MS3 Lino's Guide Exam 3 (3) PDF

**Enteral and TPN - assessment and care/management ** **[Enteral Nutrition ]** - Nutrient delivery by tube, catheter, or stoma - Pt must have a functional GI tract (present bowel sounds) - *Assess effectiveness* - Weight should ↑ & albumin levels ↑ = good protein status - **[Interven...

**Enteral and TPN - assessment and care/management ** **[Enteral Nutrition ]** - Nutrient delivery by tube, catheter, or stoma - Pt must have a functional GI tract (present bowel sounds) - *Assess effectiveness* - Weight should ↑ & albumin levels ↑ = good protein status - **[Interventions/care management ]** - Aseptic technique - Trace all lines/tubes back to pt to avoid misconnections - HOB \>30 to avoid aspiration/reflux and for 30-60 mins post feeds - Check placement bf each feeding (X-RAY, pH strips for gastric content \500 mL can cause poor tolerance - ***Bolus/intermittent feeds*** = volumes \> 200mL can also cause poor tolerance - **HOLD and reassess in 1 Hr and slow rate if needed** - Admin @ room temp → can cause diarrhea, abdominal discomfort if too cold - DO NOT microwave - Flush with 15-30mL of regular warm water (NOT sterile/saline) Q4hrs -- tube patency & hydration - Should you need to admin PO meds (crush 1 med @ a time and flush with each med) - Introduce calories gradually - Discard bag & tubing Q24hrs - **[Complications ]** - ***GI discomfort, diarrhea*** - Start infusion slowly and ↑ with tolerance - ✔ Room temp formula - Slow rate and notify HCP! - Evaluate for C.Diff if persistent diarrhea - ***Dumping syndrome*** - Fast/bolus feeds = dumping syndrome - ✔Small frequent meals, protein with each meal - NO concentrated sugars or lactose - NO fluids 1 hr pre/post meals (NO fluids with meals) - ✔Lie down post meals 20-30 mins - ***Infection*** - ✔Discard after 24hrs - ***Aspiration Pneumonia*** - Confirm tube placement - Elevate HOB at least 30 degrees during feeds and 1 hr post - Stop feeding - Turn client and suction airway - Admin oxygen if needed - Check vitals and auscultate - Notify HCP and get Xray! **Total Parenteral Nutrition (TPN)** - For sicker pts; Pts with nonfunctional GI tracts - Given thru central/PICC lines - No more than 700 calories/per day - TPN is 70% glucose - Pharmacy prepares bag - Only TWO MEDS added to this feed → Insulin & Heparin - Glucose imbalance - Hypokalemia - Hypophosphatemia - Hypocalcemia - **[Interventions/care management ]** - Assess allergies: soybeans, safflower, or eggs - Monitor for hyper/hypoglycemia - Admin @ room temp - NEVER abruptly stop TPN → Hypoglycemia - Speeding up/slowing rate is contraindicated → can cause hyper/hypoglycemia - Never increase rate to "catch up" can cause hyperglycemia - Assess VS Q4-8hrs / - Assess BSL Q4-6hrs - Daily weights - Change bag Q24hrs - Nothing piggy backs (needs own line and pump) - I & Os: dehydration and hypovolemic shock - Keep dextrose 10% @ bedside incase next bag in unavailable (to prevent hypoglycemia) - Check TPN for cracking (oil on top) → cannot administer; call pharm - Discontinue gradually (Careful with rebound hypoglycemia!) - *Desired outcomes:* - Weight gain 1kg/day - ↑ albumin & pre-albumin - **[Complications]** - ***Infection*** → Strict aseptic technique - Erythema, tenderness, exudate in site - Change dressing Q48-72hrs - Change IV tubing every 24hrs - ***Air embolus*** → sudden - SOB (dyspnea) - Chest pain - Anxiety - Hypoxia - ↑ HR - Clamp cath immediately - Place pt on left side in Trendelenburg (to trap air) - Admin oxygen and notify HCP! - ***Perforation*** - Bleeding - ↓BP - ↑ HR **Hepatitis ABCDE - prevention education ** - ↑ alcohol use and acetaminophen OD can cause hep S/S: ALL TYPES - RUQ discomfort - n/v - anorexia, weight loss - fever, chills - jaundice - dark urine, pale feces - flu like s/s TX: FOR ALL - rest - activity as tolerated - nutrition/hydration - Acute = ↑ protein, calories, vitamins - avoid alcohol - practice safe sex - hand hygiene - wash foods - daily weights **[HEP A]** Route of transmission: fecal-oral - \#1 priority hand hygiene - Vaccine for HEP A - Goes away - Children high risk - Diet: ↑ carbs **[HEP B]** - **[AKA HBV ]** Route of transmission: body fluids, semen, blood, mom to baby - Vaccine for HEP B available - Most at risk: hospitals, sex workers, drug users (needles), tattoos, cuts **[HEP C]** - **[AKA HCV ]** Route of transmission: blood, semen - Acute or chronic - Late onset of S/S 15-20 years from infection to s/s - NO vaccine - Check: baby boomers, blood transfusion pts before 1992, tattoos, needle use **[HEP D]** Route of transmission: blood - Coinfection with HBV - NO vaccine - Cannot have D unless you have B! **[Cirrhosis]** - Scarring of liver, lacks function = no coming back - Prevent infections with viral hep (B, C, D) - Avoid excessive alcohol - Give daily vitamins S/S: - Fatigue - Ascites - Beefy red tongue - Weight loss, abdo pain, abdo distention - Priuritus - Confusion (ammonia buildup) - Jaundice (bilirubin in blood) - Spider angioma (upper trunk, neck, shoulders) - Palmar erythema (estrogen) - Anemia / Thrombocytopenia - Petechiae - Gastroesophageal bleeds Labs: - Bilirubin ↑ - Ammonia: ↑ - Creatinine: ↑ - Hypoglycemia ↓ - Hematology (RBC, Hgb, Hct, Platelets): ↓ - PT/INR; PTT: longer time (obtain PT/INR times!) **[Complications]** **Liver biopsy - positioning for bleeding, s/s of internal bleeding** - ↑ risk for bleeding (liver is highly vascular) - S/S of internal bleeding: ↓ BP ↑HR, bruising, board like rigid abdomen, abdo distention - Post: turn to right lateral side **Portal hypertension with varices - care of the patient (prevent rupture), care of the patient (post rupture)** EMERGENCY! PRIORITY PT Pooling of varices that can rupture and cause airway problem **[Prevent Rupture:]** - No straining, coughing, bearing down (give Colace for constipation) - Propranolo/Nadalol to lower BP (non-cardiac selective) - No alcohol - No NSAIDs **[Post Rupture:]** - Senstaken-blakemore tube = ballon tamponade (mechanical vent bf procedure) - Ligation/sclerotherapy NOT for active bleeds - Scissors and suction @ bedside to cut tube in airway is occluded - IV access for med, fluids MEDS: PPI: PRAZOLES, ONDASETRONE, TIDINES, OCTEOTRIDE: SANDOSTATIN (continuous IV drip), Vasopressin for bleed **Ascites** [why does this happen] - Fluid out of the vascular space (so into the third space) [how to assess] S/S: - Distended abdo - s/s of dehydration - Decreased urine output - HYPOkalemia - HYPERnatremia - ↑ aldosterone - Weight gain - ↓ albumin [how to manage it] - Daily weights - Measure abdo girth - Diet: ↓ Na, ↑ K+ (avocado, cantaloupe ), fluid restrictions, NO canned foods, frozen meals, sauces - MEDS: diuretics, albumin (consent for albumin!) Diuretics check for potassium If: Potassium is ↓ = spironolactone (sparing) Potassium is ↑ = Furosemide (wasting) Potassium is normal = both - Paracentesis: for SEVERE PAIN/SOB → drains fluid measure coca, obtain consent, void bf, supine ↑ HOB, apply pressure to puncture site, post: maintain bedrest, [how do you know your interventions worked] - Albumin levels ↑ - Abdo girth ↓ **[Hepatic encephalopathy ]** [why does this happen] - Ammonia build up bc liver is unable to convert ammonia into urea - Too much protein - Constipation [what does your patient look like S/S] - Changes in LOC - Agitated, restless - Asterixis = flapping of hands HALLMARK sign\* - Fetor hepaticus (musty/sweet odor that some say is similar to rotten eggs, garlic, or fish) [how to manage it] - Fluids - MEDS: Lactulose (reduces ammonia levels) - Can become hypokalemic due to increased poops from lactulose - Low protein diet [how do you know your interventions worked ] - ↓ ammonia - AAOx4 **Pancreatitis** **LUQ** Causes= alcohol, cholecystitis Complications = rupture (peritonitis), hypovolemic shock what is it? - ACUTE: inflammatory process due to activated pancreatic enzymes autodigestion the pancreas - CHRONIC: progressive, destructive disease of inflammation and fibrosis S/S: - Sudden onset of severe boring pain (goes thru body) - HALLMARK! Epigastric pain radiates to back, LEFT flank/shoulder - FIRST assess pain - Gets better in fetal position or sitting upright bending forward - N/V - Weight loss - Generalized jaundiced - Cullen's sign -- periumbilical bruising (bluish grey) - Grey turner's sign -- ecchymoses on the flanks - Trousseau's sign -- hand spams when NP cuff Is inflated (due to HYPOcalcemia) - Chvostek's sign -- facial twitching when facial nerve is tapped (due to HYPOcalcemia) - Steatorrhea Labs - Amylase ↑ (goes back to normal faster) - Lipase ↑ (specific to pancreatitis) - Triglycerides ↑ - Blood glucose ↑ (NOT making insulin) - Erythrocyte sedimentation ↑ (inflammation) - Calcium ↓ (Chvostek/trousseau) - WBC ↑ how to manage acute and chronic - Avoid high fat foods/heavy meals - Avoid alcohol - Pancreatic enzymes with each meal, not on protein ACUTE: - NPO until pain free and can eat when lipase goes ↓ - Pain meds -- opioids: morphine, ketorolac, hydromorphone - IV fluids for dehydration - NG tube for decompression - Assess/monitor BSL Q4-6hrs, labs: amylase, lipase levels - TPN for nutrition - No smoking/alcohol - Limit stress - Position pt fetal, side lying, HOB ↑, sitting up, leaning forward - If acute necrotizing: admin Imipenem CHRONIC: - Pt will always have discomfort when eating - Daily weights - MEDS: Cimetidine (1hr bf or after), Omeprazole, pancreatic enzymes (sprinkle on food, drink full glass of water, after tidine/prazole, take with every meal/snack), **Burns** - AFTER AIRWAY PROTECTION, FLUIDS MOST IMPORTANT! - \#1 remove source ↑ - The deeper the burn the more damage, the less painful = damaged nerves - NO ICE ON BURNS **[Types of burns ]** - Chemical - Thermal: open flames, hot metals, dry ice, frost bite, steam, hot water - Electrical: difficult to assess (ICEBERG effect) - Smoke inhalation **[Who needs to be transferred to a burn unit ]** - Partial thickness burns \> 10% BSA - Burns to face, hands, feet, genitalia, perinium, major joints - Full thickness (3^rd^ degree) burns - Electrical (ICEBERG!!) - Chemical burns - Inhalation injury (SOOT!) - Complex comorbidities - Trauma w. ↑ risk of morbidity/mortality from burn - Peds pt not in a peds hospital - Special social, emotional, rehab intervention requirements **[The care of a small burn \< 10% TBSA ]** - Provide analgesics - Clean with mild soap and tepid water - Cool damp towel, immerse in water - Use antimicrobial ointment - Non-adhering dressing - Bandage fingers individually - Do not poke blisters - **[The care of a large burn \> 10% TBSA]** - Clean dry blanket/towel - DO NOT immerse in water = can cause HYPOthermia **[The care of a patient with smoke inhalation ]** - AIRWAY problem - Soot accumulates in lungs - Face BRIGHT RED - Soot around nose/mouth - Wheezing and stridor! (Maybe vent prophylactically) - 100% humidified O2 - Non-rebreather mask **[Concerns with electrical burns ]** - ICEBERG EFFECT (may look small but the injury is worst underneath) - Wants to ground itself so it can bounce off organs = damage - Can cause dysthymias - Myoglobin ↑ = AKI/AKF **[What labs to expect in the acute phase of BURNS ]** - Sodium ↓ - Potassium ↓ - Hct & Hgb ↓ - Blood Glucose ↑ **[Calculating the TBSA (rules of 9)]** **[Fluid resuscitation (Parkland formula) ]** - TOTAL amount of fluids to give in first 24 hours of burn - 4mL of LR x kg x TBSA - Must give first ½ in first 8 hours - Second half in next 16 hours *Ex: tbsa = 35% , Kg = 60* *4mLx60x35 = 8, 400mL total fluids in 24 hours* *1^st^ half in 8 hours = 4,200mL then to get rate divide by 8 = RATE: 525mL/hr* *2^nd^ half in 16 hours = 4,200mL and rate divided by 16 = RATE: 262.5mL/hr* [How do you know you are giving your patient enough fluids?] *Effective Therapy* - ↑ BP \>90 - ↓ HR \