Med Surg Test 4 PDF

Test #4 Unit 4 Exam Review (44 questions and 1 case study with 6 questions, 13 diabetes questions, 7 on pancreatitis) ★ Hiatal Hernia – health promotion such as foods to avoid ○ Hiatal hernia= a condition caused by an increased intra-abdominal pressure that results in pushin...

Test #4 Unit 4 Exam Review (44 questions and 1 case study with 6 questions, 13 diabetes questions, 7 on pancreatitis) ★ Hiatal Hernia – health promotion such as foods to avoid ○ Hiatal hernia= a condition caused by an increased intra-abdominal pressure that results in pushing the stomach & other abdominal viscera up and into the mediastinum. ○ Signs & symptoms are similar to those experienced with GERD→ heartburn, regurgitation, chest pain, nausea, heavy/full feeling of the epigastric region ○ Pt. education: avoid caffeine, spicy foods, fatty foods, chocolate, carbonated drinks, peppermint, calcium channel blockers, cholinergics, and tobacco, patient has an increased risk for dehydration and nutritional deficits, eat smaller and more frequent meals, increase exercise, avoid tight fitting clothes, eat meals 2 hours before lying supine ○ Position patient supine on the right side an elevate the HOB at least 30 degrees after meals (promotes gastric emptying) ★ Client education for Nissen Fundoplication ○ Gold standard treatment for hiatal hernia repair!!! ○ Postoperative teaching: Follow soft diet until swallowing improves, take small bites & eat slow Avoid activities that cause air to be swallowed (carbonated beverages, gum, using straws) Notify provider for chest pain or difficulty breathing Use antireflux medications Driving is allowed 1 week after narcotic pain meds have been d/c No heavy lifting, walking is encouraged Keep steri-strips clean and dry and do not peel them off Seek treatment immediately if: you feel very full with inability to vomit/burp, thick drainage/odor from incisions, dysphagia, hard/painful abdomen, signs of bleeding ★ Gastritis- Clinical Manifestations and nursing care ○ Inflammation of the inner tissues lining of the stomach→ causes mucosal lining to become compromised and exposed to viral, fungal, and bacterial infections ○ Can be caused by an overconsumption of alcohol, eating spicy/fried/acidic foods, taking NSAIDs, food poisoning, varying infections, acute stress, smoking, H.pylori  ○ Signs & symptoms: loss of appetite, bloating, belching, N/V, abdominal pain of the epigastric region, black tarry stools ○ Treatment: PPIs, H2 blockers, antacids, and antibiotics. Increase intake of cruciferous vegetables (cabbage, cauliflower, broccoli) to improve gut microbiome in pts. who have gastritis caused by H.pylori ○ Pt. education: do not lie flat for 2-3 hours after meals, avoid alcohol and NSAIDs, perform frequent hand hygiene ★ Ostomies: ○ Ileostomy – the colon is removed: stool is not going to be formed, it is more liquidy or pastey and bile-colored, continuous output ○ Colostomy – a potion of the bowel must be removed, transverse produces more formed stools, ascending produces liquid stools, sigmoid produces near-normal stools ○ Post Procedure care for both: Monitor for leakage (risk to skin integrity) Apply skin barriers and creams to peristomal skin & allow it to dry before placing a new device Empty bag when it is ⅓ to ½ full Assess for fluid & electrolyte imbalances Educate about strong odored foods: fish, eggs, asparagus, garlic, beans, and foods that cause gas like: dark leafy greens, dairy products, etc. Avoid high-fiber foods for the first 2 months after surgery, chew food well, increase fluids, evaluate for evidence of blockage ★ Ulcerative Colitis – clinical manifestations that stand out from any other disease ○ U: urgent/frequent need to have bowel movements (10-15 loose stools) ○ L: loss of weight due to constant diarrhea, low RBCs (anemia) ○ C: Cramps in abdomen & rebound tenderness ○ E: Electrolyte imbalances, elevated temperature ○ R: rectal bleeding ○ S: Severe diarrhea with pus, blood, mucus!!!! ○ Tx: colectomy ★ Crohn’s ○ Inflammation and ulceration of the GI tract, often at the distal ileum ○ S/S: Abscessesing fistulas that may form sepsis, malnourishment, anal fissures, strictures/obstructions, ulcer in the mouth & GI tract, inflammation throughout the body, RLQ pain, steatorrhea, high-pitched bowel sounds, 5 loose stools per day with mucus or pus ○ Usually develops in adolescents and young adults,  ○ Treatment: monthly B12 shots, rest the bowel and control inflammation, monitor fluid and electrolytes, avoid dairy, caffeine, alcohol, eat small frequent meals ★ Total parenteral nutrition (TPN) ○ Provide the major macronutrients (protein, carbs, and lipids) and micronutrients (electrolytes, vitamins, and trace minerals) and water ○ TPN should initiated gradually because of the high concentrations of dextrose, patients glucose and fluid tolerance should be monitored closely ○ TPN should be changed every 24 hours to decrease risk of contamination & infection ★ Peritonitis ○ Life threatening inflammation of the peritoneum & lining of the abdominal cavity, often caused by bacteria ○ S/S: rigid, board-like abdomen (hallmark indication), abdominal distention, N/V, rebound tenderness, fever, tachycardia ○ Interventions: place pt. In fowlers or semi-fowlers to promote drainage of peritoneal fluid & improve lung expansion, monitor respiratory status & NG suction, keep patient NPO, monitor fluid/electrolytes/hypovolemia ★ IBS/IBD – Meds antidiarrheals, expect patients to be on TPN (nutrition), go back and review TPN interventions. ○ IBS (irritable bowel syndrome) Unknown cause S/S: diarrhea, constipation, flatus, abdominal pain, LLQ pain, abdominal distention, pain increases after eating and is relieved with bowel movement Pt. education: avoid foods such as fructose, apples, pears, mangoes, cherries, and wheat, alternative therapies such as relaxation techniques & herbal remedies (peppermint, chamomile, and ginger) may help, identify food triggers Meds: antispasmodic, antidiarrheals, guanylate cyclase agonist ○ IBD (inflammatory bowel disease) Umbrella term for crohn's disease and ulcerative colitis Bowel rupture leading to peritonitis is a complication ★ Celiac Disease – what would you include in a plan of care (can’t digest gluten). Gluten free diet. Know the intervention. Malabsorption, electrolytes, anemias, vitamin B 12 deficiency. ○ S/S: diarrhea that is frothy, foul smelling, and light in color, steatorrhea, flatulence, weight loss, and signs of malabsorption (fatigue), severe abdominal pain and increased bleeding  ○ Complications: malnutrition, malabsorption, anemia (not getting enough folate and iron), osteopenia, and osteoporosis ○ Treatment: consult dietician, lifelong gluten free diet, identify & treat malabsorption/malnutrition, access support groups ○ Diagnosis: endoscopic biopsy, monitor CBC, electrolytes, coagulation profile, liver function ○ Foods to avoid: all food containing gluten, wheat, barley, beer, pasta, noodles, rye, seasoning soup ○ Health promotion: read food, medication, and other labels, use a dishwasher because it removes gluten residue, avoid cross contamination, join support group ★ GERD ○ Stomach acids travel up the esophagus causing irritation to the esophageal lining ○ S/S: frequent heartburn, chest pain, regurgitation, sour taste in the mouth after food intake, episodes on dysphagia, dyspepsia, odynophagia ○ *****CASE STUDY ★ PUD ○ Ulcerations & erosions in the stomach and duodenum from a variety of causes Usually occur mainly in the gastroduodenal mucosa because this tissue cannot withstand the digestive action of gastric acid and pepsin ○ Risk factors: H. pylori infection, NSAID & aspirin use, smoking & drinking alcohol, neoplasia, Crohns, hyperparathyroidism ○ S/S: depend on ulcer location & patient age, pain is the most common symptom and burning epigastric ○ Duodenal ulcers: pain aggravated by fasting and improved with food or antacids Pain 3-4 hours after eating Wake up at night with pain reports gnawing pain Normal weight Severe= dark tarry stools from GI bleeding ○ Gastric ulcers: pain is worsened by eating, little to no relief from antacids Pain 1-2 hours after eating Reports dull/aching ;ain Weight loss Severe= vomiting blood  ○ Complications: peritonitis, GI hemorrhage, perforation, abdominal or intestinal infarction GI bleedings signs: pale skin, bloating, increased HR, decreased BP, dark/tarry stools ★ Dumping syndrome: food enters the small intestine too fast before the stomach is done digesting it, food acts hypertonically & causes water from blood to enter jejunum Early dumping (15-30 minutes after eating) ○ Nausea, bloating, diarrhea ○ Quick shift of fluid—> heart tried to compensate so pt. May experience hypotension, syncope, dizziness Late dumping (3 hours after eating) ○ Hypoglycemic like effects ○ Pancreas releases insulin due to food high in carbs & sugar entering into small intestine too soon Pt’s can have 1 or both types of dumping!!!! Patient education for dumping: ○ Eat many small frequent meals ○ Avoid sugary foods and drinks ○ High protein & fiber, low carbs ○ Eat without drinking fluids, wait 30 minutes after eating ○ Lie down for 30 minutes after eating ★ Diverticulitis ○ Inflammation & infection of the bowel mucosa, ○ S/S: palpable mass, nausea/vomiting, fever, chills, tachycardia, leukocytosis, fever ○ Food can get stuck in the little pockets and lead to infection, sepsis, and obstruction ○ Avoid seeds, grease, fried foods ○ If pain is generalized then peritonitis has occurred→ hard rigid abdomen!!!! ★ Gallstones – clinical manifestations (know which one is not a clinical manifestation) ○ Hard deposits formed from bile contents that often cause obstruction of ducts in and around the gallbladder ○ Risk factors (5 F’s): fair, fat, female, fertile, over forty ○ Signs & symptoms: pain in RUQ, rebound tenderness, guarding, fever, tachycardia  ○ Give ursodiol or actigall (pancreatic enzyme) before patient eats (capsule/tablet form), you give it before so that the food can be broken down easier ★ Cholecystitis – what medication long term. What foods do you stay away from (fatty foods) ○ The gallbladder becomes inflamed due to an obstruction caused by a gallstone that may be preventing the bile from being expelled. ○ S/S: Murphy's signs, colicky pain right upper quadrant pain, rebound tenderness (blumberg sign), diaphoresis, may have jaundice, radiating shoulder pain (mimics heart attack), must rule out cardiac first!!!! ○ Hepatobiliary scan (HIDA) ○ Endoscopic retrograde cholangiopancreatography ★ EGD ○ Esophagogastroduodenoscopy: visualization of the esophagus, stomach, and duodenum ○ Used to confirm or diagnose suspected upper GI bleeding, dysphagia, epigastric pain ○ Monitor for the return of gag reflex & monitor vitals after ○ Patient should be NPO for 8-10 before procedure ★ Appendicitis – extreme sign of the lower right side of the abdomen. Roven sign. Palpate left side and pain is felt on the right side of the abdomen. What action do we care for with a patient with appendicitis (pre-op) ○ Inflammation of the appendix→ medical emergency!!! (can cause sepsis) ○ S/S: RLQ pain, Mcburney's point, DO NOT put pressure or heat because it could burst, rebound tenderness, Rovsing's sign (palpate on LLQ and the pain will be felt on the RLQ), fever, tachycardia, N/V, lack of appetite If a patient suddenly says they feel better, the appendix has most likely ruptured, prepare them for surgery ○ Complications: peritonitis, gangrene, perforation, sepsis ★ Acute pancreatitis – risk factor (alcohol). What category of medication needs to be administered for pancreatitis. Give ppi to relax stomach, pain medication, antispasmodic, do not give anticholinergic (know why –decrease intestinal motility) ○ Sudden inflammation of the pancreas due to something that has triggered the digestive enzymes to become activated inside the organ ○ Common causes: gallstones & high amounts of alcohol consumption ○ Due to the location of pancreas, the inflammation & activated digestive enzymes can spread to other organs & lead to internal bleeding, respiratory distress, etc. ○ S/S:  sudden very painful mid-epigastric pain or LUQ pain, can be felt in the back pain worse when lying flat may have pain after eating greasy/fatty foods or alcohol Fever increased HR, decreased BP N/V, hyperglycemia high amylase & lipase level in the blood Cullens & gray turner's sign ○ Cullen’s & Grey-Turner's signs are seen with severe cases of acute pancreatitis They represent retroperitoneal bleeding from leakage of digestive enzymes into surrounding tissues→ causes bleeding & leaks down into flanks and umbilicus Cullen’s sign: bluish coloration around the belly button Grey-Turner’s sign: bluish coloration on the flank ★ Chronic pancreatitis – signs and symptoms. Know the clinical manifestations. Labs to look at for pancreatitis lipase and amylase. ○ The main cause is heavy long-term alcohol use; other causes are repeated acute pancreatitis and cystic fibrosis. CANNOT be cured. ○ Signs/symptoms: Abdominal pain; chronic epigastric pain that is persistent Pain that is worsened after drinking or eating a greasy meal Mass or swelling due to cyst formation in the pancreas Steatorrhea due to lack of pancreatic enzymes to digest fats Weight loss due to poor digestion Jaundice due to the damage to the common bile duct Dark urine due to excessive bile in the body Diabetes s/s due to insulin secreting cells NOT working ○ Labs: Monitor for hyperglycemia Elevated amylase (breaks down carbs to glucose) and lipase (breaks down fats) ★ Treatment for pancreatitis: ○ goal= rest the pancreas, maintain NPO status (esp. For acute!!) ○ Maintain IV hydration, TPN may be needed ○ Monitor blood sugar→ hyperglycemia ○ Monitor stools: oily/greasy/frequency? ○ Monitor daily weights, I&O  ○ Administer pain meds, NO morphine because it can cause spasms of the sphincter ○ Have them lean forward or sit up, NO supine ○ Give pancreatic enzymes before meals, if it has to be mixed with food put it in something like applesauce or something similar that is acidic Avoid mixing enzymes with alkaline foods like ice cream, milk, pudding because they can destroy the enzymes ○ Avoid alcohol, greasy & fatty foods, low fat, bland/small meals ○ Limit sugar and avoid refined carbs, increase complex carbs (fruits, veggies, grains) ★ Hypocalcemia - why do pancreatic patients have hypocalcemia. Fatty acids (calcium deposits sit in the abdomen and have an increase in albumin) malnutrition and fat necrosis. ○ Pancreatic patients can have fat malabsorption leading to fats binding to calcium that reduces the amount of calcium in the blood. ★ Insulin pump – gives a shot of insulin continuously to maintain blood sugar. ★ DKA: a complication of DM when the body does not have enough insulin to allow for glucose to be used as energy ○ Manifestations: ketones, fruity breath, Flu symptoms in pediatrics, Kussmaul respirations (deep, rapid breathing), nausea/vomiting, abdominal pain ○ Blood glucose over 250, increase in beta-hydroxybutyrate, pH over 7.3, and HCO3 equal/less than 15 → metabolic acidosis ○ Treatment: iV insulin with K+ Fluid replacement Correction of electrolyte imbalance Administration of bicarbonate for metabolic acidosis ○ 4 S’s for Risks: stress (surgery), sepsis, skipping insulin, and stomach issues (stomach virus) ★ Anion Gap ○ Provides an estimate of unmeasured anions in the blood (bicarb, chloride, phosphate, albumin) ○ Useful in determining the cause of metabolic acidosis ○ Anion gap= Na- (Cl+ HCO3) Normal should be positive (12 plus or minus 4) DKA results in an elevated anion gap ★ Metabolic syndrome ○ Cluster of risk factors for both cardiovascular disease and type 2 DM ○ Risk factors:  Resistance to insulin HTN High cholesterol or low HDL Hypercoagulability ○ Pt is considered to have metabolic syndrome if three of these traits are present: abdominal/central obesity Increased serum triglycerides greater than/equal to 150 Decreased HDL (600 and increased plasma osmolarity > 320, absence of ketosis, hypotension, and altered mentation (NO metabolic acidosis) ○ Risks: Inadequate fluid intake Decreased kidney function Infection Stress Older age ○ S/S: 3 P’s: polyuria, polydipsia, polyphagia Neurovascular changes (decreased LOC and headache) Stroke-like symptoms Dark orange, concentrated urine ★ Hypoglycemic – seizures, neuro, loss of consciousness, get them that sugar and juice. ○ plasma concentration of glucose 70 mg/dL or less, and the blood glucose level is insufficient to meet the demands of the cells of the body. ★ Hyperglycemia ○ defined by a fasting blood glucose concentration greater than 123 mg/dL, or when it exceeds 180 an hour or two after eating ○ Risk factors: lifestyle, certain steroid medications, illness/infection, chronic stress, insomnia, family Hx., not taking enough medication to manage type 1 or 2, improperly administering insulin, TPN, dextrose infusions, phenytoin, estrogens ○ If untreated it can lead to metabolic syndrome (the precursor to DMT2), if blood glucose levels become extremely high and persist it can lead to  coma, death, damage to blood vessels/nerves/tissues/organs, CAD, PVD, poor wound healing, etc ○ S/S: polyuria (excess urination), polyphagia (excess hunger), polydipsia (excess thirst), polyuria can cause fluid imbalance & the loss of sodium and potassium, this can cause further complications of hyperglycemia & hypovolemic hypotension, dry mucous membranes, low BP and fast HR ○ Client education: must have good sleeping habits, dispose of lancets appropriately, wear medical ID bracelet, how to monitor for hyperglycemia, when to check urine for the presence of ketones, collaborate with dietician ★ Hemoglobin A1C (HbA1c) ○ Blood test that provides information about the average blood glucose level over the previous 2-3 months. As the HbA1c % increases & decreases, it correlates with higher and lower estimated average glucose levels (Ex: 6%= 126, 7%= 154) ★ Type 1 diabetes ○ Used to be referred to as juvenile onset diabetes, insulin dependent diabetes, patient is experiencing hyperglycemia because they don't have the insulin needed to move glucose into the cells ○ Risk factors: genetics, autoimmune disorders, viruses such as mumps, rubella, toxic chemicals, cytotoxins ○ S/S: Polyuria, polydipsia, polyphagia Fatigue Weight loss Glucosuria ○ Diagnosis: Hemoglobin A1C, fasting blood glucose (no caloric intake for 8 hours), oral glucose tolerance test (OGTT: pt consumes something high in glucose after fasting for 8-12 hours), random blood glucose (> 200 is indicative of T1DM) ○ Treatment: requires the use of pharmacological interventions (discussed further down), nutrition management, patient education, self-management Assess vital signs & serum glucose Potassium levels (may be decreased) Intake & output Carbohydrate intake during meal Administer isotonic fluids ★ Diabetes type 2  ○ Used to be referred to as adult onset diabetes, becoming more common in children due to obesity & inactivity ○ Risk factors: BMI > 26, physical inactivity, HDL