N372 Exam 2 Study Guide PDF

**N372 Exam 2 Study Guide** **OBESITY** 1. Overview a. Always be sensitive to weight conversations b. Never dismiss symptoms bc of weight c. BMI \>30 2. Complications d. Obesity results in chronic inflammation, everywhere. e. Two major consequences of obesity are d...

**N372 Exam 2 Study Guide** **OBESITY** 1. Overview a. Always be sensitive to weight conversations b. Never dismiss symptoms bc of weight c. BMI \>30 2. Complications d. Obesity results in chronic inflammation, everywhere. e. Two major consequences of obesity are due to increase in fat mass and production of adipokines a. Adipokines can cause 1. Insulin resistance 2. Atherosclerosis 3. Immune factor disruption 4. Cancer predisposition f. Diabetes b. Side note: if you lose a lot of weight, you may not be diabetic anymore because of decreased fat cell size g. Hypertension h. Osteoarthritis i. Sleep apnea j. GERD k. NASH l. Gallstones m. Increased CA risk 3. Precipitating factors n. Environment c. Deep south: emotion, how love/support is shown d. Low socioeconomic status: cheapest food is the food that we don't want them eating e. Cost of health issues=decreased budget for healthy foods o. Psychosocial f. Food associations begin in childhood 5. Pop tarts for hurricanes and vacations g. Eating is social, associated with fun 4. NI p. One of the most challenging health crises in the US q. Lifelong management required r. Prevention and education is essential 5. Nutritional therapy s. Success depends partly on the amount of weight to be lost h. Progress is progress t. Self-motivation is essential i. Won't work if they're doing it for someone else, they must want to do it for themselves. u. Eating behaviors j. Most issues require changes in eating lifestyle v. Realistic and healthy goals k. Get rid of fad diet culture l. Meet them where they are w. Exercise m. Essential but doesn't have to be extreme n. Start small then work up x. Restricting dietary intake to below energy requirements is effective o. Younger generation drops weight easier (increased metabolism) p. Men easier than women (increased muscle mass) y. Behavior modification q. Change reward system: no cheat days, use activities rather than food 6. Drug therapy z. Will not cure obesity r. Ozempic/diet pills decrease appetite, but the second it is discontinued, the lifestyle hasn't changed, so weight comes back 7. Surgery a. Most insurance covers if comorbidity is present, but still not easy battle b. Popular c. Lasting impact d. Criteria s. BMI \> 40 t. BMI \> 35 with one or more of the following 6. HTN 7. DM 8. CHF 9. Sleep apnea e. Gastric sleeve u. 85% of stomach removed v. Most popular f. Roux-en y gastric bypass w. Skips stomach completely by attaching the small intestine directly to the 20-30 ml "pouch" x. Absorption issues \#1 issue y. 90% of stomach removed z. Dumping syndrome \#2 issue a. Second most common 8. Pre-op care g. All specialties involved h. Gather past and current health info b. Comorbidities increase risk for complications c. Pneumonia\* i. Teach about IS j. Arrange CPAP if used at home k. Obtain longer IV catheter l. Have the right bed m. Bigger assistive devices n. Larger SCD sleeves o. Anti-infective powder to skin folds to prevent infection 9. Post-op care p. Complications d. Re-sedation 10. Fat cells hold onto anesthesia 11. Once extubated and awake, we don't feed them bc of small stomach now 12. Body breaks down fat 13. Releases sedation back into blood stream (and at this point we have no airway established) e. Excess adipose tissue compresses chest and abdomen 14. CO2 retention a. Hypoxemia b. Pulmonary HTN c. Polycythemia d. \*Narcotics already have their RR decreased f. DVTSOB chest painPE 15. Call surgeon immediately 16. Prevention e. Heparin started 24 hr post op f. SCD g. Early ambulation g. Infection 17. Less common with laparoscopic cases 18. Monitor incision sites 19. Perform daily skin checks h. Dehiscence 20. Surgical site popping open i. Delayed healing j. Bleeding 21. Intraluminal: inside GI tract h. Blood in vomit or stool 22. Extraluminal: inside the abdomen 23. S/S i. Tachycardia j. Hypotension k. Poor urinary output: kidneys not being perfused 24. Notify surgeon immediately k. Dumping syndrome 25. Caused by drinking too soon after eating, sugar/carbs, high fat 26. Doesn't break down food at all: rapid gastric emptying 27. RUN do not walk to a bathroom immediately 28. S/S l. Sweating m. Diarrhea n. Weakness o. Tachycardia l. Bowel obstruction/ileus 29. May still be pooping 30. Hyperactive BS above 31. Hypoactive BS below 32. Abdominal distention 33. Abdominal pain 34. NV q. Manage pain r. Pulmonary toilet m. Group of interventions to help with respiratory status 35. TCDB 36. Elevate HOB 37. Continuous O2 sat 38. IS p. Coughing is good! 10. Post-op diet s. 1-2 days n. Clear liquids o. Sugar free p. Carbonation free q. Caffeine free r. No straws s. Only advance per MD and dietician order t. 2 weeks t. Full liquids 11. Special considerations post-op u. Medicate as needed, but be mindful of why they are in pain (complications) v. Assess for anastomosis leaks u. Any time we detach/reattach something that's not natural and there's a leak v. S/S: sepsis 39. Hypotension 40. Fever 41. Abd pain that radiates to shoulder 42. Oliguria 43. "Sense of doom" 44. Increased HR w. Notify surgeon immediately w. Assess surgical site frequently x. Infection/excessive bleeding x. Attentive to NG tube placement y. We do NOT adjust until MD order **GASTROINTESTINAL SYSTEM** 1. Diagnostic studies a. X-ray i. Doesn't say much, just whether you're full of stool or gas b. CT scan ii. Contrast c/I in renal failure (can't filter out), metformin users, and pts. With allergies to contrast c. Nuclear medicine studies: HIDA scan iii. Tests Gallbladder function d. Endoscopic procedures iv. Biggest for GI\*\* e. Labs i. Amylase/Lipase: pancreas ii. BUN/Cr looks for dehydration 2. Endoscopic procedures f. Not surgery; purely diagnostic v. Can be combined with procedures iii. Cauterization of bleeds iv. Gallstone removal v. Polyp removal vi. Consents signed before sedation vii. NPO 8 hr viii. Sedation ix. Bowel prep g. Small intestine not reached well through esophagus or anus so use pill camera that takes pics to upload to MD h. Colonoscopy x. Shouldn't wake up with pain xi. Pain=perforation i. Esophagogastroduodenoscopy j. ERCP: pancreas k. Complications xii. Perforation xiii. Aspiration 3. Endoscopy: pre-op l. Monitor for SE of bowel prep xiv. Dehydration xv. Electrolytes m. Sedation protocols xvi. Fentanyl xvii. Propofol xviii. Versed 4. Endoscopy: post-op n. Aspiration: monitor for gag reflex return xix. Elevate HOB xx. Swallow precautions o. Perforation xxi. Pain xxii. Absent BS xxiii. Rigid abdomen xxiv. Fever xxv. S/S hemorrhage 5. Assessment of abdominal pain p. VS xxvi. S/S hypovolemic shock q. Inspection, auscultation, palpation (palpate always, even after surgery) r. PQRST xxvii. Provocation xxviii. Quality xxix. Region/radiation xxx. Severity xxxi. Timing s. Associated S/S xxxii. NVDC xxxiii. Consider other explanations t. PMH xxxiv. Women of childbearing age xxxv. Foreign travel: parasites xxxvi. Medications: metformin esp. xxxvii. Diet xxxviii. Trauma u. COMMON ACUTE ABD PAIN CAUSES: BIPO xxxix. Bleeding vi. Trauma vii. Ruptured aneurysm viii. Ruptured tubal pregnancy ix. GI bleed xl. Inflammation x. Gastroenteritis xi. Appendicitis xli. Peritonitis xii. Perforations xlii. Obstruction xiii. Mesenteric vascular occlusion xiv. Small/large bowel 6. NG v. Decompresses bowel w. First 12 hours fluid will be red/brown x. After: yellow green 7. KNOW ABDOMINAL ANATOMY Abdominal Regions - Mobile Physiotherapy Clinic 8. Nausea/vomiting a. Common causes i. Infection ii. Food poisoning iii. Pregnancy iv. MI v. Anxiety vi. Bulimia vii. Meds viii. Surgery ix. \*\*not always GI in nature b. Assessment x. Interpersonal contacts xi. Travel xii. Food intake xiii. Meds xiv. Labs xv. Electrolytes xvi. Stool C&S xvii. Color of emesis xviii. Fecal odor in emesis xix. How violent i. Regurgitation: acid reflux; not vomit ii. Projectile xx. Mallory Weiss tears iii. Small tears in esophagus from persistent vomiting c. Diet xxi. Clear liquids xxii. Bland, high carb, low fat xxiii. Potatoes, rice, cooked chicken, cereal xxiv. C/I: fiber, milk, spice, coffee, strong odor foods xxv. Eat slowly, small amounts first xxvi. Liquids in between meals 9. Diarrhea y. 3+ loose stools per day z. Primary cause are infectious organisms xliii. Bacteria xv. E. coli (bloody) xvi. C. diff (ABX caused) xvii. Salmonella xliv. Parasitic xlv. Viral xlvi. Osmotic xviii. Lactose intolerance xix. Drugs a. ABX b. PPI xlvii. Malabsorption xx. Celiac disease xxi. Short bowel syndrome xxii. Chron's disease xlviii. Inflammatory disorder xxiii. Chron's xxiv. Inflammatory bowel disease xlix. Immunocompromised xxv. Enteric feeding c. Re-feeding can cause diarrhea a. Assessment l. Mucus li. Blood lii. Parasites liii. Continuous diarrhea of unknown origin Contact precautions for C. Diff b. Treatment liv. Meds maybe if long term but prob not cause the body wants to get rid of something so we're going to let it lv. Nondrug therapy d. Peppermint e. Position f. Ginger lvi. NPO: progress slowly g. Wet dry h. Low residue/fiber diet lvii. NG tube: decompress bowel lviii. IV fluids for F/E: D5LR best hypertonic, but not for DM so LR is go to for GI lix. Gatorade lx. Prevent skin breakdown 10. NVD nursing diagnoses c. Electrolyte imbalance, risk for d. Dysfunctional gastrointestinal function e. Decreased nutrition f. Decreased hydration g. Decreased skin integrity h. Nausea 11. NVD goals i. Maintain fluid volume j. Maintain body weight **GERD** 1. Overview a. Reflux of stomach acid into the lower esophagus b. Most common upper GI problem c. Primary factor: incompetent LES d. Common cause: hiatal hernia e. Other causes i. Obesity ii. Cigarette smoking iii. Pregnancy iv. Food: chocolate, caffeine 2. Assessment f. Mild symptoms 2+ times per week g. Or moderate to severe symptoms once weekly h. Chest pain: can mimic angina v. Relieved with antacids vi. Burning, squeezing, or radiating to the back, neck, jaw or arms i. Respiratory s/s vii. Wheezing, coughing, SOB j. Otolaryngologic symptoms viii. Hoarseness ix. Sore throat x. Lump in throat xi. Hypersalivation xii. Choking 3. Complications k. Barrett's esophagus xiii. Metaplasia: Change from one type of cell to another cell type due to abnormal stimulus 1. Leads to increased risk for CA xiv. Precancerous lesions in esophagus that lead to cobblestone appearance l. Respiratory xv. Aspiration 2. \#1 complication for GERD m. Dental erosion n. Reflux esophagitis 4. Diagnostics o. H&P p. Upper GI endoscopy w/ biopsy q. Barium swallow r. Motility studies 5. Education s. Avoid triggers xvi. Fatty foods xvii. Coffee xviii. Tea xix. Acids xx. Milk xxi. Late evening meals xxii. Nighttime snacking xxiii. Fluids with meals xxiv. Alcohol t. Weight reduction u. Small, frequent meals v. Chew gum xxv. Debatable xxvi. Increases gas production xxvii. Sugar alcohols: GI upset w. HOB 30 degrees x. Smoking cessation y. Stay upright 2-3 hours after meals 6. Drugs z. Treats S/S a. Improves esophageal function b. PPI-pantoprazole (protonix) c. H2 blockers-famotidine (Pepcid) 7. Surgery d. Nissen fundoplication: take fundus of stomach and wrap around esophagus to support LES e. Reduce stomach size to decrease pressure f. Endoscopic mucosal resection & radiofrequency ablation xxviii. Remove abnormal cells in esophagus g. General post-op care xxix. Prevent aspiration xxx. Prevent infection xxxi. Maintain F/E xxxii. No not reposition NG tube unless MD orders xxxiii. Early ambulation is priority in abdominal surgery xxxiv. Splinting for pain with coughing **HIATAL HERNIA** 1. Overview a. Herniation of stomach into the esophagus through the diaphragm b. Unk cause 2. Complications c. GERD d. Esophagitis e. Hemorrhage f. Aspiration g. Stenosis h. Ulcerations i. Ischemia 3. Assessment j. S/S i. Reflux when lying supine ii. Any increase in abdominal pressure (*waist bending) causes esophageal burning* 4. Management k. Antacids l. Antisecretory agents m. Loose clothing n. Avoid heavy lifting o. No smoking or alcohol p. Weight reduction q. Surgery: Nissen fundoplication **GASTRITIS** 1. Overview a. Inflammation of gastric mucosa b. Acute/chronic 2. Risk factors c. Medications: ASA d. Diet e. H. Pylori 3. S/S f. NV g. Abdominal bloating h. *Epigastric tenderness* i. Full feeling **PEPTIC ULCER DISEASE** 1. Overview a. Erosion of mucosa from HCL and pepsin b. When gastritis goes deeper c. Causes i. Stress ii. Meds iii. H. Pylori (80%) 2. Clinical manifestations d. Gastric: iv. Women & 50+ v. Superficial lesions vi. *Epigastric "burning" pain 1-2 hours after meals* vii. *Aggravated by food* e. Duodenal viii. 35-45 ix. Penetrating lesions x. *Mid abdominal pain 2-4 hours after meals* xi. *Relieved by food* 3. Complications f. Perforation g. Hemorrhage xii. Bleeding ulcerhemorrhage hypovolemia xiii. Bright red vomit gastric xiv. Coffee groundsduodenal h. Gastric outlet obstruction xv. Scar tissue over ulcers over time cause obstruction xvi. S/S 1. NV 2. Pain 3. Bloating 4. Management i. Conservative xvii. Stop all irritants 4. NSAIDS 5. ASA 6. Steroids xviii. Rest 7. NPO 8. Small, frequent meals xix. No smoking xx. Meds xxi. Decrease stress xxii. Gastric sleeve/bypass: in cases of massive rupture of stomach j. Acute xxiii. NPO xxiv. NG xxv. Bedrest xxvi. NO SMOKING xxvii. IVF xxviii. Meds: IV PPI **UPPER GI BLEED** 1. S/S a. Hematemesis i. Bright red blood ii. Coffee grounds b. Melena iii. Black tarry stool c. Occult iv. Small amounts d. Anemic e. Hypovolemic 2. Emergency assessment f. S/S shock g. Accurate I&O h. Abdominal exam 3. Treatment i. Endoscopy w/ associated procedures to stop bleed j. NPO upon admission k. Drugs v. Octreotide (sandostatin) vi. Vasopressin (VP, terlipressin) 1. Increase blood pressure by constricting blood vessels vii. Vitamin K viii. Histamine blockers and PPI 2. Decrease acid so that HCL isn't eating open sores ix. Lactulose and neomycin 3. Prevents hepatic encephalopathy l. Blood, clotting factors **IRRITABLE BOWEL SYNDROME** 1. Diagnosis a. Abdominal pain once weekly for 3 months 2. Trends b. Psych/anxiety related c. Men i. IBS D ii. Less likely to admit symptoms or seen help for them d. Women iii. 2-2.5x more often iv. IBS C v. Report more severe abdominal pain, gas, bloating vi. Lower quality of life with higher levels of fatigue and depression 3. Treatment e. Reduce stress f. High fiber diet g. Avoid gas producing foods and triggers vii. Broccoli/cabbage viii. Dairy ix. Wheat x. Beans xi. Asparagus xii. Onion xiii. Garlic xiv. Apples xv. Cherries xvi. Pears xvii. Peaches h. Lifestyle changes: make compromises **APPENDICITIS** 1. S/S a. *Periumbilical pain* b. *RLQ McBurney's point pain* c. *Rebound tenderness* 2. Complications d. Rupture e. Peritonitis f. Abscess 3. Treatment g. Surgery: hopefully before rupture h. ABX i. Pain management **PERITONITIS** 1. Causes a. Primary: blood borne organisms b. Secondary: perforation of organs 2. S/S c. Abdominal pain d. *Rigid, boardlike abdomen* e. Tenderness over area involved 3. Complications f. Hypovolemic shock g. Sepsis h. Intraabdominal abscess i. Paralytic ileus j. ARDS 4. Interventions k. NPO l. NG m. IVF n. ABX o. Analgesia p. Antiemetics 5. Surgery q. Post op: NPO, IV, NG, blood, parenteral nutrition **ULCERATIVE COLITIS** 1. Overview a. Inflammatory bowel disease of colon and rectum b. Mucosa and submucosa c. Begins distally and progresses upward d. All autoimmune: white Jewish people 2. S/S e. Diarrhea f. Bloody stool g. Weight loss h. Fatigue 3. Treatment i. CRAMPS j. Control diarrhea and inflammation i. Steroids ii. Antidiarrheals iii. Immunosuppressants k. Relieve pain/restore fluid l. Anticholinergics/antimicrobials m. Meals: correct nutritional deficits iv. NPO bowel rest v. TPN enteralnormal diet n. Psychological counseling o. Support emotionally/coping 4. Nutritional therapy p. Common triggers vi. Lactose intolerance vii. High fiber/fat viii. Cold foods q. Enteral feedings to supplement calories during exacerbations r. Probiotics to restore gut bacteria s. Supplements for vitamins and electrolytes ix. Cobalamin for B12 x. Zinc xi. Iron xii. Vit. D xiii. Ca (deficit can be from steroids) t. High protein, low residue diet 5. Medications u. Amino salicylates (5-ASA) v. Antimicrobials w. Biologic/targeted therapy x. Corticosteroids y. Immunosuppressants 6. Surgery z. 25-40% of patients a. Total proctocolectomy with ileostomy or anastomosis (connection of anus to the small bowel) b. Total colectomy with end ileostomy xiv. Permanent ostomy c. J-pouch creation and loop ileostomy xv. Temporary d. J-pouch takedown and ileostomy reversal xvi. Resolution of above 7. Complications e. Intestinal hemorrhage f. Perforation g. Stricture obstructions xvii. Healing scar tissue buildup h. Toxic megacolon xviii. Dilation of colon i. Abscesses and fistulas j. Malabsorption issues k. After 10 years: higher risk for colon cancer **CROHN'S DISEASE** 1. Overview a. Anywhere in GI system b. *Cobblestone appearance* c. Skip lesions d. Fistula formation common 2. S/S e. See UC except less bloody stool 3. Treatment: see UC 4. Nutrition: see UC 5. Medications: see uc 6. Surgery f. 75% of patients g. Bowel resection of affected area 7. Complications h. See uc **INTESTINAL OBSTRUCTION** 1. Types a. Mechanical i. Adhesions ii. Hernias iii. Strictures iv. Tumors b. Non mechanical v. Paralytic ileus vi. Vascular: no blood to affected area c. Can be complete or incomplete 2. Clinical manifestations d. *Hyperactive BS above* e. *Hypoactive BS below* f. Small intestine vii. Rapid onset viii. Frequent vomiting ix. Colicky, intermittent pain x. Feces for short time xi. Upper: no distention xii. Lower: increased distention g. Large intestine xiii. Gradual onset xiv. Vomiting rare xv. Low grade abdominal cramping pain xvi. Absolute constipation xvii. Increased abdominal distention 3. Management h. NPO i. NG j. Pain management k. Anticipate surgical interventions l. Large bowel: monitor F/E, when blood supply is being obstructed, surgery needed m. Small bowel: usually can decompress without surgery **ABDOMINAL TRAUMA** 1. Blunt and penetrating 2. Assessment a. S/S hypovolemic shock b. H&H c. Bruising d. Open wounds 3. Diagnostics e. Determines what part of GI is damaged i. CBC, electrolytes, UA ii. Serum lactate elevation: sepsis iii. LFT iv. Amylase/lipase **ALTERNATE NUTRITION** 1. Parenteral a. Into venous system b. Central line: PN c. Peripheral: PPN i. If long term: advocate for CL d. NO NOT MIX ANYTHING WITH FEED UNLESS RX CONSULT e. Obtain daily weight: fluid assessment f. BUN ii. Assess kidneys bc they have to filter all this out 2. Enteral g. Into GI system 3. Both h. High in sugar i. Prioritize iii. glucose checks iv. Monitor S/S infection v. Tubing changes **GENERAL LIVER** 1. Circulation a. Hepatic artery: 1/3 blood supply b. Portal vein: 2/3 blood supply c. All blood from GI system must be filtered through liver d. When liver is not functioning, there is a backup of GI blood 2. Major function e. Filters everything f. Creates bile (made from bilirubin, which is a byproduct of RBC destruction) g. Helps break down protein into albumin h. Releases thrombopoietin i. PLT formation 3. Dysfunction S/S i. Pain j. Fever k. Anorexia l. Fatigue m. Hepatomegaly n. Lymphadenopathy o. Splenomegaly p. Jaundice q. Ascites: third spacing due to no albumin ii. Treatment 1. High carb, low sodium diet 2. Diuretics, albumin 3. Paracentesis a. Pt. sits upright with hob elevated b. Drainage of fluid from the abdomen c. Position pt. on right side to splint puncture side post procedure 4. Peritoneovenous shunt d. Careful: too fast could lead to fluid overload e. Continuous reinfusion of ascitic fluid from abdomen to vena cava iii. Monitor 5. I&O 6. Daily weight 7. Abdominal girth 8. Extremity measurement iv. Complications 9. Thrombosis 10. Infection 11. Fluid overload 12. hematoma r. Anasarca: whole body edema v. No albuminfluid not in vascular system, it's in the tissue s. Skin lesions/bruising/bleeding: no clotting factors t. Collateral circulation: formation of new blood vessels to compensate for liver backup u. Increased ammonia hepatic encephalopathy vi. Inability to NH3 and bilirubin convert to urea vii. NH3 excites CNS viii. Bilirubin depresses CNS ix. S/S 13. Altered mentation 14. Asterixis 15. Fetor hematicus x. Goal: decrease ammonia formation 16. May reduce protein in diet 17. ABX: neomycin 18. Lactulose 19. Enemas v. Hepatorenal syndrome xi. Kidney failure due to lack of fluid in blood w. \*\* more than one complication = decompensated cirrhosis 4. Effects of liver dysfunction on whole body  **CIRRHOSIS** 1. Liver scarring from repeated damage 2. Causes a. Alcohol b. Hepatitis c. Biliary obstruction d. Severe right sided heart failure\* 3. S/S e. See typical liver dysfunction f. Asterixis: flipping tremor of wrist **HEPATITIS** 1. Causes a. Viral b. Autoimmune c. Drugs d. Metabolic issues 2. S/S e. *Flu-like, but for long time* 3. Viral f. Transmissions i. A&E: fecal-oral ii. B&C: bloodborne 1. B: some people can never form immunity, no matter how many vaccinations they receive iii. D: mutation of B virus (must have B to develop D) 4. Drugs g. Tylenol h. Tegretol i. Isoniazid j. Sulfonamides k. Thiazide diuretics l. Statins m. Alcohol 5. Wilson's disease n. Copper storage disorder o. Dx: brown/red rings around corneas 6. Hemochromatosis p. Iron storage disorder 7. Autoimmune q. Primary biliary cirrhosis 8. Metabolic r. Non-alcoholic fatty liver disease (NAFLD/steatohepatitis) iv. RF 2. Obesity 3. DM 4. High triglycerides 5. High cholesterol v. S/S 6. Flu-like 7. Altered mentation 8. Typical liver s/s s. Non-alcoholic steatosis (NASH) t. Associated with obesity vi. Body deposits fat into liver 9. Assessment u. History: to determine cause v. S/S vii. Fever viii. Lethargy ix. Lymphadenopathy x. Spider angiomas xi. Jaunice xii. Itching xiii. Dark urine xiv. Light, clay stool xv. Hepatomegaly xvi. Splenomegaly xvii. Anorexia: all blood supply is stuck in abdomen, so not able to digest properly 10. Infection stages w. Prodromal: flu-like symptoms x. Icteric: classis liver presentation y. Convalescent: resolution xviii. May still have scar tissue from damage, won't function completely normal again 11. Acute treatment z. Rest a. Diet b. Avoid irritants c. Meds xix. Antiemetics xx. Vitamins xxi. Milk thistle (silymarin) xxii. Anti-itch creams 12. Chronic treatment d. Vitamin supplements xxiii. B: anemia xxiv. K: clotting e. Antivirals xxv. Can also make pts. Feel worse bc SE xxvi. Decreases viral load xxvii. Delayed disease progression xxviii. C: direct acting antivirals (DAA) 9. 12-week regimen 10. Expensive 11. Seen to cure some cases **ESOPHAGEAL VARICES** 1. Varicose veins in esophagus 2. Can cause tears and bleeding 3. Complication of cirrhosis 4. Treatment a. Endoscopic sclerotherapy i. Inject epinephrine to constrict vessels ii. Inject clotting factor directly into vessels b. Endoscopic ligation iii. Cauterization of bleeding vessels c. Balloon tamponade iv. Balloon down esophagus to physically hold pressure on bleeding vessels d. Shunting procedures v. Shunts blood away from portal vein 5. S/S e. Bright red or coffee ground emesis **PANCREATITIS** 1. Autodigestion of pancreas caused by a. Alcohol b. Gallbladder disease/stones c. Drugs i. Antibiotics ii. Immunosuppressants iii. Cardiac meds d. Hypertriglyceridemia e. Penetrating ulcers f. Abdominal trauma g. Pancreatic malignancies 2. Clinical manifestations h. *Abdominal pain to LUQ or mid epigastrium* iv. *Radiates to back* v. Sudden onset vi. Aggravated by eating and laying down vii. Not relieved by vomiting i. Jaundice j. Guarding k. Decreased bowel sounds l. Grey-turners sign: bruising on flanks m. Cullen's sign: bruising around umbilicus n. Shock 3. Complications o. Pseudocyst viii. Resolve spontaneously ix. Later in disease process x. Can cause GI and biliary obstructions perforation and abscess/infection p. Systemic xi. ARDS 1. Respiratory disease due to excessive fluid volume resuscitation and abdominal compartment syndrome xii. Hypotension xiii. Hypocalcemia xiv. Pulmonary embolism 4. Diagnostics q. Serum amylase/lipase levels (lipase more) r. LFT s. Triglycerides (\>1000) t. Glucose u. Serum calcium decreases as a result of pancreatitis, but increased levels can cause pancreatitis v. Imaging xv. US xvi. CT: early to diagnose, late to monitor for complications xvii. MRI xviii. ERCP w. HPI 5. Treatment x. Supportive care xix. Rehydration xx. F/E 2. Moderate fluid resuscitation 3. Large amount: can cause abdominal compartment syndrome xxi. Pain management 4. IV opioids a. Can cause ileus to worsen 5. Antispasmodic agent xxii. O2 xxiii. Monitor glucose level xxiv. Minimize pancreas stimulation 6. NPO 7. NG 8. Decreased acid secretion 9. Enteral nutrition xxv. Shock 10. Prevent septic or hypovolemic shock 11. Vasopressors 12. Plasma/plasma volume expanders xxvi. Prevent/treat infection xxvii. Treat cause y. Surgical therapy xxviii. Gallstones: ERCP/cholecystectomy xxix. Uncertain diagnosis xxx. Not responding to traditional therapy xxxi. Drainage of necrotic fluid z. Nutritional therapy xxxii. Acute: NPO xxxiii. Quicker the diet is started, the better xxxiv. Start some sort of nutrition within first 24 hours xxxv. Normal foodENPN xxxvi. To prevent exacerbations: Low fat, small frequent meals, no alcohol, fat vitamin supplements 6. Assessment a. Try to determine cause xxxvii. Health history xxxviii. Medications xxxix. Surgery/treatments xl. Physical 13. Restless 14. Anxiety 15. Low grade fever 16. Sweating 17. Flushing 18. C/GT signs 19. Cyanotic 20. Jaundice 21. Decrease skin turgor 22. Dry mucous membranes 23. Tachypnea 24. Crackles in bases of lungs 25. Tachycardic 26. Hypotension 27. Abdominal distention 28. Diminished bowel sounds 7. Nursing Dx/Goals b. Acute pain c. Fluid volume deficit d. Imbalanced nutrition e. Ineffective health management f. Goals xli. Pain relief xlii. F/E balance xliii. No recurrent attacks xliv. No complications 8. Nursing interventions g. Monitor Cl, Na, K, Mg h. Monitor for decrease in Ca xlv. Tetany 29. Chesovech's sign b. Facial twitch 30. Trousseau's sign c. BP cuff: hand adducts to body xlvi. Treat with calcium gluconate i. Resp. function j. Pain management xlvii. Side lying with HOB elevated 45 degrees xlviii. Flex trunk and draw knees to abdomen k. Oral/nasal care l. Antacids m. S/S paralytic ileus, renal failure, LOC changes n. Monitor glucose **GALLBLADDER DISEASE** 1. Cholelithiasis a. Gall stones b. Can lodge in biliary ducts and cause obstruction c. Most common disorder of biliary system 2. Cholecystitis d. Gallbladder inflammation e. Edema, distention, and hyperemia to gallbladder f. Scarring and fibrosis after attack 3. Clinical manifestations g. Pain severe when stones are moving or obstructing a duct a. Steady, may refer to shoulder 1. 3-6 hours after high-fat meal or when pt. lays down b. *Residual tenderness in RUQ* c. Posturing h. Toal obstruction d. Dark urine e. Clay colored stool f. Itching g. Fat intolerance h. Bleeding 4. Diagnosis i. US j. ERCP k. Percutaneous transhepatic cholangiography l. Labs i. Increased 2. WBC 3. Bilirubin (blood and urine) 4. LFT 5. Amylase 5. Treatment m. Conservative j. Depends on staging k. Oral dissolution therapy 6. Go in to try to dissolve stone l. ERCP with sphincterotomy 7. Small cut to enlarge bile duct m. Extracorporeal shock-wave lithotripsy 8. Laser to break stone into smaller pieces able to pass n. Acute n. Infection watch o. NG p. Cholecystectomy 9. Treatment of choice 10. GB is physically attached to liver, so removal can cause hepatic hematoma q. Opioids r. Anticholinergics 11. Decrease GI secretions 12. Counteract smooth muscle spasms o. Drugs s. Opioids t. Atropine (anticholinergic) u. Fat soluble vitamins v. Bile salts w. Cholestyramine (itching) p. Nutrition x. Laparoscopic chole 13. Liquids first day 14. Light meals for days after y. Open chole 15. Liquids to regular diet after BS return 16. Restrict fats for 4-6 weeks 6. Post laparoscopic chole z. Shower available day after a. Report signs of infection b. Return to work in 1 week c. May need low fat diet for several weeks **RESPIRATORY DISTRESS** 1. Interventions a. O2 i. Ask for forgiveness later ii. Except COPD \>2L b. Wall nebulizers c. Anti-anxiety d. Pursed lipped breathing e. Calm pt. f. Elevate HOB 2. Hypoxia g. Not enough o2 in tissue h. S/S iii. Confusion iv. Anxiety v. Wheezing vi. Restlessness vii. Tachycardia at first then bradycardia viii. SOB ix. Cyanosis at first then cherry red x. Cool clammy skin i. Stages xi. SpO2 \>94: normal xii. 90: mild 1. Restlessness 2. Tachycardia 3. Dysrhythmias in cardiac pts 4. SOB 5. HTN 6. Tx: a. Nasal cannula b. Calm patient c. Fix cause xiii. 88: moderate 7. Confusion 8. Lethargy 9. Hypotension 10. Accessory muscle use 11. Tx d. Rapid response e. Bipap xiv. 75: severe 12. Cyanosis 13. Coma 14. Respiratory and/or cardiac arrest 15. Tx f. Intubation g. Invasive positive pressure 3. Capnography j. End tidal CO2 k. Best way to monitor respiratory status l. Used during xv. OR sedation 4. ABG m. pH: 7.35-7.45 n. CO2: 35-45 (acid) o. HCO3: 22-28 (base) p. Respiratory will have CO2 changes q. Metabolic will have bicarb changes r. Mixed will have both +-----------------------+-----------------------+-----------------------+ | Respiratory acidosis | High CO2 | - Respiratory | | | | failure | | | | | | | | - PNA | +=======================+=======================+=======================+ | Respiratory alkalosis | Low CO2 | - Hyperventilation | | | | | | | | - Anxiety | | | | | | | | - Improper | | | | ventilator | | | | settings | | | | | | | | - Zealous bagger | | | | during rapid | | | | response | +-----------------------+-----------------------+-----------------------+ | Metabolic acidosis | Low bicarb | - DKA | | | | | | | | - Sepsis | | | | | | | | - Renal disease | | | | | | | | - Diarrhea | | | | (ileostomy) | +-----------------------+-----------------------+-----------------------+ | Metabolic alkalosis | High bicarb | - Gastric suction | | | | | | | | - Renal disease | +-----------------------+-----------------------+-----------------------+ **AIRWAY OBSTRUCTIONS** 1. Causes a. Allergic rxn: angioedema (swelling of airway) b. Chemical inhalation burns c. Epiglottis: children mostly d. Foreign bodies e. Altered LOC: dysphagia f. Severe sleep apnea g. Infection i. Peritonsillar abscess ii. Retropharyngeal abscess h. Tracheomalacia iii. Muscles fail in trachea i. Vocal cord problems j. Trauma k. Throat cancer l. Post op complications 2. Assessment m. RR \> 24 n. Shallow o. No BS: complete obstruction p. Noisy BS: pt. still getting some air-partial obstruction q. Stridor: inhalation musical sound r. Wheezing: expiration s. Cyanosis t. Decreased SpO2 u. Increased HR v. Increased BP w. Decreased LOC x. Restlessness y. Use of assessor muscles z. Flaring nostrils 3. Intervention a. Complete Obstruction: emergency treatment iv. Heimlich maneuver for adults v. Back blows for children vi. Intubation vii. Cricothyroidotomy viii. Tracheostomy b. Other interventions ix. Elevate HOB x. O2 xi. Suction/manual removal xii. Decrease edema 1. Steroids 2. Antihistamines 3. Ice packs for trauma **TRACEOSTOMIES** 1. Tracheotomy a. Surgical incision into the trachea to establish an airway 2. Tracheostomy b. Stoma that results from tracheotomy 3. Indications c. Bypass upper airway d. Removal of secretions e. Long term ventilation: \>14 days f. Assist with weaning from mechanical ventilation g. Permits oral intake and speech for long term vents 4. Advantages h. Easier to clean ET tube i. Stable airway j. Increased comfort k. Pt. can eat l. Increased mobility m. Decreased vocal cord damage 5. Procedure of tracheostomy (bedside or OR: airway is priority not infection) n. RT must be present o. Pt. supine p. Administer sedation and analgesia q. Equipment i. Ambu bag & mask ii. Obturator 1. Placed inside the outer cannula with the rounded tip protruding from the end to ease insertion 2. Must be removed immediately after insertion to allow airflow r. Trach cuff inflated s. Confirm placement iii. X-ray iv. Lung sounds 6. Complications t. Air leak u. Altered body image v. Aspiration w. Bleeding x. Fistula formation: trachea and esophagus y. Infection z. Subcutaneous emphysema: air under skin (crepitus) a. Tracheal necrosis: Inflate balloon too much b. Tracheal stenosis: scarring that narrows airway c. Tube displacement 7. Management d. Assess at least q shift e. Cleaning v. Site care 3. Cleaning around stoma 4. Changing dressing 5. Change ties: per MD order a. Two-person technique b. After 24 hours then prn vi. Inner cannula care 6. Clear secretions (suction or replace tube) f. Suction vii. Monitor cuff pressures q 8 hours viii. Should not exceed 20-25 mm hg 8. Bedside equipment g. Humidified air or oxygen h. Obturator i. Tube replacement ix. Same size or smaller j. Suction equipment k. AMBU bag 9. Precautions of dislodgement l. First change by MD m. If dislodgement occurs x. Hold hole open xi. Replace tube 10. Types of tubes n. Non-fenestrated xii. Traditional xiii. Cannot speak or eat o. Fenestrated xiv. Allows normal airflow xv. Long term xvi. Not on vent xvii. Can speak, cough, and eat 11. Management p. Inflate cuff q. Aspiration risk evaluation r. Mechanical ventilation 12. Swallowing s. Evaluate aspiration t. Give colored liquid and evaluate coughing and secretions u. Suction trachea for colored secretions v. Test secretions for glucose (mucus should be low) 13. Decannulation w. Weaning period xviii. Trach plugged to evaluate QOB xix. Fenestrated tube might be utilized x. When patient can adequately exchange air and expectorate xx. Tube removed xxi. Stoma closed with tape and covered with occlusive dressing (Vaseline gauze) xxii. Instruct patient to split stoma with fingers when coughing, swallowing, or speaking y. Tissue forms in 24-48 hours without surgical intervention z. If dressing gets wet or soiled must be changed immediately 14. Laryngectomy/radical neck surgery a. Main concern is to monitor for airway damage **PNEUMONIA** 1. Overview a. Excess of fluid in the lungs caused by an inflammatory process 2. Causes b. Microorganisms c. Aspiration d. Chemical irritant inhalation 3. Community acquired e. Onset in community or 2 days of hospitalization f. Highest incidence in midwinter i. Not because of temp, but closer quarters with more people g. Smoking is important risk factor h. S/S ii. Sudden onset of fever iii. Chills iv. Cough 1. Productive of purulent, blood tinged, or rust colored sputum v. Pleuritic chest pain 2. Lung area 3. Sharp 4. Worse with deep breathing 4. Hospital acquired i. 48 hours or longer after admission j. Second most common Nomo social infection k. Risk factors vi. Immunosuppressive therapy vii. General debility viii. Endotracheal intubation 5. Prevention of aspiration pneumonia l. Identify clients at risk ix. GERD: especially post op x. Stroke xi. Semi-conscious 5. Place in side-lying position elevated HOB xii. Tube fed patients 6. Assess placement q 4 hours 7. Assess residuals q 4 hours 8. Avoid bolus feedings for high risk 6. Diagnostic tests m. History and physical n. CXR o. Sputum C&S p. Pulse ox q. Blood cultures xiii. Two sites xiv. 30 minutes apart 7. Management r. Increase fluid intake to 3L daily s. Balance activity and rest t. Oxygen u. Physiotherapy v. DVT/PE prophylaxis w. Meds xv. Bacterial: 9. Antibiotic for 10-14 days 10. Fluroquinolone xvi. Viral: 11. Antivirals 12. Aymanadine 13. Flumadine xvii. Mucolytics/expectorants 14. Mucinex 15. If fluids are c/I, not super helpful xviii. Antipyretics xix. Antitussive 16. Don't suppress cough too much 17. Robitussin 18. Tessalon pearls xx. Analgesic 19. Morphine 20. Codeine 21. Dilaudid 8. Interprofessional care x. Pneumonia vaccine y. Oxygen z. Flu drugs/vaccine a. Fluids b. Small, frequent meals c. Prevent aspiration d. TCDB: position change q 2 hours **TUBERCULOSIS** 1. Airborne 2. At risk a. Poor b. Underserved c. Prison d. Dorms e. Small houses, large families 3. S/S f. Progressive fatigue g. Wt. loss h. Chronic cough that will have blood in advanced stages i. Night sweats 4. Drug therapy j. Pt. considered noninfectious after i. 2-3 weeks of continuous medication ii. Three neg. sputum smears k. SE iii. Long term treatment of latent TB meds can cause liver damage iv. Rifampin 1. Red-orange bodily fluids **CHEST TRAUMA** 1. Chest trauma a. Blunt trauma i. MVA most common b. Penetrating trauma ii. Firearms and stabbing iii. Cover wound with occlusive dressing that is secured on 3 sides c. Result iv. Ineffective ventilation 1. Pain 2. Rib fractures 3. Air or blood in thoracic cavity 4. Pulmonary contusion v. Ineffective circulation 5. Injury to heart 6. Obstructive shock a. Blood in pericardial sac b. Tension pneumothorax i. Air where lung usually is pushes heart and other lung over, inhibiting breathing more ii. Trachea won't be midline 2. Flail chest d. Rib fractures vi. S/S 7. SOB 8. Localized pain 9. Chest wall bruising 10. Crepitus/deformity e. Flail chest vii. 2+ fractures on 2+ sites on 2+ ribs viii. Paradoxical chest movement ix. Requires intubation **PNEUMOTHORAX** 1. Types a. Spontaneous i. Rupture of small blebs b. Iatrogenic ii. Oops during operation c. Tension iii. Pressure d. Hemothorax iv. Blood v. Massive hemothorax 1. \> 1500+ ml e. Chylothorax vi. Lymphatic fluid **PLEUR-EVACS** 1. Dry seal a. More suction b. Easier to set up 2. Wet/water seal c. Water levels rise and fall with breaths d. Pneumothorax: bubbles initially are normal e. Vigorous, big bubbles=air leak bad f. Bright red blood=problem g. Dark red blood in hemothorax= normal 3. Nursing management h. Respiratory status i. Chest tube assessment i. Patency ii. Drainage iii. Suction iv. Air leaks j. Clamping v. Tube change vi. Leak assessment k. Tape to floor l. Keep below chest during pt. transportation 4. Removal m. Order only n. Sutures removed o. MD removes, not RN **OXYGEN** 1. Nasal cannula a. 1-6 l/min 2. Face mask with reservoir b. 6-10 l/min 3. Face mask with o2 bag c. 6-10 l/min 4. High flow cannula d. 30-60 l/min