Med-Surg Exam 2 (Second Set)

Front 1

Mortality rate from Upper GI bleeds

Back 1

6-10% (for the past 40 years)

Front 2

Increased incidence of UGIB in ____________

Back 2

-Elderly (especially women)
-Anyone who has increased use of NSAIDs

Front 3

MAJOR cause of GIB is ___________

Back 3

NSAIDs

Front 4

Upper GI Bleed Etiology/Pathophysiology

Back 4

-Characterized by sudden onset
-Insidious bleeding

Front 5

Different origins of GI bleeds (3):

Back 5

-Venous
-Capillary
-Arterial

Front 6

"obvious" UGI bleed:

Back 6

-Hematemesis, blood is bright read and visible in emesis, or coffee ground-like appearance
-Malena, black tarry stool caused by digestion of blood in the GI tract. Caused by slow bleeding from an upper GI source

Front 7

"occult" bleeding

Back 7

Small amounts of blood in gastric secretions/vomitus/stools, undetectable by looking at it, must use guaiac test

Front 8

Esophageal origin GI bleed

Back 8

-"Chronic esophagitis" (from GERD, mucosa-irritating drugs, alcohol/cigarettes)

-Mallory-Weiss tear

-Esophageal varices (often due to liver cirrhosis. veins become engorged and torturous)

Front 9

Stomach and duodenal origin GI bleed causes

Back 9

-Gastric cancer
-Hemorrhagic gastritis
-PUD (H. pylori or NSAID use)
-Polyps
-Stress-related mucosal disease, physiologic stress ulcers

Front 10

Drug-induced origin- major cause is _________

Back 10

NSAIDs!

Aspirin, Excedrin, Alka-seltzer, Corticosteroids

OTC use history is really important!

Front 11

80-85% of patients with massive GI bleed spontaneously _________ ______________.

Back 11

stop bleeding.

Front 12

Emergency assessment for someone with a GI bleed (4):

Back 12

-BP! (VS q 15-30 minutes)
-Rate and character of pulse
-Peripheral perfusion with capillary refill
-Observation of neck vein distention (filling or flat?)

Front 13

Management of emergency GI bleed:

Back 13

-Evaluate s&s of shock
-Treatment/interventions ASAP
-Assess respiratory status
-Abdominal exam: is it tense/rigid? (may indicate perforation/peritonitis)

Front 14

Once immediate interventions have started:

Back 14

1. Get complete history of events leading to bleeding
2. Ask (patient or family): if/how many previous bleeds, weight loss, ever received blood transfusion, other illnesses (liver??), medication use (!), religious preferences regarding blood product usage

Front 15

Emergency lab studies in GI bleed:

Back 15

-CBC
-BUN/Creatinine
-Serum electrolytes
-Blood glucose
-Prothrombin time
-Liver enzymes
-ABGs
-Emesis/stool tested for occult blood
-Urinalysis
-Test blood for type for possible transfusions

Front 16

Emergency interventions for GI bleed:

Back 16

-Fluid replacement (saline, lactated ringers)
-Blood replacement

Front 17

Why people need a tracheostomy;

Back 17

Something is interfering with their own trachea and we need to create an artificial airway for them.

(can be due to tumor, trauma, head/neck surgery, chewing tobacco, smoking)

Front 18

Advantages of a trach (know to explain to patient):

Back 18

-Less risk of long-term damage to airway
-Increased comfort
-Patient can eat
-Increased mobility because tube is secure

Front 19

Put new _______ around old one to replace it quickly in case the patient _________ it out

Back 19

STRING, COUGHS

Front 20

MAKE SURE there is a ____________ close by (on the wall, in a drawer, somewhere nearby)

Back 20

Obturator

Front 21

Tracheostomy patients are at HIGH risk for __________

Back 21

pneumonia

Front 22

Tracheostomy care is a _______________ procedure

Back 22

sterile

Front 23

Increased risk of ____________ pneumonia

Back 23

ASPIRATION pneumonia. Sit them ALL THE WAY up when eating.

Front 24

Retention sutures

Back 24

Placed during insertion of the trach, when trach is taken out (or coughed out) the sutures pull the skin together for healing

Front 25

Need to clean under the _________

Back 25

Flange

Front 26

After insertion, immediately remove the _________

Back 26

obturator

Front 27

When cleaning tube, always wear a ____________ with a ________

Back 27

SHIELD with a MASK

Front 28

If they are an aspiration risk or on mechanical ventilation, they get an _________ cuff

Back 28

INFLATED

Front 29

If the patient can protect themself against aspiration, or they do not require mechanical ventilation, they get a _________ tube

Back 29

CUFFLESS

Front 30

Cuff should not exceed ________ mm Hg or _______ cm H2O

Back 30

20, 25

Front 31

Excessive cuff pressure will:

Back 31

-Compress tracheal capillaries
-Limit blood flow
-Predispose to tracheal necrosis

Front 32

Providing tracheostomy care includes (5):

Back 32

-Suctioning the airway to remove secretions
-Cleaning around the stoma
-Changing ties
-Inner cannula care
-Oral hygiene

Front 33

Deflate during ________

Back 33

EXHALATION

Front 34

Reinflate during _____________

Back 34

INHALATION

Front 35

Precautions for tube placement

Back 35

-Tube of same size or smaller must be at the bedside
-Tapes not changed for at least 24 hours after insertion, but within 7 days
-FIRST change is performed by the physician

Front 36

Accidental dislodging:

Back 36

Immediately replace tube!
-Spread the opening w/ retention suture or hemostat
-Insert the obturator (lubricate first with saline, insert at 45 degrees)
-Once new tube is inserted successfully, remove obturator to allow air to flow

Front 37

If tube cannot be replaced:

Back 37

-Assess level of respiratory distress
-Allieve minor dypsnea with semi-fowler's position
-Cover stoma with sterile dressing ing and ventilate with manual bag-mask until help arrives (call for it!)

Front 38

Nursing diagnoses for Trach care

Back 38

-Ineffective airway clearance
-Impaired verbal communication
-Risk for infection
-Impaired swallowing
-Ineffective therapeutic regimen management

Front 39

Emergency management of UGIB

Back 39

-Whole RBCs/frozen plasma if loss from massive hemorrhage--blood replacement
-Fluid replacement--isotonic crystalloid

Front 40

Emergency assessment and management of UGIB

Back 40

MONITOR HBG AND HCT CLOSELY!
-Initial hemtocrit may be normal and not reflect loss until 4-6 hours after replacement
-Supplemental O2
-Indwelling urinary catheter (assess urine volume)
-Central venous pressure line to assess patient's fluid volume status

Front 41

Endoscopy

Back 41

Primary tool for assessing source of bleeding
(may need to lavage before scoping for a clearer view)
-NG or orogastric tube placed, room-temp water or saline used
-NEVER ADVANCE AGAINST RESISTANCE

Front 42

How to remove GIB clots:

Back 42

aspiration of stomach contents through a large-bore tube (Ewald tube)

Front 43

Angiography:

Back 43

-Used only when endoscopy cannot be done
-Invasive procedure, may not be appropriate for high-risk/unstable patient
-Catheter placed into left gastric or superior mesenteric artery until site of bleeding is discovered

Front 44

Barium Contrast

Back 44

Limited use while treatment is going on, but after treatment this test can document a lesion, but cannot verify its source

Front 45

Nursing assessment for GIB

Back 45

-LOC
-VITAL SIGNS q15-30 MINUTES! check for orthostatic
-Appearance of neck veins
-Skin color
-Capillary refill
-Abdominal distention, guarding, peristalsis

Front 46

SIGNS AND SYMPTOMS OF SHOCK

Back 46

-Low BP
-Rapid, weak pulse
-Increased thirst
-Cold, clammy skin
-Restlessness

Front 47

ACUTE nursing intervention for UGIB

Back 47

-Approach calm manner to decrease patient's anxiety
-IV maintenance
-I&O
-Caution when administering sedatives for restlessness (warning signs of shock may be masked by drugs)

Front 48

Accurate intake and output record during GIB

Back 48

-Urine output hourly
-At least 0.5 ml/kg/hr indicates adequate renal perfusion
-Urine specific gravity measured (Normal 1.005-1.025)

Front 49

Check CVP line or PAC line readings every ___________

Back 49

1 to 2 hours

Front 50

Tests relating to blood levels during UGIB:

Back 50

-Assess stools for obvious and occult blood
-Monitor Hb and Hct every 4-6 hours
-BUN assessed (fluid status and renal perfusion)

Front 51

Oxygen management during UGIB:

Back 51

Monitor O2 Saturation/PaCO2

Front 52

Nutrition as an acute intervention for UGIB:

Back 52

-Observe for symptoms of nausea/vomiting
-Recurrence of bleeding
-Feedings initially include clear fluids or milk q Hr
-GRADUAL introduction of food as tolerated

Front 53

DRUG THERAPY in UGIB: actue meds

Back 53

-Decrease bleeding
-Decrease hydrochloric acid secretion
-Neutralize hydrochloric acid that is present

Front 54

Acute hemostasis:

Back 54

injection therapy during endoscopy

Front 55

What to give for bleeding due to ulceration:

Back 55

Epinephrine (combined with other therapies. Put pressure on bleeding course because it produced tissue edema)

Front 56

For esophageal variceal bleeding:

Back 56

vasopressin (Pitressin)

-causes vasoconstriction, increased smooth muscle activity of the GI tract
-Used in patient who do not respond to other therapies and are poor surgical risk
-Administered at the site of bleeding

Front 57

Side effects of Pitressin

Back 57

-Decreased myocardial contractility
-Decreased coronary blood flow
-Visceral and peripheral and ischemic s/e
-Used cautiously in those with vascular disease

Front 58

Acid reducers:

Back 58

-Histmine 2 receptor blockers
-Proton Pump Inhibitors

Part of standard treatment but no ability to control active bleeding

Front 59

H2 Receptor Blockers

Back 59

cimetidine (Tagamet), raniditine (Zantac)

-Inhibits action of histamine at H2 receptors and decreases HCL acid secretion

Front 60

PPIs (Proton Pump Inhibitors)

Back 60

pantoprazole (Prontonix), esomeprazole (Nexium)

-Suppress gastric secretion by inhibiting H+/K+ ATPase enzyme system, inhibits gastric pump

Front 61

Patient education related to UGIB:

Back 61

-Disease process/drug therapy
-Avoidance of gastric irritants like alcohol and cigarettes
-Take only prescribed medications, limit OTC
-Methods of testing for occult bleeding
-potential a/e relating to GI bleeds
-Prompt treatment of patient with esophageal varices
-If aspirin is required use enteric coated
-Meds with food will decrease potential irritating effects
-

Front 62

Education to prevent future bleeding episodes:

Back 62

-NO other drugs other than those prescribed
-No smoking/alcohol
-Need for follow up care
-Instruction for what to do if a future acute hemorrhage occurs