med surg

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med surg
2013-08-02 22:22:00

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  1. another name for hiatal hernia
    esophageal or diaphramatic
  2. what is hiatal hernia
    protrusion of stom through esophageal hiatus (opening) of the diaphragm
  3. 2 types of hiatal hernias
    • sliding - most common 
    • rolling
  4. % population w hiatal hernia
    • 25-30
    • most asymptomatic
  5. 3 causes of hiatal hernia
    • congenital problems
    • trauma
    • incr abd pressure
  6. 5 s/s hiatal hernia
    • ger
    • pyrosis (heartburn after eating)
    • belching
    • regurgitation
    • vomiting
  7. hernias may become and do
    • incarcerated and necrotic
    • hemorrhage
  8. 3 ways to dx hernia
    • ugi
    • barium swallow
    • egd
  9. 7 txs of hernia
    • antacids
    • h2 antagonists
    • proton pump inhibitors
    • reglan (gi stimulant, promotes gastric emptying)
    • elevate hob
    • limit fatty foods/caff/etoh/smoke
    • avoid eating 3 hrs before sleep
  10. surgery to repair hernias and/or incompetent area
    • laparoscopic Nissen fundoplication / 
    • Angelchik prosthsis
  11. 4 post op hernia surgery care
    • tcdb
    • nasogastric tube in place on suction 1-2 d
    • only ivs until bowel function returns
    • mild dysphagia several wks
  12. 7 teaching points
    hiatal hernia
    • 1. drug therapy- know what they are, dosage, sched, and a/e
    • sm, freq meals. avoid foods that aggravate.
    • 3. maintain norm wt to decr abd pressure
    • 4. elevate hob to discourage reflux
    • 5. no smoking
    • 6. learn stress management
    • 7. avoid bending forward, lifting, straining, and tight clothes
  13. GERD
    6 s/s
    • 1 heartburn (pain radiating to beck, jaw, back - mimic heart attack)
    • 2 regurgitation
    • 3 belching/flatulence
    • 4 dysphagia/odynophagia (pain w)
    • 5 nocturnal cough/wheezing
    • 6 hoarseness
  14. 4 aggravating factors for GERD
    • 1. fatty/acidic foods:
    • (citrus, tomato, garlic, onions, choc, peppermint, caff, etoh, nicotine, nsaids/asp)

    2 incr intraabdominal pressure (from strain, obese, preg)

    3 lying down/bending over

    4 enetics
  15. 3 GERD meds
    1 h2-receptor blocker agents: (ranitidine-Zantac)

    2 prokinetic agents: (metoclopramide-Reglan)

    3 Proton Pump inhibitor agents: (omeprazole - Prilosec)
  16. 4 Tx for GERD
    • dietary/lifestyle changes
    • reducing intraabdominal pressure
    • smoking cessation
    • surgery
  17. most common site of PUD
    duodenum - 80%
  18. PrevPak tiple therapy
    H. Pylori infection
    • Prevacid 30 mg bid
    • Amoxicillin 1 g bid
    • Biaxin 500 mg bid
    • for 10 days
  19. PUD Complications HOP
    • hemorrhage
    • obstruction
    • perforation
  20. PUD hemorrhage occurs when
    • bld vessels erode
    • large amounts: frank
    • small: occult
  21. 5 tx hemorrhage PUD
    • NGT for lavage
    • dx tests/surgery to locate source/evaluate/tx
    • endoscopy w laser/cauterization stop blding
    • esophageal balloon
    • transfusion
  22. PUD obstruction
    • tissures near ulcer become edematous/scar
    • gastric outlet obstruction
  23. PUD obstruction leads to
    • retention of food in stom
    • persistant vomiting
  24. dx and tx of PUD obstruction
    • ugi
    • gastroscopy
    • ngt to suction
  25. PUD perforation
    erosion through all layers, with spilling of contents of gi tract into peritoneum

    • danger of hemorrhage and peritonitis
  26. 6 PUD perforation s/s
    • sudden severe pain (refer to shoulders)
    • abd rigidity 
    • rebound tenderness
    • decr bowel sounds
    • fever
    • shock
  27. 4 tx PUD perforation
    • surgery
    • NGT to suction
    • transfusion
    • antibiotics - peritonitis
  28. gastric ulcers have a tendency to
  29. duodenal ulcers have a tendency to
  30. most peptic ulcer disease cases are caused by
    bacterial infection Helicobacter pylori
  31. surg tx PUD 
    truncal vagotomy
    vagus nerve supplies the stom is severed
  32. surg tx PUD
    truncal vagotomy
    decr stimulation of gastric acid secretion
  33. surg tx pud
    tuncal vagotomy
    4 ae
    • delayed gastric emptying
    • feeling of fullness
    • dumping syndrome
    • diarrhea
  34. surg tx pud
    selective/superselective vagotomy
    • severs prt of vagus nerve that stimulates acid production 
    • spares nerve supply to pyloric sphincter
  35. surg tx pud
    select/super vagotomy
    decr stimulation of gastric acid secretion
  36. surg tx pud
    selct/super vagotomy
    delayed gastric emptying
  37. surg tx pud
    widens pylorus
  38. surg tx 
    • improves passage of stom contents into dou
    • done w vagotomy to prevent gastric stasis
  39. surg tx pud
    dumping syndrome from rapid emptying stom into dou
  40. surg tx pud
    simple gastroenterostomy
    creates passage bw bd of stom and jejunum
  41. surg tx pud
    simple gastroenterostomy
    permits passage of alkaline int secretions into stom to neutralize gastric acid
  42. surg tx pud
    simple gastroenterostomy
    incr gastric acid secretion
  43. surg tx pud
    removal of antrum of the stom
  44. surg tx pud
    reduces gastric acid by removing source of acid secretion
  45. surg tx pud
    5 ae
    • diarrhea
    • feeling of fullness
    • dumping syndrome
    • malabsorption
    • anemia
  46. gastroduodenoscopy
    Billroth 1
    • part of distal portion of stom, including antrum, removed
    • remaining stom is anastomosed to duodenum
  47. gastroduodenoscopy
    Billroth 1
    reduces acid by removing source of acid secretion
  48. gastroduodenoscopy
    Billroth 1
    5 ae
    • dumping syndrome (but less often than others)
    • anemia
    • malabsorption
    • wt loss
    • bile reflux
  49. gastrojejunostomy
    billroth II
    part of distal portion of stom and antrum removed. remaining stom is anastomosed to jejunum
  50. gastrojejunostomy
    billroth II
    removes source of acid secretion
  51. gastrojejunostomy
    billroth II
    6 ae
    • dumping syndrome
    • wt loss
    • malabsorption
    • duodenal infection
    • pern. anemia
    • afferent loop syndrome (obstruction of duo loop)
  52. total gastrectomy
    • removal of entire stom
    • esophagus anastomosed to duodenum
  53. total gastrectomy
    removes source of gastric acid secretion
  54. total gastrectomy
    4 ae
    • consume only sml, freq meals
    • semisolid good
    • pern anemia
    • dumping syndrome
  55. dumping syndrome
    rapid emtying of stom contents into sml intestine
  56. dumping syndrome causes (5)
    sweating, palpitation, tachy, pallor, other vasomotor s/s approximately 30-60 minutes pc
  57. 4 directions for dumping syndrome
    • 1. diet low in carbs, refined sugar, moderate in fat, and high in protein
    • 2. smaller, more freq meals
    • 3. drink fluids bw meals, not with
    • 4. lie down for 30 min after meals
  58. postprandial hypoglycemia
    drop in bld sugar approx 2 hrs pc
  59. pernicious anemia
    b12 def r/t loss of intrinsic factor
  60. 5 nsg care gastrectomy
    • 1. know your drugs
    • 2. eat small freq meals 
    • 3. call dr if n/v/abd pain/dark tarry stools
    • 4. reduce recurrance- no caff/etoh/asp/nsaids
    • 5. stress management
  61. diverticulosis
    sml sacs/outpouches (herniations) in wall of colon resulting from protrusion of muc mem through weakened muscle wall
  62. diverticulitis
    inflammation/infection of decerticula due to filling of pockets w material passing thru gi (mucus and fecal matter)
  63. diverticulitis
    5 s/s
    • llq abd pain and tenderness
    • n/v
    • flatus
    • fever
    • rectal blding
  64. diverticulitis
    5 severe s/s
    severe - obstruction, gangrene, perforation, peritonitis, hemorrhage
  65. diverticulitis
    low residue diet foods (5)
    tx without spicy foods, nuts, seeds, fruits, or veggies
  66. colon resection
    affected part of colon is removed and temporary colostomy may be created to rest the colon while the surgical incisions heald
  67. anastomosis
    communication or connection bw two organs or parts of organs
  68. appendicitis
    pre-op care (3)
    • semi fowlers/side lying w hips flexed
    • withold analgesics until dr diagnoses & explain
    • ruptured? elevate head to localize inf
  69. appendicitis
    post-op care (7)
    • antibiotic agents
    • iv fluids
    • gi decompression
    • assist in tcdb or IS
    • show how to splint incision 
    • inspect wound (redness, swelling, foul odor)
    • wound care as ordered
  70. inflammatory bowel disease
    Crohn's (7)
    • chronic, relapsing, infl disorder of GI
    • cobblestone appearance (skip lesions)
    • not continuous
    • most freq occurs asc colon (right)
    • no smoking
    • s/s diarrhea w mucus and pus
    • not cured by surgery
  71. uc vs crohns
    young-middle vs. young
  72. uc vs crohns
    common in both
  73. uc vs crohns
    abd cramp pain
    possible vs. common
  74. uc vs cr
    during attacks vs common
  75. uc vs cr
    wt loss
    common vs severe
  76. uc vs cr
    rectal blding
    common vs infreq
  77. uc vs cr
    severe vs rare
  78. uc vs cr
    malabsorption and nutritional def
    minimal vs common
  79. uc vs cr
    starts distally and spreads in cont pattern up colon


    anywhere along gi tract in skip lesions (terminal ileum frequently)
  80. uc vs cr
    continuous vs segmental
  81. uc vs cr
    depth of involvement
    • mucosa and submucosa
    • vs
    • entire thickness of bowel wall (transmural)
  82. uc vs cr
    absent vs common
  83. uc vs cr
    cobblestoning of mucosa
    rare vs common
  84. uc vs cr
    common vs rare
  85. uc vs cr
    small-bowel involvement
    minimal vs common
  86. us vs cr
    rare vs common
  87. us vs cr
    rare vs common
  88. us vs cr
    anal abscesses
    rare vs common
  89. us vs cr
    common in both
  90. us vs cr
    toxic megacolon
    common vs rare
  91. us vs cr
    • incr incidence after 10 yrs of disease
    • vs
    • slightly greater than general population
  92. us vs cr
    recurrence after surgery
    cured vs 70% chance
  93. volvulus
    twisting of the bowel on itself
  94. intussception
    telescoping of the bowel
    • Change in bowel/bladder habits
    • A sore that does not heal
    • Unusual blding or discharge
    • Thickening or lump in breast/elsewhere
    • Indigestion of difficulty swallowing
    • Obvious change in wart or mole
    • Nagging cough or hoarseness
  96. colorectal screening guidelines
    ACS (6)
    • fecal occult bld test FOBT
    • or fecal immunochemical test FIT
    • Stool DNA
    • FSIG Flex. sigmoidoscopy 
    • double contrast barium enema DCBE
    • CT colonography
  97. leukoplakia 4
    • white patch, smokers patch
    • chronic irritation/heat exposure
    • precancerous 5%
    • dental hygienist discovers
  98. erythroplakia (6)
    • red, velvety patch
    • precancerous 90%
    • Barrett's esophagus-changes in epithelial lining r/t severe GERD
    • chronic gastritis w h pylori
    • IBD- ulverative coll/crohns
    • colonic polyps
  99. most common gi cancer
    colrectal ca
  100. vagotomy
    • part of tx, sever vagus nerve innervation to stom to decr acid secretion by cells
    • total or selective
  101. melena
    tarry stools from digested blood
  102. ACS colorectal screening guidelines
    class h/o
    • fobt annually and sigmoidoscopy q 5 yrs
    • screening for all above 50 and younger if you are at risk
  103. colorectal risk factors (5)
    • age over 50
    • personal/fam hx
    • hx of polyps and IBD (ulcer coll and crohns)
    • low-fiber/high fat diets
    • obesity
  104. colorectal ca
    • silent disease 5-15 yrs of growth before s/s
    • 40% discovered in localized stage
    • 91% are over 50
  105. colorectal ca
    most occur in
    • distal colon
    • sigmoid/rectum
  106. s/s colorectal ca 6
    occult rect blding, change in bowel habits, narrow ribbon stools, incomplete emptying, dull abd discomfort, distention
  107. pouch ileostomy
    Kock pouch
    internal pouch constructed from ileum; end of eleum intussescepted to form one-way nipple valve
  108. draining Kock pouch
    • via cath inserted thru stoma (pressure of full pouch forces nipple valve to close).
    • initially- q 2-4 h, as heals-qid
  109. ileoanal reservoir
    • takes 2 surgeries
    • one for colectomy/ileostomy and creation of reservoir, then one for closure of ileostomy a few mos later
    • continent within 3-6 mo
  110. ostomy care 5
    • change face as needed
    • remove carefully
    • use solvent prn to loosen adhesive
    • wash and dry gently 
    • proper fit and skin barrier
  111. stoma assessment 4
    • bright red swollen at first
    • turns pink when healed
    • monitor for blding, assess skin for brk down
    • monitor output, drainage, dont let fill over 1/2 full
  112. stoma irrigation procedure
    part 1
    • id pt, explain, gather, wash, privacy, position, relaxed pace
    • solution bag 500-1000 ml luke warm water
    • flush tubing w solution to clear line and clamp
    • hang container 18-24 in above
    • apply irrigation sleeve, place end in toilet
  113. stoma irrigation procedure
    part 2
    • lube cone, insert but not beyond widest point
    • hold secure, flow steady for 5-10 min
    • slow/stop if cramps
    • clamp off when complete
    • allow 20 min for fecal matter to expell
    • clean, rinse, dry stoma, reapply appliance
    • reposition, document, and teach
  114. stool characteristics
    • ascending - liquid, very irritating to skin
    • transverse - paste/liquid
    • descending - solid or formed
  115. NSG goals Kocks pouch 5
    • facilitate pt adaptation
    • promote healing, skin integrity
    • maintain bowel function
    • adequate nutrition and f&e balance
    • promote comfort
  116. Kocks pouch drainage key points 3
    • no 28 cath
    • insert 2 in past stoma
    • if too thick - instill 30 ml of ns
  117. liver biopsy
    obtain cell sample; microscopic exam to r/o ca, cirrhosis, hepatitis
  118. liver biopsy
    check PT level
    • high risk for hemorrhage bc liver so vascular 
    • high level - postpone test; Vit K inj
  119. Pre liver biopsy
    NPO, baseline vs, pt voids, review breathing instructions, mild sedative 30 min before, needle bx at bedside, gather, pt supine, r arm behind head, folded towel under r side, during procedure pt deep breath in, out, and hold; aspiration bx needle thru intercostal space, ad wall, liver; spec injected into preservative solution/lable/lab, pressure dressing
  120. after liver biopsy
    check order
    • keep pt r side w blanket against site for few hr
    • br 24 hrs
    • freq vs: assess for complications
  121. post liver bx complications 4
    • blding at site (shock- incr hr, restless, cool/clammy/pale, decr bp)
    • infection - incr temp, chills
    • pneumothorax - sob, incr resp/shallow, incr hr
    • peritonitis - fever, rigid/pain abd, rebound, distention
  122. HIDA scan 
    another name
    cholescintigraphy; overhead
  123. HIDA scan***
    • NM test: iv radioactive substance
    • HydroxyIminoDiacetic Acid 
    • given/taken up by bile, flows where bile goes, then scanner, passed over area of gb, also give cholecystokinin to cause gb to contract/squeeze, evaluates gb function/obstruction/bile leak
  124. US diagnoses
    tumors and cirrhosis
  125. ERCP
    endoscopic retrograde cholangiopancreatography
    used for retrieval of stones in common bile duct, bx and dx tomors/cysts, or to dilate strictures
  126. paracentesis
    peritoneal tap to drain ascitic fluid from abd cavity for dx and tx purposes
  127. GB series/IV cholangiogram
    low fat meal pm before test 4pm, then 6pm, radiopague iodine dye taken (1 tab q 5 min w ample water; 6 tabs total); then NPO; xray next day
  128. portal venography/hepatic arteriography
    contrast introduced into hep circulation, then xrays taken to assess vess and flow from them
  129. liver scan
    • NM test: IV radioisotope given (trace dose) then scan liver
    • evaluates size, shape, tumors, and abscesses