Med Surg Exam 1

Front 1

Assessment PUD pain
1.general
2.gastric
3.duodenal

Back 1

1. general - left epigastric pain, if ulcer has perforate pain in right shoulder

2. Gastric Ulcers- onset of pain is 0.5-1 hr after eating, rarely at night, sometime relieved by vomiting, eating doesn’t help and may actually increase pain

3. Duodenal Ulcers- onset of pain is 2-3 hours after eating, often awakened by pain between 1-2 AM, eating relieves pain

Front 2

menu selection /teaching PUD (5)

Back 2

small frequent meals, avoid milk products as these stimulate gastric secretion, no food before bed, no EtOH, no smoking

Front 3

3 major complications of PUD (with s/s)

Back 3

1.Perforation/penetration signs include severe upper abdominal pain that may be referred to the shoulder (phrenic nerve), vomiting and collapse, tender board-like abdomen, and symptoms of shock/impending shock.
2. Hemorrhage
3. Pyloric Obstruction- s/s: N/V, constipation, fullness, anorexia, weight loss (later), tx: NG tube, IV fluids and electrolytes, balloon dilation, surgery

Front 4

Assessment of dumping syndrome

Back 4

15-30 minutes after meals, N/V, abdominal cramping, fullness, diarrhea, palpitations, tachycardia, hypotension, diaphoresis, weakness, dizziness, pallor, dehydration

Front 5

Nursing interventions for dumping syndrome

Back 5

B. Nursing intervention dumping syndrome- low Fowler’s position after meals, lie down for 1 hour after eating, avoid fluid with meals, minimal flushing with tube feeds, meal with more dry items than liquid items, eat high protein diet, fat as tolerated but keep CHO intake low and avoid concentrated carbs, eat small frequent meals, dietary supplements as prescribed, vitamins, and B12 injections

Front 6

assessment of ulcerative colitis

Back 6

Assessment ulcerative colitis- proceeds linearly upward from anal and rectal areas, does not affect underlying mucosa, diarrhea with blood and mucus 15-20 times/day, abdominal pain, cramping, N/V, fever, loss of appetite, wt. loss, dehydration, tenesmus

Front 7

assessment of Crohn's Disease

Back 7

Crohn’s disease assessment: Lesions anywhere in the GI tract mouth to anus. Large ulcerations deep into the mucosal lining of 4 layers of the intestinal tract, pain in RLQ, abdominal cramps and spasms after meal, nausea, flatulence, wt. loss, elevated temperature, chronic diarrhea sometimes with blood and mucus, sores/abscesses around the anus, gallstones, ulcerations of the tongue, uveitis- inflammation of the eye, erythema nodosum (rash on legs)

Front 8

patient teaching for ileostomy care

Back 8

patient teaching ileostomy care- stool thickens to porridge/toothpaste consistency may take several weeks, stool should never be formed, stool consistency is diet and fluid dependent, stool passes into ileostomy 1.5-4 hours after eating, contains harsh enzymes so avoid contact with skin, stoma should be pink and moist (concerned if it turns gray), bloody discharge within 48 h of the procedure, 24-48h before ileostomy starts to function, swelling will decrease over the course of 6 weeks, discharge green

Front 9

Risk factors for colorectal cancer

Back 9

family history, age over 50, colorectal polyps, genetic alterations, personal hx of cancer, ulcerative colitis, Crohn’s disease, diet that is high in fat and low in calcium, fiber and folate and low in fruits and vegetables, cigarette smoking

Front 10

assessment of colorectal cancer

Back 10

colonoscopy, changes in bowel movements, fatigue, weakness, abdominal and rectal pain, usually asymptomatic until disease is advanced, melena, weight loss

Front 11

preop prep for colorectal cancer

Back 11

. Preoperative preparation patient with colorectal cancer (colostomy)- low residue diet several days prior, liquid diet around 2 days before surgery, NPO after midnight, TPN may be necessary, series of enemas or bowel prep evening before, oral anti infectives day prior to decrease bacteria in the intestine, NG tube to remove gastric secretions day of surgery and prevent N/V

Front 12

stoma assessment

Back 12

pink, moist, look for signs of complication including necrosis, retraction, stenosis, prolapse, parastomal hernia (which may require surgery)

Front 13

stool characteristics/nursing assessment of blood in stool

Back 13

streaky bright red= hemorrhoids, upper GI bleed= black tarry stool, lower GI bleed= bright red bleed

Front 14

assessment of bowel obstruction/paralytic ileus

Back 14

early obstruction- bowel sounds are high pitched/tinkling proximal to obstruction, silent distally; late obstruction bowel sounds are silent, abdominal pain, colicky, vomiting with fecal odor, abdominal distention, VS normal early progressing to shock. Diagnosed by hx, physical findings and abdominal X ray

Front 15

nursing interventions for bowel obstruction / paralytic ileus

Back 15

Nursing interventions- NG tube, IV fluids and electrolytes, NPO to give bowel rest,

Front 16

patient teaching for an upper GI series

Back 16

withhold food and fluids 6-8 h before, no smoking, low residue diet 2-3 days before, stool will be light colored for up to 3 days, if gastrografin is used may have significant diarrhea, may experience flatulence, bloating, belching, contact physician if they develop: difficulty swallowing, epigastric, substernal or shoulder pain, vomiting blood or black tarry stools, fever

Front 17

describe fecal occult screening

Back 17

picks up abnormal blood loss of 10 ml in the stool, do 3 tests (sensitivity 92%), dietary restrictions 72 h before test include: red meat, radishes, turnips, cabbage, cauliflower, horse radish, uncooked broccoli, cantaloupe, citrus fruits, vitamin C supplements. Seven says before the test, stop ASA, NSAIDs and anticoagulants, if have hemorrhoids wait until stop bldg, no blood collected during period, avoid toilet bowl cleaners

Front 18

nursing interventions: acute diverticulitis

Back 18

liquid or low fiber foods advised during acute attacks but high fiber foods are recommended once symptoms have subsided, antibiotics as prescribed, surgery if necessary. Monitor for fever, abscess, peritonitis

Front 19

patient teaching for a hiatal hernia

Back 19

lose weight, antacids and PPIs as needed, no snacking at night, no heavy lifting, small frequent meals, stay upright for one hour pc , avoid constrictive clothing, avoid flexion at the waist

Front 20

discharge teaching for GERD

Back 20

no eating late at night, stay upright 1 hour pc, antacids. Factors that decrease of LES : nicotine, caffeine, chocolate, fatty foods, EtOH, peppermint, high levels of estrogen and progesterone, anti cholinergic drugs, tight clothing, hiatal hernia. Seek a MD even if sx go away bc could develop Barrett’s Esophagus.

Front 21

assessment of appendicitis

Back 21

abdominal pain generalized or localized in the RU abdomen eventually localizing in the RL abdomen (McBurney’s Point), anorexia, N/V, board like abdomen, rebound tenderness, sudden sensation of pain if ruptured, low grade fever, tecchycardia, diarrhea/constipation. Diagnosis by CT scan, WBC count

Front 22

assessment of hemmorhoids

Back 22

A. Assessment- bright red, streaky blood in the stool, painful tortuous veins

Front 23

risk factors for hemmorhoids

Back 23

B. Risk factors: pregnancy, obesity, chronic constipation, heavy lifting, prolonged standing, prolonged sitting, straining, severe coughing, aging

Front 24

endoscopy interventions before and after procedure.

Back 24

withhold food and fluids until the gag reflex returns, NPO 6-12 hours before the test

Front 25

what is the nursing role wrt surgical consent?

Back 25

Nursing role surgical consent- nurse can witness signature, but MD must explain procedure and consent form

Front 26

pt teaching about antihypertensive meds prior to surgery

Back 26

This is a case by case basis. A patient needs to be npo before surgery, however if you think it will be detrimental for a patient to not have their antihypertensive medicine before surgery, administering the medication is more important than the patient being npo.

Front 27

postop complications in obese pt.s

Back 27

higher risk for dehiscence and evisceration, impaired wound healing

Front 28

pt. teaching post-op management

Back 28

In order for a patient to heal properly and do their exercises (such as coughing and incentive spirometry) we need to make sure the patients pain is adequately managed. The RN should teach the patient to take their medications as prescribed, and keep up with the doses to maintain a constant analgesic effect and avoid spikes in pain. The RN can teach the patient alternative strategies to decrease pain (deep breathing, meditating, and visualization). The RN needs to remember that a patient’s pain is subjective.

Front 29

rationale for preop colon cleansing

Back 29

It is imperative to cleanse the colon before bowel surgery because they are filled with bacteria that could cause an infection during surgery if the bacteria is exposed to other tissue, or the patient’s circulating blood. It is vital to empty the bowel of stool (low residue diet 2 days before surgery, liquid diet day before surgery, enemas or oral bowel preparation evening before/morning of surgery). The patient will be given oral-anti-infectives the day before surgery to decrease the bacteria in the intestine and help prevent postoperative infection. Cleansing is also important in order for the MD to be able to efficiently visualize bowel and identify polyps, ulcers, etc.

Front 30

nursing assessment post-op PACU

Back 30

In the Immediate post op stage (1-4 hours post op) respiratory function is the most important thing! The RN should monitor VS, ensure patent airway (suction prn, position)observe for bilateral chest movement (especially if the patient was intubated or had thoracic surgery), encourage coughing and deep breathing, monitor/administer O2, monitor pulse ox, monitor for s/s of atelectasis (alveolar collapse)

Front 31

assessment and treatment of malignant hyperthermia

Back 31

uncontrolled skeletal muscle contraction. Can occur as quickly as 20 minutes after induction or several hours post operatively. Initial s/s are increased C02, masseter muscle rigidity, cardiac arrhythmias, and a hyper metabolic state. Later s/s are hyperthermia (temp up to 109 degrees F), arrhythmia, and muscle breakdown. Death will result if the triggering event is not stopped, and the body isn’t cooled. Give DANTROLENE- a skeletal muscle relaxant to decrease skeletal muscle rigidity.

Front 32

how to determine risk for malignant hyperthermia

Back 32

B. Risk for: This is a genetic disorder. There is a screening tool, however it is expensive so it is not used often. Ask the patient if a family member has had any adverse effects to anesthesia.

Front 33

interventions for ammonia reduction

Back 33

Ammonia buildup in a patient can cause a change in neurologic status. If a person is constipated, there is an increase in the time for bacteria to digest foodstuff and make ammonia. Tell a patient to reduce the protein in their diet. If a patient is on narcotics, discontinue them to speed up their digestion and prevent constipation. If someone has kidney failure, they can have decreased clearance of ammonia and urea.

Front 34

nursing interventions for hepatic encephalopathy

Back 34

Administer Lactulose to decrease the pH of the bowel and decrease the production of ammonia by bacteria in the bowel and facilitates the excretion of ammonia. Administer Neomycin as prescribed to inhibit protein synthesis in bacteria in the bowel and decrease the production of ammonia. Avoid meds such as narcotics, sedatives, and barbiturates.

Front 35

prophylactic medical interventions - esophageal varices

Back 35

In a patient with no history of bleeding, should be treated with non-selective beta-adrenergic blockers (ex: propranolol), provided that the use of beta-blockers is not contraindicated. If there is a contraindication, long acting nitrates are a good alternative. The use of beta blockers decreases the risk of varices bleeding by 45%. The dose of the beta blocker is determined by a 25% decrease in resting heart rate, or a decrease in heart rate to 55 bpm, or development of adverse effects. Surgically, there is endoscopic sclerotherapy or variceal ligation.

Front 36

diuretic therapy/ascites nursing assessment

Back 36

Ascites is a build-up of up 15 L of albumin rich fluid in the peritoneal cavity. Diuretics are used to shed some of this fluid, but it is important to make sure that they are potassium sparing diuretics as the pt. already has elevated sodium leading to water retention. Eliminating potassium supplies would exacerbate the water retention.

Front 37

nursing care of paracentesis

Back 37

Nursing care paracentesis- Preprocedure: make sure there is informed consent prior to procedure, encourage the patient to void before procedure to empty bladder, and move the bladder away from the paracentesis needle, measure abdominal girth, obtain pt. weight and baseline VS (keep BP cuff on pt), position patient sitting at the foot of the bed with back supported and patient’s feet resting on a stool (they can remain in Fowler’s position if the patient is confined to a bed). Post procedure: VS 15 minx1 hr, 30 min x2hr, q1hr x 2 hours, then q4 hrs x24 hrs. Check temp q4hrs. Keep patient on bed rest, apply dry-sterile dressing to insertion site. Monitor insertion site for s/s of bleeding, measure abdominal girth and weight, monitor for hematuria indicating bladder trauma, and instruct pt. to notify MD if urine becomes bloody, pink, or red.

Front 38

Stages of Hepatic Encephalopathy

Back 38

Stage 1.) Normal LOC with periods of lethargy and euphoria: reversal of day/night sleep patterns.
Stage 2.) Increased drowsiness, disorientation, inappropriate behavior, mood swings, agitation
Stage 3.) Stuporous, difficult to arouse, sleeps most of the time, marked confusion, incoherent speech
Stage 4.) Comatose; may not respond to painful stimuli
B. Nursing interventions re:diet. Limit protein (especially red meat) because ammonia is a byproduct. Increase fiber in order to avoid constipation.

Front 39

nursing interventions for esophageal balloon

Back 39

Nursing interventions esophageal balloon (Sengstaken-Blakemore Tube)-NG inserted balloon with 4 lumen (2 balloons, 2 for aspiration) at the top that are inflated to put pressure on the varicose veins to stop the bleeding. RN interventions: monitor for complications including re-bleeding when you remove the device, rupture, nasal ulcer.
If bleeding esophageal varix: Assess rate and volume of bleeding, gain venous access and obtain immediate hematocrit (IV blood, hematocrit, measure platelet count, PTT), check renal and liver function tests, establish airway, insert NG tube to lavage gastric contents before endoscopy. If needed, fresh frozen plasma and vitamin K.

Front 40

nursing interventions: liver biopsy

Back 40

After biopsy, have patient lie on their right side to place pressure on the area where the needle was inserted to try to stop bleeding. Watch for signs of bleeding, and signs of shock. This can start for up to 15 days after biopsy.

Front 41

Serum lab changes cholelithiasis

Back 41

Increased WBC count indicates inflammation, increased cholesterol

Front 42

diagnosis of acute pancreatitis?

Back 42

Diagnosis is serum amylase and serum lipase rise in excess of 3 times normal upper limit in 24 hours.

Front 43

assessment of acute pancreatitis

Back 43

- s/s severe constant knife like pain in the RUQ, gastric and or radiating to the back. In acute pancreatitis, inflammation of pancreas from activated enzymes that auto digest the pancreas. The pain and discomfort is not relieved by vomiting. Weight loss, the pain is worse when lying down and/or eating, Turner’s sign (ecchymosis of flank), Cullen’s sign (blue-ish peri umbilical discoloration), steatorrhea, generalized jaundice, paralytic ileus, hyperglycemia.

Front 44

Nursing interventions for acute pancreatitis

Back 44

Rest for pancreas is priority. NPO until pain free, NG tube, TPN, no EtOH, no smoking, limit stress. When diet is resumed, bland low fat food with no stimulants and small, frequent meals. For pain management, take opioids as prescribed, position for comfort (fetal side lying with head of bed elevated, or sitting up and leaning forward.) Monitor blood glucose levels, monitor hydration levels, monitor stool for steatorrhea, and administer abx and vitamin supplements as prescribed.

Front 45

assessement of acute cholecystitis

Back 45

- indigestion, chest pain after eating fatty, fried food, jaundice, episodic colicky pain in epigastric area which radiates to the R side of back and shoulder, N/V, fullness, elevated temperature, steatorrhea, Murphy’s Sign (pain d/t peritoneal rubbing, in RUQ of abdomen)

Front 46

Post-Op teaching for laproscopic cholocystectomy

Back 46

Pt. may experience free pain in R shoulder, ambulation is helpful, monitor Jackson Pratt drains. Encourage small frequent meals, low fat diet and weight loss, avoid gas forming foods. Laparoscopy has faster recovery and less pulmonary issues.

Front 47

pancreatic enzyme therapy

Back 47

Pancreatic enzymes such as pancreatin (Donnazyme), pancrelipase (Viokase) may be prescribed with meals to aid in digestion of fats and proteins.

Front 48

etiology of gallbladder disease

Back 48

Gallstone prone pts. have decreased bile acid synthesis and increased cholesterol synthesis in the liver resulting in bile which is supersaturated with cholesterol, which precipitates out of the bile to form stones which act as an irritant that produces inflammatory changes in the GB. Inflamed gallbladder can’t contract in response to fatty foods entering the duodenum because of obstruction by calculi or edema

Front 49

Factors that decrease tone of LES

Back 49

Factors that decrease tone of LES : nicotine, caffeine, chocolate, fatty foods, EtOH, peppermint, high levels of estrogen and progesterone, anti cholinergic drugs, tight clothing, hiatal hernia