Unit 4 Medical Notes PDF

**Unit 4** 1. **Gallstones**: a. **Dx:** i. **Endoscopic Retrograde Cholangiopancreatography (ERCP)** 1. **Procedure using fiberoptic technology to visualize the biliary system (gallbladder and biliary ducts)** 2. **NPO several hrs prior,...

**Unit 4** 1. **Gallstones**: a. **Dx:** i. **Endoscopic Retrograde Cholangiopancreatography (ERCP)** 1. **Procedure using fiberoptic technology to visualize the biliary system (gallbladder and biliary ducts)** 2. **NPO several hrs prior, receive moderate sedation** 3. **Post: s/sx of perforation and infection** ii. US, cholangiogram, laparoscopy, cholesterol levels (elevated), pancreatic enzymes (amylase and lipase), LFTs b. **S/s:** iii. Gallstones may be silent, producing no pain or mild GI s/s iv. Epigastric distress, fullness, abdominal distention, and vague pain in the RUQ (book) v. RUQ pain radiates to back/right shoulder, Biliary colic (pain, N/V after heavy meal) vi. Jaundice and pruritus, Changes in urine or stool color (steatorrhea, gray colored stool) vii. Vitamin deficiency, fat soluble (vitamins A, D, E, and K) c. **Physical examination:** referred pain to the right shoulder d. **Tx: laparoscopic cholecystectomy** viii. **Teaching:** 4. **Sitting upright in bed or a chair,** walking, or using a heating pad may ease the discomfort 5. May drive after 3-4 days if not taking narcotic pain relievers 6. Splint a pillow over abdomen while coughing and breathing deeply 7. If pain occurs in the right shoulder or scapular area, the nurse may recommend a heating pad for 15 to 20 minutes hourly. ix. **Post-op**: monitor for bleeding/infection, vital signs, education on a low fat diet x. **Complications**: peritonitis (monitor for temp, increase in pain), sepsis 2. **Pancreatitis**: e. **Patho**: Pancreatic duct becomes obstructed, and enzymes back up, causing auto digestion and inflammation of the pancreas f. **Cause:** gallstones, alcohol use, malnutrition g. **S/s**: Severe abdominal pain, abdominal tenderness, back pain, decreased peristalsis, N/V, fever, jaundice, mental confusion, epigastric pain, rigid or boardlike abdomen, ecchymosis in the flank area, and agitation h. **Plan of care:** xi. NPO, NGT (decompress the stomach/remove bile to avoid ulcer) xii. **Monitor:** Amylase and Lipase, VS, I's and O's (fluid and electrolyte disturbances) xiii. Improve breathing by keeping them in semi-fowlers b/c it decrease pressure on diaphragm xiv. Turn, cough and deep breath xv. Relieve pain and discomfort, improve nutritional status, maintain skin integrity due to bed rest xvi. **Education/discharge teaching:** avoid high-fat foods, heavy meals, and ETOH; utilize the teach-back methods i. Medications (is this it???): Pain relief may require parenteral opioids such as morphine, fentanyl, or hydromorphone (book) 3. **Cirrhosis**: j. **S/s:** xvii. **Compensated:** means that the liver is damaged but still functioning well enough to perform its essential tasks 8. s/s: abdominal pain, ankle edema, firm/enlarged liver, flatulent dyspepsia, intermittent mild fever, palmar erythema, splenomegaly, unexplained epistaxis, vague morning indigestion, and vascular spiders xviii. **Decompensated:** the liver can no longer perform its functions effectively 9. **s/s: purpura (purple or red splotches due to decreased platelet count)**, ascites, clubbing, mild fever, epistaxis, gonadal atrophy, muscle wasting, sparse body hair, spontaneous bruising, white nails, weakness, jaundice, weight loss, hypotension k. **Assessment/dx:** xix. **Labs**: increased AST/ALT, Ammonia, prolonged PTT, decreased albumin xx. Ultrasound, CT, MRI, liver scans l. **POC/nursing management:** xxi. **Provide skin care \[a lot of skin breakdown due to bile salts\]** 10. **Lotion may be used to soothe the irritated skin (minimize scratching by the pt)** xxii. Promote rest. Reduce the risk of injury xxiii. **Improve nutritional status: low sodium, moderate protein, high calorie,** small frequent meals 11. **Patients with prolonged or severe anorexia and those who are vomiting or eating poorly for any reason may receive nutrients by the enteral or parenteral route** xxiv. Manage potential complications: Bleeding, hepatic encephalopathy, fluid volume excess xxv. Education: quit drinking, infection prevention m. **Tx:** Transjugular intrahepatic portosystemic shunt (TIPS) is a method of treating ascites in which a cannula is threaded into the portal vein by the transjugular route n. **Medications**: xxvi. H2 antagonists: Famotidine, Pepcid xxvii. Vitamins and supplements, spironolactone (K sparing diuretics), Antifibrotics xxviii. Diuretics for ascites, lactulose for potential built up ammonia xxix. Paracentesis could occur if diuretics aren't working. 12. **Complication**: Circulatory collapse a. Use **albumin** to prevent this 4. **Hepatic encephalopathy:** o. Patho: Ammonia builds up as a result from profound liver failure/damage p. **S/s:** xxx. **Altered mental status, motor disturbances, mood swings,** asterixis, constructional apraxia, fector hepaticus (chronic bad breath due to liver failure) xxxi. **Early signs**: mental change and motor changes. Pt appears confused & unkempt & has alterations in mood & sleep patterns \[book\] xxxii. **Later signs**: difficult to awaken, completely disoriented to time & place. Eventually lapses into frank coma & may have seizures \[book\] q. Labs: serum ammonia r. Tx/meds: xxxiii. **Lactulose traps ammonia in the stool & eliminates it** 13. **Closely monitor for hypokalemia & dehydration** 14. Should have @ least 2-3 stools/day 15. The pt receiving lactulose is monitored closely for the development of watery diarrhea stools b/c it could indicate a medication overdose (book) 5. **Hepatitis B**: s. **Transmission: Blood, saliva, semen, vaginal secretions through broken mucous membranes & skin** t. **Risk factors, chart 43-7:** xxxiv. Close contact with carriers of hepatitis B virus. Hemodialysis. xxxv. Frequent exposure to blood, blood products, or other body fluids u. **Standard precautions** v. Immunity for Hep B: xxxvi. **Active Immunity: Vaccine** 16. For an exposed high risk population. Any pt with chronic liver disease xxxvii. **Passive Immunity: Immune Globulin \[HBIG\]** 6. **Liver disease, pg. 2576** w. **Patho:** Most blood coagulation factors are synthesized in the liver. Therefore, liver dysfunction (due to cirrhosis, hepatitis, and tumor) can lead to reduced amounts of the factors needed for coagulation and hemostasis x. **s/s:** patients may experience minor bleeding (e.g., ecchymoses) but are also at risk for significant bleeding, especially after surgery or trauma (these pts are at a high risk for death) 7. **Cancer:** y. **RF for cancer:** smoking, radiation, genetics, alcohol, obesity, environmental exposure, gender z. **External radiation therapy:** xxxviii. **Must be in exact same position for all treatment** xxxix. Care: maintain skin integrity \[radiation dermatitis\] 17. Appliances to shield normal tissue?? 18. Do not wipe off markings for external radiation therapy xl. Patho: killing rapidly dividing cancer cells (kills normal cells as well) xli. SE: N/V (radiation to abdomen), gastritis, stomatitis 19. Tx of stomatitis: NS rinses, viscous lidocaine/swish-and-spit solution, soft foods to help with appetite, tepid foods, supplements (protein shakes, smoothies, puddings) 20. **Meds: Corticosteroids, phenothiazines, sedatives, and antihistamines (benadryl)** a. **Internal radiation therapy/Brachetherapy:** xlii. High dose radiation for short period of time OR Low dose over extended period xliii. **Source of radiation is placed within pt** 21. **Since the pt is radioactive, visitors are limited** 22. Soluble isotopes -- ingested or injected 23. Implanted sources of RT b. Seeds/beads -- prostate, cheek, cervical i. Stay in place but eventually loses its radioactivity c. Needles -- tongue; Rods -- brain; Cervical implant xliv. **Education: no children can visit, no prepregnant people, nurse can only come in so many times a day + limit visitors = 30 min time limit, stay 6 feet away from patient** xlv. **Nurses should be wearing dosimeter badges.** b. **Lab values drop with cancer:** xlvi. All cells lines (pancytopenia) xlvii. Meds to help with this: colony-stimulating factors (filgrastim) 8. **Palliative VS Hospice** Pg. 1117 c. **Palliative Care**: uses an interdisciplinary model of care, **focusing on symptom management and psychosocial/spiritual support** for those with serious, life-limiting illnesses \[book\] - Palliative care: a philosophy of care and a system for delivering care for a pts with a life-threatening illness - Goals: Identify pts/families' goals of care. Assist with informed decision making; Facilitate quality symptom management - S/s management (pain, dyspnea, anorexia, hydration, anxiety, delirium, depression) - When to call the palliative care consult team? - Anytime you have a chronic condition OR new condition, when you need to discuss goals of care and when you need s/s management in outpatient care setting - **Hospice Care**: type of palliative care, **focusing on comfort at the end-of-life** - All hospice care is palliative care - Focus is on quality of life and includes realistic emotional, social, spiritual, and financial preparation for death. Goal is for the pt to remain at home - End of life care - Once they agree to go on hospice care, they give up any curative tx - Less than 6 months to live 9. **Shock** d. **Causes**: hypovolemic, cardiogenic, sepsis, anaphylactic, neurogenic e. **Stages** xlviii. **Compensatory/initial: compensation** 24. **S/s:** normal BP, tachycardia, tachypnea, cold & clammy skin in peripheral & warm centrally b/c shunting blood 25. Care: ABC, fluid IV, O2, monitor xlix. **Progressive \[decompensating\]** 26. **S/s:** Hypotension, increased HR \> 150, increased RR \[rapid & shallow\], crackles, pulmonary edema, arrhythmias, ischemia, mottling, petechiae, lethargy, metabolic acidosis, declining mental status, jaundice, GI ulcers 27. **Care**: vasopressors \[MUST have full tank/fluid FIRST\], blood transfusion/platelet, preventing complications, promote rest & comfort, support family members 28. **Labs**: lactic acid, ammonia \[possibly\], ABGs, CBC w/ diff, CMP l. **Irreversible** 29. **S/S: Worsening metabolic acidosis, pulmonary dysfunction leads to respiratory arrest & cardiac arrest.** Tachypneic, rapid shallow respirations, crackles, atelectasis, pulmonary edema, skin is cool and clammy, petechiae, shunting, acute lung injury, progressive kidney injury anuria, poor cardiac perfusion f. **MODS**: li. At least 2 or more organs failing lii. **s/s** \[pg. 940\]: dyspnea and resp failure, hyperglycemia, increased BUN liii. **Management**: early detection, control the initiating event, promote adequate organ persuasion, providing nutritional support, and maximizing pt comfort liv. **Education** 30. Preventing further infections/injury. 31. S/s to monitor. 32. Continuing/transitional care 33. Long-term care facility/rehab. 34. Hospice/End of life g. **Cardiogenic shock:** lv. **Patho:** Failure of the heart as an effective pump when blood volume is adequate. Supply of O2 is inadequate for heart & tissues. lvi. Decreased cardiac contractility → **decreased stroke volume and CO** → pulmonary congestion, decreased systemic tissue perfusion, and decreased coronary artery perfusion lvii. **MC:** Myocardial infarction lviii. **S/sx:** tachycardia, hypotension, oliguria (\< 30ml/hr), cool clammy skin, tachypneic lix. **Stop further myocardial damage and preserve the healthy myocardium to improve cardiac function.** Correct underlying cause lx. **Treatment/Plan of care: fluids, mechanical assistance/intubation, 12-lead ECG** 35. O2, pain, hemodynamic monitoring (lab markers), medications, enhance safety and comfort, 36. **Morphine**, **oxygen, dobutamine** d. Aspirin, nitroglycerin e. **Watch for arrhythmias when administering these meds** f. **May need dopamine for BP, norepinephrine/levophed** g. Nitro + Dobutamine can go together. IV Morphine vasodilates and may decrease anxiety 10. **Delegation is key** **Important information NOT in the study lab:** 11. **Eyes/Ears:** h. **Cataracts Pg. 5080** lxi. Patho: Opacity of the lens that distorts images projected onto the retina. Can progress to blindness i. **Glaucoma Pg. 5065** - **Increase intraocular pressure due to inadequate drainage of aqueous humor (AH) or overproduction of aqueous humor.** - Needs to be treated or it can cause blindness - Treatment: The goal is to prevent damage to the optic nerve by reducing IOP. - Miotics (cholinergics): constrict pupils & improve outflow of aqueous humor: - **Pilocarpine, carbachol** - **S/E: cholinergic side effects (blurry vision, headache, N/V, sweating, abdominal cramps, diarrhea)** - Medications to decrease production of aqueous humor: - Carbonic anhydrase inhibitors -- **Acetazolamide** - Beta blockers -- **Timolol maleate** - **S/E: bronchospasm, bradycardia, hypotension** j. **Macular Degeneration Pg. 5103** - **Patho: a disease that causes gradual vision loss in the center of the eye** - **Can cause blindness** k. **Retinal Detachment Pg. 5098 EMERGENCY** lxii. Separation of two layers of the retina causing vitreous humor seeps between the layers and detachment of the retina from the choroid l. **Meniere's Disease** - **Patho: An increased amount of inner ear fluid** m. **Acoustic Neuroma** - Patho: slow-growing, benign tumor of cranial nerve VIII