Advanced med-surg exam 4 review

IBD

inflammatory bowel disease

(Ulcerative colitis and Crohn's disease fall under IBD)

Ulcerative colitis

WHAT: chronic inflammation of the colon/rectum with presence of ulcers

CAUSES: stress, smoking, and sepsis

S/S: inflammation, bleeding colon, 15-20 bloody/liquid stools per day, abdominal pain, rebound tenderness, low hemoglobin/hematocrit, and ulcers throughout colon

Crohn's disease

WHAT: chronic inflammation of the intestinal tract

CAUSES: stress, sepsis, smoking, and a high fat diet

S/S: sporadic lesions throughout colon, 5 loose stools per day with mucus/pus (steatorrhea), weight loss, abdominal pain, and N/V

management for IBD (ulcerative colitis/Crohn's)

-fluid/electrolyte management (strict I/O's, increase fluids to 2 L per day, monitor for hypokalemia)

-increase protein and calories in diet

-avoid caffeine

-SMALL, FREQUENT MEALS

-keep food journal

-decrease fiber intake

-for pain, analgesics

-stress reduction techniques

-emotional support (takes a toll on pt. mentally)

-most patients get a colostomy/ileostomy bag to bypass intestines

-pharmacological: steroids to decrease swelling, antidiarrheals, and sulfasalazine (stops body from attacking itself)

complications of ulcerative colitis and Crohn's disease:

primary complication is perforation that can lead to peritonitis (watch for fever and rebound tenderness)

-peritonitis is a medical emergency and can lead to septic shock

IBS

WHAT: inflammatory bowel syndrome

CAUSES: usually due to food sensitivity or stress

S/S: bloating, constipation and/or diarrhea, and abdominal pain/cramping

EDUCATION: keep food journal, and reduce stress levels

DIET: increase fiber/fluids, limit alcohol/caffeine, SMALL, FREQUENT MEALS, limit gas-producing foods such as dairy/beans

Celiac disease

WHAT: an autoimmune disorder characterized by a severe reaction to foods containing gluten

S/S: diarrhea, severe bloating, abdominal pain, fatty stools, and weight loss (after ingesting gluten)

EDUCATION/MANAGEMENT: increase fat-soluble vitamins (A,D,E,K), and *avoid ALL gluten containing foods*

Appendicitis

WHAT: inflammation of the appendix

CAUSES: usually due to hard fecal matter stuck in appendix

S/S: fever, RLQ pain with rebound tenderness (which is relieved by bending over)

MANAGEMENT: prevent rupture which can lead to peritonitis/sepsis , NPO before surgical removal, and pain meds AFTER doctor has determined appendix issue

EDUCATION: no laxatives, no heating pads, no enemas, avoid adding pressure, and remain NPO before surgery

post-appendectomy care:

-avoid heavy lifting

-prevent pneumonia with early ambulation/deep breathing)

-prevent infection (no baths until incision heals)

Diverticulitis

WHAT: infected/inflammed diverticula

S/S: fever, N/V, LLQ pain, diarrhea/constipation, increased WBC's, low hemoglobin/hematocrit, and low blood volume

MANAGEMENT: avoid straining/consitpation, NPO, pain meds, IV normal saline, increase fiber, and prevent peritonitis

peritonitis symptoms

-Abdominal pain

-Vomiting

-Rigid, board-like abdomen

-Fever

-Leukocytosis (increased white cells in blood)

TREATMENT: IV antibiotics, increase fluids, oxygen therapy, NPO diet, NG tube, and usually surgery

(always monitor vitals since this can lead to sepsis)

Small bowel obstruction

WHAT: blockage of the small intestines (can be mechanical such as a hernia/volvus or non-mechanical such as a paralytic ileus aka paralyzed bowel from GI surgery etc.)

S/S: rapid onset of N/V, abdominal pain/distention, hyperactive bowel sounds above obstruction and hypoactive below obstruction

TREATMENT: NPO, NG tube, IV fluids, pain meds (non-opioids), semi-fowler's position, or surgery (colostomy/ileostomy) and prevent peritonitis

Dumping syndrome

WHAT: Rapid emptying of gastric contents into small intestines (usually after gastric bypass or GI surgery)

S/S: severe abdominal pain, hypotension (from rapid fluid. shifts), N/V, tachycardia, and sweating

TREATMENT: small meals, lie down after eating (to prevent emptying), correct hypoglycemia in late signs, monitor/manage symptoms, and prevent complications (septic shock)

post-op GI surgery care (to prevent dumping syndrome)

-NPO then adjust to clear liquids

-apply SCDs

-early ambulation

-incentive spirometry

-lie down after eating

-SMALL, FREQUENT MEALS

Peptic ulcers

WHAT: open sores that affect the mucous membranes of the digestive system

(often form H. pylori infection or NSAID/alcohol use)

(can be gastric in stomach or duodenal in small intestine)

S/S: dyspepsia/epigastric pain

gastric ulcer--> pain increases with food and bloody vomit

duodenal ulcer--> pain decreases with food, blood in stool (melena) and is worse at night

TREATMENT: antibiotics for H. pylori, antacids, PPI's, and mucosal protectants such as sucralfate

education for patients with gastric or duodenal ulcers:

-No smoking

-No alcohol

-No spicy/fatty foods

-No caffeine

-reduce stress levels

-avoid NSAIDs

-report any black/tarry stool (could indicate GI bleed)

GI cancers:

Esophageal cancer--> risk factors include GERD that goes untreated, obesity, alcohol use + smoking

Colon/colorectal cancer--> risks include ulcerative colitis, family hx, or diverticulitis long-term

Colon/colorectal cancer

WHAT: Cancer of the colon- the large intestines & the rectum (3rd most common cancer in both men and women)

S/S: unexplained weight loss, change in bowel habits, bloody stool, abdominal pain, and low hemoglobin

DIAGNOSTICS: colonoscopy

TREATMENT: surgery or chemotherapy, patient education on no smoking/alcohol, increase fiber in diet, and lose weight

Colostomy/ileostomy must knows:

Colostomy (in colon) --> brown/firm stool

Ileostomy (in small intestine)--> green/yellow, loose stool

INDICATIONS: Ulcerative colitis, Crohn's disease, or colon cancer

COMPLICATIONS: electrolyte/fluid loss/imbalance

EDUCATION: red/beefy/pink/moist= good stoma; cold/pale/purple- bad stoma (lack of circulation), avoid high fiber foods, increase fluids due to fluid loss, empty pouch when 1/3-1/2 full, do not use alcohol to clean around stoma

Gastritis

WHAT: inflammation of the stomach lining (gastric mucosa)

acute--> often due to NSAIDs, alcohol, or infection

chronic--> H. pylori infection, autoimmune causes, and chronic irritants

(usually a EGD detects it or lab work to test for H. pylori)

S/S: epigastric pain, N/V, bloating, hiccups, and chronic could cause fatigue/pallor and fullness after meals

COMPLICATIONS: increased risk for gastric cancer, peptic ulcers, or anemia due to GI bleeding

TREATMENT: smoking cessation, avoid NSAIDs/alcohol, PPI's, H2 blockers, antacids, and SMALL/FREQUENT MEALS

Gastric cancer

WHAT: malignant tumor of the stomach

S/S: early--> usually asymptomatic, later signs--> persistent epigastric pain, unexplained weight loss, vomiting, melon, anemia, feeling full, and loss of appetite

TREATMENT: surgery or chemotherapy

Small intestinal tumors

WHAT: tumors within the small intestine (usually more rare than other GI issues)

S/S: abdominal pain/cramping, unexplained weight loss, N/V, and bloating

TREATMENT: removal/resection surgery or chemotherapy/radiation

Addison's disease

WHAT: occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone

S/S: hypotension, low body weight, bronze appearance, fatigue/weakness, hypoglycemia, dehydration, HYPERkalemia, and N/V (can lead to Addisonian crisis--> severe hypotension/shock--> treat with IV hydrocortisone)

TREATMENT: no cure, just management; add steroids lifelong (prednisone etc.), increase fluids to bring BP up, and a high protein diet

side effects of long-term steroid use:

-hyperglycemia

-swelling

-sepsis

-osteoporosis

-cataracts

(patients with Addison's disease for example must be on lifelong steroids, so watch for these side effects)

Cushing's Disease

WHAT: when the adrenal glands make too much cortisol in the body (often due to long-term steroid use or tumors)

S/S: high BP, high temperature, high body weight (big belly, and a moon face), hyperglycemia, hypernatremia, HYPOkalemia, and fluid retention (edema)

TREATMENT: slowlyyy decrease steroids or remove tumor (if a tumor is what is the cause) and manage symptoms

Adrenal crisis (or Addisonian crisis)

WHAT: An acute, life-threatening emergency due to severe cortisol deficiency (which is essential for maintaining BP, glucose, and fluid balance in the body)

-Addison's disease patients are at a high risk for this

Common triggers: sudden cessation of long-term corticosteroids, stress on the body (sepsis, surgery, trauma, or emotional stress), or adrenal gland damage

S/S: hypotension, hyponatremia, hypoglycemia, severe dehydration, fever, and N/V

TREATMENT: get BP up #1 priority (with IV push steroids), increase fluids, and give dextrose to raise BS

Diabetes Mellitus

WHAT: autoimmune condition where the body attacks the beta cells in the pancreas; in type 1, NO insulin I produced, in type 2, body produces insulin but cells are resistant

S/S: BOTH: polyuria, polydipsia, polyphasic (signs of hyperglycemia)

type 1--> weight loss, fatigue, and at risk for DKA

type 2--> recurrent infections, slow wound healing, blurry vision, and at risk for HHNS

TREATMENT: type 1--> lifelong insulin therapy; type 2--> weight loss/lifestyle changes, oral anti diabetic drugs, and last resort insulin therapy

risk factors for type 2 diabetes:

meeting 3 or more of these criteria indicates metabolic syndrome, which is the strongest precursor to type 2 diabetes:

-high BP

-high BS

-obesity

-high cholesterol

functions of insulin:

-transports and metabolizes glucose for energy

-stimulates storage of glucose in the liver and muscle as glycogen

-signals the liver to stop the release of glucose

-enhances storage of dietary fat in adipose tissue

-accelerates transport of amino acids into cells

-inhibits the breakdown of stored glucose, protein, and fat

Diagnostic findings for diabetes

fasting glucose: 126 or more (indicates diabetes)

casual/random glucose: over 200 (indicates diabetes)

for a diabetic patient, what is the target glucose finding?

under 150= controlled

-want the fasting glucose to remain between 90-110

-A1C goal is under 6-7%

causes of acute hyperglycemia:

the 4 S's: stress, sepsis, skipping insulin, and steroids like prednisone

causes of acute hypoglycemia:

-exercise

-alcohol

-insulin peak times

(ALWAYS give patient a plate of food at peak insulin times to raise sugar)

S/S and treatment of hypoglycemia:

cool/pale/clammy= give candy

-trembling

-irritability

-lethargy

-headache

-weakness

"you're not you when you're hungry"

#1 treatment--> give sugar! when awake, give juice/soda; if sleeping, stab with dextrose IV

S/S of hyperglycemia:

the 3 P's: polyuria, polydipsia, polyphagia

complications of diabetes:

-retinopathy (microvascular)

-kidney failure (microvascular)

-neuropathy

-HTN/atherosclerosis/strokes (macrovascular)

long-acting insulins include:

-detremir (lasts all year)

-glargine (large-lasting)

-lantus (Lantern burns all night)

-NO peak

-24 hours duration

-do not mix with other insulin types

-does not have to be timed with meals

rapid-acting insulins include:

-asparat

-lispro

-glulisine

-3-5 hours duration

-15 minute onset

-peak =30-90 minutes

-take immediately before meal

_______ is the only insulin that can be given through IV

regular

(regular insulin has a 5-8 hour duration and 2-4 hour peak time)

-take 30-60 minutes before meals

when insulin peaks, ________

give food !!!

oral antidiabetic drugs for type 2:

-metformin

-glipizide

-thiazolinedine

-acarbose and precose

(major side effect of all these is hypoglycemia and monitor patient for liver/kidney fx)

complications of insulin therapy:

-local or systemic allergic reactions

-resistance to injected insulin

-morning hyperglycemia

patient education for insulin therapy/diabetes management:

-teach s/s of both hyperglycemia (the 3 P's) and hypoglycemia (cool/clammy skin)

-check blood sugar often

-take insulin/oral anti diabetics as prescribed (for hyperglycemia)

-call HCP if BS exceeds 300 (for hyperglycemia)

-always carry fast acting glucose (in case of hypoglycemia)

-rotate insulin injection sites

-do not mix long-acting insulin with others

-teach healthy lifestyle changes

Diabetic Ketoacidosis (DKA)

WHAT: A form of hyperglycemia in uncontrolled diabetes which leads to acidosis and creation of ketones in the body

-type 1 diabetics at highest risk

CAUSES: stress, sepsis, and skipping insulin

S/S: high glucose levels, metabolic acidosis, kussmals respirations, abdominal pain, dehydration, and presence of ketones (that cause fruity breath)

TREATMENT: regular insulin therapy to lower BS, 0.9% NS for dehydration, add potassium (to treat hypokalemia), treat underlying cause (infection etc.)

Hyperosmolar Hyperglycemic Syndrome (HHS)

WHAT:A metabolic complication of uncontrolled type 2 diabetes, similar in severity to diabetic ketoacidosis but without ketosis and acidosis

causes--> illness/infections

S/S: hyperglycemia, extreme dehydration, neuro changes (confusion), but NO acidosis or ketones

TREATMENT: hydration with 0.9% NS, stabilize sugar with insulin (IV regular with hourly BS/BP checks)

functions of the thyroid gland

1. Regulate metabolism

2. Functions in growth and development

3. Secretes the hormones thyroxine, triiodothyronine, and calcitonin

hypothyroidism

WHAT: A disorder caused by a thyroid gland that is slower and less productive than normal (lack of T3 + T4)

major cause--> Hashimoto's

S/S: (low + slow)--> low BP, constipation, low energy, low body temperature (cold intolerance), dry skin, fatigue, and hair loss

TREATMENT: levothyroxine (lifelong) , and avoid narcotics

hyperthyroidism

WHAT: excessive activity of the thyroid gland

S/S: high energy, grape eyes, HTN, goiter, weight loss, sweating, diarrhea, and heat intolerance

TREATMENT: methimazole, PTU, SSKI (radioactive iodine therapy), and beta blockers to lower BP/HR or thyroidectomy (if drugs fail)

Post-op thyroidectomy care:

priority is ABC's (have trach tube at bedside)

-semi-fowler's position

-monitor calcium levels (can drop significantly after removal)

--> positive trousou's + Chvosek's sign indicate hypocalcemia

hyperparathyroidism

WHAT: overactive parathyroid gland leading to hypercalcemia and low phosphate levels

CAUSES: low calcium intake, malabsorption, renal failure, or tumors

S/S: (all signs of hypercalcemia) --> constipation, bone pain, kidney stones, decreased DTR's, and severe mm weakness

TREATMENT: parathyroidectomy or fixing the calcium issue

hypoparathryoidism

WHAT: under activity of the parathyroid glands leading to hypocalcemia and high phosphate levels

CAUSES: autoimmune issues, thyroidectomy, radiation, or low magnesium levels

S/S: positive trousseau's and Chvostek's sign, diarrhea, and mouth tingling

TREATMENT: fix calcium disorder (no surgery can be done)

Latent autoimmune diabetes

WHAT: Type 1.5 diabetes where diabetes develops in adults (starts as similar to type 2 and eventually leads to type 1)

Key sign--> type 2 diabetic patient who is not overweight who does not respond to oral antidiabetic drugs

S/S: polydipsia, fatigue, polyuria, blurry vision (s/s of type 2), and then progresses into unexplained weight loss/type 1 s/s

TREATMENT: insulin therapy eventually required and lifestyle management similar to other types

Parkinson's disease

WHAT: slow, progressive neurologic movement disorder associated with decreased levels of dopamine

S/S: tremors, mm rigidity, bradykinesia, postural stability, dysphagia (aspiration risk), drooling, and anxiety

TREATMENT: benztropine for tremors and levodopa-carbidopa for dopamine loss (over time, becomes less effective), and assistance with ADLs with preservation of independence, FALL RISK precautions, and improve mobility

Huntington's disease

WHAT: a chronic progressive and hereditary disease that results in choreiform movement and dementia

S/S: chorea (jerky movements), muscle rigidity, cognitive/memory impairment, impaired gait, speech problems (slurred speech), dysphagia, and personality/mood changes

INTERVENTIONS: (no cure)--> antipsychotic meds or tetrabenazine for s/s, fall precautions, prevent aspiration, high-calorie diet (due to involuntary movements often), thickened liquids, PEG tubes in late stages if swallowing become unsafe, and assistance with ADLs

Alzheimer's disease

WHAT: a progressive brain disorder that leads to deterioration of memory, reasoning, language, and lastly, physical functioning

S/S: short-term memory loss, difficulty with ADLs, sundowning, dysphagia, incontinence, and loss of ability to communicate as it progresses

INTERVENTIONS: safety is priority (fall precautions), short/simple communication, clear instructions (1-step), maintain consistent routines, and reorient gently but do not orient to reality (makes them more aggravated)

Amyotrophic lateral sclerosis

WHAT: degenerative disorder of motor neurons in the spinal cord and brainstem

S/S: progressive muscle weakness and atrophy, mm cramps, twitching, spasticity, dysphagia, lack of coordination, and eventually difficulty breathing (cognitive function remains intact)

INTERVENTIONS: airway/breathing is top priority, prevent aspiration, PT/ROM exercises, communication boards, a high-calorie diet, and psychosocial support