Exam 5 NS 238
How long is the hepatitis B vaccine effective?
15 years
What pt education needs to be given to a pt who is going to have a 24 hr urine test to check for pheochromocytoma?
2 days before the urine test: NO chocolate, banana, coffee, tea or vanilla
How do we diagnose cushing's?
24 hour urine for breakdown of hydroxycorticosteroids Increased Na and glucose Decreased serum K blood corticosteroid test dexamethasone sup. test check for feedback control working or not
What are the s/s of transesophageal fistula or esophageal atresia?
3 C's - coughing, chocking with feeds and cyanosis Suspected in newborns if "blowing bubbles' or has unexplained cyanotic spells Apnea, respiratory distress after feeding, abdominal distention
What is the max dose of acetaminophen per day?
4g/day
How much fluid loss per day do we see with HHS?
8-10L/day Fluid loss from ALL TISSUES, including the brain
When is cleft palate repair typically done?
9-12 months of age Encourage mother to breastfeed
What is hepatitis B?
A DNA virus that replicates in the liver Found in blood, semen, cervical secretions, saliva and wounds - this is an easier form of hepatitis to catch anytime you come in contact with one of these
What is pheochromocytoma?
A tumor - usually non malignant Involves the adrenal medulla - Fight or Flight
What is an imperforate anus?
Absence of a visible anus, baby fails to pass meconium, nurse unable to insert rectal thermometer after birth
What is hepatitis?
Acute or chronic inflammation of the liver cells Inflammation limits the ability to perform normal fx Liver is exposed to causative agents (HAV, HBV, acetaminophen, etc.)
What happens with adrenocortical hypofunction? (primary adrenal insufficiency)
Addison's disease
Who is the hepatitis be vaccine recommended for?
All newborns and up given in 3 infections over 12 months
how do we diagnose hirschprung's (aganglionic megacolon)?
Barium enema - be careful, may not evacuate the barium Definitive dx made by rectal biopsy - shows no ganglion cells
DKA has resolved when:
Blood glucose level is below 200 serum bicarb is greater than 18 Venous pH is above 7.3 the calculated anion gap is below 12
What HHS IV fluids do we give?
Bolus 1 L of NS or LR over 15-20 minutes Start initial infusion of NS at 250-500 mL/hr until volume depletion is mild Elevate corrected serum sodium, then give 1/2 NS or NS based on Na level When glucose reaches 250, add glucose to prevent cerebral complication associated with hypoglycemia
What are the possible pre-operative problems for a child with cleft lip of palate?
Bonding problems (due to the appearance of the child) Feeding problems (hard for baby to latch on)
What are the s/s of Addison's disease?
Bronze pigmentation of the skin hypoglycemia postural hypotension wt loss GI disturbances weakness tachycadia
What is the treatment for omphalocele?
C-section, then surgically close the defect Surgery is not always possible immediately, because there isn't enough room in the abdomen - if this occurs, bowel is suspended above by gravity over several days Any necrotic bowel is removed during surgery Usually required multiple surgeries and long term TPN use
When should a pt call a dr if they think they may be developing DKA?
Call when glucose exceeds 250 does not respond to medications Ketouria lasts more than 24 hours Pt cannot take food or fluids Illness lasts more than 1-2 days
What is a pituitary tumor?
Can be secreting or non-secreting Usually non-malignant Seems to run in families Sometimes linked to radiation exposure Idiopathic factors Prolactinoma is the most common
How do we diagnose pheochromocytoma?
Catecholamines in urine and bood dx with a 24 hour urine test
What teaching needs to be done for pts with DKA?
Check blood sugar q 3-4 hrs Maintain food and fluid intake (2L/day) Check urine for ketones when blood glucose is >300
What is a transesophageal fistula?
Congenital abnormality in which the esophagus does not form correctly. TEF is a fistula between the esophagus and the trachea (usually see this as esophageal atresia) If the upper esophagus has the fistula, then fluid/saliva flows directly into the lungs If the lower esophagus has the fistula, then air from the trachea distends the stomach and stomach secretions can enter the lungs
What is hirschprung's (aganglionic megacolon)?
Congenital absence of ganglionic innervation in a segment of the bowel (usually lower sigmoid colon) Absence of nerve cells results in no peristaltic waves in affected section, so feces does not move readily Portion of bowel proximal to aganlionic area becomes distended
What is a diaphragmatic hernia?
Congenital defect in which abdominal contents protrude into thoracic cavity Can prevent lung and heart from forming normally
what do we do post-op for a pt with a transespohageal fistula?
Continue respiratory monitoring Thermoregulation chest tube care G tube open and elevated care for esophagostomy fluid and nutrition prevent infection pain family needs
What is the treatment for pyloric stenosis?
Correct fluid and electrolyte imbalances Perform surgery: pyloromyotomy via incision or laparascopically
What is the treatment for cleft lip and palate?
Corrective surgery is the tx of choice, but not necessare - this is not a life threatening condition
What is dwarfism and what is the treatment?
Could be from a non-secreting tumor of problem with releasing factor tx: give pt GH
What can occur from adrenocortical hyperfunction?
Cushings
What is hepatitis C?
Damages to the liver over decades through chronic inflammation causing liver cells to scar which can progress to cirrhosis
What is diabetes insipidus?
Deficiency of ADH from the posterior pituitary
How can hepatitis C be prevented?
Do not share injection needles, razor blades, toothbrushes or nail clippers Abstain from unprotected sex Cover cuts and sores with bandages Never donate blood if you have hepatitis C because you will spread it
How do we prevent the spread of hepatitis B?
Do not share injection needles, razors, toothbrushes, or nail clippers Abstain from unprotected sex Cover cuts and sores with bandages Get a hep B vaccine booster q15-20 years
What is the tx for gastroschisis?
Essentially the same as omphalocele (C-section, then surgically close the defect) Surgery is not always possible immediately, because there is not always enough room in the abdomen - if this occurs, bowel is suspended above by gravity over several days Any necrotic bowel is removed during surgery usually requires multiple surgeries and long term TPN use
How is cleft palate diagnosed?
Finger in the mouth to feel for the defect
What are the consequences of diarrhea?
Fluid volume deficit electrolyte imbalance metabolic acidosis nutritional problems skin breakdown
What are the consequences of vomiting?
Fluid volume deficit electrolyte imbalances metabolic alkalosis
What long term care is needed for cleft palate?
Follow ups speech problems dental malocculsion recurrent otitis media hearing problems so need multidisciplinary care careful teeth brushing - teach to JUST brush the teeth and not to put the toothbrush all the way into the mouth
What are the S/S of pyloric stenosis?
Forceful, PROJECTILE vomiting, non-bilious vomiting Palpable olive like mass in RUQ Visible peristaltic waves from LUQ to RUQ
When does pyloric stenosis usually occur in formula fed babies? When in breastfed babies?
Formula fed - 4 weeks of age Breastfed - 6 weeks of age
What is viral hepatitis?
From a secondary infection (epstein-barr, CMV, herpes simplex virus, varicella-zoster), exposure to toxins (environmental/industrial, drugs, alcohol) or an autoimmune response
What is cleft lip and palate?
Fusion malformation that occurs during the embryonic development Defects can occur separately or together See more often in mothers who are deficient in folic acid - maternal smoking increases the risk
What do we give for chronic HBV tx?
Give antivirals Oral - tenofovir, entecavir, lamivudine (1 year course) this is a treatment, not a cure - long treatment Subcutaneous - pegylated interferon alfa 2a, interferon 2b
What is the treatment for mild/moderate FVD?
Give oral rehydrating solution to rehydrate/replenish Maintenance with breast milk, formula, bland solids Weight Maintenance Fluid Allowance 0 - 10 Kg 100 ml for each kilogram 10 - 20 kg 50 ml for each kilogram between 10 and 20 add 1000ml for the first 10 kg (10 x 100 = 1000) Over 20 kg 20 ml for each kilogram over 20 add 1500 ml for the first 20 kg (10 x 100 = 1000 +10 x 50 = 500)
What is the treatment for short bowel syndrome?
Give very small amounts of TPN to stimulate the gut, then do tube feedings - to get the nutrients
What is celiac disease?
Gluten-induced enteropathy, gluten-sensitive enteropathy, celiac spruce Occurs primarily in caucasians
What is the treatment for hepatitis A?
HAV vaccine Receiving IgM or HAV vaccine within 14 days as post exposure prophylaxis
What are the s/s of pheochromocytoma?
HIGH blood pressure!! HTN is the main s/s because of vasoconstriction - can be as high as 200-300/150-175 intermittient high blood pressure sympathetic s/s
What is the most common cause of chronic hepatitis, cirrhosis and liver cancer worldwide?
Hepatitis C
What causes pyloric stenosis?
Hypertrophy of the pyloric sphincter between the stomach and the duodenum - the milk cannot progress from the stomach to the gut
What is the tx for celiac crisis?
IV fluids, albumin, steroids to decrease inflammation
What interventions do we do for HHS?
IV regular insulin is administered Typical intervention is initial bolus dose of 0.15units/kg IV Reduce blood glucose at a rate of 50-75/hr Electrolyte replacement (K, Na, Ca, bicarb) assess mental status Record I&O's Sometimes the pt may have to be intubated Treat infection or other known cause EKG monitoring (because of the K) Assess BP every hour Monitor for fluid overload (especially in the elderly) Assessment of cardiovascular and respiratory status
What is the surgical treatment for cushing's?
If on the adrenal gland, remove but make sure the other gland is working! MUST have glucocorticoids to survive - give steroids for a few days until the other starts working - monitor BP, glucose, tell pt to avoid stress If the tumor is on the pituitary or ectopic, remove the tumor Decrease steroid use for cushing's syndrome
What medication do we give for a pt with cushing's?
If the tumor is inoperable - mitotane (blocks the production of adrenal hormone) ketoconazole (antifungal - used off label to stop steroid synthesis - WATCH for liver damage!!) pasireotide (suppressess hormones)
When should parents call a dr when their child has diarrhea?
If their child is not having at least 6 wet diapers/day
What teaching needs to be done for the family of a pt with a diaphragmatic hernia?
If they survive surgery, there is a long recovery period The family needs lots of support
What is the treatment for diaphragmatic hernia?
If this is diagnosed in utero, it's possible to do fetal surgery There will be major respiratory distress at birth - they need surgery within hours! - until surgery, keep head elevated with the affected side down Very critically ill pt, mortality rate of 30%
What are the s/s of hirschprung's (aganglionic megacolon)?
In newborns: may fail to pass mecomium within first 24-48 hrs May be okay initially, then develop chronic constipation and/or ribbon like stools Can develop total obstruction, ischemia of bowel or enterocolitis (life threatening infection)
What does epinephrine do?
Increases CO Increases BP MARKEDLY increases pulse dilates bronchi stimulates the nervous system dilates pupils decreases GI motility an secretions Promotes conversion of glycogen to glucose for energy
What are the S/S of Graves Disease?
Intolerance to heat Fine, straight hair bulging eyes facial flushing enlarged thyroid tachycardia increased systemic BP Weight loss, but eating constantly Muscle wasting Finger clubbing Tremors Increased diarrhea Menstrual changes (amenorrhea) Localized edema
What is acromegaly and what is the treatment?
Large hands, feet, enlarged face - due to the tumor tx: remove tumor, give octreotide to stop the release of GH or bromocriptine to stop GH release and shrink the tumor
What medications are administered for Addison's disease?
Lifelong steroids dexamethasone, hydrocortisone, methylprednisone (the "sone" meds)
Define chronic hepatitis
Liver inflammation lasting >6 months - may lead to cirrhosis and liver cancer
Define acute hepatitis
Liver inflammation that usually resolves
What kind of conflict resolution is avoiding/withdrawing?
Lose/Lose both parties know there is a conflict, but they refuse to to face it or work toward a resolution Can be appropriate for minor conflicts, when one party holds more power than the other party, or if the issue can work itself out over time because the conflict remains, it can resurface again at a later date and escalate over time
What kind of conflict resolution is smoothing?
Lose/Lose one party attempts to smooth another party by trying to satisfy the other party Often used to preserve or maintain a peaceful work environment The focus can be on what is agreed upon, leaving conflict largely unresolved
What kind of conflict resolution is cooperating/accommodating?
Lose/Win One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing The original problem might not actually be resolved This solution can contribute to future conflict
What are the s/s of prolactimona in men?
Loss of libido Decreased testosterone Infertility Headache visual disturbances Milk production
What does norepinephrine do?
MARKEDLY increased BP slight increase in pulse dilates pupil decreases GI motility and secretions Promotes conversion of glycogen to glucose for energy
What are the s/s of cushings?
Moon face Increased susceptibility to infection Males: gynecomastia buffalo hump (fat deposits on back) osteoporosis hyperglycemia thin extremities GI distress Anemorrhea Thin skin Purple striae bruises petechiae thinning hair pendulous abdomen with weight gain slow wound healing HTN CHF (from the increased volume) hair growth on the face and back alkalosis
Who is at risk for developing hepatitis B?
Multiple sex partners male homosexuals IV drug abusers Hemodialysis pts Healthcare workers Travels to endemic areas Household contacts of individuals with HBV Infants born to infected mothers
What are the s/s of hepatitis A?
N/V Anorexia Malaise Fatigue RUQ pain hepatosplenomegaly Fever Jaundice Dark urine (same symptoms as cirrhosis)
What do mineralocorticoids do?
Na and H2O retention K excretion Decreased BP to the kidney causes this to be secreted and will increase BP by increasing volume Secreted by ACTH
HHS pathophysiology
Normally the kidneys will eliminate excess glucose Lack of insulin and persistent hyperglycemia not taking enough fluids Kidneys cannot eliminate glucose The glucose becomes very high, causing hyperosmolarity This high concentrate causes water to leave cells
Treatment for vomiting
ORS in small amounts, advance slowly May need to rest stomach Tx underlying cause May need IV fluids
What is short bowel syndrome?
Occurs when significant amounts of the intestine is lost Cannot absorb and digest a regular diet Non use of gut leads to atrophy, so will continue to get small amounts enterally even though pt is on TPN
What treatments (aside from medications) are used to treat pheochromocytoma?
Positive 24 hr urine test means they have pheyochromocytoma - look for a tumor on the adrenal medulla Before surgery, the pt needs to be on alpha and beta blocker medications for 2 weeks to reduce BP Post surgery: check BP, abdominal incision care If removing 1 adrenal gland, be sure the other is working - may need to gve meds until the other adrenal medulla kicks back in
What medications can be used to treat hepatitis B?
Post exposure: prophylaxis: Unvaccinated persons should receive hep B immunoglobins and HBV vaccine within 24 hours or ASAP If vaccinated, receive one vaccine booster (without confirmation of immune status) Infants born to mothers with HBV should receive a HBV vaccine
What treatment do we do for a transesphageal fistula?
Prevent aspiration (suction, elevate HOB) Provide IV fluids Surgically correct (one surgery or staged - both have G tube to feed through, staged usually has esophagostomy where they bring the esophagus to the skin)
What pt education do we need to give to help people avoid hepatitis A?
Proper handwashing Avoid contaminated food and water in countries of high incidence Wash food
What are the s/s of omphalocele?
Protrusion of usually just the intestine, but can also include the stomach and liver
What treatment is done for alcoholic hepatitis?
Provide nutritional support along with supplemental vitamins and minerals Abstinence from alcohol essential to preventing further damage
Who should be screened for hepatitis C?
Pts born before 1945-1965 Blood transfusions before 1994 dialysis pts Close contact with someone who has HCV Close contact with someone who has HIV Abnormal liver tests
What is DKA and who can develop it and when?
Pts with type 1 diabetes more commonly but can occur in type 2 as well during severe illness or stress when the pancreas cannot beet the extra demand for insuling Caused by a combination of insulin deficiency and increase in release of hormones - leads to an increase in liver and kidney glucose production and a decrease in glucose use in the peripheral tissues Hyperglycemia leads to osmotic diuresis with dehydration and electrolyte loss Loss of 4-6L/day
What are the s/s of hepatitis?
RUQ pain and discomfort The pt cannot: maintain blood glucose fat metabolism protein metabolism removal of drugs/toxins storage of vitamins and minterals
What treatments do we do for a pt with Grave's disease?
Radioactive iodine therapy: 131 I - not for pregnant pts, or pts allergic to shellfish - pt will be radioactive after treatment Give in 1 or 2 doses of radioactive iodine - destroys part of the thyroid, but it's not always guaranteed that you won't destroy it all and cause hypothyroidism Thyroid surgery: remove part of thyroid gland (nerve damage, respiratory obstruction and hemorrhage are all possible) Will have an anterior dressing (not too tight), drain in the incisional area (should have 50mL or less of drainage in the first 24 hrs) - elevate HOB, small pillow under head - check for bleeding behind pt
What post op nursing care is needed for a pt after a pyloromyotomy to correct pyloric stenosis?
Re-feed with 15-30mL of ORS or formula at 2-4 hrs post op (to prevent adhesions) and progress each hr, should be at full feeds by 24 hrs Maintain IVF until adequate PO intake Check incision and keep clean Assist family - teaching, fears, etc
What is the treatment for imperforate anus if the problem is stenosis?
Rectal dilation (stretch the opening to an adequate size)
What is the treatment for severe FVD?
Rehydrate with IV fluids until LOC and HR improve, then give ORS Weight Maintenance Fluid Allowance 0 - 10 Kg 100 ml for each kilogram 10 - 20 kg 50 ml for each kilogram between 10 and 20 add 1000ml for the first 10 kg (10 x 100 = 1000) Over 20 kg 20 ml for each kilogram over 20 add 1500 ml for the first 20 kg (10 x 100 = 1000 +10 x 50 = 500) Maintenance with breast milk, formula, bland solids
What is the treatment for lactose intolerance?
Remove lactose from diet Provide for Ca and vit D needs Use commercial lactase preparations (take the enzyme and they can break down the dairy - take with lactose containing food/drinks)
What are the s/s of Addisonian crisis?
Severely hypoglycemic profound fatigue dehydration vascular collapse renal shut down decreased serum Na Increased serum K sudden pain in the lower back severe headache shock
What is gastroschisis?
Similar to omchaplocele, but abdominal wall defect is not at umbilicus and organs are not contained by a peritoneal membrane, so there are even more problems
What is an umbilical hernia?
Soft, skin covered protrusion of intestine and amentum through a weakness in the abdominal wall around the umbilicus More common in African American, low birth wt and girls Herniated area protrudes more w/ crying, straining for BM or coughing Most resolve spontaneously by age 5
What are the s/s of celiac disease?
Steatorrhea diarrhea FTT (failure to thrive) abdominal distention muscle wasting anemia lethargy irritability Unable to tolerate gluten (found in wheat, barley, rye and can have crossover sensitivity to oat)
What is the treatment needed for an umbilical hernia?
Surgery is indicated if strangulation occurs, protrusion is increasing after age 2, or if not resolved by age 4-5 Surgery is usually outpatient, a pressure dressing is applied and stays for several days
How is a volvulus treated?
Surgically to relieve volvulus and reattach bowel so it is not longer free moving
High thyroid hormone = low ___________?
TSH
Low thyroid hormone = high ___________?
TSH
What pt education do we give with steroids?
Take in AM Take with food Do not omit Wear medical bracelet Call dr for infections and stress Eat food rich in potassium
What education needs to be done for umbilical hernias?
Teach family the indications of strangulation (hard area, lots of pain -> call dr asap) Avoid use of bellybands or sivr dollar - does not help and may increase the risk of obstruction or strangulation - leave it alone, it usually goes away on its own
what is the treatment for imperforate anus if the problem is a more severe defect?
Temporary colostomy with staged surgery: complete repair and "pull through" at 6-12 months (do a little work, then go back a month later and do a little more)
What do we need to warn parents with a child diagnosed with imperforate anus?
The child may have delayed achievement in bowel control as they get older
What increases the risk of hepatitis B developing into a chronic infection?
The earlier that the virus is transmitted
What is an esophageal atresia?
The esophagus is not continuous from mouth to stomach (it stops somewhere) There is no way for fluid/saliva to enter the stomach, secretions fill a blind pouch and are aspirated
What is lactose intolerance?
The inability to digest lactose (sugar in dairy products) Congenital type (rare) - no lactase Acquired - appears later in childhood
How do we treat viral hepatitis D?
There is no vaccine or viral treatment for HDV available
What is the nursing care for a pt with omphalocele?
Thermoregulation (warmed isolette) Sterile technique when dealing with defect Keep defect moist! (saline dressing and plastic wrap or sterile bowel bag) Risk for respiratory and circulatory problems Much family support is needed
What nursing care is needed for gastroschisis?
Thermoregulation (warmed isolette) Sterile technique when dealing with the defect Keep the defect moist! (saline dressing and plastic wrap or sterile bowel bag) Risk for respiratory and circulation problems Much family support needed
What is Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?
Too much ADH
What is non-viral hepatitis? (toxic hepatitis, alcoholic hepatitis, and autoimmune hepatitis)
Toxic hepatitis is caused by chemicals, drugs, (prescription and OTC) and nutritional supplements Alcoholic hepatitis is caused by drinking too much alcohol causing liver damage autoimmune hepatitis is caused by the immune system attacking the liver. The immune system can attack the liver for unknown reasons, causing inflammation, liver scarring, liver cancer and liver failure. Some diseases and certain toxic substances and drugs can cause this to happen
What is volvulus?
Twisting of the intestines, leading to bowel obstruction and decreased blood supply to the involved intestine (often associated with malrotation of the gut)
What are the causes of graves disease?
Unknown may be hereditary gender (more common in women) can occur after a stressful time
What is the nursing care for a child with imperforate anus post operatively?
Usual GI things Meticulous wound care Position prone, side or supine with legs at 90 degree angle (laying flat with legs out straight increases pressure on rectum) Ostomy care if needed Family support Pain control
What is intusseception?
When one section of the intestine invaginates (telescopes) into another Result will eventually be bowel obstruction
What kind of conflict resolution is competing/coercing?
Win/Lose One party pursues a desired solution at the expense of others Managers can use this when a quick or unpopular decision must be made The party who loses something can experience anger, aggravation, and a desire for retribution
What kind of conflict resolution is compromising/negotiating?
Win/Lose - Win/Lose Each party gives something up To consider this a win/lose - win/lose situation, both parties must give up something equally important If one party gives up more than the other, it can become a win/lose situation
What kind of conflict resolution is collaborating?
Win/Win Both nurses have come to an agreement and are working toward a common goal. They are collaborating to achieve a soluton that avoids this situation in the future
S/S of diarrhea
abdominal pain cramps tenesmus increased bowel sounds hematochezia (passing of fresh blood from the anus) foul smell
What causes drug induced hepatitis?
acetaminophen is the most common cause of drug related liver injury
What occurs if there is oversecretion of growth hormone in adulthood?
acromegaly
How do we treat acetaminophen overdose?
activated charcoal N-acetylcysteine given to help restore glutathione
What is the treatment for Addison's disease?
administer replacement hormones Monitor vitals and EKG monitor electrolytes monitor glucose Teach pt about steroids
What are the causes of Addison's disease?
adrenal gland has been removed, HIV, TB, histoplasmosis, adrenal gland shutting down, autoimmune disorder, been on steroids for too long and then go off the adrenal gland can stop working, tumor on the pituitary, *sepsis, hypofx of the pituitary
Who is HHS most commonly seen in?
adults between 50-70 years old Type 2 DM with renal disease burn victims heat stroke hyperthermia GI hemorrhage Sepsis Large amounts of fluid loss ->dehydration
What are the s/s of congenital adrenogenital hyperplasia?
ambiguous genitalia in females - unsure externally, internally have normal organs Precocious genital development in males usually have problems with growth - small person
What is diabetic ketoacidosis?
an acute life-threatening condition characterized by hyperglycemia (>300) resulting in the breakdown of body fat for energy and an accumulation of ketones in the blood and urine
What is hyperosmolar hyperglycemic state?
an acute, life threatening condition characterized by profound hyperglycemia (>600 mg/dL), hyperosmolality that leads to dehydration and an absence of ketosis Lack of sufficient insulin r/t undiagnosed DM. There is sufficient insulin to prevent ketosis but not enough to prevent hyperglycemia Inadequate fluid intake or poor kidney fx This has a higher mortality rate than DKA
What are the clinical presentations of drug induced hepatitis?
anorexia, N/V, jaundice and hepatomegaly
What medication should be given with vomiting?
anti-emetics for older kids (ondansetron)
What medications are used for helmenthic infections?
anti-helminthic meds are given to the entire family and need to be repeated in 2 weeks to prevent reinfection These meds only kill the adults, not the eggs, so you need another round after the eggs have hatched to kill them, too
What medications do we give for hepatitis C?
antivirals/immune modilators - subcutaneous pegylated interferon (6-12 months) - ribabirin BID PO (12-48 weeks) Direct acting antivirals - ledipasvir-sofobuvir (really long treatment and makes you feel awful so most pts stop taking it) - glecaprevir-pibrentasvir (mavyet) (this medication is a cure for hep c, but it costs about $20,000 for a 6 week course and insurance doesn't like to pay because most people just continue the lifestyle and get it again)
What is the self management for hepatitis?
avoid any medication other than those prescribed that could have acetaminophen Avoid alcohol Vitamins K, A, D and E may be beneficial Standard universal precautions when handling blood hand hygeine safe sexual practices prophylactic treatment for close contact Vaccinate against HAV and HBV if possible If viral, don't handle needles, razors, clippers or toothbrushes
What causes infectious gastritis?
bacteria, virus or parasite Rotavirus or norovirus Salmonella, shingella, campylobacter, E. coli, C diff Giardia lamblia
what medications are used to tx infectious gastritis?
bacterial: tx with antibiotics C. diff: tx with metronidazole or vancomycin and probiotics, special cleaning needed in the hospital Giardia: tx with "zole" meds NO anti-diarrheal medications!
How is a volvulus diagnosed?
barium study or ultrasound
How is pyloric stenosis diagnosed?
based on hx, confirmed by xray, ultrasound, barium swallow
How do we destroy hepatitis A?
bleach and extremely high temperatures - hard to kill
When is cleft lip repair usually done?
by 8-12 weeks of age (sometimes as early as 2-3 days)
How do we diagnose helmenthic infections?
by ova and parasite presence
How do we diagnose viral hepatitis D?
by the presence of HDV
What are the s/s of imperforate anus?
can't pass meconium Inability to insert rectal thermometer
What do glucocorticoids do?
carb metabolism emotional fx (can't live without this - helps manage stress) suppresses inflammation Decreased immune response Acts in conjunction with insulin - increases your blood glucose while insulin decreases your blood glucose
What are the nursing interventions for diarrhea?
check diaper q 1-2 hours check cap refill weight strict I & O assess stools, VS, and fluid status - replace as needed control fever change diaper promptly clean with water use skin protection expose bottom to air
How do we diagnose infectious gastritis?
confirmed by stool culture
What causes helmenthic infections?
contracted from contaminated water, food or soil or by hand to mouth contact (fecal/oral) contact
What is the tx for intussecption?
correct fluid and electrolyte imbalances (IVF until taking PO fluids) Observe for passage of stools before and after tx and notify dr if stool changes (may resolve spontaneously) If surgery is required - usually GI surgery things needed: NGT, NPO until peristalsis returns, care for incision and prevent infection Support family
What happens if Na drops too fast?
death
What medications do we give for SIADH?
demeclocycline (a semisythetic tetracycline antibiotic used off label in tx of hyponatremia due to SIADH) - reduces the responsiveness of collecting tubule cells to ADH, increases Na retention
How do we diagnose addison's disease?
dereased Na dereased glucose increased K increased Ca dereased glucocorticoids and mineralocorticoids ACTH stimulation test (IV ACTH - check levels to see if it's increased - if they don't increase, the problem is with the adrenal gland)
What meds do we give for diabetes insipidus?
desmopressin acetate (DDAVP) - synthetic vasopressin (doesn't cause vasoconstriction so no elevated BP) - give oral, sublingual or intranasal
What occurs if there isn't enough growth hormone in childhood?
dwarfism
How do we diagnose intussecption?
dx by history, confirmed by contrast enema
when does overactive thyroid tend to occur and in what gender?
early in life (20-40 years) and in women
What is the nursing care for a child with imperforate anus stenosis?
encourage breastfeeding (easier to pass breastfed curd than formula curd), teach family the correct use of dilators
What does the adrenal medulla secrete?
epinephrine and norepinephrine
How does alcoholic hepatitis present?
fever, hepatomegaly, jaundice, coagulopathy, ascites, encephalopathy, variceal hemorrhage usually progresses to cirrhosis as alcohol ingestion continues
What is cushing's syndrome?
from prolonged stroid thrapy - transplant pts, COPD, on lifelong steroids -> will cause them to get cushing's (see this more often than cushing's disease)
What treatments are done for a pituitary tumor?
gamma knife radiation - high dose radiation to tx to shrink the pituitay tuor before surgery Surgery - craniotomy: not done as often anymore - more invasive, pt in ICU and NPO for several days after Hypophysectomy: incision on the gum line - go through the sphenoid sinus, grab the tumor and pull it out - mustache dressing, incision on abdomen for graft - nose packed, so they will be mouth breathing - need lots of oral care, no teeth brushing for 10-14 days while the incision heals, can use dental floss or gentle mouthwash
What occurs if there is oversecretion of growth hormone in childhood?
gigantism
What does the adrenal cortex secrete?
glucocorticoids, mineralocorticoids, androgens
How do we diagnose HHS?
glucose >600 Negative for ketones elevated serum osmolarity >320 mOsm/L serum pH >7.4 Na initially lower, then higher as HHS is treated K can be low or high - insulin drives K back into the cell
What is the treatment for celiac disease?
gluten free diet for life NO wheat, barley, rye Grains can be added to hot dogs, lunch meat, ice cream, canned soup, chocolate, candy, mayo, ketchup, vinegar avoid hydrolyzed vegetable protein and modified food starch CAN eat: corn, rice, gluten free oats, quinoa, buckwheat, tapioca
What disease does hyperactive thyroid cause?
grave's disease
What is the best way to prevent the spread of infectious gastritis?
handwashing, enteric precautions
What causes SIADH?
head trauma brain tumor cerebral edema putting pressure on the pituitary causing damage infection medication oat cell carcinoma of the lung Ventilator use CPAP use General anasthesia use overdose of acetaminophen
What happens if Na drops below 115?
heart attack, letheragy
what are the s/s of primary aldosteronism?
hypertension (but not as high as with pheochromocytoma) retain H2O and Na, lose K and hydrogen atoms - causes metabolic alkalosis Increased aldosterone Normal renin levels
What is Grave's disease?
hypoerthyroidism Infiltrative ophthalmopathy (exophthalmos) Stimulation by gland of IgG immunoglobulins Thyroid stimulating immunoglobulins
What nursing care and family teaching is needed for hirschprung's (aganglionic megacolon)?
if an enema is needed, use saline only - teach family how to mix enema All usual GI surgery and ostomy things if needed: treat pain, avoid infection, maintain skin integrity, NGT, fluid and electrolyte balance, nutrition, teaching for family (address family stress of caring for an ostomy if needed)
How do we diagnose a transesophageal fistula?
inability to pass NG tube, confimed by xray
what is congenital adrenogenital hyperplasia?
inborn deficiency of enzymes needed for biosynthesis of cortisol Cortisol cannot be synthesized so ACTH will be increased and androgens increased (hard to tell the baby's gender) Adrenal cortex not synthesizing - usually the glucocorticoid not being synthesized
What are the side effects of steroids?
increased Na Increased H2O retention Decreased K Increased appetite Moon face Redistribution of body fat Increased glucose Decreased immune system Androgen effects
What diagnostic tests do we use for Grave's disease?
increased T3 and T4 Decreased TSH Thyroid uptake test - to check for hyperactivity
Causes of vomiting
infection obstruction allergy metabolic problems central nervous system abnormalities psychological problems overheating pregnancy
What are the primary causes of HHS?
infection (pneumonia, UTI) mediations (thiazides propolol, calcium channel blockers, corticosteroids) stress response (stroke, MI, intracranial hemorrhage) Dehydration
What is hepatitis A?
inflammation of the liver from a transmission via oral-fecal route virus found in contaminated water or food (seafood and shellfish specifically) increased incidence in unsanitary conditions Consumption of contaminated shellfish, raw fruits and vegetables hardy virus that is able to survive on human hands Short incubation period (IgM comes first, then IgG)
What medications do we give for DKA?
initial therapy is used to lower serum glucose by 50-75mg/dL/hr. Regular insulin by continuous IV infusion usually IV bolus dose given at start of insulin 0.1units/kg then IV 0.1units/kg/hr (continuous insulin is used because the half life is short) Subq is started when the pt can take oral fluids and ketosis has stopped. DKA is considered resolved when blood glucose is <200mg/dL and serum bicarb is >18mEq/L, pH >7.3 and calculated anion gap is <12mEq/L K replacement is started after level falls below 5.0 Assess for s/s of hypokalemia (fatigue, malaise, confusion, muscle weakness, shallow respirations, abdominal distention or paralytic ileus, hypotension, weak pulse) sodium bicarb is given IV infusion over several hours. Indicated when pH is <7.0 and the serum bicarb is <5
Who are at the biggest risk for developing hepatitis A?
international travelors to area's with poor sanitation or high HAV infection People living in close quarters with a large population Occupation related (daycare, healthcare, correctional facility workers) IV drug users men who have sex with other men
Causes of diarrhea?
intestinal infection foods malabsorption disease of the gut other systemic infection
Who are the biggest spreaders of hepatitis A?
kids <6 (usually spreads in daycares)
When does underactive thyroid tend to occur?
later in life
what medication can cause pt to develop a goiter or hypothyroidism?
lithium
What secretes growth hormone?
made in the pituitary gland stored in the anterior pituitary
What do we do pre-op for a pt with a transesophageal fistula?
maintain airway keep pt warm maintain fluid status meet family needs
What is the treatment for diabetes insipidus?
may drink up to 30 L/day of fluid IV fluid infusion of 1/2 normal saline (hypotonic) Monitor daily wt
What are the s/s of prolactimona in women?
milk production infertility headache visual disturbances - from optic nerve being so close
What pt teaching is needed for someone with celiac disease?
must read all ingredients to be sure gluten has not been added MUST continue diet for life
What happens if Na drops below 125?
nausea
What post op teaching needs to be done after a hypophysectomy?
no bending or straining (stool softener), prevent coughing (anytime to increase ICP)
What medications are used to treat pheochromocytoma?
phenoxybenzamine, proazosin (these are alpha blocking agents that prevent the constriction of vessels to decrease BP) atenolol, metoprolol (these are beta blockers that block the release of epinephrine to decrease BP) May see a combination of the alpha and beta blockers
How is celiac disease diagnosed?
physical exam, anti-gliadin antibodies (AGA), genetic markers, jejual biopsy Improves on gluten free diet
What are the s/s of diabetes insipdus?
polyuria polydipsia low specific gravity (1.001-1.005) increased urine output (200mL/hr) decreased urine osmolality increased blood osmolality increased Na (pt is excreting H2O but not as much Na) -> confusion, muscle twtching, Na over 160=coma and death hypotension tachycardia lethargic cellular dehydration
What are the s/s of DKA?
polyuria polydipsia rotting citrus fruit odor breath vomiting abdominal pain dehydration weakness confusion shock coma mental status can vary from alert to coma Low pH (metabolic acidosis) Kussmaul respirations (very deep, rapid respirations) Increased K (mild DKA) Decreased K (severe DKA) Decreased Ca, Mg, PO Ketones in urine and blood increased BUN >30 Dehydration Hyperglycemia >300 Creatinine >1.5 cerebral edema (leading cause of death in children with DKA)
what are the s/s of HHS?
polyuria polyphagia polydipsia Wt loss and dehydration Fatigue Blurred vision cardiac arrhythmias (because of potassium - moving out of cells causing serum hyperkalemia) Hyperglycemia, dehydration, and serum hyperosmolality are usually more severe than in DKA Neurological symptoms (seizures, paralysis, coma) hypothermia (from vasodilation) Vascular thrombosis (from hyperosmolarity - easier to form a clot)
What is the post op care for cleft palate?
prevent trauma to site provide nourishment - NOTHING in mouth but specifically ordered feeding device clean mouth suture manage pain distract to prevent rubbing tongue on roof of mouth
What is the post op care for cleft lip?
prevent trauma to surgical site provide nutrition clean suture line manage pain don't let baby rub face be very careful wth suction Once recovered, usually no more treatment is needed
What are the s/s of intussecption?
previously healthy child develops abdominal pain, draws knees to abdomen and screams, then is OK for a few minutes, then pain again Bile stained vomitus "currant jelly" stools (bloody mucus), may have normal stools initially Sausage shaped mass in RUQ
what are the s/s of celiac crisis?
profuse, watery diarrhea and vomiting causing: fluid volume deficit metabolic acidosis shock
What is an omphalocele?
protrusion of abdominal contents into the base of the umbilical cord No skin but is covered by the peritoneum Can also be associated with other defects, cardiac, GU, chromosomal, craniofacial abnormalities Usually seen prenatally, obvious at birth
What needs to be watched for in pts with cushing's?
pt safety infection control watch for s/s of CHF
Who is at risk for getting hepatitis E?
pts who are international travelers
What possible complications can occur when treating HHS?
pulmonary edema hypokalemia hypoglycemia cardiac dysrhythmias cerebral edema
what is the onset of DKA like?
rapid - 1-2 days
How do we diagnose hepatitis C?
rapid antibody test, may be confirmed with the presence of HCV
What medications can be given for a pituitary tumor?
sandostatin - stops GH bromocriptine - stop prolactin and GH a little, shrinks the tumor so it's easier to operate
What happens if Na drops below 110?
seizures, coma, death
What are the causes of DKA?
severe stress trauma surgery infection
Define fulminant hepatitis
severe, often fatal form or acute hepatitis
What medication do we use to treat primary aldosteronism?
spironolactone
What medications are used for congenital adrenogenital hyperplasia?
steroids at a maintenance level - this pt has to have steroids to get glucocorticoids and mineralcorticoids
What is celiac crisis?
sudden accumulation of glutamine, causing mucosal damage - usually occurs due to infection or increased ingestion of gluten
What is the treatment for hepatitis?
symptomatic treatment monitor liver damage support the liver while it regenerates -> promote rest (but not complete bedrest) Diet high in carbs and calories, moderate fat and protein Small frequent meals Contact precautions!!
What meds are the steroids?
the "sone" meds - combination of glucocorticoids and mineralocorticoids
How is hepatitis E diagnosed?
the presece of anti-HEV IgM
What meds to we give for Grave's disease?
thioamides: propylthiouracil (PTU) methimazole - these meds stop the synthesis of T3, T4 - takes 2-4 weeks to work, decrease WBC iodides: lugol's solution - stop the release of the thyroid hormone - can get iodine toxicity - dilute with juice, drink ONLY with a straw (stains teeth) beta adronergic: propranolol metoprolol - cardioselective for asthma pt - treatment for tachycardia
Who are carriers of hepatitis B?
those in an active state may infect others, yet have no obvious signs of the disease are at high risk for cirrhosis and liver cancer Transmission is possible without symptoms
How is viral hepatitis D transmitted?
through blood to blood contact and unprotected sex To get HDV you have to also have HBV
What treatment is done for DKA?
treat the underlying cause first, restore volume and maintain perfusion to vital organs (IV therapy) (15-20mL/kg/hr for the first hr bolus - then 4-14mL/kg/hr until BP comes up) When BG reaches 250mg/dL give 5% dextrose in 1/2 normal saline to prevent hypoglycemia and cerebral enema Pt may need 6-10L in the first 24 hours Assess pt for fluid overload (CHF or pulmonary edema) Assess status of fluid replacement by monitoring BP, I&O's and changes in daily wt Check blood glucose every hour if on an insulin pump Check electrolytes every 1-2 hrs to avoid hypokalemia Monitor K: In DKA potassium is low in the serum, when we give insulin, potassium comes out of the cells into the serum and the potassium becomes normal to elevated - we must monitor this CLOSELY because it will be excreted in the urine and can lead to hypokalemia - watch when pt has urine output of 30-60mL/hr -> we may need to give a potassium supplement
What causes primary aldosteronism?
tumor secreting aldosterone - Too much aldosterone makes the kidneys hang on to sodium and water and flush potassium into the urine
How is imperforate anus confirmed?
ultrasound and xray
What are the causes of diabetes insipidus?
unknown causes brain tumor or head injury pituitary surgery or radiation infection rare - nephrogenic stroke or tumor
How is hepatitis C transmitted?
via blood, unprotected sex, close contact with open wounds (similar to hepatitis B but hep C is a little harder to get than hep B)
How is viral hepatitis E transmitted?
via fecal-oral route
What do we need to look for and do after a hypophysectomy?
watch for s/s of diabetes insipidus (strict I & O's and watch specific gravity) Watch for drainage - halo effect - dark in the center and lighter around the outside - could be from glucose -> spinal fluid leak -> meningitis (look on the sheets or pillow) Keep HOB elevated at least 30 degrees Widening pulse pressure - ICP, bradycardia
What is the treatment for SIADH?
water restriction increase salt intake and WATCH Na LEVELS!! remove the cause Hypertonic (3% NS) given as a LAST RESORT! - must give slowly!! No more than 50mL/hr (Fluids shift from cells to blood vessels and will destroy the myelin sheath of the brain which will result in death!) = CPM (central pontine myelinolysis) frequent cardiac and neuro assessments needed monitor I&O's daily wt Na replacement max of 500 mL/day of fluids
What are the s/s of SIADH?
water retention dilutional hyponatremia -> can cause neuro changes, seizures, coma (Na <120) cerebral edema pt is not peeing fluid volume overload dark tea colored urine specific gravity >1.032 Hypertension increased preload -> HF -> JVD, crackles decreased BUN decreased hematocrit (dilutional anemia)
What is gigantism and what is the treatment?
will have increased glucose but not diabetes - too much GF from a secreting tumor tx: remove tumor, give octreotide to stop the release of GH or bromocriptine to stop GH release and shrink the tumor
What is cushing's disease?
(rare) - corticol secreting adrenal tumor secreting the 3 s's - too much salt, sugar and sex hyperplasia of adrenal cortex due to excess ACTH (pituitary tumor secreting ACTH) ectopic hypersecretion - ACTH secreting tumor somewhere else in the body
What are the S/S of a helmenthic infection?
*anal itching Usually no diarrhea N/V Wt. Loss
