MS II Exam 3 Study Guide.pdf

Med-Surg II Exam 3 Study Guide GI Part 1 Anatomy & Physiology Mouth (teeth, tongue, salivary glands) →esophagus → stomach → duodenum → jejunum → ileum → colon → rectum & anal c...

Med-Surg II Exam 3 Study Guide GI Part 1 Anatomy & Physiology Mouth (teeth, tongue, salivary glands) →esophagus → stomach → duodenum → jejunum → ileum → colon → rectum & anal canal Wall of GI Tract Inner to outer o Mucosa: absorption o Submucosa o Muscularis: peristalsis & movement of GI tract o Serosa Focused GI Assessment Focused Interview o Chief complaint o Present health status ▪ Change in appetite, weight gain/loss, dysphagia, food intolerance, N/V, change in bowel patterns, abdominal pain, dyspepsia, jaundice ▪ Coffee ground emesis (vomit) indicates bleeding in upper GI ▪ Stools Maroon/purple jelly stools indicate massive bleeding (foul smelling) Dark stools can be from iron supplements or Pepto Bismol Bright red stool indicates bleeding in lower GI o Past health history o Current lifestyle o Psychosocial status o Family health history Physical assessment o Oral assessment ▪ Lips, gums, mucosal membrane, teeth, tongue o Abdominal assessment ▪ Inspection Color, bulges, masses, hernias, ascites, spider/enlarged veins, pulsations or movements, inability to lie flat ▪ Auscultation Done before percussion & palpation to prevent production of false bowel sounds ▪ Percussion Used to assess size & density of organs & detect air-filled, fluid-filled, or solid masses Tympany vs. dullness ▪ Palpation Light: tenderness, muscular resistance (0.5-0.75 inch) Deep: to identify masses (1.5-2 inches) Note any areas where pain is reported (look for signs of guarding) o Rectal inspection & palpation Assessing & Interpreting Lab Values Amylase Lipase AST/ALT Bilirubin Ammonia Diagnostic Studies Stool tests o Culture, parasites Abdominal ultrasound Genetic testing Imaging studies o CT, PET, MRI, virtual colonoscopy  Endoscopic procedures o EGD o Colonoscopy GI Treatment Modalities GI intubation Feedings o Enternal & parenteral Endoscopic procedures o Endoscopy & colonoscopy Surgery Ostomies GI Intubation Insertion of plastic tube into the stomach, duodenum, or intestine through mouth/nose/abdominal wall Indications o Decompress the stomach → remove gas & fluid o Lavage the stomach → remove ingested toxins o Administer tube feedings, fluids, medications o Compress a bleeding site o Aspirate gastric contents for analysis Types of tubes o Orogastric tube: mouth to stomach, wide outlet for removal of gastric contents (patient with an overdose that needs large volumes of contents removed) o Oral/nasal tube: short term use, should stay in place no more than 4 weeks before being replaced Lavage tubes o Levin: decompression ONLY ▪ Single lumen connected to low intermittent suction to prevent adherence of tube to inner mucosa of stomach o Gastric (Salem) sump: decompression OR feeding ▪ Radio opaque tube, clear plastic, double lumen (inner smaller lumen vents larger suction to atmosphere) ▪ Inner sump tube protects fragile gastric mucosa by maintaining low continuous force of suction at drainage opening ▪ Continuous suctioning Enteric tubes: feeding ONLY o Nasoduodenal, nasojejunal ▪ Inserted in nose o Dobbhoff terminates in the duodenum; Tiger tube terminates in jejunum ▪ Tiger is for self-advancing tubes, radio opaque, used for short term feeding Nasogastric Tube Placement Measure distance from nostril to tip to earlobe to tip of xiphoid process (NEX) Secure tube to gown, leaving slack for head movement & prevent migration of tube Tiger Tube Placement Advanced into stomach & then slowly over time self-advances with cilia flaps & permanent normal peristalsis of GI tract PEG Tube Exclusively for feeding Inserted directly through abdominal wall Jejunostomy Tube Placed when gastric route is not accessible (disease of stomach or small intestine) Placed when increased risk for aspiration Nursing Care: Patients Undergoing NG or Nasoenteric Intubation Instruct patient about purpose of tube & the procedure Describe the sensations to be expected Assisting with tube insertion Confirming placement of the tube Monitoring the patient & maintaining tube function Providing oral & nasal hygiene & skin care Monitoring, preventing & managing potential complications  Removing the tube NG/NE Intubations: Potential Problems & Complications Fluid volume deficit o Dry skin & mucous membranes, decreased urinary output, lethargy & decreased body temperature Pulmonary complications o Inability to clear secretions o Impaired coughing/deep breathing o Tube dislodged Irritation of the mucous membranes o Nostrils, oral mucosa, esophagus, trachea PEG/PEJ Assessment Patient knowledge & ability to learn Self-care ability & support Skin condition Nutrition & fluid status Inspection of the tube o Migration, flow of output (if placed for decompression), flow of feeding (if placed for feeding) kinks, secured to gown properly, surrounding skin & mucus membranes PEG/PEJ Nursing Diagnosis Imbalanced nutrition disturbed body image Risk of infection Risk for impaired skin integrity PEG/PEJ Planning/Implementation Meet nutritional needs Prevent infection: o Hand hygiene, proper dressing, monitor dressing, maintain skin around insertion site, stabilizing disc to prevent skin breakdown cleanliness Enhance body image Monitor for potential complications Nursing Process: Evaluation Document PEG/PEJ: Complications Wound infection, cellulitis, leakage GI bleeding o Be cognizant of where tube is during repositioning, kinks, etc. Premature dislodgment of tube Conditions That May Require Enteral Therapy Tube Feeding Administration Methods Tubes  o Nasogastric or nasoenteric o Gastrostomy or jejunostomy tubes for long-term feeding Methods o Intermittent bolus feedings ▪ Gravity infusion o Continuous infusion o Cyclic feeding ▪ Patients weaning off Medication Administration via Feeding Tube Enteric-coated tablets are absorbed in intestines Time-release tablets o Do not crush these, it can cause an overdose Enteral Feeding Assessment Tube placement Patient’s ability to tolerate formula and amount Clinical response Signs of dehydration Elevated blood glucose level Check gastric residual I&O, weekly weights, dietician consult Enteral Feeding Nursing Diagnosis Imbalanced nutrition Disturbed body image Risk of infection Risk for impaired skin integrity Enteral Feeding Planning/Implementation Maintain nutrition balance and tube function Maintain normal bowel elimination Reduce risk for aspiration Maintain hydration Promote coping Prevent complications Patient education Nursing Process: Evaluation o Patient education, tolerance Document NG/Enteral Feeding Complications Diarrhea Nausea and vomiting Gas, bloating, cramping Dumping syndrome o When gastric contents move too quickly out of stomach and into intestine; shift in fluids/sugars causes intense abdominal pain, cramping; relieved by pooping Aspiration pneumonia Tube displacement  Tube obstruction Nasopharyngeal irritation Hyperglycemia Dehydration and azotemia o Azotemia: buildup of nitrogen waste products in blood and signal kidney injury ▪ Causes elevated BUN and serum creatinine levels Maintaining Nutrition Balance & Tube Function HOB 30-45 degrees Use a 30-mL or larger syringe Administer feeding at prescribed rate and method, according to patient tolerance Measure GRV before intermittent feedings; every 4-8 hours during continuous feedings Administer H2O before and after each medication and each feeding, before and after checking residual, every 4-6 hours, and whenever the tube feeding is discontinued or interrupted Do not mix medications with feedings Do not hang more than 4 hours of feeding in an open system o Increased risk of bacterial contamination Maintaining Normal Bowel Elimination Selection of TF formula; consider fiber, osmolality, and fluid content Prevent contamination of TF: maintain closed system; do not hang more than 4 hours TF in an open system Maintain proper nutritional intake Assess for reason for diarrhea and obtain treatment as needed Avoid cold TF & administer TF slowly to prevent dumping syndrome Reduce Risk for Aspiration Elevate head of bed at least 30-45 degrees during and for at least one hour after feedings Monitor gastric residual volume (GRV) Maintain hydration by supplying additional water and assessing for signs of dehydration Promote coping by support and encouragement; encourage self-care and activities Patient education Parenteral Feeding Method of providing nutrients to the body via an IV route Indications o 10% deficit in bodyweight compared to pre-illness weight; disinterest or inability to ingest food orally or by tube; major infection, fever, trauma, burns, major surgery; prolonged pre or post operative nutritional needs IV access o PPN (peripheral) vs. TPN (central) ▪ PPN: solution is less hypertonic, not nutritionally complete (less protein and dextrose); administered peripherally Lipids given to buffer and protect veins (also source of fat for patients) Patients typically on for 5-7 days ▪ TPN: full calories, more dextrose, central venous catheters; administered slowly and advanced gradually; have 5/6 times solute concentration of blood Dextrose over 10% CANNOT go through peripheral veins because it will cause phlebitis Nursing interventions o Maintaining optimal nutrition, preventing infection, encouraging activity when the patient is physically capable, and patient education o Monitor I&O o Monitor glucose (IMPORTANT) o Weighing patient o CBC, platelets, Mg, Ph Indications for Parenteral Nutrition TPN vs. PPN If TPN runs out, 10% dextrose is given before replacement bag o Need to discontinuous slowly to prevent hypoglycemia PPN given with lipids and amino acid-dextrose solutions Parenteral Nutrition Assessment Assist in identifying patients who are candidates for PN o Nutrition status; decreased oral intake >1 week o Weight loss 10% or more of usual weight o Muscle wasting, decreased tissue healing o Persistent N&V Hydration status Electrolytes Caloric intake Review medications Assess respiratory status Parenteral Nutrition Nursing Diagnosis Imbalanced nutrition Risk for infection Risk for imbalanced fluid volume Risk for activity intolerance Parenteral Nutrition Planning/Implementation Review medications Assess respiratory status De-clog tube per protocol Maintain optimal nutrition o Daily weight at same time of day  o Accurate I&O o Caloric count o Trace elements included in solution Prevent infection Hand hygiene Sterile technique for dressing changes Wear mask for changing the dressing Assess insertion site Assess for indicators of infection Proper IV and tubing care Maintain fluid balance o Use infusion pump. Flow rate should not be increased or decreased rapidly. If fluid runs out, hang 10% dextrose solution o Monitor indicators of fluid balance and electrolyte levels o I&O, daily weights o Monitor blood glucose levels Patient education o Goals and purpose o Potential complications and actions Nursing Process: Evaluation o Patient education o Improved nutritional status Document Parenteral Nutrition Complications Pneumothorax o Air enters pleural cavity o Central venous access Air embolism o Central venous access o Fatal Clotted catheter or displaced catheter o Central venous access Line sepsis Hyperglycemia o Dextrose in solution Rebound hypoglycemia o When D10 is not hung Fluid overload Endoscopic Procedures Endoscopy o Esophageal, gastric and duodenal mucosa visualization Colonoscopy o Large intestine, anus, rectum ▪ Larger in diameter and longer than endoscopy Management of Diagnostic Testing Patients Endoscopy o Upper GI: esophagus, stomach, duodenum o Management: ▪ Pre-Op: Education, monitor vital signs, NPO ▪ Post-Op: Education, Return of gag reflex, vital signs Colonoscopy o Lower GI: rectum, sigmoid colon, descending colon, transverse colon, ascending colon o Management: ▪ Pre-Op: Education, monitor vital signs, Bowel prep, NPO ▪ Post-Op: Education, Vital signs Colonoscopy Direct visualization of rectum, sigmoid, descending, transverse, and ascending colon Used to detect diverticulosis, polyps, colon cancer, and other abnormalities Surgeries & Ostomies Gastric surgery Bariatric surgery Care of the Gastric Surgery Patient: Assessment General health assessment Patient and support system knowledge Nutritional status Abdominal assessment Postoperatively assess for potential complications Care of the Gastric Surgery Patient: Nursing Diagnosis Anxiety Pain Deficient knowledge Imbalanced nutrition Care of the Gastric Surgery Patient: Planning/Implementation Provide interventions to reduce anxiety o Education, meditation, breathing, meds, movie Prevent post-operative complications o Gastric, general post-op Manage Pain o Administer analgesics as prescribed o Position in semi-Fowler position o Maintain function of NG tube Patient education o Diet: to delay stomach emptying and dumping syndrome, assume low semi-Fowler position after meals; lie down for 20 to 30 minutes; avoid fluid with meals and high carbohydrate and sugar intake (dumping syndrome); eat frequent, small meals; take dietary supplements as prescribed; reduce fat intake and administer loperamide aka Imodium (steatorrhea: stool with very high fat content) Evaluation-pain relief, surgical site, education Document Care of the Gastric Surgery Patient: Complications Gastric outlet obstruction o Narrowing of pyloric outlet o May require NG tube for suction to decompress stomach o NPO o Bariatric patients should not have NG tube Hemorrhage Dietary deficiencies Bile reflux o Treated with PPI Dumping syndrome o Develops after surgery o When food especially sugar or carbs moves very quickly from your stomach into small bowel o N/V/D, weakness, sweating, palpitation, syncope o Prevent by eating smaller meals, limiting high sugar foods o Meds/surgery to repair pylorus Steatorrhea o Reduce fat intake or eat loperamide to treat Bariatric Surgery Morbid obesity: >2x IBW, BMI exceeds 30 kg/m2, or more than 100 pounds greater than IBW; high risk for health complications Surgery only after nonsurgical methods have failed Selection factors: body weight, patient history, failure to lose weight using other means, absence of endocrine disorders, and psychological stability The average weight lost after bariatric surgery is 25-35% of previous body weight Patients at increased risk for osteoporosis as the duodenum is bypassed (primary site for absorption of calcium)  Risk for pernicious anemia: intrinsic factor to absorb vitamin B12 might be removed from surgery so they cannot absorb nutrients Calcium deficiency Care of the Bariatric Surgery Patient Preoperative care; evaluation and counseling Postoperative care is like gastric resection, but the patient is at greater risk for complications because of obesity Postoperative diet: clear liquids, then slowly advance to six small meals daily Patients require psychosocial interventions to modify their eating behaviors Prevent complications: VTE, hemorrhage, bile reflux, dumping syndrome, steatorrhea Education regarding long-term effects Follow-up care, Evaluation, Document Care of the Ostomy Patient: Assessment Stoma for color: immediate post-op → beefy red, then pink, never dusky (notify provider if dusky) Peristomal skin Scant bleeding only Size of stoma for proper fitting ostomy appliances Diet tolerance Readiness for learning Care of the Ostomy Patient: Nursing Diagnosis Disturbed body image R/T new colotomy Anxiety R/T bowel incontinence Risk for impaired skin integrity R/T irritation of the peristomal skin by the effluent Care of the Ostomy Patient: Planning/Implementation Fit wafer to stoma to prevent excoriation from stool, note any leakage Empty bag when about half full Check for fungal infection of skin, may need nystatin powder Encourage verbalization of concerns and fears o Invite significant other to participate to discuss sexual/intimacy concerns Monitor fluid balance Education Include support system o Encourage verbalization of concerns and fears o How to cleanse the peristomal skin gently o How to prepare the appliance for installation, adequate fit, emptying, irrigation (if necessary) o Signs/symptoms of irritated/inflamed skin o Diet: avoid foods that increase peristalsis, gas (nuts, seeds, prunes, bananas) o Monitor fluid balance: daily weights, adequate hydration, skin turgor, appearance of the tongue Evaluation & Document o Return demonstration, verbalized understanding Oral & Esophageal Disorders Impaired oral health Dysphagia Hiatal hernia Barrett’s Esophagus Zenker Diverticulum Esophageal varices Impaired Oral Health Changes in the oral cavity: o Influence the type and amount of food ingested Diseases of the mouth interferes with communication Esophageal problems: o Affect food and fluid intake o Jeopardize general health Connection to systemic disease: CV, DM, rheumatoid arthritis Impaired Oral Health: Management Promoting mouth care Dental care before surgery or radiation therapy Frequent gentle brushing and flossing or if patient cannot tolerate brushing (use of mouthwashes and other methods of cleaning and rinsing) Patient education related to oral hygiene Encourage fluid intake to reduce dry mouth Use of synthetic saliva or a saliva production stimulants Dysphagia: Management Assessment o Bedside swallow evaluation; barium swallow (x-ray) o Inability to manage secretions Nursing Diagnosis o Impaired swallowing, Risk for aspiration, Imbalanced nutrition: less than body requirements Nursing Interventions o Aspiration precautions--HOB raised upright/OOB; eat small amounts slowly; thickening of liquids; avoid use of straws; avoid distractions during mealtime; suction at the bedside o Patient/support system education Hiatal Hernia: Management Assessment o Sliding- none, regurgitation, heartburn o Paraoesophageal- none, fullness, CP after eating ▪ Reduced space in heart, causing chest pain Nursing Interventions o Frequent, small meals; do not recline for one hour after eating, elevate HOB 4-8 inches at bedtime; Medications o Prepare for surgery (torsion) o Patient/support system education Evaluation and Document Barrett’s Esophagus: Management Untreated GERD, lining of esophagus has changed from pink to red o Squamous cells replaced by columnar epithelium o Precursor to cancer Diagnosed by EGD (esophagogastroduodenoscopy) and confirmed by biopsy Management like patients with GERD Close monitoring by Gastroenterologist o Biopsies, endoscopic ablation, esophagectomy (if severe) Zenker Diverticulum Assessment o Dysphagia, fullness in the neck, belching, regurgitation of undigested food, and gurgling noises after eating, c/o of halitosis and sour taste in mouth o Avoid NG tube or esophagoscopy for risk of perforation, risk of mediastinitis o Esophagus creates pouch, which is filled with food/fluid and when they lie down it is regurgitated Treatment o Surgical removal o Observe incision for evidence of leakage from esophagus and developing fistula o NPO post-operatively until x-rays show no leakage at the surgical site o Start with liquids, advance as tolerated Esophageal Varices Esophageal varices are abnormal, enlarged veins in esophagus This condition occurs most often in people with serious liver diseases Esophageal varices develop when normal blood flow to the liver is blocked by a clot or scar tissue in the liver Bleeding esophageal varices is life-threatening condition and can be fatal in up to 50% of patients Treatment with variceal ligation is effective in controlling first-time bleeding episodes in about 90% of patients Conditions of the Esophagus: Nursing Diagnosis Imbalanced nutrition: less than body requirements R/T dysphagia Acute pain R/T dysphagia, ingestion of an abrasive agent, tumor, or frequent episodes of gastric reflux Deficient knowledge about the esophageal disorder, diagnostic studies, medical management, surgical intervention, and rehabilitation Risk for aspiration R/T difficulty swallowing or tube feeding Conditions of the Esophagus: Planning/Implementation Encouraging adequate nutritional intake Decreasing risk of aspiration Relieving pain Providing patient education Education Evaluation Document Gastric & Duodenal Disorders Gastroesophageal Reflux Disease (GERD) Gastritis Peptic Ulcers o Gastric ulcers o Duodenal ulcers GERD: Management Assessment o Complaints burning sensation, indigestion, pain on swallowing, or hypersalivation, may mimic MI Nursing Interventions o Dietary restrictions ▪ Low-fat diet: avoid caffeine, tobacco, beer, milk, foods with peppermint/spearmint, carbonated beverages, avoid eating/drinking 2 hours or sooner before bedtime o Medications: to treat and to avoid ▪ PPI’s ▪ Avoid aspirins, NSAIDS, anticoagulants, antiplatelets These meds erode stomach lining and increase gastric acid secretion o Elevate HOB at bedtime, maintain healthy body weight o Patient/support system education; Document Gastritis Inflammation of the stomach o From bile reflux, alcohol, NSAIDS, stress, H.Pylori Assessment o Acute: abdominal discomfort, headache, weakness, nausea, vomiting, hiccupping o Chronic: epigastric discomfort, anorexia, heartburn after eating, belching, sour taste in the mouth, nausea and vomiting, intolerance of some foods; potential B12 deficiency due to decreased intrinsic factor, leads to pernicious anemia Diagnosis is usually by upper GI x-ray or endoscopy and biopsy Care of the Patient with Gastritis: Diagnoses Acute pain Anxiety Imbalanced nutrition Deficient knowledge Risk for fluid volume imbalance Care of the Patient with Gastritis: Planning/Implementation Reduce anxiety; use calm approach and explain all procedures and treatments Promote optimal nutrition; for acute gastritis, the patient should take no food or fluids by mouth. Slowly reintroduce clear liquids and solid foods as prescribed. Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, cigarette smoking. Refer for alcohol counseling and smoking cessation Promote fluid balance; monitor I&O, for signs of dehydration, electrolyte imbalance, and hemorrhage Measures to relieve pain: diet and medications Nursing Process: Evaluation Document Comparison of Peptic Ulcers 2 main types and 2 major types: H.Pylori and use of NSAIDS o Ask when they have pain ▪ Gastric ulcers have pain is 30 mins to hour after meal ▪ Duodenal ulcer pain occurs 90 mins to 2-3 hours after meals (or during night) Eating helps relieve duodenal pain More common; associated with increased parietal cells (acid secreting cells of stomach) Form when acid erodes lining of digestive tract Assessment Peptic Ulcers: Management Nursing interventions: o Medication regimen, dietary restrictions ▪ Low fat diet, avoid caffeine/tobacco/beer/milk/foods with peppermint/spearmint/sodas ▪ No eating/drinking before bedtime o Pain management/reduce anxiety ▪ Medication, relaxation techniques ▪ PPI’s to decrease acid formation and avoid NSAIDS/aspirin o Maintain optimal nutritional status o Monitor for complications ▪ Hemorrhage, perforation, peritonitis Perforation leads to peritonitis (tender, rigid abdomen, N/V that needs surgery) o Patient/support system education Evaluation and Document GI Part 2 Intestinal & Rectal Disorders Constipation Diarrhea Appendicitis Cholecystitis Pancreatitis Diverticular disease Inflammatory bowel disease Intestinal obstruction Constipation A symptom from another condition (meds, spinal cord injury, physical inactivity, holding onto stool) Defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise Increased risk in older age Constipation: Assessment Fewer than three bowel movements per week Abdominal distention, pain, and bloating Decreased appetite A sensation of incomplete evacuation Straining at stool Elimination of small-volume, hard, dry stools Diagnostic tests o Barium enema, sigmoidoscopy, and stool testing (occult blood) Constipation: Planning/Implementation Administer laxatives, suppositories, enema as ordered Education o Normal variations of bowel patterns ▪ Pooping 3 times a day is normal for some patients’ vs every other day is normal for other patients o Establishment of normal pattern o Dietary fiber and fluid intake o Responding to the urge to defecate o Exercise and activity o Avoid overuse of laxative Avoid complications Constipation: Complications Hypertension o Valsalva maneuver, straining Fecal impaction o Cannot be passed Hemorrhoids o Dilated anal veins o Common in pregnant pts Anal Fissures Rectal prolapse o Treat with pelvic floor exercises o Common in older women after childbirth Megacolon o Inflammatory bowel disease causes colon to expand, dilate, distend o Painful, rare, can be life-threatening Medications to Treat Constipation Stool softeners Bulk producing laxatives Osmotic laxatives (short-term use only) o Milk of magnesia, MiraLAX o Can lead to dehydration and electrolyte imbalance Stimulant laxatives (use cautiously) o Dulcolax o Increase peristalsis, can cause abdominal cramping, N/V o Electrolyte imbalance with long term use Suppositories Enemas Diarrhea Increased frequency of bowel movements (> 3/day) with altered consistency (i.e., increased liquidity) of stool o Loss of water, sodium K, Na, can lead to metabolic acidosis Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors  May be acute, persistent, or chronic Causes: infections, medications, tube feeding formulas, and various disease processes and disorders Diarrhea: Assessment Increased frequency and fluid content of stools Abdominal cramps Distention Borborygmus o Stomach gurgles from peristalsis Anorexia and thirst Painful spasmodic contractions of the anus Tenesmus o Rectal pain Diagnostic tests o CBC, stool testing (culture, ova, and parasites) Diarrhea: Planning/Implementation Treat underlying cause first o Food poisoning Administer medications as ordered o Imodium IV fluids Oral rehydration therapy Stool Management system o Can remain for 28-29 days for patients with loose, continuous, watery stools Education o Rest, diet and fluid intake: avoid irritating foods, including caffeine, carbonated beverages, very hot and cold foods; may need to avoid milk, fat, whole grains, fresh fruit, and vegetables; take probiotics, yogurt; bland foods until diarrhea resolved o Perianal skin care, medications, lactose intolerance Avoid complications Diarrhea: Complications Fluid and electrolyte imbalances Dehydration Cardiac dysrhythmias Chronic diarrhea → skin breakdown → irritant dermatitis Medications to Treat Diarrhea Antibiotics (if bacterial origin) Antidiarrheals (no longer than 3 days) IV fluids for severely dehydrated patients Replace electrolytes due to fluid loss o Pedialyte o Oral rehydration solution Gerontologic Considerations: Constipation & Diarrhea Older patients who have decreased activity may be more prone to constipation Aging causes slower peristalsis, which results in increased water absorption from feces Older patients may tend to overuse laxatives, resulting in diarrhea Constipation or diarrhea may result from polypharmacy, which is increased in older patients Appendicitis Most frequent cause of acute abdomen in the US, most common reason for emergency abdominal surgery Appendix becomes inflamed, edematous due to kink or occlusion by a fecalith or lymphoid hyperplasia Once obstructed, appendix becomes ischemic → bacterial overgrowth → eventually gangrene or perforation Appendicitis: Planning/Implementation Monitor o Vital signs for changes: temperature, heart rate o Pain level: sudden increase in pain or sudden relief of pain (indicates peritonitis) o Monitor fluid status and provide IV fluids o Monitor labs (WBCs) Prepare/educate patient & support system for emergency surgery o Expectations before and after surgery o Provide emotional support o Encourage them to verbalize anxieties and fears o Reassure and educate Administer analgesics, antibiotics, antipyretics as ordered Avoid complications (pre and postoperatively) o Monitor signs of infection, pain o Slowly reintroduce foods Appendicitis: Complications Preoperative o Perforation o Peritonitis ▪ Pain, tenderness, rigid abdominal muscles, fever, nausea and vomiting) o Paralytic ileus ▪ Obstruction of intestine due to perforation of appendix o Death Postoperative o Surgical site infection, atelectasis, PNA, VTE, constipation, urinary retention, hemorrhage Gerontologic Considerations: Appendicitis Symptoms may vary or may be vague or suggestive of bowel obstruction Increased risk for perforation is due to vague or lacking symptoms Cholecystitis Inflammation of the gall bladder Main cause: cholelithiasis (gall stones) Risk factors: Obesity, high cholesterol, liver disease Signs of stones: intensifying pain in RUQ o Pain may also appear in other areas such as right shoulder o Complaints of N/V Cholecystitis: Treatment Preventative measures o Lose weight o Decrease saturated fat intake May require cholecystectomy (surgery) o T-tube drain ▪ Drain bile while duct is healing o Splint incision when coughing o Avoid abdominal pressure for first 4 weeks o Initially avoid fatty food, can return to normal diet Medications: antibiotics, analgesics, antispasmodics NPO, gastric decompression Diagnostic or Treatment: MRCP, ERCP  o MRCP to view pancreas, gallbladder, liver (like MRI) ▪ For diagnosing o ERCP is endoscopic and goes through mouth to view pancreas, gallbladder, liver ▪ For treatment Pancreatitis Inflammation of the pancreas Causes o Acute: Gallstones, heavy alcohol drinking o Chronic: Excessive alcohol intake (main cause) ▪ CAGE assessment C- cut down on drinking? A- annoyed friends about your drinking? G- guilty about drinking? E- eye opener: drink first thing in morning or for hangover ▪ Librium taper to assist with withdrawal symptoms Lab tests and diagnostic studies o Increased amylase and lipase o Ultrasound, CT, MRI to visualize pancreas o ERCP to visualize pancreatic and bile ducts Signs/symptoms: severe epigastric pain worse after meals, N/V, fever Pancreatitis: Treatment NPO during acute phase o May place NG tube, start IVF Avoid alcohol, caffeine, & spices Slowly advance diet as tolerated Low fat, high protein, bland diet in small meals Monitor for hyperglycemia Monitor downward trend of labs (amylase, lipase) Diverticular Disease Most common in sigmoid colon Diverticulosis: o Multiple diverticula without inflammation Diverticulitis: o Infection and inflammation of diverticula Genetic link, older age, low-fiber diet Diagnosis is usually by colonoscopy o Develops when fecalith hardens in diverticula and causes inflammation → edema → bleeding and perforating → peritonitis Colon resection can treat Diverticular Disease: Assessment Changes in bowel habits Abdominal pain (LLQ), distension and tympany with diverticulitis o Typically, sudden and intense, worse after eating, better after defecation or flatus Elevated temperature and pulse Anorexia, nausea, and vomiting with diverticulitis Melena if diverticular bleed Labs and Diagnostic Tests o CBC with differential o ESR (erythrocyte sedimentation rate) ▪ Signifies inflammation o CT, sigmoidoscopy, or colonoscopy Diverticular Disease: Planning/Implementation Monitor o Severity of symptoms o Character, frequency, presence of blood in stools o WBCs (elevated?) H&H o Temperature  Supportive measures o IV fluids o PO intake o Encourage rest o Avoid bending, lifting, straining, coughing (increases intra-abdominal pressure) Antibiotics with diverticulitis, analgesics as ordered Educate on diet o Softer foods with increased fiber to encourage stool to be expelled from body o Whole grains, fruits, veggies o Fiber supplements Increase physical activity level Avoid complications Diverticular Disease: Complications Partial or complete obstruction Bowel perforation Peritonitis Fistula formation Hemorrhage Medications to Treat Diverticular Disease Antibiotics to treat infection Anticholinergics/antispasmodics to control bowel contractions Pain medication for severe discomfort Bulk-forming laxatives to reduce constipation Stool softeners Gerontologic Considerations: Diverticular Disease The risk for developing diverticular disease increases as people age 35% of U.S. adults aged 50 years or younger have diverticulosis, while about 58% of those older than age 60 have diverticulosis Inflammatory Bowel Disease Crohn's disease: regional enteritis; chronic, recurrent inflammation of mucosa in bowel; deep ulcers develop that penetrate all layers of bowel wall; 3-4 stools a day with fat present in stool Ulcerative colitis: diffuse inflammation of mucosal and submucosal layers only; have ulcers that are not deep; thickening and edema of mucosa, large intestine, rectum; bleeding; 5-over 20 stools a day with blood and mucus Inflammatory Bowel Disease: Assessment Health history o Identify onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history Discuss dietary patterns o Any intake of alcohol, caffeine, or nicotine? Assess bowel elimination patterns and stool Abdominal assessment Inflammatory Bowel Disease: Planning/Implementation Major goals may include o Attainment of normal bowel elimination patterns o Relief of abdominal pain and cramping o Prevention of fluid deficit o Maintenance of optimal nutrition and weight o Avoidance of fatigue o Reduction of anxiety & promotion of effective coping o Absence of skin breakdown o Increased knowledge of disease process o Therapeutic regimen o Avoidance of complications Identify relationship between diarrhea and food, activities, or emotional stressors Provide ready access to bathroom or commode Encourage bed rest to reduce peristalsis Administer medications as prescribed  Record character of stools: frequency, consistency, character, and amounts Assessment and treatment of pain or discomfort, anticholinergic medications before meals, analgesics, positioning, diversional activities, and prevention of fatigue Fluid deficit, I&O, daily weight, assessment of symptoms of dehydration or fluid loss, encourage oral intake, measures to decrease diarrhea Optimal nutrition: elemental feedings that are high in protein and low residue or PN may be needed Reduce anxiety, use a calm manner, allow patient to express feelings, listening, patient education Education o Understanding of disease process o Nutrition and diet o Medications (NSAIDS, corticosteroids, anticholinergics, immunosuppressants) o Information sources: National Foundation for Ileitis and Colitis o Bowel resection (Crohn’s), Ileostomy (UC or Crohn’s) care if applicable Avoid complications Inflammatory Bowel Disease: Complications Electrolyte imbalance Cardiac dysrhythmias GI bleeding Perforation of the bowel → peritonitis Fistulas Megacolon Gerontologic Considerations: Inflammatory Bowel Disease Ulcerative Colitis o 3 times more common than Crohn’s disease o Can occur at any age, peak between 15-30 years and again between 50-70 years old Crohn’s Disease o Can occur at any age, most likely diagnosed around 30 years old Intestinal Obstruction Blockage prevents the normal flow of intestinal contents through the intestinal tract Mechanical obstruction: o Intraluminal obstruction or mural obstruction from pressure on the intestinal wall Functional or paralytic obstruction: o The intestinal musculature cannot propel the contents along the bowel o The blockage also can be temporary and the result of the manipulation of the bowel during surgery Mechanical obstructions (physical blockage) o Strangulated hernia o Tumors o Adhesions (from scar tissue) o Fecal impaction o Volvulus (twisting of bowel) o Intussusception (telescoping of bowel) Functional/Paralytic obstruction o Paralytic ileus (absence of peristalsis) ▪ Due to abdominal or spinal surgery ▪ Due to peritonitis ▪ Lack of blood supply to intestines ▪ Electrolyte imbalances (e.g., low potassium) Intussusception Check for blood and mucus in stools (red currant jelly appearance) Emergency Blood and mucus may be in stools, jelly stools Intestinal Obstruction: Management Maintaining the function of the nasogastric tube Assessing and measuring the nasogastric output Assessing for fluid and electrolyte imbalance Monitoring nutritional status Assessing for manifestations consistent with resolution  o Return of normal bowel sounds, passage of flatus or stool, decreased abdominal distention, subjective improvement in abdominal pain and tenderness Slowly reintroduce diet and monitor tolerance Hepatic Metabolic Functions of the Liver Glucose metabolism Drug metabolism Protein metabolism o Ammonia byproduct Fat metabolism o Bile formation Ammonia conversion o Converts ammonia to urea (water soluble substance secreted in urine) Vitamin and iron storage Bile formation Bilirubin excretion o Buildup plays role in jaundice Assessment: Manifestations of Liver Dysfunction Jaundice Portal hypertension Ascites and varices Hepatic encephalopathy or coma Nutritional deficiencies Assessment: Liver Function Studies & Diagnostic Studies Serum aminotransferase: o AST, ALT, GGT, GGTP, LDH ▪ Indicates hepatitis, cancer, cirrhosis Serum protein studies Direct and indirect serum bilirubin, urine bilirubin, and urine bilirubin and urobilinogen Clotting factors Serum alkaline phosphatase (ALP) Serum ammonia o Can build up and affect LOC (reduce protein to avoid this) Lipids Diagnostic tests: o Liver biopsy o Ultrasonography, CT, MRI Jaundice Hyperbilirubinemia Signs and symptoms o Malaise, fatigue, weakness o Dark orange-brown urine, clay-colored stools o Lack of appetite, nausea or vomiting, weight loss o Dyspepsia, intolerance of fats o Pruritus ▪ Bile salt accumulation 3 types: o Hepatocellular: result of liver disease/injury o Hemolytic: hemolysis o Obstructive: obstruction along biliary tree/liver disease Portal Hypertension Obstructed blood flow through the liver results in increased pressure throughout the portal venous system Commonly associated with hepatic cirrhosis and can also occur with non-cirrhotic liver disease Results in  o Ascites o Esophageal varices ▪ Top 2 are main symptoms o Caput medusae ▪ Sign of severe portal hypertension Ascites Seen with cirrhosis, cancer, heart failure Contributing factors: o Portal hypertension resulting in increased capillary pressure and obstruction of venous blood flow o Vasodilatation of splanchnic circulation (blood flow to the major abdominal organs) o Changes in the ability to metabolize aldosterone, increasing fluid retention o Decreased synthesis of albumin, decreasing serum osmotic pressure o Movement of albumin into the peritoneal cavity Ascites: Assessment Daily abdominal girth and weight Striae, distended veins, or umbilical hernia Potential fluid and electrolyte imbalances Ascites: Treatment Low-sodium diet Diuretics o Potassium sparring Bed rest and positioning to promote respiratory efficiency, decrease risk for injury Paracentesis o Monitor during this is over 1 liter in a session is removed Administration of salt-poor albumin (SPA) Transjugular intrahepatic portosystemic shunt (TIPS) o Shunt Hepatic Encephalopathy Two major alterations underlie its development in acute and chronic liver disease o Hepatic insufficiency: the inability of the liver to detoxify toxic by-products of metabolism (e.g., salts, urea, ammonia) o Portosystemic shunting: collateral vessels develop allowing elements of the portal blood (laden with potentially toxic substances usually extracted by the liver) to enter the systemic circulation Early signs: mental changes and motor disturbances o Can be reversed when caught early Later stages: life threatening Hepatic Encephalopathy: Assessment Stages of Hepatic Encephalopathy Hepatic Encephalopathy Asterixis o Involuntary flapping of hands o Seen in stage 2 encephalopathy Apraxia o Inability to write/draw figures Hepatic Encephalopathy: Treatment Eliminate precipitating cause Lactulose to reduce serum ammonia levels Protein restriction Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics Discontinue sedatives, analgesics, and tranquilizers Monitor or treat complications and infections Portal Systemic Shunts Treats portal pressure Transjugular Intrahepatic Portosystemic Shunt (TIPS) TIPS is a shunt (tube) placed between the portal vein which carries blood from the intestines and intraabdominal organs to the liver and the hepatic vein which carries blood from the liver back to the vena cava and the heart Complications: bleeding, sepsis, HF, thrombosis, organ perforation, progressive liver failure Second line therapy for refractive ascites Abdominal Paracentesis Sterile, invasive procedure to drain peritoneal fluid Fluid specimen for analysis Nursing Diagnosis o Ineffective breathing pattern o Activity intolerance o Risk for infection Complications o Infection, shock, bleeding, peritonitis o Do not remove over 1 liter during each episode Interventions o Monitor vital signs, daily weights, measure abdominal girth daily, nutritional supplementation Esophageal Banding  Treats esophageal varices Removes varix Endoscopic Sclerotherapy Sclerosing agent is injected through fiberoptic endoscope into bleeding esophageal varices to promote local coagulation and eventual sclerosis of bleeding site → slough off Complications: chest pain, mucosal ulcerations, rebleeding, bacteremia → sepsis and pleural effusions Replaced by esophageal banding Hepatic Disorders Esophageal varices Hepatitis Hepatic cirrhosis Fatty liver Esophageal Varices Occurs in ~ 1/3 of patients with cirrhosis and portal hypertension First bleeding episode has a mortality rate of 10—30% depending on severity Manifestations: o Hematemesis, melena, general deterioration, and shock Patients with cirrhosis should undergo screening endoscopy every 2—3 years Esophageal Varices: Nursing Diagnoses Esophageal Varices o Risk for bleeding o Imbalanced Nutrition (NPO) Bleeding Varices o Risk for aspiration o Fluid volume deficit o Risk for shock Treatment for Bleeding Varices: Medications EMERGENCY Treat for shock; administer oxygen IV fluids, electrolytes, volume expanders, blood and blood products Vasopressin, somatostatin, octreotide to decrease bleeding Nitroglycerin in combination with vasopressin to reduce coronary vasoconstriction Propranolol and nadolol to decrease portal pressure; used in combination with other treatment Treatment for Bleeding Varices: Procedures Balloon tamponade o Tube placed in esophagus that compresses walls to stop bleeding Endoscopic sclerotherapy  Endoscopic variceal ligation (esophageal banding therapy) Transjugular intrahepatic portosystemic shunt Surgical management Bleeding Esophageal Varices: Management Maintain safe environment; prevent injury, bleeding and infection Administer prescribed treatments and monitor for potential complications o Chest pain, mucosal ulcerations, re-bleeding, bacteremia sepsis Encourages deep breathing and position changes. Education and support of patient and family Hepatitis Viral hepatitis: a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes o A and E: fecal–oral route o B and C: bloodborne o D: only people with hepatitis B are at risk Non-viral hepatitis: toxin and drug induced 5 types o A: from poor hand hygiene o B: from blood or body fluid; major cause of cirrhosis and liver cancer o C: from blood, sexual contact, needle sticks, most common blood borne infection ▪ Screening, safe needles o D: only people who had Hep B are at risk o E: only people who had Hep A can get it Hepatic Cirrhosis Types o Alcoholic: scar tissue characteristically surrounds the portal areas o Post-necrotic: broad bands of scar tissue o Biliary: scarring occurs in the liver around the bile ducts Manifestations: o Liver enlargement, portal obstruction, ascites, infection and peritonitis, GI varices, edema, vitamin deficiency, anemia, mental deterioration Hepatic Cirrhosis: Planning/Implementation Medications o Diuretics, anti-HTN, ammonia reducers, antibiotics Promoting rest o Rest and supportive measures o Positioning for respiratory efficiency o Oxygen o Planned mild exercise and rest periods o Measures to prevent hazards of immobility Improving nutritional status o I&O o Encourage small frequent meals  o High-calorie diet, sodium restriction o Protein modified if patient is at risk for encephalopathy ▪ Keep daily protein between 1.2 and 1.5 g/kg per day o Supplemental vitamins, minerals, B complex, provide water-soluble forms of fat-soluble vitamins if patient has steatorrhea Providing skin care Frequent position changes Reduce scratching related to pruritus Gentle skin care, creams, antihistamines Reducing risk of injury Prevent falls, trauma related to risk for bleeding Monitoring and managing potential complications Hepatic Cirrhosis: Complications Hemorrhage Hepatic encephalopathy Fluid volume excess Death Medications to Treat Liver Dysfunction Lactulose to reduce ammonia levels o Results in bowel movements Immunize for hepatitis A, B; pneumonia; and annual influenza Nutritional supplements Vitamins (folic acid, vitamin B1, B6, B12) Gerontologic Considerations Many older adults take multiple medications for a variety of health conditions Drug metabolism occurs mainly in the liver, and thus, may result in hepatotoxicity Due to aging, the underlying liver function is reduced, therefore, predisposing the elderly to reduced ability to tolerate adverse drug effects and the effects of alcohol Fatty Liver Disease (Steatosis) Non-Alcoholic (simple) o Lipids accumulate in the hepatocytes o Liver failure symptoms o Reversible with lifestyle change o Symptoms: malaise, N/V, discomfort in abdomen o Subtype = Nonalcoholic steatohepatitis (NASH) ▪ Inflammatory ▪ More extreme form, inflammation present that can lead to cirrhosis “scarring” Alcoholic o Due to heavy alcohol use o Causes liver damage o Liver failure symptoms + jaundice o Symptoms: jaundice, malaise, N/V, discomfort in abdomen o Leads to alcoholic hepatitis and cirrhosis Risk factors: obesity, diabetes, high blood pressure Acetaminophen Most common cause of acute liver failure in USA What is the maximum dose of acetaminophen for a 24-hour period? o 4g o Educate patients on meds they are taking Musculoskeletal Functions of the MSK System Protect vital organs, framework that supports body structures and mobility, movement, producing heat, maintaining body temperature, facilitating return of blood to heart, reservoir for immature blood cells and vital minerals Bones, muscles, joints Joints:  o Arthritic, moveable joints (skull) o Anti-arthritic joints, limited movement (vertebral) o Freely movement joints (shoulder) Flaccidity: lower motor neuron lesion (muscle dystrophy) Spasticity: upper motor neuron lesion (CP) Bone is in a constant state of turnover o Nutrients in diet (Ca, vitamin D) o Environment (physical activity) Gerontologic Considerations Fragile bones Stumbling and falls from muscle weakness Stiff joints Osteoarthritis, joint swelling o Dependent on diet, lifestyle comorbidity Assessment: Health History Include data related to functional ability o ADLs o IADLs Past health, social, and family history General health maintenance; occupation Medications o Prescription & OTC Learning needs; socioeconomic factors Assessment: Physical Assessment Pain, tenderness, altered sensation Posture and gait Bone integrity Joint function Muscle strength and size Skin Neurovascular status o Important because musculoskeletal injury can cause other tissue and nerve damage o Circulation, Motion, Sensation exams o 6 P’s ▪ Pallor ▪ Poikilothermia: inability to regulate temp, cold ▪ Pulselessness ▪ Paralysis ▪ Pain ▪ Paresthesia Diagnostic Tests Radiographs Computed tomography MRI Bone densitometry o Detects osteopenia (weak bones from bone breakdown faster than its being replaced); predecessor to osteoporosis Bone scan o Injection of tracer or radioisotope distributed throughout body and gets picked up in hotspots where there is increased bone metabolism (i.e. inflammation, infection, bone tumors) Arthrography Arthroscopy Arthrocentesis Electromyography Biopsy Laboratory studies Nursing Intervention: Diagnostic Studies  MRI o May hear knocking sound o Assess for contraindications o Assess for allergies for contrast testing Biopsy o Monitor site for bleeding and edema o Administer analgesics and antibiotics Bone scan o Assess for allergies to radioisotopes o Encourage flids to distribute isotope (circulates 2-4 hours) o Post: encourage fluids to flush out isotope Nursing Interventions: MRI Studies Metal-containing objects must be removed before the MRI is performed Credit cards with magnetic strips, nonremovable cochlear devices o Check pacemakers for compatibility Transdermal patches that have a thin layer of aluminized backing must be removed A 27-year-old male patient presents to ED complaining of severe pain to left hip after falling while shoveling snow in his driveway, what is the priority nursing diagnosis? A. Impaired physical mobility B. Acute pain C. Disturbed body image D. Ineffective coping Musculoskeletal Care Modalities Splints, braces, and casts External fixators Traction (skin and skeletal) Orthopedic Surgery (hip/knee joint replacement) Splints & Braces Contoured splints of plaster or pliable thermoplastic materials may be used for: Conditions that do not require rigid immobilization o For those in which swelling may be anticipated ▪ Can be opened o And for those who require special skin care Braces (i.e., orthoses) are custom fitted to various parts of the body and are used to: o Custom-fitted, intended for longer-term use o Provide support o Control movement o And prevent additional injury o TLSO Brace (Thoracolumbosacral Orthotic) ▪ For sustained spinal surgery Splints are general, readily available Braces are custom fitted for ACL impairments Casts & Cast Care A rigid, external immobilizing device Uses o Immobilize a reduced fracture ▪ Reduction: active restoring the fracture fragments to anatomic alignment and positioning; place fractured bones in right position o Correct or prevent a deformity like clubfoot or hip displacement o Apply uniform pressure to underlying soft tissues o Support and stabilize weakened joints Materials: non-plaster (fiberglass), plaster of Paris (heavy, white, thicker material) o Paris is for more severe injuries Types of Casts Arm (short or long) Leg (short or long)  Walking: rocker boot for walking Spika cast: o Shoulder spika: encircles trunk and shoulder and elbow o Hip spika: encircles trunk and extremities ▪ Center remains open for bowel and urinary elimination Nursing Process: Casts, Splints, Braces Assessment o General health assessment o Emotional status, readiness to learn o Presenting signs and symptoms and condition of the area o Neurovascular assessment using “6 Ps” Nursing diagnosis o Acute pain o Impaired physical mobility o Risk for disuse syndrome ▪ Muscle atrophy from bedrest, physical immobility ▪ Encourage exercises Planning/ Implementation o Prepare patient for application by explaining procedure ▪ Provide information about the purpose of treatment o Treat lacerations and abrasions before cast, brace, splint o Describe exact site, character, and intensity of pain o Treat with elevation, ice packs, and analgesics (RICE) ▪ R = rest ▪ I = ice area 15-20 mins on and off every hour for first 24-48 hours to prevent swelling ▪ C = compression to prevent swelling ▪ E = elevation to raise affected area above level of heart to encourage venous return o Monitor neurovascular status, potential complications Evaluation o Patient understanding of patient education (RICE, complications, when to call 911) o Effectiveness of pain meds o Evaluate and continually assess for neovascular changes DOCUMENT! Potential Complications Pressure ulcer: o Caused by inappropriately applied cast o Treatment: cut out window for inspection, bivalve Disuse Syndrome: o Muscle atrophy and loss of strength o Treatment: Isometric exercises, muscle setting exercises Compartment syndrome: o Occurs from increased pressure in a confined space o Compromises blood flow o Ischemia and irreversible damage can occur within hours ▪ Pressure needs to be relieved within 6 hours o SURGICAL EMERGENCY ▪ A is normal ▪ B shows compressed nerves and vessels from swelling muscle fibers in fixed area No perfusion to tissue, no innervation Pain that is unrelieved by mends Will complain of paresthesia, burning, pain Dx: Clinical assessment of 6 Ps; pain and paresthesia are early indicators Treatment: Notify physician, cast may be removed, and emergency fasciotomy may be necessary Patient Education Impact of injury to functioning o Activity, exercise, rest Medications o May cause constipation o Encourage fluid, fiber, activity  Keep the cast dry Controlling of swelling and pain Care of minor skin irritation o Pad rough edges with moleskin o Pedal edges of cast (place waterproof tape around edges of cast to protect skin in case urine/feces gets through diapers and soil cast such as in hip Spika) o No sticking foreign objects in cast (risk of breaking skin integrity and potential for infection) ▪ Order antihistamine if itching is intense ▪ Blow-dryer can relieve mild itching Signs and symptoms to report: o Persistent pain or swelling o Changes in sensation, movement, skin color, or temperature o Signs of infection or pressure areas Required follow-up care Cast removal and after care DOCUMENT! External Fixators Metal apparatus that consists of pins or wires, clamps, and a metal frame to manage open fractures that is severe, comminuted, splintered, or crushed bone with soft tissue damage Patient requires reassurance because of appearance of device Discomfort is usually minimal, and early mobility may be anticipated with these devices Elevate to reduce edema Monitor for signs and symptoms of complications, including infection, vascular status Pin care o Nurse should inspect traction pin site for signs of inflammation or evidence of infection q8h Pin Care Assess every 8 hours o Signs/symptoms of infection o Goal = avoid osteomyelitis o After 72 hours, initial symptoms of inflammation should subside Clean and dress as prescribed General guidelines: o Hand hygiene before and after o Clean each pin separately to avoid cross contamination o S/s of infection present or pins becomes loose, notify provider IMMEDIATELY Traction The application of pulling force to a part of the body Used as short-term intervention until definitive plan/surgery occurs Purposes o Reduce muscle spasms o Reduce, align, and immobilize fractures o Reduce deformity o Increase space between opposing forces Used as a short-term intervention until other modalities are possible 2 types: skin, skeletal Skin traction is applied by strapping pts affected lower limb and attaching a weight Bux traction o Foam boot applied o Foot plate is attached to a weight Skeletal traction o Pin, wire, screw into bone and weights attached to bone to pull back into alignment Traction must be continuous to be effective; do not interrupt, do not remove weights (unless intermittent traction prescribed) Patient must be in good body alignment in center of bed Ropes must not be obstructed (linens, etc.); weights must hang freely (not rest on bed or floor) Knots in robe or footplate must not touch pulley or foot of bed Nursing Process: Skin Traction Assessment o General health assessment  o Emotional status (e.g., fear, anxiety) o Readiness to learn o Extremity in traction (neurovascular assessment) o Proper application and maintenance of traction Nursing Diagnosis o Acute pain o Risk for VTE o Risk for peripheral neurovascular dysfunction o Risk for impaired skin integrity Planning/Implementation o Education ▪ Procedure, purpose, pain, meds, safety precautions o Administer analgesics PRN Administer analgesics PRN Inspect skin at least 3 times a day Assess neurovascular changes: circulation, sensation, movement, 6 P’s Assess for indicators of venous thromboembolism & infection Assist with self-care Evaluation o Understanding of education o Effectiveness of analgesics o Prevention of complications DOCUMENT! Nursing Process: Skeletal Traction/External Fixators Assessment o General health assessment o Emotional status (e.g., fear, anxiety) o Readiness to learn o Evaluate traction apparatus and patient position (maintain alignment of body) o Evaluate external fixator apparatus (loose pins, s/s of infection) Nursing Diagnosis o Acute pain o Risk for VTE o Risk for peripheral neurovascular dysfunction o Risk for impaired skin integrity Planning/Implementation o Pin care o Overhead trapeze o Assess pressure points in skin every 8 hours ▪ Special mattresses or other pressure reduction devices o Exercises to maintain muscle tone and strength ▪ Muscle exercises, leg exercises, isometric, exercises of unaffected extremity o Encourage use of incentive spirometer o DVT prophylaxis o Assist with self-care Evaluation o Understanding of education provided o Effectiveness of analgesics and other interventions put in place o Prevention of complications DOCUMENT! Potential Complications Pressure ulcer Atelectasis and pneumonia Constipation Anorexia Urinary stasis Infection DVT Patient Education  Impact of injury to functioning (ADLs, IADLs) Activity, exercise, rest o Exercises to maintain muscle tone and strength o Shifting/repositioning o Incentive spirometry Medications Controlling of swelling and pain Signs and symptoms to report: o Persistent pain or swelling, o Changes in sensation, movement, skin color or temperature o Signs of infection or pressure areas DOCUMENT! Nurses should never adjust clamps on external fixator frame A. True B. False Orthopedic Surgery Orthopedic Surgery o Indications: unstable fractures, necrotic or infected tissue, tumors Hand/Wrist and Foot o Usually outpatient, patient education is key Joint Replacement o Hip or knee joint disease ▪ Osteoarthritis, rheumatoid arthritis, trauma, congenital deformity Goals before and after surgery: o Pain relief, adequate neurovascular function, health promotion, improved mobility, and positive self-esteem Postoperative goal: o Absence of complications Pre-Operative Assessment Routine preoperative assessment Hydration status o Hypovolemic: insufficient circulation and decreased oxygen delivery to organs and tissues o Fluid overload: interstitial edema, local inflammation Medication history o Blood thinners, antibiotics Possible infection o Ask specifically about colds, dental problems, urinary tract infections, infections within 1 to 2 weeks Assess knowledge and coping (e.g., fear, anxiety) Provide education and support (patient and support system) Hand/Wrist & Foot Surgery Indications: repair deformity, trauma o e.g., Dupuytren’s contracture, carpal tunnel, ganglion cyst o Dupuytren's contracture: autosomal dominant inherited disease in males of Scandinavian/Celtic heritage 50 and over; slowly progressive contracture of fascia in palm that causes flexion of 5th and 4th fingers (sometimes middle) o Carpal tunnel: surgery to release median nerve from thickened tendon sheath; affects thumb, index, middle finger Usually performed on an outpatient basis, unless major trauma Post-op goals: o Regain strength, ROM/improved mobility o Regain fine motor skills o Reduce pain Avoid complications Nursing Process: Hand/Wrist & Foot Surgery Assessment o General health assessment o Emotional status (e.g., fear, anxiety) o Readiness to learn o Level and type of discomfort o Limitations in function  o Neurovascular (CMS/6 Ps) Nursing Diagnosis o Acute pain o Risk for peripheral neurovascular dysfunction o Risk for infection Planning/Implementation o Patient/support system education o Control of edema by elevating extremity and applying ice intermittently if prescribed o Educate/encourage use of assistive devices (e.g., crutches or walker) o Neurovascular assessment every hour for 1st 24 hours o Assess motor function, encourage PT/OT as prescribed o Pain control measures: medication, elevation, intermittent ice or cold packs Evaluation o Effectiveness of pain management o Understanding of education DOCUMENT Potential Complications Uncontrolled swelling and pain, purulent drainage, redness Cool, pale fingers or toes, paresthesia, paralysis Signs of deep vein thrombosis or pulmonary embolism Patient Education: Hand/Wrist & Foot Surgery Describe postoperative care: o Diet and activities Encourage control of edema Demonstrate safe use of assistive devices Consume a healthy diet to promote healing Medications State indicators of wound infections or complications Which of the following is an early sign of neurovascular decline indicative of compartment syndrome? A. Paralysis B. Pallor C. Pulselessness D. Paresthesia a. And pain are early signs Joint Replacements Used to treat severe joint pain and disability and for repair and management of joint fractures or joint necrosis Frequently replaced joints include the hip and knee Joints including the shoulder, elbow, wrist, fingers, and ankle may also be replaced Nursing Process: Total Hip Arthroplasty Assessment (post-op) o General health assessment o Emotional status (e.g., fear, anxiety) o Readiness to learn o Level and type of discomfort o Limitations in function o Neurovascular assessment of affected extremity Nursing Diagnosis o Acute pain o Impaired physical mobility o Activity intolerance Plan/Implement: Hip Arthroplasty Preventing dislocation of hip prosthesis o Correct positioning using splint, wedge, pillows o Keep hip in abduction when turning o No hip flexion >90 degrees Mobility and ambulation  o Early ambulation --1 day after surgery using walker or crutches o Weight bearing as prescribed by the surgeon Drain use postoperatively o Assess for character and amount of output o Drain removed within 24 to 48 hours No crossing legs! Remain 90-degree angle when sitting! Do not turn toes inward! Keep hip in abduction when turning → abduction pillow to prevent crossing midline Precautions stay 6-12 months post op Prevent infection o Strict hygiene practices o At risk for up to 24 months o Prophylactic antibiotic may be given Prevent DVT o Appropriate prophylaxis o Instituting preventive measures o Monitoring for signs of DVT and PE Patient education and rehabilitation o Hip precautions, use of hip kit items ▪ 26-inch grabber ▪ Molded sock aid with handles ▪ Long handle sponge ▪ Plastic shoehorn o Pain management o Encourage inpatient/outpatient rehab, as prescribed o S/s of infection and complications Total Knee Arthroplasty Assessment o General health assessment o Emotional status (e.g., fear, anxiety) o Readiness to learn o Level and type of discomfort o Limitations in function o Neurovascular assessment of affected extremity Nursing Diagnosis o Acute pain o Impaired physical mobility o Activity intolerance Planning/Implementation o Neurovascular assessments o Monitor and empty indwelling drain o Prevent infection/post-op complications ▪ Complications: excessive wound draining, bleeding, VTE, infection, pressure ulcers o Education: ▪ Meds, safety precautions, bed alarms Some patients are more confident than they should be when moving post-surgery Cluster care and ask if they need anything before leaving ▪ Hip and knee education about weight bearing status ▪ Encourage foot exercises (prevent DVT) ▪ S/S of infection and complications o Encourage early ambulation, CPM, mobility as tolerated, independence o Pain management (medicate before planed therapy and ambulation) Evaluation o Effectiveness of pain meds, understanding of education DOCUMENT! Nursing Process: Knee Replacement Continuous passive motion (CPM) o Promote ROM, circulation, and healing o Prevent scar tissue in knee o Placed in device immediately after surgery Physical therapy  o Strength and ROM o Ankle and calf-pumping exercises o Assistive devices o Ambulate first post op day Acute rehab o 1 to 2 weeks o Total recovery 6 weeks Potential Post-Operative Complications Hypovolemic shock Atelectasis Pneumonia Urinary retention Constipation or fecal impaction Thromboembolism: DVT or PE Infection (surgical site, sepsis) MSK Disorders Common Upper/Lower Extremities Conditions Low Back Pain Osteomalacia & Osteoporosis Osteomyelitis Rheumatoid Arthritis Common Upper/Lower Extremity Conditions Upper Extremity: o Impingement Syndrome o Carpal tunnel syndrome o Dupuytren’s contracture Lower Extremity: o Hallux vagus o Hammer toe o Plantar fasciitis Low Back Pain: Assessment Interview: o Detailed pain assessment: ▪ OPQRST ▪ Leg weakness? Radiculopathy: results from pinched nerve like sciatica/cervical/thoracic o Description how the pain has been managed by the patient o Work and recreational activities Physical exam: o Spinal curvature, back and limb symmetry o Palpate paraspinal muscles o Movement ability and effects on ADLs o DTRs, sensation, and muscle strength o Assess posture, position changes, and gait Low Back Pain: Diagnosis Acute pain Impaired physical mobility Activity intolerance Self-care deficit Low Back Pain: Planning/Implementation Education: o Pain management (educate and administer) o Exercise, as tolerated o Back conservation techniques Body mechanics o Stress reduction o Health promotion; activities to promote a healthy back  o Dietary plan and encouragement of weight reduction Work modifications o Sitting vs. standing, breaks, ergonomic equipment (height of desk, chair support), lumbar support belts Encourage use of assistive devices, as prescribed (brace, walker, etc.) Evaluation o Effectiveness of pain medication o Understanding of education DOCUMENT! Osteomalacia A metabolic bone disease characterized by inadequate bone mineralization o Breaks down faster than being replaced Softening and weakening of the long bones causes pain, tenderness, and deformities caused by the bowing of bones and pathologic fractures Deficiency of activated vitamin D causes lack of bone mineralization and low extracellular calcium and phosphate Causes: GI disorders, severe renal insufficiency, hyperparathyroidism, and dietary deficiency Osteomalacia: Treatment Physical, psychological, and pharmaceutical measures to reduce discomfort and pain Correct underlying cause Kidney disease → supplement calcitriol Malabsorption → Increased doses of vitamin D and calcium are usually recommended Exposure to sunlight may be recommended; ultraviolet radiation transforms a cholesterol substance (7-dehydrocholesterol) present in the skin into vitamin D Osteoporosis Most prevalent bone disease in the world; > 1.5 million osteoporotic fractures occur each year Normal bone turnover is altered, and the o Rate of bone resorption is greater than the rate of bone formation o Resulting in loss of total bone mass Bone becomes porous, brittle, and fragile and breaks easily under stress Silent and progressive Frequently results in compression fractures of the spine, fractures of the neck or intertrochanteric region of the femur, and fractures of the wrist Osteoporosis: Prevention Balanced diet high in calcium and vitamin D throughout life Use of calcium supplements to ensure adequate calcium intake Regular weight-bearing exercises: 20 to 30 minutes a day o Increases balance o Reduces incidence of falls and fractures Weight training stimulates bone mineral density (BMD) Osteoporosis: Pharmacologic Therapy Bisphosphonates o MOA: inhibit osteoclast activity, the cells responsible for bone resorption (the breakdown of bone tissue) o Common Meds: ▪ Alendronate (Fosamax) ▪ Risendronate (Actonel) ▪ Ibandronate (Boniva) ▪ Zoledronic acid (Reclast, Zometa) ▪ Etidronate (Didronel) o How does it prevent bone loss: helps to maintain or increase bone mineral density (BMD) and reduce the risk of fractures Calcitonin Estrogen Parathyroid hormone Osteoporosis: Assessment Occurrence of osteopenia and osteoporosis o Osteopenia is precursor to osteoporosis  Family history Previous fractures Dietary consumption of calcium Exercise patterns Onset of menopause Use of corticosteroids as well as alcohol, smoking, and caffeine intake Symptoms such as back pain Physical assessment may disclose o Localized pain o Constipation o Altered body image Osteoporosis: Planning/Implementation Education of osteoporosis and treatment plan Relieving pain o Encourage short periods of rest in between activities o Supportive mattress o Intermittent heat and back rubs ▪ Heat eases stiff muscles Improving bowel elimination o Encourage high fiber diet, fluids, stool softeners Preventing injury and promote safe environment o Physical activity as tolerated to improve muscles and balance o Safety precautions to remove clutter or trip hazards o Use assistive devices o Toilet prior to pain meds (sedative effects) Evaluation o Understandings of intervention and education Document! Osteomyelitis Infection of the bone Occurs because of o Extension of soft tissue infection o Direct bone contamination o Bloodborne spread from another site of infection ▪ This typically occurs in an area of bone that has been traumatized or has lowered resistance Causative organisms o Methicillin-resistant Staphylococcus aureus (MRSA) o Other: Proteus and Pseudomonas spp., Escherichia coli Treat with surgery to remove portion of bone that have died and strong antibiotics (several weeks) Osteomyelitis: Assessment Prevention of osteomyelitis is the goal Risk factors o Bacteremia, infected catheters, soft tissue infections, trauma, infected prosthetics from orthopedic surgeries Signs and symptoms of infection o Localized pain, edema, erythema, fever, drainage, increased WBCs Osteomyelitis: Planning/Implementation Relieving pain o Administer analgesics o Mobilization o Elevation o Handle affected extremity with great care Improving physical mobility o Gentle ROM o Patient ADLs Encourage adequate hydration, vitamins, and protein Administer and monitor antibiotic therapy Patient and family education o Weeks of antibiotic education (home IV therapy)  o Safety and injury prevention o Post op and follow up care Referral for home health care Evaluation Document! Rheumatoid Arthritis Chronic autoimmune, inflammatory disorder Attacks the lining of the joints, painful swelling, bone erosion and joint deformity Pain is worse in the AM and after inactivity Most common in females aged 40-60 years Anti-rheumatics drugs slow progression, give NSAIDs Tai chi and fish oil used as alternative forms of treatment Compared to Osteoarthritis, degeneration of cartilage o OA: Pain worsens with activity as the day progresses (PM) Joint Dislocations Dislocation: distal and proximal bones that form joint are no longer in anatomical alignment Subluxation: partial dislocation that does not cause as much deformity as complete dislocation Signs/symptoms o Pain o Swelling o Deformity of the affected joint Interventions o Immobilization of the joint (splint, cast, traction) o Analgesia, muscle relaxants, possibly anesthesia → reduction of the dislocation o Neurovascular assessments before/after reduction o PT to restore ROM and strength o Education Complications o Increasing pain despite analgesia, numbness, tingling (6 Ps) → Compartment syndrome Fractures Closed or simple o No break in the skin Open or compound/complex o Wound extends to the bone o May have amputation involved if severe Intra-articular o Extends into the joint surface of a bone Manifestations of Fracture Acute pain Loss of function Deformity Shortening of the extremity (e.g., hip fracture = shortened, externally rotated) Crepitus o Note on assessment, never try to feel for this, but note if it happens o Caused by rubbing of bone fragments on each other Local swelling and discoloration Diagnosis by symptoms and radiography Patient usually reports an injury to the area Emergency Management of a Fracture Immobilize the body part Splinting: o Supported/immobilize joints distal and proximal to fracture Assess neurovascular status Open fracture: o Prevent contamination, cover with sterile dressing Do not attempt to reduce the fracture  Medical management: o Closed: ▪ Uses manipulation and manual traction ▪ Traction may be used (skin or skeletal) o Open: ▪ Internal fixation devices hold bone fragment in position (metallic pins, wires, screws, plates) o Immobilization: ▪ External (cast, splints) or internal fixations Management of Specific Fractures Pelvic fractures o Management depends on type and extent of fracture and associated injuries o Stable fractures are treated with a few days of bed rest and symptom management o Early mobilization reduces problems related to immobility o Unstable fractures happen at articulating surfaces like at joints and ligaments; treated by stabilizing pelvic bones and compressing any bleeding vessels with pelvic girdle Femoral shaft fractures o Lower leg, foot, and hip exercises to preserve muscle function and improve circulation o Physical therapy, ambulation, and weight bearing are prescribed o Active and passive knee exercises are begun as soon as possible to prevent restriction of knee movement o Risk for vascular compromise, muscle spasms o Anticipate skeletal traction for Complications of Fractures Early complications o Hypovolemic shock o Fat embolism o Compartment syndrome o VTE (DVT, PE) Delayed complications o Delayed union, malunion, and nonunion ▪ Failure to reach proper healing by 6 months o Avascular necrosis of bone ▪ Bone tissue dies o Complex regional pain syndrome (CRPS) ▪ Chronic condition that affects limb after injury o Heterotopic ossification ▪ New bone grows in unexpected areas Secondary o Pressure ulcers o Disuse syndrome Fat Embolism Fat globule moves into the bloodstream after fracture of long bone, pelvis, crush injury, or orthopedic surgery DANGEROUS – CAN BE FATAL Nurse should assess for: o Classical manifestations: hypoxemia, neurologic compromise, petechial rash o First symptoms: tachypnea, dyspnea, tachycardia, hypoxia, chest pain Interventions o Notify the provider immediately o Call RR or code depending on LOC Amputations May be congenital or traumatic, or caused by conditions o Progressive peripheral vascular disease, infection, or malignant tumor Used to relieve symptoms, improve function, and improve quality of life The health care team needs to communicate a positive attitude to facilitate acceptance and participation in rehabilitation Amputation: Assessment Neurovascular status and function of affected extremity or residual limb and of unaffected extremity Signs and symptoms of infection Nutritional status  Concurrent health problems Psychological status and coping Amputation: Nursing Diagnosis Acute pain Impaired skin integrity Disturbed body image Grieving Self-care deficit Impaired physical mobility Amputation: Planning/Implementation Major goals include: o Relief of pain o Absence of altered sensory perceptions o Wound healing o Acceptance of altered body image o Resolution of grieving processes o Restoration of physical mobility o Absence of complications Relief of pain o Administer analgesic or other medications as prescribed o Changing position o Alternative methods of pain relief: mirror box therapy, distraction, TENS unit Promoting wound healing o Handle limb gently o Residual limb shaping (compression stocking, conditioning, prone positioning) ▪ Prone positioning to prevent flexion contractures in residual limb Evaluation o Pain relief o Understanding of education o Readiness to participate in self-care Amputation: Complications Phantom limb pain Postoperative hemorrhage Infection Skin breakdown Joint contracture o Happens from positioning and protective flexion withdrawal patterns that occur due to pain and muscle imbalance as result of amputation Amputation: Rehabilitation Needs Psychological support o Set realistic goals o Encourage acceptance Prostheses fitting and use Physical therapy Vocational or occupational training and counseling Use a multidisciplinary team approach Patient teaching