Review - Test 3 Topic 5 GI Conditions 2024-25 PDF

**Topic 5.1 - Hiatal Hernia/GERD:** - **What are the two types of hiatal hernia? How do each differ in terms of symptoms and treatment?** - Sliding: Stomach slides into the thoracic cavity when supine, goes back into the abdominal cavity when standing upright- most comm...

**Topic 5.1 - Hiatal Hernia/GERD:** - **What are the two types of hiatal hernia? How do each differ in terms of symptoms and treatment?** - Sliding: Stomach slides into the thoracic cavity when supine, goes back into the abdominal cavity when standing upright- most common type - Paraesophageal or rolling: Esophagus junction remains in place, but fundus and greater curvature of stomach to roll up through diaphragm - **What are the risk factors, diagnostic tests and potential complications for hiatal hernia?** - Factors involved Structural Changes: Weakening of muscles in diaphragm - Increase intra abdominal Pressure: Obesity, Pregnancy, Heavy Lifting - Increasing age, Trauma, Poor Nutrition, Forced Recumbent position, Congenital Weakness - **Clinical Manifestations:** May be asymptomatic, symptoms may include: Heartburn, dysphasia - **Complications:** GERD, Hemorrhage from erosion, Stenosis, Ulcerations of herniated portion, Strangulation of hernia, Regurgitation with tracheal aspiration - **Diagnostic Studies:** Barium Swallow, Endoscopy - **Hiatal hernia: Conservative therapy? Surgical Therapy?** - **Conservative Therapy:** Lifestyle modifications: Eliminate alcohol, elevate HOB, Stop Smoking, avoid lifting/ straining, Weight Reduction (if appropriate), use of antisecretory agents and antacids - **Surgical Therapy:** Goal- to reduce reflux by enhancing the integrity of the LES , reduction of herniated stomach, Nissen Fundoplication, Toupet Fundoplication, Hill Gastropexy, Belsey Fundoplication - **What health teaching would be included for a client with hiatal hernia?** - Eating smaller frequent meals - Avoid trigger foods like fatty foods, caffeine, alcohol and chocolate - Not lying down immediately after eating - Elevating head of the bed - Maintaining a healthy weight and quitting smoking if applicable - **What are the clinical manifestations and potential complications of GERD?** - Heartburn - Otalaryngological Symptoms: hoarseness, sore throat, globes sensation (lump in throat) choking - Regurgitation: return of food or gastric contents from stomach into esophagus or mouth - Gastric Symptoms: feeling full easily, bloating nausea, vomiting - **Because GERD is a syndrome (often associated with hiatal hernia) what would be included in the collaborative care for GERD** - Lifestyle modification - Nutritional Therapy - Drug Therapy - Surgical Therapy - Endoscopic Therapy **Topic 5.2 - Peptic Ulcer Disease (PUD) - Gastric and Duodenal:** - **What is a peptic ulcer (etiology)? Where are the ulcers most commonly found?** - Erosion of the GI mucosa due to digestive action of HCL and pepsin - Can develop anywhere in lower esophagus, stomach, duodenum and margin of gastro- jejunal anastomosis after surgical procedures - **What are the leading causative factors in the development of a peptic ulcer?** - Helicobacter pylori (H.Pylori) Infection, and (NSAIDS) - **How do the symptoms differ for a gastric versus a duodenal ulcer?** - **Gastric:** Pain worsens shortly after eating when the stomach is full - May led to weight loss - **Duodenal:** Pain often arises a few hours after eating and can improve with food - May cause weight gain due to pain relief with meals - More likely to wake someone up at night due to pain when stomach is empty - **What are the three major complications of PUD?** - Hemorrhage - Perforation - Gastric outlet obstruction - **How are peptic ulcers treated?** - **Conservative Therapy:** Rest, Bland Diet, Smoking cessation, Drug therapy, Stress Reduction - **Acute Exacerbation Without Complications:** Rest, Smoking Cessation, NPO, Iv fluid Replacement, Drug Therapy - **Acute Exacerbations with Complications:** Total bed rest, Blood transfusion, Iv fluids (LR), NG to suction, NPO, Possible Stomach Lavage **Topic 5.3 - Gastritis - Acute and Chronic:** - **Acute vs. chronic -- what is the difference?** - **Acute:** Inflammation of the gastric mucosa - **Chronic:** Usually involves an underlying pathology that results in atrophy of gastric mucosa - **What are some common causes of acute gastritis? Chronic gastritis?** - **Acute:** Irritating foods, Alcohol, Medications (ASA, NSAIDs, Caffeine, Corticosteroids) - Secondary to other diseases or conditions: Major Trauma (burns), Crohn's Disease, Severe Infection, Renal Failure (uremia) Major surgery - **Chronic:** Autoimmune, Diffuse antral, Multifocal, associated with pernicious anemia and infection with H.Pylori, Increased risk for developing stomach cancer - **Acute gastritis:** - **Clinical Manifestations:** Nausea and vomiting, Anorexia, Epigastric tenderness, Feeeling of fullness, Cramping, Painless GI bleeding, usually self limiting, laying only a few hours to a few days - **Collaborative Care:** Treatment for acute gastric is symptomatic and supportive- Bedrest, IV Fluids, NPO, Meds (antiemetics, H2 antagonist, PPIs Antacids), Hemorrhage likely- frequent vital signs, NG- either for lavage or suction, For gastric bleeding- blood transfusion, iced saline lavage, Last Resort- surgery to remove gangrenous or perforated tissue, when ready start with clear fluids and gradually increase diet - **Chronic gastritis: collaborative care (medications, lifestyle changes -- including diet).** - Similar to acute gastritis - Same may have no symptoms - As the acid secreting cells are atrophied, the intrinsic factor is lost (intrinsic factor is essential for absorption of cobalamin (vitamin B12) causing a deficiency and inability to produce RBC- resulting in Anemia, Neurological Complications - Chronic Gastritis- immediate priority is to eliminate the causative agent - Bacterial gastritis treated with antibiotics, Antibiotic and antisecrretory agents, If pernicious anemia- oral or parenteral cobalamin, Lifestyle changes- eliminate substance that aggravate symptoms (spicy foods, alcohol, cigarettes, stress), six small meals a day with of antacid after meals - **What is included in diagnostic testing for gastritis?** - Diagnosis Acute Gastritis: History of drug and alcohol abuse - Diagnosis of Chronic Gastritis: Diagnosis may be delayed or miss because of nonspecific symptoms- Gastroscopy (tissue biopsy to rule of carcinoma), Stool for occult blood, CBC-High, Breath Test, Analysis of Gastric Contents- Severe atrophic gastritis can result in- hypochlorhydria (decreased acid secretion) or achlorhydria (lack of acid secretions) **Topic 5.4 - Inflammatory Bowel Disease: Ulcerative Colitis and Crohn's Disease:** - **Ulcerative Colitis Etiology:** Infection, Atuoimmunity, Toxin Exposure, immunodeficiency - **Ulcerative Pathophysiology:** Involves a number of factors, genetics, environmental factors, abnormal immune resounds - **Begins:** In the rectum and colon - **Crohn's Disease:** exact cause unknown but may involve abnormal immune response against microorganisms in which your tissues are attacked - **Crohn's Pathophysiology:** ulceration, granuloma formation, scarring, fistula formation - **Begins:** Small intestine or the beginning of the large intestine - **What would diagnostic findings show for each (i.e what would be seen with a colonoscopy)?** - Will show inflammation, ulcers, or bleeding in the large intestine - **What are the clinical manifestations for each (including onset, fever, fatigue, weight, nutritional absorption, pain, bleeding, and stool characteristics)?** - Chronic diarrhea - Abdominal pain and cramping - Blood in the stool - Bloating and gas - Fatigue - Fevers - Lack or loss of appetite - Weight loss - Mouth ulcers - Arthritis - UTI - Inflammation of the bile ducts - **What are the potential complications of each?** - **Crohn's:** Bowel obstruction, Ulcers, Fistulas, Anal Fissures, Abscesses, Intestinal Issues, Skin Problems - **Ulcerative Colitis:** Bleeding, Bone Loss, Eye Inflammation, Skin Inflammation, Joint Inflammation, Liver Disease, Kidney Problems, Growth and Development issues, Blood clots, colon cancer - **What is the dietary management and medical interventions for each?** - **Crohn's:** Low- residue diet (Soft bland foods), Eat smaller foods, Drink more liquids, Add omega 3-fatty acids, eat a variety of protein sources - **Medical:** Nutritional Supplements, Prebiotics and Probiotics, Partial Enteral Nutrition - **Ulcerative Colitis:** Low fibre diet, Small frequent meals, Hydration, identity trigger foods - **Medical:** Anti-inflammatory medications, Immunomodulators, Biological Therapies, Corticosteroids, Surgery (Colectomy) **Topic 5.5 - Intestinal/Bowel Obstructions:** - **how might NG to suction pertain to intestinal obstruction?** - They made it to decompress the stomach, relieving pressure and nausea by removing accumulated fluids and gas that can't pass through the blockage in the intestine - Reduces stomach distention - Prevents aspiration - Allows for bowel rest - Monitoring bowel function **Topic 5.6 and 5.12 - Appendicitis/Peritonitis/Gastro-enteritis** - **Appendicitis** - **Clinical Manifestations:** Initially periumbilical pain- amorexia, nausea and vomiting - Persistent and continuous pan shifts to right lower quadrant- localized at McBurney's point - Rebound tenderness (Blumberg sign) - Muscle guarding - Patient lays still with right leg flexed - Low grade fever - **Complications:** Perforation, Peritonitis, Abscesses - **Peritonitis** - Acute or chronic - The result of local generalized inflammation in the peritoneum - May be caused by rupture or trauma of abdominal organs that contain chemical irritants or bacteria- Peptic ulcer perforation, Ruptured appendix, Gunshot wound - Mahomes be secondary to other diseases and conditions- pancreatitis, perforated peptic ulcer, or diverticulitis rupture, obstruction, peritoneal dialysis - **Collaborative Care:** Identify and eliminate the underlying cause- CBC, WBC, Peritoneal aspiration, x-ray, ultrasound or CT - Combat infection - Prevent Complications- Hypovolemic shock, Septicemia, Intra-abdominal abscess, paralytic ileus, organ failure - **Gastro-enteritis** - Inflammation of the mucosa of the stomach and small intestine - **Clinical Manifestations:** N/V, Diarrhea, Abdominal Cramping, Distention, Fever, Elevated WBC, Bloody or mucous stools - Various causative agents- and usually self limiting - Strict medical asepsis and infection control precautions when indicated (depending on causative organism) **[Topic 5.7 - Hernia: ]** - **Understand what each of the terms mean with regard to hernias: reducible, irreducible, incarcerated and strangulated.** - [Reducible:] when the hernia can be placed back into the abdominal cavity by manipulation or by spontaneously reduction when the person lies down - [Irreducible/Incarcerated:] when the hernia cannot be placed back into the abdominal cavity and when the intestinal flow is obstructed - [Strangulated:] when the hernia cannot be placed back into the abdominal cavity and when the intestinal flow and blood flow are obstructed. This results in an acute intestinal obstruction and ischemia, which requires surgery - **What is the difference between the types of hernias -- inguinal, femoral, umbilical and ventral.** - Inguinal: - Most common type - Occurs at the point of weakness in the abdominal wall where the spermatic cord emerges (in men) and round ligament (in women) - Femoral: - Occurs when there is a protrusion through the femoral ring into the femoral canal - Occurs below the inguinal ligament as a bulge - Becomes strangulated easily and is more common in women - Umbilical: - Occurs when the rectus muscles are weak, or the umbilical opening fails to close after birth - Ventral/Incisional: - Caused by weakness in the abdominal wall at the site of a previous incision - More common is obese pts, pts with multiple surgeries in that area and who have inadequate wound healing - **What are the special concerns with post-op care for surgical treatment of a hernia?** - Post inguinal repair -- may have difficulty voiding - Check for distended bladder - Monitor 24-hour fluid balance record - Coughing is not encouraged but deep breathing and turning are encouraged - If need to cough or sneeze- the incision should be splinted during these functions - Pt is restricted from heavy lifting for 6-8 weeks - If pt wears a trust, nurse should check for skin irritation caused by the rubbing **Topic 5.8 - Diverticulosis/Diverticulitis:** - **Diverticulosis:** condition that develops when pouches (diverticula) form in the wall of the colon - **Diverticulitis:** inflammation of the irregular bulging pouches (diverticulum) in the wall of the large intestine. Caused by retention of stool and bacteria in the diverticulum which forms a hardened mass. - **What causes diverticular disease and where is the most common site?** - Cause: no known cause, believed to be related to deficiency in dietary fibre - Most common site is the sigmoid colon but may devlop anywhere along the GI tract - **What is the difference between diverticulosis and diverticulitis?** - Diverticulosis is the presence of small pouches in the colon wall, while diverticulitis is when those pouches become inflamed or infected. Diverticulitis is more serious than diverticulosis. - **What are appropriate nursing diagnoses, interventions and teachings for each?** - [Nursing Diagnoses] - Acute Pain - Risk for Infection - Imbalanced Nutrition: Less than Body Requirements - [Nursing interventions ] - Pain Management: - Give analgesics as needed - Monitoring and Assessment: - Monitor vital signs for signs of infection (e.g., increased temperature, increased heart rate). - Assess for changes in bowel patterns and abdominal tenderness. - Nutritional Support: - Consult with a dietitian for dietary modifications. - Encourage a high-fiber diet (for diverticulosis) once the patient is stable, and a clear liquid diet during acute diverticulitis episodes. - Lifestyle Modifications: - Encourage regular physical activity to promote bowel health. - Advise avoiding straining during bowel movements and proper hydration. - Recognizing Symptoms: - Instruct patients to recognize signs of complications, such as severe abdominal pain, changes in bowel habits, fever, or rectal bleeding. - **What signs and symptoms should someone with diverticulosis watch for?** - Diverticulosis patients may have no symptoms or crampy abdominal pain in the LLQ that\'s made better when passing flatus or BM - Diverticulitis causes abdominal pain over the involved area of the colon, a tender LLQ mass may be felt on palpation on the abdomen, fever, chills, nausea, anorexia and elevated WBC may be present - Diverticulosis patients who experience any diverticulitis symptoms should see their HCP **Topic 5.13 - Hemorrhoids:** - **What is the causative or contributing factors to the formation of hemorrhoids?** - Pregnancy - Prolonged constipation - Straining in an effort to defecate - Heavy lifting - Prolonged standing and sitting - Portal hypertension - **What are the symptoms of internal hemorrhoids? External?** - internal hemorrhoids - may be asymptomatic until they become constricted (then painful) - bright red bleeding -- streaks on toilet paper after defecation - chronic, dull, aching discomfort - external hemorrhoids - reddish blue - only bleed if vein ruptures - blood clots in hemorrhoids may become inflamed and painful (i.e. thrombosed) - intermittent pain, pain on palpation, itching, and burning **Hepatitis:** - **What are the pathophysiology and systemic effects of viral hepatitis?** - Widespread inflammation of liver tissue - Hepatocytes (cells in the liver) are targeted by direction action of virus (hep C) or through cell-mediated immune response (hep B) - Liver injury affects protein metabolism, blood coagulation and bile production and flow (cholestasis) - Systematic effects: - The circulating immune complexes activate the complement system, clinical manifestations of this activation are rash, fever, arthritis, malaise. - **What is the difference between Type A, B and C hepatitis** - Refer to hepatitis PowerPoint - **What teaching is needed in terms of an explanation of how the disease is transmitted, what the clinical manifestations are, and what is involved in prevention, treatment, and recovery for each type of hepatitis?** - Refer to hepatitis PowerPoint **Cirrhosis:** - **What are the various causes of cirrhosis?** - Excessive alcohol intake - Chronic viral hepatitis - Non-alcoholic fatty liver disease (NAFLD) - Autoimmune hepatitis - Extreme dieting - Malabsorption - Obesity - Cardiac cirrhosis - **What is the difference between compensated and decompensated cirrhosis?** - Compensated cirrhosis- liver continues to function normally with normal liver function tests (despite liver injury) - Decompensated cirrhosis- - **What are the clinical manifestations of advanced cirrhosis?** - Jaundice - Skin lesions - Hematological problems - Endocrine disturbances - Peripheral neuropathy - **What is included in collaborative care and nursing management for a client with advanced cirrhosis?** - [Collaborative Care:] - Mangement of hepatic encephalopathy: - Goal of treatment is to reduce ammonia formation and promote excretion via the GI tract. - Lactulose can be used to prevent hepatic encephalopathy by removing ammonia through the intestines - Treatment of precipitating causes - Treat electrolyte disorders, acid-base imbalances and infections - Liver transplant considered for recurrent hepatic encephalopathy and end-stage liver disease - [Nursing interventions:] - Energy conservation - Monitor dietary intake and GI status - Assess skin, sclera and hard palate for signs of jaundice - Assess colour of urine and stools (presence of excessive bilirubin) - Accurate 24-hour fluid balance - Assessment and measurement of edema and ascites - Semi-fowlers position for maximum respiratory efficiency - Skin care to avoid breakdown from edema - Monitor serum labs (liver function and electrolytes) - What are the major clinical manifestations for acute pancreatitis? - Severe unrelenting LUQ and midepigastric pain - Radiates thru the back - Distension - Vomiting - Profound dehydration - Postural hypotension - Tachycardia - Bowel sounds decreased or absent - Respiratory distress - Mild jaundice - Cyanosis or greenish to yellow-brown discoloration of the abdominal wall - Grey Turner spots: a bluish flank discoloration - Cullen's sign: bluish periumbilical discoloration - Shock: hemorrhage, effect of enzymes causes altered vasomotor tone with massive fluids shifts - **What are the potential complications of acute pancreatitis?** - Pancreatic pseudocysts - Pancreatic abscess - Respiratory: main systemic complication - Pleural effusion - Atelectasis - Pneumonia - Hypotension - Diabetes - Shock - Hypocalcaemia - **What diagnostic tests would be used?** Labs - Serum amylase and lipase -- usually elevated and an important test - Liver enzymes - Urinary amylase - WBC, bilirubin - Blood glucose, serum calcium, and triglycerides - Xray - CT - Abdominal U/S - MRCP - Diagnostic laparotomy - What treatment is used to manage acute pancreatitis? Why might an NG tube be required as part of the collaborative care? - Early surgery is usually contraindicated in patients with uncomplicated acute pancreatitis - Hydration -- Fluid and electrolyte imbalances - Pain management - Nutrition - NPO to decrease pancreatic secretions - Management and prevention of metabolic complications - Adapt lifestyle -- no more alcohol - Blood sugars - NG Tube - to decompress the stomach, prevent vomiting, and allow the pancreas to rest by minimizing stimulation from food intake - What is the most common cause for chronic pancreatitis? What is the difference between obstructive and non-obstructive? - 70% of cases due to alcohol related disorder - Obstructive: associated with biliary disease - Inflammation of the sphincter of Oddi - Cancer of the ampulla of Vater of the duodenum - Non-obstructive: inflammation and sclerosis - Mainly at the head of the pancreas - What are the clinical manifestations of chronic pancreatitis? How do they differ from acute pancreatitis? - Recurring attacks of pain and back pain - Unrelieved even with large doses of opioids - Vomiting - Pancreatic insufficiency - Constipation - Stool changes - Mild jaundice, dark urine - What treatment is used to manage chronic pancreatitis? (Lifestyle adaptation, nutrition, pain and nausea control, medications, surgical procedures.) - Change lifestyle -- no alcohol - Pain control & antiemetics - Pancreatic enzymes with meals - Diet -- high calorie, high CHO and protein - Surgery -- drainage T tube - Cholecystectomy -- if biliary tract disease - Sphincterotomy -- indicated to enlarge a pancreatic sphincter that has become fibrous - Pancreatojejunostomy -- to relieve obstruction and allow drainage of pancreatic secretions **Cholelithiasis and Cholecystitis:** - Cholelithiasis: an imbalance between which three things results in gall stone formation? - When imbalance between cholesterol, bile salts, and calcium in solution precipitate - May be related to infection and disturbances in cholesterol metabolism - Which of the three are the stones most often comprised of? - Cholesterol stones - Black pigment gallstones - Polymerized calcium bilirubinate - Brown pigment stones - Consist of conjugated bilirubin and calcium salts - Cholecystitis: either considered acalculous or secondary to cholelithiasis. - What are the clinical manifestations? - Vary from indigestion - Pain, tenderness and rigidity of URQ abdomen - N&V - Diaphoresis - Leukocytes and fever - Murphy sign -- painful response with palpation of right subcostal region - The lack of bile salts in the intestine leads to a deficiency in which type of nutrients (think fat-soluble vitamins). How might this lead to bleeding tendencies? - Lack of vitamin K absorption -- vitamin K is needed to stop bleeding - What are some treatment options to cholelithiasis? Cholecystitis? Surgical interventions? - Pain control during acute attack - Antibiotics if infection Gastric decompression - Pharmalogical - ERCP -- widens the duct mouth by incising the sphincter muscle - Electracorporteal shock wave lithotripsy - Surgical intervention - Laparoscopic cholecystectomy - Transhepatic biliary catheter - T Tube - Post-op care considerations with cholecystectomy? Consider pharmacological and non-pharmacological collaborative care.) - Monitor for signs of bleeding - Make the pt comfortable - Common to have referred pain to shoulder - Place pt in sims position if they have shoulder pain and pain when breathing in - Early ambulation - Severe pain can be controlled by opioids **Thyroid Conditions (Hypothyroid, hyperthyroid, thyroid storm):** - What clinical findings would you see with each of the conditions? - Remember hypothyroid is a slowing of the metabolic processes, and hyperthyroid is a speeding up. - Hyperthyroidism - Hyperexcitable - Irritable - Apprehensive - Palpitations - Rapid pulse - Increased systolic BP - Heat intolerance - Skin flushed, excessive perspiration - Increased appetite - Weight loss - Amenorrhea - Increased bowel sounds, increased bowel movements - Hypothyroidism - Onset of symptoms may be slow - Severity depends on extent of thyroid hormone deficiency - Fatigue, lethargy, personailtity and mental changes, appears depressed, low initiative, slowed speech, impaired memory - Low cardiac output, decreased heart contractility, low exercise tolerance and SOB on exertion - Anemia, elevated cholesterol - Decreased GI motility, constipation - Painful menstruation - Why might hypothyroidism go undiagnosed for an extended period of time? - Symptoms are slow onset and can go unnoticed for months or years - What are some potential nursing diagnoses for a client with hypothyroidism before starting treatment? - Reduced Stamina resulting from physical deconditioning - Constipation resulting from decrease in GI motility - Goals: experience relief from all symptoms. Maintain a euthyroid state, maintain a positive self-image, adhere to a life long regimen of thyroid replacement therapy - What nursing interventions and teaching is necessary for someone newly diagnosed with hypothyroidism and prescribed thyroid replacement therapy? - Follow prescribed therapy - Do not abruptly stop taking medications - Follow up TSH levels - **Start with a lower dose** of levothyroxine and increase gradually to prevent cardiac strain. - Monitor for **angina, arrhythmias, or heart failure symptoms** since thyroid hormones increase metabolism and cardiac workload. - Increased risk of **osteoporosis**---monitor bone health, encourage weight-bearing exercises, and consider calcium/Vitamin D supplementation (taken separately from thyroid meds). - Assess for **cognitive changes**, as untreated hypothyroidism can mimic dementia. - Hyperthyroidism - What is Grave's Disease? - Autoimmune disease of unknown etiology marked by thyroid enlargement and excessive thyroid secretion - S&S: excessive sweating, heat intolerance, tachycardia, tremors, muscle weakness - Nutritional therapy: high calorie diet to satisfy hunger and prevent tissue break down - 6 meals a day plus snacks **Diabetes Mellitus (DM):** - Considering pathophysiology - what is the difference between prediabetes, Type 1 DM, and Type II DM? - Prediabetes - Blood glucose levels that are higher than normal but not yet high enough to be diagnosed with type 2 diabetes - Usually no symptoms, but should watch for symptoms and check blood sugars regularly - T1DM - Autoimmune response - Destruction of insulin producing cells - Require exogenous source of insulin - Pancreases doesn\'t produce insulin because the body attacks the cells that make it - No cure, managed with insulin - T2DM - Can be prevented with diet and exercise - Resistance to insulin - Pancrease produces less insulin - Why do we no longer refer to them as 'Insulin Dependent" or "Non-insulin Dependent" diabetes? - Even with type 2 diabetes you still may need to be treated with insulin therapy as their condition progresses - What are the clinical manifestations of hyperglycemia and hypoglycemia? - Hyperglycemia - Urinating lots - Excessive thirst - Tired - Dry mouth - Frequent hunger - Weight loss - Hypoglycemia - Paleness - Shakiness - Headache - Sweating - Hunger or nausea - Fatigue - Irritability or anxiety - What are the "3 P's" (polyuria, polyphagia, polydipsia), relate these symptoms to the pathophysiology - Polyphagia: excessive hunger - Due to lack of glucose inside cells and caloric loss of glucose in urine - Polydipsia: excessive thirst - From cellular dehydration and excessive loss of fluids thru urine - Polyuria: excessive urination - Loss of fluids due to increased osmotic diuresis - Consider the priority nursing interventions for a client newly diagnosed with DM. - How to read blood glucose - How to prevent DKA/HHS - How to administer insulin - Review the medications used to manage Type I and Type II. What would need to be taught to a client newly diagnosed with DM on medication for Type I? Type II? - How to take the medication -- is it an injeciton, or oral - Side effects of the medications - How to interpret when to take medications depending on blood glucose reading - Types of Meds: See tables on page 1276-1277 - What is DKA (diabetic ketoacidosis)? - What is DKA: - Hyperglycemia, dehydration and electrolyte loss, acidosis - "diabetic coma" - Cause: - Caused by an absence or markedly inadequate amount of insulin - Missed dose of insulin, illness or infection, undiagnosed and intreated diabetes - Clinical Presentations - Dehydration - Headache, weakness - Acetone breath - N&V - Hyperglycemia - Treatment: - Rehydrate - Restore electrolytes - Insulin - What is hyperosmolar hyperglycemic state (HHS)? - Develops gradually over several weeks - Often follows an infection, flue, pneumonia, other healthy problems - a life-threatening diabetic complication characterized by extremely high blood sugar levels, severe dehydration, and a significantly elevated blood osmolality, all occurring without significant ketone production (ketoacidosis) - Causes: dehydration and high blood glucose - Treatment - Replace fluids and electrolytes - Administer insulin to decrease blood glucose levels - Determine the cause to prevent recurrence - How do DKA and HHS differ? - Differs from DKA -- the very high blood glucose from slow progression and prolonged osmotic diuresis and dehydration allows the blood glucose levels to reach very elevated levels. It produces profound dehydration and confusion. Lethargy and mild confusion are common (may also mimic a stroke) - No abd pain or Kussmauls breathing with HHS because there is no acidosis. They often do not seek medical attention as quickly. - What are the long-term complications of untreated diabetes? - Blood vessel damage/blockage: atherosclerosis - Diabetic ulcers - Retinopathy - Neuropathy - What would need to be included in a teaching plan for Type 1 and Type 2 DM to prevent complications when preparing a client for discharge home? - Guidelines for dealing with minor sickness - Blood glucose monitoring - Nutritional planning - Administration of meds - Monitoring for complications - Take meds as usual - Test glucose more frequently - Call physician if altered intake and output **[Kidneys role in maintaining fluid and electrolyte balance, acid base balance, and BP]** Primary and secondary functions of the kidneys: - **[Primary]**: Filter waste products from the blood, maintain fluid and electrolyte and acid-base balance, excrete metabolic waste products - **[Secondary]**: Regulate blood pressure (production and secretion of renin), regulate bone density, regulate erythropoiesis, activation of vitamin D - Fluid, electrolyte, and acid-base imbalances: - **Consider the kidneys role in water and sodium movement in the body -- what roles do ADH and aldosterone play? How does this relate to blood pressure regulation?** - ADH causes the kidneys to release water, decreasing the amount of urine produced - ADH signals the kidneys to reabsorb more water form the urine, which directly impacts blood volume and consequently blood pressure - When ADH is high more water retained and leads to increased blood volume and pressure - When ADH levels are low increased urine production and decreased blood pressure - **Why do we use body weight as a measurement of body fluid?** - 1 litre of water weighs 1kg - Over a short period, changes in body weight is probably associated with change in body fluids, measurement of body weight may be a more accurate way of estimating fluid status - **When using loop diuretics, what are the potential dangers of sodium loss? What about dangers of potassium loss -- how might this relate to the need for cardiac monitoring?** - Sodium loss there is increased risk of cardiac arrhythmias - Abnormal heart rhythms, muscle weakness and high blood pressure - Need to be monitoring these patients for cardiac complications - **What does it mean that calcium and phosphate have an 'inverse relationship'?** - When calcium is high phosphate is low - When phosphate is high calcium is low - **How do the kidneys help to regulate acid-base balance? Consider the three mechanisms for maintaining acid-base balance...how does the renal system relate in terms of timing to respond?** - Kidneys actively absorb bicarbonate form the urine back into the bloodstream while simultaneously secreting hydrogen ions into the urine - Buffer system that acts in seconds - Respiratory system that acts in minutes - Renal system that acts in hours to days - **There will be ABG interpretation questions.** - **What nursing assessments are important when caring for a client with altered renal function?** - 24 hour fluid balance- give valuable information regarding fluid and electrolyte problems - Daily weights- an increase in 1kg is equal to 1000mls of fluid retention - Respiratory changes - Neuro Changes - Skin assessment - Edema **[Urinary Tract Infections- on the worksheet ]** **[Renal calculi]** - **Common causes and predisposing factors for renal calculi** - Infection - Urinary Stasis - Immobility - Dehydration, urinary obstruction, Increased calcium concentrations, hyperparathyroidism, excessive intake of Vit D, excessive intake of milk and alkali, certain cancers - **Clinical manifestations of renal calculi** - Vary with location, size and cause - Acute sharp intermittent pain or dull tender ache in flank - Some may cause little symptoms but big damage - Hematuria - Pyuria - Symptoms onset related to obstruction of urinary flow - Abdominal or flank pain - Hematuria - Pain may cause N/V - **What is included in the collaborative care for a client with renal calculi?** - Treat infection and pain - Identify and correct cause - Eradicate stone - Relieve Obstruction - Relieve pain - Nutritional therapy: for prevention of further stones - **What is included in patient teaching for passing a stone and preventing recurrence of stone formation? What is *lithotripsy*?** - Encourage fluids to facilitate passage of stones - Warn that analgesics may be necessary and there may be some bleeding - Encourage frequent walking to assist in passage of stone fragments - Lithotripsy: A treatment typically using ultrasound shock waves, by which a kidney stone or other calculus is broken into small particles that can be passed out by the body **[Surgical considerations]**: - **What are the most important post-op assessments for a client who has had renal or ureteral surgery?** - Special consideration of lucid intake and electrolyte balance - Instruct patient they will have a flank incision and hyperextended position during surgery may cause muscle aches post op - Urinary output - Daily weights - Respiratory status - Abdominal distension **[Acute kidney injury (AKI) ]** - **Consider the three major categories of acute kidney injury: prerenal, intrarenal and postrenal. What is the difference between each, and what are some causes of each? Which is/are more potentially dangerous, and how are each treated?** - **Prerenal:** Hypoperfusion of kidney, results in reduction in excretion of sodium (increased sodium and water retention) and decreased urinary output - **Intrarenal:** Actual damage to the kidney- Acute Tubular Necrosis: death of tubular epithelial cells that form the renal tubules of the kidneys - **Post renal:** Mechanical obstruction to urine flow- urine relfuxes into renal pelvis impairs kidney function - Prerenal and postrenal resolve quickly when cause is determined and corrected - Intrerenal is the most dangerous - **Differentiate clinical manifestations of initiation, maintenance and recovery phases** - **Initiation:** Increase in serum creatinine and BUN and decreased in urinary output - **Maintenance:** May last from days to weeks - Changes in urinary output- Anuric, oliguria or non oliguric - Continued increase in BUN and Creatinine - Fluid Volume excess - Metabolic acidosis - Sodium Balance - Hyper Kalemia - Haematological Disorders - Hypocalcaemia with hyperphosphatemia - Waste product accumulation - Neurological disorders - **Recovery:** Return of BUN, creatinine and GFR to normal ranges - May experience a diuretic phase - High urinary volume due to osmotic diuresis and inability of tubular concentration - Resume ability to excrete waste- but not to concentrate urine - May last 1-3 weeks- must closely monitor electrolyte and for signs of dehydration - Renal function my take up 12 months to stabilize - If they do not recover they may profess to chronic kidney failure - **What is included in treatment of hyperkalemia with AKI?** - Regular insulin with glucose IV causes movement of K+ into cells - Na bicarb: corrects acidosis and shifts potassium into cells - Kayexalate - Dietary restriction of potassium - **When is renal replacement therapy required?** - Progression of disease occurs and to prevent complications such as hyperkalemia with cardiac arrhythmias, increasing serum creatinine - Fluid overload compromising cardiac and respiratory function - Elevated potassium levels - Metabolic acidosis - BUN greater than 43mmol - Significant change in mental status - Pericarditis, pericardial effusion or cardiac tomponade - **How can we maintain fluid and electrolyte balances? Nutritional considerations? Correcting acidosis?** - Strict motoring of I&O - Diuretics may be used if impeding complications such as CHF, Hypertension, or edema - Lasts may some times initiate diuresis - Restrict Sodium - Fluid Restriction - Daily Weight **[Chronic kidney diseases (CKD)]** - **What are causes of chronic kidney disease? (think co-morbidities)** - Diabetes - Hypertension - Chronic Glomerulonephritis - Pylonephritis - Obstruction of urinary tract - Environmental- toxic agents - **Consider the various body systems and how they are impacted by CKD, How will these present as clinical manifestations?** - **Neuro:** Fatigue, Headache, Sleep disturbances - **Metabolic:** Carbohydrate intolerance, hyperlipidemia - **Cardio:** Hypertension, Heart Failure, CAD, Pericarditis, PAD - **Integumentary:** Pruitus, Ecchymosis, Dry, Scaly skin - **GI:** Anorexia, Nausea,Vomiting, GI Bleeding, Gastritis - **Collaborative care to treat and prevent complications of: hyperkalemia, hypertension, anemia, calcium and phosphorous imbalance** - 24 hour urine - Hyperkalemia: Dietary potassium restriction, Iv insulin and glucose, RRT - Hypertension: r/t sodium and water retention- may delay of disease by managing BP with anti-hypertensive medications - Sodium and fluid restrictions - Anemia: Parenteral erythropoietin may also require iron and folic acid - Calcium and phosphorus imbalance: Mineral and bone disorder, loss of ability for vitamin D synthesis, limit dietary phosphate - **What is the purpose of dialysis?** - Movement of fluid and molecules across a semi permeable membrane from one compartment to another - Process to remove fluid and uremic waste products form body when the kidneys are unable to do so - **What are the differences between hemodialysis and peritoneal dialysis? What are the benefits, and what are the potential complications of each type of dialysis?** - **Hemodialysis:** most common method of dialysis - Patients blood on side and dialysate on other side of semipermeable membrane= diffusion filtration and osmosis - Blood cleaned and excess fluid removed - Usually takes 3-4 hours - **Complications:** Hypotension, Muscle Cramps, Loss of blood, Hepatitis, Sepsis, Disequilibrium Syndrome - **Peritoneal Dialysis:** Unable or unwilling to have hemodialysis or renal transplant, clients with underlying diseases that interfere or make hemo dangerous - **Complications:** Peritonitis, Leakage, Bleeding, Hernias, Cardiac, Exit site infection, Abdominal pain, outflow problems, lower back problems, pulmonary complications, protein loss **[Diagnostic testing for renal function]**: Review the following tests: BUN & creatinine, 24 urine for creatinine clearance (GFR), urinalysis, urine osmolality, urine for C&S, KUB x-ray, renal ultrasound, CT and MRI