Basic Meds-Surg Exam 3 -> 3.26.08

a systolic BP consistently greater than or equal to 135 mmHg and a diastolic BP consistently greater than or
equal to 85 mm Hg.
-Person must have the elevated BP on two or more different occasions

a systolic BP of 120-139 and a diastolic BP of 80-89

should have a systolic BP of less than 119 and a diastolic BP less than 79

an elevated BP with no know cause.
-accts for about 90% of all cases.

-family history
-abnormal Na and H20 retention
-obesity
-elevated cholesterol and triglyceride levels
-high salt diet
-stress
-older
-male
-African american
-alcohol consumption

-pain & tenderness of abdomen/rebound tenderness
-rigid,boardlike abdomen(classic)
-abdominal distention
-paralytic ileus/decr bowel sounds
-incr WBC count
-incr temp
-N/V & dehydration
-hiccups:due to irritation of the diaphragm
-signs of shock

-tachycardia
-decr BP
-oliguria
-restlessness
-pallor

-surgery:to correct underlying probs
-antibiotics
-correction of any electrolyte imbalances
-TPN
-pts are usually critically ill

-Crohn's dz
-ulcerative colitis

unknown but has been linked to the following:
-family hist(more common in crohn's dz)
-infectious dzs/autoimmune disorders
-environmental stimuli:mycobacterium paratuberculosis
-aggravated by smoking cessation:more common in crohn's dz

15-25 years and 55-65 yrs for UC

15-40 years

it's a diffuse, continuous inflammatory process char by edema and shallow mucosal ulcerations.
-begins in rectum and proceeds continuously back towards cecum

may develop superficial bleeding points and they may become ulcers.

czs the mucosa to thicken and scar which results in loss of elasticity(which results in megacolon) & the development of pseudopolyps(incr risk of cancer)

inflammatory process may occur anywhere along the GI tract but it often involves the terminal ileum.

affects all layers of the mucosa.

will have a "cobblestone" appearance where the inflamed areas are separated 4m the normal tissue.
-fistulas may develop czing perforation(then at risk for peritonitis)

*Talk to pt about BM's
-Diarrhea:classic symptom
•is profuse(10-20 stools/day)
•stools contain mucus,pus,bld
•may have cramping prior to stool
•electrolyte imbalances
•tenesmus:uncontrolled straining

-Diarrhea
•5-6 large semisolid stools/day
•may contain mucus & pus but no blood
•steathorrhea
•abd colicky pain relieved w/ BM
•R lower quadrant pain which mimics appendicitis

-anorexia
-weakness/malaise
-weight loss
-fever
-leukocytosis
-iron deficiency anemia

-h/o symptoms,severity and duration
-stool specimens to R/O infectious disorders
-lab test:CBC,ESR,albumin
-barium enema
-upper GI
-sigmoidoscopy or colonoscopy

-sulfazalazine(Azulfidine)
-steroids
-immunosuppressive therapy
-antibiotics
-other

-used to tx mild to moderate forms of UC & Crohn's dz.
-unsure exactly how it works but is thought to decr infl w/ bacterial suppression.

-Olsalazine(Dipentum)
-Mesalamine(Asacol,Pentasa):may be given as a suppository. Not used for Crohn's dz.

in periods of exacerbation(then decr gradually) bc of anti-inflammatory effect.

-Cyclosporine:may take up to 4-6 months to work.
-side effects a prob(bleeding, inf)
-not effective alone but when given in combo w/ steroids, amt of steroids can be decr.

-not a primary tx modality but may be used as adjunctive therapy w/ bacterial overgrowth. Flagyl is commonly used.

used for refractory dz.(not responsive to other therapy)
-works to decr infl
-works better w/ Crohn's dz

-antidiarrheal agents for symptom relief
-vitamin supplements
-iron supplements

-diet control is more important for comfort than for tx

diet is very individualized but common diets restrict raw fruit and veggies,spicy foods,alcohol,caffeine
-may need to restrict dairy prods
-low fiber diet
-may need TPN

-perforation
-toxic megacolon
-hemorrhage requiring transfusion
-cell dysplasia or cancer
-failure of medical therapy

-proctocolectomy w/ ileostomy
-total colectomy w/ continent ileostomy
-total colectomy w/ ileoanal anatomosis
-total colectomy w/ ileoanal reservoir

removal of the colon,rectum & anus w/ permanent closure of the anus. The terminal end of the ileum is brought out thru abd wall.
-drainage 4m the ileostomy is watery and continuous.
-this cures UC.

An order. Need an order for EVERY bag of TPN that is hung.

-must be administered via an infusion pump
-must be infused at a constant rate

When initiating or discontinuing TPN infusion must gradually start and/or stop. [For 1st hr, run at 1/2 recommended rate.

D10W

every 6 hrs

every 24 hrs.

cannot give with blood or blood products

-monitor labs(electrolytes) daily
-monitor weights daily

a newer procedure in which stool is stored in a pouch until evacuated by the pt

removal of the colon & rectum w/ the ileum being sutured into the anal canal

the rectal sphincter is left intact & a J-pouch is created.
-pt has no ostomy

segmental resection
-doesn't cure prob bc dz has potential to reappear

bowel is resected from 5-10 cm above and below the visible dz
-maybe done laparoscopic

dz usually reappears at or near the anastomosis at a rate of 10% per yr.

-promote comfort
-control diarrhea
-promote nutrition
-restrict raw fruits and veggies, milk prod

-assess duration,severity, character, and relationship of pain, stool, flatus to drinking and eating

-keep record of severity, frequency, character of each BM
-good skin care to anal area after each stool
-monitor F & E, I & O

-may be on TPN or enteral feedings
-low-residue, high protein, high caloric diet

well balanced, high protein, incr caloric diet

-emotional stress can influence the severity & frequency of exacerbations.
-Encourage the pt to be an active participant in all decisions, allow pt to verbalize, support groups

-assess duration,severity, character, and relationship of pain, stool, flatus to drinking and eating

-keep record of severity, frequency, character of each BM
-good skin care to anal area after each stool
-monitor F & E, I & O

-may be on TPN or enteral feedings
-low-residue, high protein, high caloric diet

well balanced, high protein, incr caloric diet

-emotional stress can influence the severity & frequency of exacerbations.
-Encourage the pt to be an active participant in all decisions, allow pt to verbalize, support groups

-assess duration,severity, character, and relationship of pain, stool, flatus to drinking and eating

-keep record of severity, frequency, character of each BM
-good skin care to anal area after each stool
-monitor F & E, I & O

-may be on TPN or enteral feedings
-low-residue, high protein, high caloric diet

well balanced, high protein, incr caloric diet

-emotional stress can influence the severity & frequency of exacerbations.
-Encourage the pt to be an active participant in all decisions, allow pt to verbalize, support groups

-assess duration,severity, character, and relationship of pain, stool, flatus to drinking and eating

-keep record of severity, frequency, character of each BM
-good skin care to anal area after each stool
-monitor F & E, I & O

-may be on TPN or enteral feedings
-low-residue, high protein, high caloric diet

well balanced, high protein, incr caloric diet

-emotional stress can influence the severity & frequency of exacerbations.
-Encourage the pt to be an active participant in all decisions, allow pt to verbalize, support groups

-assess level of knowledge
-visit w/ ET nurse
-allow time for verbalization
-nutritional assessment-is TPN needed?
-bowel cleansing program

-NPO
-NG tube:to suck out secretions in stomach
-maintain F & E
-I & O(remember drainage 4m ileostomy is liquid & constant)
-skin integrity
-monitor nutrition
-assess stoma:should look pink,shiny

the blockage of mvmt or intestinal contents thru the large or small intestines

1. can be mechanical(something is blocking the bowel)
2. paralytic(nonmechanical):peristalsis stops. can be due to narcotics

-early on the bowel sounds are loud,high pitched & frequent
-later on the bowel sounds are absent
-may have profuse,nonfecal vomiting & upper abd pain(seen w/ proximal SBO)
-may have fecal type vomiting,cramping,poorly localized abd pain & distention(seen w/ distal BO)
-complete obstruction:absent bowel sounds w/ no passage of gas or stool-obstipation:no bowel mvmts
-s/s of dehydration
-air & fluid filled areas of obstruction visualized on x-ray

-NG tube
-IV fluids
-surgery for mechanical obstruction
-correct electrolyte imbalances

-monitor F & E
-monitor temp
-monitor urinary output
-listen for bowel sounds
-maintain NG care
-promote ventilation
-provide comfort:admin analgesics w/ caution, may further decr peristalsis
-prepare pt for surgery

an impairment of gastric mucosal defenses so that they no longer protect the epithelium lining 4m the effects of acid & pepsin

-unsure of exact cz
-genetic factors
-environmental factors
-drug effects:esp NSAIDS
-infection:H. pylori

-gastric
-duodenal

-have normal gastric acid secretion & normal rate of emptying
-have incr diffusion of gastric acid back into the tissue & impaired mucosa protection

-have normal diffusion of gastric acid back into the tissue
-ahve incr gastric acid secrections especially bw meals & incr empyting
-often assoc w/ H. pylori inf

-ulcers that occur after a medical crisis or trauma
-assoc w/ incr hospital stay & incr mortality

-c/o fullness,epigastric discomfort,vague nausea, distention,bloating,anorexia,
weight loss,dyspepsis,sharp, burning,gnawing sensation(very common)

pain occurs 1-2 hrs after meals and the pain is made worse with food or antacids

pain occurs 90 min to 3 hrs after meals & at night(12mn-3a) & the pain is relieved w/ food or antacids

-made based on the symptoms
-endoscopy allows for definitive dx

allows for:
-gastric analysis allows for presence of acid oversecretion
-biopsy for gastric cancer
-presence of H. pyloric bacteria
-may also have Hgb & Hct & barium enema done

-provide pain relief
-eradicate H. pylori inf
-heal ulcerations
-prevent recurrence

-antacids(used for symptom control)
-proton pump inhibitors
-H2 antagonists
-other

Antacids

work by neutralizing hydrochloric acid preventing it from irritating the lining of the GI tract & allowing the mucosal lining to heal.

at low doses they promote gastric mucosal defensive mechanisms forming a protective barrier against HCL

that they have to be taken so frequently. 1 & 3 hrs after meals & at bedtime.

-any med that binds to the antacid & therefore is not available to be absorbed
-any med that is changed based on the pH of the stomach
-any med that is changed by the pH of the urine

-aluminum based:Maalox(preferred)
-magnesium based:MOM
-calcium based:TUMS

assess for:
-CHF
-hypertension
-sodium restrictions
-fluid imbalances
-GI obstructions
-renal dz
-pregnancy

do not use sodium bicarbonate for antacid bc of the risk of alkalosis.

-don't take other meds w/in 1-2 hrs of antacid
-be sure that the chewable tablets are well chewed and the liquids are well shaken
-take with a full glass of water
-monitor bowel activity:may cz constipation

proton pump inhibitors/aka antisecretory agents

work to block the secretion of acid by blocking the ability of the hydrogen ions to move out of the parietal cells which is the last step in the acid secretory process.

-used for erosive esophagitis
-GERD that doesn't respond to other txments
-ulcers

should only be used short term
-no longer than 8 wks

many but they aren't very common.
Include:
-H/A,dizziness,N/V,diarrhea, abdominal pain,anorexia, hematuria,thrombocytopenia

-increase serum levels of diazepam(Valium) & phenytoin(Dilatin) & incr potential for bleeding if on Coumadin

-Lansoprazole(Prevacid)
-pantoprazole(Protonix):if giving IV check compatibility
-esomeprazole(Nexium)

H2 antagonists

work by binding to & blocking the histamine receptors on the parietal cells & therefore suppressing acid prod in the stomach

-used for the tx of gastric ulcers,GERD, hypersecretory conds,duodenal ulcers & upper GI bleeds

may include: H/A, lethargy, confusion,abd pain,rash, thrombocytopenia

pts in renal failure. 1 side effect is elevated BUN/creatinine
-also use w/ caution in the elderly & the confused/disoriented:1 side effect is confusion

-absorption may be impaired in pts who smoke
-should be taken 1 hr b4 antacids
-tagamet may bind w/ other meds that are metabolized by the liver(Theophyllin, coumadin, lanoxin, Dilantin)

-Cimetindine(Tagamet)
-Famotidine(Pepcid)
-Rantidine(Zantac)

Sucralfate(Carafate) a protective agent

works by binding itself to the base of the ulcer or erosions & forms a protective coat over the ulcer. This prevents pepsin 4m being able to access the ulcer which assists in the healing of the ulcer.

used for stress ulcers, erosions, PUD

(uncommon)
Include: constipation,N, dry mouth

should not be taken w/ any other med bc the absorption of the med may be impaired
-should be taken on an empty stomach

-txment of H. pyloric bacteria
-diet
-surgery

not sure how it effects the development ulcers but definitely effects ulcer relapse.

pepto-bismol
amoxicillin or tetracycline
flagyl

-no longer think that a bland diet assists w/ healing
-now say to eliminate or restrict any foods that cz discomfort

surgery is done for the mgmt of acute complications & for ulcers that are resistant to standard txment

may be minimally invasive:
-vagotomy
-antrectomy as Billroth I or II
-subtotal gastrectomy
-gastroenterostomy
-pyloroplasty

reduces acid prod by decr the cholinergic stimulation of the parietal cells & limiting the response to gastrin by cutting the vagus nerve.

removal of as much as 50% of the lower stomach by making an incision into the walls of the stomach
-considered the most effective surgical method for ulcer control
-may be a Billroth I or a Billroth II

procedure where the remaining gastric segment is sewn to the duodenum

procedure where the remaining gastric segment is sewn to the jejunum

removes as much as 75% of the distal stomach w/ either a Billroth I or Billroth II

neutralizes gastric acid by allowing regurgitation of alkaline secretions 4m the duodenum into the stomach

removal of as much as 50% of the lower stomach by making an incision into the walls of the stomach
-considered the most effective surgical method for ulcer control
-may be a Billroth I or a Billroth II

procedure where the remaining gastric segment is sewn to the duodenum

procedure where the remaining gastric segment is sewn to the jejunum

removes as much as 75% of the distal stomach w/ either a Billroth I or Billroth II

neutralizes gastric acid by allowing regurgitation of alkaline secretions 4m the duodenum into the stomach

surgery to enlarge opening of pylorus to facilitate emptying of stomach contents

-maintain patent airway
-provide adequate nutrition:TPN
-prevent post op probs

-turn,cough,deep breathe
-bleeding:monitor NG drainage
-dumping syndrome
-acute gastric dilation
-NG probs:need an MD order to reposition
-recurrent ulceration

occurs due to the rapid emptying of food directly into the jejunum

weakness,faintness, palpitations,diaphoresis, feeling of fullness, discomfort, nausea
-symptoms occur during the meal or from 5-30 min after the meal

Billroth II

eat moderate fat,high protein diet w/ limited carbs, avoid simple sugars, & DISCOURAGE FLUIDS W/ MEALS

occur 90 min to 3 hrs after eating.

czed by a release of an excessive amt of insulin due to repaid emptying of the food into the jejunum.

-Pectin(dry powder):may prevent syndrome
-Octreotide(Sandostatin): given in severe cases

-eat small, frequent feedings
-avoid drinking liquids w/ meals
-eliminate caffeine/alcohol
-stop smoking
-lie flat after eating: delays the emptying of food 4m stomach

-hemorrhage:bleeding czd by the ulcer
-perforation: erosion of the ulcer thru the wall of the stom or duodenum
-obstruction
-intractable dz

-tarry stools
-coffee ground emesis
-bright red blding
-abd cramping & discomfort
-signs of shock

-notify the MD
-NG lavage
-fluid & bld replacement
-IV meds

-severe sharp abd pain
-rigid abd w/ rebound tenderness
-tachycardia
-tachypnea & diaphoresis

-notify the MD
-surgery

-not common
-occurs due to repeated cycles of ulceration & healing

-infl of the gastric mucosa
-will be either erosive or non erosive & either acute or chronic.

-H. pylori inf
-non steroidal anti-inflammatory drugs
-radiation therapy
-ingestion of corrosive subs
-stress
-NPO status

-autoimmune disorders
-H pylori inf
-situations of sustained infl
-irritation via smoking, radiation therapy,alcohol
-surgical procedures such as Billroth II

-pain in the epigastric area:rapid onset w/ acute; w/ chronic pain complaints vague
-anorexia
-cramping
-N/V
-bleeding:acute
-dyspepsia:acute
-pernicious anemia:chronic

-cholelithiasis
-cholecystitis
-choledocholithiasis

stone formation in gallbladder

infl of the gallbladder usually czed by gall stones

stone formation in the common bile duct.

-anything that incr the components of the gall stone: such as cholesterol, bile salts, calcium, bilirubin, proteins
-anything that upsets the balance of cholesterol in the bile has the potential to cz a stone to develop.

-age
-obesity
-effect of hormones
-GI stasis

-may be asymptomatic
-indigestion after consuming a high caloric fatty diet
-sudden onset of pain in the RUQ
-more gas than normal after eating
-anorexia
-N/V
-dypepsia
-feeling of fullness
-rebound tenderness

fever & chills

-jaundice
-decr urine urobilinogen
-clay colored stools

-sudden onset of pain in the midepigastrium
-pain that spreads to the back,under the scapula, & to the right shoulder
-tachycardia
-diaphoresis
-inability to be still

-r/o other dzs
-ultrasound will show edema of gallbladder wall & fluid

-pain control:Demerol(morphine is not used due to biliary spasms & constriction
-NPO-IV
-antibiotics:ifcholecystitis is present
-vitamin K:if jaundice is present & PT is prolonged

-catheter that opens up the heptic duct so that bile can flow
-used when surgery is not possible

-extracorporeal shock wave lithotripsy(ESWL)
-cholecystectomy:primary txment for symptomatic for GB dz
●laparoscopic
●open

shock waves are used to disintegrate the gall stones & then the fragments are ecreted thru the common bile duct into the small intestines

uses a laser to remove the gall bladder. It is less invasive & has less chance of wound inf. Pt's recover faster.

gall bladder is removed thru an abd incision.

protrusion of an organ or structure 4m its normal cavity.

usually develop w/ muscle weakness & incr intraabdominal pressure r/t heavy lifting, obesity or pregnancy

-reducible
-irreducible or incarcerated
-strangulated

protruding structure requires manipulation to return to proper position

cannot be returned to proper position

emergency situation where bld flow to the protruding segment is decr.

-indirect/direct inguinal
-femoral
-umbilical hernias
-incisional or ventral hernia

hernia that has moved into the inguinal canal

protrudes into the femoral ring

may be either congenital or acquired

hernias at sites of previous surgeries

-lump which may appear suddenly or always be present
-vague feeling of discomfort
-"dragging" feeling in the abdomen

-Surgery:should be done as an elective procedure. All hernias should be corrected to prevent strangulation in the future. May be done as minimal invasive procedure.

Same as with other surgeries except NO COUGHING

any group of conds that results 4m esophageal reflux.

when the gastric content or intraabdominal pressure incr or when the esophageal sphincter tone decr

infl which heals & then gets inflamed again over & over until scarring & esophageal strictures occur

-vary 4m pt to pt
-heartburn:most common symptom
-substernal or retrosternal pain
-pain that may radiate upward into the neck, jaw or back
-pain that starts 20 min to 2 hrs after eating
-dysphagia
-frequent belching & flatulence
-nocturnal cough, wheezing & hoarseness

-mild cases the dx is made based on symptoms
-more definitive diagnostic test is 24 hr pH monitoring

records the #, duration & severity of the reflux episodes thru an electrode which is placed in the lower esophageal sphincter & is then attached to a transnasal catheter.

-antacids
-H2 antagonists
-proton pump inhibitors
-antacid + alginic acid(Gaviscon) a med that neutralizes gastric acid & forms a viscous foam that prevents reflux

-not usually done unless the symptoms are severe & the pt does not respond to other txments

-eat 4-6 meals/day
-low fat,adequate protein diet
-reduce intake of caffeine
-limit or eliminate alcohol
-chew food completely
-don't eat b4 bedtime:remain upright after eating
-lose weight if necessary
-stop smoking
-avoid constrictive clothing
-avoid activities that cz bending over or lifting heavy objects
-reverse trendelenberg position

-swallowing incoordination
-pharyngeal weakness
-esophageal disorders

occurs when the lower esophageal muscles & sphincter fail to relax appropriately in response to swallowing

-gradual onset of dysphagia
-pain
-regurgitation
-weight loss
-halitosis

esophageal dilators

an acute infl of the appendix

no clear cut cz but usually occurs when the lumen of the appendix becomes blocked

-RLQ pain that comes in waves
-pain @ McBurney's pt: halfway bw the umbilicus & the anterior iliac crest
-N/V
-anorexia
-rebound tenderness
-side lying position w/ knees drawn up
-incr temp, incr wbc, incr neutrophils(shift to the left)

-symptoms
-r/o other kidney or urinary tract probs

perforation

-remove the appendix:either open or laparoscopic

-diverticulosis
-diverticulitis

the presence of asymptomatic multiple diverticula(small outpouchings or herniations of the mucosal lining of the GI tract)

acute infl & inf of the diverticula due to trapped fecal material

-may be asymptomatic
-crampy lower left quadrant abd pain:intermittently initially
-fever
-pain gets worse w/ mvmt,coughing, straining
-N/V
-abd tenderness & distension
-w/ perforation: signs of peritonitis

-history & presenting symptoms
-CT scan of the abdomen
-barium enema
-colonoscopy/sigmoidoscopy

prevention of constipation w/ a high fiber diet & bulk laxatives

rest and clear liquid diet

-NPO
-IVs
-antibiotics:Metronidazole (Flagyl)
-analgesics
-anticholinergics:decr peristalsis
-NG tube

-required in about 25% of all cases
-resect the diverticuli & do an end to end anastomosis
-may need a temporary colostomy

Prevention
-encourage fluids
-soft foods,incr in fibers
-avoid nuts,seed foods
-bulk forming laxatives
*Routine post op care if surgery is done

chronic cond w/ altered bowel habits (most often diarrhea) w/ exacerbation & remissions w/o changes to the lining of the bowel

-symptoms are usually brought on by stress, anxiety or dietary habits
-occur intermittently
-abd pain relieved by defecation
-changes in character of stools
-abd distention
-feeling of incomplete evacuation of stool
-presence of mucus in stool

made after other czs have been ruled out

-lifestyle changes:ways to cope w/ stress
-eat well balanced meals

occlusion of the vascular bed of the bowel

-seen in pts w/ heart dz when an embolism is thrown to the intestines
-common in the elderly

the bowel dies due to that lack of bld flow

-depends on the loc & the size of the emboli
-pain which is crampy or colicky & lasts for several hrs after eating
-pain may be sudden & sharp
-may be assoc w/ N/V
-elevated WBC
-abd distention w/ no bowel sounds

-NG intubation, NPO
-IV fluids
-surgical removal of clots or dead bowel
-post op admin of Heparin/Coumadin
-critically ill:close monitoring, high mortality rate

Stool exams
-Interpretations of stool color
*white:barium
*clay:lack of bile, biliary obstruction
*red:lower GI bld, red food intake
*tarry: upper GI bld
*green: rapid peristalsis
Stool tests
-fecal occult bld test
-ova & parasites
-fecal fats:steatorrhea
-C. diff

-Upper GI
-barium enema

visualizes esophagus, stomach, duodenum & upper jejunum thru contrast dye

outlines the large intestines thru contrast dye

-esophagogastroduodenoscopy
-endoscopic retrograde cholangiopancreatography
-colonoscopy
-proctosigmoidoscopy
-enteroscopy

allows for direct visualization of the esophagus, stomach & duodenum

procedure in which a special lumen is threaded retrograde into the ampulla of Vater to release gall stones. May also have dye instilled to outline the pancreatic & biliary ducts

visualizes the entire colon

visualizes the anus, rectum, & distal sigmoid colon

visualizes bowel thru small capsule which is swallowed

-NPO
-informed consent
-sedation
-any oral endo procedure: assess gag reflex b4 being allowed to eat after procedure
-any bowel endo procedure: need a bowel prep

Eplerenone(Inspra)

Potassium.

-work by decr the heart rate which czs a decr in cardiac output.
*CO= stroke vol x heart rate. Normal CO is 4-8 L/min.

bc they decrease the contractions of the heart.

bc they can also act as a bronchoconstrictor.

-Propranolol
-Atenolol
-Nadolol
-Metoprolol

work by stopping vasoconstriction by acting on the CNS to reduce the activity of the sympathetic nervous. (relaxes CNS since is antiadrenergic)

Methyldopa(Aldomet) & Clonidine(Catapres)

given by transdermal patch: helps make pts more compliant.

the 1st line of txment

works by czing vasodilation.
-Not seen very often anymore.

-Hydralazine(Apresoline)
-Minoxidil