med surg/psych test 3

SIRS/autoimmune, upper GI, lower GI, non-inflamm intestinal disorders, inflammatory intestinal disorders, acute inflammatory intestinal disorders, Liver, gallbladder and pancreas issues. Psych: mental health, mental illnessmaslow hwirarchy of needs, anxiety, defence mechanisms, loss + grief, and mental status exam

what is VRE

vancomycin resistant enterococcus

what are nursing interventions for MRSA and CRE

bathing patients with 2% chlorhexidine wipes DAILY

what medication can be used for MRSA

nasal mupirocin ointment ino the care to treat MRSA colonization

what is the cause of C. Diff

a spore that is present, that is not removed with hand sanitizer. Usually presents after prolonged vancomycin IV

treatment of oral vancomycin

ORAL vancomycin (since it stays more in GI tract, there are less systemic effects).

patient education for MRSA, VRE, CRE and C. Diff

frequent hand hygiene (avoid hand sanitizer for C. diff), avoid close contact with people who have infectious wounds or active infection, avoid large crowds, avoid contaminated surfaces, use good overall hygiene.

assessment findings for a patient with an infection

local site - swelling, heat, redness/hyperpigmentation, pus

systemic - fever (above 101), chills, malaise, enlarged lymph nodes, pharyngitis, GI disturbance (N/V)

labs and diagnostics ran for patients with symptoms of infection

-PAN culture (2 blood cultures, speutum culutre and urine culture)

• 1 anaerobic culture, 1 aerobic culture from different sites

  • peripheral site & central line

-wound culture (if present)

BLOOD: CBC, CMP, lactic acid, Procalcitonin, ESR

IMAGING: xray and CT of chest

progression of infection/inflammation

when an infection is present or suspected, there is an increase in pro-inflammatory cytokines = widespread inflammation. When it gets so widespread = SIRS develops

SIRS

an outflow of pro-inflammatory cytokines that trigger EXCESSIVE, WIDESPREAD INFLAMMATION

sepsis

SIRS + an infection source

criteria for SIRS

TEMPERATURE: above 38/100.4 OR below 36/96.8

HR: above 90 bpm

RR: over 20 br/min OR PaCO2 < 32 mm Hg

WBC #: above 12,000/mm OR less than 4000/mm OR >10% immature neutrophils

• patient has to meet at least 2 of the criteria to be dx

are pts with SIRS super awake and alert

no, they are often drowsy and hard to arouse

how many of the criterion of SIRS do patients have to meet to be diagnosed with SIRS

at least 2 out of the 4 (Temperature, HR, RR, WBC count)

how can a patient be diagnosed with sepsis

a patient meeds 2 out of the 4 criterion for Sepsis (temperature, HR, RR, WBC#) and have positive cultures = confirmed infection!!!!!

symptoms of SIRS

fever or hypothermia, tachycardia, tachypnea, fatigue or malaise, edema and redness, shaking or chills, LOSS OF CONSCIOUSNESS AND CONFUSION/ALTERED MENTAL STATUS

what is MEWS & what is it used for

the modified early warning system, used to detect deteriorating patients

what are the categories of the MEWS scoring system

RR< HR, systolic BP, level of consciousness, temperature and hourly urine for 2 hours

what do higher numbers indicate in a MEWS score

that a patient is at greatest/HIGHEST risk of deterioration OR a patient is actively deteriorating

does a high MEWS score automatically mean that patient is end-stage deteriorating

no, use clinical judgment and critical thinking to look to see if there are other diagnoses that can be causing the higher scores

• but, if you get a high score, make sure to investigate to make sure your patient isn’t actively deteriorating.

what are anticipated med orders for a patient with an infection

to control symptoms - antipyretics, antiemetics, antidairrheals

to fight pathogens - antimicrobials

what are different antimicrobial classes that can be used to treat infections caused by pathogens

cell wall synthesis inhibitors - penicillin and cephalosporins

cytoplasmic membrane disruptors - antifungals

inhibiting biosynthesis/reproduction - erythromycin and gentamycin

inhibiting nucleic acid synthesis - actinomycin

nursing priorities for patients with SIRS

recognize early signs and symptoms of sepsis, intervene to promote hemodynamic stablility and adequate organ perfusion

• monitor BP and HR because they change RAPIDLY

what orders do you anticipate from providers for a pt with SIRS

early resuscitation with IV fluids → IV FLUIDS = #1 PRIORITY (and get them in quick!), supplemental oxygen, broad spectrum anitbiotics until culutre results then narrow spectrum antibiotics, if hemodynamic changes occurr → trendelenburg positioning to get more blood to brain

why are IV fluids #1 priority for SIRS trtmt

widespread inflammation = body is dehydrated because inflammatory mediators are VASODILATORS that open capillary beds, so you need fluids!

pt education for Infection and SIRS

how to prevent infection, recognizing S+S of SIRS/sepsis (especially Altered LOC), when to seek medical care, educate about current treatments and meds they are currently on → especially their antibiotics, educating them on the administration and how long they will be on them.

is there a realtionship between auto-immunes and SIRS

if a patient has an autoimmune disorder, they will already often have more inflammation in their body. Because of the increased inflamm, they are at high risk for SIRS

do all autoimmune diseases have the same triggers

no, there are various triggers, so monitor all autoimmune diseases for flare-ups and triggers throughout your care

autoimmune → SIRS paathway

auto-immune trigger → increase in pro-inflammatory cytokines → widespread inflammation → SIRS develops (& sepsis if confirmed infection source)

what are COMMON auto-immune triggers

stress, injury, environmental triggers, infection, hormones, medication

what is stomatitis

ifnlammation of the mouth

key concern for stomatitis

pain, impaired nutrition

key concern for GERD (gastro-esophageal reflux disease)

pain, altered nutrition

key concern for gastritis

pain, UGIB (upper GI bleeds) and sometimes infections

key concerns for peptic ulcer disease

pain, infection (often), UGIB, perforation and peritonitis

key concerns for UGIB (upper GI bleed)

hypovolemia (bleeding), shock and death

what is peritonitis

inflammation of the peritoneal cavity

what are the key concerns for peritonitis

sepsis (bc this fluid shouldn’t be in peritoneal cavity), shock, death

causes of stomatitis

infection (like thrush/candiasis) from impaired nutrition OR antibiotic/corticosteriod use, some ethnic populations have increased risk, and some are ideopathic → we don’t know the actual cause, like canker sores

is stomatitis life threatening

no

what to assess for a pt with stomatitis

history (how long have they had it), physical = pain, redness, lesions, coating of the oral mucosa → candidiasis

• assess effect on eating, swallowing, breathing, communication

nursing diagnoses for stomatitis

impaired tissue integrity, pain, knowledge deficit

interventions/pt education for impaired tissue integrity r/t stomatitis

avoid commerical mouthwashes (bc they have chemicals and alcohol that irritate tissue), oral care q2 hours, ensure proper fit of dentures,

pharmacologic treatment for stomatitis

clotrimazole lozenges or nystatin (swish and spit) for candidiasis

chlorhexidine (swish and spit) for bacterial infections

interventions/pt education for pain r/t stomatitis

rinse mouth frequently with warm saline or sodium bicarbonate solution (esp salt water swish and spit!), do oral hygiene with a soft brush or gauze, eat soft foods and have cold/cool liquids, use topical analgesics (like viscous lidocaine)

risk factors for GERD (gastro-esophageal reflux disease)

obesity, H-pylori (d/t gastritis and poor gastric emptying), pregnancy, certain medications (esp. NSAIDs, prednisone and anticholinergics), foods, tobacco, alcohol use, NG tube (bc it keeps the esopho-gastric sphincter always partially open)

symptoms of GERD

chestt/epigastric pain, dyspepsia (indigestrion), regurgitation, coughing at night, pyrosis (heartburn), dysphagia (so much heartburn chornically influences how you swallow)

what can (chronic) GERD lead to

development of esophageal strictures or Barretts esophagus (ulcerations in esophagus)

what test diagnoses GERD

no defininitive diagnostic test, just S+S and r/o of other diseases

nursing diagnoses for GERD

pain, imbalanced nutrition, deficient knowledge

Pharmacologic therapy for GERD (classes of meds)

antacids, histamine blockers, proton pump inhibitors)

medical interventions for GERD

medications, endoscopic management (Stretta procedure) or surgical management (Lap-Nissen Fundoplication) → which makes the esopho-gastric sphincter a tighter, stronger connection by wrapping the fundus of the stomach around the end of the esophagus.

nursing interventions and patient education for GERD

identify and eliminate trigger foods, eat SMALL and freuqnet meals (not large meals), wait 3 hours after eating before lying down, sleep with elevated HOB, limit/avoid alcohol and tobacco, lose weight if applicable, educate about prescribed medications

class + MOA for omeprazole

proton pump inhibitor, it suppresses gastric acid secretion (via suppression of an enzyme)

nursing considerations for omeprazole

take capsule whole (DO NOT CRUSH), give 30 min before main meal of the day → always give BEFORE FOOD

class and mechanism of action of ranitidine/famotidine

H2 receptor blocker, decreases gastric acid secretions by blocking histamine receptors in parietal cells

nursing considerations for H2 blockers (ranitidine/famotidine)

give single dose at bedtime, since it decreases nocturnal acid production

class and MOA of aluminum hydroxide

antacid, increases the pH of gastric contents by deactivating pepsin

nurisng considerations for aluminum hydroxide

give 1 hour after meals at at bedtime, do not give other drugs within 1-2 hours of antacids or absorption will be impaired

risk factors for acute gastritis

use of coffee/caffiene, alochol, nicotine ; overuse of ASA, NSAIDs or corticosteroids ; radiation therapy targeted near GI tract ; STRESS ; exposure to foodborne infectious organisms

symptoms of acute gastritis

N?V, epigastric pain, hematemesis, possible melena (blood in stool)

complications of acute gastritis

gastrointestinal bleeding

risk factors for chronic gastritis

H/ pylori infection (MOST COMMON CAUSE), radiation therapy targeted near GI tract over prolonged period of time, crohn’s disease, long-term alcohol or nicotine use

symptoms of chronic gastritis

few symptoms, especially if the pt has had the inflammation for a long time

• they could have N/V and epigastric pain (but you can have the inflamm w/o any symptoms!!)

complications of chronic gastritis

pernicious anemia (lack of B12) can occur bc loss of intrinsic factor from inflammation = less B12 absorbed, also increased risk of gastric cancer (bc chronic inflammation increases the risk of mutations in specific areas)

diagnosis of gastritis

through esophagogastroduodenoscopy (EGD) via endoscope with biopsy, looking for inflammation and biopsy when needed

nursing diagnoses r/ tgastritis

nausea, impaired comfort/pain, knowledge deficit, risk for imbalanced fluid/electrolytes, risk for gastrointestinal bleeding.

medications in trtmt of ACUTE gastritis

same medications as GERD (omeprazole, famotidine/rinatidine, aluminum hydroxide) and mucosal barrier fortifier - SUCRALFATE/KARAFATE that coats the lining of the GI tract to protect it before eating

medications used in trtmt of chronic gastritis

Vitamin B12 injections if anemia, antibiotics if H. Pylori present

nursing interventions for both acute and chronic gastritis

eliminate causative factors, avoid toxic substances like alcohol and nicotine

nursing interventions/pt education for ACUTE gastritis

limit intake of high acid foods and caffeine, pt should eat bland diet with smaller/more frequent meals as tolerated.

-monitor for gastrointestinal bleeding - hematemesis, melena and signs of shock (tachy and hypotension)

how quick does acute gastritis usually resolve

within a few days on its own

what are the three types of ulcers in peptic ulcer disease

duodenal, gastric and stress (d/t medical crisis/trauma) ulcers

risk factors for peptic ulcer disease

H. pylori bacteria (MOST COMMON CAUSE), stress, alcohol and nicotine use, family history, use of NSAIDS and/or corticosteriods

symptoms of peptic ulcer disease

often asymptomatic, sometimes epigastric pain and N/V

• if ulcers are bleeding: hematemesis, melena, low Hgb/Hct + symptoms of hypovolemia

complications of peptic ulcer disease

gastrointestinal bleeding, perforation (which can lead to) peritonitis (where GI contents and acid come into contact with abdominal cavity, causing inflammation and possible infection)

diagnosis of peptic ulcer disease

H. pylori tests (serum, breath, stool), fecal occult blood test (FOBT) to evaluate bleeding, esophagogastroduodenoscopy = most accurate

• EGD is best because it is visually looking at the source, the FOBT can say something in GI tract is bleeding - but doesn’t guarantee where the bleed is from

nursing diagnoses for peptic ulcer disease

impaired comfort (PAIN), risk for perforation, peritonitis, GI bleeding

medications for peptic ulcer disease

same meds as gastritis → omeprazole, famotidine, aluminum hydroxide and karafate/sucralfate

• if PUD d/t h. pylori → admin antimicrobials of metronidazole (GI antibiotic) and tetracycline!

nursing interventions and pt education for peptic ulcer disease

monitor for signs of GI bleeding, educate about avoiding alcohol and nicotine, stress management and diet as tolerated (small meals of bland foods - avoid trigger foods)

risk factors for GI bleeding

peptic ulcer disease (PUD), impaired coagulation (factor V, anticoags, etc)

symptoms of Gastrointestinal bleeding

hematemesis OR blood (from colon)/black (upper GI) stools (currant jelly blood clots = LOTS of upper GI bleeding), low Hgb/Hct, & symptoms of hypovolemia (tachycardia, hypotension, diaphoresis, sycope, decrease urine output)

S+S of hypovolemia (& which is a late/extreme sign)

tachycardia, hypotension, diaphoresis, syncope, decreased urine output

• decreased urine output = late/extreme sign

complications of GI bleeding

hypovolemic shock, death

is upper GI bleeding or lower GI bleeding more of a medical emergency

UPPER GI BLEEDING → there is more vasculature around upper GI and more pressure (esp. from throwing up) and acid content in upper GI to cause more problems

upper GI bleed progression

gastritis/coagulopathies/PUD → UGIB → hematemesis & low Hgb/Hct → hypotension, hypovolemic shock, acute kidney injury - AKI (bc not enough fluid/blood to kidneys)

medical dx of gastrointestinal bleeding

esophagogastroduodenoscopy (EGD), positive fecal occult blood test (+FOBT) or decreased H/H

nursing diagnoses r/t gastrointestinal bleeding

fluid volume deficit, fatigue, fear, risk for electrolyte imbalance, risk for acute kidney injury

medical interventions for gastrointestinal bleeding

endoscopic (surgery) or interventional radiologic procedures to stop bleed, medications to control gastric acidity (h2 receptors blockers, PPIs), isotonic IV fluid replacement, packed red blood cells for low H/H (MASS TRANSFUSION IF SEVERE BLEEDING), fresh frozen plasma if prolonged bleeding time (bc it has platelets along with fluid resuscitation to help clotting)

nursing interventions for GI bleeding

NG tube placement, IV placement, monitor fluid status (BP, HR, I&Os), monitor Hct/Hgb & coagulation studies, monitor for fluid overload

NG tube care

check placement q4-8 hours, ensure patency, secure tube, oral & nasal hygiene q2-4 hours, HOB elevated at least 30 degrees

key complications of intestinal obstruction (acute)

perforation → peritonitis → sepsis → death

key complications of Inflammatory bowel disease (crohn’s disease + ulcerative colitis)

impaired comfort (PAIN) and QOL& many other complications

key complications of peritonitis

sepsis and death

key complications of appendicitis

rupture of appendix → rupture → peritonitis → sepsis → death

key complications of gastroenteritis

fluid/electrolyte imbalance & dehydration → hypovolemic shock → death (RARE)

key complications of diverticular disease

pain and infection → perforation & peritonitis → sepsis → death

types (cause) of intestinal obstruction

mechanical (blockage outside bowel wall, in bowel wall or in lumen)

• physical blockages, like from injury or intusseception

non-mechanical (paralytic illeus)

• peristalsis absent or decreased d/t neuromuscular disturbance, like after surgery & spinal injuries

complications of intestinal obstruction

fluid/electrolyte imbalence, acid-base imbalance, acute kidney injury, intestinal perforation → peritonitis → sepsis → death

what is intestinal intussiception

when bowel folds into itself