Med Surg Exam 2

Med Surg Exam 2 Small Intestine Absorption of nutrients Folic acid Cobalamin Iron Fat-soluble vitamins Hormones and neurotransmitters Absorption of fat, carbohydrates, and proteins Abdominal Quadrants Right upper o Pylorous o Duodenum o Gallbladder o Liver Left upper o Stomach o Spleen Right lower o Cecum o Appendix Left lower o Sigmoid colon Midline o Urinary bladder o Uterus GI Focused Assessment Health History Current GI Symptoms Previous GI Problems Family History of GI Problems Medication Use: prescription and OTC Diet and Nutrition (Food Allergies) Use of Alcohol, street drugs, Caffeine Bowel Elimination Pattern Social/Cultural Factors GI Focused Assessment Physical Vital Signs Height and Weight Lab and diagnostic test results Emesis, amount, color, consistency Stool, amount, color, consistency, odor. Oral Assessment Abdominal Assessment Rectal Assessment Factors affecting bowel elimination Age Diet Fluids Physical activity Personal habits Pain Pregnancy Surgery & anesthesia Medications Effects of Aging Mouth o Teeth loosen, reduced circulation to gums, teeth darken and fracture o Decreased output of salivary glands o Decreased stimulation of taste buds Stomach o Atrophy of gastric mucosa o Decreased secretion of hydrochloric acid o Decreased bile secretion Decreased muscle tone and strength Diagnostic Tests Lab tests o Bowel preparations o Colonoscopy o Provides direct visualization of the rectum, colon, entire large intestine, and distal small bowel. A flexible scope is inserted through the rectum and advanced to the cecum. o Useful in detecting lower GI disease. o Positioning: LT side with knees to chest o Anesthesia: Moderate sedation (Midazolam, fentanyl, and/or propofol) o Prep ▪ Bowel Prep (laxatives, such as bisacodyl and polyethyline glycol) ▪ Clear liquid diet, NPO after midnight ▪ Patient must avoid medications such as aspirin, anticoagulants, and antiplatelets. o Post ▪ Monitor for rectal bleeding ▪ Do not drive or use equipment for 12-18 hrs after Laparoscopy o The peritoneal cavity, pelvis, and abdomen are examined. This test is used to detect cysts, adhesions, fibroids, infections of the uterus, fallopian tubes, and ovaries, ectopic pregnancies, liver lacerations, and cirrhosis. Esophagogastoduodenoscopy o Insertion of endoscope through the mouth into the esophagus, stomach, and duodenum to identify or treat areas of bleeding, dilate an esophageal stricture, and diagnose gastric lesions or celiac disease. o Position: LT side laying with head of bed elevated o Anesthesia: Moderate sedation per IV access. Topical anesthetic to depress gag reflex, atropine to decrease secretions. o Prep: NPO 6-8 hrs. o Post: Withhold fluids until return of gag reflex Proctosigmoidoscopy o Digital examination to dilate the anal sphincters to detect obstruction that might hinder passage of the endoscope, a sigmoidoscope to examine the distal sigmoid colon and rectum, and a proctoscope to examine the lower rectum and anal canal. The proctosigmoidoscopy is used to identify internal hemorrhoids, hypertrophic anal papillae, polyps, fissures, fistulae, and rectal and anal abscesses. Paracentesis o The aspiration of fluid from the abdominal cavity. Nutrition Support Daily weights Gastrostomy feedings o Patients require 25–30 kcal/kg/day and 30 mL free water/kg/day. o If the feeding tube will be used for less than 30 days, select a nasogastric tube in the range of 8-Fr to 18-Fr. A larger bore nasogastric tube allows for suction if needed. Smaller tubes, 8-Fr to 12-Fr, are used for intestinal feeding (duodenal and jejunal). Parenteral nutrition o Providing nutrients to patients in an intravenous (IV) solution. Functions of the Kidney (A WET BED) Acid-base balance Water removal Erythropoiesis Toxin removal Blood pressure control Electrolyte balance Vitamin D activation Acute Abdomen Pathophysiology o Three major pathological processes, inflammatory, obstructive, and vascular, can produce acute abdominal pain. Inflammation may be infectious or chemical, but regardless of cause, the chain of pathological events is the same. Affected structures demonstrate reactive hyperemic, with exudation of fluid into tissues due to increased vascular permeability and an increase of filtration pressure. Assessment o Pain score, SPECIFIC location, quality, duration, onset. o Vital signs o Review current medication list o Appetite o Bowel pattern and consistency o Bowel sounds o Distention Diagnostic tests o MRI - which is least invasive o CBC, BMP o Liver function test AST, ALT, albumin(low) and bilirubin will be evaluated to indicate any cirrhosis or hepatitis o Amylase increase will indicate pancreatitis o 12 lead electrocardiogram (ECG) Implementation o Ensure adequate hydration o Patient may need IV fluids duet to nausea or NPO status. o Control pain o Repositioning, heat/cold, analgesics, muscle relaxants o Monitor I&Os o Bowel monitoring Crohn’s Disease Chronic inflammatory bowel disorder with a relapsing and remitting course. Once remission is achieved, the main aim of the management of Crohn's disease is maintenance of that remission. Assessment with clinical manifestations o Abdominal pain (RLQ) o Abdominal tenderness o Pain is relieved temporarily with defecation o Diarrhea Nursing Interventions o Diet: high- calorie, high protein o Weigh daily o Maintain calorie count o Monitor I&O Acute Inflammatory Disorders: Appendicitis Pathophysiology o The function of the appendix is not completely known, but it does regularly fill with and empty digested food. If untreated, necrosis, gangrene, and perforation follow. If the perforation is contained by the omentum, an appendiceal abscess results; if containment does not occur, generalized peritonitis results. Assessment with clinical manifestations o Periumbilical pain o Nauseous o Low- grade fever o Rovsing’s sign (Rebound tenderness) o Pain in the LLQ o McBurney’s point (pain elicited in the RLQ when firm pressure is applied) Diagnostic tests o CBC (elevated WBC) o CT o Urinalysis o Ultrasound Planning and implementation o Treatment: Appendectomy is the most common emergency abdominal surgery in the United States. Evaluation of outcomes o Acute pain related to the appendicitis. The patient should verbalize an adequate relief of pain along with the ability to realistically cope with the pain if it is not completely relieved. Diverticulitis Diverticula disorders increase with age. Low fiber diets and those high in processed foods are associated with diverticular disease. Other correlates with the disorder are decreased activity levels and constipation. Pathophysiology o The muscles where there are diverticular areas thicken, and the lumen is narrowed, which increases intraluminal pressure. With the deficient fiber intake seen in diverticular disease, the bowel develops a higher pressure, and the mucosa herniates through the muscle wall, which forms the diverticulum. As the diverticulum increases in size, it obstructs the bowel area and causes irritability of the colon. Assessment with clinical manifestations o Constipation or diarrhea o Abdominal pain in the LLQ o IBS development o Abdominal cramping o Generalized fatigue o Low-grade fever Diagnostic tests o CT scan of the abdomen and pelvis o CBC (leukocytosis, elevated sedimentation rate) o X-ray Planning and implementation o Nurses can perform patient education in the community related to the necessary dietary changes, including an increased fiber intake and teaching the early symptoms of diverticular disease. Obstruction Etiology o Paralytic ileus reflects altered neuromuscular function that impairs gut motility and has multiple potential causes. o Medication use (some anesthetic agents, opiates) may contribute to this state of localized paralysis. Intraperitoneal and retroperitoneal infection, arterial or venous injury, and metabolic derangements (hypokalemia) may also be associated with ileus. Pathophysiology o Ingested fluids, food, swallowed air, digestive juices or secretions, and gas accumulate proximal to the blockage. The distal bowel collapses and the proximal loops dilate. Distension stimulates secretory activity, and the absorptive functions of mucous membranes fail. o Can be either mechanical (physical or structural) or functional. Most obstructions occur in the small intestine. Assessment with clinical manifestations