary tract involvement NURSING  Prevention of recurrence MANAGEMENT: Nursing implementation URINARY TRACT  Health promotion ▪ Identify at risk individuals INFECTION (CONT.) ▪ Activities: educating client on preventative measures ▪ Prevention of health care-associated infections 48-11  NURSING Nursing implementation  Acute intervention MANAGEMEN ▪ Adequate fluid intake (if it is not contraindicated) T: ▪ Emphasize taking full course of antibiotics  Ambulatory and home care URINARY ▪ Work with the client to promote understanding about the need for ongoing care TRACT Evaluation INFECTION (CONT.) 48-12 ACUTE PYELONEPHRITIS Etiology and pathophysiology oPyelonephritis – inflammation of the renal pelvis and kidney oUrosepsis – systemic infection arising from a urological source ▪ Can lead to septic shock and death if untreated oMost common cause is a bacterial infection (E.coli) ▪ Less commonly caused by fungi, protozoa, or viruses oRecurring episodes of pyelonephritis can lead to chronic pyelonephritis 48-13  ACUTE PYELONEPHRITIS 48-14 Clinical manifestations and diagnostic studies oRange from mild fatigue to the sudden onset of chills, fever, vomiting, malaise, flank pain, and the bothersome LUTS characteristic of cystitis oCostovertebral tenderness on affected side ACUTE oUrinalysis, CBC, urine culture, blood cultures (in hospitalized clients), ultrasound of the urinary PYELONEPHRITIS system (CONT.) Interprofessional care and medication therapy oMild symptoms – outpatient basis with antibiotics oSevere infections – require hospital admission 48-15 Nursing assessment and Nursing diagnoses  Include but are not limited to those for a client with a UTI NURSING Planning (Goals)  Relief of pain MANAGEMENT:  No complications ACUTE   Normal body temperature Normal renal function PYELONEPHRITIS  No recurrence of symptoms 48-16 Nursing implementation  Health promotion ▪ Similar to those for cystitis NURSING  Acute intervention and home care MANAGEMENT: ▪ Antibiotic therapy and adequate fluid intake ▪ Client health teaching about disease process ACUTE o Taking medications as prescribed o Follow-up urine culture PYELONEPHRI o Identification of risk for recurrence or relapse TIS (CONT.) Evaluation 48-17 CHRONIC PYELONEPHRITIS A term used to describe a kidney that has become shrunken and has lost function owing to scarring or fibrosis It usually occurs as the outcome of recurring infections involving the upper urinary tract Diagnosed by radiological imaging and histological testing as opposed to an assessment of clinical features Often progresses to end-stage renal disease when both kidneys are involved 48-18 URETHRITIS Inflammation of the urethra Causes  Bacterial or viral infection  Trichomonas and monilial infection (especially in women)  Chlamydia  Gonorrhea (especially in men) 48-19 Symptoms  LUTS, similar to cystitis Diagnosis  Split urine cultures or any urethral discharge URETHRITIS  Difficult to diagnose in women (CONT.) Treatment  Identifying and treating the cause  Providing symptomatic relief 48-20 IMMUNOLOGICAL DISORDERS OF THE KIDNEY Glomerulonephritis Acute post-streptococcal glomerulonephritis Goodpasture’s syndrome Rapidly progressive glomerulonephritis Chronic glomerulonephritis Nephrotic syndrome 48-21 GLOMERULONEPHRITIS Etiology and pathophysiology oAn immune-related inflammation of the glomeruli oCharacterized by proteinuria, hematuria, decreased urine production, and edema oAffects both kidneys equally Clinical manifestations oHematuria (ranging from microscopic to gross) and urinary excretion of various formed elements (Ex. RBCs, WBCs, and casts) oProteinuria and elevated BUN and creatinine 48-22  ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS (APSGN) Most common in children and young adults Develops 5 to 21 days after an infection of the pharynx or the skin Clinical manifestations and complications oMay include generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria Diagnostic studies oComplete history and physical examination and laboratory studies to determine presence or history of a group A β-hemolytic streptococcus in a throat or skin lesion 48-23 Management focuses on symptomatic relief  Rest is recommended until signs of glomerular inflammation (proteinuria, hematuria) and hypertension subside  Edema is treated by restricting sodium and fluid NURSING AND intake and by administrating diuretics  Severe hypertension is treated with INTERPROFESSIONAL antihypertensive medications. MANAGEMENT:  Dietary protein intake may be restricted depending on degree of proteinuria ACUTE POST-  Antibiotics only prescribed if streptococcal infection is STREPTOCOCCAL still present GLOMERULONEPHRITIS Prevention is key – encourage early diagnosis and treatment of sore throat and skin lesions 48-24 GOODPASTURE’S SYNDROME An autoimmune disease characterized by circulating antibodies against glomerular and alveolar basement membrane. oThe primary target organ is the kidney, but the lungs are also involved Rare disease that is seen mostly in young male smokers Clinical manifestations oHemoptysis, pulmonary insufficiency, crackles, wheezes, renal involvement with hematuria and renal failure, weakness, pallor, and anemia Diagnosis oCirculating serum anti-glomerular basement membrane (anti-GBM) antibodies 48-25 Prognosis was poor but has recently improved due to the development of NURSING AND immunosuppressive therapy and advances INTERPROFESSIONAL in transplantation techniques MANAGEMENT: Management consists of corticosteroids, GOODPASTURE’S immunosuppressive medications, SYNDROME plasmapheresis, and dialysis 48-26 RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS (RPGN) Glomerular disease associated with rapid, progressive loss of renal function over days to weeks  Renal failure may occur within weeks to months Clinical manifestations  Hypertension, edema, proteinuria, hematuria, and RBC casts Treatment  Correction of fluid overload, hypertension, uremia, and inflammatory injury to the kidney  Corticosteroids, cytotoxic agents, and plasmapheresis 48-27 CHRONIC GLOMERULONEPHRITIS A syndrome that reflects the end stage of glomerular inflammatory disease Most types of glomerulonephritis and nephrotic syndrome can eventually lead to chronic glomerulonephritis Characterized by proteinuria, hematuria, and the slow development of uremic syndrome Renal failure develops insidiously and progresses over many years Diagnosis – renal biopsy, ultrasound, and CT scan Treatment – supportive and symptomatic 48-28 OBSTRUCTIVE UROPATHIES ◦ Urinary obstruction – any anatomical or functional condition that blocks or impedes the flow of urine 48-29 ◦ Congenital or acquired ◦ Obstructions may be a result of intrinsic, extrinsic or functional causes OBSTRUCTIVE ◦ Damage from urinary tract obstruction affects the system above the level of the obstruction UROPATHIES (CONT.) ◦ Severity depends on location, duration of obstruction, amount of pressure or dilation, presence of urinary stasis, and presence of infection 48-30 URINARY TRACT CALCULI 1 in 10 Canadians will develop a kidney stone oMany require hospitalization Stone disorders are more common in men than in women Etiology and pathophysiology oNo single theory can explain all cases of stone formation oMetabolic, dietary, genetic, climatic, lifetyle, and occupational factors affect the incidence and the type of stone formation oOther important factors in the development of stones include obstruction with urinary stasis and urinary infection with urea-splitting bacteria oInfected stones – staghorn configuration as they enlarge oGenetic factors – Cystinuria 48-31  URINARY TRACT CALCULI 48-32 Types oCalculus – abnormal stone formed in body tissues by an accumulation of mineral salts o5 major categories of stones: ▪ Calcium phosphate ▪ Calcium oxalate URINARY TRACT ▪ Uric acid ▪ Cystine CALCULI (CONT.) ▪ Struvite (magnesium-ammonium phosphate) 48-33  URINARY TRACT CALCULI 48-34 Clinical manifestations oSymptoms include abdominal or flank pain (usually severe), hematuria, and renal colic oPain can be associated with nausea and vomiting oType of pain depends on the location of the stone oOther clinical manifestations include the presence URINARY TRACT of urinary infection accompanied by fever, CALCULI (CONT.) vomiting, nausea, and chills Diagnostic studies oUrinalysis, urine culture, IVP, retrograde pyelogram, ultrasound, and cystoscopy 48-35 Interprofessional care (2 approaches) 1.Management of the acute attack ▪ Treatment of pain (ex. Opioids), infection, or obstruction ▪ Many stones pass spontaneously ▪ Stones >4mm are unlikely to pass on their own URINARY TRACT 2.Evaluation of the cause of the stone formation and prevention of further development of stones CALCULI (CONT.) 48-36 Interprofessional care (cont.)  Endourological procedures ▪ Cystoscopy – removes small stones located in the bladder URINARY TRACT ▪ Cystolitholapaxy – removes larger stones CALCULI (CONT.) 48-37 Interprofessional care (cont.)  Lithotripsy – uses sound waves to breakdown renal stones that can then be eliminated from the urinary tract  Surgical therapy – the type of surgery depends on the location of the stone ▪ Pyelolithotomy is an incision into the renal pelvis to remove a stone URINARY TRACT ▪ Ureterolithotomy – stone is located in ureter ▪ Cystotomy – bladder calculi CALCULI (CONT.)  Nutritional therapy ▪ Drinking adequate fluids to avoid dehydration ▪ Limiting oxalate-rich foods and thereby reducing oxalate excretion 48-38 Nursing assessment oSubjective data – acute pain in flank, back, abdomen, groin, or genitalia; dysuria; fluid intake oObjective data – fever; hematuria; tenderness on palpation of renal areas; passage of stone or NURSING stones MANAGEMENT: RENAL Nursing diagnoses CALCULI oAcute pain resulting from physical injury agent, biological injury agent (effects of stones) 48-39 Planning (Goals) Relief of pain No urinary tract obstruction NURSING Understanding how to prevent recurrence of stones MANAGEMENT: Nursing implementation RENAL oAdequate fluid intake ~2 L/day CALCULI oReducing metabolic or secondary risk factors oPain management and client comfort (CONT.) Evaluation 48-40 URETERAL STRICTURES Etiology and pathophysiology oCan affect the entire length of the ureter oUnintended result of surgical intervention Clinical manifestations oMild to moderate colic – pain ranges from moderate to severe Treatment oDilation with a balloon or catheter is required for complete correction 48-41 URETHRAL STRICTURES Etiology and pathophysiology oFibrosis or inflammation of the urethral lumen oCauses: trauma, urethritis, congenital defect, or iatrogenic (following surgical intervention) Clinical manifestations oDiminished force of the urinary stream, spraying, or a split urine stream oIncomplete bladder emptying with urinary frequency and nocturia Treatment oDilation, endoscopic, or open surgical procedure 48-42 RENAL TRAUMA A rise in the incidence of traumatic renal injuries is related to an increase in the mechanization and speed of transportation and to the increase in violent crimes and injuries  Blunt trauma is the most common cause Clinical findings  History of trauma to kidneys; hematuria Diagnostic studies  Urinalysis, IVP ultrasound, CT scan or MRI, possible renal arteriography Treatment  Ranges from bedrest, fluid and analgesia to surgical exploration and repair or nephrectomy 48-43 HEREDITARY RENAL DISEASES Polycystic kidney disease POLYCYSTIC KIDNEY DISEASE (PKD) ◦ One of the most common genetic disease in Canada ◦ Involves both kidneys ◦ Occurs in males and females ◦ The cortex and medulla are filled with cysts that enlarge and destroy surrounding tissue by compression ◦ Usually progresses to end-stage renal failure 48-45 POLYCYSTIC KIDNEY DISEASE (PKD) 48-46 Clinical Manifestations oSymptoms appear when cysts enlarge oEarly symptoms – abdominal or flank pain, palpable bilateral enlarged kidneys oOther clinical findings – hematuria, UTI, and HTN oDiagnosis – clinical manifestations, family history, IVP, ultrasound or CT POLYCYSTIC KIDNEY Interprofessional Care DISEASE (CONT.) oNo specific treatment for PKD oAim of treatment is to prevent infections of the urinary tract oNursing management is the same as for end-stage renal disease 48-47  POLYCYSTIC KIDNEY DISEASE 48-48 SURGERY OF THE URINARY TRACT Renal and ureteral surgery Urinary diversion 48-49 Nephrectomy oMost common indications include renal tumour, polycystic kidneys that are bleeding or severely infected, traumatic injury to the kidney, and elective removal from a donor RENAL AND URETERAL Surgery involving the ureters and the SURGERY kidneys oMost commonly to remove calculi that becomes obstructive, correct congenital anomalies, and divert urine when necessary 48-50 Preoperative management  Ensure adequate fluid intake and a normal electrolyte balance Postoperative management  Urine output RENAL AND  Respiratory status URETERAL  Abdominal distension SURGERY Laparoscopic nephrectomy (CONT.)  Is performed using 5 puncture sites  Less painful, shorter hospital stay, faster recovery, no sutures/staples compared to conventional nephrectomy 48-51 Performed with or without cystectomy Performed to treat cancer of the bladder, neurogenic bladder, congenital anomalies, strictures, trauma to the bladder, and chronic infections with deterioration of renal function URINARY Urinary Diversion techniques and bladder DIVERSION substitutes oIncontinent urinary diversion oContinent urinary diversion – catheterized by client oOrthotopic bladder 48-52  URINARY DIVERSION (CONT.) Types of Surgical Procedures 48-53 URINARY DIVERSION (CONT.) Incontinent urinary diversion oDiversion to the skin, requiring an appliance oMost common procedure is the ileal conduit (ileal loop) oDisadvantage – visible stoma and external collection devices ▪ Led to an increasing use of continent diversions and orthotopic bladder substitutes 48-54 URINARY DIVERSION (CONT.) Continent urinary diversions oIntraabdominal urinary reservoir that is catheterizable or has an outlet controlled by the anal sphincter oInternal pouches created similarly to the ileal conduit oClient self-catheterizes every 4-6 hours but does not need to wear external attachments 48-55 Orthotopic bladder substitution oDerived from various segments of the intestines oVarious procedures include hemi-Kock URINARY DIVERSION pouch, Studer pouch, and the ileal W-neobladder ▪ Bowel is surgically reshaped to become a neobladder (CONT.) 48-56 Preoperative management oInitiating a teaching program Postoperative management oPrevent surgical complications such as postop atelectasis and shock NURSING oPreventing injury to stoma and maintaining urine output MANAGEMENT: ▪ Mucus in urine is normal URINARY DIVERSION oAssessing and managing peristomal skin oAcceptance of surgery and changes in body image oDischarge planning 48-57 BENIGN PROSTATIC HYPERPLASIA (BPH) Nonmalignant growth or hyperplasia of prostate tissue Common in aging men Common cause of lower urinary tract symptoms (LUTS) Disease progression is associated with bladder outflow obstruction Risk factors oDivided into non-modifiable and modifiable oIncluding diabetes, diet, genetic factors, localized inflammation, obesity, and metabolic syndrome 48-58 Diagnosis oUrinalysis oIPSS or American Urological Association symptom (AUA) symptom score oDigital rectal examination (DRE) BENIGN oPostvoid residual volume (PVR) to determine PROSTATIC whether the bladder is emptying adequately oUrine flow studies to determine if there is evidence HYPERPLASI of obstructive or irritative voiding A (BPH) Treatment ranges from monitoring to medical and surgical interventions depending on disease burden to client 48-59 SUMMARY Described the pathophysiology, assessment, diagnosis, treatment, nursing management, and clinical manifestations of Infectious urinary and renal disorders Inflammatory urinary and renal disorders Structural urinary and renal disorders Obstructive urinary and renal disorders Genetic urinary and renal disorders Discussed the nursing and interprofessional management of clients undergoing urinary or renal surgical procedures 60 NEXT STEPS Next week's topic: Acute and First Quiz: Opens Monday of Group Contract: Friday of Group Learning Activity: Group Discussion Posts: Surgical Gastrointestinal Week Four at 0800hrs and Week 3 at 1700hrs Friday of Week 3 by 1700hrs 1st – Due Wednesday of closes Friday of week four at Week 3 by 0800hrs 1700hrs nd 2 – Due Friday of Week 3 by 1700hrs 61 G A S T RO I N T E S T I N A L CONDITIONS HHNP3 Module 4 Lecture version LEARNING OBJECTIVES Explain the nursing and interprofessional management of a client undergoing a gastrointestinal surgical procedure Describe the etiology, pathophysiology, and clinical manifestations of inflammatory and infectious disorders of the gastrointestinal system Describe common nursing assessments, diagnostics, interventions, rationales, and expected outcomes related to inflammatory and infectious disorders of the gastrointestinal system Describe the etiology, pathophysiology, and clinical manifestations of vascular and bleeding disorders of the gastrointestinal system Describe common nursing assessments, diagnostics, interventions, rationales, and expected outcomes related to vascular and bleeding disorders of the gastrointestinal system Describe common nursing assessments, diagnostics, interventions, rationales, and expected outcomes related to acute abdominal pain and trauma YO U A R E C A R I N G F O R T H E F O L L OW I N G C L I E N T S - W H I C H D O YO U S E E F I R S T ? A.M. (he/him), 28 years old, was admitted after renal calculi found in the left ureter. Client came to the ED with complaints of sharp, colicky left flank pain. IV opioids prescribed and last dose was given 2 hours ago. His current pain level is 4 (0 -10 scale). He is voiding dark, smoke-coloured urine. Vital signs are within normal limits when last checked 2hrs ago. M.G. (she/her), 32 years old, has diabetes and was admitted with acute pyelonephritis. She complains of bilateral flank pain and her temperature is 38.2°C. Her white blood cell count is elevated, and blood culture has been drawn. Intravenous (IV) antibiotic order has been written but hasn’t been started. R.W. (he/him), 63 years old, has BPH for the past 5 years. Client was admitted because his urinary obstructive symptoms have been worsening and he presented to the ED with acute urinary retention requiring catheterization. In -dwelling catheter is in place and draining well. The client is anxious about the treatment options that are available and asks if someone can explain them again. MODULE 3 REVIEW Which statement would be most appropriate when teaching M.G. about her kidney infection (pyelonephritis)? a. “The damage to your kidneys might require dialysis.” b. “Influenza is the most likely cause of your kidney infection.” c. “You will need to be in the hospital for a 2-week course of IV antibiotics.” d. “It is very important that you maintain adequate hydration to prevent complications.” U P P E R G A S T RO I N T E S T I N A L C O N D I T I O N S Nausea and Vomiting Gastritis Upper gastrointestinal bleeding Peptic ulcer disease  N AU S E A A N D VO M I T I N G Most common manifestation of gastrointestinal disease. Nausea = feeling of discomfort with a conscious desire to vomit Vomiting = forceful ejection of partially digested food and secretions (emesis) Can occur independently, but usually treated as one condition Occurs from: GI disorders, Pregnancy, Infectious diseases, Central nervous system (CNS) disorders (ex. meningitis), Cardiovascular conditions (ex. MI, HF), Metabolic disorders (ex. Addison’s), Adverse effects of medications (ex. opioids), Allergies, and Psychological factors (stress, fear). Copyright © 2023 Elsevier Inc. All rights reserved. N & V C L I N I C A L M A N I F E S TAT I O N S Nausea (Subjective symptom) Usually accompanied by anorexia (lack of appetite) Vomiting (objective symptom) Difference in vomiting, regurgitation, and projectile vomiting Regurgitation: partially digested food is slowly brought up from the stomach. Projectile vomiting: very forceful expulsion of stomach contents without nausea Client can also experience tachycardia, tachypnea, and diaphoresis (from sympathetic activation) Increase in salivation immediately before emesis (from parasympathetic activation) Copyright © 2023 Elsevier Inc. All rights reserved.  N AU S E A A N D VO M I T I N G C O M P L I C AT I O N S If vomiting is prolonged: Water and essential electrolytes are lost (potassium, sodium, chloride etc.) Electrolyte imbalances, decreased fluid volume (dehydration), and circulatory compromise can occur Weight loss from fluid loss Metabolic alkalosis—from loss of gastric hydrochloric acid (HCl) Pulmonary aspiration is a concern in some populations  C O L L A B O R AT I V E C A R E Overall goals: determine and treat underlying cause and provide symptomatic relief. History: precipitating factors, timing, description of emesis contents etc. Colour and appearance of emesis aids in determining source and cause: Partially digested food = delayed gastric emptying Fecal odour with bile = intestinal obstruction “Coffee ground” appearance = bleeding in the stomach Bright red blood = active bleed in upper GI Early morning = pregnancy Etc.  N&V MANAGEMENT A N D T R E AT M E N T Medication therapy Use depends on the cause of the problem Table 44.1 Risk of using antiemetics prior to identifying cause (mask disease process) Medications must be administered with Copyright © 2023 Elsevier Inc. All rights reserved. caution and can’t always be used in certain populations  N&V MANAGEMENT AND T R E AT M E N T If vomiting severe require IV fluids with electrolytes and glucose NG tube with suction to decompress stomach may be required Once symptoms subside, can slowly start oral intake Nutrition therapy: Clear liquids started first Room-temp flat beverages (no carbonation) May advance to dry toast, crackers Advance to high carb, low fat next as easier to digest Eat slowly in small amounts Avoid physical activity and sit upright after meals  Most managed at home Persistent vomiting—hospitalization with NURSING IV fluids and NPO status until diagnosis made MANAGEMENT NG tube to suction may be used Accurate I & O Monitor VS and monitor for change in fluid status Assess for dehydration Proper patient positioning if risk for aspiration Maintain quiet, odour-free environment. Monitor at risk clients closely (renal or heart disease, CNS disturbances, older adult, young child etc.) Teaching depends on precipitating cause and client condition AG E - R E L AT E D C O N S I D E R AT I O N S Older Adults: More likely to have cardiac or renal insufficiency Increased risk for life-threatening fluid/electrolyte imbalances Increased susceptibility to CNS adverse effects of antiemetic medications Increased risk of aspiration Children: Dehydration can happen very quickly** and can be dangerous Water is not best; depending on age, need breastmilk/formula, or oral rehydration solution Very small amounts every 10-15min Will discuss more later in the course GASTRITIS Inflammation of Breakdown of the normal gastric mucosal the gastric mucosa barrier that protects the stomach Diagnosis is most often based on history Acute gastritis of drug and alcohol misuse. Diagnosis may be delayed or missed Chronic gastritis because of nonspecific symptoms. C L I N I C A L M A N I F E S TAT I O N S Acute gastritis: Anorexia, nausea and vomiting, epigastric tenderness, feeling of fullness Hemorrhage associated with alcohol misuse Self-limiting, lasting from a few hours to a few days and mucosa expected to heal completely. Chronic gastritis: Symptoms similar to acute gastritis, or clients may have no symptoms Mucosa does not heal; acid-secreting cells are lost and do not function properly from atrophy Cobalamin (Vitamin B12) deficiency develops over time = anemia and neurological complications NURSING MANAGEMENT: ACUTE GASTRITIS Determine cause IV fluids with and provide Vital signs electrolytes supportive care Medication therapy NPO with gradual NG tube in certain Antiemetics reintroduction of situations Antacids fluids and foods Proton pump inhibitors NURSING MANAGEMENT: C H RO N I C G A S T R I T I S Eliminating the cause Cobalamin (Vitamin B12) replacement therapy Non-irritating diet Small, frequent meals Antacids after meals Risk for gastric cancer, so require follow up and monitoring  UPPER GI BLEEDING Mortality rate of 6-10% and has remained the same for decades Higher incidence among older populations, individuals from lower SES groups, and men Severity of bleeding depends on origin (venous, capillary, arterial) Colour indicates where occurring Most common sites are esophagus, stomach, and duodenum C L I N I C A L M A N I F E S TAT I O N S Hypovolemic Hematemesis Melena Occult bleeding shock Bloody vomitus Black, tarry stools Small amounts of Hypotension appearing as fresh, (often foul smelling) blood in gastric Tachycardia bright red blood or caused by digestion of secretions, vomitus, or having “coffee blood in the stools not apparent by Decreased capillary grounds” appearance gastrointestinal tract; appearance; detectable refill (dark, grainy digested the discoloration is by guaiac test Cool, clammy skin blood) caused by the presence of iron Cyanotic From a slow upper GI Restlessness bleed I N T E R P RO F E S S I O N A L A S S E S S M E N T A N D MANAGEMENT Most clients bleeding stops spontaneously Cause needs to be identified and treatment initiated immediately Vital signs q15-30min with emphasis on blood pressure, pulse, and peripheral perfusion; observe for signs of hypovolemic shock; accurate intake and output; abdominal assessment. Two 16- to 18- gauge IV lines for fluid and blood replacement Labs: CBC, PTT, BUN, electrolytes, glucose, live enzymes, ABG, type and crossmatch Supplemental oxygen Medication therapy: Table 44.18 Treatment: surgical intervention, endoscopic therapy to stop bleeding Health promotion: need to prevent from happening again  PEPTIC ULCER DISEASE Erosion of the GI mucosa from digestive action of HCl and pepsin. Can be acute or chronic. Can also be classified as gastric or duodenal, depending on location Acute ulcers are superficial with minimal inflammation, short duration and resolve quickly when cause is removed Chronic ulcers last longer and erode further through mucosa; are more common than acute ulcers Complications: hemorrhage, perforation, and gastric outlet obstruction PEPTIC ULCER DISEASE Gastric ulcers Less common than duodenal ulcers and more common among women, older populations, and lower SES populations Medications (Aspirin, corticosteroids, NSAIDs), chronic alcohol misuse, chronic gastritis, and smoking common causes Duodenal ulcers Account for 80% of peptic ulcers; affect everyone regardless of age or SES Diseases such as COPD, cirrhosis, pancreatitis, renal failure, increase risk for development; also associated with psychological stress Alcohol ingestion, smoking, H. pylori also causes Stress-related mucosal disease: acute ulcer development after major physiological event PEPTIC ULCER DISEASE: INTER- P RO F E S S I O N A L CARE L OW E R G A S T RO I N T E S T I N A L CONDITIONS Diarrhea and constipation Acute abdominal pain Appendicitis, peritonitis, and gastroenteritis Intestinal obstruction  The frequent passage of loose, watery stools—is not a disease but a symptom. An increase in stool frequency or volume and an increase in the looseness of stool Can be acute or chronic: Acute often from infection and is self-limiting. Chronic is when persists for at least 2 weeks or when it subsides and recurs. DIARRHEA Causes: Decreased fluid absorption, Increased fluid secretions, Motility disturbances, Ingestion of infectious organisms, Infection (most commonly viral but also bacterial); Table 45.1 Other manifestations: fever, nausea, vomiting, malaise; blood, mucus or leukocytes may be in the stool Severe diarrhea can be life threatening and is a major cause of death throughout the world. D I A R R H E A : I N T E R P RO F E S S I O N A L C A R E Based on cause Replacing fluid and electrolytes and decreasing the number, volume, and frequency of stools Fluid replacement: oral rehydration (with glucose and electrolytes) if mild; IV fluids (PN may be needed) if severe Medication therapy (Table 45.3): given to coat and protect mucous membranes, absorb irritating substances, inhibit GI motility, decrease intestinal secretions, decrease stimulation of GI tract, treat infection (antibiotics) Infectious diarrhea should not be given antidiarrheal agents Antidiarrheal agents should not be given for long periods no matter the cause NURSING CARE Health history: duration, character, frequency, and consistency of stools; medication history; travel history; illnesses; dietary history etc. Physical exam: vital signs, weight, skin turgor, hydration status, assess for skin breakdown, abdominal assessment etc. Infection control practices and precautions; hand hygiene** C. difficile infection: need private room with private bathroom; signage and contact precautions; environmental cleaning; alcohol-based hand sanitizers do not kill spores, so need to wash with soap and water Perianal care to avoid skin breakdown Nutritional support: Dietician consult if needed  C O N S T I PAT I O N Decrease in frequency of bowel movements; presence of hard, difficult-to-pass stools; a decrease in stool volume; retention of feces in the rectum; or some combination of these. Many causes: insufficient fibre, inadequate fluid intake, medications, lack of exercise/sedentary lifestyle, laxative abuse, sociocultural beliefs about defecation, changes in diet or daily routines, stress and emotional factors etc. Clinical manifestations: abdominal distension and bloating, pain, anorexia, headache, flatulence, nausea, rectal pressure, palpable mass, hemhorroids  I N T E R P RO F E S S I O N A L M A N A G E M E N T Determine underlying cause Dietary changes: increase intake of fibre and fluids (3L/day unless contraindicated) Increasing fibre without increasing fluids increases risk for obstruction, impaction or worsening constipation. Regular exercise and movement Establish regular meal pattern, regular time to defecate, avoid suppressing urges. Medications: Laxatives should be used with caution; bulk-forming preparations (ex. Metamucil) is recommended versus stimulants; stool softeners might also be appropriate Enemas might be used in some situations, but long-term use should be avoided. Educate patients on misinformation about bowel function and habits; health teaching on use of laxatives and enemas Proper positioning for defecation: considerations when client is immobile or in a bed A C U T E A B D O M I N A L PA I N M A N A G E M E N T Since many potential causes, requires an interprofessional approach Determine diagnosis/cause: health history, physical exam, abdominal imaging, CBC and urinalysis, and ECG all done initially Nursing assessment: vital signs, monitor for hypovolemic changes, abdominal assessment (gentle palpation), pain assessment (PQRSTU), determine other signs and symptoms (nausea and vomiting, changes in bowl/bladder habits, vaginal discharge etc.) Emergency management: Table 45.13 Care involves fixing underlying cause, management of fluid and electrolyte imbalances, managing pain and anxiety, preventing complications (especially hypovolemic shock), maintaining nutritional status, etc. Pre-op and Post-op care as needed I N F L A M M A T O RY G I D I S O R D E R S Appendicitis Peritonitis Gastroenteritis  APPENDICITIS Inflammation of the appendix; occurs in 8% of words population Can occur at any age, but most common between 10-20 years Clinical Manifestations: periumbilical pain followed by anorexia, nausea, and vomiting. Pain is persistent and continuous, eventually shifting to right lower quadrant Localized tenderness, rebound tenderness, and muscle guarding; patient will often lie very still with right leg flexed Low grade fever may or may not be present Complications: perforation, peritonitis, and abscesses A P P E N D I C I T I S I N T E R P RO F E S S I O N A L CARE CT is preferred diagnostic procedure, but ultrasound can also be used. Health hx, physical exam, CBC, urinalysis (to rule out genitourinary conditions) Treatment: surgical removal (appendectomy) or conservative therapy with antibiotics and fluids. Treatment dependent on if complications have developed and degree of inflammation. Surgery can be performed laparoscopic. Nursing management: NPO status, monitor for complications, pre-op and post-op care Local application of heat should never be used because it may cause the appendix to rupture. PERITONITIS Localized or generalized inflammation of the peritoneum (lines peritoneal cavity) Can be acute or chronic Many causes (Table 45.15): abdominal trauma or ruptured organ, ischemic bowel disorder, GI obstruction, complication from peritoneal dialysis, complication from pancreatitis or cirrhosis etc. Clinical manifestations: abdominal pain, tenderness over involved area, rebound tenderness, muscle rigidity/spasm, abdominal distension or ascites, fever, tachycardia, tachypnea, nausea, vomiting, altered bowel habits Complications: sepsis, septic shock, intra-abdominal abcess formation, paralytic ileus, organ failure Clients are extremely ill and need lots of supportive care  P E R I T O N I T I S I N T E R P RO F E S S I O N A L MANAGEMENT Identify and treat the cause, eliminate infection, and prevent complications Treatment: antibiotics, NG suction, analgesics, IV fluids (may require PN/TPN because of increased nutritional requirements) Surgical care (if needed) NURSING MANAGEMENT: PERITONITIS A S S E S S ME NT S I N T E RV E N T I O N S Vital signs NPO Abdominal assessment NG placement, monitoring, maintenance Pain assessment IV access and fluids Monitor for sepsis and hypovolemic Fluid replacement: based on intake and output and electrolyte status shock Pain management – response to analgesics Fluid intake and output Position: knees flexed to increase comfort Bloodwork results Promote rest and quiet environment Nutritional status Antiemetics if nausea and vomiting G A S T RO E N T E R I T I S Inflammation of mucosa of stomach and small intestine Clinical manifestations: nausea, vomiting, diarrhea, abdominal cramping and distension; Fever, increased WBCs, and blood or mucus in the stool may also be present Causes are varied (Table 45.2): most are self-limiting and do not require hospitalization; however, older patients, patients who are chronically ill, or children may be unable to consume sufficient fluids to compensate for fluid losses NPO until vomiting has stopped; once oral intake is tolerated, fluids with glucose and electrolytes is needed If dehydration has occurred, IV fluids may be necessary If causative agent is identified, pharmacological therapy may be initiated. Similar to management of Nausea, Vomiting, and Diarrhea discussed previously NURSING MANAGEMENT: G A S T RO E N T E R I T I S A S S E S S ME NT S I N T E RV E N T I O N S Same assessments as discussed for Same interventions as discussed for nausea, nausea, vomiting, and diarrhea vomiting, and diarrhea Vital signs Fluid replacement based on intake and Fluid status assessment output; promote fluid intake Strict medical asepsis and infection control** Pain assessment (if needed) Accurate intake and output Health teaching: food handling, preparation, and storage Rest Medication administration as needed  I N T E S T I N A L O B S T RU C T I O N Partial or complete obstruction of the intestine which prevents intestinal contents from passing through GI tract Types of intestinal obstruction Mechanical: caused by an occlusion of intestinal tract (ex. adhesions, volvulus, colon cancer, impaction etc.) Nonmechanical: neuromuscular or vascular disorders (ex. paralytic ileus, emboli in mesenteric arteries etc.) Requires prompt treatment and intervention since can quickly lead to fluid, electrolyte and acid-base imbalances; perforation; strangulation and gangrene formation; I N T E S T I N A L O B S T RU C T I O N : C L I N I C A L M A N I F E S TAT I O N S I N T E S T I N A L O B S T RU C T I O N : I N T E R P RO F E S S I O N A L M A N A G E M E N T Potentially life-threatening CT scan and abdominal radiographic studies most useful in diagnosis Labs: CBC, electrolytes, amylase, BUN, stool sample Health history, physical exam, abdominal assessment, and clinical manifestations Type and location of obstruction usually cause characteristic symptoms High obstruction risk for metabolic alkalosis; low obstruction risk for metabolic acidosis Treatment aimed at decompression of intestine (NG tube insertion), correct fluid and electrolyte balance (IV fluids/PN), relief/removal of obstruction Most obstructions are treated surgically; colectomy, colostomy, ileostomy I N T E S T I N A L O B S T RU C T I O N : N U R S I N G MANAGEMENT A S S E S S ME NT I N T E RV E N T I O N Vital signs IV fluids Abdominal assessment Pain management Pain assessment (PQRSTU) NG monitoring/maintenance Vomiting: onset, frequency, colour, Comfort measures, restful environment, odour, amount etc. keep visitors to a minimum Bowel function changes Pre-op and post-op care Fluid and electrolyte status Accurate intake and output Monitor labs (electrolytes, CBC etc.) L I V E R , P A N C R E A S A N D B I L I A RY TRACT CONDITIONS Acute pancreatitis Cholelithiasis and cholecystitis  Acute inflammation of the pancreas; vary from mild edema to sever hemorrhagic necrosis Pancreatic enzymes spill into pancreatic tissue causing autodigestion of the pancreas In Canada, most common cause is gall bladder disease/gallstones and alcohol use disorder; also associated with hypertriglyceridemia (high serum triglycerides) ACUTE Less common: trauma (post-surgical), viral infections, duodenal ulcers, cysts, abscesses, cystic PA N C R E AT I T I S fibrosis, medications, metabolic disorders, and vascular disease High-fat diet, smoking, and genetics also factors Clinical manifestations: severe abdominal; pain is sudden, deep, piercing, and continuous/steady Other: flushing, cyanosis, dyspnea, nausea & vomiting, low-grade fever, hypotension, tachycardia, jaundice, decreased or absent bowel sounds, abdominal distension, lung crackles A C U T E PA N C R E AT I T I S Complications: Can be life threatening Shock and sepsis Permanent decrease in pancreatic endocrine function Pseudocyst and abscess formation Peritonitis Pulmonary and cardiovascular complications Serum amylase and lipase primary diagnostic tests** unique to pancreatitis Other tests: liver enzymes, triglycerides, glucose, bilirubin; abdominal ultrasound, radiograph or CT scan Hypocalcemia can occur I N T E R P RO F E S S I O N A L C A R E Goals: relieve pain, prevent or alleviate shock, reduce pancreatic secretions, control fluid and electrolyte imbalance, prevent or treat infection, remove precipitating cause Conservative therapy: supportive care IV fluids, pain management (opioids), management of metabolic complications, management of fluid and electrolyte imbalances, NPO, NG suction, infection prevention and treatment Interventional therapy: surgical interventions Medication therapy (Table 46.19): no medications cure, provide symptom support Nutritional therapy: NPO to reduce pancreatic secretions; enteral feeds if needed; small, frequent meals once re-introduce food; high carbohydrate diet; abstain from alcohol; supplemental fat-soluble vitamins may be needed NURSING MANAGEMENT Acute interventions: Vital signs, monitor for signs of shock, electrolyte imbalances, and response to IV fluids Risk of respiratory failure: respiratory assessment (auscultation, SP02, respirations etc.) Hypocalcemia: observe for symptoms of tetany, jerking, irritability, muscle twitching, numbness or tingling around the lips and fingers Pain relief: opioids Positioning: flex the trunk and draw knees up to abdomen to decrease pain NPO and NG tube care and maintenance: frequent oral and nasal care Client is susceptible to infections: monitor for fever and other manifestations of infection; prevention of respiratory infections (coughing, turning, deep breathing, Semi -fowlers positioning Blood glucose monitoring Monitor for signs of paralytic ileus, renal failure, and mental changes  CHOLELITHIASIS AND CHOLECYSTITIS Cholelithiasis: stones in the gallbladder – most common disorder of biliary system Cholecystitis: inflammation of gallbladder – usually associated with cholelithiasis Cholecystectomy (removal of gallbladder) one of the most common surgical procedures Complications: gangrenous cholecystitis, abscess formation, acute pancreatitis, biliary cirrhosis, gallbladder rupture, fistula formation CHOLELITHIASIS CON’T Silent cholelithiasis: no symptoms Severity of symptoms depends on whether stones are stationary or mobile, and whether obstruction is present Gallbladder spasms in response to a stone = spasms produce severe pain (biliary colic) Pain is severe and accompanied by tachycardia, diaphoresis, and prostration When obstruction occurs: bile duct blockage symptoms manifest Patients with upper abdominal pain and the 5 F’s for risk factors (female, fat, fertile, flatulence, and forty) are likely to have cholelithiasis CHOLECYSTITIS Most often associated with obstruction caused by gallstones, but can also be caused by other factors (prolonged immobility and fasting, diabetes, critical illness, cancer etc.) During an acute attack, gallbladder is edematous and hyperemic; may be distended and filled with bile or pus Clinical manifestations vary: indigestion, moderate pain to sever pain, fever, and jaundice Initial symptoms include indigestion and acute pain and tenderness in the right upper quadrant, which may be referred to the right shoulder and scapula. Pain is acute and may be accompanied by nausea and vomiting, restlessness, and diaphoresis. Manifestations of inflammation include leukocytosis and fever. I N T E R P RO F E S S I O N A L C A R E : CHOLELITHIASIS Once gallstones are symptomatic, surgical intervention usually needed Age and associated comorbidities factors in determining surgical risk; conservative therapy may be considered Conservative Therapy: bile acids administered to dissolve stones (risk of recurrence) Endoscopic clearing of stones (ERCP) via duodenum Shock-wave lithotripsy to break up stones Surgical Therapy: laparoscopic cholecystectomy Relatively minor procedure with few complications Most patients have minimal postoperative pain and discharged same day or next day; cam resume normal activities within 1 week I N T E R P RO F E S S I O N A L C A R E : CHOLECYSTITIS Pain control Control infection with antibiotics Maintain fluid and electrolyte balance NG tube may be inserted for gastric decompression if nausea and vomiting is severe Anticholinergics to decrease secretions and counteract smooth muscle spasms NURSING MANAGEMENT Health promotion: Patients at risk should be taught the initial clinical manifestations and be instructed to seek medical attention if these manifestations occur. Early detection and management is beneficial Acute intervention: Relieve pain Relieve nausea and vomiting Provide comfort and emotional support Maintaining fluid and electrolyte balance Maintain nutrition Making accurate assessments of treatment effectiveness Observing for complications Pre-op and post-op care as needed NURSING MANAGEMENT: ACUTE CARE A S S E S S ME NT S I N T E RV E N T I O N S Vital signs Pain medication administration Ongoing pain assessment (PQRSTU) to Comfort measures: clean bed, comfortable determine efficacy of pain management positioning, oral care Monitor for adverse effects of pain medications NG tube insertion, maintenance, and care if gastric decompression needed Accurate intake and output Progression of symptoms and monitor for Antiemetic administration complications: jaundice, clay-coloured Pruritis: baking soda or oatmeal baths, stools, dark foamy urine, fever, increased lotions, antihistamines, soft linens, WBC count etc. temperature control; keep nails short and Observe for bleeding tendencies clean Monitor for infection N U R S I N G M A N A G E M E N T : A M B U L A T O RY AND HOME CARE Dietary teaching: low in fat Weight-reduction program for clients with obesity Fat-soluble vitamin supplements Instruction about symptoms that indicate obstruction (stool and urine changes, jaundice, and pruritus etc.) Stress significance of continued follow-up health care Patients who undergo laparoscopic cholecystectomy are discharged soon after the surgery; therefore, home care is important and teaching is essential WRAP UP/LOOKING AHEAD Quiz 1 Week 4 - available Monday at 0800 and will close Friday at 1700 Week 6 Group Collaborative Learning Activity  Cancer Part One: Introduction and Overview Module #5 Mohawk College Practical Nursing Semester 3  Learning Outcomes Investigate the prevalence, incidence, and death rates of cancer in Canada. Describe the biological processes involved in cancer. Differentiate the three phases of cancer development. Describe the role of the immune system in relation to cancer. Describe the use of the classification systems for cancer. Explain the role of the nurse in the prevention and detection of cancer. Explain the use of surgery, radiation therapy, and biological therapy in the treatment of cancer.  Learning Outcomes Describe the effects of radiation therapy on normal tissues. Describe the nursing assessment and management of patients receiving radiation therapy. Describe the appropriate psychosocial support of a patient with cancer and the patient’s family. Describe the complications that can occur in advanced cancer. Describe the etiology, pathophysiology, and clinical manifestations of sepsis Describe common nursing assessments, diagnostics, interventions, rationales, and expected outcomes related to sepsis Cancer Group of more than 200 diseases Characterized by uncontrolled and unregulated growth of cells Occurs in people of all ages and ethnicities Cancer in Canada Expected that 90% of new cancer cases will be diagnosed in Canadians who are at least 50 years of age Cancer incidence and death rates increase from west to east across the country Overall mortality has declined oCancer survival has increased Cancer is the leading cause of death in Canada Modifiable Risk Factors Known risk factors include tobacco use, excessive body weight, lack of physical activity, unhealthy eating habits, alcohol consumption excessive exposure to the sun. Nurses can influence attitudes and promoting behaviours that prevent the development of cancer 18-6 Biological Processes of Cancer Two major dysfunctions present in the process of cancer: o Defective cellular proliferation (growth) Defective cellular differentiation Most human tissues contain predetermined, undifferentiated cell o Known as stem cells Predetermined stem cells give rise to mature cells of the type of tissue where they reside All cells are controlled by an intracellular mechanism that determines cellular proliferation 18-7 Defects in Cellular Proliferation Cancer cells are characterized by loss of contact inhibition They grow on top of one another and on top of or between normal cells Cancer cells respond differently from normal cells to intracellular signals regulating equilibrium Cancer cell proliferation is dysregulated, haphazard, and they divide indiscriminately and continuously Stem cell theory Loss of intracellular control of proliferation results from mutation of stem cells DNA is substituted or permanently rearranged 18-8 Defect in Cellular Differentiation (Cont.) Two types of genes that can be affected by mutation are 1. Proto-oncogenes Regulate normal cellular processes such as promoting growth Mutations activate them to function as oncogenes (tumor-inducing genes) 2. Tumour suppressor genes Suppress growth Mutations render them inactive = loss of their tumour suppressor ability  Benign vs Malignant Neoplasms Benign Neoplasms Malignant Neoplasms Well-differentiated Usually undifferentiated Usually encapsulated Able to metastasize Expansive mode of growth Infiltrative and expansive growth Metastasis absent Frequent recurrence Rarely recur Moderate to marked vascularity Rarely encapsulated Becomes less like parent cell Development of Cancer Likely to be multifactorial Origin of cancer may be Genetic Chemical Environmental Viral or immunological From causes not yet identified Stages of cancer Initiation Promotion Progression 18-11 Process of Cancer Development 18-12 Development of Cancer (Cont.) Initiation Mutation of cell’s genetic structure From inherited mutation From exposure to a chemical, radiation, or viral agent Mutated cell has the potential to develop into a clone of neoplastic cells Once initiated, mutation is irreversible Not all mutated cells form a tumour Mutated cells become tumours only when they establish the ability to self- replicate and grow Development of Cancer (Cont.) Initiation (Cont.) Cells damaged by carcinogens may Self-repair Die Replicate into daughter cells with the same genetic alteration Carcinogen effects in the stage of initiation are usually irreversible and additive Carcinogens may be Chemical Radiation Viral and Bacterial Genetic Susceptibility 18-14 Carcinogens Chemical Long latency period makes identification of carcinogens difficult Animal studies may not apply to humans Certain medications have been identified as carcinogens Radiation Ionizing radiation can cause cancer in almost any human tissue The dose of radiation needed to cause cancer is unknown Damages cellular DNA Ultraviolet (UV)s radiation is associated with melanoma and squamous and basal cell carcinoma 18-15 Carcinogens Viral and bacterial carcinogens o Hepatitis B and C viruses, Human papillomavirus, Helicobacter pylori Genetic susceptibility Cancer re