Medical-Surgical Nursing Lecture Notes

Bariatric Surgery for Morbid Obesity

• Criteria and Selection: Bariatric surgery is indicated for morbid obesity only after nonsurgical attempts at weight control have failed. Selection of candidates is critical.

• Preliminary Process: The process may necessitate $6$ to $12$ months of counseling, education, and evaluation.

• Multidisciplinary Team: Evaluation is conducted by a team including social workers, dietitians, a nurse counselor, a psychologist or psychiatrist, and a surgeon.

• Common Complications:

  • Bleeding.

  • Blood clots.

  • Bowel obstruction.

  • Incisional or ventral hernias.

  • Infection resulting from a leak at the anastomosis.

• Post-operative Care:

  • Oral intake is resumed only after bowel sounds have returned.

  • Dietary regimen involves six small feedings totaling $600$ to $800$ calories per day.

  • Fluids are encouraged to prevent dehydration.

• Gastric Bypass (Roux-en-Y):

  • Respiratory Complications: Nurses must watch for respiratory issues.

  • Post-op Leak Signs: Watch for tachycardia, fever, and severe abdominal pain.

  • Dumping Syndrome: Symptoms include nausea, cramping, diarrhea, dizziness, sweating, and tachycardia. This usually occurs after high-sugar meals.

Oropharyngeal Cancer

• Pathophysiology: Malignancies are usually squamous cell cancers. Common sites include the lips, lateral aspects of the tongue, and the floor of the mouth.

• Risk Factors:

  • Dietary deficiency.

  • Ingestion of smoked meats.

  • Prolonged exposure to sun and wind (specifically for lip cancer).

  • Tobacco use.

  • Alcohol use.

  • Human Papillomavirus (HPV) infection.

• Clinical Signs:

  • A painless sore or mass that will not heal.

  • A typical lesion is a painless indurated (hardened) ulcer with raised edges.

  • Persistent sore throat or hoarseness.

  • Difficulty swallowing.

• Treatment: Surgical resection, radiation therapy, chemotherapy, or a combination.

• Nursing Priorities:

  • Airway Priority! Monitor for stridor, dyspnea, and difficulty with secretions.

Radical Neck Dissection

• Procedure Details: Involves removing all cervical lymph nodes from the mandible to the clavicle. It also removes the sternocleidomastoid muscle (SCM), internal jugular vein (IJV), and the spinal accessory nerve (Cranial Nerve XI) on one side of the neck.

• Complications:

  • Shoulder drop.

  • Poor cosmesis (visible neck depression).

  • Xerostomia (dryness of the mouth), which is common following surgery and radiation.

  • Hemorrhage.

  • Edema.

• Post-operative Nursing Care:

  • Maintain Airway: This is the top priority.

  • Positioning: Head of bed (HOB) should be between $30-45^{\circ}$ to reduce edema and promote drainage.

  • Pain and Nutrition: Relieve pain and maintain nutrition, which may require enteral or parenteral feedings.

  • Mobility and Assessment: Assess shoulder shrugging to evaluate the spinal accessory nerve. Support mobility and established ways to communicate.

  • Wound Care: Monitor surgical wounds and teach self-care for discharge.

Continuous Tube Feedings

• Administration: Typically $24$-hour feedings using a pump.

• Nursing Interventions:

  • Placement: Verify placement with an X-ray.

  • Asepsis: Maintain aseptic technique.

  • Aspiration Prevention: Keep the HOB elevated between $30-45^{\circ}$.

  • Flushing: Flush with at least $30\,mL$ of water every $4$ hours during continuous feeding, as well as before and after medications to maintain patency.

  • Monitoring Intolerance: Watch for nausea, vomiting, abdominal distention, and diarrhea.

  • Gastric Residuals: In ICU patients, feedings should be held if gastric residual volumes (GRV) exceed $500\,mL$.

Jejunostomy Tube (J-Tube)

• Placement: Inserted into the midsection of the small intestine (jejunum).

• Indications: Typically for long-term use (greater than $6$ weeks). Used when the stomach cannot be used, aspiration risk is high, or gastric emptying is impaired.

• Feedings: Used for continuous feedings because the jejunum cannot hold large amounts of fluid. No need to check for gastric contents.

• Monitoring: Watch for infection, skin breakdown, and leakage.

Colonoscopy

• Procedure: Direct visual inspection of the large intestine (anus, rectum, sigmoid, transcending, and ascending colon) using a flexible fiberoptic colonoscope.

• Capabilities: Allows for still and video recordings, tissue biopsies, and polyp removal.

• Indications:

  • Cancer screening and surveillance (history of polyps or cancer).

  • Evaluation of changes in bowel habits, occult bleeding, or anemia.

  • Detection of strictures, Hirschsprung disease, volvulus, and intussusception.

  • Diagnosis of inflammatory bowel disease (IBD).

• Patient Care:

  • Prep: Requires bowel prep and NPO status after midnight.

  • Post-Procedure: Assess for perforation and bleeding. Patients may experience bloating or gas.

Magnetic Resonance Imaging (MRI)

• Mechanism: Uses magnetic fields and radiofrequency signals instead of X-rays.

• Advantages: Yields much more detailed diagnostic images than a CT scan.

• Clinical Uses: Characterizing pulmonary nodules, staging bronchogenic carcinoma (chest wall invasion), evaluating inflammatory activity in interstitial lung disease, acute PE, and chronic thrombolytic pulmonary hypertension.

• Safety Screening: Assess for metal implants, hearing aids, and claustrophobia.

Measuring Abdominal Girth

• Purpose: To monitor ascites, fluid retention, and liver failure.

• Procedure: To ensure consistency, the nurse marks the patient's abdomen above and below where the measurement is taken (usually at the level of the umbilicus). Measurements are taken at the same time each day and before meals using a tape measure.

• Fluid Status Indicator: Daily weight is the best indicator of overall fluid status.

Blood Transfusions

• Safety Protocols: Wear gloves. Administration must begin within $30$ minutes of retrieving blood; otherwise, return it to the blood bank. Verify the blood product with another nurse.

• Solutions: Use only $0.9\%$ sodium chloride (normal saline) to initiate the transfusion. Never use hypotonic or hypertonic solutions, as they cause hemolysis of Red Blood Cells (RBCs).

• Contraindications: No medications or other solutions should be added to or infused through the same blood set.

• Indications: Significant blood loss, symptomatic anemia, or low Hemoglobin/Hematocrit (Hgb/Hct).

• Transfusion Reactions: Symptoms include fever, chills, back pain, flank pain, dyspnea, and tachycardia.

• Nursing Action for Reaction: Stop the transfusion immediately. Disconnect the tubing, keep the IV open with normal saline, notify the provider, and monitor vital signs.

Red Blood Cell Stimulants (Erythropoiesis Stimulating Agents - ESAs)

• Mechanism: These stimulate the red bone marrow to produce RBCs (erythropoiesis).

• Medications:

  • Epoetin Alfa (Epogen, Procrit, Retacrit): Widely used; takes days to weeks to show effect.

  • Darbepoetin Alfa (Aranesp): Has a different structure that allows it to remain in the body longer, requiring less frequent administration.

• Indications: Chronic anemia secondary to chronic kidney disease (CKD), chemotherapy-induced anemia, zidovudine (AZT) therapy, and bone marrow suppression (e.g., MDS). Also used preoperatively to decrease the need for allogeneic transfusions.

• Risks and Side Effects:

  • Exceeding a Hgb goal of $11\,g/dL$ increases the risk for stroke and MI.

  • Can cause or exacerbate hypertension.

  • Rapid correction can lead to headache and seizures (primarily in kidney failure patients).

Non-Hodgkin Lymphoma (NHL)

• Pathophysiology: A heterogeneous group of cancers originating from neoplastic growth of lymphoid tissue. Primarily involves malignant B lymphocytes ($90\%$) and occasionally T lymphocytes or NK cells ($10\%$).

• Spread: Spread is unpredictable and localized disease is uncommon. Can involve multiple nodes and extranodal tissue.

• Classification:

  • Low Grade: Includes CLL and follicular lymphoma.

  • High Grade: Includes diffuse large B-cell lymphoma, peripheral T-cell lymphomas, and Burkitt lymphoma.

• Diagnostics: Differentiated from Hodgkin lymphoma by the absence of Reed-Sternberg cells.

• Symptoms (B Symptoms): Fever, night sweats, weight loss. Painless enlarged nodes.

• Nursing Considerations: Bleeding precautions (chemotherapy can cause thrombocytopenia).

Iron Supplements

• Absorption: Best taken on an empty stomach ($1$ hour before or $2$ hours after a meal). Vitamin C (orange juice, tablets) facilitates absorption.

• Interferences: Calcium supplements, dairy products, and antacids decrease absorption; these should be staggered.

• Side Effects: Diarrhea, constipation (eat high-fiber foods), epigastric discomfort, and nausea. Stools will become dark/black in color.

• Administration Tips: Do not crush or chew tablets. To prevent staining teeth with liquid preparations, use a straw or place the spoon at the back of the mouth, then rinse thoroughly.

• Monitoring Effectiveness: Hgb should rise after $1$ week and increase by $1$ to $2\,g/dL$ within $4$ to $8$ weeks.

Warfarin and INR

• Mechanism: An oral anticoagulant. Used for AFib, DVT, PE, and mechanical valves.

• Administration: Often started while the patient is still on heparin because warfarin takes $3$ to $5$ days to achieve a therapeutic effect.

• Monitoring:

  • PT/INR: Used specifically for warfarin monitoring.

  • Normal INR Range: $0.8$ to $1.2$.

  • Therapeutic INR Range: $2$ to $3.5$, depending on the diagnosis.

• Antidote: Vitamin K.

• Safety: Monitor for hematuria, hematemesis, melena, petechiae, and bruising.

Red Blood Cell Production

• Process: Kidneys sense decreased oxygen tension in renal blood flow and release erythropoietin. Erythropoietin then stimulates the bone marrow to produce RBCs.

• Requirements: Production requires adequate iron, Vitamin $B_{12}$, and folate.

Bone Marrow Biopsy

• Site: Usually the posterior iliac crest; occasionally the anterior iliac approach is used.

• Positioning: Prone or lateral decubitus.

• Anesthesia: Local anesthesia (lidocaine) is used.

• Risks: Infection, pain, and bleeding (the site is highly vascular).

• Post-Procedural Instructions:

  • Apply a sterile dressing.

  • Ache may persist for $3$ to $4$ days.

  • Do not submerge in a bath for $24$ hours.

  • Avoid aspirin-containing products to reduce bleeding risk.

Cellulitis

• Description: Common infection of the skin and subcutaneous tissue causing swelling.

• Pathogens: Typically caused by Streptococcus or Staphylococcus.

• Symptoms: Redness, warmth, swelling, pain, fever, chills, and increased White Blood Cell (WBC) count.

• Nursing Care: Mark borders to monitor spread, administer antibiotics, and elevate the affected extremity.

White Blood Cells (WBCs)

• Granulocytes: Contain granules; involved in rapid immune response.

  • Neutrophils: Primary defense against bacterial infection.

  • Eosinophils: Involved in allergic reactions.

  • Basophils: Release histamine and heparin.

• Agranulocytes: Lack granules; involved in adaptive immunity.

  • Lymphocytes: (B cells and T cells).

  • Monocytes/Macrophages: Monocytes become macrophages to perform phagocytosis.

Peripheral Arterial Disease (PAD)

• Pathophysiology: Narrowing of arteries that decreases blood flow; a manifestation of atherosclerosis.

• Clinical Signs: Intermittent claudication (pain when walking relieved by rest), cool extremities, weak or absent pulses, shiny skin, hair loss on legs, and delayed capillary refill.

• Risk Factors: High lipids (dyslipidemia) and smoking.

• Nursing Care: Encourage walking; advise against crossing legs.

Cardiac Rehabilitation

• Overview: A program targeting risk reduction through education, support, and physical activity after an MI.

• Phase I: Begins with diagnosis in the hospital (ACS, MI). Includes low-level activities and initial education for the patient and family.

• Phase II: Post-discharge outpatient program ($4$ to $6$ weeks, up to $6$ months). supervised and often ECG-monitored exercise based on stress test results.

• Phase III: Long-term conditioning and maintenance of cardiovascular stability. Self-directed and usually does not require supervision.