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Stage 1 Pressure Ulcer
- Skin intact.
- Possible blister.
Stage 2 Pressure Ulcer
- Partial thickness skin loss.
Stage 3 Pressure Ulcer
- Full thickness skin loss.
- Necrotic tissue.
Stage 4 Pressure Ulcer
- Extensive full thickness skin loss.
- Possible bone/muscle visible.
Infections acquired in the hospital
Used to examine for bladder trauma and identify UT obstruction.
May be used to remove bladder tumors or enlarged prostate.
Can use general or local anesthesia.
Pre-op care for patient with cytoscopy
A light evening meal may be eaten before.
NPO after midnight.
Bowel prep with laxatives or enemas the evening before the procedure.
Urinary Tract Infection
Described by location.
Site of infection and bacteria present determine treatment.
90% are caused by E. Coli.
Example of upper UTI
Acute infections of lower UTI
Urethritis, Cystitis, Prostatitis
Cause of Cystitis
Inflammation of the bladder.
Caused by irritation or infection.
Prevention of UTI
Reducing the use of indwelling catheters. If must be used, pay strict attention to sterile technique.
Remove catheter as early as possible.
Drink at least 3 L of water daily.
Urinate every 3-4 hours
Manifestations of Cystitis
Cloudy, foul smelling, blood tinged urine
Drug therapy for UTI
treat bacteriuria and promote comfort
antibiotics, analgesics, antispasmodics, antiseptics.
Nutrition therapy for UTI
Diet including all food groups.
More calories for the increased metabolism from infection.
Drink 50 mL of cranberry juice daily for 3-4 weeks.
Why do you drink cranberry juice to treat UTIs?
to decrease the ability of bacteria to adhere to the epithelial cells lining the urinary tract.
What is the purpose of ureteral stents?
Small tube placed in ureter.
Dilates the ureter and enlarges the passageway for the stone or stone fragments.
Prevents the passaging stone from coming in contact with the ureteral mucosa and so it reduces pain, bleeding and infection risk.
Foley catheter is places to facilitate passage of stone through urethra.
What is a loop stoma?
A loop of colon brought to the skin surface and sutured to the abdominal wall. Performed in the transverse colon and are temporary.
What is a double barrel stoma?
Split the bowel and bring the proximal and distal portions to the abdominal wall to have two stomas. The proximal stoma is functioning and eliminates stool. The distal stoma may secrete some mucus, but thats it.
What are the characteristics of a healthy stoma?
protrude about 3/4 inch from the abdominal wall
Skin around stoma should be intact, smooth and without redness.
Intermittent Catheterization Programs (ICP)
A catheter you can do yourself. Insert a a thin, hollow tube through the urethra into the bladder and allow the urine to drain out. Not permanent.
Benign Prostate Hypertrophy BPH
With aging. The prostrate gland enlarges and extends upward into the bladder and inward, causing bladder obstruction. The detrusor muscle thickens and cannot contract effectively.
Prostate will be enlarged, non tender.
Patient will have increased statis or acute or chronic retention.
S/S of BPH
Urinary Frequency, Nocturia, urinary hesitancy on initiation of voiding, hematuria
lowered force of stream, post-void dribbling from overflow incontinence, distention
evidence of renal insufficiency like edema, pallor and pruritis.
Lab tests for BPH
Urinalysis, Culture, CBC, BUN, PSA done before a DRE.
Drug therapy for BPH
- 5-alpha reductase inhibitor:
decreases testosterone levels to shrink the prostate and prevent further growth.
Side effects: decreased libido and ED
What is TURP and what are the disadvantages?
Transurethral resection of the prostate. Closed surgery (using the bodies openings)
enlarged portion of the prostate is removed endoscopically.
Disadvantage: since only a few pieces are removed, remaining tissue may continue to grow and cause urinary obstruction, requiring additional TURPs.
High risk for hemorrhage and severe bleeding
Tell me about prostate cancer.
Most common type of cancer. Slow growing and metastasizes in nearby lymph nodes, bones, lungs and liver.
Prostate will be a stony hard nodule.
Most are androgen sensitive.
Most are adenocarcinomas that arise from epithelial cells in the posterior lobe or outer portion of the gland.
S/S of prostate cancer
First symptoms are problems with starting urination, frequent bladder infections and retention.
Gross blood in the urine (most common)
Pain in pelvis, spine, hips and ribs
Swollen lymph nodes
Lab Assessments for Prostate cancer
PSA -glycoprotein protein produced by prostate
Normal level should be <4 ng/mL
What are the three surgeries for prostate cancer?
most common intervention
Radical Prostatectomy -prostate removal
TURP- to promote urination for patients with advanced cancer. It is not curative.
Bilateral Orchiectomy- removal of both testicles.
Nonsurgical Management for Prostate Cancer
Radiation therapy, hormonal therapy, chemotherapy, Cryotherapy (liquid nitrogen)
S/S of PMS-Premenstrual Syndrome
mood changes from changes in the levels of neurotransmitters serotonin.
hormonal or fluid shifts
depression, angry outbursts, anxiety, irritability, social withdrawal.
breast tenderness, edema, headache, bloating, food craving, insomnia.
Short term memory problems, difficulty concentrating, unclear thinking.
What is the most common reason for hysterectomies?
Leiomyomas (fibroids) -slow growing tumors in the uterus.
What is a total vaginal hysterectomy and what are the complications?
Surgeon removes the uterus and cervix and sometimes the vagina in pieces.
Complications: hemorrhage, urinary retention, UTIs, wound infections.
What is a total abdominal hysterectomy and what are the complications?
Uterus and cervix are removed through a horizontal bikini incision or laprascopically.
Complications: intestinal obstruction, thromboembolism, atelectasis, pneumonia, wound dehiscence, urinary retention
What does a surgeon remove in a woman's hysterectomy?
The surgeon removes the uterus and the 5 supporting ligament and the reattaches the ligaments to the vaginal cuff so normal depth of the vagina is maintained.
What is subtotal hysterectomy?
All off the uterus except the cervix is removed. Rare
What is a radical hysterectomy?
All of the uterus is removed abdominally. The lymph nodes, surrounding tissues and upper third of the vagina are also removed.
Post-op assessments for TAH
Should be less than 1 saturated perineal pad in 4 hours
small amount of abdominal bleeding at incision site
Intactness of incision
Catheter for 24 hours or less.
Patient teaching for TAH
- Showers instead of baths
- No heavy lifting
- Avoid sitting for a long period of time
- Don't cross legs
- Avoid strenuous activity for 6 weeks
- No driving for 4 weeks.
- No sex for 4-6 weeks.
- Record temp BID for 2 weeks.
What is dysmenorrhea?
Painful menstrual flow. Occurs after ovulation begins
Painful uterine cramping with spasmodic lower abdominal. Pain often travels to lower back and thighs.
What causes dysmenorrhea?
increased production and release of uterine prostaglandins which cause spasms in myometrium, which constrict uterine blood flow, resulting in ischemia and pain.
What is Dysfunctional Uterine Bleeding and when does it occur?
Bleeding in excessive amount- more than 21 mL or more than 21 days.
Occurs the the beginning or end of productive years.
a hormone imbalance because ovaries fail to ovulate. This decreases progesterone production which is needed to mature the uterine lining and prevent growth. Without progesterone, the estrogen stimulation causes the endometrium past its hormonal support, causing uterine bleeding.
Management for DUB
- Estrogen therapy
- Hormonal contraceptives
- Progestin Pills
- IUD (nuvaring)
Endometrial Ablation-removal of a buildup of endometrial lining through a laser, roller ball or balloon.
Downward displacement of the uterus through the pelvic floor.
Caused by neuromuscular damage in childbirth, increased intra-abdominal pressure related to pregnancy, obesity or physical exertion or weakening of pelvic support due to decreased estrogen.
Definition of cystocele
protrusion of the bladder through the vaginal wall, which can lead to stress incontinence and urinary tract infections.
Definition of rectocele
a protrusion of the rectum through a weakened vaginal wall.
S/S of a rectocele
feeling as if something is "falling out", dyspareunia (painful intercourse), backache and a feeling of heaviness in the pelvic region.
constipation, hemorrhoids, fecal impaction and feelings of rectal or vaginal fullness.
S/S of a cystocele
Difficulty in emptying the bladder, urinary frequency and urgency, UTIs, stres incontinence.
What are the diagnostic tests for uterine prolapse?
cystrography (to show bladder herniation)
measurement of residual urine by a bladder scan
urine culture and sensitivity testing.
Nonsurgical/Patient teaching for uterine prolapse
Intravaginal estrogen to prevent atrophy and the weakening of the vaginal wall.
Kegel exercises to elevate uterine prolapse
High fiber diet/stool softeners/laxatives
Surgical management for uterine prolapse
Anterior colporrhaphy (anterior repair rightens the pelvic muscles for better bladder support)
Posterior colporrhaphy (posterior repair reduces rectal bulging)
Hormone Replacement Therapy
A combination of estrogen and progestin.
used to "protect" against side effects of menopause.
Take at the lowest possible dose for the shortest amount of time.
What is leukorrhea?
white vaginal discharge used as a natural defense mechanism that the vagina uses to maintain its chemical balance and preserve the flexibility of the vaginal tissue.
May result from inflammation or congestion of the vaginal mucosa.
What are the causes of leukorrhea?
vaginal infection or STD (more yellow and foul smelling)
yeast infection, bacterial vaginosis
inflammatory condition of vagina or cervix.
Tell me about Complete Blood Count
diagnoses anemia and infection.
Associated with cancer, peptic ulcer disease and inflammatory bowel disease.
What is the most frequent cause of anemia?
What is prothrombin time?
the rate at which prothrombin is converted to thrombin, a process that depends on Vitamin-K associated clotting factors.
Fecal Occult Blood Test
Measures the presence of blood in the stool from GI bleeding from colorectal disease.
Done to evaluate function and integrity of GI tract.
May be collected to test for fecal fats when steatorrhea (fatty stools) or malabsorption is suspected.
What is a barium enema?
an x-ray of the large intestine. Drink to contrast for xray then expect white, chalky feces.
Lower GI series
May be given a laxative to remove barium from GI tract.
a direct visualization of the GI tract using a flexible fiberoptic endoscope. Commonly requested to evaluate bleeding, ulceration, inflammation, tumors and cancer of the esophagus, stomach, biliary system or bowel.
visual examination of the esophagus, stomach and duodenum.
- NPO for 6-8 hours prior.
- Local anesthetic used to inactive the gag reflex and facilitate passage of the tube.
Check vitals every 30 minutes.
Tell me about a colonoscopy.
- an endoscopic examination of the entire large bowel.
- All men and woman should have one done every 10 years after the age of 50.
Evaluates the chronic diarrhea and locate the source of bleeding.
Patient teaching for colonoscopy.
stay on a liquid diet for 12-24 hours.
NPO for 6-8 hours.
Drink an oral prep for cleaning the bowel the evening before an exam and repeat the procedure the morning before a study.
endoscopic examination of the rectum and sigmoid colon using a flexible scope.
Screen for colon cancer, investigate the source of GI bleeding, diagnose or monitor inflammatory bowel disease.
Clear liquid diet 24 hours prior. Cleansing enema the morning of the procedure.
measures the hydrochloric acid and pepsin content for evaluation of aggressive gastric and duodenal disorders.
What is a peptic ulcer?
a mucosal lesion of the stomach or duodenum. Results when mucosal defenses become impaired and can no longer protect the epithelium from effects of acid and pepsin.
What happens to form a gastric ulcer and what plays an important role in the formation?
Acid, pepsin and H. Pylori
When the pyloric sphincter dysfunctions, the bile backs up into the stomach. This reflux breaks the integrity of the mucosal barrier and produced hydrogen ion back-diffsion which results in mucosal inflammation. Toxic agents and bile destroy the membrane of gastric mucosa.
What is a duodenal ulcer?
Most occur in upper part of abdomen.
Deep, sharply demarcated lesions that penetrate into the muscle layer.
pH levels are low.
What is a stress ulcer?
Mucosal lesions that occur after an acute medical crisis or trauma, head injury or sepsis.
Bleeding caused by gastric erosion is the main manifestation of acute stress ulcers.
What are physical assessment findings for Peptic Ulcer Disease?
Epigastric tenderness located midline
hyperactive bowel sounds
most commonly reported symptom is dyspepsia (indigestion)
What is the difference between gastric ulcer pain and duodenal ulcer pain?
Gastric Ulcer Pain: upper epigastric area, left upper midline, aggravated by food, worsened by ingestion of food and occurs 30-60 minutes after a meal
Duodenal Ulcer Pain: right of epigastrum. Occurs 90 minutes to 3 hours after eating. Awakens patients at night. Made worse by certain food. Relieved by ingestion of food.
Non-surgical interventions for patients with peptic ulcer disease.
Avoid substances that stimulate gastric acid secretions-coffee, tea, cola. Avoid bedtime snacks.
Avoid alcohol and tobacco.
pouch like herniations of the mucosa through the muscular wall of any portion of the gut but most commonly the colon.
What is the difference between diverticulosis and diverticulitis?
Diverticulosis is the presence of many diverticula in the wall of the intestine.
Diverticulitis is the inflammation of one or more of the diverticula.
Drug therapy for diverticulitis
Broad-spectrum antimicrobial drugs.
Opioid analgesic to alleviate pain.
Anticholinergenics to reduce intestinal hypermotility but should be avoided for older adults.
Patient teaching for diverticulitis
- Avoid heavy lifting, straining, coughing and bending.
- Low fiber and clear fluids
Food to eat with diverticulosis
- eat a high in cellulose diet found in wheat bran and cereals.
- Fresh fruits and vegetables high in fiber to add bulk to stool.
- Drink plenty of fluids to prevent bloating
- Avoid acohol.
What food do you want to avoid with diverticulitis
Avoid all fiber because high fiber foods are irritation.
widespread inflammation of the rectum and rectosigmoid colon. Associated with remissions and flareups.
What is the difference between mild and severe inflammation in ulcerative colitis?
Mild- intestinal mucose is hyperemic (increased blood flow), edematous and reddened.
Severe- lining can bleed and small erosions, or ulcers occur. Abscesses can form and result in tissue necrosis (cell death).
S/S of Ulcerative Colitis
Patient reports tenesmus (unpleasant and urgent sensation to defecate)
stool typically contains blood and mucus.
lower abdominal colicky pain relieved with defecation
Malaise, anorexia, weight loss
Nonsurgical interventions for Ulcerative Colitis
- record characteristics of stools
- eliminate gas producing and spicy foods and foods containing lactose.
- Low fiber, high protein, high calorie diet
- Caffeine, pepper, alcohol and smoking can cause discomfort
- Teach patient about correct use of antidiarrheal medications
- Monitor skin in perineal area for irritation and ulcerations from loose, frequent stool.
- Rest the bowel
Surgical Management for Ulcerative Colitis
Colonoscopy is the most definite to diagnose UC.
Total proctocolectomy with permanent ileostomy- loose,dark green liquid with some blood in stool, pouch worn at all times, skin care
Total Colectomy with Continent (Kock's) Ileostomy- internal ileal reservoir, intra-abdominal pouch, monitor drainage
Total Colectomy with Ileoanal Anastomosis (J-pouch) - J-pouch is an ileoanal reservoir that spares the renal sphincter and the need for an ostomy
Chrohn's disease. What is it and what does it result in?
- an inflammatory disease in the small intestine (most often), colon or both.
- Can affect GI tract from mouth to anus but usually the terminal ileum.
- causes a thickened bowel wall.
- Strictures and deep ulcerations (cobblestone) appearance which predispose the patient to fistulas. Result is severe diarrhea and malabsorption of nutrients.
- Cancer of the bowel may develop after the disease has been present for 15-20 years.
Surgical Management for Chrohn's disease
MIS via Laparoscopy
Small bowel resection and ileocecal resections
Stricturoplasty which increases the bowel diameter.
What is a mechanical obstruction?
the bowel is physically blocked by problems outside the intestine (adhesions) in the bowel wall (crohn's disease), or in the intestinal lumen (tumors)
The intestinal contents accumulate at and above the area of obstruction. Distention results from the intestines inability to absorb the contents and move them down the intestinal tract. Peristalsis increases to try to move the contents forward. This increase stimulates more secretions which leads to additional distention.
What is a non-mechanical obstruction?
also known as paralytic ileus. does not involve a physical obstruction in or outside the intestine. Peristalsis is decreased or absent as a result of neuromuscular disturbance, resulting in a slowing of the movement or a backup of intestinal contents.
most common cause is the handling of intestines during abdominal surgery.
What are some problems that occur from intestinal obstructions?
- Reduced circulatory blood volume (hypovolemia)
- electrolyte imbalances
- Obstruction high in the small intestine
- causes a loss of gastric hydrochloride
- makes more basic
- Obstruction at the end of the small intestine and lower in the intestinal tract that causes a loss of alkaline fluids.
- makes more acidic
- bacteria that lies stagnant in the obstructed intestine.
- closed-loop obstruction (blockage in two areas).
- obstruction with compromised blood flow.
twisting of the intestine
telescoping of a segment of the intestine within itself
Nonsurgical management for intestinal obstructions.
- NG tube- to decompress the bowel by draining fluid and air.
- Question about passage of flatus.
- Flatus or stool means that peristalsis has returned.
- IV fluid replacement and management.
Surgical Management for Intestinal Obstruction
Exploratory laparotomy- a surgical opening of the abdominal cavity to investigate the cause of the obstruction. If adhesions are found, they are lysed (cut and released)
Rapid emptying of food contents into the small intestine, which shifts fluid into the gut causing abdominal distention. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, desire to lay down.
Management for dumping syndrome
- nutrition changes that include decreasing the amount of food taken at one time, and eliminating liquids ingested with meals.
- Eat a high-protein, high-fat, low to moderate carb diet.
- are sacs resulting from herniation of esophageal mucosa. Patients report dysphagia, regurgitation, nocturnal cough, halitosis (bad breath).
- Diagnosed with EGD.
- Major interventions are nutrition therapy and positioning. Avoid vigorous exercise after meals. Elevate HOB. No restrictive clothing. NO frequent bending.
Surgical Management for esophageal diverticula
aimed at removing diverticula. NPO for several days to promote healing.
IV fluid for pain-relief measures
monitor for bleeding or perforation.
NG tube is placed during surgery for decompression and is not irrigated or repositioned unless requested by surgeon.
- occur when esophageal veins become distended from increased pressure.
- Potential to bleed depends on size
- Often occur in distal esophagus. can also be present in stomach and rectum.
- are a life-threatening medical emergency.
Greater than the normal amount of fat in the feces
Protrusion of the stomach through the esophageal hiatus into the diaphragm.
What are the two types of hiatal hernias?
Sliding- most common. stomach slides upward through the esophageal hiatus into the chest, usually as a result of a weakened diaphragm. Major concern is the development of esophageal reflux.
Paraesophageal (rolling) reflux- fundus rolls into the thorax beside the esophagus. Reflux is not usually present. High risk for volvulus, obstruction and strangulation.
Surgical management of hiatal hernias
Laproscopic Nissen Fundoplication- surgeon wraps a portion of the stomach fundus around the distal esophagus to anchor and reinforce the LES
preop care for a patient with hiatal hernias
teach PT about chest tubes
inform NGT will remain for several days
clear liquids after parastalsis is reestablished
high incision makes breathing painful, teach about post op pain and incintive spirometer
Post-op care of hiatal hernias
primary focus of care is to prevent respiratory complication
Promote lung expansion and lower diaphragm. Begin ambulating.
splint during coughing.
Have a NG tube to prevent the fundoplication wrap from becoming too tight around the esophagus.
Common complication of LNF (Laprascopic Nissen Fundoplication)
Gas bloat syndrome, where the patients are unable to voluntarily burp. Avoid carbonated beverages and eating gas-producing foods, chewing gum and drinking through a straw.
Other complication is aerophagia (air swallowing) from attempting to reverse or clear acid reflux. Frequent position changes and ambulation.
Total Proctocolectomy with a permanent ileostomy
Removal of colon, rectum and anus.
for patients undergoing a colectomy.
bring the ileum out through the abdominal wall and forms a stoma.
- After surgery, output is a lose, dark green liquid that may contain blood. Ileostomy adaptation will occur.
- Small intestine will begin to perform previous colon functions, like absorption of water and sodium.
- Effluent fluid material will have little or sweet odor. Any foul or unpleasant odor may be a sign of blockage or infection.
ileostomy (location, care, and what you would expect)
loop of the ilieum is placed through the abdominal wall for drainage of fecal material into a pouching system worn on the abdomen
care: empty when 1/3 to 1/2 full, change entire pouch every 3-7 days
protect skin from contact with ostomy contents
include adequate amounts of salt and water in the diet
teach pt to avoid foods that cause gas or make the stool thicker
TPN (total parental nutrition)
specialized nutrition support in which nutrients are provided IV to PT's that are not receiving adequate nutrients or that cannot handle a regular diet.
PT receives 3-4 L per day
delivered through a PICC line, the subclavian or internal jugular vein.
administered with an infusion pump, controlled delivery is essential.
What is an intervention for PT's with Cirrhosis of the liver and potential for hemorrhage?
Use of a Sengstaken-Blakemore Tube
a balloon inflated to apply pressure to the bleeding variceal are.
Pt is usually placed on mechanical ventilator to protect the airway.
JP drain (how to use)
drains wound directly through a tube via gravity and vacuum. drain is sutured in place to create seal.
sterile technique is used to handle
Jaundice is a result of what three conditions?
Cirrhosis- hepatocellular disease (cannot excrete bilirubin) or intrahepatic obstruction (from edema or scarring of the bile ducts
-rxn to hepatic inflammation and necrosis
Hepatits- intrahepatic obstruction (edema of liver's bile channels)
what are the four liver deficiencies related to cirrhosis?
Postnecrotic- drugs or chemicals
biliary cirrhosis- biliary obstruction
cardiac cirrhosis- heart failure
what is compensated cirrhosis?
liver is scarred but can still perform essential functions without causing major symptoms
what is decompensated cirrhosis?
the livers function is impaired with obvious manifestations of liver failure
Complications of cirrhosis:
increased in pressure within the portal vein from increased resistance or obstruction of blood flow. blood flows back to spleen, veins in esophagus, stomach, intestines, abdomen, and rectum become dilated.
free fluid in peritoneal cavity from increased hydrostatic pressure from portal hypertension.
results from fluid shift into abdomen.
esophageal veins become distended from increased pressure. Emergency!
production of bile in liver is decreased, preventing absorption of vitamin K
bleeding and easy bruising
enlargement of spleen from backflow of blood into the spleen
platelets are destroyed
high risk for bleeding
yellow coloration of skin. liver cells cannot effectively excrete bilirubin.
port systemic encephalopathy
toxic substances are absorbed into the intestine and not broken down
affects function of the brain
- s/s: sleep, mood, mental, and speech problems
- can lead to neuromuscular problems
drug therapy for hepatic encephalopathy
lactulose to cleanse the bowel of the toxins that can cause encephalopathy
nonabsorbable antibiotics for an intestinal for an intestinal antiseptic used to reduce or eliminate ammonia levels in the body
nutrition therapy for ascites
low sodium diet to control fluid accumulation in the abdomen
vitamin supplements because the liver cannot store vitamins
drug therapy for ascites
diuretics to reduce fluid accumulation with potassium to prevent potassium wasting
a trocar catheter is inserted into the abdomen to remove and drain ascitis fluid from the peritoneal cavity
may be used for temporary relief when diet and diuretics do not work
nursing interventions for ascites
monitor 02 sat, apply oxygen if necessary
elevate HOB 30
encourage pt to sit in chair to relieve dyspea
labs to be concerned with for ascites
Transjugular intrahepatic portal system-shunt
used to control long term ascites and reduce variceal bleeding
postop for transjugular intrahepatic portal system-shunt
auscultate lung sounds for crackles
monitor coagulation tests
measure abdominal girth
Blood to Blood
Get if carrier has Hep B
fecal contamination of food and water
s/s of hepatitis
changes in skin or sclera
tenderness of RUQ
how are hep a,b,c confirmed/diagnosed
a-antibody in blood
b-antibody systems and detectable viral count in blood
c-antibodies have developed
establish stage and grade of liver damage
percutaneous procedure with a local anesthetic
nursing interventions for hepatitis
slowly add self care and ambulation
high calorie and carb diet with fat and protein
b,c- antiviral and immunomodulating drugs are used
what kind of PT's are candidates for liver transplant?
most common, hep c
end stage liver disease or acute liver failure not responding to other treatments
what are symptoms of liver transplant rejection
tachycardia, fever, RUQ or flank pain
decreased bile pigment and volume
increased jaundice, elevated bilirubin
what infections that can correlate with liver transplant?
early-pneumonia, wound infection, UTI
after 1 month- TB, herpes simplex
what is the most common type of cholecystitis
when chemical irritation and inflammation results from gallstones that obstruct the cystic duct, gallbladder neck, or common bile duct
what happens in cholecystitis?
since the gallbladder is inflamed the bile is trapped and reabsorbed and is irritating to the gallbladder wall. causes ischemia and infection when combined with impaired circulation, edema, and gallbladder distention.
results in tissue sloughing with necrosis and gangrene
inflammation of gallbladder without gallstones, associated with biliary stasis caused by any condition that affects the regular filling or emptying or the gallbladder
What is chronic cholecysitis and what are some signs and symptoms?
results from repeated episodes of cystic duct obstruction that cause inflammation.
Calculi are common.
Gallbladder becomes fibrotic and contracted. Decreased motility and efficient absorption.
Patient will have clay colored stool and dark, foamy urine.
Jaundice and icterus (yellowing of the sclera) occur.
What is the difference between extrahepatic intrahepatic jaundice?
Extrahepatic- occurs from obstructed bile flow from edema of the ducts or gallstones.
Intrahepatic- results from inflammation of the livers bile channels or ducts.
In both, normal flow of bile is blocked and bile salt accumulates in the skin which causes pruritis.
Signs and symptoms for cholecysitis?
Abdominal pain varies. Flatulence, dyspepsia, eructation, anorexia, nausea, vomiting or abdominal pains after fatty foods are eaten.
Pain may radiate to right shoulder or scapula.
Biliary Colic- severe pain that happens when a stone is moving through or lodged in a duct and tissue spasm occurs in order to mobilize the stone through the duct.
What are the diagnostic assessments for cholecystitis?
no tests that are specific.
Increased WBC count can mean inflammation.
Elevated serum levels.
Calcified gallstones can be viewed in x-rays.
Ultrasound in RUQ is the best diagnostic test.
Nonsurgical Management for cholecystitis
- Avoid fatty foods to prevent biliary colic.
- Opioid analgesics for acute biliary pain.
- Anticholinergenic drugs used to relax smooth muscle and decrease ductal tone and spasm.
- Antiemetics- control nausea and vomiting.
- Lithotripsy- break up large stones into small ones.
What is the difference between laprascopic and traditional cholecystectomy?
- surgical removal of the gallbladder.
- Laprascopic- dissect gallbladder for liber bed and cystic artery and duct are closed. Gallbladder is removed through umbilical port. Discharged within a day.
- Traditional- chronic lung disease or heart failure. Large incision to remove gallbladder and locate stones. T-tube is inserted to prevent fluid accumulation (400+ mL qday) Teach pt that feces will pass much more quickly.
Tell me crap about the T-Tube
- main priority for care is to keep drain system below gallbladder.
- semi-fowler position
- Bloody drainage to green/brown bile.
- 400mL qday excreted
- assess for foul odor or purulent drainage.
- Inspect skin around T-tube and insertion site.
- Keep dressing dry.
- NEVER IRRIGATE, ASPIRATE OR CLAMP A T-TUBE. (unless given an order)
- Can clamp when pt is allowed to eat 1-2 hours before and after meals.
- stool will return brown after 7-10 days.
- serious. life-threatening.
- Pancreatic enzymes should be inactive until they reach the small intestine. There is an early activation of the enzymes which results in auto digestion and fibrosis of the pancreas.
What are 4 major processes that occur with acute pancreatitis?
Lipolysis- fatty acids are released and combined with calcium. Body cannot use this combination. Must have calcium by itself. Low calcium levels.
Proteolysis-splitting of proteins by hydrolysis by peptide bonds. May lead to thrombosis or gangrene.
Necrosis of blood vessels-results in bleeding. Can lead to hemorrhaging.
Inflammatory stage- leukocytes have clustered around the necrotic areas in the pancreas.
What are the complications for acute pancreatitis?
Jaundice, Intermittent hyperglycemia.
Cullens sign-turners sign
- Multisystem organ failure.
- Coagulation defects.
Shock. Hypovolemia/ paralytic ileus.
Causes and risks for acute pancreatitis
- alcohol and biliary tract disease
- trauma from surgery
S/S of acute pancreatitis
and pain when drinking alcohol or eating a fatty meal?
any abdominal surgery
any sudden onset of pain radiating to the back, left flank or shoulder.
Nausea and vomiting resulting in weight loss.
Diagnostic assessments for actue pancreatitis
Serum amylase levels are increased and remain high for 3-4 days.
Trypsin is the most accurate indicator for pain.
Elevated WBC count, ESR and serum glucose levels.
Nonsurgical management for acute pancreatitis
Fasting and rest- NPO durring actue period. IV fluids to maintain hydration. NG tube . Assess for return of peristalsis.
Drug Therapy- PCA pump.
Comfort measures- side-lying position may decrease pain. oxygen for easy breathing. oral hygiene to keep membranes moist.
progressive, destructive disease. repeated episodes of acute pancreatitis or chronic obstruction of common bile duct.
S/S of Chronic Pancreatitis
- Major- abdominal pain. continuous, burning, gnawing.
- Respiratory complications. auscultate for adventitious sounds or decreased aeration.
- Obtain a stool sample
- assess for unintentional weight loss, muscle wasting, jaundice, dark urine, polyuria.
Diagnosing Chronic Pancreatitis
- based on manifestation, lab and imaging assessment
- CT, MRI, Ultrasounds are done.
- Slightly elevated serum bilirubin and alkaline phosphate levels.
Drug and Nutrition Therapy for Chronic Pancreatitis
- Opioid analgesics
- Pancreatic enzymes are given with meals or snacks to aid in digestion and absorption of fat and protein.
- Drugs to decrease gastric acid.
Surgical Management for Chronic Pancreatitis
If the pancreatic duct sphincter is fibrotic, the surgeon performs a sphincterotomy (incision of the sphincter)
Laparoscopic cholecystectomy- done if biliary tract disease is the cause of pancreatitis.
Done to manage pain
What is the primary surgery for pancreatic cancer?
- Whipple procedure
- removal of the head of the pancreas, duodenum, a portion of the jejunum, stomach and gallbladder.
Pre-op care- catheter into jejunum for feedings. TPN. No bowel prep. NPO 6-8 hours.
Post-op- NPO/ NG tube. Monitor NG drainage. It should be serosanguineous. Semi-fowlers position to reduce tension on suture line. Monitor H&H levels.
What is cataracts what what is it related to?
a opacity of the lens that distorts the image projected onto the retina. Maybe age related or caused by trauma or exposure to toxic agents.
S/S of Cataracts
- Blurred vision, decreased color perception
- lens cloudiness
- double vision that gets worse
- No pain or eye redness associated with age
What is the only cure for Cataracts?
- Extracapsular removal- front capsule is opened with a small incision.
- Phacoemulsification- probe is inserted through the capsule and high-frequency sound waves break up the cataractous lens into small pieces and removed by suction.
After the lens will be replaced because without it, the eye has lost most of its refractive ability and has no accommodative power.
What is post-op care for patients with cataracts?
- Antibiotics immediately.
- Mild itching and bloodshot appearance are normal.
- Avoid aspirin.
- Pain early after surgery is not good. can indicate increase in IOP or hemorrhage.
- Creamy, white, dry, crusty drainage is normal.
Primary open-angle glaucoma
most common. affects both eyes. outflow of aqueous humor through the chamber angle is reduced. IOP increases because fluid cannot leave the eye at the same rate as it is reduced.
S/S- foggy vision, reduced accommodation, mild aching in eyes, headaches.
late symptoms include halos around light, losing peripheral vision, decreased visual acuity. Not correctable with glasses.
- less common. sudden onset. emergency.
- Narrowed angle and forward displacement of the iris. Movement of the iris against the cornea narrows and closes the chamber angle, obstructing the flow of aqueous humor.
What are 4 diagnostic tests for glaucoma?
- Tonometry- shows elevated IOP. 10-21 mmHg. puff of air
- Perimetry- used to test visual fields
- Gonioscopy- when high IOP is found. Determines whether it is an open or closed angle.
- Optic Nerve Imaging- pts with ocular hypertension. assess nerve thickness and contours.
Nonsurgical treatment for patients with glaucoma
- Drug therapy that reduce IOP.
- Eyedrops to prevent an increase in IOP.
Surgical Treatment for glaucoma
Laser trabeculoplasty- burns the meshwork, scarring it and causing the fibers to tighten which improves the outflow of aqueous humor and reduces IOP.
Filtering microsurgery- creates a drainage hole in the iris between the posterior and anterior chamber. If it wont stay open, a shunt can be put in place.
What is the most serious complication from surgery for patients with glaucoma?
Choroidal hemorrhage. If IOP is too low, fluid may enter the suprachoroid space and cause a choroidal detachment. Extra fluid may break blood vessels located there.
S/S- acute pain deep in the eye, decreased vision and vital sign changes.
What happens when you have a ruptured tympanic membrane?
It ruptures and pus or blood drains from the ear.
Can heal ny themselves.
What are the three main symptoms of meniere's disease?
Tinnitus, one-sided sensoineural hearing loss and vertigo
What is Meniere's disease and what are the signs and symptoms of it?
an excess of endolymphatic fluid that distorts the entire canal system. Cause is known but it often occurs with infections, allergic reactions and fluid imbalances.
vertigo, headaches, increasing tinnitus, hearing loss, nausea, vomiting, feeling fullness in affected ear, rapid eye movements.
Nonsurgical Intervention for Meniere's disease
Teach patient to move slowly to prevent worsening of vertigo. Stop smoking. Avoid high salt foods and caffeine.
Meniett device- applies a low-pressure micropulse to the inner ear for 5 minutes three times daily. It displaces the fluid from the inner ear and this relieves manifestations.
What does drug therapy do for Meniere's disease?
aims to control the vertigo and vomiting and restore normal balance.
Mild diuretics to decrease endolymph volume.
Nicotonic acid to vasodilate.
Antihistamines to reduce the severity or stop an acute attack.
What surgical intervention is for Meniere's disease?
Last resort. Labyrinthectomy. involves resection of the vestibular nerve or total removal of the labyrinth. Endolymphatic sac is drained and a small tube is inserted to improve fluid damage.
- Use-laxative, decreases constipation, and blood ammonia level.
- Administration- orally. full glass of fruit juice, water or mild. Rectally with a retention enema
- Teaching- Do not take if you have abdominal pain, nausea, vomiting. Repot electrolyte imbalances. Do not take at bedtime.
- Use- useful in treating Meniere's disease because of its vasodilatory effects. Decreases cholesterol and LDL levels.
- Admin- orally. Dont break, crush, chew or give with meals or milk. IV, give after diluting.
- Teaching- side effects should discontinue after 2 weeks. No alcohol. No sunlight. Report clay colored stool, anorexia, jaundice, sclera.
- Target tissue: Kidney
- Actions: Promotes water reabsorption
- given to relax smooth muscle and decrease ductal tone and spasm
inhibition of Hep C
What liver lab studies are elevated during liver failure?
ALT, AST, LDH, Alkaline Phosphatase
- Females - 12-16
- Males 14-18
- Females 4.2-5.4
- Males 4.6-6.1
Four complications of hepatic dysfunction
Hypertension, esophageal varices, ascites and hepatic encephalopathy
Describe skin care for patients with jaundice
Patients nails cut short to prevent excorciation due to pruritis. apply medicated creams and lotions to relieve itching. inspect skin for breakdown and provide support to edematous areas. turn every 2 hours. refrain from using alkaline soap on skin
Home care for patients with ascites
Important to continue health care and seek medical attention if symptoms of complications occur. Discuss proper diet, rest and avoidance of hepatotoxic drugs like acetaminophen, and abstinence of alcohol.
Provide info regarding community support programs
Provide written info about diet, skin care, medications, avoid coughing to prevent hemorrhage
What type of diet should a pt with hepatic failure follow?
foods high in calories, high protein, low fat, low sodium
What are symptoms of hepatic encephalopathy?
neurologic and mental unresponsiveness, sleep disturbances to lethargy and deep coma. Monitor function involving tremors called ASTERIXIS
What are the early and later stages of hepatic encephalopathy?
Early- euphoria, depression, apathy, irritability, memory loss, confusion, yawning, drowsiness, insomnia, agitation
Later- slow slurred speech, emotional lability, impaired judgement, hiccups, slow and deep respirations, hyperactive reflexes. disorientation to time, place and person. As condition worsens, so does the patients mental status. Fetor Hepaticus- musty, sweet odor to breath.
Medications to help control the ammonia in the system
Lactulose, Flagyl, Vancomycin, rifaximin. cathartics and enemas for constipation
Nursing interventions for a patient who is bleeding or has a tendency to bleed easily.
- Avoid aspirin, alcohol and irritating foods. Upper respiratory infections should be treated promptly. Coughing should be controlled.
- Treated with Sondostatin, Vasopressin, Nitroglycerine, inderal, sclerotherapy, ligation of varices and shunt therapy.
What is the most common cause of cirrhosis in the liver?
Characteristics of cirrhosis
Early signs- anorexia, dyspepsia, flatulence, nausea, vomiting, diarrhea, constipation, fever, slight weight loss, enlarged liver and spleen.
Late signs- jaundice, skin lesions, palmar erythema, thrombocytopenia, leukopenia, anemia, coagulation disorders, gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence
Clinical manifestations of compensated liver function
abdominal pain, ankle edema, continuous mild fever, spiders and palmar erythema
Clinical manifestations of decompensated liver functions
splenomegaly, jaundice, clubbing of fingers, firm and enlarged abdomen, purpura and spontaneous bleeding, gonadal atrophy
What are the purposes of all three lumens of the Sengstaken-Blakemore tube?
One for each of the two balloons and one for gastric aspiration
Nursing care for a patient with Sengstaken-Blakemore tube
Explain the use of the tube and how it will be inserted. Balloons are checked for patency, lumens should be labeled to prevent confusion. Nursing care includes monitoring for complications of rupture or erosion of the esophagus, regurgitation and aspiration of gastric contents and occlusion of the airway by the balloon. Nursing needs to encourage the patient to expectorate the saliva, frequent oral and nasal care provides relief from the taste of blood and irritation from mouth breathing.
What is the preferred drug to treat bleeding esophageal varices by non-surgical management? What are other drugs used?
Sandostatin. Other drugs are Vasopressin, Nirtoglycerin, B-adrenergic blockers (Inderal)
Contraindications for liver transplant
Wide spread malignant disease, severe pulmonary hypertension, morbid obesity, obstructed splanchnic blood flow.
What are the two main drugs for liver transplant and side effects?
- Interleukin- 2 receptor antagonists
Mode of transmission for HAV
Fecal Oral transmission
Mode of transmission for HEV
Mode of transmission for HBV
Parenteral, sexual and prenatal contact
Mode of transmission for HDV
parenteral, sexual contact
Mode of transmission for HCV
Parenteral, high-risk sexual contact, prenatal contact
Which hep viruses are acute only?
A & E
What hep viruses are both acute and chronic?
B, C, AND D
What is the confirmatory test for diagnosing HCV?
HCV RNA (RNA polymerase chain reaction assay)
Side effects of interferon
arthralgia, myalgias, loss of strength (astheria), fatigue, headache, fever, nausea/anorexia, depression or irritability, hair thinning, insomnia, itching skin, diarrhea, weight loss, injection site reaction
Main side effect of Ribavirin? Other side effects
- Terogenicity- interferes with normal fetal development
- Other side effects are anemia, anorexia, cough, insomnia, pruritis, rash
Main cause of pancreatitis in men and women
- Women- biliary tract disease
How do amylase and lipase react to acute pancreatitis
Serum amylase and lipase elevate. Amylase rises early and remains elevated for 24-72 hours. Serum lipase also elevates and is a helpful complementary test since there are other disorders that increase serum amylase.
What mineral is lost with acute pancreatitis?
Calcium is lost. Treat with calcium gluconate.
What is the pain management for pancreatitis?
- Morphine for pain relief
- Nitroglycerine or papaverine for relaxation of smooth muscle and relief of pain
Nutritional teaching strategies would you incorporate into client education for pancreatitis
- Small frequent means, high carb content, low in fat, bland
- alcohol is totally avoided
- avoiding smoking and stressful situations
- avoid caffeine
Describe the result of malabsorption in the patient chronic pancreatitis
Muscle wasting, weight loss, loss of energy, constipation, mild jaundice with dark urine, steatorrhea and DM