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Adult.Med. Surg.

Adult I Final

Hyperthyroidism Lab Results  TSH and TRH- decrease  T3-T4- increase  Thyroid uptake of radioiodine- increase  BMR- increase  WBC count- decrease (caused by deceased granulocytosis)
Hypothyroidism Lab Results  TSH and TRH- increase  T3-T4- normal to low  Thyroid uptake of radioiodine- decreased  Elevated cholesterol, lipids, protein
Hyperparathyroidism Lab Results  Calcium- increase  Phosphorus- decrease
Hyeperthyroidism Subjective Data Everything is HIGH--• Nervousness, mood swings, palpitations, heat intolerance, dyspnea, weakness, lack of sleep
Hyperthyroidism Objective Data exopthalamos,stare, lid lag•Skin:warm, moist, velvety, >sweating, edema,thickened skin,hyperpigmentation•Weight:loss, >appetite•Muscle:Weakness, tremors, hyperkinesias•Vitals:>BP, tachycardia•Goiter:noticeable and palpable•GYN: abn. menstruation•GI: frequ
Hypothyroidism Subjective data •Weakness, fatigue, lethargy, HA, Slowed memory, psychotic behavior, loss of interest in sexual activity
Hypothyroidsm Objective Data < BMR, cardiomegaly, bradycardia, hypotension, anemia GYN: menorrhagia, amenorrhea, infertility Skin: dry skin, brittle nails, coarse hair, hair loss, slowed speech, hoarseness, thickened tongueWeight: gain r/t edema, periorbital puffy, cold intolerance
Hypothyroidism Subjective data •Weakness, fatigue, lethargy, HA, Slowed memory, psychotic behavior, loss of interest in sexual activity
Hypothyroidsm Objective Data < BMR, cardiomegaly, bradycardia, hypotension, anemia GYN: menorrhagia, amenorrhea, infertility Skin: dry skin, brittle nails, coarse hair, hair loss, slowed speech, hoarseness, thickened tongueWeight: gain r/t edema, periorbital puffy, cold intolerance
Parathyroid assessment characterized by... • Bone resorption causing osteopenia and bone pain • Renal calculi • GI symptoms • Dysrhythmias • Weakness, fatigue • Psychomotor/behavioral disturbances
RN care for hyperthyroidism  Protect from stress: • Private room, restrict visitors, quite environment Promote physical and emotional equilibrium: •Have a quiet, cool well ventilated environment.
RN care for hyperthyroidism (2) • Eye care by patches, shields, lubricant (methylcellulose), sunglasses. • High calorie, high protein, high vitamin B diet with 6 meals per day, daily weights and avoiding stimulants (coffee, tea, tobacco).
RN care for hypothyroidism  Provide comfort and safety: • Monitor for trauma or infection • Provide warmth, prevent heat loss • Administer thyroid medications as ordered
continued hyperthyroidism health teaching Prepare for additional treatment as needed •Radioactive iodine therapy (to decrease thyroid activity)- dissolve in water,give PO. Hospital necess. when lg dose is admin. Effectiveness seen in 2-3wks. Monitor s/s of hypothyroidism.•Thyroidectomy
Health teaching for hypothyroidism •Low-cal, high protein diet. Monitor s/s of hypo/hyperthy. •Teach about life-long meds (dosage, desired effect and SE). Medication adjustment (take 1/3 to ½ of usual dose of narcotics and barbiturates). Stress-mgmt techniques, exercise program.
hyperthyroism health teaching  Stress reduction techniques  Importance of meds (desired and SE)  Methods to protect eyes  S/S of thyroid storm
Hyperthyroid medication TPU, Tapazole, Lugol's solution or SSKI (iodine preps) et Propranolol
continued hyperthyroidism health teaching Prepare for additional treatment as needed •Radioactive iodine therapy (to decrease thyroid activity)- dissolve in water,give PO. Hospital necess. when lg dose is admin. Effectiveness seen in 2-3wks. Monitor s/s of hypothyroidism.•Thyroidectomy
Blocks thyroid synthesis; hyperthyroidism returns when therapy is stopped. Can effect WBC production, monitor closely (5000-10000 Normal range). PTU
Hyperthyroid medication TPU, Tapazole, Lugol's solution or SSKI (iodine preps) et Propranolol
Blocks thyroid synthesis; hyperthyroidism returns when therapy is stopped. Can effect WBC production, monitor closely (5000-10000 Normal range). PTU
Used in combo with above medications when hyperthyroidism is not well controlled. Give through a straw to prevent staining teeth. Dilute in water, milk or juice to make more palatable. SSKI or Lugol's solution
Inhibits thyroid hormone synthesis. Can effect WBC production, monitor closely Tapazole
Used in combo with above medications when hyperthyroidism is not well controlled. Give through a straw to prevent staining teeth. Dilute in water, milk or juice to make more palatable. SSKI or Lugol's solution
 To relieve symptoms such as tachycardia, tremors, and anxiety. propranolol
Hypothyroid medication Synthroid et Cytomel
most common thyroid medication synthroid
Dose adjusted according to symptoms  Dosage adjustment: take 1/3 to ½ usual dose of narcotics and barbiturates cytomel
Hyperparathyroidsm medication Oral Phosphatase Restrict dietary Ca NS- give IV
Dose adjusted according to symptoms  Dosage adjustment: take 1/3 to ½ usual dose of narcotics and barbiturates cytomel
Hyperparathyroidsm medication Oral Phosphatase Restrict dietary Ca NS- give IV
Partial removal of thyroid gland (for hyperthyroidism) or total removal (for malignancy of thyroid). Thyroidectomy
Skin Changes in elders  Loss of sub-q tissue  Decreased elasticity or turgor  Loss of melanocyte  Increased capillary fragility  Decreased perspiration  Hormonal changes  Hyperpigmentation in exposed areas
More changes of skin in elders  Hypopigmentations in general areas  Decreased skin moisture  Senile lesions  Hair thinner on head and body  Brittle, thickened nails with longitudinal ridges
Pruritis RN Care  Apply topical keratolytic agents  Occlusive wraps and wet dressings  Coal tar or anthralin therapy  Photochemotherapy  Teach  Avoid skin trauma  Shampoo frequently
Bacterial infection RN care  Warm moist dressing to bring boil to head  Isolate drainage  Systemic antibiotics  Wound isolation if hospital  Separate bath linens  Avoid squeezing
Eye Assessment (Abbreviations for Right et Left eye) o Assess for severe pain or pressure o OD- right eye o OS- left eye (think left hand of God, sinister)
 Detachment interrupts transmission of visual images from retina to optic nerve causing progressive loss of vision and eventually blindness retinal detachment
s/s of retinal detachment flashes of light, floating spots, NO PAIN
Tx of retinal detachment Remove accumulated fluid. Avoid coughing and bending over which will increase pressure
 Obstruction to drainage of aqueous humor. Increased intraocular pressure causing damage to the optic nerve and progressive loss of vision. glaucoma
Most common. Obstruction in the trabecular meshwork. open angle glaucoma
s/s of glaucoma Slow loss of vision, halos around lights, persistent dull eye pain, HA, tunnel vision
Tx of glaucoma (meds/surgery)  Meds: miotics, carbonic ahydrase inhibitors, beta blockers  Surgery: trabeculectomy, trabeculoplasty
Acute, angle closure. Outflow impaired due to closing angle between iris and cornea. Can be an emergency narrow angle glaucoma
s/s of narrow angle glaucoma – SEVERE PAIN. Enlarged/fixed pupil. Halos around light. Red eye. Permanent blindness if increased IOP for 24-48h.
Tx of narrow angle glaucoma (meds/surgery)  Meds: osmotic diuretics, mitics, carbonic anhydrase inhibit  Surgery: peripheral iridectomy/iridotomy. Avoid activities that increase IOP.
 Altered metabolism and movement of nutrients within lens. Pupil becomes gray to milky white. cataracts
early s/s of cataracts clouding of lens, late: radual painless blurring vision and eventual loss of site.
Tx of cataracts o Treatment  Surgery: cataract removal with intraocular lens implant
Eye patient teaching/care oAvoid activities that increase IOP (coughing, bending over, heavy lifting) Assist with ADL’s and gradually resume over 1-2 wks oUse eye drops, shields, patches oPosition on back or unaffected side oPermanent blindness if increased IOP for 24-48 hrs
Musculoskeletal inflammatory PREVENTION: EXERCISE
inflammation of bursa bursitis
s/s of bursitis pain, limited motion, edema, redness
Tennis elbow or inflammation of the tendon epicondylitis
Epicondylitis/Bursitis care • Restrict activity • Cold app x24hrs, the heat • NSAIDS • Corticosteroids- x 3 at most
Decreased bone density increased fx risk for these pts. 1:4 have it osteoprosis
risk factors for osteoporosis • Female • Low Ca+ intake • + family hx • Increased caffeine use • Surgically induced menopause • Lack of wt bearing exersice
s/s of osteoporosis • Fx with minimal trauma • “dowgers hump” weakened vertebrae • Sig. loss of height
prevention/tx of osteoporosis • High Ca+ diet • Reg exercise • Supp. Ca+ 800mg (Ca+ citrate is best) • Vit D with Ca+ • Rx: Boniva or Reclast
bone infection, staph aureus most common. osteomyelitis
s/s of osteomyelitis red, warm, swollen, pain, PURULENT DRAINAGE is open, leukocytosis
osteomyelitis RN care • IV abx • Surgical I&D with debridement • Sterile warm saline soaks • MOST IMPORTANT TO HAVE PATENT IV LINE
Lateral curve of spine from midline, can be “S” or “C” shape scoliosis (restrictive disorder)
Scoliosis corrective surgery Harrington Rods( video we saw) This is unilateral Cortel-Dubousset- this is rod bilaterally
Scoliosis Patient teaching - Considerations: don’t touch back may have increased pain - Good preop teaching esp cough/deep breath - Post op- early ambulation - Usually up in chair first day - Good neuro checks of ALL extremities
Fracture complications Fat embolism et compartment syndrome
usually long bone fx, release of fatty bone marrow, will be put on anti-coag tx to decrease the risk of this; can cause a PE fat emboli
fluid builds up in sm spaces; Faciotomy is possible of not controlled compartment syndrome
Assessment of fractures • Hx of injury • Degree of pain • The five P’s: Pain, Pallor, Pulse, Parenthesis, Paralysis • Deformity in extremity • Swelling • Discoloration
Managment of fractures 1 Analgesics • Splinting • R.I.C.E- Rest-Ice-Compression-Elevation • Neurovascular check(CMS) o Color o Temp o Swelling o Peripheral pulses o Cap refills o Sensation o Mobility
Cast care • Handle with palms • Support with pillows • Assess skin for breakdown • Do not dry with heat (can burn pt) use cool fans
Describe the three types of reduction • Closed- manual mngmt •O.R.I.F: (pins, plates, screws and wire) •External Fixation: This is pins screws, ect….above and below the fx but are attached from the outside of the skin o Increased risk for infection with this
Pulls bone fragments apart and allows realignment. Also [prevent limb rotation AND immobilizes joint. traction
- usually uses body weight, with balance suspension, increase by elevation FOB contraction
Direct pull. Extremity supported is splint held with balanced counter weights balance suspension
Fracture RN care -Make sure weights hang free, knots secure/free of pully -Inspect skin (LOOK AT HEELS) -Wts must remain constant ( DON’T REMOVE) -Assess for complications; hypostatic pneumonia, constipation) #1 concern
fx occure near but outside the joint (intertrochanteric) extracapsular hip fracture
fx occurs within the joint surface (Femoral neck) o A-vascular necrosis will happen with this break. intracapsular hip fracture
s/s of hip fracture o Pain o Shortened leg o Abduction
Hip fracture pre-op o Bedrest o ANALGESICS o HOB at 45 degree angle
Hip fracture post-op o Prevent external rotation o Maintain abduction ( pillows abductor pillows, ect.) o DO NOT CROSS LEGS o AVOID SEVERE HIP FLEXION o Less than 90 degrees….DO NOT LEAN FORWARD! o Out of bed on operative side of bed
Describe degenerative joint disease o Degenerative joint disease- disc dehydrates and crumbles
Tx for degenerative joint disease o NSAIDS, muscle relaxants, and analgesics o Surgery: Laminectomy. Discectomy, Fusion( decreased mobility)
Back surgery RN care o Logroll…make sure you have more than one person to roll pt o Neuro checks to extremities
Upper et lower extremity surgery o HOB- down 24-48 hrs o A.P.C.- Arm Pit Care—keep very dry, (use ABD pad is needed)
resurfacing one or both sides of joint o Hip o Knee o Shoulder arthroplasty
Respiratory general assessment o Dyspnea (DOE, dyspnea on excertion) o Cough- most common symptom of resp disease o Sputum production o Chest pain o Adventitious lungs ***effectiveness measured by ABG, best way to measure oxygenation
What are the types of low flow O2 systems? o Cannula- most common, 1-6L, o Simple face mask- 3-6L o Partial Rebreather
get sample early morning before breakfast, prior to antibiotics, deep from lungs and in a sterile container, C&S done sputum test
NPO until gag reflex has returned, postop: monitor for signs of laryngeal edema or laryngospasm (stridor (high-pitched sound) & dyspnea) bronchoscopy
insertion of needle into pleural space, done to draw out fluid, place on unaffected side thoracentesis
isotope injected into peripheral vein, measures blood perfusion through lung and looks for PE lung scan or ventilation perfusion scan
common cold Nasal discharge, sneezing, edema(irritation) HA, Contagious 2-3 days after sx. rhinitis
Rhinitis RN care common cold Nasal discharge, sneezing, edema(irritation) HA, Contagious 2-3 days after sx.
blockage of sinus passages sinusitis
s/s of sinusitis - HA, pain and tenderness over sinus - Stuffy nose - Possibly purulent drainage
Dx of sinusitis o X-ray or MRI
Sinusitis RN care oPromote drainage- moist air, decongestants, increase fluids ocontrol infection- hand washing, take meds as prescribed oPain relief (positioning, moist heat over sinuses, analgesics) o
Sinusitis Patient Teaching Teaching: • Avoid cold places • Keep environment same temp always • No smoking • Get rest • Inform dentist prior to tooth extraction
Sinus surgery Post-Op oCk for posterior packing.mouthcare is vital,soft toothbrushoHOB 30-45ospit out drainage…DO NOT SWOLLOW.air with O2 (15L)oMonitor for excess bleedingoNo oral tempoChg nasal drip pad PRN, inc fluidsoPacking comes out after 24-48 hrs
Sinus surgery teaching o Don’t blow nose for 48 hrs o Report s/s of infection o Expect tarry stools from swallowing blood o Avoid straining o Takes meds as prescribed
infection/inflammation of lung tissue can be bacterial, viral, fungal pnemonia
s/s of pneumonia o Cough early sign persistent and painful (pleurisy) o Dyspnea o Wheezing/crackles o Chest pain- usually d/t pleurisy o ABG’s are off….decreased O2(hypoxia) decreased CO2(hypercapnia) o Elevated WBC
Foul smelling sputum is indicative of pneumonia, what about the colors? o Yellow- staph o Green- pseudomonas o Rust- klebsiella
Pneumonia RN care oMeds as Ordered, id bacterial give abx ( levofloxacin, z-pack) if mycoplasma take oCorticosteroids- decreaseinflammationoBronchodilatorsoAnalgesics.antitussive.oCDBopromote drainageoForce fluids- 2-3L/dayoIncrease protein/CHO for healing oFreq sm meals
6-1.2 0-25% nephron loss 2X baseline 50% nephron loss, STAGE 1 kid failure 8X baseline 75% nephron loss, STAGE 2 kid failure- edema/other signs of “renal insufficiency” 10 >baseline 90% nephron loss, STAGE 3, E.S.R.F. dialysis needed!!! Creatinine GFR
Renal labs BUN: 8-23---end of protein metabolism Creatinine- 0.6-1.2---MOST SENSATIVE KIDNEY TEST, end production of muscle metabolism
1. ↑ both or ↑creatinine with ↓BUN …Indicates kidney disease 2. ↑BUN only …indicates “prerenal” BUN/Creatinine Ratio
increase risk for kidney issues o Atherosclerosis causes decreased renal bld flow o 40% glomeruli at age 70 and 46% by age 90 o ↓ ability to concentrate urine, ↓sensitivity to ADH o Increased risk of electrolyte imbalance renal changes c age
cysts form within the nephron, slow progression, eventually leads to renal failure..trasplant will be needed, congenital inherited disorder 1) infantile: autosomal recessive, VERY RARE 2) Adult autosomal dominant, MOST COMMON polycystic disease
s/s of polycystic disease o Commonly seen in 40’s o Abd or flank pain o Hematuria, polyuria, protenuria o HTN major problem o Recurrent UTI o Knobby kidney o Can be one or both sides
tx of polycystic disease o Symptomatic o When bleeding put on bed rest while sx are still going on
Polycystic Rn care o Analgesics o Teach s/s of infection o Get genetic counseling
renal calculi o Urolithiasis- urinary stone o Most common form in kidney o Ca+ is the most common mineral
s/s of renal calculi o PAIN o N/V o Hematuria o Have to have an IVP done to dx that it really is a stone
Medical Tx of renal calculi LITHOTRIPSY o Extra Corporeal Shock Wave Lithotripsy (ESWL)- done as out pt. o Breaks stone into grains of sand o Shock wave sent through bag of water, timed with EKG
Post Op of lithotripsy PAIN RELIEF, force fluids(3-4L/day), strain urine and look for stone pieces  Inform pt that bruising is normal at site where waves were applied
name two types of urinary surgeries o Nephrostotomy- cath into kidney o Nephrectomy- when remove kidney, watch UOP carefully, hemorrhage, other kidney is functioning, daily weight
Rn urinary surgery care o If allowed force fluids o Urine output q 1-2- hrs owt and I&O…look at color and consistency (1 lb. weight = 500 ml) oMaintain patency of tubes oNever clamp or irrigate without Dr. order specific gravity, bun, creatinine ocreatinine clearance
o Asparagus o Beets o Black tea o Chocolate o Dried figs o Ground pepper o Poppy seeds o Spinach o Swiss chard o Nuts foods high in oxalic acid, avoid if having calculi issues
contains amino acids, concentrated dextrose electrolytes, vit and minerals..also may contain lipids TPN
RN indications for TPN o Always given through central line o Monitor BS…may need insulin while on TPN because of concentrated formula o Monitor fluid balance o Always on a pump never a push
RN indications for TPN part 2 o Always filtered (0.02 micron) o If using Lipid formula make sure you use 1.2 filter…0.02 will clog o When changing it always use sterile tech. o If given peripheral….change site often will cause phlebitis!!
o 10meq/100ml/hr will be the most concentrated dose o K+ is always given in a lg amt of fluid K+!!!! NEVER give DIRECT IV!
Disturbance of normal blood flow, lack of O2 to tissue, accumulation wastes and fluid, tissue ischemia with eventual necrosis and gangrene. PVD
s/s of PVD o intermittent claudication (pain during exercise) o rest pain o coolness and pallor of extremeties o rubor (redness) o cyanosis o trophic changes (muscle changes) o leg ulcers and cellulitis
PAD s/s (arteriole) o decrease or absent pulses o trophic changes o cool skin temp o ulcers on pressure points of feet o leg skin color blanched when increase and dusky red when decrease o pain (intermittent claudication) o decrease sensation
PVD s/s (venous) o dilated superficial veins o aching muscle pain with legs dependent (night cramps) o edema o dependent cyanosis o brown skin discolorations (hemosiderin) o ulcers of lower legs and ankles
PAD care Arterial • Do not cross legs • Do not put legs above heart • Encourage moderate amount of walking (followed by rest) • Increase HOB (reverse tranlenenburg) • Sit with feet on floor
PVD care Venous • Elevate extremity above heart • Discourage standing/sitting long periods • Encourage moderate amount of walking (followed by rest) • For bedrest clients, increase foot of bed
o Maintain warmth/avoid chilling (gloves/socks) o Don’t apply heat directly to skin o Avoid smoking o Avoid stress o Avoid constricting clothing o Avoid crossing legs o Administer vasodilator drugs and adrenergic blocking agents promote vasodilation/prevent vascular compression
relieve PAD/PVD pain o Positioning (promote increase circulation) o Analgesics
maintain tissue integrity c PAD/PVD o Avoid trauma o Wash extremities with antibacterial soaps to keep the growth of bacteria from occurring. o Promote good nutrition o Good foot care o Exercise o Avoid smoking o Check with HCP before taking any medication
Deficiency in Hgb, Hct and RBC…Causes hypoxia anemia
depression or cessation of all blood-forming elements in bone marrow. Injury or destruction of common stem cell. aplastic anemia
abnormal destruction of hemolysis of RBC at such a rate that bone marrow is unable to compensate- jaundice can occur from chronic RBC hemolysis in the spleen. acquired hemolytic anemia
•Vitamin B12 is essential for RBC synthesis and peripheral nerve conduction. • B12 is a water soluble vitamin. • Cause: insufficient amount of B12 available or absorbed from GI tract or inadequate amount of stomach tissue to produce the intrinsic fac Pernicious Anemia/megaloblastic anemia
blood loss of 1000ml or more hemorrhage
s/s of hemorrhage shock:pallor, cold, clammy, thirsty, restless, ↑pulse, ↑RR, ↓BP
Tx of hemorrhage stop bleeding, restore blood loss (IV fluid, plasma expanders, packed red cells), give O2 for hypoxia, vasopressors (to increase circulation to vital organs)
Alternate rest with activity to balance oxygen supply and demand. *Protect from infection and bleeding hemorrhage RN care
Normal Values of CBC Red Blood Cells: 4.5 in women and 5.5million/cubic ml for men White Blood cells: 5000-12000 Platelets: 200,000-350,000 Hgb: 12-16 women, 14-18 men Hct: 35-50% women, 40-55% men (3x the Hgb value)
fever, tachycardia, vomiting, hypotension, dark red urine, chill, rigor, pain in chest, back, arms, fullness in chest, anxiety, urticaria, nausea, ha, burning sensation at site of infusion, generalized bleeding, anuria/oliguria, shock. transfusion reaction
Prior to transfusion, pt/RN role • Must have signed consent to administer blood • 18 gauge catheter for IV • Use ONLY normal saline (0.9%NaCl) • Colloid solution used as a volume expander to replace acute bld loss- Plasmanate Solution
Transfusion implications continued... • VS before administering blood • Blood must be infused in 3hours or less • Verify with another staff member between recipients are band and blood bag. (hospital #, name, unit # on bag, ABO group, RH type) • Infuse at slow rate for first 15 minutes, no
transfusion implications continued • Tubing should not be used for longer than 6 hours (can be used for more than one unit of blood) • If hemolytic reaction (shock) occurs, stop blood et start NEW normal saline bag. S/S: tachycardia, tachypnea, chills, and low back pain shortly after tra
HTN ranges Prehypertension: 120/80-139/89 Hypertension Stage 1: 140/90 Hypertension Stage 2: 160/90
HTN drug therapy loop diuretics (watch k+levels), adrenergic inhibitors, vasodilators, angiotensin converting enzyme inhibitors (ACE inhibitors), calcium anatagonist
HTN factors (occupation, changes in electrolytes, personality type, illnessdiabetes) •Smoking constricts blood vessels asymptomatic (dizziness, elevated BP, changes in arterioles in retina, brain, kidney, symptoms indicate vascular damage)
Patient education for HTN decrease salt and fat intake, weight reduction, increase ambulation slowly, exercise, no alcohol or smoking, stress management, take meds as ordered everyday. off meds it will cause rebound HTN (catapres, wytensin, tenex)
Rn care for HTN o Assess patients beliefs and knowledge of HTN o Monitor BP and pulses o Obtain history related symptoms o Knowledge of risk factors o Compliance (meds may cause erectile dysfunction)
• Direct visualization of the lining of the esophagus, stomach and duodenum with a fiberoptic scope EGD
Pre-op of EGD NPO after midnight, written consent, possible premedicate
Post-op of EGD NPO until gag reflex returns, monitor VS, monitor for dyspnea, dysphagia, abdominal pain, fever, bleeding
• Fluoroscopic visualization of structure and function of esophagus, stomach et small bowel • NPO after midnight • Monitor stools after • Possible laxative • This test is done after the EGD Barium swallow
RN tube care feeding tubes, gastrostomy, percutaneous endoscopic gastrostomy tube (PEG)
elevate HOB 35 degrees, decrease rate as needed, check for residual regurgitation c aspiration
always check tube placement before instilling anything tube dislodgment
flush before and after with 30ml NS and q4h if continuous tube obstruction
check residual 2x 1 hour apart, if > 100-150ml, may need to slow rate or amount of feeding abdominal distention
Tube Care RN implications • Nausea • Bacterial contamination • Dehydration • Diarrhea – may give ½ strength preparations • Hyperglycemia • Skin care important
• Difficulty swallowing (fluids are more difficult than solids) dysphagia
s/s of dysphagia drooling, inability to swallow, regurgitation – foul odor, esophageal diverticulum. May be seen several hours after eating while sleeping when body horizontal
nursing care of dysphagia supervise closely, have patient concentrate on swallowing, try double swallowing, use feeding syringe, have suction equipment available, leave HOB elevated
• Acidic gastric contents reflux back in to the lower esophagus • Caused by abdominal pressure (overeating), or reduced esophageal sphincter pressure (tone) GERD
s/s of GERD heartburn may resemble chest pains of an MI
GERD Rn care teach patient to eat small frequent meals high in protein and low in fat, remain upright for 1-2 hours after meals • Sleep with HOB elevated 6-10 inches • Avoid smoking, heavy lifting and bending over • Avoid caffeine and alcohol
GERD Meds • Antacids 1-3 hours after meals • Histamine – 2 blockers (decreases gastric acid content 90%) Tagamet, Zantac, pepcid • Proton pump inhibitors• Raglan – increases lower esophageal sphincter tone and enhances peristalsis to promote stomach emptying.
• Inflammation of gastric/duodenal mucosa, small hemorrhages and erosion of mucosal lining. peptic acid disease
Peptic Acid Disease RN teaching • Eat small frequent meals • Avoid foods that make symptoms worse; have client start a journal • Pain • Perforation into vessel or through wall • Destruction of mucosal lining: NSAIDS (aspirin) • Corticosteroids • Alcohol
Peptic acid disease RN teaching part two • Some antibiotics • Backflow of bile/pancreatic juices • Viral or bacterial infection (h. Pylori) • Smoking, caffeine, stress can increase gastric acid secretion
medications for peptic acid disease 10 days–12 wks flagyl, amox 2-3 wks, pepto 4-6wks.Antibiotics.PPIsdecrease acid secretion.H2 receptor antagonist blocks acid secretion.Coating agents sucralfate 30 mins before they eat.Antacids (neutralize acid) – after they eat 1-3h.Anti-emetics – raglan
What would you use for gastric decompression? salem pump tube
o Intermittent or continuous o Maintain patency/suctioning o Assess: drainage, distention, NVirrigate with air/NS (DO NOT USE TAP WATER, COULD CAUSE ELECTROLYTE IMBALANCES) o HOB 30-35 degrees to prevent aspirations o Assess nasal mucosa salem pump tube
24-48 hours after stressful event  severe burns H2 blockers given before or after GI surgery Cushings ulcer – greatly increased gastric hyersecretion. CNS related stress ulcers
Ulceration esophagus, stomach, duodenum Decreased resistance of mucosa to acid Discomfort with eating, anorexia, wt loss, gastric ulcers
Increase acid secretion, increase gastric emptying Epigastric pain when stomach is empty, pain goes away with eating, pain may radiate to scapula (because of vagus nerve) peptic (duodenal)ulcer
where is the most common place for ulcers? duodenum
Ulcer RN care o Small freq meals (avoid overdistention) o Avoid food that make it worse, smoking o Assess effectiveness of meds (antacids, proton pump inhibitors, h2 blocker, sucralafate) o Avoid meds that irritate mucosa (NSAIDS, ASA) o Avoid alcohol
o Increase in white blood count o Sudden, sever pain o Muscle gets rigid (abdomen is like a board) o Decrease BP, increase RR, increase HR complication of ulcers that is a perforation of posterior wall or hemorrhage of anterior wall
Post op of surgery from ulcer complications o Monitor NG tube drainage – DO NOT IRRIGATE WITHOUT DR. ORDER, no fresh blood after 12 hours, maintain ordered suction, maintain patency o Monitor Bowel sounds – turn off NG suction to listen SHOULD BE NO BOWEL SOUNDS FOR FIRST 48 HOURS AFTER SURGERY
Post op of surgery from ulcer complications part two dumping syndrome – stomach dumps large amt of hypertonic solution (high CHO) into jejunum, pulling H20 from blood, causing abd cramping, weakness, feeling of fullness, NV, tachycardia, sweating. occurs 5-20 mins after eating and lasts up to an hour.
Post op of surgery from ulcer complications teaching o Teach patient to have a low CHO high fat diet (slows digestion) and high protein (stomach digests) o No fluids with meals o Small freq meals
Post op of surgery from ulcer complication part three o Remain recumbent half hour after eating o Anticholinergic drugs may help (Probanthine) DON’T GIVE OPIOIDS FOR GAS PAINS
o NPO, AMBULATION!!!, may need NG tube suction o Reglan increases peristalsis. paralytic ileus
tumor, adhesions, perforation, mesenteric thrombosis, volvulus (twisting) o Everything above affected area is distended, and hyperperistalsis bowel obstruction
s/s of bowel obstruction o NV (may vomit feces), no BM, abdomen is firm et distended, tympanic bowel sounds. Bowel sounds are decreased or absent below obstruction
Tx for bowel obstruction o Surgery to relieve obstruction. May have temporary colostomy for healing. NG suction, NPO UNTIL BOWEL SOUNDS RETURN, monitor BS carefully!
Small out-pouchings of intestinal mucosa through defects in muscular wall of colon o Sigmoid most common. o Related to stress, obesity, dietary fiber intake. Could also be autoimmune diverticulosis
s/s of diverticulitis LLQ pain, constipation alternating with diarrhea, fever, leukocytosis, hurts to eat, so they may become malnutritioned.
o Bowels may leak into peritoneal cavity bowels are not sterile, but the cavity is, so if there is a leak then peritonitis may occur et S/S of infection will develop diverticulitis
Tx for diverticulitis antispasmodics, antibiotics, high fiber diet, surgery if it perforates bowel, may have temp colostomy to allow bowel to rest
Diverticulitis RN care rest, pain relief, teaching high fiber diet, decrease stress
protrusion of abdominal organs through defect from its normal cavity incarcerated hernia
manually replaced to normal position reducible hernia
trapped in defect. Must do surgery to release – will result in infarction and death of entrapped organ strangulated hernia
protrusion of stomach through diaphragm into thoracic cavity. Causes heartburn or indigestion. Can cause severe chest pain. hiatal hernia
Tx of hernia decrease intra-abdominal pressure, use antacids, avoid caffeine, eat slowly, eat small freq meals, avoid smoking, avoid lying fro 30 mins after eating.
Post op of hernia surgery avoid abdominal straining (stool softeners), no heavy lifting for several weeks.
Surgical repair of hernia to close defect or place prothesis around esophagus to prevent protrusion. (not always successful).
may not need treatment unless very large or incarcerated umilical hernia
most common in men, inguinal canal defects. May be bilateral or unilateral. May need more than one repair. Polyester mesh to reinforce. inguinal hernia
ventral abdominal wall do to previous abdominal surgery. o Risk factors : obesity, debilitation, poor nutrition, poor wound healing. central hernia
Inflammation of gallbladder o Middle-aged white females (fair,fat,forty,female) Cholecystitis
s/s of cholecystitis o S/S: indigestion, RUQ pain, referred pain under right scapula, frequent flatus, biliary colic (severe pain), possible fever and leukocytosis o If obstructed : jaundiced, clay colored stools o Bile colored urine
Tx of cholecysitis lithotripsy, dissolution therapy, laproscoy, cholecystectomy
Cholecystitis RN care morphine for pain, position of comfort, NPO – IV fluids so asses hydration, possible NG tube, antiemetics, low fat diet.
Post op of cholecystitis surgery pain relief (it hurts to deep breath), maintain patency if NG tube, low fowlers, ambulate.
Created by: melissaaclark