AHII Exam I
Where should a pt w a balloon tamponade be?
ICU!!! very close monitor
neomycin can cause ----
auditory loss and nephrotoxicity
what is high in fiber
cabbage raw fruit and vegtables
Thiamine deficiency
can lead to wernicke encephalopathy *must replace with thiamine which is common with alcoholics beriberi, polyneuritis
esophageal varices
caused by portal hypertension enlarged and swollen veins at the lower end of the esophagus
What part of the brain controls and coordinates muscle movement?
cerebellum
Hepatopulmonary syndrome (HPS) manifestations
clubbing cyanosis dyspena this is caused from the pulmonary capillary dialtion
bedside of a pt w esophageal varices
et tube for intubation to prevent aspiration of blood
Papilledema
is edema of the optic nerve (CN II)
Causes of xerostomia
pts. w HIV Pts. who cannot close their mouths Pts. w endotracheal tubes or tracheostomy tubes psychopharmacological agents Pts. w poor oral food intake
hepatic encephalopathy
results from the breakdown of blood in the GI tract and rising serum ammonia level
Acute complications of SCI
spinal and neurogenic shock and deep vein thrombosis (DVT)
when is logroll used for moving a pt
when the spinal cord has to be kept straigt
If a pt is having an ischemic stroke within how long do they need alteplase for it to be effective
within a 3 hour window of symptom onset book says 3 ati says 3-4.5
misoprostol
- This can induce uterine contractions, so women of childbearing age must r/o pregnancy. - Prevents ulceration in clients taking non steroidal anti-inflammatory drugs (NSAIDs)
herniation of brain
- severe increased ICP - shifting of brain tissue from one compartment to another - places pressure on cerebral blood vessels and vital centers (medulla) - death results
Ingestion of how much alcohol can cause liver disease?
60g/day for men 30g/day for women 10g of alcohol is a standard shot, glass of wine, and beer for reference
What is the concentration of bilirubin when jaundice first occurs?
>3mg/dL
lower motor neuron lesion
A lesion of the anterior horn of the spinal cord, nerve roots, or peripheral nerves resulting in decreased reflexes, flaccid paralysis, and atrophy Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control
Positive romberg sign
A positive Romberg sign is indicated when a client loses their balance while attempting to stand erect with their eyes closed.
achlorhydria
Absence of hydrochloric acid from the gastric juice.
small intestine main function
Absorbs most nutrients; Main absorption organ of the digestive tract
common causes of chronic liver disease
Alcohol hepatitis B&C Virus nonalcoholic fatty liver
A patient diagnosed with hepatic encephalopathy is receiving lactulose. When preparing to administer this medication, the nurse understands that it is used to decrease which serum level? Calcium Ammonia Potassium Sodium
Ammonia
Amylase
Amylase is an enzyme secreted by the pancreas and intestine that breaks down starches into glucose.
Battle sign
Bruising behind an ear over the mastoid process that may indicate a skull fracture. An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign)
A nurse is teaching a client with a new diagnosis of peptic ulcer disease (PUD) who has a prescription for bismuth subsalicylate. The client asks the nurse, "How will this medication help my ulcer?" Which of the following statements should the nurse make? A. "This medication will decrease prostaglandins." B. "The amount of bicarbonate in your body will be increased." C. "This medication can decrease bacteria in the gastrointestinal tract." D. "This medication acts by increasing blood flow to the stomach."
C. "This medication can decrease bacteria in the gastrointestinal tract." The nurse should include in the teaching that bismuth subsalicylate can assist by eliminating the bacteria Helicobacter pylori, which can cause PUD.
A halo sign is indicative of what?
CSF leakage it is a blood stain surrounded by a yellowish stain, typically seen in ben linens or the head dressing
CSF rhinorrhea
CSF running from the nose usually an indication of a basal skull fracture early onset that stops within 3-5 days typically doesn't require surgery but it it appears 7+ days after the accident, surgery is most likely warranted
Parasympathetic nerve stimulation effect on the GI tract?
Causes peristalsis, and increases secretory activities Sphincters relax Parasympathetic- rest and digest!
during the sympathetic response to stress what does the liver do?
Convert glycogen to glucose for immediate use. a process called glycogenolysis
one of the earliest signs of ICP (intracranial Pressure) elevation?
Decreased Level of consiousness
Cushings triad is a late manifestation of IICP what is the cushing triad?
Decreased respiration Bradycardia Hypertensions
Which assessment finding does the nurse expect as a normal consequence of aging? a. Increased salivation and drooling b. Hyperactive bowel sounds and loose stools c. Increased gastric production and heartburn d. Decreased sensation to defecate and constipation
Decreased sensation to defecate and constipation Older adults may lose the sensation to defecate, resulting in constipation.Salivation decreases with aging, along with peristalsis and gastric acid production
xerostomia
Dryness of the mouth caused by reduction/ cessation of saliva
what increases ammonia buildup
GI bleeding ( bleeding esophageal varices, chronic GI bleeding) high protein diet bacterial infection uremia
Physical exam findings that hepatic function is decreased
Jaundice ecchymosis spider angiomas palmar erythema (reddening of palms) sclera icterus (yellowing of the sclera) leukonychia of nails (whote spots on nails) clubbing of fingers
Manifestations of ulcerative colitis
Left lower quadrant abdominal pain bloody diarrhea passage of mucus urgency intermittent tenesmus (feeling of having to poop even of you dont have to) fever
Lipase
Lipase is an enzyme secreted by the pancreas that breaks down triglycerides into monoglycerides. Steapsin is an enzyme secreted by the gastric mucosa that breaks down triglycerides into monoglycerides.
What devices are appropriate for TPN?
PICC Line Central Line tripple lumen catheter AND PORT
Pepsin
Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body.
Which of the following foods could give a false-positive result on the fecal occult blood test (FOBT)? Select all that apply. Red meats Pasta Turnips Fish Whole-grain bread
Red meats Turnips Fish
Manifestations of regional enteritis
Right lower quadrant abdominal pain unrelieved by defecation fatigue diarrhea weight loss
After a seizure what position would be best for the pt. to be in, why?
Side lying to facilitate drainage of oral secretions
Post gastric surgery dietary considerations
To delay stomach emptying and dumping syndrome, assume a low Fowler position (head of bed [HOB] elevated 30 degrees) during mealtime; after the meal, the patient should lie down for 20-30 minutes. Dont drink fluids w meals, stop one hr before and resume one hour after Take antispasmodics as prescribed to aid in delaying the emptying of the stomach have food be more dry than liquid Similar to post bariatric surgery nutrition guidelines
visual agnosia
Visual agnosia is the loss of ability to recognize objects when seeing them happens when injury occurs to the occipital area
Patients with severe chronic liver dysfunction often have problems related to inadequate intake of sufficient vitamins. What vitamin deficiency would result in hemorrhagic lesions of scurvy? Riboflavin Vitamin C Vitamin A Vitamin K
Vitamin C
A headache in the morning is suggestive of what?
a brain tumor
Hepatorenal syndrome (HRS)
a complication of advanced liver disease characterized by functional renal failure with oliguria, sodium and water retention, hyppotension and peripheral dilation
A headache without fever may be associated with
a tumor or intracranial bleeding
Which medication should the nurse question before administering it to a patient with peptic ulcer disease? a. E-mycin, an antibiotic b. Prilosec, a PPI c. Flagyl, an antimicrobial agent d. Tylenol, a nonnarcotic analgesic
a. E-mycin, an antibiotic The antibiotic E-mycin is irritating to the GI tract and should be questioned ina patient with PUD
A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal? a. Slows gastric emptying b. Provides much needed rest c. Allows for better absorption of vitamin B12 d. Removes tension on internal suture line
a. Slows gastric emptying Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful.
herniation
abnormal protrusion of an organ or other body structure through a defect or natural opening
asterixis
aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & extend.
chronic pancreatitis main cause
alcohol use
abg results for hepatic encephalopathy will show
alkalosis (potassium will be low - hypokalemia) ammonia and potassium are in inverse relationships
hepatic encephalopathy path
ammonia is produced by liver as byproduct of protein breakdown ammonia is also produced by colon and small intestine the liver converts ammonia to urea to be excreted through urine when the liver fails to convert the ammonia to urea it cannot be excreted out of the body and a toxic build up occurs, affecting the neurological system.
A fever and headache is associated with
an infection process; like meningitis or encephalitis
encephalopathy
any disease of the brain
planning for the discharge of a client with peptic ulcer disease. Which outcome must be included in the plan of care? a. The client's pain is controlled with NSAIDs. b. The client understands and maintains lifestyle modifications. c. The client takes antacids around the clock. d. The client has no episodes of GI bleeding.
b. The client understands and maintains lifestyle modifications. Maintaining the lifestyle adjustments of eating an appropriate diet, reducingstress, decreasing or stopping smoking, and following a medication regimen are the goal totreat and prevent complications
A 47yo male w epigastric pain is being admitted to the hospital. During the admission assessmet, what specific info should the nurse obtain for the pt, who is suspected of having peptic ulcer disease? a. Any allergies to food or medications b. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) c. Medical history for two previous generations d. History of side effects of all medications
b. use of NSAIDs Use of NSAIDs in the patient suspected of peptic ulcer disease increases therisk of GI bleeding
hepatic fetor
bad breath associated with liver disease compared to freshly cut lawn, acetone, or old wine
hematochezia
blood in stool
what may you see or do for a pt who is having a esophageal varices bleed
bp measured noninvasively or via an arterial catheter o2 administered to prevent hypoxia iv fluids w electrolytes indwelling urinary catheter to closly monitor output potential blood admin watch for rebound admin of somatostatin or octreotide (octreotid is best)
contusion
bruise
What assessment finding supports a client's diagnosis of gastric ulcer? a. Presence of blood in the client's stool for the past month b. Complaints of sharp pain in the abdomen after eating a heavy meal c. Periods of pain shortly after eating any food. d. Complaints of epigastric burning that moves like a wave
c. Periods of pain shortly after eating any food. Experiencing sharp pain 30 to 60 minutes after meals is common with gastric ulcers; patients with duodenal ulcers can have night pain that is relieved by eating and pain occurs 2-3 hr PC
signs and symptoms of shock
cool clammy skin, hypotension, tachycardia, decreased urine output, restlessness, weak peripheral pulses
The client with a peptic ulcer is admitted to the hospital's intensive care unit with obvious gastric bleeding. What is the priority intervention for the nurse? a. Keep an accurate record of intake and output. b. Provide for quiet environment, restrict visitors. c. Prepare the client for an endoscopy. d. Monitor vital signs and observe for signs of hypovolemia.
d. Monitor vital signs and observe for signs of hypovolemia. The goal is to directly stop the bleeding and remove blood/clots/secretions from GI tract so that an endoscopy can be performed and the patient does not vomit and aspirate gastric contents.
Dysarthria
difficulty forming words - motor speech
hepatic encephalopathy DTR
early on they are hyperactive then they become flaccid stages 1-3 they're there and stage 4 they are gone
All of the GI tract besides the --- is located in the peritoneal cavity; where is the --- located?
esophagus; mediastinum
pt who has pancrititis
experience an increase in pancreatic enzymes, amylase, and lipase.
most common causes for TBI (traumatic brain injuries)
falls motor vehicle accidents collisions assaults
Cirrhosis
final stage of all chronic liver disease
Normal liver on palpation
has a sharp smooth edge and is firm but not hard and the left lobe in nonpalpable
bleeding esophageal varices manifestation
hematemesis, melena, decreased mental and physical status hx of alcohol abuse s&s of shock
constructional apraxia
inability to reproduce a simple figure seen in hepatic encephalopathy ask pt to draw a star daily to see if it gets worse
what may lead to the dx of primary sclerosing cholangitis
inflammatory bowel disease (ulcerative colitis / chrons)
Sympathetic nerves exert an ---- effect on the GI tract
inhibitory; decreases gastric secretion and motility causing the sphincters and blood vessels to constrict. think about fight or flight , at the time when you need the blood else where and it isn't as important to have gi function
sclerotherapy for esophageal varices
injection of a solution into a vein to thrombose /sclerosis (abnormal hardening) it
decompensated cirrhosis hallmark
jaundice ascites pedal edema gastroesophageal varices hepatic encephalopathy
ulcerative colitis diet
low-fiber Acute- NPO progress diet clear liquids --> low fiber, high protein, vitamins & supplements Avoid gas forming foods- dairy, whole wheat grains, raw fruits and veggies, pepper, etoh, caffeine
who is most at risk for a TBI?
males 15-24 children under 5 older adults over 75
early ss of hepatic encephalopathy
minor mental changes and motor disturbances appears slightly confused and unkept sleep during day and insomnia at night
Dumping syndrome manifestations
nausea, weakness, diaphoretic, diarrhea, vomiting, belching, the feeling of epigastric fullness, and abdominal cramping
neoplasm
new growth (tumor)
Vitamin A deficency
night blindness and eye and skin changes
what does the nurse monitor for after the tx of acute hemmorrhage in the esophagus
observe for bleeding perforation of the esophagus aspiration pneumonia esophageal stricture
Tetraplegia
paralysis of all four limbs; quadriplegia
paraplegia
paralysis of both legs and the lower part of the body
Appendicitis signs and symptoms
right lower quadrant pain increased WBC count Fever decreased appetite Rovsing sign n&v Pain may radiate to umbilical area
pt education for hepatic encephalopathy
stop eating a lot of protein (1-1.5g/kg) take this lactulose take this rifaximin or neomycin sulfate
why are anticoagulants not given to patients with brain tumors?
the risk of CNS hemmorage does not outweight the reward of decreased DVT or PE
laminectomy
the surgical removal of a lamina, or posterior portion, of a vertebra
Lactulose is administered to a pt with hepatic encephalopathy why?
to reduce ammonia levels - monitor for watery stools because they may indicate a medication overdose
pancreatitis
trypsin breaks down the pancreases (self digestion bc the pancrease releases trypsin) severe midepigastrium pain 24-48 hrs after a heavy meal or alcohol consumption
What can cause fulminant hepatic failure
viral hepitis acetaminophen overdose drug induced liver injury autoimmune hepatitis metabolic disorders like wilsons disease poisonous mushroom ingestion obstruction to hepatic bf Budd-Chiari syndrome
what vitamin does the liver cells use to make prothrombin?
vitamin K deficiency can lead to hypoprothrombinemia which will result in prolonged bleeding
Hemiparesis
weakness on one side of the body
CSF otorrhea
when CSF leaks from the ears typically seen in basilar skull fractures typically does not require surgery to stop.
