Adult Exam 3

Vascular Access for Hemodialysis

A, Arteriovenous fistula. B, Arteriovenous graft.

Problems Not Associated with IBS

Anemia Fever Persistent diarrhea Rectal bleeding Severe constipation Weight loss

Emotional manifestations MS

Anger Depression Euphoria Physical and emotional trauma, fatigue, and infection may aggravate or trigger signs and symptoms.

Muscle relaxantsMS

CNS stimulants Anticholinergics Tricyclic antidepressants Selective potassium channel blocker Antiseizure drugs Amantadine (Symmetrel) and CNS stimulants (pemoline [Cylert], methylphenidate [Ritalin], and modafinil [Provigil]) are used to treat fatigue. Anticholinergics are used to treat bladder symptoms. Tricyclic antidepressants and antiseizure drugs are used for chronic pain syndromes. Dalfampridine (Ampyra) = improve walking speed in MS patients, potassium channel blocker = NOT for seizure disorders or moderate to severe kidney disease.

Objective Data - MS

Apathy, inattentiveness Pressure ulcers Scanning speech Tremor Nystagmus Ataxia Spasticity Hyperreflexia decr Hearing Muscular weakness Paresis Paralysis Foot dragging Dysarthria

Objective Data - PD

Blank faces, infrequent blinking Seborrhea - Dandruff Ankle edema Postural hypotension Tremor at rest Aggravated with anxiety; absent in sleep "Pill rolling" Poor coordination Cognitive impairment and dementia Impaired postural reflexes Cogwheel rigidity Dysarthria Bradykinesia Contractures Stooped posture Shuffling gait

Dopamine Receptor Agonist

Bromocriptine (Cycloset) Mechanism of action unknown Thought that patients with type 2 diabetes have low levels of dopamine Increases dopamine receptor activity Alone or in combination Bromocriptine (Cycloset) is a dopamine receptor agonist that improves glycemic control. The mechanism of action is unknown. Patients with type 2 diabetes are thought to have low levels of dopamine activity in the morning. These low levels of dopamine may interfere with the body's ability to control blood glucose. Bromocriptine increases dopamine receptor activity. It can be used alone or as an add-on to another type 2 diabetes treatment.

Esophageal CancerNursing Implementation Evaluation

Expected Outcomes Maintain a patent airway Have relief of pain Be able to swallow comfortably Consume adequate nutritional intake Understand prognosis of the disease Experience quality of life appropriate to stage of disease and prognosis

Evaluation CRC

Expected Outcomes Minimal alteration in bowel elimination patterns Optimal nutritional intake Relief of pain Quality of life appropriate to disease progression Feelings of comfort and well-being

Eval COPD

Expected Outcomes Return to baseline respiratory function Demonstrate an effective rate, rhythm, and depth of respirations Experience clear breath sounds Maintain clear airway by effective coughing PaCO2 and PaO2 return to levels normal for patient Awareness of need to seek medical attention Behaviors minimizing risk of infection No infection Maintenance of normal body weight Normal serum protein levels Feeling of being rested Improvement in sleep pattern

Alzheimer's DiseaseNursing Diagnoses

Impaired memory Self-neglect Risk for injury Wandering Nursing diagnoses for AD may include, but are not limited to, the following: Impaired memory related to the effects of dementia Self-neglect related to memory deficit, cognitive impairment, and neuromuscular impairment Risk for injury related to impaired judgment, gait instability, muscle weakness, and sensory/perceptual alteration Wandering related to cognitive impairment

Exogenous insulin

Insulin from an outside source Required for type 1 diabetes Prescribed for patients with type 2 diabetes who cannot manage blood glucose levels by other means Exogenous (injected) insulin is needed when insulin is inadequate to meet specific metabolic needs.

Ablation Surgery - PD

Locate, target, destroy area of brain affected by PD Destroys tissue that produces abnormal chemical or electrical impulses leading to tremors or other symptoms Ablation surgery involves locating, targeting, and destroying an area of the brain affected by PD. The goal is to destroy tissue that produces abnormal chemical or electrical impulses leading to tremors or other symptoms. Typical targets of ablation are the thalamus (thalamotomy), globus pallidus (pallidotomy), and subthalamic nucleus (subthalamic nucleotomy).

Acute PancreatitisComplications- Pancreatic abscess

Infected pseudocyst Results from extensive necrosis May rupture or perforate Upper abdominal pain, mass, high fever, leukocytosis Requires prompt surgical drainage

Clinical ManifestationsReproductive System CKI

Infertility and decreased libido Experienced by both sexes Low sperm counts Sexual dysfunction Pregnancy poses significant risk to mother and infant Women = decreased levels of estrogen, progesterone, and luteinizing hormone Men = loss of testicular consistency, decreased testosterone levels, low sperm counts. pregnant + dialysis =can carry a fetus to term

Hepatitis

Inflammation of the liver Causes Viral (most common) Alcohol Medications Chemicals Autoimmune diseases Metabolic abnormalities Hepatitis is a broad term that means "inflammation of the liver." Hepatitis is most commonly caused by viruses. Hepatitis can also be caused by substances (e.g., alcohol, medications, chemicals), autoimmune diseases, and metabolic abnormalities.

Dx of alzheimer

CT MRI PET (1407) Urine, blood, CMP, infection(UTI) Rule out delirium first Can be done by nurse or provider MMSE - mini mental status exam MCE - mini cognitive exam Depression scale - PHQ-9

Acute PancreatitisNursing Implementation - Ambulatory Care

Counseling regarding abstinence from alcohol cigarettes can stimulate the pancreas, smoking should be avoided. Low-fat, high-carbohydrate No crash diets Signs of infection, diabetes mellitus, steatorrhea Medications/diet Carbohydrates are less stimulating to the pancreas and are encouraged.

DeliriumEtiology and Pathophysiology

Dementia is leading risk factor Delirium is a risk factor for subsequent development of dementia Linked to onset Stress Surgery Sleep deprivation Pain and depression Especially in postop older patients Older patients have limited compensatory mechanisms to deal with physiologic insults such as Hypoxia Hypoglycemia Dehydration Older patients are more often treated with multiple drugs More susceptible to drug-induced delirium cause or contribute to delirium - sedative-hypnotics, opioids (especially meperidine [Demerol]), benzodiazepines, anticholinergic

Delirium Mnemonic for Causes

Dementia, dehydration Electrolyte imbalances, emotional stress Lung, liver, heart, kidney, brain Infection, ICU Rx Drugs Injury, immobility Untreated pain, unfamiliar environment Metabolic disorders

Classification of IBS

Depending on the stool patterns, IBS is categorized as IBS with constipation IBS with diarrhea IBS mixed IBS unsubtyped Depending on the stool patterns, IBS is categorized as IBS with constipation, IBS with diarrhea, IBS mixed, and IBS unsubtyped.

Interprofessional CareDrug Therapy ibs

Drug selection depends on severity and location of inflammation Step-down approach Uses biologic and targeted therapy first Medications containing 5-ASA (5- aminosalicylic acid) Mainstay in achieving and maintaining remission and preventing flare-ups of IBD Sulfasalazine (Azulfidine) New generation of sulfa-free drugs Olsalazine (Dipentum) Mesalamine (Pentasal) Aminosalicylates are more effective for ulcerative colitis. Drug Alert - Sulfasalazine (Azulfidine) May cause yellowish orange discoloration of skin and urine. Avoid exposure to sunlight and ultraviolet light until photosensitivity is determined. Corticosteroids Decrease inflammation Used to achieve remission Helpful for acute flare-ups . Corticosteroids must be tapered to very low levels Immunosuppressants Suppress immune response Maintain remission after corticosteroid induction therapy Require regular CBC monitoring Immunosuppressants (6-mercaptopurine, azathioprine [Imuran]) are given to maintain remission after corticosteroid induction therapy. These drugs require regular CBC monitoring because they can suppress the bone marrow and lead to inflammation of the pancreas or liver. They have a delayed onset of action and are therefore not useful for acute flare-ups. Methotrexate is most useful in Crohn's disease patients who cannot stop corticosteroid use without a flare-up or in whom other medications have been ineffective. Many patients have flu-like symptoms with use, and some develop bone marrow depression and liver dysfunction. Correct dosing is critical to minimize the risk of toxicity. Careful monitoring of the CBC and liver enzymes is essential. Advise women of childbearing age to avoid pregnancy because use causes birth defects and fetal death. Biologic and targeted therapies TNF (antitumor necrosis factor) agents Infliximab (Remicade) Adalimumab (Humira) Certolizumab pegol (Cimzia) Golimumab (Simponi) Integrin receptor antagonists Natalizumab (Tysabri) Vedolizumab (Entyvio) Infliximab is a monoclonal antibody to TNF (proinflammatory cytokine). This drug is given IV to induce and maintain remission in patients with Crohn's disease and in patients with draining fistulas who do not respond to conventional drug therapy. The other TNF agents are given subcutaneously and have effects similar to those of infliximab. The anti-TNF agents have similar side effects. The most common adverse effects are upper respiratory and urinary tract infections, headaches, nausea, joint pain, and abdominal pain. More serious effects include reactivation of hepatitis and tuberculosis (TB); opportunistic infections; and malignancies, especially lymphoma. Patients need to know the risks before starting therapy. They are tested for TB and hepatitis before treatment begins and cannot receive live virus immunizations. Teaching includes how to prevent infection and recognize early signs and symptoms (e.g., fever, cough, malaise, dyspnea). Two biologic and targeted medications are integrin receptor antagonists: natalizumab (Tysabri) and vedolizumab (Entyvio). They inhibit leukocyte adhesion by blocking α4-integrin, an adhesion molecule. The use of integrin receptor antagonists is limited to those who have not had an adequate response with other therapies (corticosteroids, immunosuppressants, or TNF agents). Both are given by IV infusion. Their use is associated with increased risk of infection, hepatotoxicity, and hypersensitivity reactions. Because of the risk of progressive multifocal leukoencephalopathy, natalizumab is available only through a restricted program. Biologic and targeted agents do not work for everyone Costly May produce allergic reactions Immunogenic They are immunogenic, meaning that patients receiving them frequently produce antibodies against them.

Interprofessional Care Immunosuppressive Therapy MS

Drug therapy = slow progression Immunosuppressants - modify the disease progression and prevent relapses. Immunomodulators - relapses Adrenocorticotropic hormone immunomodulator = progression and prevent relapses. (1) interferon β-1a (Rebif, Plegridy [given subcutaneously]) and interferon β-1a (Avonex) (given IM) (2) interferon β-1b (Betaseron, Extavia) (given subcutaneously) (3) glatiramer acetate (Copaxone) (given subcutaneously).

Alzheimer's DiseaseNursing Implementation

Early recognition and treatment are important Inform patients and their families regarding early signs of AD

Clinical ManifestationsUrinary System CKI

Early stages No change in urine output Polyuria may be present related to diabetes. As CKD progresses patients have increasing fluid retention After a period on dialysis, patients may become anuric Since diabetes is the primary cause of CKD, polyuria may be present, but not necessarily as a consequence of kidney disease. CKD progresses = increasing difficulty with fluid retention and require diuretic therapy.

Nursing Management - gerd

Elevate head of bed 30 degrees Do not lie down for 2-3 hours after eating Avoid factors that cause reflux Stop smoking Avoid alcohol and caffeine Avoid acidic foods Stress reduction techniques Weight reduction, if appropriate Small, frequent meals Evaluate effectiveness of medications Observe for side effects of medications PPI = before the first meal of the day Headache = PPI. Antacids = constipation, whereas those that contain magnesium can cause diarrhea. Laparoscopic fundoplication is often an outpatient procedure.

Chronic PancreatitisNursing Management

Focus is on chronic care and health promotion Patient and family teaching Dietary control Pancreatic enzyme with meals/snack Observe for steatorrhea Monitor glucose levels Antacids after meals and at bedtime No alcohol

Diaphragmatic (abdominal) breathing

Focuses on use of diaphragm to Achieve maximum inhalation Slow the respiratory rate May increase the workload of breathing Diaphragmatic (abdominal) breathing focuses on using the diaphragm instead of the accessory muscles of the chest may increase the work of breathing and dyspnea. moderate to severe COPD = poor candidates for diaphragmatic breathing.

Acute PancreatitisInterprofessional Care - Surgical Therapy

For gallstones ERCP Cholecystectomy Uncertain diagnosis Not responding to conservative therapy Drainage of necrotic fluid collections acute pancreatitis = gallstones = urgent ERCP plus endoscopic sphincterotomy (severing of the muscle layers of the sphincter of Oddi) severe acute pancreatitis = drainage of necrotic fluid collections.

Interprofessional Care ibs

Goals of treatment of IBD Rest the bowel Control inflammation Combat infection Correct malnutrition Alleviate stress Relieve symptoms Improve quality of life

Basal-bolus regimen

Most closely mimics endogenous insulin production Rapid- or short-acting (bolus) insulin before meals Intermediate- or long-acting (basal) background insulin once or twice a day Less intense regimens can also be used The insulin regimen that most closely mimics endogenous insulin production is the basal-bolus regimen: Rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day Goal: to achieve a glucose level of 80 to 130 mg/dL before meals

Dialysis

Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid and electrolyte imbalances and to remove waste products in kidney failure Can be used to treat drug overdoses Clinically, dialysis is a technique in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate). Begun when patient's uremia can no longer be adequately treated conservatively Initiated when GFR < 15 mL/min/1.73 m2 This criterion can vary widely in different clinical situations, and the nephrologist determines when to start dialysis based on the patient's clinical status. Certain uremic complications, including encephalopathy, neuropathies, uncontrolled hyperkalemia, pericarditis, and accelerated hypertension, indicate a need for immediate dialysis.

Dementia

Neurocognitive disorder with dysfunction or loss of Memory Orientation Attention Language Judgment Reasoning Other characteristics that can manifest Personality changes Behavioral problems such as Agitation Delusions Hallucinations Problems ultimately disrupt individual's Work Social responsibilities Family responsibilities Ability to perform ADLs

Long-term management cirrhosis

Nonselective β-adrenergic blockers Repeated band ligation Portosystemic shunts Because there is a high incidence of recurrent bleeding with each bleeding episode, continued therapy is necessary. Long-term management of patients who have had an episode of bleeding includes nonselective β-blockers, repeated band ligation of the varices, and portosystemic shunts in patients who develop recurrent bleeding.

Clinical ManifestationsType 2 Diabetes Mellitus

Nonspecific symptoms Classic symptoms of type 1 may manifest Fatigue Recurrent infection Recurrent vaginal yeast or candidal infection Prolonged wound healing Visual changes

Nursing ManagementPlanning cirrhoiss

Overall Goals Relief of discomfort Minimal to no complications Return to as normal a lifestyle as possible

PET Scan of Normal and AD Brain

Positron emission tomography (PET) scan can be used to assist in the diagnosis of Alzheimer's disease (AD) by differentiating AD from other forms of dementia. Radioactive fluorine is applied to glucose (fluorodeoxyglucose), and the yellow areas indicate metabolically active cells. A, A normal brain. B, Advanced AD is recognized by hypometabolism in many areas of the brain.

Mealtime Insulin (Bolus)

Rapid-acting (bolus) Lispro, aspart, glulisine Onset of action 15 minutes Injected within 15 minutes of mealtime Short-acting (bolus) Regular with onset of action 30 to 60 minutes Injected 30 to 45 minutes before meal Onset of action 30 to 60 minutes To manage postprandial blood glucose levels, the timing of administration of rapid- and short-acting insulin in relation to meals is crucial. Rapid-acting synthetic insulin analogs Include lispro (Humalog), aspart (NovoLog), and glulisine (Apidra) Have an onset of action of approximately 15 minutes Sould be injected within 15 minutes of mealtime Short-acting regular insulin Onset of action is 30 to 60 minutes, and preparation is injected 30 to 45 minutes before a meal to ensure that the onset of action coincides with meal absorption. Short-acting insulin = more likely to cause hypoglycemia = longer duration of action.

Nursing and Interprofessional Management

Similar to management and drug therapy of patients with AD Vascular dementia can often be prevented through treatment of risk factors Hypertension, diabetes, smoking, hypercholesterolemia, cardiac dysrhythmias

COPDInterprofessional Care

Stable COPD Treated as outpatients Hospitalized for complications Acute exacerbations Acute respiratory failure Evaluate for environmental or occupational irritants Influenza virus vaccine - get it Pneumococcal vaccine - 19 and over get it Smoking cessation = Biggest impact Keep O2 saturation > 90% during rest, sleep, and exertion, or PaO2 > 60 mm Hg Long-term O2 therapy improves Survival Exercise capacity Cognitive performance Sleep in hypoxemic patients O2 delivery systems are high- or low-flow Low-flow is most common - mixed with room air, delivery is less precise than high-flow High-flow fixed concentration Venturi mask Venturi = high-flow device = delivers fixed concentrations of O2 (e.g., 24%, 28% independent of the patient's respiratory pattern).

Ileoanal Pouch

The most commonly used surgical procedure for ulcerative colitis is a total proctocolectomy with ileal pouch/anal anastomosis (IPAA).

Chronic ComplicationsDiabetic Neuropathy

Treatment for sensory neuropathy Managing blood glucose levels Drug therapy Topical creams Tricyclic antidepressants Selective serotonin and norepinephrine reuptake inhibitors Antiseizure medications Managing blood glucose is the only treatment for diabetes-related neuropathy. It is effective in many, but not all, cases. Capsaicin - topical cream made from chili peppers, three to four times a day, increase in symptoms at the start of therapy, which is followed by relief of pain in 2 to 3 weeks. Tricyclic antidepressants = diabetic neuropathy, inhibiting the reuptake of norepinephrine and serotonin Duloxetine = relieve pain by increasing the levels of serotonin and norepinephrine, Antiseizure medications decrease the release of neurotransmitters that transmit pain.

Laparoscopic cholecystectomy

Treatment of choice Removal of gallbladder through one to four puncture holes Resume normal activities, including work, within 1 week The surgeon makes a small cut below the umbilicus and inserts a needle into the area. Carbon dioxide gas is passed into the abdomen to expand the area, which allows the surgeon to see the organs more clearly and provides more room to work. The main complication is injury to the common bile duct.

Shunting procedures

Used more after second major bleeding episode Nonsurgical: transjugular intrahepatic portosystemic shunt (TIPS) Surgical: portacaval and distal splenorenal shunt Nonsurgical and surgical methods of shunting blood away from the varices are available. Shunting procedures tend to be used more after a second major bleeding episode than an initial bleeding episode. Transjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical procedure in which a tract (shunt) between the systemic and portal venous systems is created to redirect portal blood flow. Various surgical shunting procedures may be used to decrease portal hypertension by diverting some of the portal blood flow and at the same time allowing adequate liver perfusion. Currently, the surgical shunts most commonly used are the portacaval shunt and the distal splenorenal shunt.

COPDInterprofessional Care Humidification

Used because O2 has a drying effect on the mucosa Supplied by nebulizers, vapotherm, and bubble-through humidifiers cannula or a mask = bubble-through humidifier. humidified O2 is via a nebulizer. Vapotherm Precision Flow can deliver high flows (up to 40 L/min) of warm humidified gas (air/oxygen)

COPDDepression and Anxiety

anxious = teach pursed lip breathing Buspirone (BuSpar)= treat anxiety, has few if any respiratory depression effects.

Oral Agents

Work on 3 defects of type 2 diabetes Insulin resistance Decreased insulin production Increased hepatic glucose production Can be used in combination OAs and noninsulin injectable agents work to improve the mechanisms by which insulin and glucose are produced and used by the body. These drugs work on three defects of type 2 diabetes: (1) insulin resistance, (2) decreased insulin production, and (3) increased hepatic glucose production. These drugs may be used in combination with agents from other classes or with insulin to achieve blood glucose goals.

COPDHeredity

a-Antitrypsin (AAT) deficiency Genetic risk factor for COPD Accounts for 3% of COPD AAT is an autosomal recessive disorder. protein produced by the liver and normally found in the lungs = protect normal lung tissue from attack leads to premature bullous emphysema in the lungs found on x-ray. most common abnormal genes = S and Z alleles; normal genes are labeled M. The most common genotype associated with AAT disease is ZZ. blood test = low levels of AAT. IV-administered AAT (e.g., Prolastin-C) augmentation therapy

Prediabetes

↑ Risk for developing type 2 diabetes Impaired glucose tolerance (IGT) OGTT - 140-199 mg/dL Impaired fasting glucose (IFG) Fasting glucose of 100-125 mg/dL Intermediate stage between normal glucose homeostasis and diabetes A diagnosis of IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL (7.8 to 11.0 mmol/L). IFG is diagnosed when fasting blood glucose levels are 100 to 125 mg/dL (5.56 to 6.9 mmol/L). prediabetes = do not have symptoms. polyuria, polyphagia, and polydipsia. Asymptomatic but long-term damage already occurring Patient teaching important Undergo screening Manage risk factors Monitor for symptoms of diabetes Maintain healthy weight, exercise, make healthy food choices

Transplantation = PD

of fetal neural tissue into the basal ganglia Provides DA-producing cells in the brains of patients Research and clinical trials are ongoing Transplantation of fetal neural tissue into the basal ganglia is designed to provide DA-producing cells in the brains of patients with PD. Research and clinical trials of this form of therapy is ongoing.

CPAP With Nasal Mask

pressure supplied by air coming from the compressor opens the oropharynx and the nasopharynx.

Waist circumference

People with visceral fat and truncal obesity are at an increased risk for cardiovascular disease and metabolic syndrome Men >40" waist Women >35" waist Waist circumference is another way to assess and classify a person's weight. The average waist size has increased by more than one inch (from 37.6 inches to 38.8 inches) in the past decade. People who have visceral fat with truncal obesity are at an increased risk for cardiovascular disease and metabolic syndrome.

Reasons for temporary colostomy

Perforation Peritonitis Hemodynamic instability A patient who has a perforation, peritonitis, or is hemodynamically unstable, may need a temporary colostomy or ileostomy.

Sengstaken-Blakemore Tube

A, Sengstaken-Blakemore tube. B, Tube inserted into esophagus and stomach. SAFETY ALERT: Label each lumen to avoid confusion. Secure the tube to prevent movement of the tube which could result in occlusion of the airway. Deflate balloons for 5 minutes every 8 to 12 hours per institutional policy to prevent tissue necrosis.

Evaluation - PD

Perform physical exercise to deter muscle atrophy and joint contractures Use assistive devices appropriately for ambulation and mobility Maintain nutritional intake adequate for metabolic needs Experience safe passage of fluids and/or solids from mouth to stomach Use methods of communication that meet needs for interaction with others

Peritoneal Dialysis

Peritoneal access is obtained by inserting a catheter through anterior abdominal wall Technique for catheter placement varies, Usually done via surgery PD is initiated immediately or delayed for 2 weeks The technique for catheter placement varies. It is usually placed surgically so that the catheter can be directly visualized, minimizing potential complications. Preparation of the patient for catheter insertion includes emptying the bladder and bowel, weighing the patient, and obtaining a signed consent form. After placement, PD may be initiated immediately with low volume exchanges, or delayed for 2 weeks pending healing and sealing of the exit site. Daily catheter care varies. Some patients just wash with soap and water and go without a dressing (Fig. 46-6), whereas others require daily dressing changes. Showering is preferred to bathing.

dialysis 2 types

Peritoneal dialysis (PD) Hemodialysis (HD) In PD the peritoneal membrane acts as the semipermeable membrane. In HD an artificial membrane (usually made of cellulose-based or synthetic materials) is used as the semipermeable membrane and is in contact with the patient's blood.

Chronic PancreatitisInterprofessional Care - Endoscopic procedures

Pancreatic drainage ERCP with spincterotomy and/or stent placement Pancreatic drainage procedures can relieve ductal obstruction and are often done with ERCP. Some patients may undergo ERCP with sphincterotomy and/or stent placement at the site of obstruction. These patients will require follow-up procedures such as ERCP to either exchange or remove the stent.

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1

Clinical ManifestationsPsychologic Changes CKI

Personality and behavioral changes Emotional lability Withdrawal Depression Fatigue and lethargy contribute to the feeling of illness.

MSE

3 word recall Alphabet backwards Name 7 words that begin with F Look at imagines (elephant rhino) and say what they are Drawing clock -

Nursing ManagementEvaluation CKI

The patient with CKD will maintain Fluid and electrolyte levels within normal ranges An acceptable weight with no more than a 10% weight loss

Sleeve Gastrectomy

75% of the stomach is removed Not reversible Stomach function is preserved Results in elimination of hormones produced in the stomach that stimulate hunger Ghrelin

Multiple Sclerosis stats

400,000 Americans affected More prevalent in temperate climates Researchers suspect that exposure to some environmental agent before puberty may predispose a person to develop MS later in life An estimated 400,000 people in the United States have MS, with approximately 10,000 new cases diagnosed annually. MS is more prevalent in temperate climates (between 45 and 65 degrees of latitude), such as those found in the northern United States, Canada, and Europe, as compared with tropical regions. People who are born in an area of high risk but migrate to an area of low risk before age 15 assume the risk of their new home. Researchers thus suspect that exposure to some environmental agent before puberty may predispose a person to develop MS later in life. MS is less common in Hispanics, Asians, and people of African descent. It rarely occurs in some ethnic groups, including Alaskan Natives and Aborigines.

Inhaled Insulin

Afrezza Rapid-acting inhaled insulin Administered at beginning of each meal or within 20 minutes after starting a meal Not a substitute for long-acting insulin Afrezza must be used in combination with long-acting insulin in patients with type 1 diabetes. It is not recommended for the treatment of diabetic ketoacidosis or in patients who smoke. The most common adverse reactions are hypoglycemia, cough, and throat pain or irritation. Afrezza should not be used in patients with chronic lung disease, such as asthma or COPD, because bronchospasm can occur.

Cultural Considerations: Asthma

African Americans and Hispanics have higher rates of poorly controlled asthma and deaths Disparities in socioeconomic status and access to proper health care

Continuous Vevovenous Therapies

Basic schematic of continuous venovenous therapies. A blood pump propels blood through the circuit. A highly permeable, hollow-fiber hemofilter removes plasma water and nonprotein solutes, which are collectively termed ultrafiltrate. The ultrafiltration rate (UFR) may range from 0 to 500 mL/hr. Replacement fluid is designed to replace volume and solutes such as sodium, chloride, bicarbonate, and glucose.

Stages of PD

Beginning stages Mild tremor, slight limp, ↓ arm swing Later stages Shuffling, propulsive gait with arms flexed, loss of postural reflexes Up to 90% of patients also experience speech abnormalities (hypokinetic dysarthria) that can affect communication and quality of life. None of these manifestations alone is sufficient evidence for a diagnosis of the disease.

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

Blocking reabsorption of glucose by kidney Increasing glucose excretion Lowering blood glucose levels Canagliflozin (Invokana) Dapagliflozin (Farxiga) Empagliflozin (Jardiance)

Combination Insulin Therapy

Can mix short- or rapid-acting insulin with intermediate-acting insulin in same syringe Provides mealtime and basal coverage in one injection Commercially premixed or self-mix For patients who want to use only one or two injections per day, a short- or rapid-acting insulin is mixed with intermediate-acting insulin in the same syringe. This allows patients to have both mealtime and basal coverage without having to administer two separate injections. Although this may be more appealing to the patient, most patients achieve more optimal blood glucose levels with basal-bolus therapy. Patients may mix the two types of insulin themselves or may use a commercially premixed formula or pen. Premixed formulas offer convenience to patients, who do not have to draw up and mix insulin from two different vials. This is especially helpful to those who lack the visual, manual, or cognitive skills to mix insulin themselves. However, the convenience of these formulas limits the potential for optimal blood glucose levels because there is less opportunity for flexible dosing based on need.

Bronchial thermoplasty

Catheter applies heat to reduce muscle mass in the bronchial wall A catheter is introduced via fiberoptic bronchoscopy reversing the accumulation of excessive tissue that is part of the remodeling process that causes narrowing of the airway size and adds to bronchoconstriction.

Cerebellar manifestations MS

Cerebellar signs include nystagmus, ataxia, dysarthria, and dysphagia. Severe fatigue is present in many MS patients and causes significant disability for some patients. The fatigue is aggravated by heat, humidity, deconditioning, and medication side effects.

Secondary obesity

Chromosomal and congenital anomalies Metabolic problems CNS lesions and disorders Drugs (corticosteroids, antipsychotics)

Commercially Available Insulin Preparations

Commercially available insulin preparations showing onset, peak, and duration of action. Individual patient responses to each type of insulin are different and affected by many different factors.

Deep Brain Stimulator

DBS involves placing an electrode in the thalamus, globus pallidus, or subthalamic nucleus and connecting it to a generator placed in the upper chest (like a pacemaker). The device is programmed to deliver a specific current to the targeted brain location.

Chronic ComplicationsAngiopathy

Damage to blood vessels secondary to chronic hyperglycemia Leading cause of diabetes-related death Macrovascular and microvascular Tight glucose levels can prevent or minimize complications Angiopathy is one of the leading causes of diabetes-related deaths These chronic blood vessel dysfunctions are divided into two categories: macrovascular complications and microvascular complications.

COPDOccupational & Environmental

Dusts, vapors, irritants, or fumes High levels of air pollution Fumes from indoor heating or cooking with fossil fuels coal biomass

Sexual dysfunction can occur in MS

Erectile dysfunction Decreased libido Difficulty with orgasmic response Painful intercourse Decreased lubrication Diminished sensation can prevent a normal sexual response in both men and women. The emotional effects of chronic illness and the loss of self-esteem also contribute to loss of sexual response. Some women with MS who become pregnant experience remission or an improvement in their symptoms during the gestation period. Hormonal changes associated with pregnancy appear to affect the immune system. However, during the postpartum period, women are at greater risk for exacerbation of the disease.

Primary obesity

Excess caloric intake for body's metabolic demands The majority of obese persons have primary obesity.

Peritoneal DialysisComplications

Exit site infection - Staphylococcus aureus or Staphylococcus epidermidis Peritonitis - S. aureus or S. epidermidis. Hernias -Because of increased intraabdominal pressure Lower back problems Bleeding Pulmonary complications Protein loss The primary clinical manifestations of peritonitis are abdominal pain, rebound tenderness, and cloudy peritoneal effluent with a WBC count greater than 100 cells/µL (more than 50% neutrophils) or demonstration of bacteria in the peritoneal effluent by Gram stain or culture. GI manifestations of peritonitis may include diarrhea, vomiting, abdominal distention, and hyperactive bowel sounds. Fever maybe Atelectasis, pneumonia, and bronchitis may occur from repeated upward displacement of the diaphragm, resulting in decreased lung expansion. The amount of protein loss is usually about 0.5 g/L of dialysate drainage, but it can be as high as 10 to 20 g/day.

Chronic cholecystitis

Fat intolerance Dyspepsia Heartburn Flatulence Manifestations of chronic cholecystitis include a history of fat intolerance, dyspepsia, heartburn, and flatulence.

Administration of insulin

Given by subcutaneous injection Regular insulin may be given IV Cannot be taken orally Routine doses of insulin are administered by subcutaneous injection. Regular insulin can be given IV when immediate onset of action is desired. Insulin is not taken orally because it is inactivated by gastric juices. Teach patients to avoid injecting insulin intramuscularly because rapid and unpredictable absorption could result in hypoglycemia. Absorption is fastest from abdomen, followed by arm, thigh, and buttock Abdomen is often preferred site Do not inject in site to be exercised Rotate injections within and between sites The speed with which peak serum concentrations are reached varies with the anatomic site for injection. The fastest subcutaneous absorption is from the abdomen, followed by the arm, thigh, and buttock. Although the abdomen is often the preferred injection site, other sites also work well. Caution the patient about injecting into a site that is to be exercised. For example, injecting into the thigh and then going jogging could increase body heat and circulation, which could increase the rate of insulin absorption and speed it onset of action, thus resulting in hypoglycemia. Teach patients to rotate the injection within and between sites. This allows for better insulin absorption. For example, it may be helpful to think of the abdomen as a checkerboard, with each half-inch square representing an injection site. Injections are rotated systematically across the board, with each injection site at least ½ to 1 inch away from the previous injection site. It can be helpful to inject fast-acting insulin into faster absorbing sites and slow-acting insulin into slower absorbing sites. Usually available as U100 insulin (1 mL contains 100 U of insulin) Syringes marked for units: various sizes Only user recaps syringe No alcohol swab for self-injection; wash with soap and water Inject at 45- to 90-degree angle Most commercial insulin is available as U100, indicating that 1 mL contains 100 U of insulin. U100 insulin must be used with a U100-marked syringe. Disposable plastic insulin syringes are available in a variety of sizes, including 1.0, 0.5, and 0.3 mL. The 0.5-mL size may be used for doses of 50 U or less, and the 0.3-mL syringe can be used for doses of 30 U or less. The 0.5- and 0.3-mL syringes are in 1-U increments. This provides more accurate delivery when the dose is an odd number. The 1.0-mL syringe is necessary for patients who require more than 50 U of insulin. The 1.0-mL syringe is in 2-U increments. When patients change from a 0.3- or a 0.5-mL to a 1.0-mL syringe, make them aware of the dose increment difference. Only the person using the syringe should do the recapping. Never recap a needle used by a patient. The use of an alcohol swab on the site before self-injection is no longer recommended. Routine hygiene such as washing with soap and rinsing with water is adequate. This applies primarily to patient self-injection technique. When injection occurs in a health care facility, policy may dictate site preparation with alcohol to prevent health care-associated infection (HAI). Insulin injections are typically given at a 90-degree angle. For extremely thin or muscular patients in the hospital, perform injections at a 45- degree angle. At home, patients inject at a 90-degree angle using the shortest needle desired. Pinching up of the skin to avoid intramuscular injection is no longer necessary because of the availability of short needles.

Nursing ManagementNursing Implementation cirrhois

Health Promotion Reduce or eliminate risk factors Treat alcoholism Maintain adequate nutrition Identify and treat acute hepatitis Bariatric surgery for morbidly obese Common risk factors for cirrhosis include alcoholism, malnutrition, viral hepatitis, biliary obstruction, obesity, and right-sided heart failure. Prevention and early treatment of cirrhosis must focus on reducing or eliminating these risk factors. Urge patients to abstain from alcohol, and encourage those with alcohol abuse history to enroll in alcoholic anonymous or other support their groups. Adequate nutrition, especially for the person who abuses alcohol and other individuals at risk for cirrhosis, is essential to promote normal liver regeneration. Identify and treat acute hepatitis early so that it does not progress to chronic hepatitis and cirrhosis. Bariatric surgery for morbidly obese individuals reduces the incidence of NAFLD. Acute Care Rest needs Prevent complications Modify schedule Nutritional needs Oral hygiene Between-meal nourishment Food preferences Explanation of dietary restrictions The focus of nursing care for the patient with cirrhosis is on conserving the patient's strength while maintaining muscle strength and tone. When the patient requires complete bed rest, implement measures to prevent pneumonia, thromboembolic problems, and pressure ulcers. Modify the activity and rest schedule according to signs of clinical improvement (e.g., decreasing jaundice, improvement in liver function studies). Anorexia, nausea and vomiting, pressure from ascites, and poor eating habits all create problems in maintaining an adequate intake of nutrients. Oral hygiene before meals may improve the patient's taste sensation. Make between-meal nourishments available so that they can be taken at times when the patient can best tolerate them. Provide food preferences whenever possible. Explain the reason for any dietary restrictions to the patient and caregiver. Acute Care Assess for jaundice Measures to relieve pruritus Cholestyramine or hydroxyzine Baking soda or Alpha Keri baths Lotions, soft or old linen Temperature control Short nails; rub with knuckles Monitor color of urine and stools Nursing assessment and care should include the patient's physical status. Is jaundice present? Where is it observed: sclera, skin, hard palate? What is the progression of jaundice? If the jaundice is accompanied by pruritus, measures to relieve itching should be carried out. Cholestyramine (Questran) or hydroxyzine (Atarax) may be ordered to help relieve the pruritus. Measures to help alleviate pruritus include baking soda or moisturizing bath oils (Alpha Keri) baths, lotions containing calamine, antihistamines, soft or old linen, and control of the temperature (not too hot and not too cold). Keep the patient's nails short and clean. Teach patients to rub with their knuckles rather than scratch with their nails when they cannot resist scratching. Note the color of the urine and stools and assess for movement/normalization of color. When jaundice is present, the urine is often dark brown and the stool is gray or tan. Acute Care Accurate I/O recording Daily weight measurement Extremities measurement Abdominal girth measurement Edema and ascites are frequent manifestations of cirrhosis and necessitate nursing assessments and interventions. Accurate calculation and recording of intake and output, daily weights, and measurements of extremities and abdominal girth help in the ongoing assessment of the location and extent of the edema. The abdomen should be marked with a permanent marker so that girth is measured at the same location each time. Acute Care Paracentesis Patient voids immediately before High Fowler's position or sitting on side of bed Monitor for hypovolemia and electrolyte imbalances Monitor BP and heart rate Monitor dressing for bleeding/leakage Immediately before a paracentesis, have the patient void to prevent a puncturing of the bladder during the procedure. When the paracentesis is completed, have the patient sit on the side of the bed or place him/her in high Fowler's position. Also monitor for hypovolemia and electrolyte imbalances. Check and monitor BP and heart rate following the procedure. Check the dressing for bleeding and/or leakage of ascetic fluid. Acute Care Relief of dyspnea Semi- or high Fowler's position Skin care Special mattress Turning schedule, at least every 2 hours ROM exercises Coughing/deep breathing exercises Elevate lower extremities/scrotum Dyspnea is a frequent problem for the patient with severe ascites and can lead to pleural effusions. A semi-Fowler's or high Fowler's position allows for maximal respiratory efficiency. Use pillows to support the arms and chest as they will increase the patient's comfort and ability to breathe. Meticulous skin care is essential because the edematous tissues are subject to breakdown. Use an alternating-air pressure mattress or other special mattress. A turning schedule (minimum of every 2 hours) must be adhered to rigidly. Support the abdomen with pillows. If the abdomen is taut, cleanse it gently. The patient will tend to avoid moving because of the abdominal discomfort and dyspnea. Range-of-motion exercises are helpful. Implement measures such as coughing and deep breathing to prevent respiratory problems. The lower extremities may be elevated. If scrotal edema is present, a scrotal support provides some comfort. Acute Care Monitor for fluid and electrolyte disturbances Hypokalemia Water excess (hyponatremia) Observe for bleeding disorders Assess patient's response to altered body image Supportive listening When the patient is taking diuretics, monitor the serum levels of sodium, potassium, chloride, and bicarbonate. Monitor renal function (blood urea nitrogen [BUN], serum creatinine) routinely and with any change in the diuretic dosage. Observe for signs of fluid and electrolyte imbalance, especially hypokalemia. Hypokalemia may be manifested by cardiac dysrhythmias, hypotension, tachycardia, and generalized muscle weakness. Water excess (hyponatremia) is manifested by muscle cramping, weakness, lethargy, and confusion. Observe for and provide nursing care for any hematologic problems. These include bleeding tendencies, anemia, and increased susceptibility to infection. Assess the patient's response to altered body image resulting from jaundice, spider angiomas, palmar erythema, ascites, and gynecomastia. The patient may experience a great deal of anxiety and embarrassment about these changes. Explain these phenomena, and be a supportive listener. Provide nursing care with concern and encouragement to help the patient maintain his or her self-esteem. Acute Care Bleeding varices Close observation for signs of bleeding Balloon tamponade care Explanation of procedure Check for patency Position of balloon verified by x-ray If the patient has esophageal or gastric varices, observe for any signs of bleeding from the varices, such as hematemesis and melena. If hematemesis occurs, assess the patient for hemorrhage, call the HCP, and be ready to transfer the patient to the endoscopy suite and/or assist with equipment to control the bleeding. The patient's airway must be maintained. Patients with bleeding varices are usually admitted to the ICU. Balloon tamponade may be used in patients who have refractory bleeding that is unresponsive to band ligation or sclerotherapy. When balloon tamponade is used, explain to the patient and caregiver the use of the tube and how it will be inserted. Check the balloons for patency. It is usually the HCP's responsibility to insert the tube, which may be inserted via the nose or the mouth. Then the gastric balloon is inflated with approximately 250 mL of air, and the tube is retracted until resistance (lower esophageal sphincter) is felt. The tube is secured by placement of a piece of sponge or foam rubber at the nostrils (nasal cuff). For continued bleeding, the esophageal balloon is then inflated. A sphygmomanometer is used to measure and maintain the desired pressure at 20 to 40 mm Hg. The position of the balloons is verified by x-ray. Acute Care Balloon tamponade Monitor for complications (i.e., aspiration pneumonia) Scissors at bedside Semi-Fowler's position Oral/nasal care Nursing care includes monitoring for complications of rupture or erosion of the esophagus, regurgitation and aspiration of gastric contents, and occlusion of the airway by the balloon. If the gastric balloon breaks or is deflated, the esophageal balloon will slip upward, obstructing the airway and causing asphyxiation. If this happens, cut the tube or deflate the esophageal balloon. Keep scissors at the bedside. Minimize regurgitation by oral and pharyngeal suctioning and by keeping the patient in a semi-Fowler's position. The patient is unable to swallow saliva because the inflated esophageal balloon occludes the esophagus. Encourage the patient to expectorate, and provide an emesis basin and tissues. Frequent oral and nasal care provides relief from the taste of blood and irritation from mouth breathing. Acute Care Hepatic encephalopathy Maintain safe environment Assess carefully Level of responsiveness Sensory and motor abnormalities Fluid/electrolyte imbalances Acid-base balance Effects of treatment measures Nursing care of the patient with hepatic encephalopathy focuses on maintaining a safe environment, sustaining life, and assisting with measures to reduce the formation of ammonia. Patients with hepatic encephalopathy may exhibit confusion and be at risk for falls or other injuries. Assess (1) the patient's level of responsiveness (e.g., reflexes, pupillary reactions, orientation), (2) sensory and motor abnormalities (e.g., hyperreflexia, asterixis, motor coordination), (3) fluid and electrolyte imbalances, (4) acid-base imbalances, and (5) the effect of treatment measures. Acute Care Hepatic encephalopathy Perform neurologic assessment every 2 hours Prevent falls and injuries Minimize constipation Encourage fluids Control factors known to precipitate encephalopathy Assess the neurologic status, including an exact description of the patient's behavior, at least every 2 hours. Plan your care of the patient with neurologic problems according to the severity of the encephalopathy. Institute measures to prevent falls and injuries. In addition, measures to minimize constipation are important to reduce ammonia production. Give drugs, laxatives, and enemas as ordered. Encourage fluids, if not contraindicated. Any GI bleeding may worsen encephalopathy. Assess the patient taking lactulose for diarrhea and excessive fluid and electrolyte losses. Control factors known to precipitate encephalopathy as much as possible, including anything that may cause constipation (e.g., dehydration, opioid medications). In patients with altered levels of consciousness or whose airway may become compromised, have safety measures and emergency equipment readily available. Ambulatory Care Supportive measures Proper diet Rest Avoidance of hepatotoxic OTC drugs Abstinence from alcohol Caring attitude always The patient with cirrhosis may be faced with a prolonged course and the possibility of serious, life-threatening problems and complications. The patient and caregiver need to understand the importance of continuous health care and medical supervision. Supportive measures include proper diet, rest, avoidance of potentially hepatotoxic OTC drugs such as acetaminophen in high doses, and abstinence from alcohol. Abstinence from alcohol is important and results in improvement in most patients. Achieving abstinence from alcohol is extremely difficult and requires a lot of emotional support. Explore your own attitude towards the patient whose cirrhosis is secondary to alcohol abuse. Always provide care without being condescending or judgmental. Treat patients with respect and concern for their well-being. Ambulatory Care Community support programs Symptoms of complications When to seek medical attention Written instructions with adequate explanations for patient/family Referral to community or home health nurse Cirrhosis is a chronic disease and people can live many years with symptoms and complications secondary to cirrhosis. The patient is affected not only physically but also psychologically, socially, and economically. Major lifestyle changes may be required, especially if alcohol abuse is the primary cause. Provide information regarding community support programs, such as Alcoholics Anonymous, for help with alcohol abuse. Teach the patient and caregiver about manifestations of complications and when to seek medical attention. Explain both verbally and in writing information about salt/fluid restriction or possible dietary changes. Include instructions about adequate rest periods, how to detect early signs of complications, skin care, drug therapy side effects, observation for bleeding, and protection from infection. Counseling the patient regarding sexual issues may be helpful. Referral to a community or home health nurse may sometimes be necessary to ensure adherence with prescribed therapy. Home care for the patient with cirrhosis should focus on helping the patient with activities of daily living while maintaining the highest level of wellness possible.

Chronic Kidney Disease (CKD)

Involves progressive, irreversible loss of kidney function Over half a million Americans are receiving treatment for ESRD Because the kidneys are highly adaptive, kidney disease is often not recognized until there has been considerable loss of nephrons. Individuals with CKD are frequently asymptomatic, resulting in CKD being underdiagnosed and untreated. It has been estimated that about 70% of people with CKD are unaware that they have the disease. Kidney damage Pathologic abnormalities Markers of damage Blood, urine, imaging tests Low glomerular filtration rate (GFR) <60 mL/min for longer than 3 months Kidney Disease Improving Global Outcomes (KDIGO) - presence of kidney damage or a decreased GFR less than 60 mL/min/1.73 m2 for longer than 3 months. At this point, renal replacement therapy (dialysis or transplantation) is required to maintain life. Disease staging based on decrease in GFR Normal GFR: 125 mL/min, which is reflected by urine creatinine clearance Last stage of kidney failure = End-stage renal disease (ESRD) GFR <15 mL/min

Esophageal DiverticulaComplications

Malnutrition Aspiration Perforation

Vibration

Mild vibration tolerated better than percussion slowly exhales a deep breath.

Nursing Management IBD

Nursing Assessment Autoimmune disorders, infection Use of prescribed and OTC medicines Family history Diarrhea (presence of blood) Weight loss Anxiety, depression Diarrhea Imbalanced nutrition: less than body requirements Ineffective coping Nursing diagnoses for the patient with IBD include, but are not limited to Diarrhea related to bowel inflammation and intestinal hyperactivity Imbalanced nutrition: less than body requirements related to decreased absorption and increased nutrient loss through diarrhea Ineffective coping related to chronic disease, lifestyle changes, inadequate level of confidence in ability to cope Additional information on nursing diagnoses is presented in eNCP 42-2 on the website for this chapter. Planning: Overall Goals Decreased number and severity of acute exacerbations Normal fluid/electrolyte balance Freedom from pain or discomfort Compliance with medical regimen Nutritional balance Improved quality of life During acute phases, implement strategies that focus on Hemodynamic stability Pain control Fluid and electrolyte imbalance Nutritional support Maintain accurate intake and output records, and monitor the number and appearance of stools. Assess for the presence of blood in stools and emesis. Administer IV fluids, electrolytes, analgesics, and antiinflammatory medications as ordered. Monitor serum electrolytes, CBC, and vital signs, being alert for any changes related to diarrhea and dehydration. If the patient experiences orthostatic hypotension, teach the patient to change position slowly and use safety precautions. Manage hygiene until diarrhea is controlled Tend to odor control Prevent skin breakdown Monitor I and O Weigh daily Assess bowel sounds Consult with dietitian Until diarrhea is controlled, help the patient stay clean, dry, and free of odor. Place a deodorizer in the room. Meticulous perianal skin care using plain water (no harsh soap) together with a moisturizing skin barrier cream prevents skin breakdown. Dibucaine (Nupercainal), witch hazel, sitz baths, and other soothing compresses or ointments may reduce irritation and discomfort of the anus. Monitor the patient's intake and output and calculate the adequacy of the daily calorie intake. Obtain a daily weight. Assess the abdomen, including bowel sounds, as needed. Consult with a dietitian regarding diet modifications and the need for nutritional supplements. Teaching includes How to manage this chronic illness Importance of rest and diet management Perianal care Drug action and side effects Symptoms of recurrence of disease When to seek medical care Ways to reduce stress IBD is a chronic illness. Assist the patient in accepting the chronicity of IBD and learning strategies to cope with its recurrent, unpredictable nature. Teaching includes (1) the importance of rest and diet management, (2) perianal care, (3) drug action and side effects, (4) symptoms of recurrence of disease, (5) when to seek medical care, and (6) ways to reduce stress. Excellent teaching resources, written in easily comprehensible language are available from the Crohn's and Colitis Foundation of America (www.ccfa.org). Establish rapport Encourage discussion of self-care strategies Fully explain all procedures and treatments Helps build trust Decreases apprehension Increases self-control Once you have established a therapeutic relationship, talk with smokers who have Crohn's disease about quitting since smoking is associated with more severe disease. Assist in setting realistic goals Consider need for increased rest Schedule activities around rest periods The patient and caregiver may need your help setting realistic short- and long-term goals. Patients may suffer severe fatigue, which limits their energy for physical activity. Rest is important. Patients may lose sleep because of frequent episodes of diarrhea and abdominal pain. Nutritional deficiencies and anemia leave the patient feeling weak and listless. Teach them to schedule activities around rest periods. Emotional support Intermittent exacerbations and remission of symptoms can be common Frustration, depression, anxiety need managed Therapy Stress management Support groups Many patients experience intermittent exacerbations and remissions of symptoms. Given the chronicity and uncertainty related to the frequency and severity of flares, the patient may experience frustration, depression, and anxiety. Psychotherapy and behavioral therapies may help patients deal with their feelings about the disease and help to manage their symptoms. Because of the relationship between emotions and the GI tract, teach the patient strategies for managing stress (see Chapter 6). Suggest that your patient seek support through a local or online support group from the Crohn's and Colitis Foundation of America.

Nursing Management COPD

Obtain complete health history and conduct a complete physical assessment

Nursing ManagementNursing Assessment CRC

Past health history Previous breast or ovarian cancer Familial polyposis Villous adenoma Adenomatous polyps Inflammatory bowel disease Medications Weakness or fatigue Change in bowel habits High-calorie, high-fat, low-fiber diet Increased flatus Feelings of incomplete evacuation Diarrhea Constipation Fear Anxiety Ineffective coping Diagnoses include but are not limited to Diarrhea or constipation related to altered bowel elimination patterns Fear and anxiety related to diagnosis of CRC, surgical or therapeutic interventions, and possible terminal illness Ineffective coping related to diagnosis of cancer and side effects of treatment

Bariatric Surgery

Patients with type 2 diabetes When lifestyle and drug therapy management is difficult BMI >35 kg/m2 Bariatric surgery may be considered for patients with type 2 diabetes who have a body mass index (BMI) greater than 35 kg/m2, especially if the diabetes or associated co-morbidities are difficult to manage with lifestyle and drug therapy. Patients with type 2 diabetes who have undergone bariatric surgery need lifelong lifestyle support and monitoring.

Diagnostic Studies hep

Specific antigen and/or antibody for each type of viral hepatitis Anti-HAV IgM , anti-HAV IgG HBsAg, anti-HBs, HBeAg, anti-Hbe, anti-HBc IgM, anti-HBc IgG, HBV DNA quantitation Anti-HCV, HCV quantitation Anti-HDV, HDV Ag None currently for HEV The only definitive way to distinguish among the various forms of viral hepatitis is by testing the patient's blood for the specific antigen and/or antibody. Hepatitis A Anti-HAV immunoglobulin M (IgM) indicates acute infection. Anti-HAV immunoglobulin G (IgG) indicates previous infection or immunization. Not routinely done in clinical practice. Hepatitis B HBsAg (hepatitis B surface antigen) is a marker of infectivity. It is present in acute or chronic infection and in chronic carriers. Anti-HBs (hepatitis B surface antibody) indicates previous infection with hepatitis B or immunization. HBeAg (hepatitis B e antigen) indicates high infectivity and is used to determine the clinical management of patients with chronic HBV infection. Anti-HBe (hepatitis B e antibody) indicates previous infection. Anti-HBc IgM (antibody to hepatitis B core antigen) indicates acute infection and does not appear after vaccination. Anti-HBc IgG indicates previous infection or ongoing infection with hepatitis B. It also does not appear after vaccination. HBV DNA quantitation indicates active ongoing viral replication. It is the best indicator of viral replication and effectiveness of therapy in patient with chronic HBV infection. Hepatitis C Anti-HCV (antibody to hepatitis C) is a marker for acute or chronic infection with HCV. HCV RNA quantitation indicates active ongoing viral replication. Hepatitis D Anti-HDV (antibody to hepatitis D) is present in past or current infection with hepatitis D. HDV Ag (hepatitis D antigen) is present within a few days after infection. Hepatitis E Currently, no serologic tests to diagnose HEV infection are commercially available in the United States. However, diagnostic tests are available in research laboratories to detect IgM and IgG anti-HEV and HEV RNA levels. Liver function tests Viral genotype testing HBV HCV Physical assessment findings Liver biopsy FibroScan FibroSure (FibroTest) In viral hepatitis, many of the liver function tests show significant abnormalities. AST, ALT, and GGT (liver enzymes) and alkaline phosphatase levels all are elevated. Serum proteins: γ-globulin level normal or increased; albumin level normal or decreased. Serum bilirubin (total) and urinary bilirubin levels increase. Urinary urobilinogen level increased 2 to 5 days before jaundice appears. Prothrombin time prolonged. Viral genotype testing is done in patients undergoing drug therapy for HBV or HCV infection. There are at least eight different genotypes (A to H) of HBV. In some centers, HBV genotyping is performed before treatment starts. HBV genotype may be useful in predicting disease course and treatment outcomes. There are 6 genotypes and more than 50 subtypes of HCV. In the United States, 75% of HCV infections are caused by HCV genotype 1. For patients who test positive for HCV, genotyping is obtained before drug therapy is started. The genotype determines the choice and duration of therapy. It is one of the strongest predictors of response to drug therapy Physical assessment may reveal hepatic tenderness, hepatomegaly, and splenomegaly. The liver is palpable. A liver biopsy is not indicated in acute hepatitis unless the diagnosis is in doubt. In chronic hepatitis, a liver biopsy may be done. Biopsy of liver tissue allows for histologic examination of liver cells and characterization of the degree of inflammation, fibrosis, or cirrhosis that may be present. A patient who has a bleeding disorder may not be an appropriate candidate for a percutaneous liver biopsy because of the risk of bleeding. In these patients, a transjugular biopsy may be an alternative. Techniques for noninvasive assessment of liver fibrosis may eventually replace the need for liver biopsy. Options include the use of ultrasound elastography (FibroScan), which uses an ultrasound transducer is used to determine the degree of liver fibrosis. FibroSure (FibroTest) is a biomarker for which the results of serum tests (e.g., liver enzyme levels) are used to assess the extent of hepatic fibrosis.

What lifestyle changes should you recommend for D.B.?

Teaching regarding medication use (e.g., corticosteroids) and need for follow-up evaluation (colonoscopy); nutrition counseling to prevent further weight loss; pain and discomfort management; fluid and electrolyte replacement; stress reduction.

Vascular Access Catheter

Temporary double-lumen vascular access catheter for acute hemodialysis. A, Soft, flexible dual-lumen tube is attached to a Y-hub. B, The distance between the arterial intake and the venous return lumina typically provides recirculation rates of 5% or less.

Treatment of relapsing forms of MS

Teriflunomide (Aubagio) Immunomadulatory agent with antiinflammatory properties Fingolimod (Gilenya) Prevents lymphocytes from reaching the CNS and causing damage

Monitoring for Tetany

Tests for hypocalcemia. Chvostek's sign = facial muscles in response to a light tap over the facial nerve in front of the ear. Trousseau's sign - carpal spasm induced by- inflating a blood pressure cuff above the systolic pressure for a few minutes.

Stages of Colorectal Cancer

The surgical decision for treatment of CRC depends on the staging and location of the cancer and ability to restore normal bowel function and continence.

Risk factors of alzheimers 59-13, 1410

To decrease: Challenge your mind Don't do drugs Exercise/sleep/diet Tx Depression Tx HD/DM Avoid trauma - concussions

Esophageal StricturesInterprofessional Care

Treatment Dilated endoscopically Surgical excision Patient may have a temporary or a permanent gastrostomy

Sensory manifestations MS

↓ Hearing Vertigo and tinnitus - 1st sing of hearing loss Chronic neuropathic pain - hard to fix, use GABA Lhermitte's sign - transient sensory symptom described as an electric shock radiating down the spine or into the limbs with flexion of the neck. paresthesias or numbness and tingling. pain = low thoracic and abdominal regions.

OmniPad Insulin Management System

A, OmniPod Insulin Management System. The Pod holds and delivers insulin. B, The Personal Diabetes Manager (PDM) wirelessly programs insulin delivery via the Pod. The PDM has a built-in glucose meter.

α-Glucosidase Inhibitors

"Starch blockers" Slow down absorption of carbohydrate in small intestine Take with first bite of each meal Example Acarbose (Precose) Miglitol (Glyset) Also known as starch blockers, these drugs work by slowing down the absorption of carbohydrate in the small intestine. Taken with the first bite of each main meal, they are most effective in lowering postprandial blood glucose. Their effectiveness is measured by checking 2-hour postprandial glucose levels. Acarbose (Precose) and miglitol (Glyset) are the available drugs in this class.

Intermediate-acting insulin

(Basal) Background Insulin NPH Duration 12 to 18 hours Peak 4 to 12 hours Can mix with short- and rapid-acting insulins Cloudy; must agitate to mix Intermediate-acting insulin (NPH) is also used as a basal insulin. Its action has a duration of 12 to 18 hours. The disadvantage of NPH is that its peak of action ranges from 4 to 12 hours, which can result in hypoglycemia. NPH can be mixed with short- and rapid-acting insulins. NPH is a cloudy insulin that must be gently agitated (not shaken) before administration.

Interprofessional Care:CholelithiasisExtracorporeal shock-wave lithotripsy

(ESWL) If stones cannot be removed via endoscope High-energy shock waves disintegrate stones Takes 1-2 hours Used in conjunction with bile acids

Corticosteroids for MS

(methylprednisolone, prednisone) Helpful in treating acute exacerbations, edema, acute inflammation at the site of demyelination Therapeutic plasma exchange (plasmapheresis) and IV immunoglobulin G

Stages of Chronic Kidney Disease

1 - best 5- worst

Portosystemic Shunts

A, Portacaval shunt. The portal vein is anastomosed to the inferior vena cava, diverting blood from the portal vein to the systemic circulation. B, Distal splenorenal shunt. The splenic vein is anastomosed to the renal vein. The portal venous flow remains intact, and esophageal varices are selectively decompressed. (The short gastric veins are decompressed.) The spleen conducts blood from the high-pressure esophageal and gastric varices to the low-pressure renal vein.

Diabetes Mellitus

A chronic multisystem disease characterized by hyperglycemia related to abnormal insulin production, impaired insulin utilization, or both Seventh leading cause of death

The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain by suppressing pancreatic secretions is the use of antibiotics. NPO status. antispasmodics. proton pump inhibitors.

Answer: B Rationale: Pain from acute pancreatitis is aggravated by eating; NPO status will help to alleviate the pain by decreasing pancreatic secretions.

Interprofessional Care: Drug Therapy Hep

Acute HAV infection: no specific Acute HBV infection: only if severe Acute HCV infection Pegylated interferon or DAAs Supportive drug therapy Antihistamines Antiemetics There are no drug therapies for the treatment of acute HAV infection. Treatment of acute HBV infection may be indicated only in patients with severe hepatitis and liver failure. In persons with acute hepatitis C, treatment with pegylated interferon or use of one of the direct-acting antivirals (DAAs) within the first 12 to 24 weeks of infection decreases the development of chronic hepatitis C. Supportive drug therapy may include antihistamines for generalized itching and antiemetics for nausea. These drugs include prochlorperazine (Compazine), promethazine (Phenergan), and ondansetron (Zofran).

Nursing Management:Nursing Implementation Cholecystitis

Acute Care Post-ERCP care Bed rest complications = pancreatitis, perforation, infection, and bleeding. Abdominal pain, fever, and increasing amylase and lipase may indicate pancreatitis. Teach the patient the need for follow-up if the stent is to be removed or changed. Observe for signs of obstruction of the ducts by stones. These signs include jaundice; clay-colored stools; dark, foamy urine; steatorrhea; fever; and increased WBC count. When manifestations of obstruction are present, bleeding may result from decreased prothrombin production by the liver. Common sites to observe for bleeding are the mucous membranes of the mouth, nose, gingivae, and injection sites. If injections are given, use a small-gauge needle and apply gentle pressure after the injection. Know the patient's prothrombin time and use it as a guide in the assessment process. Pruritus relief measures Antihistamines Baking soda or Alpha Keri baths Lotions Soft linen Control of temperature Short, clean nails Scratch with knuckles rather than nails Manage n/v -NG tube, gastric decompression

Interprofessional Care Hep

Acute and chronic Adequate nutrition Well balanced diet Vitamin supplements Rest (degree and strictness varies) Avoid alcohol intake and drugs detoxified by liver Notification of possible contacts

Diagnostic Studies - DM A1C

A1C Glycosylated hemoglobin: reflects glucose levels over past 2 to 3 months Used to diagnose, monitor response to therapy, and screen patients with prediabetes Goal: < 6.5% to 7% A1C measures the amount of glycosylated hemoglobin as a percentage of total hemoglobin. The amount of hemoglobin that is glycosated depends on the blood glucose level. Diseases affecting RBCs (e.g., iron deficiency anemia or sickle cell anemia) can influence the A1C level and should be considered in interpreting results.

Nursing ManagementNursing Assessment asthma

ABGs Lung function tests Asthma Control Test (ACT) Physical examination Use of accessory muscles Diaphoresis Cyanosis Lung sounds

Esophageal CancerNursing Implementationacute/preop care

Acute Care Preoperative care Provide emotional support and information Clarify test results Maintain positive attitude The patient and caregiver usually react with shock, disbelief, and depression when they are told about a diagnosis of esophageal cancer. Provide emotional and physical support, provide information, clarify test results, and maintain a positive attitude with respect to the patient's immediate recovery and long-term survival. High-calorie, high-protein diet IV fluid replacement or parenteral nutrition may be needed Teach patient/caregiver to keep I/O record Teach how to assess for fluid and electrolyte disturbances Oral care Cleanse mouth, tongue, gingivae, and teeth or dentures thoroughly Use swabs or gauze pads to scrub mouth and tongue Milk of magnesia with mineral oil helps to remove crust formation Teach patient and caregiver about Chest tubes (if open thoracic approach used) IV lines NG tubes Pain management Gastrostomy feeding (if appropriate) Turning Coughing, deep breathing

Alzheimer's DiseaseCaregiver Support

AD disrupts all aspects of personal and family life Very stressful Caregivers also exhibit adverse consequences Employment and emotional and physical health Can result in family conflict and strain More than 15 million Americans provide unpaid care for people with Alzheimer's or other dementia. Most of these are family members providing care in the home. Caregiving increases risk for development of dementia Chronic and severe stress can affect the hippocampus Hippocampus is a region of the brain responsible for memory Assess caregiver expectations Work with the caregiver to assess stressors and to identify coping strategies to reduce the burden of caregiving. For example, ask which behaviors are most disruptive to family life at a given time, while remembering that this is likely to change as the disease progresses. Determining what the caregiver views as most disruptive or distressful can help to establish priorities for care. Safety of the patient is a high priority. It is also important to assess what the caregiver's expectations are regarding the patient's behavior. Are the expectations reasonable given the progression of the disease? A family and caregiver teaching guide based on the disease stages is provided in Table 59-14. Other tips for caregivers are listed in Table 59-15. A nursing care plan for the family caregiver (eNursing Care Plan 59-2) is available on the website for this chapter.

DiabetesNutritional Therapy Goals

ADA healthy food choices Maintain blood glucose levels to as close to normal as safely possible Normal lipid profiles and blood pressure Prevent or slow complications Individual needs; personal, cultural preferences Maintain pleasure of eating Guidelines from the ADA indicate that within the context of an overall healthy eating plan, a person with diabetes can eat the same foods as a person who does not have diabetes. This means that the same principles of health nutrition that apply to the general population also apply to the person with diabetes. According to the ADA, the overall goal is to assist people with diabetes in making healthy nutritional choices that will lead to achieving and/or maintaining safe and healthy blood glucose levels. Additional specific goals include the following: 1. Maintain blood glucose levels to as close to normal as safely possible to prevent or reduce the risk for complications of diabetes. 2. Achieve lipid profiles and blood pressure levels that reduce the risk for cardiovascular disease. 3. Prevent or slow the rate of development of chronic complications of diabetes by modifying nutrient intake and lifestyle. 4. Address individual nutrition needs while taking into account personal and cultural preferences and respecting the individual's willingness or ability to change eating and dietary habits. 5. Maintain the pleasure of eating by encouraging a variety of health food choices.

Subcutaneous Injection Sites

Abdomen is preferred site, but arms, thighs, and back can be used. Patient can also rotate within each site by using checkerboard pattern, as noted in this figure.

Chronic PancreatitisClinical Manifestations

Abdominal pain Located in same areas as in acute pancreatitis Heavy, gnawing feeling; burning and cramplike heavy, gnawing feeling or sometimes as burning and cramplike. The pain is not relieved with food or antacids. The patient may have episodes of acute pain, but it usually is chronic (recurrent attacks at intervals of months or years). The attacks may become more and more frequent until they are almost constant, or they may diminish as pancreatic fibrosis develops. Some abdominal tenderness may be present. Pseudocyst formation Bile duct or duodenal obstruction Pancreatic ascites Pleural effusion Splenic vein thrombosis Pseudoaneurysm Pancreatic cancer Malabsorption with weight loss Constipation Mild jaundice with dark urine Steatorrhea Diabetes mellitus

Acute PancreatitisClinical Manifestations

Abdominal pain predominant Left upper quadrant or midepigastrium Radiates to back Sudden onset Deep, piercing, continuous or steady Aggravated by eating Starts when recumbent Not relieved with vomiting Abdominal pain is the predominant manifestation of acute pancreatitis. The pain is due to distention of the pancreas, peritoneal irritation, and obstruction of the biliary tract. The pain is usually located in the left upper quadrant, but it may be in the midepigastrium. radiates to the back because of the retroperitoneal location of the pancreas. severe, deep, piercing, and continuous or steady. aggravated by eating, and frequently has its onset when the patient is recumbent. Flushing Cyanosis Dyspnea Nausea/vomiting Low-grade fever Leukocytosis Hypotension, tachycardia Jaundice flexion of the spine in an attempt to relieve the severe pain. Abdominal tenderness with muscle guarding Decreased or absent bowel sounds Crackles in lungs Abdominal skin discoloration Grey Turner's spots or sign - a bluish flank discoloration Cullen's sign - a bluish periumbilical discoloration Shock Paralytic ileus may occur and causes marked abdominal distention. Intravascular damage from circulating trypsin (a proteolytic enzyme) may cause areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall. These result from seepage of blood-stained exudate from the pancreas and may occur in severe cases. Shock may result from hemorrhage into the pancreas, toxemia from the activated pancreatic enzymes, or hypovolemia as a result of fluid shift into the retroperitoneal space (massive fluid shifts).

Drug therapy - PD

Aimed at correcting imbalances of neurotransmitters within the CNS Antiparkinsonian drugs either Enhance or release supply of DA Antagonize or block the effects of overactive cholinergic neurons in the striatum Drugs are either dopaminergic or anticholinergic in their effects.

Evaluation hep

Ability to explain methods of transmission and methods of preventing transmission

Complications -Ascites

Accumulation of excess fluid in peritoneal cavity Due to reduced protein levels in blood, which reduces the plasma oncotic pressure

Mechanisms of CKD-Mineral and Bone Disease

Activated vitamin D is necessary to optimize absorption of calcium from the GI tract. As kidney function deteriorates, less vitamin D is converted to its active form, resulting in decreased serum levels. Low levels of active vitamin D results in decreased serum calcium levels. Serum calcium levels are primarily regulated by parathyroid hormone (PTH). When hypocalcemia occurs, the parathyroid gland secretes PTH, which stimulates bone demineralization, releasing calcium from the bones. Phosphate is released as well, leading to elevated serum phosphate levels. Hyperphosphatemia also results from decreased phosphate excretion by the kidneys. Hyperphosphatemia decreases serum calcium levels and further reduces the ability of the kidneys to activate vitamin D.

interprofessional Care - Health Promotion: Hepatitis A

Active immunization: HAV vaccine Children at 1 year of age Adults at risk Post-exposure prophylaxis with HAV vaccine and immune globulin (IG) Preventive measures include personal and environmental hygiene and health education to promote good sanitation. Hand washing is essential and is probably the most important precaution. Teach about careful hand washing after bowel movements and before eating. Control and screening (signs, symptoms) of food handlers can also help to control outbreaks. Vaccination is the best protection against HAV. All children at 1 year of age should receive the vaccine. Adults at risk should also receive the vaccine. These include people who travel to areas with increased rates of hepatitis A, MSM, injecting and noninjecting drug users, persons with clotting factor disorders (e.g., hemophilia), and persons with chronic liver disease. Havrix, Vaqta, and Avaxim: Primary immunization consists of a single dose administered IM in the deltoid muscle. A booster is recommended 6 to 12 months after the primary dose to ensure adequate antibody titers and long-term protection. Use of immune globulin Early administration (1-2 weeks after exposure) to those exposed Prophylaxis for travelers to areas where hepatitis A is common if not vaccinated with HAV vaccine Special considerations for health care personnel Wash hands after contact with a patient or removal of gloves Use infection control precautions

Nursing Implementation Hep

Acute Care Assess for jaundice Comfort measures Adequate nutrition Small, frequent meals Measures to stimulate appetite Carbonated beverages Adequate fluid intake In patients with hepatitis, assess for the presence and degree of jaundice. In light-skinned persons, jaundice is usually observed first in the sclera of the eyes and later in the skin. In dark-skinned persons, jaundice is observed in the hard palate of the mouth and inner canthus of the eyes. The urine may have a dark brown or brownish red color because of bilirubin excretion from the kidneys. Comfort measures to relieve pruritus (if present), headache, and arthralgias are helpful. Ensuring that the patient receives adequate nutrition is not always easy. The anorexia and distaste for food may cause nutritional problems. Assess the patient's tolerance of specific foods, as well as eating pattern. Small, frequent meals may be preferable to three large ones and may also help prevent nausea. Often, a patient with hepatitis finds that anorexia is not as severe in the morning, so it is easier to eat a good breakfast than a large dinner. Include measures to stimulate the appetite, such as mouth care, antiemetics, and attractively served meals in pleasant surroundings, should be included in the nursing care plan. Carbonated beverages and avoidance of very hot or very cold foods may help alleviate anorexia. Adequate fluid intake (2500 to 3000 mL/day) is also important. Acute Care Physical rest Psychologic and emotional rest Diversion activities Rest is a critical factor in promoting hepatocyte regeneration. Assess the patient's response to the rest and activity plan, and modify it as needed. Liver function tests and symptoms are used as a guide to activity level. Psychologic and emotional rest is as essential as physical rest. Limitation in activity may produce anxiety and extreme restlessness in some patients. Diversion activities, such as reading and hobbies, may help a patient cope with the plan of care and ensure adequate rest.

Acute Care - DM

Acute Care Hypoglycemia Diabetic ketoacidosis Hyperosmolar hyperglycemic nonketotic syndrome

Pathophysiology Hepatitis

Acute infection Large numbers of hepatocytes are destroyed Liver cells can regenerate in normal form after resolution of infection Chronic infection can cause fibrosis and progress to cirrhosis Rash Angioedema Arthritis Fever Malaise Cryoglobulinemia Glomerulonephritis Vasculitis acute viral hepatitis, large numbers of infected hepatocytes are destroyed. Bile production, coagulation, blood glucose, and protein metabolism can be affected. Detoxification and processing of drugs, hormones, and metabolites (e.g., ammonia from protein catabolism) may also be disrupted. Chronic viral hepatitis can be silent = persistent and continual destruction of infected hepatocytes = scar tissue can develop = fibrosis and compromised liver function. Fibrosis can lead to cirrhosis and liver failure. Antigen-antibody complexes activate complement system The antigen-antibody complexes between the virus and its corresponding antibody may form circulating immune complexes in the early phases of hepatitis. The circulating immune complexes activate the complement system. Cryoglobulinemia (abnormal proteins found in the blood), glomerulonephritis, and vasculitis can occur secondary to immune complex activation

Acute Pancreatitis

Acute inflammatory process of pancreas Spillage of pancreatic enzymes into surrounding pancreatic tissue causing autodigestion and severe pain Varies from mild edema to severe necrosis Acute pancreatitis is most common in middle-aged men and women. It affects women and men equally. African Americans is three times higher than in white persons.

Complications Hep

Acute liver failure Chronic hepatitis Some HBV and majority of HCV infections Cirrhosis Portal hypertension Hepatocellular carcinoma

Hepatitis B Virus (HBV)

Acute or chronic disease Incidence decreased with vaccination DNA virus transmitted Perinatally Percutaneously Via small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids Hepatitis B virus (HBV) is a blood-borne pathogen that can cause either acute or chronic hepatitis. Starting in the 1990s the incidence of HBV infection has decreased because of the widespread use of the HBV vaccine. HBV is a deoxyribonucleic acid (DNA) virus. It can be transmitted (1) perinatally by mothers infected with HBV; (2) percutaneously (e.g., IV drug use, accidental needle-stick punctures); or (3) via small cuts on mucosal surfaces and exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). HBV has been detected in almost every body fluid. Infected semen and saliva contain much lower concentrations of HBV than does blood, but the virus can be transmitted via these secretions. If gastrointestinal (GI) bleeding occurs, feces can be contaminated with the virus from the blood. There is no evidence that urine, feces (without GI bleeding), breast milk, tears, and sweat are infective.

Acute PancreatitisNursing Diagnoses

Acute pain related to distention of pancreas, peritoneal irritation, obstruction of biliary tract, and ineffective pain and comfort measures Deficient fluid volume related to nausea, vomiting, restricted oral intake, and fluid shift into the retroperitoneal space Imbalanced nutrition: less than body requirements related to anorexia, dietary restrictions, nausea, loss of nutrients from vomiting, and impaired digestion Ineffective health management related to lack of knowledge of preventive measures, diet restrictions, alcohol restriction intake, and follow-up care

Hepatitis C Virus (HCV)

Acute: asymptomatic Chronic: liver damage RNA virus transmitted percutaneously Dialysis Perinatal exposure Infection with the hepatitis C virus (HCV) can result in both acute illness as well as chronic infection. HCV is an RNA virus that is primarily transmitted percutaneously. most commonHCV transmission = contaminated needles High-risk sexual behavior (e.g., unprotected sex, multiple partners), especially among MSM, is associated with increased risk of transmission. Approximately 10% of all cases of HCV infection in the United States are due to occupational exposure, hemodialysis, and perinatal transmission. Some patients with HCV cannot identify a source. The risk of perinatal HCV transmission is higher in women who are co-infected with both HIV and HCV. Persons who were given blood or blood products before 1992 (when blood product testing for HCV began are at higher risk for chronic HCV infection and should be routinely tested.

Esophageal Cancer

Adenocarcinomas Arise from glands lining esophagus Resemble cancers of stomach and small intestine Squamous cell tumors Esophageal cancer (malignant neoplasm of the esophagus) is not common. However, the rates are increasing. Esophageal cancer rates are three times greater in men than in women.

Restrictive Surgery

Adjustable gastric banding (AGB) Most common procedure Limits stomach size with an inflatable band around fundus of the stomach Connected to a subcutaneous port that can be inflated or deflated to meet patient's needs as weight is lost The restrictive effect of the band creates a sense of fullness as the upper portion of the stomach now accommodates only a small portion of what an average stomach can hold. The band then causes a delay in stomach emptying providing patients with further satiety.

Hiatal Hernia

Herniation of portion of stomach into esophagus through an opening or hiatus in diaphragm Also referred to as diaphragmatic hernia and esophageal hernia Most common abnormality found on upper GI x-ray More common in older adults and women

Nutritional therapyesoph CA

After surgery, parenteral fluids given Jejunostomy, gastrostomy, or esophagostomy feeding tube may be placed Observe the patient for signs of intolerance of the feeding or leakage of the feeding into the mediastinum. Symptoms that indicate leakage are pain, increased temperature, and dyspnea. Swallowing study may be done before patient can have oral fluids When permitted, water (30-60 mL) is given hourly Gradual progression to small, frequent, bland meals Maintain upright position Observe for intolerance of feeding

PD akinesia/bradykinesia

Akinesia - Absence or loss of control of voluntary muscle movements Bradykinesia - Slowness of movement = loss of automatic movements physical and chemical alteration of basal ganglia in the extrapyramidal portion of CNS. In the unaffected patient, automatic movements are involuntary and occur subconsciously. blinking of the eyelids, swinging of the arms while walking, swallowing of saliva, self-expression with facial and hand movements, and minor movement of postural adjustment. Stooped posture Masked face Drooling Festination (shuffling gait)

Hepatitis D Virus (HDV)

Also called delta virus Defective single-stranded RNA virus Cannot survive on its own Requires HBV to replicate Transmitted percutaneously No vaccine Hepatitis D virus (HDV), also called delta virus, is a defective single-stranded RNA virus that cannot survive on its own. It requires hepatitis B to replicate. It can be acquired at the same time as HBV, or a person with HBV can be infected with HDV at a later time. HDV is also transmitted percutaneously, similar to HBV. It can cause a spectrum of illness ranging from an asymptomatic chronic carrier state to acute liver failure.

Dwell

Also known as equilibration Diffusion and osmosis occur between patient's blood and peritoneal cavity Duration of dwell time varies, depending on method of PD The duration of the dwell time can be brief lasting 20 to 30 minutes or up to 8 or more hours, depending on the method of PD.

Altered Mechanisms in Type 1 and Type 2 Diabetes

Altered mechanisms in type 1 and type 2 diabetes mellitus. Panc, liver, adipose, muscles

Types of dementia

Alzheimers Vascular - heart disease, low CO Lewy bodies - problems with neurons

Clinical ManifestationsHematologic System CKI

Anemia Due to ↓ production of erythropoietin From ↓ of functioning renal tubular cells Also decreased iron stores Folic acid lost in dialysis (1mg/day) Bleeding tendencies Defect in platelet function A normocytic, normochromic anemia=decreased production of the hormone erythropoietin by the kidneys. Infection Changes in WBC function Altered immune response and function Hyperglycemia and external trauma Other factors contributing to the increased risk of infection include hyperglycemia and external trauma (e.g., catheters, needle insertions into vascular access sites).

Inflammatory Bowel Disease Etiology and Pathophysiology

An autoimmune disease Involves an immune reaction to a person's own intestinal tract Some agent or combination of agents triggers an overactive, inappropriate, sustained immune response Results in widespread inflammation and tissue destruction Environmental factors Genetic predisposition Alterations in immune function Diet Exposure to air pollution Stress Smoking More prevalent in industrialized countries High dietary intake of total fats, polyunsaturated fatty acid (PUFA), omega-6 fatty acids, and meat is associated with an increased risk of IBD. Crohn's disease High fiber and fruit intake associated with ↓ risk Oral contraceptives and NSAIDS exacerbate symptoms Ulcerative colitis High vegetable intake associated with ↓ risk High fiber and fruit intake is associated with a decreased risk of Crohn's disease, while a high vegetable intake is associated with a decreased risk of ulcerative colitis. Oral contraceptives and (NSAIDs) exacerbate Crohn's disease. Numerous genome-wise association studies have confirmed a genetic predisposition IBD occurs more frequently in family members of persons with IBD Especially monozygotic twins Numerous genome-wide association studies have confirmed a genetic predisposition. others are associated with ulcerative colitis, and many are associated with both. An increased prevalence occurs in the presence of other inflammatory disorders with genetic susceptibility, such as psoriasis and multiple sclerosis. The recent identification of the first gene associated with Crohn's disease, the NOD2 gene, was a major breakthrough. NOD2 gene changes are associated with a form of Crohn's disease that affects the ileum in persons of northern European descent. Changes in the NOD2 gene trigger an abnormal immune response that allows bacteria to grow unchecked and invade intestinal cells, causing chronic inflammation and digestive problems. The discovery of numerous gene variations suggests that IBD is a group of diseases that produce similar types of mucosal destruction. A genetically susceptible person who is not exposed to a triggering agent will not become ill, and a person who is not genetically susceptible will not develop IBD even if exposed to a triggering agent. The pathway from genetic mutation to abnormal immune responses varies depending on which gene or genes are affected. This genetic variation may explain differences in patient responses to various drug therapies for IBD.

Water Therapy - ms

An especially beneficial type of physical therapy is water exercise. Water, which gives buoyancy to the body, allows the patient to have more control over the body and perform activities that would normally be impossible.

Insulin Pen

An insulin pen is a compact portable device loaded with an insulin cartridge that serves the same function as a needle and syringe. Pen needles are available in various lengths and sizes. Insulin pens offer convenience and flexibility. They are portable and compact, their use is more discreet than using a vial and syringe, and they provide consistent and accurate dosing. For patients with poor vision, the pen is a better option as they can hear the clicks of the pen as the dose is selected. Insulin pens come packaged with printed instructions including pictures of the steps to take when using the pen. These instructions are helpful to use in teaching new users and in reviewing technique with current users of a pen.

Chronic PancreatitisInterprofessional Care

Analgesics for pain relief (morphine or fentanyl patch [Duragesic]) Diet Bland, low-fat Small, frequent meals No smoking No alcohol or caffeine Pancreatic enzyme replacement Bile salts Insulin or oral hypoglycemic agents Acid-neutralizing and acid-inhibiting drugs Antidepressants pancreatic enzymes usually enteric coated to prevent their breakdown or inactivation by gastric acid. Bile salts are sometimes given to facilitate the absorption of the fat-soluble vitamins (A, D, E, and K) and prevent further fat loss. If diabetes develops, it is controlled with insulin (more commonly) or oral hypoglycemic agents. Acid-neutralizing drugs (e.g., antacids) and acid-inhibiting drugs (e.g., H2-receptor blockers, proton pump inhibitors) may be given to decrease hydrochloric (HCl) acid secretion but have little overall effect on patient outcomes. Antidepressants, such as nortriptyline (Aventyl), have been shown to reduce the neuropathic pain associated with chronic pancreatitis.

Targeted therapy CRC

Angiogenesis inhibitors inhibit the blood supply to tumors Bevacizumab (Avastin) Ziv-aflibercept (Zaltrap) Several targeted therapies have a role in treating metastatic CRC. Angiogenesis inhibitors, which inhibit the blood supply to tumors, include aflibercept (Zaltrap) and bevacizumab (Avastin). Bevacizumab is often added to a combination chemotherapy regimen (e.g., 5-FU- irinotecan or 5-FU, leucovorin, oxaliplatin) to treat metastatic CRC. Multikinase inhibitors block several enzymes that promote cancer growth Regorafenib (Stivarga) Block epidermal growth factor receptor Cetuximab (Erbitux) Panitumumab (Vectibix) Regorafenib (Stivarga) is a multikinase inhibitor that blocks several enzymes that promote cancer growth. Cetuximab (Erbitux) and panitumumab (Vectibix) block the epidermal growth factor receptor.

Incidence of Cancer

Annually about 136,800 people in the United States are diagnosed with CRC and 50,300 people die from CRC. CRC has an insidious onset, and symptoms do not appear until the disease is advanced. Regular screening is necessary to detect precancerous lesions. Approximately one half of all colon cancers occur in the rectosigmoid area. Percentages are listed for males (M) and females (F).

After teaching D.B. about dietary modifications, you determine that teaching was effective when he chooses which menu? Baked cod, baked sweet potato, and canned pears Barbecued brisket, coleslaw, baked beans, and angel food cake Fried shrimp with cocktail sauce, corn on the cob, and a fruit roll-up Turkey burger with cheese on a whole wheat bun, french fries, and an orange

Answer: A Rationale: Patients with inflammatory bowel disease require a high-calorie, high-vitamin, high-protein, low-residue, lactose-free (if lactase deficiency) diet. High-fat foods may trigger diarrhea. Cold foods and high-fiber foods may increase gastrointestinal transit.

D.B. must undergo surgical intervention. Which comment indicates that additional instruction about the care of his new ileostomy is needed? "I should change the appliance daily to prevent odors." "When I change the appliance, I should check the skin for irritation." "I should clean around the stoma with mild soap and water and pat dry." "I'll need to alter the appliance opening when the stoma becomes smaller as the area heals."

Answer: A Rationale: The appliance is changed every 4 to 7 days unless leakage occurs. Flatus is expelled from the bag through a charcoal filter that helps control odor. Skin around the stoma should be washed with pain water or mild soap, rinsed with warm water, and dried thoroughly before the barrier is applied. When the appliance is changed, the skin should be assessed for irritation. Mild to moderate swelling of the stoma in the first 2 to 3 weeks after surgery is expected. Therefore, the size of the pouch opening that fits around the stoma needs to be adjusted to accommodate the stoma's changing size. Review next slides.

A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patient's diet? Fat Protein Calories Carbohydrates

Answer: B Rationale: Dietary protein guidelines for peritoneal dialysis (PD) differ from those for hemodialysis because of protein loss in the dialysate. During PD, protein intake must be high enough to compensate for the losses, so that the nitrogen balance is maintained. Recommended protein intake is at least 1.2 g/kg of ideal body weight per day, and it increases according to the individual needs of the patient.

An older patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate? "Depression is a common cause of confusion in older adults in the hospital." "It is normal for an older person to have cognitive problems while in the hospital." "The mental changes are most likely caused by the infection and most often reversible." "Drug therapy with antipsychotic agents is indicated to slow the progression of dementia."

Answer: C Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient's underlying condition with a precipitating event.

After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective? "I can have a glass of low-fat milk at bedtime." "I will have to eliminate all spicy foods from my diet." "I will have to use herbal teas instead of caffeinated drinks." "I should keep something in my stomach all the time to neutralize the excess acids."

Answer: C Rationale: Patients with gastroesophageal reflux disease should avoid foods (such as tea and coffee) that decrease lower esophageal pressure. Patients should also avoid milk, especially at bedtime, as it increases gastric acid secretion. Patients may eat spicy foods, unless these foods cause reflux. Small, frequent meals help prevent overdistention of the stomach, but patients should avoid late evening meals and nocturnal snacking.

D.B. is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for him is to let him know what behavior is socially appropriate. assist him with all self-care to maintain self-esteem. maintain familiar routines of sleep, meals, drug administration, and activities. promote orientation at every encounter with the patient by asking the day, time, and place.

Answer: C Rationale: The nurse should maintain familiar routines by identifying usual patterns of behavior for activities such as sleep, medication use, elimination, food intake, and self-care.

A patient with advanced cirrhosis who has ascites is short of breath and has an increased respiratory rate. The nurse should Initiate oxygen therapy at 2 L/min to increase gas exchange. Notify the health care provider so that a paracentesis can be performed. Ask the patient to cough and breathe deeply to clear respiratory secretions. Place the patient in Fowler's position to relieve pressure on the diaphragm.

Answer: D Rationale: Dyspnea is a frequent problem for the patient with ascites, and a semi-Fowler's or Fowler's position allows for maximal respiratory efficiency. Oxygen administration is not indicated; SpO2 level less than 90% would be an indication for oxygen. The respiratory distress is caused by ascites (not by respiratory secretions); coughing and deep breathing will not alleviate the respiratory distress. A paracentesis may be performed to remove ascitic fluid; however, this procedure provides only temporary relief and is reserved for severe respiratory distress or abdominal pain.

The surgical treatment of choice for the patient with symptomatic gallbladder disease is a cholecystotomy. choledocholithotomy. cholecystoduodenostomy. laparoscopic cholecystectomy.

Answer: D Rationale: Laparoscopic cholecystectomy is the surgical treatment of choice for patients with symptomatic cholelithiasis. The procedure is minimally invasive (puncture sites only), and the patient experiences minimal postoperative pain and is discharged on the day of surgery or on the day after. Most patients are able to resume normal activities and return to work within 1 week.

The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD is different from forgetfulness. You describe early warning signs of AD, including Forgetting a colleague's name at a party Repeatedly misplacing car keys or a wallet Leaving a pot on the stove that boils dry and burns Having no memory of preparing a meal and forgetting to serve or eat it

Answer: D Rationale: Memory loss that affects job skills: Frequent forgetfulness or unexplainable confusion at home or in the workplace may signal that something is wrong. This type of memory loss goes beyond forgetting an assignment, a colleague's name, a deadline, or a phone number. Difficulty performing familiar tasks: It is not abnormal for most people to become distracted and to forget something (e.g., leave something on the stove too long). People with Alzheimer's disease (AD) may cook a meal but then forget not only to serve it but also that they made it. Misplacing things: For many individuals, temporarily misplacing keys, purses, or wallets is a normal albeit frustrating event. Persons with AD may put items in inappropriate places (e.g., eating utensils in clothing drawers) but have no memory of how they got there.

The nurse teaches a patient with chronic kidney disease about prevention of complications. What should the nurse include in the teaching plan? Monitor for proteinuria daily with a urine dipstick. Perform self-catheterization every 4 hours to measure urine. Take calcium-based phosphate binders on an empty stomach. Check weight daily and report a gain of greater than 4 pounds.

Answer: D Rationale: Patients with chronic kidney disease are taught to report weight gain greater than 4 pounds (2 kg). Proteinuria is an expected finding and is not monitored. Calcium-based phosphate binders should be taken with meals because most phosphate is absorbed within 1 hour after eating. Self-catheterization is not indicated and may lead to infection.

After discharge instructions for a patient who has had bariatric surgery for treatment of obesity, the nurse determines that additional teaching is needed when the patient says "I shouldn't eat concentrated sweets." "I can eat small, frequent meals throughout the day." "I should drink several glasses of fluids with my meals." "I will need to have a cobalamin injection once a month."

Answer: c Rationale: Discharge teaching for a patient after bariatric surgery may include six small meals/day, a diet high in protein and low in fat and carbohydrates, avoidance of ingestion of solids with fluids, avoidance of large amounts of fluids at one time, restriction of fluid intake to less than 1000 mL/day, and avoidance of sugary foods. The dietary restrictions will help to prevent dumping syndrome and will aid in weight loss. Cobalamin injections or intranasal spray will prevent cobalamin-deficiency anemia.

An important factor associated with both short-term and long-term weight-loss success is Higher initial body mass index. Simultaneous smoking cessation. A strong desire to improve appearance. Fewer dieting attempts in the past year. Answer: c Rationale: Motivation to lose weight is essential for a favorable and successful outcome. See next slides.

Answer: c Rationale: Motivation to lose weight is essential for a favorable and successful outcome. See next slides.

The nurse teaches a patient about safe and successful weight loss. Which statement, if made by the patient, would indicate an understanding of the instructions? "I will keep a diary of daily weights to chart my weight loss." "I plan to lose 4 pounds a week until I have lost my goal of 60 pounds." "I should not exercise more than what is required because increased activity increases the appetite." "I plan to join a behavior-modification group to make permanent changes necessary for weight control."

Answer: d Rationale: Behavior-modification programs deemphasize the diet and focus on how and when to eat; support groups offer support and information on dieting tips. Patients should set a weight loss goal of 1 to 2 lb/wk. Weight should be checked weekly; daily weights are not recommended because of the frequent fluctuations that result from retained water (including urine) and elimination of feces. No evidence indicates that increased activity promotes an increase in appetite or leads to dietary excess.

Interprofessional Care Drug Therapy - PD

Antiviral agent - amantadine ↑ Dopamine release; blocks reuptake Anticholinergics - trihexyphenidyl (Artane) and benztropine (Cogentin) ↓ Activity of Ach MAO-B inhibitors - Selegiline (Eldepryl) and rasagiline (Azilect) ↑ Levels of DA Prolong half-life of levodopa The antiviral agent amantadine (Symmetrel)= NMDA-type glutamate receptors, increases dopamine release, and blocks dopamine reuptake = mild relief/withdrawal can worsen dyskinesias. Antihistamines (e.g., diphenhydramine [Benadryl]) with anticholinergic properties may be used to manage tremors. Rivastigmine (Exelon) or donepezil (Aricept) is used to treat dementia. Amitriptyline may be used to treat depression.

Nursing Management:Evaluation Cholecystitis

Appear comfortable and verbalize pain relief Verbalize knowledge of activity level and dietary restrictions

Body shape

Apple-shaped body Fat located primarily in abdominal area Android obesity Pear-shaped body Fat located primarily in upper legs Gynoid obesity Genetics has an important role in determining a person's body shape and weight.

Arteriovenous Fistula

Arteriovenous fistula created by anastomosing an artery and vein. A subcutaneous AVF is most commonly created in the forearm with an anastomosis between an artery and a vein (usually cephalic). The fistula allows arterial blood to flow through the vein. The vein becomes "arterialized" increasing in size and developing thicker walls = better for venipunctures. Maturation may take 6 weeks to months. AVF should be placed at least 3 months before the need to initiate HD. Normally, a thrill (buzzing sensation) can be felt by palpating the fistula, and a bruit (rushing sound) can be heard with a stethoscope.

Mechanisms of Ascites

Ascites is manifested by abdominal distention with weight gain (Fig. 43-8). If the ascites is severe, the increase in abdominal pressure from the fluid accumulation may cause eversion of the umbilicus. Abdominal striae with distended abdominal wall veins may be present. Patients may show signs of dehydration (e.g., dry tongue and skin, sunken eyeballs, muscle weakness) and a decrease in urine output. Hypokalemia is common, and is due to an excessive loss of potassium caused by hyperaldosteronism. Low potassium levels can also result from diuretic therapy used to treat the ascites. Because of alterations in immune function associated with cirrhosis, patients with ascites are at risk for spontaneous bacterial peritonitis (SBP). SBP is a bacterial infection of the ascites fluid. This occurs in approximately 15% to 25% of hospitalized patients with cirrhosis and ascites, and it is particularly common after variceal hemorrhage. The bacteria most frequently found are gram-negative enteric pathogens such as E. coli.

Gross Ascites

Ascites is manifested by abdominal distention with weight gain. If the ascites is severe, the umbilicus may be everted. Abdominal striae with distended abdominal wall veins may be present. Because of alterations in immune function associated with cirrhosis, patients with ascites are at risk for spontaneous bacterial peritonitis (SBP). SBP is a bacterial infection of the ascitic fluid. In SBP, bacteria normally found in the intestines are translocated into the peritoneal space. The bacteria most frequently responsible for the infection are a gram-negative enteric pathogen such as Escherichia coli. SBP occurs in approximately 15% to 25% of hospitalized patients with cirrhosis and ascites. It particularly common after variceal hemorrhage.

Acute PancreatitisNursing Implementation - Health Promotion

Assessment of patient for predisposing and etiologic factors Encouragement of early treatment of these factors Early diagnosis/treatment of biliary tract disease Elimination of alcohol intake

Type 1 Diabetes MellitusOnset of Disease

Autoantibodies are present for months to years before symptoms occur Manifestations develop when pancreas can no longer produce insulin—then rapid onset with ketoacidosis In type 1 diabetes, the islet cell autoantibodies responsible for β-cell destruction are present for months to years before the onset of symptoms. person's pancreas can no longer produce sufficient amounts of insulin symptoms is usually rapid, present with impending or actual ketoacidosis. sudden weight loss, as well as the classic symptoms of polydipsia (excessive thirst), polyuria (frequent urination), and polyphagia (excessive hunger). diagnosed type 1 diabetes may experience a remission, or "honeymoon period," for 3 to 12 months after treatment is initiated = requires very little injected insulin because β-cell insulin production remains sufficient for healthy blood glucose level, more β-cells are destroyed and blood glucose levels increase

Type 1 Diabetes MellitusEtiology and Pathophysiology

Autoimmune disorder Body develops antibodies against insulin and/or pancreatic β cells that produce insulin Results in not enough insulin to survive Genetic link Idiopathic diabetes Latent autoimmune diabetes in adults (LADA) Autoantibodies to the islet cells = reduction of 80% to 90% of normal function before hyperglycemia and other manifestations occur. Predisposition to type 1 diabetes is related to human leukocyte antigens (HLAs).= viral infection = β cells of the pancreas are destroyed, Hispanic, African, or Asian ancestry. Latent autoimmune diabetes in adults (LADA), a slowly progressing autoimmune form of type 1 diabetes, occurs in adults and is often mistaken for type 2 diabetes.

Peritoneal DialysisDialysis Solutions and Cycles

Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25% Electrolyte composition similar to that of plasma Solution warmed to body temperature Dialysis solutions vary, and the choice of exchange volume is determined primarily by the size of the peritoneal cavity. A larger person may tolerate a 3-L exchange volume without any difficulty, whereas an average-size person usually tolerates a 2-L exchange. Ultrafiltration (fluid removal) during PD depends on osmotic forces; glucose is the most effective osmotic agent currently available.

Clinical Manifestations MS

Chronic, progressive deterioration in some patients Remissions and exacerbations in others Overall trend is progressive deterioration in neurologic function Onset of the disease is often insidious and gradual Vague symptoms occur intermittently over months or years = dont seek medical attention = dx long after 1st symptoms Symptoms vary according to areas of CNS involved Some have severe, long-lasting symptoms early in disease Others have occasional and mild symptoms for several years

Clinical Manifestations - Convalescent phase

Begins as jaundice is disappearing Lasts weeks to months Major complaints Malaise Easy fatigability Hepatomegaly persists Splenomegaly subsides The convalescent phase following the acute phase begins as jaundice disappears and lasts for weeks to months, with an average of 2 to 4 months. Hepatomegaly remains for several weeks, but splenomegaly subsides during this period.

Acute PancreatitisNursing Assessment - Subjective Data

Biliary tract disease Alcohol use Abdominal trauma Duodenal ulcers Infection Metabolic disorders Medications Thiazides NSAIDs Surgery or other treatments Pancreas, stomach, duodenum, biliary tract ERCP Alcohol abuse Fatigue Nausea, vomiting, anorexia Dyspnea Pain - severe midepigastric or left upper quadrant pain that may radiate to the back, aggravated by food and alcohol intake and unrelieved by vomiting

Nursing ManagementNursing Assessment CKI

Because many drugs are potentially nephrotoxic, ask the patient about both current and past use of prescription drugs, over-the-counter drugs, and herbal preparations. Medications - antacids, decongestants, and antihistamines. NSAIDs (aspirin, ibuprofen, naproxen) can contribute to the development of AKI and progression of CKD, especially when taken in higher doses than recommended. Assess the patient's dietary habits and discuss any problems regarding intake. Measure the patient's height and weight, and evaluate any recent weight changes. Assess the patient's support systems. The choice of treatment modality may be related to support systems available.

Combination oral therapy DM

Blend two different classes of medications to treat diabetes Improves adherence because patient takes fewer pills Other drugs affecting blood glucose levels Drug interactions can potentiate hypoglycemia and hyperglycemia effects Many combination drugs are currently available. These drugs combine two different classes of medications to treat diabetes. (Examples of these agents are listed in Table 48-7.) One advantage of combination therapy is that the patient takes fewer pills, thus improving adherence to taking medications. Both the patient and the HCP must be aware of drug interactions that can potentiate hypoglycemia and hyperglycemia effects. For example, β-adrenergic blockers can mask symptoms of hypoglycemia and prolong the hypoglycemic effects of insulin. Thiazide and loop diuretics can potentiate hyperglycemia by inducing potassium loss, although low-dose therapy with a thiazide is usually considered safe.

Dipeptidyl Peptidase-4 (DDP-4) Inhibitor

Blocks inactivation of incretin hormones ↑ Insulin release ↓ Glucagon secretion ↓ Hepatic glucose production Examples (gliptins) Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Incretin hormones are released by the intestines throughout the day, but levels increase in response to a meal. When glucose levels are normal or elevated, incretins increase insulin synthesis and release from the pancreas, as well as decrease hepatic glucose production. The incretin hormones are normally inactivated by dipeptidyl peptidase-4 (DPP-4). DPP-4 inhibitors block the action of the DPP-4 enzyme, which is responsible for inactivating incretin hormones (gastric inhibitory peptide [GIP] and glucagonlike peptide [GLP-1]). The result is an increase in insulin release, a decrease in glucagon secretion, and decreased hepatic glucose production. Because the DPP-4 inhibitors are glucose dependent, they lower the potential for hypoglycemia. The main benefit of these drugs over other medications for diabetes with similar effects is the absence of weight gain as a side effect. DPP-4 inhibitors (also known as gliptins) come in pill form and includes sitagliptin (Januvia), saxagliptin (Onglyza), and linagliptin (Tradjenta).

Classification of Body Weight and Obesity - assessment

Body mass index (BMI) Waist circumference Waist-to-hip ratio Determination of body shape The degree to which a patient is classified as underweight, normal weight, overweight, obese, or extremely obese can be assessed using several methods. A number of assessment methods are available, including body mass index (BMI), waist circumference, waist-to-hip ratio (WHR), and body shape. The most widely used and endorsed measures are BMI and waist circumference. These measures are cost-effective, reliable, and easily used in all practice settings.

Parkinson's Disease (PD)

Chronic, progressive neurodegenerative disorder characterized by Bradykinesia - slowness in the initiation and execution of movement Rigidity -increased muscle tone Tremor at rest Gait disturbance It is the most common form of parkinsonism (a syndrome characterized by similar symptoms). Affects up to 1 million Americans Incidence incr with age = 4% diagnosed before age 50 More common in men by a ratio of 3:2

Multiple Sclerosis

Chronic, progressive, degenerative disorder of central nervous system (CNS) Characterized by segmental demyelination of nerve fibers of brain and spinal cord = Lesions forming in the brain, where they are depend on s/s

Type 2 Diabetes Mellitus

Formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (NIDDM) Most prevalent type (90% to 95%) Many risk factors: overweight, obesity, advanced age, family history Type 2 diabetes mellitus is the most prevalent type of diabetes, accounting for over approximately 90% to 95% of cases of diabetes. African Americans, Asian Americans, Hispanics, Native Hawaiians or other Pacific Islanders, and Native Americans

Type 1 Diabetes Mellitus

Formerly known as juvenile-onset or insulin-dependent diabetes Accounts for about 5% to 10% of all people with diabetes Generally affects people under age 40 Can occur at any age Type 1 diabetes mellitus, formerly known as juvenile-onset diabetes or insulin-dependent diabetes, accounts for about 5% to 10% of all people with diabetes. Type 1 diabetes generally affects people under 40 years of age, although it can occur at any age.

Autonomic neuropathy

Can affect nearly all body systems Gastroparesis Delayed gastric emptying Cardiovascular abnormalities Postural hypotension, resting tachycardia, painless myocardial infarction Autonomic neuropathy = hypoglycemia, bowel incontinence, d/, urinary retention. Gastroparesis (delayed gastric emptying) is a complication of autonomic neuropathy that can produce anorexia, nausea, vomiting, gastroesophageal reflux, feelings of fullness. Gastroparesis can trigger hypoglycemia Cardiovascular = postural hypotension, resting tachycardia, and painless myocardial infarction Sexual function Erectile dysfunction Decreased libido Vaginal infections Neurogenic bladder → urinary retention Empty frequently, use Credé's maneuver Medications Self-catheterization Decreased libido is a problem for some women with diabetes. Candidal and nonspecific vaginitis are also common. A neurogenic bladder may develop as the sensation in the inner bladder wall decreases, causing urinary retention. A patient with retention has infrequent voiding, difficulty in voiding, and a weak stream of urine. Emptying the bladder every 3 hours in a sitting position helps prevent stasis and subsequent infection. Tightening the abdominal muscles during voiding and using Credé's maneuver (mild massage downward over the lower abdomen and bladder) may also help with complete bladder emptying. Cholinergic agonist drugs such as bethanechol (Urecholine) may be used. The patient may also need to learn self-catheterization.

Clinical ManifestationsMusculoskeletal System CKI

CKD mineral and bone disorder Systemic disorder of mineral and bone metabolism Results in Skeletal complications (osteomalacia, osteitis fibrosa) Soft tissue complications (vascular calcifications) CKD mineral and bone disorder (CKD-MBD) develops as a systemic disorder of mineral and bone metabolism caused by progressive deterioration in kidney function (Fig. 46-3).

Health History - PD

CNS trauma Cerebrovascular disorders Exposure to metals and CO2 Encephalitis Medications Major tranquilizers Reserpine Methyldopa Amphetamines Fatigue Excessive salivation Dysphagia Weight loss Constipation Incontinence Difficulty initiating movements, falls Loss of dexterity Diffuse pain in head, shoulders, neck, back, legs, and hips Insomnia Depression Mood swings

Clinical ManifestationsCardiovascular System CKI

CV disease and CKD closely linked Traditional CV risk factors Hypertension Elevated lipids Nontraditional CV risk factors Vascular calcification Arterial stiffness The most common cause of death in patients with CKD is CV disease. Leading causes of death are myocardial infarction, ischemic heart disease, peripheral arterial disease, HF, cardiomyopathy, and stroke. CV disease and CKD are so closely linked that if patients develop cardiac events (e.g., myocardial infarction, HF), kidney function is evaluated. Traditional CV risk factors such as hypertension and elevated lipids are common in CKD patients. CV disease may also be related to nontraditional CV risk factors such as vascular calcification and arterial stiffness. Calcium deposits associated with stiffness of blood vessels Vascular smooth muscle cells change Chondrocytes or osteoblastlike cells High calcium and phosphate totals Impaired renal excretion Drug therapies to treat bone disease The calcium deposits in the vascular medial layer are associated with stiffening of the blood vessels. The mechanisms involved are multifactorial. They include vascular smooth muscle cells changing into chondrocytes or osteoblastlike cells high total body amount of calcium and phosphate resulting from abnormal bone metabolism impaired renal excretion drug therapies to treat the bone disease (e.g., calcium phosphate binders) Hypertension Both a cause and a consequence of CKD Aggravated by sodium and water retention Hypertension is aggravated by sodium retention and increased extracellular fluid volume. increased renin production contributes to hypertension Hypertension + DM are contributing risk factors for vascular complications. hypertension, fluid volume overload, and anemia = left ventricular hypertrophy Hypertension can cause retinopathy, encephalopathy, and nephropathy.

Chronic Complications

Chronic complications associated with diabetes are primarily those of end-organ disease from damage to blood vessels (angiopathy) secondary to chronic hyperglycemia. Identify chronic complications to be discussed.

Three pathologic processes characterize MS

Chronic inflammation Demyelination Gliosis (scarring) in the CNS An unknown trigger in genetically susceptible individuals may initiate this process.

Delirium Clinical Manifestations

Can present with a variety of manifestations Delirium usually develops over a 2- to 3-day period Can develop within hours present with = hypoactivity and lethargy to hyperactivity, hallucinations. Patients can also have mixed delirium, manifesting both hypoactive and hyperactive symptoms. Early manifestations often include Inability to concentrate Disorganized thinking Irritability Insomnia Loss of appetite Restlessness Confusion Later manifestations may include Agitation Misperception Misinterpretation Hallucinations Can last from 1 to 7 days Some manifestations may persist for months or years Some patients do not completely recover Key distinctions of delirium rather than dementia Sudden cognitive impairment Disorientation Clouded sensorium

HemodialysisEffectiveness

Cannot fully replace normal functions of kidneys Can ease many of symptoms Can prevent certain complications HD does not alter the accelerated rate of development of cardiovascular disease and the related high mortality rate.

Esophageal CancerEtiology and Pathophysiology

Cause is unknown Risk factors Barrett's esophagus Smoking Excessive alcohol intake Obesity History of achalasia Current smoking or a history of smoking are associated with a two-fold higher risk of esophageal cancer. Those with injury to the esophageal mucosa (e.g., from occupational exposure to asbestos and cement dust) are at greater risk. Achalasia, a condition in which there is delayed emptying of the lower esophagus, is associated with squamous cell cancer. Majority of tumors located in middle and lower portions of esophagus Malignant tumor Usually appears as ulcerated lesion May penetrate muscular layer and outside wall of esophagus Obstruction in later stages The majority of patients have advanced disease at the time of diagnosis. The cancer spreads via the lymph system, with the liver and lung being common sites of metastasis.

Etiology and PathophysiologyCholelithiasis

Cause of gallstones unknown Develops when= cholesterol, bile salts, and calcium in solution is altered = precipitation Bile secreted by liver supersaturated with cholesterol (lithogenic) Conditions that upset this balance include infection and disturbances in the metabolism of cholesterol. In patients with cholelithiasis, the bile secreted by the liver is supersaturated with cholesterol (lithogenic bile). The bile in the gallbladder also becomes supersaturated with cholesterol. When bile is supersaturated with cholesterol, precipitation of cholesterol occurs in the gallbladder. components of bile = bile salts, bilirubin, calcium, and protein. Stones may remain in gallbladder or may migrate to cystic or common bile duct Stasis of bile → supersaturation and changes in composition of bile (biliary sludge) Immobility, pregnancy, and inflammatory or obstructive lesions of biliary system ↓ bile flow Stasis of bile leads to progression of the supersaturation and changes in the chemical composition of the bile (biliary sludge). Immobility, pregnancy, and inflammatory or obstructive lesions of the biliary system decrease bile flow. Hormonal factors during pregnancy may cause delayed emptying of the gallbladder, resulting in stasis of bile. The stones may remain in the gallbladder or migrate to the cystic duct or to the common bile duct.

Acute PancreatitisPathophysiology

Caused by autodigestion of pancreas #1 Injury to pancreatic cells Activation of pancreatic enzymes Activation of trypsinogen to trypsin within pancreas leads to bleeding The etiologic factors cause injury to pancreatic cells or activation of the pancreatic enzymes in the pancreas rather than in the intestine. This may be due to reflux of bile acids into the pancreatic ducts through an open or distended sphincter of Oddi. This reflux may be due to blockage created by gallstones. Obstruction of pancreatic ducts results in pancreatic ischemia. Trypsinogen is an inactive proteolytic enzyme produced by the pancreas. It is released into the small intestine via the pancreatic duct. In the small intestine, it is activated to trypsin by enterokinase. Normally, trypsin inhibitors in the pancreas and plasma bind and inactivate any trypsin that is inadvertently produced. In pancreatitis, activated trypsin is present in the pancreas. This enzyme can digest the pancreas and produce bleeding. alcohol increases the production of the digestive enzymes in the pancreas.

Chronic PancreatitisPathophysiology - Two major types

Chronic obstructive pancreatitis #1 Inflammation of sphincter of Oddi Cancer of ampulla of Vater, duodenum, or pancreas Chronic nonobstructive pancreatitis Inflammation and sclerosis in head of pancreas and around duct Most common cause is alcohol abuse inflammation/sclerosis = head of the pancreas and around the pancreatic duct.

Alzheimer's DiseaseDiagnostic Criteria

Changes in brain May precede symptoms by many years May not correlate with behaviors Spectrum of Alzheimer's disease Preclinical AD Mild cognitive impairment Dementia (terminal stage of disease) AD may cause changes in the brain many years before symptoms appear. Guidelines address the use of imaging and biomarkers (discussed in following section on diagnostic studies) that may help determine whether changes are due to AD.

Alzheimer's DiseasePathophysiology

Changes in brain structure and function Amyloid plaques Neurofibrillary tangles Loss of connections between neurons Neuron death In both FAD and sporadic AD, the pathogenesis of AD is similar. {See next slide for figure.}

Inflammatory Bowel Disease

Characterized by chronic, recurrent inflammation of intestinal tract Periods of remission are interspersed with periods of exacerbation Exact cause is unknown There is no cure

Gallbladder Disease

Cholelithiasis = Most common disorder of biliary system Stones in gallbladder Cholecystitis = Inflammation of gallbladder Usually associated with cholelithiasis The gallstones may get lodged in the neck of the gallbladder or in the cystic duct. Cholecystitis usually associated with cholelithiasis and usually occurs together but a person can have cholelithiasis without cholecystitis. Cholecystitis may present acutely or chronically.

Tx Alzheimer's

Cholinesterase inhibiters ACH helps neurons communicate Memantine Glutamate - helps maintain levels Normal level - Memory and attention High = kill neuron

Complications - Chronic hepatitis

Chronic HBV is more likely to develop in infants and those under age 5 HCV infection is more likely than HBV to become chronic Manifestations include anemia and coagulation problems, as well as skin manifestations Alterations in the patient's cellular immune response may be important in the development of the chronic HBsAg carrier state and the progression of acute HBV to chronic HBV. develop chronic liver disease, cirrhosis, portal hypertension, and liver cancer. The liver is responsible for producing clotting factors, so in persons with liver disease, clotting and bleeding times can be impaired or prolonged. Skin manifestations may include spider angiomas, palmar erythema, and gynecomastia. Some patients have splenomegaly, hepatomegaly, or cervical lymph node enlargement.

Alzheimer's Disease

Chronic, progressive, neurodegenerative brain disease Most common form of dementia ~5.4 million Americans suffer from AD 11% people over age 65 have AD ~ 33% of those over age 85 have AD 6th leading cause of death in the United States It is the most common form of dementia, accounting for 60% to 80% of all cases of dementia. AD is named after Alois Alzheimer, a German physician who in 1906 described changes in the brain tissue of a 51-year-old woman who had died of an unusual mental illness. Ultimately, the disease is fatal, with death typically occurring 8 to 10 years after diagnosis, although some patients live for 20 years. Only cause of death among the top 10 that cannot be prevented, cured, or even slowed Burden of care is staggering Known as the "long good-bye" or "death in slow motion" The incidence of AD is higher in African Americans and Hispanics. AD has been associated with lower socioeconomic status and education level and poor access to health care . Women are more likely than men to develop AD, primarily because they live longer.

Cirrhosis

Cirrhosis that developed secondary to alcoholism. The characteristic diffuse nodularity of the surface is due to the combination of regeneration and scarring of the liver.

Clinical ManifestationsType 1 Diabetes Mellitus

Classic symptoms Polyuria (frequent urination) Polydipsia (excessive thirst) Polyphagia (excessive hunger) Weight loss Weakness Fatigue - no energy for cells osmotic effect of glucose produces polyuria, polydipsia, and polyphagia.

Clinical Manifestations Hep

Classified as acute and chronic Many patients: asymptomatic Symptoms intermittent or ongoing Malaise Fatigue Myalgias/arthalgias Right upper quadrant tenderness Acute phase Maximal infectivity; lasts 1-6 months Symptoms during incubation Anorexia Lethargy Weight loss Fatigue Nausea/vomiting RUQ tenderness Distaste for cigarettes ↓ Sense of smell Low-grade fever Skin rashes Myalgias Arthralgias Skin rashes The acute phase is the period of maximal infectivity. The acute phase usually lasts from 1 to 4 months. During the incubation period, symptoms may include malaise, anorexia and weight loss, fatigue, nausea, occasional vomiting, and abdominal (right upper quadrant) discomfort. The patient may find food repugnant and, if a smoker, may have distaste for cigarettes. Sense of smell is also decreased. Other symptoms may include headache, low-grade fever, arthralgias, and skin rashes. Hepatomegaly Lymphadenopathy Splenomegaly Icteric (jaundice) or anicteric Dark urine Light or clay-colored stools Pruritus Physical examination may reveal hepatomegaly, lymphadenopathy, abdominal tenderness, and sometimes splenomegaly. If conjugated bilirubin cannot flow out of the liver because of obstruction or inflammation of the bile ducts, the stools will be light or clay-colored.

Etiology and Pathophysiology DM

Combination of causative factors Genetic Autoimmune Environmental Absent/insufficient insulin and/or poor utilization of insulin Normal glucose and insulin metabolism Produced by -cells in islets of Langerhans Stabilizes glucose level in range of 70 to 110 mg/dL Insulin is a hormone produced by the β-cells in the islets of Langerhans of the pancreas The average amount of insulin secreted daily by an adult is approximately 40 to 50 U, or 0.6 U/kg of body weight.

Inflammatory Bowel Disease Gerontologic Considerations

Second peak in occurrence of IBD is in the 6th decade Proctitis and left-sided ulcerative colitis are more common Diagnosis can be difficult and confused with CDI Colitis is associated with diverticulosis or NSAID ingestion

Alzheimer's DiseaseInfection Prevention

Common Urinary tract infection Pneumonia Ultimate cause of death in many AD patients Manifestations need prompt evaluation and treatment Because of feeding and swallowing problems, the patient with AD is at risk for aspiration pneumonia. Reduced fluid intake, prostate enlargement in men, poor hygiene, and urinary drainage devices (e.g., catheter) can predispose to bladder infection. Any manifestations of infection, such as a change in behavior, fever, cough (pneumonia), or pain on urination (bladder), need prompt evaluation and treatment.

Description of GERD

Common problem Chronic symptom of mucosal damage Not a disease, but a syndrome GERD is the most common upper GI problem seen in adults. Approximately 10% to 20% of the U.S. population experience GERD symptoms (heartburn or regurgitation) at least once a week.

Crohn's DiseaseSurgical Therapy

Commonly performed for complications Strictures Obstructions Bleeding Fistula Most patients eventually require surgery Disease often recurs at anastomosis site The most common surgery is a resection of the diseased segments and then the remaining intestine is reanastomosed. Unfortunately, the disease often recurs at the anastomosis site. Short bowel syndrome Too little small intestine surface area to maintain normal nutrition and hydration from disease or surgery Lifetime fluid boluses and parenteral nutrition may be needed Strictureplasty Opens up narrowed areas obstructing bowel Reduces risk of developing short-bowel syndrome and associated complications because intestine remains intact

Surgical goals

Complete resection of tumor Thorough exploration of abdomen Removal of all lymph nodes that drain the area Restoration of bowel continuity Prevention of surgical complications Goals of surgical therapy include (1) complete resection of the tumor together with adequate margins of healthy tissue, (2) a thorough exploration of the abdomen to determine if the cancer has spread, (3) removal of all lymph nodes that drain the area where the cancer is located, (4) restoration of bowel continuity so that normal bowel function will return, and (5) prevention of surgical complications. Surgical therapy Polypectomy during colonoscopy is used to resect colorectal cancer in situ Successful when Resected margin of polyp is free of cancer Cancer is well differentiated No lymphatic or blood vessel involvement is apparent Some polyps can be removed during colonoscopy, whereas others necessitate surgery. Site of cancer dictates site of resection Right or left hemicolectomy Stage I tumors Removal of tumor and at least 5 cm of surrounding intestine and nearby lymph nodes Cancer-free ends are sewn back together May be done laparoscopically Surgical removal of stage I cancer includes removal of the tumor and at least 5 cm of intestine on either side of the tumor plus removal of nearby lymph nodes. The remaining cancer-free ends are sewn back together (anastomosis). Laparoscopic surgery is sometimes used for stage I tumors, especially those in the left colon. Low-risk stage II tumors Wide resection and reanastomosis High-risk stage II tumors Same as for low-risk stage II tumors, plus chemotherapy Stage III tumors Surgery and chemotherapy Low-risk stage II tumors are treated with wide resection and reanastomosis, and chemotherapy is used in addition to surgery for high-risk stage II tumors. Stage III tumors are treated with surgery and chemotherapy. Radiation and chemotherapy may be done before surgery to reduce tumor size. Stage IV tumors Indicates cancer has spread to distant sites Surgery is palliative Chemotherapy and radiation used to control the spread and provide pain relief Once the cancer has spread to distant sites (stage IV), any surgery is usually palliative, with chemotherapy and radiation used to control the spread and provide pain relief. Select patients with limited lung or liver metastases can achieve a cure after primary and metastatic tumor resection and chemotherapy.

ComplicationsParkinson's Disease

Complications ↑ as disease progresses Motor symptoms Weakness Akinesia Neurologic problems Neuropsychiatric problems As PD progresses = dementia, = increase in mortality. dysphagia = malnutrition or aspiration may result. debilitation = pneumonia, urinary tract infections, and skin breakdown. Orthostatic hypotension, loss of postural reflexes, may result in falls or other injury. increased fall risk

Chronic PancreatitisDiagnostic Studies

Confirming diagnosis can be challenging Based on Signs/symptoms Laboratory studies Imaging Laboratory tests Serum amylase/lipase levels May be ↑ slightly or not at all ↑ Serum bilirubin level ↑ Alkaline phosphatase level Mild leukocytosis ↑ Sedimentation rate ERCP CT, MRI, MRCP, abdominal and/or endoscopic ultrasonography Stool samples for fat content ↓ Fat-soluble vitamin and cobalamin levels Glucose intolerance/diabetes Secretin stimulation test ERCP is used to visualize the pancreatic and common bile ducts. Imaging studies such as CT, MRI, MRCP, abdominal ultrasonography, and EUS are useful in patients with chronic pancreatitis. These procedures show a variety of changes, including calcifications, ductal dilation, pseudocysts, and enlargement of the pancreas. Stool samples are examined for fecal fat content. Deficiencies of fat-soluble vitamins and cobalamin, glucose intolerance, and possible diabetes may also be found in patients with chronic pancreatitis. A secretin stimulation test may be used to assess the degree of pancreatic dysfunction.

CRRT versus HD

Continuous rather than intermittent Fluid volume can be removed over days versus hours Solute removal by convection (no dialysate required) in addition to osmosis and diffusion Less hemodynamic instability Does not require constant monitoring by HD nurse Does not require complicated HD equipment

Insulin pump

Continuous subcutaneous infusion Battery-operated device Connected to a catheter inserted into subcutaneous tissue in abdominal wall Program basal and bolus doses that can vary throughout the day Potential for keeping blood glucose levels in a tighter range An insulin pump delivers a continuous subcutaneous insulin infusion through a small device worn on the belt, in a pocket, or under clothing. Insulin pumps use rapid-acting insulin, which is loaded into a reservoir or cartridge and connected via plastic tubing to a catheter inserted into the subcutaneous tissue. All insulin pumps are programmed to deliver a continuous infusion of rapid-acting insulin 24 hours a day, known as the "basal rate." Basal insulin can be temporarily increased or decreased on the basis of carbohydrate intake, activity changes, or illness. Some individuals require different basal rates at different times of the day. At mealtime, the user programs the pump to deliver a bolus infusion of insulin appropriate to the amount of carbohydrate ingested and an additional amount, if needed to bring down or correct high preprandial blood glucose. Insulin pump users check their blood glucose level at least four times per day. Monitoring eight times or more per day is common. A major advantage of the insulin pump is the potential for keeping blood glucose levels in a tighter range. This is possible because insulin delivery becomes very similar to the normal physiologic pattern.

Chronic Pancreatitis

Continuous, prolonged inflammatory, and fibrosing process of the pancreas Etiology Alcohol, gallstones, tumor, pseudocysts, trauma, systemic disease, Acute pancreatitis, Idiopathic The pancreas becomes progressively destroyed as it is replaced with fibrotic tissue. Strictures and calcifications may also occur in the pancreas.

Interprofessional Care:Cholecystitis

Control possible infection Antibiotic treatment n/v = NG tube A cholecystostomy = drain purulent material from the obstructed gallbladder. Anticholinergics = decrease GI secretions and counteract smooth muscle spasms.

COPD Complications

Cor pulmonale Exacerbations of COPD Acute respiratory failure Peptic ulcer disease Depression/anxiety

Counterregulatory hormones DM

Glucagon, epinephrine, growth hormone, cortisol Oppose effects of insulin Stimulate glucose production and release by the liver Decrease movement of glucose into cell Glucagon, epinephrine, growth hormone, and cortisol are counterregulatory hormones that work to oppose the effects of insulin.

Classes of Diabetes

Type 1 Type 2 Gestational Other specific types Prediabetes The two most common are type 1 and type 2 diabetes mellitus. Finally, there is a category of disorder called "prediabetes" - individuals with prediabetes are at an increased risk for the development of type 2 diabetes.

Diagnostic Studies CKI

History and physical examination Dipstick evaluation of protein Urinalysis Renal ultrasound/ biopsy Albumin-to-creatinine ratio (first morning void) GFR proteinuria= kidney damage estimate GFR are the Cockcroft-Gault formula and the Modification of Diet in Renal Disease (MDRD) Study equation (see Table 46-8). MDRD is the preferred method.

Goals - DM

Goals of diabetes management Decrease symptoms Promote well-being Prevent acute complications Delay onset and progression of long-term complications Need to maintain blood glucose levels as near to normal as possible The goals of diabetes management are to reduce symptoms, promote well-being, prevent acute complications related to hyper- and hypoglycemia, and prevent or delay the onset and progression of long-term complications. These goals are most likely to be met when the patient is able to maintain blood glucose levels as near to normal as possible.

What problems do D.V.'s history and symptoms suggest? What important teaching topics should you discuss with her?

History and symptoms are suggestive of irritable bowel syndrome (constipation type). Patient needs teaching and reassurance. Encourage her to keep a symptom and stool pattern diary for 1 month. Discuss strategies for reducing stress at work. Teach relaxation strategies, to use particularly before meals. Discuss ways to increase dietary fiber (rather than laxatives) to produce soft, painless bowel movements.

Bariatric Surgery

Currently only treatment found to have a successful and lasting impact Overall mortality is very low but there are a number of complications Criteria for surgery BMI ≥40 kg/m2 BMI ≥35 kg/m2 with other significant comorbidities Hypertension, type 2 diabetes, heart failure, sleep apnea Many insurance carriers do not cover the cost of bariatric surgery. If they do consider reimbursing for the surgery, most of them require documentation of medically supervised weight loss programs for about 6 months. Must be screened for Psychologic, physical, and behavioral conditions that have been associated with poor surgical outcomes Patients are not good candidates for bariatric surgery if they have untreated depression, binge-eating disorders, and drug and alcohol abuse that may interfere with the commitment required to lifelong behavioral changes. Advanced cancer, end-stage renal, liver, and cardiopulmonary disease, severe coagulopathy, or inability to comply with nutritional requirements are also contraindications. Three broad categories Combination of restrictive and malabsorptive restrictive procedures, the stomach is reduced in size (less food eaten) malabsorptive procedures, the small intestine is shortened or bypassed (less food absorbed). laparoscopically- there are fewer wound infections, shorter hospital stays, and a faster recovery period.

Interprofessional Care Drug Therapy MS

Currently there is no cure for MS Early intervention is most effective

Assessment of Gastrointestinal System KEY POINTS

Lewis: Medical-Surgical Nursing, 10th Edition Chapter 42 Lower Gastrointestinal Disorders KEY POINTS DIARRHEA • Diarrhea is the passage of at least three loose or liquid stools per day. It can be acute, persistent, or chronic. • Diarrhea can result from alterations in gastrointestinal motility, increased secretion, and decreased absorption. The primary cause is ingesting infectious organisms. • All cases of acute diarrhea should be considered infectious until the cause is known. Strict infection control precautions are necessary. • Most infectious diarrhea runs its course and does not require hospitalization. • Patients receiving antibiotics are susceptible to Clostridium difficile (C. difficile), which is a serious bacterial infection. Infections are treated with antibiotic therapy or fecal microbiota transplant. • Accurate diagnosis and management require a thorough history, physical examination, and laboratory testing. Treatment depends on the cause. • The overall goals are that the patient with diarrhea will have (1) no transmission of the microorganism causing the infectious diarrhea, (2) cessation of diarrhea and resumption of normal bowel patterns, (3) normal fluid and electrolyte and acid-base balance, (4) normal nutritional status, and (5) no perianal skin breakdown. FECAL INCONTINENCE • Fecal incontinence, the involuntary passage of stool, occurs when the normal structures that maintain continence are disrupted. • Risk factors include constipation, diarrhea, obstetric trauma, surgical trauma, neurologic diseases or injuries, and fecal impaction. • The best means to prevent and treat fecal incontinence is a comprehensive bowel training program. CONSTIPATION • Constipation is a decrease in the frequency of bowel movements from what is "normal" for the individual; hard, difficult-to-pass stools; a decrease in stool volume; and/or retention of feces in the rectum. • There are numerous causes of constipation. Clinical presentation varies from chronic discomfort to an acute event, often depending on cause. • The overall goals are that the patient with constipation will increase dietary intake of fiber and fluids; increase physical activity; have the passage of soft, formed stools; and not have any complications, such as bleeding hemorrhoids. • An important role for you is to teach the patient the importance of dietary and activity measures to prevent and treat constipation. • CHRONIC ABDOMINAL PAIN • Common causes of chronic abdominal pain include irritable bowel syndrome (IBS), diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflammatory disease, and vascular insufficiency. • Treatment for chronic abdominal pain is comprehensive and directed toward palliation of symptoms using nonopioid analgesics and antiemetics, as well as nutritional, psychologic, or behavioral therapies. IRRITABLE BOWEL SYNDROME • Irritable bowel syndrome (IBS) is a chronic functional disorder characterized by intermittent and recurrent abdominal pain or discomfort and stool pattern irregularities (diarrhea, constipation, or both). • The cause is unknown and there are no specific findings. Treatment is directed at psychologic and dietary factors as well as medications to regulate output and reduce pain/discomfort. ABDOMINAL TRAUMA • Blunt abdominal trauma commonly occurs with motor vehicle accidents and falls and may not be obvious because it does not leave an open wound. • Penetrating trauma occurs with gunshot or knife wounds. • Common injuries of the abdomen include lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragm rupture, urinary bladder rupture, great vessel tears, renal injury, and stomach or intestine rupture. • Emergency management of abdominal trauma focuses on establishing a patent airway and adequate breathing, fluid replacement, and prevention of hypovolemic and septic shock. CHRONIC INFLAMMATORY DISORDERS Inflammatory Bowel Disease • Crohn's disease and ulcerative colitis are immunologically related disorders that are referred to as inflammatory bowel disease (IBD). • IBD is characterized by an overactive, inappropriate, sustained immune response to substances that are normally tolerated. • Patients suffer mild to severe acute exacerbations that occur at unpredictable intervals over their lifetimes. • Ulcerative colitis affects the mucosal layer of the rectum and colon, but some patients do have mild inflammation in the terminal ileum. The primary symptoms are bloody diarrhea and abdominal pain. Medications are used to achieve and maintain remission. • Crohn's disease can occur anywhere in the GI tract from the mouth to the anus but occurs most commonly in the terminal ileum and colon. The inflammation involves all layers of the bowel wall with segments of normal bowel occurring between diseased portions—the so-called skip lesions. • With Crohn's disease, diarrhea and colicky abdominal pain are common symptoms. If the small intestine is involved, weight loss and nutritional problems are common because of malabsorption. Patients may have systemic symptoms such as fever. • Treatment goals for IBD include bowel rest, control of inflammation and infection, improved nutrition, alleviation of stress, symptomatic relief, and improved quality of life. • ♣ Five major classes of medications are used to treat IBD: aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, and biologic and targeted therapy. • ♣ Ulcerative colitis can be cured with a total colectomy, since the colon and rectum are not necessary for survival. Surgery is a last resort for Crohn's disease because of high recurrence rates and the risk for developing short bowel syndrome. • ♣ Surgery is indicated if the patient with IBD fails to respond to treatment; exacerbations are frequent and debilitating; massive bleeding, perforation, strictures, and/or obstruction occur; tissue changes suggest that dysplasia is occurring; or carcinoma develops. • During an acute exacerbation of IBD, nursing care is focused on hemodynamic stability, pain control, fluid and electrolyte balance, and nutritional support. • Nurses and other team members can assist patients to accept the chronicity of IBD and learn strategies to cope with its recurrent, unpredictable nature. COLORECTAL CANCER • Major risk factors for colorectal cancer (CRC) include increasing age, a family or personal history of CRC, colorectal polyps, and IBD. Lifestyle factors associated with CRC include obesity, smoking, alcohol, and diet. • Symptoms do not appear until the advanced stages and include rectal bleeding, abdominal pain, and/or changes in bowel habits. Symptoms appear earlier with left-sided cancer as compared to right-sided cancer. • Most CRC arises from adenomatous polyps. Therefore early detection and removal of precancerous polyps can prevent most CRC. • Beginning at age 50, both men and women at average risk for developing CRC should have screening tests done to detect both polyps and cancer or tests that primarily detect cancer. Colonoscopy is the gold standard for CRC screening. • CRC prognosis and treatment correlate with stage of the disease. Treatments include endoscopic removal, surgical removal alone, surgical removal plus chemotherapy, or palliative chemotherapy for nonresectable CRC. • The goals for the patient with CRC include normal bowel elimination patterns, quality of life appropriate to disease progression, relief of pain, and feelings of comfort and well-being. • Psychologic support for the patient with CRC and family is important. The recovery period is long, and the cancer could return. • Bowel surgery can disrupt nerve and vascular supply to the genitals. Radiation therapy, chemotherapy, and medications can also alter sexual function. OSTOMY SURGERY • An ostomy is the surgical creation of an opening called a stoma that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen. An ostomy is used when the normal elimination route is no longer possible. • The two major aspects of nursing care for the patient undergoing ostomy surgery are emotional support as the patient copes with a radical change in body image and patient teaching about the many aspects of stoma care and the ostomy. • Postoperative nursing care includes assessment of the stoma and provision of an appropriate pouching system that protects the skin and contains drainage and odor. • The patient should be able to perform a pouch change, provide appropriate skin care, control odor, care for the stoma, and identify signs and symptoms of complications. • The patient with an ileostomy should be observed for signs and symptoms of fluid and electrolyte imbalance, particularly potassium, sodium, and fluid deficits. • With time and proper support, people learn to manage the stoma and resume work, social, and sexual activities. Accurate information, emotional support and mastering basic skills will help patients learn to live a full life with an ostomy and accept their change in body appearance and function. FISTULAS • A fistula, an abnormal tract between two hollow organs or a hollow organ and the skin, is named by the track it takes. • Fistulas are classified as simple or complex and by the amount of output. • Fever and abdominal pain are early indicators of a fistula. Other manifestations vary depending on the type of fistula. • Nursing care involves maintaining fluid and electrolyte balance, controlling infection, protecting the surrounding skin, managing output, and providing nutritional support. • Most fistulas heal spontaneously. Surgery may be necessary to address complications. DIVERTICULOSIS AND DIVERTICULITIS • Diverticula are saccular dilations or outpouchings of the mucosa that develop in the colon. Diverticulitis is inflammation of the diverticula, resulting in complications such as perforation, abscess, fistula formation, and bleeding. • The cause of diverticuli is unknown. The main factor contributing to the development of diverticuli is lack of dietary fiber. The majority of patients with diverticular disease are asymptomatic. Those with symptoms typically have abdominal pain, bloating, flatulence, and/or changes in bowel habits. • Patient and caregiver teaching regarding a high-fiber diet, mainly from fruits and vegetables, with decreased intake of fat and red meat are recommended for preventing exacerbations of diverticular disease. HERNIAS • A hernia is a protrusion of a viscus through an abnormal opening or a weakened area in the wall of the cavity in which it is normally contained. • Types of hernias include inguinal, femoral, and ventral or incisional. Diagnosis is based on the history and physical examination relative to the type of hernia. • Surgery is the treatment of choice for hernias. • If the hernia becomes strangulated, the patient will experience severe pain and symptoms of a bowel obstruction, such as vomiting, cramping abdominal pain, and distention. Emergency surgery is required to treat a strangulated hernia. MALABSORPTION SYNDROME • Malabsorption results from impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins. • Causes of malabsorption include biochemical or enzyme deficiencies, bacterial proliferation, disruption of small intestine mucosa, disturbed lymphatic and vascular circulation, and short bowel syndrome. CELIAC DISEASE • Celiac disease is an autoimmune disease characterized by damage to the small intestinal mucosa from the ingestion of wheat, barley, and rye in genetically susceptible individuals. • Three factors necessary for the development of celiac disease (gluten intolerance) are genetic predisposition, gluten ingestion, and an immune-mediated response. • Classic signs of celiac disease include foul-smelling diarrhea, steatorrhea, flatulence, abdominal distention, and symptoms of malnutrition. • Early diagnosis and treatment of celiac disease can prevent complications such as cancer (e.g., intestinal lymphoma), osteoporosis, and chronic inflammation. • A gluten-free diet is the only effective treatment for celiac disease. Most patients need to maintain on a gluten-free diet for the rest of their lives. LACTASE DEFICIENCY • Lactase deficiency is a condition in which the lactase enzyme is deficient or absent. • Symptoms include bloating, flatulence, cramping abdominal pain, and diarrhea, which usually occur within a half hour to several hours after ingesting a milk product. • Treatment consists of eliminating lactose from the diet by avoiding milk and milk products and/or replacement of lactase with commercially available preparations. SHORT BOWEL SYNDROME • Short bowel syndrome (SBS) results from surgical resection of too much small bowel, congenital defect, or disease-related loss of absorption. The length and portions of small bowel affected are associated with the number and severity of symptoms. • SBS is characterized by the inability to obtain adequate nutrients from a standard diet. • SBS is treated with dietary changes, supplements, and antidiarrheal medications. • In severe cases, patients need parenteral nutrition for survival or a small intestine organ transplant. GASTROINTESTINAL STROMAL TUMORS • Gastrointestinal stromal tumors (GISTs) are a rare form of cancer that originates in cells found in the wall of the GI tract. • Although GISTS are surgically removed, many have metastasized by the time of diagnosis. • Although GISTs are unresponsive to conventional chemotherapy, the discovery of specific gene mutations led to the development of highly effective drugs that have greatly improved the prognosis in patients with certain types of GISTs. ANORECTAL PROBLEMS Hemorrhoids • Hemorrhoids are dilated hemorrhoidal veins. They may be internal (occurring above the internal sphincter) or external (occurring outside the external sphincter). • Classic symptoms include bleeding with defecation, anal pruritus, prolapse, and pain. • Surgery may be indicated when there is prolapse or excessive bleeding or pain. • Nursing management includes teaching patients to prevent constipation, avoid prolonged standing or sitting, properly use over-the-counter (OTC) drugs, and seek medical care for severe symptoms (e.g., excessive pain and bleeding, prolapsed hemorrhoids). • • Anal Fissure • An anal fissure is a skin ulcer or a crack in the lining of the anal wall that is caused by trauma, local infection, or inflammation. • The major symptoms are anal pain and bleeding. • Surgical repair is done if conservative treatment with medications is ineffective. Anorectal Abscess • Anorectal abscesses are collections of perianal pus resulting from an infection in the anal glands. • Manifestations include local pain and swelling, foul-smelling drainage, tenderness, and fever. • Treatment consists of drainage of the abscess. The patient must be taught afterward about wound care, sitz baths, and cleansing of the area after bowel movements. • Anal Fistula • An anal fistula is an abnormal tunnel leading from the anus or rectum, often into the vagina, or outside skin. It is often accompanied by infection and incontinence. • Fistulas are closed by surgery or using fibrin glue. Postoperative nursing care is the same as for the patient after a hemorrhoidectomy. Anal Cancer • Anal cancer is uncommon in the general population, but the incidence is increasing. Human papillomavirus (HPV) is associated with approximately 80% of anal cancer. • Risk factors include smoking, immunosuppression, men who have sex with men, women with cervical or vulvar cancer or precancerous lesions, and HIV infection. • Most frequently the initial symptom is rectal bleeding. Other symptoms include rectal pain and sensation of a rectal mass. Some patients have no symptoms, which leads to delayed diagnosis and treatment. • Two FDA-approved vaccines (Gardasil, Gardasil 9) are available to help prevent cervical, vulvar, vaginal, and anal cancers and associated precancerous lesions due to certain HPV types. • Treatment depends on the size and depth of the lesions. Treatment options include local ablation, chemotherapy and radiation, and surgical resection.

Liver, Pancreas, and Biliary Tract Problems KEY POINTS

Lewis: Medical-Surgical Nursing, 10th Edition Chapter 43 Liver, Pancreas, and Biliary Tract Problems KEY POINTS DISORDERS OF THE LIVER Viral Hepatitis • Viral hepatitis can cause both acute and chronic liver disease. The types of viral hepatitis are A, B, C, D, and E. • Hepatitis A Virus • Hepatitis A virus (HAV) is an RNA virus that is transmitted primarily through the fecal-oral route by ingestion of food or liquid infected with the virus. Hence, poor hygiene, improper handling of food, crowded situations, and poor sanitary conditions are all factors related to HAV transmission. • The greatest risk of transmission occurs before clinical symptoms are apparent. • Hepatitis B Virus • Hepatitis B virus (HBV) is a DNA virus that is transmitted perinatally by mothers infected with HBV; percutaneously (e.g., IV drug use); or horizontally by mucosal exposure to infectious blood, blood products, or other body fluids (e.g., semen, vaginal secretions, saliva). • HBV is a complex structure with three distinct antigens: the surface antigen (HBsAg), the core antigen (HBcAg), and the e antigen (HBeAg). • Hepatitis C Virus • Hepatitis C virus (HCV) is an RNA virus that is primarily transmitted percutaneously. • The most common mode of HCV transmission is the sharing of contaminated needles and paraphernalia among IV drug users. Other risk factors include transfusion of blood or blood products prior to 1992, high-risk sexual behavior, occupational exposure, and hemodialysis. • Hepatitis D and E Virus • Hepatitis D virus (HDV) is an RNA virus that cannot survive on its own. It requires pre-existing infection with HBV to replicate. • Hepatitis E virus (HEV) is an RNA virus that is transmitted by the fecal-oral route. • Clinical Manifestations of Hepatitis • Clinical manifestations of hepatitis are divided into acute and chronic phases. There is some slight variation in manifestation among the types of hepatitis. o Many patients with acute hepatitis have no symptoms. o The acute phase may be anicteric (no jaundice) or icteric (jaundice). Other symptoms of the acute phase include malaise, anorexia, lethargy, fatigue, nausea, vomiting, low-grade fever, myalgias/arthralgias, and abdominal (right upper quadrant) discomfort. o Physical examination may reveal hepatomegaly, lymphadenopathy, and sometimes splenomegaly. o Most patients with acute viral hepatitis recover completely with no complications. o Like acute hepatitis, those with chronic hepatitis may be asymptomatic. Others, however, may have intermittent or ongoing malaise, fatigue, myalgias, arthralgias, and hepatomegaly. o Complications of Hepatitis • Complications that can occur include acute liver failure, chronic hepatitis, cirrhosis of the liver, and hepatocellular carcinoma. o Acute viral hepatitis can result in severe impairment or necrosis of liver cells and potential liver failure. o Approximately 75% to 85% of patients who acquire HCV and many HBV infections will go on to develop chronic viral infection. o Diagnostic Tests • Diagnostic tests are used to distinguish among the various forms of viral hepatitis by evaluating for the presence of viral antigens and the subsequent development of antibodies to them. Interprofessional Care • There is no specific treatment or therapy for acute viral hepatitis. • Drug therapy for chronic HBV is focused on decreasing the viral load and decreasing the rate of disease progression. o Drugs to treat chronic HBV include nucleoside and nucleotide analogs: lamivudine (Epivir), adefovir (Hepsera), entecavir (Baraclude), telbivudine (Tyzeka), tenofivir (Viread), and ribavirin. Interferon is also used. • Drug therapy for chronic HCV cures HCV infection and prevents HCV complications. o Treatment for HCV includes orally administered direct-acting antivirals (DAAs) and/or ribavirin. o Use of injectable interferon is no longer considered a preferred first-line treatment for chronic HCV infection. • Hepatitis A vaccine and immunoglobulin (IG) are used for prevention of hepatitis A. • Immunization with HBV vaccine is the most effective method of preventing HBV infection. For postexposure prophylaxis, the vaccine and hepatitis B immune globulin (HBIG) are used. • Currently there is no vaccine to prevent HCV. • Most patients with viral hepatitis will be cared for at home, so you must assess the patient's knowledge of nutrition and provide the necessary dietary teaching. Alcoholic Liver Disease • Alcohol can cause a range of acute and chronic liver disease, ranging from mild elevation in serum liver enzymes to alcoholic cirrhosis with end-stage liver disease. • Patients with alcoholic hepatitis may have jaundice, ascites, hepatomegaly, variceal bleeding, and prolonged prothrombin time. Treatment includes cessation of alcohol intake and supportive measures. • Alcoholic cirrhosis is often undetected until the patient presents with symptoms of decompensated cirrhosis. Abstaining from alcohol is the mainstay of treatment, along with supportive measures to reduce risk of death from complications of liver disease. Some patients who abstain and enroll in alcohol cessation programs may be eligible for liver transplantation • Drug-Induced Liver Injury and Chemical Hepatoxicity • Liver injury and death may occur after the inhalation, parenteral injection, or ingestion of certain drugs and chemical substances. • The two major types are drug-induced liver injury (DILI) and chemical hepatotoxicity. • Treatment is generally supportive. AUTOIMMUNE/GENETIC/ METABOLIC LIVER DISEASES Autoimmune Hepatitis • Autoimmune hepatitis is a chronic inflammatory disorder of unknown cause. It is characterized by the presence of autoantibodies, high levels of serum immunoglobulins, and frequent association with other concomitant autoimmune diseases. • Autoimmune hepatitis is treated with corticosteroids or other immunosuppressive agents. Wilson's Disease • Wilson's disease is a progressive, familial, terminal neurologic disease accompanied by chronic liver disease leading to cirrhosis associated with increased storage of copper. • The hallmark of Wilson's disease is corneal Kayser-Fleischer rings on the cornea. • Treatment seeks to promote the urinary excretion of copper through the use of chelating agents such as D-penicillamine. Hemochromatosis • Hemochromatosis is a systemic disease caused by the inappropriate absorption of iron, leading to cirrhosis, diabetes, cardiovascular disease, and hepatocellular carcinoma. Primary Biliary Cirrhosis • Primary biliary cirrhosis (PBC) is a chronic inflammatory condition of bile ducts in the liver characterized by generalized pruritus and hepatomegaly. • The goals of PBC treatment are the suppression of ongoing liver damage, prevention of complications, and symptom management. Primary Sclerosing Cholangitis • Primary sclerosing cholangitis (PSC) is a disease of unknown etiology marked by chronic inflammation, fibrosis, and strictures (narrowing) of the medium and large-sized bile ducts. The majority of patients with PSC also have ulcerative colitis or Crohn's disease. • Drug therapy has not been beneficial. Treatment is directed at reducing incidence of biliary complications and screening for bile duct and colorectal cancers. Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis • Nonalcoholic fatty liver disease (NAFLD) is a group of disorders that is characterized by hepatic steatosis (accumulation of fat in the liver) that is not associated with other causes such as hepatitis, autoimmune disease, or alcohol. • Nonalcoholic steatohepatitis (NASH) refers to the inflammation and scarring that result from the accumulation of fat in the liver. • NAFLD can be a complication of metabolic syndrome, which includes obesity, diabetes, hyperlipidemia. • Most patients are asymptomatic and there is no definitive treatment. Patients should be monitored for the progression of NAFLD to liver cirrhosis. • There is no currently approved treatment for NAFLD. The goal of therapy is directed at reducing risk factors, which includes (1) reducing body weight, hyperlipidemia, and hyperlipidemia and (2) managing diabetes. CIRRHOSIS • Cirrhosis is a chronic progressive disease characterized by extensive degeneration and destruction of the liver parenchymal cells. • Any chronic (long-term) liver disease, most frequently excessive alcohol intake and viral hepatitis, can cause cirrhosis. Other causes include NAFLD, malnutrition, biliary obstruction, and right-sided heart failure. Clinical Manifestations and Complications • Manifestations of cirrhosis include jaundice, fatigue, hepatomegaly, skin lesions (spider angiomas), hematologic problems (thrombocytopenia, leucopenia, anemia, coagulation disorders), endocrine problems, and peripheral neuropathy. • Patients without complications of cirrhosis are said to have compensated cirrhosis; those who have more than one complication of their liver disease are described as having decompensated cirrhosis. • Major complications of cirrhosis include portal hypertension, esophageal and gastric varices, peripheral edema and ascites, hepatic encephalopathy, and hepatorenal syndrome. o Portal hypertension, a persistent increase in BP in the portal venous system, is characterized by increased venous pressure in the portal circulation, as well as splenomegaly, large collateral veins, ascites, and esophageal varices. o Bleeding esophageal varices, enlarged tortuous veins at the lower end of the esophagus, are the most life-threatening complication of cirrhosis. o Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity, and may be accompanied by lower extremity edema, dehydration, hypokalemia, and bacterial peritonitis. o Hepatic encephalopathy is considered a terminal complication in liver disease. A characteristic symptom of hepatic encephalopathy is asterixis (flapping tremors). o Hepatorenal syndrome is characterized by functional renal failure with advancing azotemia and oliguria. o Diagnostic Studies • Diagnostic test results in cirrhosis include elevations in liver enzymes, bilirubin, prothrombin time; decreased total protein and albumin; fat metabolism abnormalities; and positive liver biopsy for cirrhosis. • Fibroscan is a noninvasive test that can be used to identify the degree of liver fibrosis. Interprofessional Care • There is no specific therapy for cirrhosis. • Management of ascites is focused on sodium restriction, diuretics, and fluid removal. • The main therapeutic goal for esophageal and gastric varices is avoidance of bleeding and hemorrhage. o If the patient has esophageal and/or gastric varices, observe for any signs of bleeding from the varices (e.g., hematemesis, melena). o If bleeding occurs, the nurse must be prepared. The management of bleeding varices includes prophylactic, therapeutic, and emergency interventions. o A transjugular intrahepatic portosystemic shunt (TIPS) may be created to redirect portal blood flow. o Patients are monitored for spontaneous bacterial peritonitis (SBP), which can occur after variceal hemorrhage. • Management of hepatic encephalopathy is focused on reducing of ammonia formation and treating precipitating causes. The focus of nursing care of the patient with hepatic encephalopathy is on maintaining a safe environment, sustaining life, and assisting with measures to reduce the formation of ammonia. • The diet for the patient with cirrhosis without complications is high in calories (3000 cal/day) with high carbohydrate content and moderate to low fat levels. Sodium restrictions are placed on the patient with ascites and peripheral edema. • An important nursing focus is the prevention and early treatment of complications from cirrhosis. ACUTE LIVER FAILURE • Acute liver failure (fulminant hepatic failure) is a clinical syndrome characterized by severe impairment of liver function associated with hepatic encephalopathy. • The most common cause is drugs, usually acetaminophen in combination with alcohol. • Manifestations include jaundice, coagulation abnormalities, and encephalopathy. • Liver transplantation is the curative treatment. LIVER CANCER (HEPATOCELLULAR CARCINOMA) • Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. • The manifestations are similar to cirrhosis, making it difficult to diagnose in its early stage. • Prevention of liver cancer is focused on identification and treatment of chronic viral hepatitis (B and C). Treatment of chronic alcohol ingestion may also lower the risk of liver cancer. • Treatment of liver cancer depends on the stage of the cancer: size, location, and number of tumors; invasion of blood vessel; and presence of spread beyond the liver. It also depends on liver function and overall age and health of the patient. LIVER TRANSPLANTATION • Indications for liver transplant include chronic viral hepatitis B and C, alcoholic liver disease, congenital biliary abnormalities (biliary atresia), inborn errors of metabolism, HCC (confined to the liver), NAFLD, and acute hepatic failure. • Postoperative complications of liver transplant include bleeding, rejection, and infection. • The patient who has had a liver transplant requires highly skilled nursing care. DISORDERS OF PANCREAS Acute Pancreatitis • Acute pancreatitis is an acute inflammatory process of the pancreas. The primary etiologic factors are biliary tract disease (most common cause in women) and alcoholism (most common cause in men). It is also associated with hypertriglyceridemia. Smoking is an independent risk factor. • The pathophysiologic involvement of acute pancreatitis is classified as either mild pancreatitis (edematous or interstitial) or severe pancreatitis (necrotizing pancreatitis). • Abdominal pain usually located in the left upper quadrant is the predominant symptom of acute pancreatitis. Other manifestations include nausea, vomiting, low-grade fever, elevated WBC count, hypotension, tachycardia, and jaundice. • Two significant local complications of acute pancreatitis are pseudocyst and abscess. A pancreatic pseudocyst is a collection of pancreatic fluid continuous with or surrounding the outside of the pancreas. An abscess is a collection of infected fluid with pus that sometimes develops from a pancreatic pseudocyst often as a result of pancreatitis. • The primary diagnostic tests for acute pancreatitis are serum amylase and lipase. Additional studies are used to determine the cause. • Objectives of interprofessional care for acute pancreatitis include relief of pain; prevention or alleviation of shock; reduction of pancreatic secretions; control of fluid and electrolyte imbalances; prevention or treatment of infections; and removal of the precipitating cause. • Treatment is focused principally on supportive care, including aggressive hydration, pain management, management of metabolic complications, and minimization of pancreatic stimulation. • Nursing management of the patient with pancreatitis focuses on the nursing diagnoses of acute pain, fluid volume deficit, imbalanced nutrition, and ineffective self-health management. Chronic Pancreatitis • Chronic pancreatitis is a continuous, prolonged, inflammatory, and fibrosing process of the pancreas. The pancreas becomes progressively destroyed as it is replaced with fibrotic tissue. Strictures and calcifications may also occur. • Clinical manifestations of chronic pancreatitis include abdominal pain; symptoms of pancreatic insufficiency, including malabsorption with weight loss; constipation; mild jaundice with dark urine; steatorrhea; and diabetes mellitus. • When the patient with chronic pancreatitis is experiencing an acute attack, the therapy is identical to that for acute pancreatitis. • Except during an acute episode, the focus of nursing management is on palliative care and health promotion. Measures used to control the pancreatic insufficiency include diet, pancreatic enzyme replacement, and management of diabetes. Pancreatic Cancer • The majority of pancreatic cancers have metastasized at the time of diagnosis. The signs and symptoms of pancreatic cancer are often similar to those of chronic pancreatitis. • CT scan is the most commonly used diagnostic imaging techniques for pancreatic diseases, including cancer. • Surgery provides the most effective treatment of cancer of the pancreas; however, only 15% to 20% of patients have resectable tumors. Medical treatment for pancreatic cancer includes radiation therapy and chemotherapy and may be used before or after surgery for better outcome. • Because the patient with pancreatic cancer has many of the same problems as the patient with pancreatitis, nursing care includes many of the same measures. Provide symptomatic and supportive nursing care, including ensuring adequate nutrition and the administration of medications and palliative measures to relieve pain. Psychologic support is essential, especially during times of anxiety or depression. DISORDERS OF BILIARY TRACT Cholelithiasis and Cholecystitis • The most common disorder of the biliary system is cholelithiasis, or stones in the gallbladder. Cholecystitis, an inflammation of the gallbladder, is usually associated with cholelithiasis or biliary sludge (a mixture of cholesterol crystals and calcium salts). • Cholelithiasis develops when the balance that keeps cholesterol, bile salts, and calcium in solution is altered and precipitation of gallstones occurs. • Manifestations of cholecystitis vary from indigestion to moderate to severe pain, fever, and jaundice. Initial symptoms of acute cholecystitis include indigestion and pain and tenderness in the right upper quadrant. • Cholelithiasis may produce severe symptoms or none at all, depending on whether the stones are stationary in the gallbladder or traveling down the bile ducts and getting stuck in route. • Complications of cholelithiasis and cholecystitis include gangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis (inflammation of biliary ducts), biliary cirrhosis, fistulas, and rupture of the gallbladder, which can produce bile peritonitis. • During an acute episode of cholecystitis, treatment is mainly supportive and symptomatic, focusing on control of pain, control of possible infection with antibiotics, and maintenance of fluid and electrolyte balance. • Ultrasonography is commonly used to diagnose gallstones. • Treatment of gallstones depends on the patient and stage of disease. Laparoscopic cholecystectomy is the treatment of choice for symptomatic cholelithiasis. Medical dissolution therapy is recommended for patients with small radiolucent stones who are mildly symptomatic and are poor surgical candidates. • Postoperative nursing care following a laparoscopic cholecystectomy includes monitoring for complications such as bleeding, making the patient comfortable, and preparing the patient for discharge. • The nurse should assume responsibility for recognition of predisposing factors of gallbladder disease in general health screening. Gallbladder Cancer • Primary gallbladder cancer is rare. Its symptoms mimic cholecystitis and cholelithiasis. • Overall, prognosis is poor since disease is usually advanced at the time of diagnosis. Nursing management, therefore, involves palliative care with attention to nutrition, skin care, pain relief, and psychosocial concerns.

Peritoneal DialysisSystems

Cycler delivers the dialysate Times and controls fill, dwell, and drain phases Continuous ambulatory peritoneal dialysis (CAPD) Manual exchange during the day APD most popular = allows patients to accomplish dialysis while they sleep. The size of a cycler is similar to a DVD player. The automated cycler times and controls the fill, dwell, and drain phases. The machine cycles four or more exchanges per night with 1 to 2 hours per exchange. It is difficult to achieve the required solute and fluid clearance solely with nighttime APD. One or two daytime manual exchanges also be prescribed to ensure adequate dialysis. CAPD: Exchanges are carried out manually with 2 to 3 L of peritoneal dialysate four times daily, with dwell times averaging 4 hours. A common schedule includes exchanges at 7:00 AM, 12:00 noon, 5:00 PM, and 10:00 PM.

Leading causes CKD

Diabetes- 50% Hypertension- 25% Individuals with CKD are frequently asymptomatic Results in CKD being underdiagnosed and untreated Although CKD has many different causes, the leading causes are diabetes (about 50%) and hypertension (about 25%). Less common etiologies include glomerulonephritis, cystic diseases, and urologic diseases. Because the kidneys are highly adaptive, kidney disease is often not recognized until there has been considerable loss of nephrons.

Delirium Diagnostic Studies

Diagnosis complicated by inability to communicate Medical history Psychologic history Physical examination Careful attention to medications Cognitive measures Confusion Assessment Method (CAM)

Other interventions MS

Dorsal column electrical stimulation Intrathecal baclofen pump Spasticity is primarily treated with muscle relaxants. surgery (e.g., neurectomy, rhizotomy, cordotomy), dorsal-column electrical stimulation, or intrathecal baclofen (Lioresal) delivered by pump may be required. Tremors that become unmanageable with drugs are sometimes treated by thalamotomy or deep brain stimulation.

DiabetesNutritional Therapy

Counseling Education Ongoing monitoring Interprofessional team Registered dietitian with expertise in diabetes management Individualized nutritional therapy, consisting of counseling, education, and ongoing monitoring, is a cornerstone of care for person with diabetes and prediabetes. Changing eating habits can be challenging for many people. Achieving nutrition goals requires a coordinated team effort that takes into account the behavioral, cognitive, socioeconomic, cultural, and religious aspects of the patient. Because of these complexities, it is recommended that a registered dietitian with expertise in diabetes management work with the person who has diabetes. The dietitian starts with a nutrition assessment and develops an individualized food plan. Additional team members may include nurses, certified diabetes educators, clinical nurse specialists, HCPs, and social workers.

Inflammatory Bowel Disease Pattern of Inflammation

Crohn's disease = mouth to the anus, but most commonly involves the distal ileum and proximal colon. Segments of normal bowel can occur between diseased portions, so-called "skip" lesions. Ulcerative colitis = starts in the rectum = continual fashion toward the cecum = disease of the colon and rectum. Inflammation patterns differ between Crohn's disease and ulcerative colitis The inflammation in Crohn's disease involves all layers of the bowel wall = deep and longitudinal and penetrate = inflamed edematous mucosa, causing the classic cobblestone appearance. Strictures = bowel obstruction = microscopic leaks can allow bowel contents to enter the peritoneal cavity - In active Crohn's disease, fistulas are common. Because water and electrolytes are not absorbed through inflamed mucosa, diarrhea with large fluid and electrolyte losses is common. Areas of inflamed mucosa form pseudopolyps = tongue-like projections into the bowel lumen.

Culturally Competent Care

Culture can have a strong influence on dietary preferences and meal preparation High incidence of diabetes Hispanics Native Americans African Americans Asians and Pacific Islanders Because culture can have a strong influence on dietary preferences and meal preparation practices, culturally competent care has special relevance for the patient with diabetes. For example, certain ethnic and cultural groups, such as Hispanics, Native Americans, African Americans, and Asians and Pacific Islanders have a high incidence of diabetes. The increased prevalence can be attributed to genetic predisposition, environmental factors, and dietary choices. Explore the influences of culture on food choices and meal planning with the patient as part of the health history. When giving diet instructions, consider the patient's cultural food preferences. Nutrition resources specifically designed for members of different cultural groups are available from the ADA.

Lewy bodies - PD

Lewy bodies Unusual clumps of protein Found in brains of patients with PD Unknown cause Presence indicates abnormal brain functioning Lewy body dementia

Chronic Kidney Disease KEY POINTS

Lewis: Medical-Surgical Nursing, 10th Edition Chapter 46 Chronic Kidney Disease KEY POINTS CHRONIC KIDNEY DISEASE • Chronic kidney disease (CKD) involves progressive, irreversible loss of kidney function. • CKD usually develops slowly over months to years. • The prognosis of CKD is variable depending on the etiology, patient's condition and age, and adequacy of follow-up. • An elevation in serum creatinine is demonstrated only after over 50% of functioning kidney function (nephron mass) has been lost. • Uremia is a syndrome that incorporates all the signs and symptoms seen in the various systems throughout the body in CKD. • ♣ Fatigue, lethargy, and pruritus are symptoms associated with progression of kidney dysfunction. Hypertension is both a cause and a consequence of CKD. • ♣ Hyperglycemia, hyperinsulinemia, and dyslipidemia may be seen. • ♣ Metabolic alterations, including hyperkalemia, hyponatremia, and metabolic acidosis, tend to occur in the later stages of CKD. • ♣ Normocytic anemia is due to decreased production of endogenous erythropoietin. • The most common cause of death in patients with CKD is cardiovascular disease, including ischemic heart disease, heart failure, and cardiac dysrhythmias. • Other complications include infections, neurologic changes, peripheral neuropathy, CKD-mineral and bone disease, pruritus, infertility, personality and behavioral changes, lethargy, and depression. • The primary goal of care in CKD is directed at reducing the risk of cardiovascular disease and premature death. • Secondary goals of CKD therapy are to deter the progression of kidney dysfunction, recognize and treat the associated complications, and provide for the patient's comfort. • ♣ Medical management is started in an effort to postpone the need for maintenance dialysis. • ♣ In certain situations, CKD progression can be delayed by using drug therapy to reduce the damaging effects of proteinuria and hypertension. • ♣ Erythropoietin and iron replacement are used for the treatment of anemia. • ♣ Statins (HMG-CoA reductase inhibitors) are the most effective drugs for lowering low-density lipoprotein (LDL) cholesterol levels. • ♣ Prior to dialysis, dietary protein may be restricted to slow the progression of kidney dysfunction. Once the patient starts dialysis, protein intake is usually increased. • ♣ Fluid intake depends on the daily urine output. NURSING MANAGEMENT: CHRONIC KIDNEY DISEASE • The overall goals are that a patient with CKD will demonstrate the knowledge and ability to participate in treatment decisions and good self-care practices. A goal is to have active participation in determining their own treatment plans to the highest degree that is achievable. • Most persons with CKD are cared for in an ambulatory care setting. Hospital care is required for the management of complications. • Nursing care for the patient revolves around the nursing diagnoses of excess fluid volume, risk for injury, imbalanced nutrition, and grieving. DIALYSIS • Dialysis is a therapeutic intervention in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate). Dialysis solutions have an electrolyte composition similar to that of plasma. • The two methods of dialysis are peritoneal dialysis (PD) and hemodialysis (HD). PERITONEAL DIALYSIS • Two types of PD are automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). • PD is indicated (as a patient preference) when there are vascular access problems or when a patient is intolerant of HD. • The three phases of the PD cycle (called an exchange) are inflow (fill), dwell (equilibration), and drain (outflow). • The patient dialyzing at home will be given a daily prescription of exchanges that is specific for the individual patient. • The most common complications associated with PD are infection of the peritoneal catheter exit site, peritonitis, and pain. Additional complications include hernias, lower back pain, protein loss, bleeding, atelectasis, pneumonia, and bronchitis. • Learning the self-management skills required to do PD at home usually requires a 3- to 7-day training program. HEMODIALYSIS • The types of vascular access include arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs), and temporary catheters. • ♣ AVFs are created most commonly in the forearm with an anastomosis between an artery (usually radial or ulnar) and a vein (usually cephalic). Native fistulas have the best overall patency rates and least number of complications. • ♣ AVGs are made of synthetic materials and form a "bridge" between the arterial and venous blood supplies. Grafts are placed under the skin and are surgically anastomosed between an artery (usually brachial) and a vein (usually antecubital). • The majority of HD patients are treated in community-based dialysis facilities and routinely dialyze for 3 to 4 hours 3 days each week. Prior to each dialysis, nurses complete an assessment that includes evaluation of a patient's fluid status (weight, BP, peripheral edema, lung and heart sounds), condition of vascular access, and temperature. • Complications associated with HD include hypotension, muscle cramps, and blood loss. • Individual adaptation to maintenance HD varies considerably. The primary nursing goals are to help the patient regain or maintain a positive self-image and achieve the highest degree of independent functional capacity possible. CONTINUOUS RENAL REPLACEMENT THERAPY • Continuous renal replacement therapy (CRRT) is an alternative or adjunctive treatment for a hemodynamically unstable patient. • Uremic toxins and fluids are removed, while acid-base status and electrolytes are adjusted slowly and continuously. Vascular access is achieved through the use of a double-lumen catheter placed in the femoral, jugular, or subclavian vein. Anticoagulation is used to prevent blood clotting during CRRT. KIDNEY TRANSPLANTATION • Kidneys are the most frequently transplanted organs. • One-year graft survival rates for kidney transplantation are 90% for deceased (cadaveric) donor transplants and 95% for live donor transplants. At present, the wait time for a deceased kidney transplant is 2 to 5 years or more. • Kidney transplantation for treatment of chronic kidney disease offers the greatest chance for long-term survival and quality of life. • Contraindications to transplantation include disseminated malignancies, refractory or untreated cardiac disease, chronic respiratory failure, extensive vascular disease, chronic infection, and unresolved psychosocial disorders. • Kidneys for transplantation may be obtained from compatible-blood-type deceased donors, blood relatives, emotionally related living donors, and altruistic living donors. • Live donors must undergo an extensive evaluation to be certain that they are in good health and have no history of disease that would place them at risk for developing kidney failure or operative complications. • ♣ In a live donor transplant, the donor nephrectomy is performed either through an open (conventional) incision or laparoscopically. • ♣ The usual postoperative care for the living donor is similar to that following open or laparoscopic nephrectomy. • Deceased kidney donors are relatively healthy individuals who have suffered an irreversible brain injury. Permission from the donor's legal next of kin is required after brain death is determined even if the donor carried a signed donor card. • The transplanted kidney is usually placed extraperitoneally in the right iliac fossa to facilitate anastomoses and minimize complications. NURSING MANAGEMENT: KIDNEY TRANSPLANT RECIPIENT • Nursing care of the patient in the preoperative phase includes emotional and physical preparation for surgery. • For the kidney transplant recipient, the first priority during this period is maintenance of fluid and electrolyte balance. Very large volumes of urine may occur in the immediate postoperative period, resulting in volume depletion, hypokalemia, and metabolic acidosis. • Postoperative teaching should include the prevention and treatment of rejection, infection, and complications of surgery and the purpose and side effects of immunosuppression. • Rejection, a major problem following kidney transplantation, can be hyperacute, acute, or chronic. Immunosuppressive therapy is used to prevent rejection while maintaining sufficient immunity to prevent overwhelming infection. • Infection is a significant cause of morbidity and mortality after kidney transplantation. Transplant recipients usually receive prophylactic antifungal drugs. Viral infections, including CMV, are common. • Cardiovascular disease is the leading cause of death following kidney transplant. Hypertension, dyslipidemia, diabetes mellitus, smoking, immunosuppressive medications, rejection, and infections can all contribute to the development of cardiovascular disease. • The overall incidence of malignancies in kidney transplant recipients is higher than in the general population. The primary cause is the immunosuppressive therapy. GERONTOLOGIC CONSIDERATIONS: CHRONIC KIDNEY DISEASE • Approximately 35% to 65% of patients who have CKD are 65 or older. Physiologic changes in the older CKD patient include diminished cardiopulmonary function, bone loss, immunodeficiency, altered protein synthesis, impaired cognition, and altered drug metabolism. • Most older end-stage renal disease (ESRD) patients select hemodialysis as their choice for renal replacement therapy. Challenges in establishing vascular access for HD may occur because of atherosclerotic changes. • The most common cause of death in the older ESRD patient is cardiovascular disease (MI, stroke), followed by withdrawal from dialysis.

Planning for MS

Maximize neuromuscular function Maintain independence in activities of daily living for as long as possible Manage disabling fatigue Optimize psychosocial well-being Adjust to the illness ↓ Factors that precipitate exacerbations

Hiatal HerniaClinical Manifestations

May be asymptomatic Heartburn After meal or when lying supine Dysphagia s/s like GERD. Bending over may cause a severe burning pain, which is usually relieved by sitting or standing. pain form include large meals, alcohol, and smoking.

Diffusion

Movement of solutes from an area of greater concentration to an area of lesser concentration In kidney failure, urea, creatinine, uric acid, and electrolytes (potassium, phosphate) move from the blood to the dialysate with the net effect of lowering their concentration in the blood. RBCs, WBCs, and plasma proteins are too large to diffuse through the pores of the membrane.

Chronic ComplicationsDiabetic Nephropathy

Damage to small blood vessels that supply the glomeruli of the kidney Leading cause of end-stage renal disease Risk factors Hypertension Genetics Smoking Chronic hyperglycemia Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. It is the leading cause of end-stage kidney disease in the United States and is seen in 20% to 40% of people with diabetes. Results of the DCCT and UKPDS research have demonstrated that kidney disease can be significantly reduced when near-normal blood glucose levels are maintained. Annual screening If albuminuria present, drugs to delay progression: ACE inhibitors Angiotensin II receptor antagonists Patients with diabetes are screened for nephropathy annually for albuminuria and a measurement of the albumin-to-creatinine ratio in a random spot urine collection. Serum creatinine is also measured. Serum creatinine measurements provide an estimation of the glomerular filtration rate and thus the degree of kidney function. Patients with diabetes who have albuminuria receive either angiotensin-converting enzyme (ACE) inhibitor drugs (e.g., lisinopril [Prinivil, Zestril]) or angiotensin II receptor antagonists (e.g., losartan [Cozaar]). Both classifications of these drugs are used to treat hypertension and have been found to delay the progression of nephropathy in patients with diabetes. Hypertension will significantly accelerate the progression of nephropathy. Therefore, aggressive blood pressure management is indicated for all patients with diabetes. Keeping blood glucose levels in a healthy range is also critical for the prevention and delay of diabetes-related nephropathy.

When total obstruction occurs Cholecystitis :

Dark amber urine Clay-colored stools Pruritis Intolerance to fatty foods Bleeding tendencies Steatorrhea When total obstruction occurs, symptoms related to bile blockage are manifested (Table 43-21) If the common bile duct is obstructed, no bilirubin will reach the small intestine to be converted to urobilinogen. Thus bilirubin will be excreted by the kidneys instead, causing dark amber to brown urine.

Lack of dopamine (DA) - PD

Degeneration of dopamine-producing neurons in substantia nigra of midbrain Disrupts dopamine-acetylcholine balance in basal ganglia Essential for normal functioning of extrapyramidal motor system The pathologic process of PD involves degeneration of the DA-producing neurons in the substantia nigra of the midbrain = turn disrupts the normal balance between DA and acetylcholine (ACh) in the basal ganglia. DA = extrapyramidal motor system = posture, support, and voluntary motion. Manifestations of PD do not occur until 80% of neurons in the substantia nigra are lost.

Neurodegenerative Diseases

Dementia with Lewy bodies (DLB) Characterized by presence of Lewy bodies in brainstem and cortex Intraneural cytoplasmic inclusions Since it has some features of Parkinson's disease, medication therapy may assist with symptoms. Frontotemporal lobar degeneration (FTLD) Rare Caused by shrinking frontal and temporal lobes of the brain Care is supportive characterized by disturbances in behavior, sleep, personality, and eventually memory.

Delirium s/s

Dementia, dehydrationElectrolyte imbalance, emotional stressLung, liver, heart, kidney, brainInfection, ICURx drugsInjury, immobilityUntreated pain, unfamiliar enviroMetabolic disorders Can happen in hours or days

Nonmotor symptoms - PD

Depression and anxiety Apathy Fatigue Pain Urinary retention and constipation Erectile dysfunction Memory changes In addition to the motor signs of PD, many nonmotor symptoms are common. They include depression, anxiety, apathy, fatigue, pain, urinary retention and constipation, erectile dysfunction, and memory changes.

Nutritional Therapy CKI

Designed to maintain good nutrition Monitor laboratory parameters Protein intake Normal for HD patient Increased for PD patient Fluid restriction Intake depends on daily urine output. For the patient who is undergoing dialysis, protein is not routinely restricted. For CKD stages 1 through 4, many HCPs encourage a diet with normal protein intake. avoid high-protein diets Generally, 600 mL (from insensible loss) plus an amount equal to the previous day's urine output is allowed for a patient receiving HD. Sodium restriction Diets vary from 2 to 4 g/day Salt substitutes should be avoided because they contain potassium chloride Salt substitutes should be avoided in potassium-restricted diets because they contain potassium chloride. Potassium restriction Limit: 2 to 3 g High-potassium foods should be avoided - oranges, bananas, melons, tomatoes, prunes, raisins, deep green and yellow vegetables, beans, and legumes. Phosphate restriction in ESRD Limit: 1 g/day Foods high in phosphate Meat Dairy products Most foods high in phosphate are also high in protein Phosphate binders essential meat, dairy products foods containing dairy products (e.g., pudding). Since patients on dialysis are encouraged to eat a diet containing protein, phosphate binders are essential to control the phosphate level.

Health Risks of Obesity

Obesity is a significant risk factor for cardiovascular disease and hypertension in both men and women. As many as 80% of patients with type 2 diabetes are obese. Obesity can lead to a number of medical problems, including osteoarthritis, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, nonalcoholic steatohepatitis, and cancer. Obesity in older adults can exacerbate age-related declines in physical function and lead to frailty and disability.

DementiaDiagnostic Studies

Diagnosis is focused on determining the cause Thorough medical, neurologic, psychologic history, and mental status testing Rule out other conditions Neuroimaging techniques The diagnosis of dementia is focused on determining the cause (e.g., reversible versus nonreversible factors). Screening for cobalamin (vitamin B12) deficiency and hypothyroidism is often performed. Based on patient history, testing for neurosyphilis may be performed. Neuroimaging techniques (CT or MRI) may be used to rule out or confirm causes of dementia. (Diagnostic studies for Alzheimer's disease are discussed later.)

Alzheimer's DiseaseAcute Care

Diagnosis is very traumatic Patient often responds with Depression Denial Anxiety and fear Withdrawal Feelings of loss Hospitalization can precipitate Worsening of dementia Development of delirium

Inflammatory Bowel Disease Clinical Manifestations

Diarrhea - bloody sometimes Weight loss Abdominal pain Fever Fatigue rectal bleeding In moderate disease, the patient has increased stool output (up to 10 stools/day), increased In severe disease, diarrhea is bloody, contains mucus, and occurs 10 to 20 times a day. fever, rapid weight loss greater than 10% of total body weight, anemia, tachycardia, dehydration are present.

Interprofessional CareNutritional Therapy ibs

Dietary consultant Goals of diet management Provide adequate nutrition without exacerbating symptoms Correct and prevent malnutrition Replace fluid and electrolyte losses Prevent weight loss An individualized diet is an important component in the treatment of IBD. It is essential that people with IBD eat a balanced, healthy diet with sufficient calories, protein, and nutrients. Consult a dietitian regarding dietary recommendations. Nutritional deficiencies are due to Decreased oral intake Blood loss Malabsorption of nutrients Depends on location of inflammation Patients with diarrhea often decrease their oral intake to reduce diarrhea. Inflammatory mediators reduce appetite. Bloody diarrhea leads to iron-deficiency anemia, which may need treatment with supplemental iron (ferrous sulfate or ferrous gluconate). Parenteral or IV iron may be needed for patients who cannot tolerate oral iron or if anemia is severe. Disease of the terminal ileum reduces absorption of cobalamin and bile acids. Reduced cobalamin contributes to anemia, and bile salts are important for fat absorption and contribute to osmotic diarrhea. Those who develop anemia should receive cobalamin injections. Medications can contribute to nutritional problems Sulfasalazine Daily folic acid supplements Corticosteroids Calcium supplements to prevent osteoporosis Potassium supplements Vitamin D deficiency is common Cholestyramine, an ion-exchange resin that binds unabsorbed bile salts, helps control diarrhea. Zinc deficiency can result from severe or chronic diarrhea, and supplementation may be necessary. Medications can contribute to nutritional problems. Patients receiving sulfasalazine should receive folate (folic acid) daily. Those receiving corticosteroids are prone to osteoporosis and need calcium supplements. Potassium supplements may be necessary with corticosteroids. Vitamin D deficiency requiring supplementation is common. This may be due to malabsorption due to inflammation, surgical resection of intestine, reduced sunlight exposure, and decreased dietary intake.

Nursing Implementation ambulatory care hep

Dietary teaching Plan activities after periods of rest Teach how to prevent transmission What to report Assessment for complications Most patients with viral hepatitis are cared for at home. Assess the patient's knowledge of nutrition and provide the necessary dietary teaching. Caution the patient about overexertion and the need to follow the HCP's advice about when to return to work. For patients who suffer from fatigue, tell them to plan activities after periods of rest when energy levels are highest. Teach the patient and caregiver how to prevent transmission to other family members. Also teach what symptoms should be reported to the HCP. Assess the patient for any manifestations of complications. These include bleeding tendencies with increasing prothrombin time values, manifestations of encephalopathy, sudden increase in weight and abdominal girth (may indicate fluid retention and/or ascites), bloody or tarry stools, vomiting of blood, or elevated liver enzymes. Regular follow-ups for at least 1 year after diagnosis No alcohol Medication education How to administer interferon Side effects No blood donation by HBsAg- or HCV-positive patients Instruct the patient to have regular follow-ups for at least 1 year after the diagnosis of hepatitis. Because relapses occur with hepatitis B and C, teach the patient the symptoms of recurrence and the need for follow-up evaluations. All patients with chronic HBV or HCV should avoid alcohol, as it can accelerate disease progression. The patient who is receiving interferon for the treatment of HBV or HCV requires education regarding this drug. Because interferon is administered subcutaneously, the patient or caregiver needs to be taught how to administer the drug. The numerous side effects with the therapy, including flu-like symptoms (e.g., fever, malaise, fatigue), make adherence to therapy challenging for some patients. It should also be noted that patients who are positive for HBsAg (chronic carrier status) or HCV antibody cannot be blood donors.

Nursing Management:Nursing Implementatio Ambulatory Care Cholecystitis

Dietary teaching is usually necessary. take fat-soluble vitamin supplements. Provide instructions regarding observations that the patient should make that indicate obstruction (e.g., stool and urine changes, jaundice, pruritus). Laparoscopic cholecystectomy Remove bandages day after surgery and then can shower Report signs of infection Gradually resume activities Return to work in 1 week May need low-fat diet for several weeks Open-incision cholecystectomy No heavy lifting for 4-6 weeks Usual sexual activities, including intercourse, can be resumed as soon as the patient feels ready unless given other instructions by the HCP.

DiabetesDiet teaching

Dietitian initially provides instruction Carbohydrate counting Serving size is 15 g of CHO Typically 45 to 60 g per meal Insulin dose based on number of CHOs consumed Patient teaching essential Most often the dietitian initially teaches the principles of nutrition management. Whenever possible, be prepared to work with dietitians as part of an interprofessional diabetes care team. In some instances, access to a dietitian is not possible for patients with limited insurance coverage or who live in remote areas. In these cases, you may need to assume responsibility for teaching basic nutrition principles to patients with diabetes. Carbohydrate counting is a meal planning technique that people with diabetes use to keep track of the amount of carbohydrates they eat with each meal and per day. Advise patients to keep carbohydrates within a healthy range. The amount of total carbohydrates per day depends on blood glucose levels, age, weight, activity level, patient preference, and prescribed medications. A serving size of carbohydrates is 15 g. A typical adult usually starts with 45 to 60 g of carbohydrate per meal. For some patients, insulin doses are tailored to the number of carbohydrates a patient will consume at the meal, with a set number of units insulin given per every 15 g of carbohydrate (or sometimes another number). Teach the patient about the foods that contain carbohydrates, how to read food labels, and appropriate serving sizes.

Sleep problems are common - PD

Difficulty staying asleep Restless sleep Nightmares Drowsiness during the day REM behavior disorder Violent dreams Potentially dangerous motor activity during REM sleep Sleep problems are common and include difficulty staying asleep at night, restless sleep, nightmares, and drowsiness or sudden sleep onset during the day. In particular, rapid eye movement (REM) behavior disorder is a preparkinsonian state that occurs in about one-third of patients with PD. It is characterized by violent dreams and potentially dangerous motor activity during REM sleep.

Cognitive manifestations MS

Difficulty with Short-term memory attention Attention Information processing Planning Visual perception Word finding General intellect, including long-term memory, conversational skills, and reading comprehension, remains unchanged and intact. cognitive difficulties occur later in the course of the disease.

Dilation and Sent esoph CA

Dilation Increases lumen of esophagus Relieves dysphagia Allows for improved nutrition Stent Allow food and liquid to pass through stenotic area Endoscopic laser therapy may be used in combination with dilation. Laser therapy can be repeated if obstruction recurs as the tumor grows. Sometimes these procedures are combined with radiation therapy. Stents allow food and liquid to pass through the stenotic area of the esophagus. Self-expandable metal stents are available with features to prevent stent migration and tumor ingrowth. Stents may be placed before surgery to improve the patient's nutritional status.

Chronic ComplicationsMacrovascular Angiopathy

Diseases of large and medium-sized blood vessels Greater frequency and earlier onset in patients with diabetes Cerebrovascular disease Cardiovascular disease Peripheral vascular disease Macrovascular complications are diseases of the large and medium-size blood vessels that occur with greater frequency and with an earlier onset in people with diabetes. Macrovascular diseases include cerebrovascular, cardiovascular, and peripheral vascular disease. Decrease risk factors (yearly screening) Obesity Smoking Hypertension High fat intake Sedentary lifestyle Screen for and treat hyperlipidemia Treating hypertension in those with diabetes results in a decrease in macrovascular and microvascular complications. Hypertension causes an increase in mortality rate among people with diabetes in comparison with those with hypertension without diabetes. A target BP of less than 140/90 mm Hg is recommended for all patients with diabetes. Patients with diabetes have an increase in lipid abnormalities. This contributes to the increase in cardiovascular disease seen in this population. The American Diabetes Association recommends the LDL cholesterol goal of less than 100 mg/dL (2.6 mmol/L), triglyceride levels of less than 150 mg/dL (1.7 mmol/L), and HDL cholesterol levels greater than 40 mg/dL (1.0 mmol/L) in men and greater than 50 mg/dL (1.3 mmol/L) in women as target values. over age 40 years = statin treatment + lifestyle therapy. under 40 years + type 1 diabetes = statin

Storage of insulin

Do not heat/freeze In-use vials may be left at room temperature up to 4 weeks Extra insulin should be refrigerated Avoid exposure to direct sunlight, extreme heat or cold Store prefilled syringes upright for 1 week if 2 insulin types; 30 days for one As a protein, insulin requires special storage considerations. Heat and freezing alter the insulin molecule and can make it less effective. Insulin vials and insulin pens currently in use may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86º F (30º C) or below freezing (less than 32º F [0º C]). Store unopened insulin vials and insulin pens in the refrigerator. Prolonged exposure to direct sunlight should be avoided. A patient who is traveling in hot climates may store insulin in a thermos or cooler to keep it cool (not frozen). Patients who are traveling or caregivers of patients who are sight impaired or who lack the manual dexterity to fill their own syringes may prefill insulin syringes. Prefilled syringes containing two different insulins are stable for up to 1 week when stored in the refrigerator; syringes containing only one type of insulin are stable up to 30 days. Teach patients to store syringes in a vertical position with the needle pointed up to avoid clumping of suspended insulin in the needle. Before injection, gently roll prefilled syringes between the palms 10 to 20 times to warm the insulin and resuspend the particles. Some insulin combinations are not appropriate for prefilling and storage because the mixture can alter the onset, action, and/or peak times of either of the types. Consult a pharmacy reference as needed when mixing and prefilling different types of insulin.

Drug Therapy IBS

Drug therapy is individualized Antispasmodic medications decrease GI motility and smooth muscle spasms Reduces pain and diarrhea Hyoscamine (Cystospaz) Dicyclomine (Bentyl) Alosetron (Lotronex) Severe pain and diarrhea in women Serious side effects Severe constipation Ischemic colitis (reduced blood flow to intestines) Alosetron (Lotronex) Available only in a restricted access program for those who have not responded to other IBS therapies because of its serious side effects Alosetron (Lotronex) Drug Alert Teach patient to discontinue the drug and contact HCP for any constipation, rectal bleeding, bloody diarrhea, or abdominal pain Patients may experience severe constipation and ischemic colitis (reduced blood flow to intestines). If constipation occurs, drug should be discontinued. Symptoms of ischemic colitis include abdominal pain and blood in stool. Loperamide (Imodium) Used to treat incidences of diarrhea Synthetic opioid Decreases intestinal transit Lubiprostone (Amitiza) Approved for treatment of women with IBS-related constipation Linaclotide (Linzess) Approved for treatment of men and women with IBS-related constipation Contraindicated in patients with history of mechanical obstruction or prior bowel surgery Selective chloride channel activator Increases intestinal fluid secretion and motility Action: usually within 24 hours Used in the treatment of idiopathic constipation and irritable bowel syndrome with constipation (women only) Contraindicated in patients with history of mechanical GI obstruction Antidepressants Low doses of tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) seem to provide benefit Possibly work by decreasing peripheral nerve sensitivity

Complications CKI

Drug toxicity Digoxin Diabetic agents Antibiotics Opioid medications CKD causes decreased elimination that leads to an accumulation of drugs and the potential for drug toxicity. Drug doses and frequency of administration are adjusted based on the severity of the kidney disease. Increased sensitivity may result as drug levels increase in the blood and tissues. Drugs of particular concern include digoxin, diabetic agents (metformin, glyburide), antibiotics (e.g., vancomycin, gentamicin), and opioid medications.

Alzheimer's DiseaseDrug Therapy

Drugs available today help many people but not for very long and not very well Some modest ↓ in rate of decline of cognitive function No effect on overall disease progression Although drug therapy for AD is available (Table 59-11), these drugs do not cure or reverse the progression of the disease. The use of drugs may lead to a modest decrease in the rate of decline of cognitive function. However, the drugs have no effect on overall disease progression. A, Acetylcholine is released from the nerve synapses and carries a message across the synapse. B, Cholinesterase breaks down acetylcholine. C, Cholinesterase inhibitors block cholinesterase, thus giving acetylcholine more time to transmit the message. Cholinesterase inhibitors block cholinesterase, the enzyme responsible for the breakdown of acetylcholine in the synaptic cleft. Cholinesterase inhibitors include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). Rivastigmine is available as a patch. Memantine (Namenda) protects nerve cells against excess amounts of glutamate Glutamate is released in large amounts by cells damaged by AD The attachment of glutamate to N-methyl-D-aspartate (NMDA) receptors permits calcium to flow freely into the cell, which in turn may lead to cell degeneration. Memantine may prevent this destructive sequence by blocking the action of glutamate. Treating associated depression May improve cognitive ability May help with sleep problems SSRIs are often used Antipsychotic drugs Manage behavioral problems ↑ Risk of death in older patients Selective serotonin reuptake inhibitors include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and citalopram (Celexa). The antidepressant trazodone (Desyrel) = sleep =hypotension. Although antipsychotic drugs are approved for treating psychotic conditions (e.g., schizophrenia), they have been used for the management of behavioral problems (e.g., agitation, aggressive behavior) that occurs in patients with AD

DementiaEtiology and Pathophysiology

Due to treatable and nontreatable causes Treatable conditions can become irreversible with prolonged exposure or disease Treatable causes may initially be reversible most common causes of dementia = neurodegenerative conditions =Alzheimer's disease. Vascular conditions are the second most common cause of dementia. Vascular dementia Also called multiinfarct dementia Loss of cognitive function due to brain lesions caused by cardiovascular disease Ischemic lesions Hemorrhagic brain lesions Result of decr blood supply from narrowing and blocking of arteries that supply brain Can be caused by a single stroke or by multiple strokes Mixed dementia 2 or more types of dementia present at the same time Hallmark abnormalities of Alzheimer's disease + another type of dementia Usually vascular dementia Usually the other type of dementia is vascular dementia, but it can be other types. Normal pressure hydrocephalus Uncommon Caused by obstruction of CSF flow Meningitis, encephalitis, head injury Manifestations - dementia, urinary incontinence and difficulty walking Treatable when diagnosed early If diagnosed early, normal pressure hydrocephalus is treatable by surgery in which a shunt is inserted to divert the fluid away from the brain.

Combination of Restrictive and Malabsorptive Surgery

Dumping syndrome is a complication of the RYGB Gastric contents empty too rapidly into small intestine Avoidance of sugary foods is recommended Symptoms can include v/n, weakness, sweating, faintness, and, on occasion, diarrhea. Sections of the small intestine are bypassed, poor absorption of iron can cause iron-deficiency anemia. multivitamin with iron and calcium supplements.

Neuropathy: Neurotrophic Ulceration

Foot injury and ulcerations can occur without the patient's ever having pain. Neuropathy can also cause atrophy of the small muscles of the hands and feet, causing deformity and limiting fine movement.

Acute PancreatitisNursing Implementation - Acute Care

During the acute phase, it is important to monitor vital signs. Hemodynamic stability may be compromised by hypotension, fever, and tachypnea. Monitor the response to IV fluids. Also closely monitor fluid and electrolyte balance. Frequent vomiting, along with gastric suction, may result in decreased chloride, sodium, and potassium levels. Respiratory failure may develop in the patient with severe acute pancreatitis. Assess respiratory function (e.g., lung sounds, O2 saturation levels). If ARDS develops, the patient may require intubation and mechanical ventilation support. Monitor fluid and electrolyte balance Chloride, sodium, and potassium Hypocalcemia Tetany Calcium gluconate to treat Hypomagnesemia Closely monitor fluid and electrolyte balance. Frequent vomiting, along with gastric suction, may result in decreases in chloride, sodium, and potassium levels. Because hypocalcemia can also occur, observe for symptoms of tetany, such as jerking, irritability, and muscular twitching. Numbness or tingling around the lips and in the fingers is an early indicator of hypocalcemia. Assess the patient for positive Chvostek's sign or Trousseau's sign. Calcium gluconate (as ordered) should be given to treat symptomatic hypocalcemia. Hypomagnesemia may also develop, necessitating the monitoring of serum magnesium levels. Pain assessment and management Morphine Flex trunk and draw knees to abdomen Side-lying with head of bed elevated 45 degrees Measures such as comfortable positioning and frequent changes in position assist in reducing the restlessness that usually accompanies the pain. flex the trunk and draw the knees up to the abdomen may decrease pain. If the patient is taking antacids to neutralize gastric acid secretion, they should be sipped slowly or inserted in the NG tube.

Esophageal DiverticulaClinical Manifestations

Dysphagia Regurgitation Chronic cough Aspiration Weight loss Food becomes trapped in the outpouches, which is the cause of tasting sour food and smelling a foul odor.

D.V. states that abdominal pain and bloating are relieved by having a bowel movement. She is often constipated for which she takes laxatives.

On examination, bowel sounds are present. Vital signs and WBC count are normal.

Interprofessional CareDrug Therapy ibs

Goals of drug treatment are to induce and maintain remission Aminosalicylates Antimicrobials Corticosteroids Immunosuppressants Biologic and targeted therapy Since the cause is unknown, treatment relies on drugs to treat the inflammation and maintain remission. Since the recurrence rate is high after surgical treatment of Crohn's disease, drugs are the preferred treatment. The goal of drug treatment in IBD is to induce and maintain remission. Five major classes of medications used to achieve this goal: aminosalicylates, antimicrobials, corticosteroids, immunosuppressant, and biologic and targeted therapy.

Teach patient MS

Good balance of exercise and rest Minimize caffeine intake Increase fiber if constipated The patient should consult a HCP before taking nonprescription drugs. Bladder control = anticholinergics = self-catheterization. Bowel problems = constipation = Increasing dietary fiber Maintain or improve muscle strength and mobility

ESRD

ESRD treated with dialysis because There is a lack of donated organs Some patients are physically or mentally unsuitable for transplantation Some patients do not want transplants An increasing number of individuals, including older adults and those with complex medical problems, are receiving maintenance dialysis. A patient's chronologic age is not a factor in determining candidacy for dialysis.

Sinemet - PD

Effectiveness of Sinemet could wear off after a few years of therapy Some HCPs initiate therapy with a DA receptor agonist Directly stimulates DA receptors Sinemet is added when moderate to severe symptoms develop Ropinirole (Requip) and pramipexole (Mirapex) may be used alone or in combination with Sinemet. Bromocriptine (Parlodel) and pergolide (Permax) should not be used as first-line treatment because of possible serious side effects (e.g., high blood pressure, seizure, heart attack, stroke). extended release = improve patients' ability to adhere to treatment regimens. Rotigotine (Neupro), another DA receptor agonist, is a transdermal patch applied once daily as an adjunctive therapy for patients taking Sinemet.

DiabetesNutritional Therapy: Type 2 DM

Emphasis on achieving glucose, lipid, and BP goals Weight loss Nutritionally adequate meal plan with ↓ fat and CHO Spacing meals Regular exercise Nutrition therapy in type 2 diabetes emphasizes achieving glucose, lipid, and BP goals. Modest weight loss has been associated with improved insulin resistance. Therefore, weight loss is recommended for all individuals with diabetes who are overweight or obese. There is no one proven strategy or method that can be uniformly recommended. A nutritionally adequate meal plan with appropriate serving sizes, a reduction of saturated and trans fats, and low carbohydrates can decrease calorie consumption. Spacing meals is another strategy that spreads nutrient intake throughout the day. A weight loss of 5% to 7% of body weight often improves blood glucose levels, even if desirable body weight is not achieved. Weight loss is best attempted by a moderate decrease in calories and an increase in caloric expenditure. Regular exercise and adopting new behaviors and attitudes can help facilitate long-term lifestyle changes. Monitoring of blood glucose levels, hemoglobin A1C, lipids, and blood pressure provide feedback on how well the goals of nutritional therapy are being met.

Nursing Implementation - MS

Exacerbations of MS are triggered by infection (URI and UTI), trauma, immunization, delivery after pregnancy, stress, and change in climate. During acute exacerbation, prevent major complications of immobility Focus teaching on building general resistance to illness Avoid fatigue, extremes of hot and cold, exposure to infection acute exacerbation = immobile and confined to bed. avoiding exposure to cold climates, sick, early treatment of infection

Type 2 Diabetes MellitusOnset of Disease

Gradual onset Hyperglycemia may go many years without being detected Often discovered with routine laboratory testing Average person has had diabetes for 6.5 years onset in type 2 diabetes is usually gradual.

What nutritional recommendation could you make to D.V.? How should you address her concerns about cancer?

Gradually increase fiber intake, limit gas-producing foods. Suggest that she have plenty of noncaffeine liquids each day. Allow her to vent her concerns. Teach her about her disorder. Reassure her that there is no direct relationship to cancer. Encourage her to follow up regularly with her health care provider.

Self-Monitoring of Blood Glucose (SMBG)

Enables decisions regarding diet, exercise, and medication Accurate record of glucose fluctuations Helps identify hyperglycemia and hypoglycemia Helps maintain glycemic goals A must for insulin users Frequency of testing varies Self-monitoring of blood glucose (SMBG) is a critical part of diabetes management. By providing a current blood glucose reading, the primary advantage of SMBG is that it enables the patient to make decisions regarding food intake, activity patterns, and medication dosages. It also produces accurate records of daily glucose fluctuations and trends and alerts the patient to acute episodes of hyperglycemia and hypoglycemia. Furthermore, it provides patients with a tool for achieving and maintaining specific glycemic goals. SMBG is recommended for all patients who use insulin to manage their diabetes. Other patients with diabetes use SMBG to help achieve and maintain glycemic goals, and monitor for acute fluctuations in blood glucose related to medications, food, and exercise. The frequency of monitoring depends on several factors, including the patient's glycemic goals, the type of diabetes that the patient has, the medication regimen, the patient's ability to check blood glucose independently, and the patient's willingness and ability to do so. The recommendation for patients who use multiple insulin injections or insulin pumps is to monitor their blood glucose four or more times each day. Patients using less frequent insulin injections, noninsulin therapy, or medical nutrition management will monitor as often as needed to achieve their glycemic goals.

Support Groups - obesity

Encourage person to join a support group of other obese persons who are receiving help to modify eating habits Many self-help groups are available Take Off Pounds Sensibly (TOPS) Workplace-based programs Weight loss programs at the workplace are beneficial for both employers and employees. Rationale is that better health repays the cost of the programs through improved work performance, decreased absenteeism, and eventually less hospitalization. Many of these programs are staffed by nurses and/or dietitians. These weight-reduction centers are costly and therefore are cost prohibitive for those with limited financial resources.

Cirrhosis of Liver

End-stage of disease liver Extensive degeneration and destruction of liver cells Results in replacement of liver tissue by fibrous and regenerative nodules Cirrhosis is the end-stage of liver disease. Cirrhosis is characterized by extensive degeneration and destruction of the liver cells. This results in the replacement of liver tissue by fibrosis (scar tissue) and regenerative nodules that occur from the liver's attempt to repair itself.

Endoscopic therapy - gerd

Endoscopic mucosal resection (EMR) Photodynamic therapy Cryotherapy Radiofrequency ablation For patients with high-grade dysplasia, endoscopic mucosal resection is also a diagnostic modality in that cancer can be ruled out through biopsy and histologic examination.

Esophageal DiverticulaDiagnostic Studies

Endoscopy Barium studies

Esophageal CancerDiagnostic Studies

Endoscopy with biopsy Necessary for definitive diagnosis Endoscopic ultrasonography (EUS) Important tool to stage Esophagogram (barium swallow) Endoscopic biopsy is necessary to make a definitive diagnosis of esophageal cancer. Capsule endoscopy is recommended for the monitoring of patients with Barrett's esophagus who are at risk for esophageal cancer. Esophagram (barium swallow) may show narrowing of the esophagus at the tumor site (Table 41-11). Bronchoscopic examination Detect involvement of lung CT MRI

Anemia CKI

Erythropoietin (EPO) Epoetin alfa (Epogen, Procrit) Darbepoeitin alfa (Aranesp) Administered IV or subcutaneously Increased hemoglobin and hematocrit in 2 to 3 weeks Side effects: thromboembolism, hypertension Darbepoetin alfa (Aranesp) is longer acting and can be administered weekly or biweekly. Higher hemoglobin levels and higher doses of EPO are associated with a higher rate of thromboembolic events and increased risk of death from serious cardiovascular events (heart attack, heart failure, stroke). EPO can increase BP and is contraindicated in uncontrolled hypertension. The underlying mechanism is related to the hemodynamic changes (e.g., increased whole blood viscosity) that occurs as the anemia is corrected. Iron supplements If plasma ferritin level is <100 ng/mL Side effects: gastric irritation, constipation May make stool dark in color EPO therapy may lead to the development of iron deficiency from the increased demand for iron to support erythropoiesis. Orally administered iron should not be taken at the same time as phosphate binders because calcium binds the iron, preventing its absorption. Most patients receiving HD are prescribed IV iron sucrose injection (Venofer) or sodium ferric gluconate complex in sucrose injection (Ferrlecit). Folic acid supplements Needed for RBC formation Removed by dialysis Avoid blood transfusions Increase the development of antibodies May lead to iron overload Supplemental folic acid (1 mg/day) is usually given because it is needed for RBC formation and is removed by dialysis. Blood transfusions should be avoided in treating anemia unless the patient experiences an acute blood loss or has symptomatic anemia (i.e., dyspnea, excess fatigue, tachycardia, palpitations, chest pain). Transfusions increase the development of antibodies, thus making it more difficult to find a compatible donor for kidney transplantation. Multiple blood transfusions may lead to iron overload because each unit of blood contains about 250 mg of iron.

Complications cirrhoiss

Esophageal and gastric varices Peripheral edema Abdominal ascites Hepatic encephalopathy Hepatorenal syndrome Patients who are cirrhotic but who have no obvious complications are considered to have compensated cirrhosis. Those who have one or more complications of their liver disease have decompensated cirrhosis. Major complications of cirrhosis are portal hypertension with resultant esophageal and/or gastric varices, peripheral edema and ascites, hepatic encephalopathy (mental status changes, including coma), and hepatorenal syndrome. Portal hypertension Increased venous pressure in portal circulation Splenomegaly Large collateral veins Ascites In patients with cirrhosis, the liver undergoes structural changes. These changes lead to obstruction of blood flow in and out of the liver. Ultimately this results in increased pressure within the liver's circulatory system (portal hypertension). Portal hypertension is characterized by increased venous pressure in the portal circulation, splenomegaly, large collateral veins, ascites, and gastric and esophageal varices. Esophageal varices Complex of tortuous, enlarged veins at lower end of esophagus Gastric varices - Upper portion of stomach Ruptured esophageal varices are the most life-threatening complication of cirrhosis and considered a medical emergency. Gastric varices are located in the upper portion of the stomach. These account for 20% of all varices. Peripheral edema ↓ Colloidal oncotic pressure from impaired liver synthesis of albumin ↑ Portacaval pressure from portal hypertension Occurs as lower extremities/presacral edema Edema results from decreased colloidal oncotic pressure from impaired liver synthesis of albumin and increased portacaval pressure from portal hypertension. Several mechanisms Portal hypertension Hypoalbuminemia Hyperaldosteronism One mechanism of ascites occurs with portal hypertension, which causes proteins to shift from the blood vessels into the lymph space (Fig. 43-7). When the lymphatic system is unable to carry off the excess proteins and water, they leak into the peritoneal cavity. The osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity A second mechanism of ascites formation is hypoalbuminemia resulting from the liver's decreased ability to synthesize albumin. The hypoalbuminemia results in decreased colloidal oncotic pressure. A third mechanism of ascites is hyperaldosteronism, which occurs when the hormone aldosterone is metabolized by damaged hepatocytes. The increased level of aldosterone causes increased sodium reabsorption by the renal tubules. This retention of sodium, combined with an increase in antidiuretic hormone in blood, leads to additional water retention. Because of edema formation, there is decreased intravascular volume and, subsequently, decreased renal blood flow and glomerular filtration.

Surgical procedures - esoph CA

Esophagectomy Removal of part or all of esophagus Use of Dacron graft to replace resected part Esophagogastrostomy Resection of portion of esophagus and anastomosis of remaining portion to stomach Esophagoenterostomy Resection of a portion of esophagus and anastomosis of segment of colon to remaining portion Surgical approaches may be open or laparoscopic Minimally invasive esophagectomy (e.g., laparoscopic vagal nerve sparing surgery) is being performed with increased frequency. It has the advantages of using smaller incisions, decreasing ICU and hospital stay, and leading to fewer pulmonary complications.

Complications - GERD

Esophagitis Inflammation of esophagus Frequent complication scar formation, esophageal stricture, dysphagia Barrett's esophagus (esophageal metaplasia) Replacement of flat epithelial cells with columnar epithelium Precancerous lesion Thought to be primarily due to GERD reversible. African Americans and Asians are at lower risk Barrett's esophagus Diagnosed in 5% to 20% of patients with chronic reflux Signs and symptoms: none to perforation Must be monitored every 2-3 years by endoscopy Biopsy of the esophageal mucosa confirms metaplasia. Because patients with evidence of metaplasia on an initial endoscopic examination are at risk for esophageal cancer, a surveillance endoscopy every 2 to 3 years is often recommended. Respiratory From irritation of upper airway by secretions Cough Bronchospasm Laryngospasm Cricopharyngeal spasm These complications are due to irritation of the upper airway by gastric secretions. From aspiration: Potential for asthma, bronchitis, and pneumonia Dental erosion From acid reflux into mouth Especially posterior teeth

Hiatal HerniaDiagnostic Studies

Esophagogram (barium swallow) May show protrusion of gastric mucosa through esophageal hiatus Endoscopy Visualize lower esophagus Information on degree of inflammation or other problems

Exercise - obesity

Essential part of a weight loss program Daily for 30 minutes to an hour Can diminish appetite Reduces waist-to-hip ratio Helps maintain weight loss Psychologic benefits Cardiovascular benefits when using large muscles in exercise. Walking, swimming, and cycling have long-term benefits. Weekend exercise and spurt of strenuous activity is not advantageous and can actually be dangerous for the overweight person.

Nursing Interventions Related toDrug Therapy - obesity

Evaluate for medical conditions Teach Drugs will not cure obesity Changes in food intake and exercise are essential for sustained weight loss Proper administration, side effects, and appropriate use of drugs As with any drug treatment, there are side effects. Careful evaluation for the presence of other medical conditions can help determine which drugs, if any, would be advisable for a given patient. Many insurance companies do not cover the cost of weight loss drugs. The modification of dosage without consultation with the HCPhealth care provider can have detrimental effects. Emphasize that diet and exercise regimens are the cornerstones of permanent weight loss.

Clinical ManifestationsGastrointestinal System CKI

Every part of GI system is affected Cause: excessive urea Stomatitis with ulcerations Uremic fetor (urinous odor of breath) Gastrointestinal system Diabetic gastroparesis GI bleeding Constipation Anorexia, nausea, and vomiting may = is not treated with dialysis. Diabetic gastroparesis (delayed gastric emptying) GI bleeding is also a risk because of mucosal irritation and the platelet defect. Constipation = iron salts and/or calcium-containing phosphate binders

Interprofessional CareSurgical Therapy IBS

Exacerbations are debilitating and frequent Massive bleeding Perforation Strictures and/or obstruction Tissues changes indicating dysplasia or carcinoma Surgery is indicated if treatment fails

What should you teach G.O.'s wife and family in regard to his postoperative health care needs?

He will have alterations in his stool and bowel movements. They will need to know how to take care of his wounds They should know new dietary changes and signs to look for in the event of an infection or future problem.

Etiology and PathophysiologyParkinson's Disease

Exact cause of PD unknown Possibly a result of a complex interplay between environmental factors and the person's genetic makeup Family history in 15% of cases well water, pesticides, herbicides, industrial chemicals, wood pulp mills, Rural residence Many forms of secondary/atypical parkinsonism exist Exposure to chemicals Drug-induced Prescribed Illicit Others Many forms of secondary (atypical) parkinsonism exist other than PD. Symptoms of parkinsonism occurre with carbon monoxide and manganese, meperidine analog synthesis Drug-induced parkinsonism can also follow therapy with metoclopramide (Reglan), reserpine (Serpasil), methyldopa (Aldomet), lithium, haloperidol (Haldol), and chlorpromazine (Thorazine). Parkinsonism =after use of illicit drugs = amphetamine and methamphetamine. causes - hydrocephalus, other neurodegenerative disorders, hypoparathyroidism, infections, stroke, tumor, and trauma. Lewy bodies, unusual clumps of protein, are found in the brains of patients with PD. It is not known what causes these bodies to form, but their presence indicates abnormal functioning of the brain. Lewy body dementia is discussed in Chapter 59.

Alzheimer's DiseaseEtiology

Exact etiology is unknown but likely due to multiple factors Greatest risk factor is age Most diagnosed at or after age 65 Not a normal part of aging Age alone is not sufficient to cause AD Exact etiology is unknown but likely due to multiple factors Family history Those with a 1st degree relative with dementia are more likely to develop AD Even higher risk with > 1 relative Family history is not necessary for an individual to develop AD

Nursing ManagementNursing Diagnoses CKI

Excess fluid volume Risk for electrolyte imbalance Risk for injury Imbalanced nutrition: less than body requirements Excess fluid volume related to impaired kidney function Risk for electrolyte imbalance related to impaired kidney function resulting in hyperkalemia, hypocalcemia, hyperphosphatemia, and altered vitamin D metabolism Imbalanced nutrition: less than body requirements related to restricted intake of nutrients (especially protein), nausea, vomiting, anorexia, and stomatitis

Nursing ManagementEvaluation IBD

Expected Outcomes Decreased number of diarrhea stools Body weight maintained within normal range Freedom from pain and discomfort Use of effective coping strategies

Alzheimer's DiseaseEvaluation

Expected Outcomes Functions at highest level of cognitive ability Performs basic personal care activities of daily living including Bathing, dressing, feeding, and toileting by self or with assistance as needed Expected Outcomes Experiences no injury Remains in restricted area during ambulation and activity Additional information on the expected outcomes for the patient with AD is addressed in eNursing Care Plan 59-1 (available on the website for this chapter).

Acute PancreatitisNursing Implementation

Expected Outcomes Have adequate pain control Maintain adequate fluid volume Be knowledgeable about treatment regimen Get help for alcohol dependence and smoking cessation (if appropriate) The expected outcomes are that the patient with acute pancreatitis will Have adequate pain control Maintain adequate fluid balance Be knowledgeable about treatment regimen to restore health Get help for alcohol dependence and smoking cessation (if appropriate)

Nursing ManagementEvaluation - DM

Expected Outcomes Knowledge Self-care measures Balanced diet and activity Stable, safe, and healthy blood glucose levels No injuries Verbalize key elements of the therapeutic regimen, including knowledge of disease and treatment plan Describe self-care measures that may prevent or slow progression of chronic complications Maintain a balance of nutrition, activity, and insulin availability that results in stable, safe, and healthy blood glucose levels Experience no injury resulting from decreased sensation in feet Implement measures to increase peripheral circulation Additional information on expected outcomes for the patient with diabetes is presented in eNCP 48-1 available on the website for this chapter.

Clinical ManifestationsNeurologic System CKI

Expected as kidney disease progresses Result of ↑ Nitrogenous waste products Electrolyte imbalances Metabolic acidosis Atrophy and demyelination of nerve fibers The central nervous system (CNS) becomes depressed, resulting in lethargy, apathy, decreased ability to concentrate, fatigue, irritability, and altered mental ability. Seizures and coma may result from a rapidly increasing BUN level and hypertensive encephalopathy. CNS depression Lethargy, apathy Decreased ability to concentrate Fatigue, irritability Altered mental ability Seizures Coma Hypertensive encephalopathy Slowing of nerve conduction Restless legs syndrome Paresthesias Foot drop Muscle weakness and atrophy Loss of deep tendon reflexes Peripheral neuropathy

What follow-up care will G.O. need once he has healed from his surgery?

He will need regular medical follow-up and screening for the possibility that this problem may recur. He should know when to be concerned and call his doctor (changes in bowel routine, abdominal pain, bleeding with the stool or from the rectum).

Pancreas Transplantation

For type 1 diabetes with kidney transplant Eliminates need for exogenous insulin, SMBG, dietary restrictions Can also eliminate acute complications Long-term complications may persist Lifelong immunosuppression Islet cell transplantation experimental Pancreas transplantation can be used as a treatment option for patients with type 1 diabetes. Usually it is done for patients who have end-stage kidney disease and who have had or plan to undergo kidney transplantation. Kidney and pancreas transplantations are often performed together, or a pancreas may be transplanted after kidney transplantation. Pancreas transplantation alone is rare. Successful pancreas transplantation can improve quality of life for people with diabetes, primarily by eliminating the need for exogenous insulin, frequent blood glucose measurements, and the risks involved with hyper- and hypoglycemia. Transplantation can also eliminate the acute complications commonly experienced by patients with type 1 diabetes (e.g., hypoglycemia, hyperglycemia). However, pancreas transplantation is only partially successful in reversing the long-term renal and neurologic complications of diabetes. The patient will also require lifelong immunosuppression to prevent rejection of the graft. Complications can result from immunosuppressive therapy. Pancreatic islet cell transplantation is another potential treatment measure. During this procedure, the islet cells are harvested from the pancreas of a deceased organ donor. Most recipients require the use of two or more pancreases. The islet cells are infused via a catheter through the upper abdomen into the portal vein of the liver. With only the islet cells transplanted, pain and recovery time are diminished in comparison with whole pancreas transplantation. Currently, this procedure is experimental in the United States. Research is continuing to determine the best ways to implant the islet cells and to prevent their rejection.

Alzheimer's DiseaseEtiology

Familial Alzheimer's disease (FAD) Clear pattern of inheritance Onset before age 60 Rapid disease course Sporadic Alzheimer's disease No familial connection Other cases where no familial connection can be made are termed sporadic. FAD=early onset (before 60 years of age) = rapid disease course. In both FAD and sporadic AD, the pathogenesis of AD is similar. Brain and heart/circulatory health are closely linked Many factors ↑ risk of CV disease Diabetes Hypertension Obesity Hypercholesterolemia Smoking Many factors increase the risk of cardiovascular disease = dm, hnt, obesity, hypercholesterolemia, and smoking. Chronic high levels of insulin and glucose may be toxic to brain Insulin resistance may interfere with ability to break down amyloid Head trauma Chronic high levels of insulin and glucose may be directly toxic to brain cells. Insulin resistance, which causes high blood glucose and in some cases leads to type 2 diabetes, may interfere with the body's ability to break down amyloid, a protein that forms brain plaques in AD. In addition, high blood glucose along with high cholesterol has a role in atherosclerosis, which contributes to vascular dementia. Diabetes may contribute to poor memory and diminished mental function in various other ways. The disease causes microangiopathy, which damages small blood vessels throughout the body. People with diabetes may lose brain volume (especially gray matter) as the disease progresses. Head trauma is also a risk factor for dementia. Professional football players and military veterans who had traumatic brain injury or post-traumatic stress disorder are at an increased risk for AD and other types of dementia.

Alzheimer's DiseaseAmbulatory Care

Family members and friends care for most AD patients in their homes Various facilities should be evaluated Consider stage of AD patient when choosing Nursing care intensifies over time In early stages, memory aids may provide benefit Depression often develops Advance directives should be set An example of a memory aid is a calendar. Adult day care For example, many facilities have designated areas that allow the patient to walk freely within the unit while the unit is secured, so the patient cannot wander outside of it. As the patient with AD progresses to the late stages (severe impairment) of AD, there is increased difficulty with the most basic functions, including walking and talking. Total care is eventually required.

Gallbladder Disease - Risk factors

Female Multiparity Age older than 40 years Estrogen therapy Sedentary lifestyle Genetics/ethnicity Obesity Cholecystectomy (removal of the gallbladder) ranks among the most common surgical procedures performed in the United States. Postmenopausal women on estrogen replacement therapy and oral contraceptives are = increased risk Oral contraceptives = cholesterol production, incr cholesterol saturation. gallbladder disease = high in the Native American population=Navajo and Pima tribes.

Nursing Management: CholecystitisNursing Assessment - Objective

Fever Restlessness Jaundice, icteric sclera Diaphoresis Tachypnea Splinting Cardiovascular: tachycardia Gastrointestinal: palpable gallbladder, abdominal guarding and distention Possible diagnostic findings: ↑ serum liver enzymes, alkaline phosphatase, and bilirubin levels; absence of urobilinogen in urine, ↑ urinary bilirubin level; leukocytosis, abnormal gallbladder ultrasound findings

Nursing Assessment - obesity

First rule out physical conditions that may be causing or contributing to obesity Be sensitive and nonjudgmental Clarify rationale for inquiries about weight, dietary habits, and exercise history and physical exam are the first approach to treating obesity. genetic and endocrine factors = hypothyroidism, hypothalamic tumors, Cushing syndrome, hypogonadism in men, and PCOS. Laboratory tests assist in evaluating the cause and effects of obesity. When no organic cause is associated with obesity, the disorder should be considered a chronic, complex illness.

Chronic ComplicationsInfection - DM

Flu and pneumonia vaccine more susceptible to infections = mobilization of inflammatory cells and impaired phagocytosis by neutrophils and monocytes. Candida albicans, boils and furuncles = suspect diabetes. Persistent glycosuria may predispose to bladder infections, especially in patients with a neurogenic bladder. Decreased circulation resulting from angiopathy can prevent or delay the immune response. Antibiotic therapy has prevented infection from being a major cause of death among patients with diabetes.

Acute PancreatitisComplications - Pseudocyst

Fluid, enzyme, debris, and exudates surrounded by wall Abdominal pain, palpable mass, nausea/vomiting, anorexia Detected with imaging Resolves spontaneously or may perforate and cause peritonitis Surgical or endoscopic drainage Two significant local complications of acute pancreatitis are pseudocyst and abscess. pancreatic pseudocyst is an accumulation of fluid, pancreatic enzymes, tissue debris, and inflammatory exudates surrounded by a wall adjacent to the pancreas. pseudocyst = abdominal pain, palpable epigastric mass, n/v, anorexia. incr serum amylase, CT, MRI, and endoscopic ultrasonography (EUS) cysts = resolve spontaneously within a few weeks but may perforate, causing peritonitis, or rupture into the stomach or duodenum. Tx -surgical drainage procedure, percutaneous catheter placement and drainage, and endoscopic drainage.

DeliriumNursing/Interprofessional Mgmt

Focus on eliminating precipitating factors Protect patient from harm Encourage family members to stay at bedside Care of the patient with delirium focuses on eliminating precipitating factors. If it is drug induced, medications are discontinued. Keep in mind that delirium can also accompany drug and alcohol withdrawal. Fluid and electrolyte imbalances and nutritional deficiencies (e.g., thiamine) are corrected if appropriate. If the problem is related to environmental conditions (e.g., an overstimulating or understimulating environment), changes should be made. If delirium is secondary to chronic illness such as chronic kidney disease or heart failure, treatment focuses on these conditions. Care of the patient with delirium focuses on eliminating precipitating factors. If it is drug induced, medications are discontinued. Keep in mind that delirium can also accompany drug and alcohol withdrawal. Depending on patient history, drug screening may be performed. Fluid and electrolyte imbalances and nutritional deficiencies (e.g., thiamine) are corrected if appropriate. If delirium is secondary to chronic illness such as chronic kidney disease or heart failure, treatment focuses on these conditions. Reorientation and behavioral interventions—used in all patients with delirium Create a calm and safe environment Provide reassurance Pay attention to environmental stimuli Clocks, calendars, noise, and light levels If the patient uses eyeglasses or a hearing aid, these should be made readily available because sensory deprivation can precipitate delirium. Use reorientation and behavioral interventions in patients with delirium. Personal contact through touch and verbal communication can be an important reorienting strategy. If the patient uses eyeglasses or a hearing aid, these should be made readily available because sensory deprivation can precipitate delirium. Avoid the use of restraints. Patient experiencing delirium is also at risk for Immobility Skin breakdown

Food composition DM

Food composition Healthy balance of nutrients is essential to maintain blood glucose levels and overall health Energy from food intake can be balanced with energy output Individualized to lifestyle and health goals A healthy balance of nutrients is essential to maintain blood glucose levels and overall health. Energy from food intake can be balanced with the patient's energy output. Patients plan their individual meal plan with their lifestyle and health goals in mind.

Supportive measures for acute bleed cirrhoiss

Fresh frozen plasma Packed RBCs Vitamin K Proton pump inhibitors Lactulose (Cephulac) and rifaximin (Xifaxan) Antibiotics Supportive measures during an acute variceal bleed include: Administration of fresh frozen plasma and packed RBCs Vitamin K (AquaMEPHYTON) Proton pump inhibitors (e.g., pantoprazole [Protonix]) Lactulose (Cephulac) and rifaximin (Xifaxan) administration may be started to prevent hepatic encephalopathy from breakdown of blood and the release of ammonia in the intestine. Antibiotics are given to prevent bacterial infection.

Complications - Acute liver failure

Fulminant hepatic failure Manifestations include Encephalopathy Gastrointestinal bleeding Disseminated intravascular coagulation Liver transplant is usually the cure Manifestations include encephalopathy, gastrointestinal bleeding, disseminated intravascular coagulation, fever with leukocytosis, renal manifestations (oliguria, azotemia), ascites, edema, hypotension, respiratory failure, hypoglycemia, bacterial infections, thrombocytopenia, and coagulopathies.

Description of IBS

Functional GI disorder characterized by chronic abdominal pain or discomfort and alteration of bowel patterns Diarrhea or constipation Either may predominate May alternate No known organic cause Manifestations are intermittent and may occur for years Patients often report a history of GI infections and food intolerances Fructans Galactans Lactose Fructose Sorbitol Xylitol Psychologic stressors are associated The role of food allergies in IBS is unclear. Other dietary factors that may contribute to symptoms include fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs). Examples include fructans (found in wheat, rye, onions, garlic and legumes), galactans, lactose (found in milk and yogurt), fructose (found in honey, apples, pears and high fructose corn syrup), sorbitol, and xylitol. Based solely on symptoms Rome III criteria Presence of abdominal pain and/or discomfort at least 3 months and associated with 2 or more of following: Improvement with defecation Change in stool frequency at onset Change in stool appearance at onset The Rome III criteria for diagnosing IBS require the presence of abdominal pain and/or discomfort at least 3 months that is associated with 2 or more of the following: improvement with defecation, change in stool frequency at onset, or change in the stool appearance at onset. Psychologic stressors (e.g., depression, anxiety, sexual abuse, post- traumatic stress disorder) are associated with development and exacerbation of IBS.

Hiatal HerniaComplications

GERD Esophagitis Hemorrhage from erosion Stenosis Ulcerations of herniated portion Strangulation of the hernia Regurgitation with tracheal aspiration Increased risk of respiratory problems

Esophageal CancerPMH

GERD Hiatal hernia Achalasia Barrett's esophagus Tobacco use Alcohol use The patient at highest risk for Barrett's esophagus is older and white and has a history of heartburn.

Clinical Manifestations IBS

GI symptoms Abdominal pain Diarrhea or constipation Abdominal distention Excessive flatulence Bloating Urgency Sensation of incomplete evacuation Non-GI symptoms Fatigue Headache Sleep disturbances

Nursing ManagementNursing Implementation CKI

Health Promotion Identify individuals at risk for CKD Diabetes mellitus Hypertension History or family history of kidney disease Repeated urinary tract infection most care for CKD occurs on an outpatient basis Take daily B Inform the patient that even while on dialysis, transplant remains an option. Let the patient know that if a transplanted organ fails, the patient can return to dialysis.

Diagnostic Studies - GERD

History and physical examination Upper GI endoscopy Useful in assessing LES competence, degree of inflammation, scarring, strictures Obtain biopsy and cytologic specimens Ambulatory esophageal pH monitoring Radionuclide tests Detect reflux of gastric contents Evaluate rate of esophageal clearance Ambulatory esophageal pH monitoring may be done for patients with refractory symptoms and no evidence of mucosal inflammation. Barium swallow Can detect protrusion of gastric fundus Esophageal manometric (motility) studies Measure pressure in esophagus and LES Manometric studies measure pressure in the esophagus and LES and esophageal motility function.

Inflammatory Bowel Disease Complications

GI tract (local) complications Hemorrhage Strictures Perforation (with possible peritonitis) Abscesses Fistulas CDI Colonic dilation (toxic megacolon) Patients with toxic megacolon are at risk of perforation and may need an emergency colectomy. Toxic megacolon is more common with ulcerative colitis. Perineal abscess and fistulas occur in up to a third of patients with Crohn's disease. CDI increases in frequency and severity in patients with IBD. Hemorrhage may lead to anemia, and needs to be corrected with blood transfusions and iron supplements. Nutritional problems are especially common in Crohn's disease when the terminal ileum is involved. Bile salts and cobalamin are exclusively absorbed in the terminal ileum. Thus disease in the terminal ileum can result in fat malabsorption and anemia. High risk for colorectal cancer Systemic complications Joint, eye, mouth, kidney, bone, vascular, and skin problems Circulating cytokines trigger inflammation Liver failure Patients with a history of IBD have an increased risk for colorectal cancer. Those with Crohn's disease are at increased risk for small intestinal cancer. Cancer screening at regular intervals is important in persons with IBD. Systemic (extraintestinal) complications also occur. Routine liver function tests are important because primary sclerosing cholangitis, a complication of IBD, can lead to liver failure.

Acute PancreatitisEtiology

Gallbladder disease (women) #1 Chronic alcohol intake (men) #2 Smoking Hypertriglyceridemia -serum levels >1000 mg/dL Biliary sludge or microlithiasis, which is a mixture of cholesterol crystals and calcium salts, is found in 20% to 40% of patients with acute pancreatitis. The formation of biliary sludge is seen in patients with bile stasis. Less common causes Trauma Viral infections - mumps, HIV Penetrating duodenal ulcers Cysts Abscesses Less common causes Cystic fibrosis Kaposi sarcoma Certain drugs Metabolic disorders Vascular diseases Idiopathic causes

Complications - Cholecystitis

Gangrenous cholecystitis Subphrenic abscess Pancreatitis Cholangitis Biliary cirrhosis Fistulas Gallbladder rupture → peritonitis Choledocholithiasis Complications of cholelithiasis and cholecystitis include gangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis (inflammation of biliary ducts), biliary cirrhosis, fistulas, and rupture of the gallbladder, which can produce bile peritonitis. In older patients and those with diabetes, gangrenous cholecystitis and bile peritonitis are the most common complications of cholecystitis. Choledocholithiasis (stone in the common bile duct) may occur, producing symptoms of obstruction.

Esophageal Disorders

Gastroesophageal reflux disease (GERD) Hiatal hernia Esophageal cancer Esophageal diverticula Esophageal strictures Achalasia Esophageal varices

interprofessional Care - Health Promotion: Hepatitis B

General measures Immunization Recombivax HB, Engerix-B Series of three IM injections All children and at-risk adults Postexposure prophylaxis: vaccine and hepatitis B immune globulin (HBIG) The best way to reduce incidence of HBV infection is to identify those at risk, screen them for HBV, and vaccinate those who have not been infected. Teach individuals at high risk for contracting HBV to reduce risks by maintaining good hygienic practices, including hand washing and the use of gloves when expecting contact with blood, are important. Patients should not share razors, toothbrushes, and other personal items. Teach patients to use a condom for sexual intercourse. In addition, the partner be vaccinated. The HBV vaccine is the best means of prevention. The HBV vaccines (Recombivax HB, Engerix-B) contain HBsAg that promotes the synthesis of specific antibodies directed against HBV. The vaccine is given in a series of three IM injections in the deltoid muscle. The second dose is administered within 1 month of the first one, and the third one within 6 months of the first. The vaccine is more than 95% effective. Only minor adverse reactions have been reported with vaccination, including transient fever and soreness at the injection site. The vaccine is not contraindicated during pregnancy. The first dose of hepatitis B vaccine should be given at birth, and the vaccine series completed by ages 6 to 18 months. Older children and adolescents who did not previously receive the hepatitis B vaccine should also be vaccinated. It is also important to vaccinate adults who are in the at-risk groups and are not immune. Members of the household of a patient with HBV should be tested and vaccinated if they are HBsAg- and antibody-negative. Hepatitis vaccination is recommended for patients with chronic kidney disease before they start dialysis. Dialysis recipients should routinely have their antibody titer levels checked to determine the need for revaccination. For postexposure prophylaxis, the HBV vaccine and hepatitis B immune globulin (HBIG) are used. HBIG contains antibodies to HBV and confers temporary passive immunity. HBIG is prepared from plasma of donors with a high titer of anti-HBs. HBIG is recommended for postexposure prophylaxis in cases of needle stick, mucous membrane contact, or sexual exposure and for infants born to mothers who are HBsAg-positive. Ideally, HBIG should be given within 24 hours of exposure. The vaccine series should also be started.

Human insulin

Genetically engineered in laboratories Rapid-acting Short-acting Intermediate-acting Long-acting Today only genetically engineered human insulin is made in laboratories. The insulin is derived from common bacteria (e.g., Escherichia coli) or yeast cells through recombinant DNA technology. In the past, insulin was extracted from beef and pork pancreas, but these forms of insulin are no longer available. The onset of activity, peak, and duration times are manipulated by adding zinc, acetate buffers, and protamine. The zinc and protamine added to make intermediate-acting NPH (neutral protamine Hagedorn) can cause an allergic reaction at the injection site in susceptible individuals.

Factors of obesity

Genetics Socioeconomical Lack Physical Exercise Association at Childhood Mindless Eating Environmental factors play an important role in obesity. Eating outside of home interferes with the ability to control the quality/quantity of food. Portion sizes have increased dramatically. Underestimating portion sizes and therefore caloric intake is common. With increases in technology and laborsaving devices, Americans are expending less energy in their everyday lives. Elimination of physical education programs in schools, along with increased time spent playing video games and watching TV, have contributed to the increase in sedentary habits. Socioeconomic status = risk factor for obesity in a variety of ways = stretch their food dollars by purchasing less expensive foods = poor nutritional = greater caloric content.

Inflammatory Bowel Disease Gerontologic Considerations

Greater risk of complications in frail older patients with IBD Adverse events from corticosteroids Increased infection and malignancy associated with drug therapy Volume depletion and electrolyte imbalance from diarrhea Physical limitations that impact self care Colitis For the healthy older adult the interprofessional care of IBD is similar to that of the younger patient. For the frail older patient with IBD, the usual treatments may increase the risk of adverse events, hospitalization, or mortality. Older adults are more prone to adverse events from corticosteroids. Immunosuppressants and biologic therapy have a higher risk of infection and malignancy in older patients. Those with diminished renal and cardiovascular function are more vulnerable to the consequences of volume depletion from diarrhea. Those with physical limitations may have difficulty handling fecal urgency and multiple trips to the bathroom without assistance. In addition to Crohn's disease and ulcerative colitis, older adults are vulnerable to inflammation of the colon (colitis) from drug use and systemic vascular disease. Drugs such as NSAIDs, digitalis, sumatriptan (Imitrex), vasopressin, estrogen, and allopurinol (Zyloprim) have been associated with the development of colitis in the older patient. Colitis may also be secondary to ischemic bowel disease related to atherosclerosis and heart failure.

Metabolic Syndrome

Group of risk factors that increase an individual's chance of developing cardiovascular disease, stroke, and diabetes mellitus More prevalent in those 60 years of age and older Metabolic syndrome is characterized by a cluster of health problems, including obesity, hypertension, abnormal lipid levels, and high blood glucose. If three or more of the following Waist circumference ≥40 inches (men) or ≥35 inches (women) Triglycerides >150 mg/dL HDL cholesterol <40 men, <50 women Blood pressure ≥ 130 mm Hg systolic or ≥ 85 mm Hg diastolic Fasting glucose ≥ 100 mg/dL

Serologic Events in HBV Infection

HBV is a complex structure with three distinct antigens: the surface antigen (HBsAg), the core antigen (HBcAg), and the e antigen (HBeAg). Each antigen along with its corresponding antibody may appear or disappear in serum depending on the phase of infection and immune response. Screening for HBV = high risk for infection and testing the blood for the presence of HBsAg, hepatitis B surface antibody (anti-HBs), and hepatitis B core antibody (anti-HBc) presence anti-HBs = indicates immunity from the HBV vaccine or from past HBV infectio The detection of HBsAg in the serum for 6 months or longer after infection indicates chronic HBV infection.

Esophageal CancerPlanning

Have relief of symptoms Achieve optimal nutritional intake Experience quality of life appropriate to stage of disease and prognosis Maintain regular follow-up evaluations Eliminate smoking and excess alcohol intake Maintain good oral hygiene and dietary habits Seek medical attention for any esophageal problems Counsel the patient with GERD, Barrett's esophagus, or hiatal hernia about the importance of regular follow-up evaluation.

Nursing ManagementNursing Implementation CRC

Health Promotion Encourage all persons older than 50 to have regular CRC screening Help identify those at high risk Discuss with patients how early screening helps decrease mortality rates Realize that fear and lack of information create barriers to prevention activities Health Promotion Colonoscopy detects polyps only when the bowel has been adequately prepared Provide teaching about bowel cleansing for outpatient procedures Correctly administer cleansing preparations to inpatients The patient should follow either a low-residue or a full liquid diet the day before the procedure until bowel cleansing begins. Bowel cleansing should follow a split-dose regimen. The evening before the procedure, the patient should drink 2 L of oral polyethylene glycol (PEG) lavage solution. The second 2 L dose should begin 4 to 6 hours before the procedure. A split-dose regimen started early morning the day of a procedure provides better cleansing for patients scheduled in the afternoon. Because many people find the PEG lavage solution difficult to drink and experience nausea and bloating, manufacturers have modified the PEG solutions to improve taste and palatability. Magnesium citrate solution or bisacodyl tablets or suppositories are sometimes given before the PEG lavage to remove the bulk of stool so only 2 L of solution are needed. Encourage the patient to drink all of the solution. Stools will be clear or clear yellow liquid when the colon is clean.

Nursing Implementation - DM

Health Promotion Identify, monitor, and teach patients at risk Obesity: primary risk factor Routine screening for all overweight adults and those older than 45 Diabetes risk test www.diabetes.org/risk-test.jsp Your role in health promotion relates to the identification, monitoring, and teaching of the patient at risk for the development of diabetes. Obesity is the primary risk factor for type 2 diabetes. The Diabetes Prevention Program found that a modest weight loss of 5% to 7% of body weight and regular exercise of 30 minutes five times a week lowered the risk of developing type 2 diabetes up to 58%. The ADA recommends routine screening for type 2 diabetes for all adults who are overweight or obese (BMI of 25 kg/m2 or higher) or have one or more risk factors. For people who do not have risk factors for diabetes, screening should begin at age 45. If values are normal, repeat screening at 3-year intervals. There are many factors that put an individual at an increased risk for diabetes. These include age, ethnicity (being Native American, Hispanic, African American, Asian, Pacific Islander), obesity, having a baby that weighed more than 9 pounds at birth, history of gestational diabetes, and a family history of diabetes. A diabetes risk test is available at http://www.diabetes.org/risk-test.jsp. The diabetes risk test determines if a person is at risk for prediabetes or diabetes on the basis of the number of risk factors present.

Health history - obesity

Health history Time of obesity onset Diseases related to metabolism and obesity Drugs Objective Height, weight, waist circumference, BMI Examine each body system with particular attention to the organ system in which the patient has expressed a problem or concern. Have the right equipment to take measurements. Provide special chairs, examination tables, and scales that can accommodate an obese person. Assess for any co-morbid diseases associated with obesity (e.g., hypertension, sleep apnea)

Subjective Data MS

Health history Viral infections or vaccinations Residence in cold or temperate climates Physical and emotional stress Medications Elimination problems Weight loss, dysphagia Muscle weakness or fatigue, tingling or numbness, muscle spasms Blurred or lost vision, diplopia, vertigo, tinnitus Decreased libido, impotence Anger, depression, euphoria, isolation

Esophageal CancerComplications

Hemorrhage If erodes through esophagus and into aorta Esophageal perforation with fistula formation Esophageal obstruction Esophageal perforation with fistula formation into the lung or trachea sometimes develops. The tumor may enlarge enough to cause esophageal obstruction, particularly in the later stages.

Drug TherapyChronic Hepatitis B and C

Hepatitis B virus reproduces by making copies of its viral DNA nucleosides and nucleotides. The nucleoside/nucleotide analog drugs fool the virus thinking they are normal building blocks for DNA. However, they are faulty viral DNA building blocks. They halt DNA synthesis once they become incorporated into the viral DNA, thus stopping viral replication. Nucleoside and nucleotide analogs do not prevent all viral reproduction, but they can substantially lower the amount of virus in the body. These medications include lamivudine (Epivir), adefovir (Hepsera), entecavir (Baraclude), telbivudine (Tyzeka), and tenofovir (Viread). These oral medications are indicated in the treatment of chronic HBV when there is evidence of significant active viral replication and liver inflammation. Nucleoside and nucleotide analogs have beneficial effects in terms of reducing viral load, decreasing liver damage, and decreasing serum levels of liver enzymes. Most patients with HBV will require long-term treatment with these medications. Many times when these drugs are stopped, most patients (except those who have seroconverted) will have HBV DNA and liver enzyme levels return to pretreatment levels. Severe exacerbations of hepatitis B can develop following discontinuation of treatment. If these drugs are discontinued for any reason, closely monitor liver function for several months.

Diet for patient without complications cirrhoiss

High in calories (3000 cal/day) ↑ Carbohydrate Moderate to low fat Protein restriction rarely justified The diet for the patient who has cirrhosis without complications is high in calories (3000 cal/day) with high carbohydrate content and moderate to low levels of fat. Protein restriction may be appropriate in some patients immediately following a severe flare of symptoms (i.e., episodic hepatic encephalopathy). However, protein restriction is rarely justified in patients with cirrhosis and persistent hepatic encephalopathy. For many patients, malnutrition is a more serious clinical problem than hepatic encephalopathy.

Psychologic Considerations - DM

High rates of Depression, Anxiety, Eating disorders DEBs include anorexia, bulimia, binge eating, excessive restriction of calories, and intense exercise. Patients may intentionally decrease their dose of insulin or omit the dose. This is called "diabulimia" and leads to weight loss, hyperglycemia, and glycosuria because the food ingested cannot be used for energy without adequate insulin.

Drug therapy - gerd

Histamine-2 receptor (H2R) blockers Decrease secretion of HCl acid Reduce symptoms and promote esophageal healing in 50% of patients Example: cimetidine Side effects uncommon Some formulations include an H2R blocker plus antacid combination. For example, Pepcid Complete includes famotidine, calcium carbonate, and magnesium hydroxide. Drug therapy Proton pump inhibitors (PPIs) Promote esophageal healing in 80% to 90% of patients Available in prescription and OTC preps Example: omeprazole (Prilosec) Headache: Most common side effect Drug therapy for GERD focuses on decreasing the volume and acidity of reflux, improving LES function, increasing esophageal clearance, and protecting the esophageal mucosa (see Table 41-10). Proton pump inhibitors (PPIs) and histamine-2 receptor (H2R) blockers are the most common and effective treatments for symptomatic GERD. PPIs are more effective in healing esophagitis than H2-receptor blockers. PPIs are also beneficial in decreasing the incidence of esophageal strictures, a complication of chronic GERD. PPI's are available in prescription or OTC preparations. Therapy should start with once a day dosing, before the first meal of the day. Acid protective Used for cytoprotective properties Example: sucralfate Antacids Quick but short-lived relief Neutralize HCl acid Taken 1-3 hours after meals/at bedtime Example: Maalox, Mylanta Prokinetic drugs Promote gastric emptying Reduce risk of gastric acid reflux Example: metoclopramide (Reglan) Prokinetic (motility-enhancing) drugs (metoclopramide [Reglan]) promote gastric emptying and reduce the risk of gastric acid reflux, but are not a primary therapy for GERD. Cholinergic Increase LES pressure Improve esophageal emptying Increase gastric emptying Example: bethanechol (Urecholine)

Diagnostic Studies ibs

History and physical examination Blood studies CBC Serum electrolyte levels Serum protein levels The diagnosis of IBD includes ruling out other diseases with similar symptoms and then determining whether the patient has Crohn's disease or ulcerative colitis. In early Crohn's disease, the symptoms are similar to those of IBS. Diagnostic studies provide information about disease severity and complications. A CBC typically shows iron-deficiency anemia from blood loss. An elevated WBC count may be an indication of toxic megacolon or perforation. Decreases in serum sodium, potassium, chloride, bicarbonate, and magnesium levels occur due to fluid and electrolyte losses from diarrhea and vomiting. Hypoalbuminemia is present with severe disease because of poor nutrition or protein loss. Elevated erythrocyte sedimentation rate, C-reactive protein level, and WBC count reflect inflammation. Stool examination Pus Blood Mucus Stool cultures The stool is examined for blood, pus, and mucus. Stool cultures can determine if infection is present. Imaging studies Double-contrast barium enema study Small bowel series Transabdominal ultrasonography CT MRI Colonoscopy Imaging studies such as double-contrast barium enema, small bowel series (small bowel follow through), transabdominal ultrasound, CT, and MRI are useful for diagnosing IBD. Colonoscopy allows for examination of the entire large intestine lumen and sometimes the most distal ileum. The extent of inflammation, ulcerations, pseudopolyps, and strictures is determined, and biopsy specimens taken for a definitive diagnosis. Since a colonoscope can enter only the distal ileum, capsule endoscopy (see Chapter 38) may be used to diagnose Crohn's disease in the small intestine.

Drug Therapy CKI

Hyperkalemia Restriction of high-potassium foods and drugs IV glucose and insulin IV 10% calcium gluconate Acute hyperkalemia may necessitate treatment with IV glucose and insulin or IV 10% calcium gluconate. Hyperkalemia Sodium polystyrene sulfonate Cation-exchange resin Osmotic laxative action Resin in bowel exchanges sodium ions for potassium ions Dialysis may be needed Sodium polystyrene sulfonate is commonly used to lower potassium levels in stage 4 and can be administered on an outpatient basis. expect some diarrhea because this preparation contains sorbitol, a sugar alcohol that has an osmotic laxative action and ensures evacuation of the potassium from the bowel. Never Kayexalate + hypoactive bowel (paralytic ileus) = fluid shifts = bowel necrosis. As sodium polystyrene sulfonate exchanges sodium ions for potassium ions, observe the patient for sodium and water retention. Hypertension Weight loss (if indicated) Therapeutic lifestyle changes Diet recommendations (DASH Diet) Administration of antihypertensive drugs It is recommended that the target BP be less than 130/80 mm Hg for patients with CKD and less than 125/75 for patients with significant proteinuria. The BP should periodically be measured in supine, sitting, and standing positions to effectively monitor the effect of antihypertensive drugs. Treatment of hypertension includes (1) weight loss (if obese), (2) therapeutic lifestyle changes (i.e., exercise, avoidance of alcohol, smoking cessation), (3) diet recommendations (DASH Diet), and (4) administration of antihypertensive drugs. Hypertension Antihypertensive drugs ACE inhibitors ARB agents The choice of prescribed medications is dependent on whether the patient with CKD has diabetes or not. The ACE inhibitors and ARBs = decrease proteinuria CKD-Mineral and bone disease (MBD) Phosphate not restricted until patient requires renal replacement therapy Phosphate intake then restricted to < 1 g/day Interventions for CKD-MBD include limiting dietary phosphorus, administering phosphate binders, supplementing vitamin D, and controlling hyperparathyroidism. CKD-MBD Phosphate binders Calcium acetate (PhosLo) Calcium carbonate (Caltrate) Bind phosphate in bowel and then excreted Sevelamer hydrochloride (Renagel) Lowers cholesterol and LDL levels The administration of calcium may increase the calcium load and place the patient at increased risk for vascular calcifications. Therefore when calcium levels are increased or there is evidence of existing vascular or soft tissue calcifications, noncalcium-based phosphate binders may be used.

Problems with insulin therapy

Hypoglycemia Allergic reaction Lipodystrophy Problems associated with insulin therapy include hypoglycemia, allergic reactions, lipodystrophy, and the Somogyi effect. Hypoglycemia is discussed in detail later. Local inflammatory reactions to insulin may occur, such as itching, erythema, and burning sensation around the injection site. Local reactions may be self-limiting within 1 to 3 months or may improve with a low dose of antihistamine. A true insulin allergy is rare. It is manifested by a systemic response with urticaria and possibly anaphylactic shock. Zinc or protamine, used as preservatives in the insulin, and the latex or rubber stoppers on the vials have been implicated in allergic reactions. Lipodystrophy (atrophy or hypertrophy of subcutaneous tissue) may occur if the same injection sites are used frequently. The use of human insulin has significantly reduced the risk for lipodystrophy. Atrophy is the wasting of subcutaneous tissue and presents as indentations in injection sites. Hypertrophy, a thickening of the subcutaneous tissue, eventually regresses if the patient does not use the site for at least 6 months. The use of hypertrophied sites may result in erratic insulin absorption.

Inflammatory Bowel Disease Classification

On the basis of clinical manifestations, IBD is classified as either Ulcerative colitis Inflammation and ulceration of colon and rectum Crohn's disease Inflammation of any segment of GI tract from mouth to anus Crohn's disease and ulcerative colitis are immunologically related disorders that are referred to as IBD.

HemodialysisComplications

Hypotension - decreased cardiac output, and decreased systemic intravascular resistance. Muscle cramps Blood loss may result from blood not being completely rinsed from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture, or bleeding after the removal of needles at the end of HD. At one time, hepatitis B had an unusually high prevalence in dialysis recipients, but the incidence today is low. hepatitis C virus (HCV) = dialysis recipients.

Chronic Ulcerative ColitisSurgical Therapy

IPAA Combination of two procedures Performed 8-12 weeks apart Patient able to resume control of defecation at the anal sphincter Major complication: acute or chronic pouchitis The second surgery involves closure of the ileostomy to direct stool toward the new pouch. Initially, patients may have 4-6 stools or more daily but adaptation over the next 3-6 months will result in a decreased number of bowel movements. The patient is able to control defecation at the anal sphincter. The major complication of this procedure is acute or chronic pouchitis. A permanent ileostomy may be done if pouchitis does not resolve. Total protocolectomy with permanent ileostomy One-stage surgery Removal of colon, rectum, and anus with closure Continence is not possible

Intraoperative period - DM

IV fluids and insulin Frequent monitoring of blood glucose During the intraoperative period, adjustments in the diabetes regimen can be planned to ensure safe and healthy blood glucose levels. The patient is given IV fluids and insulin (if needed) immediately before, during, and after surgery when there is no oral intake. Explain to the patient with type 2 diabetes who has been taking oral agents that this is a temporary measure and it should not be interpreted as a worsening of diabetes. When caring for an unconscious surgical patient receiving insulin, be alert for signs of hypoglycemia such as sweating, tachycardia, and tremors. Frequent monitoring of blood glucose can prevent episodes of severe hypoglycemia.

Nursing ManagementNursing Diagnoses cirrhosis

Imbalanced nutrition: less than body requirements Impaired skin integrity Excess fluid volume Ineffective health management Dysfunctional family processes

Nursing Diagnoses hep

Imbalanced nutrition: less than body requirements related to anorexia and nausea • Activity intolerance related to fatigue and weakness • Risk for impaired liver function related to viral infection

Nursing Care for alzheimers 59-15 dos and don't of care

Impaired memory r/t effects of dementia Self neglect r/t memory deficit, cog impairment, neuromuscular impairment Risk for falls/injury r/t impaired judgment, gait instability, muscle weakness, sensory/perception alterations Risk for wandering r/t cog impairment Assess for - head trauma, CNS infection, fam history of, drug use, emotion reliability, change in nutrition (anorexia, weight loss), incontinent, decr hygiene, weakness, sleep, forgetful, depression, problems w/ problem solving, withdrawal Look at appearance, do neuro check, MMSE

Nursing diagnosis - PD

Impaired physical mobility Imbalanced nutrition: less than body requirements Impaired swallowing Impaired verbal communication Nursing diagnoses for the patient with PD may include, but are not limited to, the following: • Impaired physical mobility related to rigidity, bradykinesia, and akinesia • Imbalanced nutrition: less than body requirements related to inability to ingest food • Impaired swallowing related to neuromuscular impairment (e.g., decreased or absent gag reflex) • Impaired verbal communication related to dysarthria, tremor, and bradykinesia Additional information on nursing diagnoses for the patient with PD is presented in eNursing Care Plan 58-4 (available on the website for this chapter).

Nursing Diagnoses MS

Impaired physical mobility Impaired urinary elimination Ineffective health management Nursing diagnoses for the patient with MS may include, but are not limited to, the following: • Impaired physical mobility related to muscle weakness or paralysis and muscle spasticity • Impaired urinary elimination related to sensorimotor deficits • Ineffective health management related to knowledge deficit regarding management of MS Additional information on nursing diagnoses for the patient with MS is presented in the eNursing Care Plan 58-3 (available on the website for this chapter).

Alzheimer's DiseaseOral Care

In late stages, patient will be unable to perform oral self-care Dental problems are likely to occur Patient may pocket food, adding to potential tooth decay Inspect mouth regularly and provide mouth care Dental caries and tooth abscess can add to patient discomfort or pain and subsequently may increase agitation.

Alzheimer's DiseaseSkin Care

In late stages, patients are at risk for skin breakdown Incontinence, immobility, and undernutrition Tend to rashes, areas of redness Keep skin dry and clean Change patient's position regularly It is important to monitor the patient's skin over time.

Normal Insulin Secretion

In the first hour or two after meals with normal endogenous insulin secretion, insulin concentrations rise rapidly in blood; they peak at about 1 hour. After meals, insulin concentrations promptly decline toward preprandial values as carbohydrate absorption from the gastrointestinal tract declines. After carbohydrate absorption from the gastrointestinal tract is complete and during the night, insulin concentrations are low and fairly constant, with a slight increase at dawn. The rise in plasma insulin after a meal inhibits gluconeogenesis, enhances fat deposition of adipose tissue, and increases protein synthesis. For this reason, insulin is an anabolic, or storage, hormone. The fall in insulin level during normal overnight fasting facilitates the release of stored glucose from the liver, protein from muscle, and fat from adipose tissue.

Two major consequences of obesity are due to

Increase in fat mass Production of adipokines Contribute to insulin resistance and atherosclerosis Disrupt immune factors and predispose to certain cancers Adipocytes produce at least 100 different proteins. These proteins, secreted as enzymes, adipokines, growth factors, and hormones, contribute to the development of insulin resistance and atherosclerosis. An increased release of cytokines from fat cells may disrupt immune factors, thus predisposing to certain cancers. Because visceral fat accumulation is associated with more alterations of these adipokines, people with abdominal obesity have more complications of obesity.

Gerontologic Considerations - DM

Increased prevalence and mortality Glycemic control challenging Increased hypoglycemic unawareness Functional limitations Renal insufficiency The prevalence of diabetes increases with age. A major reason for this is that the process of aging is associated with a reduction in β-cell function, decreased insulin sensitivity, and altered carbohydrate metabolism. renal function and creatinine clearance+ older than 80 years taking metformin. sulfonylurea drugs (e.g., glipizide) = hypoglycemia + renal + liver dysfunction

Gerontologic ConsiderationsObesity

Increased prevalence of obesity Decreased energy expenditure contributes to increased body fat ↓ Mobility, urinary incontinence, hypoventilation, sleep apnea ↓ Quality of life ↓ Life expectancy by 6-7 years The mechanical strain on weight-bearing joints can lead to premature immobility.

Chronic PancreatitisInterprofessional Care - Surgery

Indicated when biliary disease is present or if obstruction or pseudocyst develops Diverts bile flow or relieves ductal obstruction Choledochojejunostomy Roux-en-Y pancreatojejunostomy A choledochojejunostomy diverts bile around the ampulla of Vater, where there may be spasm or hypertrophy of the sphincter. In this procedure, the common bile duct is anastomosed into the jejunum. Roux-en-Y pancreatojejunostomy, = pancreatic duct is opened and an anastomosis is made with the jejunum.

TRAP - PD

Onset is gradual and insidious with ongoing progression TRAP Tremor Rigidity Akinesia Postural instability The onset of PD is gradual and insidious, with an ongoing progression. Only one side of the body may be involved initially. Classic manifestations of PD are easily remembered by the mnemonic TRAP (tremor, rigidity, akinesia, and postural instability).

Clinical Manifestations - Cholecystitis In addition to pain

Indigestion Fever, chills Jaundice Pain, tenderness RUQ Referred to right shoulder, scapula Nausea/vomiting Restlessness Diaphoresis Manifestations of cholecystitis vary from indigestion to moderate to severe pain, fever, and jaundice. Initial symptoms of acute cholecystitis include indigestion and pain and tenderness in the right upper quadrant, which may be referred to the right shoulder and scapula. The pain may be accompanied by nausea and vomiting, restlessness, and diaphoresis. Inflammation Leukocytosis Fever Physical examination findings RUQ or epigastrium tenderness Abdominal rigidity Manifestations of inflammation include leukocytosis and fever. Physical findings include right upper quadrant tenderness and abdominal rigidity.

Diagnostic Studies CRC

Individual and family history Regular screening for polyps and cancer from ages 50 to 75 years of age Flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Double-contrast barium enema every 5 years CT colonography every 5 years Since symptoms of CRC do not become evident until the disease is advanced, there is an increased emphasis on screening. Beginning at age 50 and continuing until age 75, men and women at average risk for developing CRC should undergo screening tests to detect both polyps and cancer according to one of the testing schedules above. CT colonography is also called virtual colonoscopy. Annual screening primarily for cancer High sensitivity fecal occult blood test (FOBT) Fecal immunochemical test (FIT) Test for blood in the stool Must be done frequently to catch intermittent bleeding common with tumors The tests that primarily detect cancer should be done every year. Less favorable, but acceptable, screening methods include stool testing for fecal blood. The FOBT and FIT look for blood in the stool. Stool tests must be done frequently, since tumor bleeding occurs at intervals and may easily be missed if a single test is done. In addition to testing for blood in human stool, new tests (PreGen-Plus, Cologuard) can detect DNA mutations that may indicate the presence of CRC. Colonoscopy "Gold standard" Entire colon is examined Biopsy samples can be obtained Polyps can be immediately removed and sent to laboratory for examination Colonoscopy is the gold standard for CRC screening because the entire colon is examined (only 50% of CRCs are detected by sigmoidoscopy), biopsies can be obtained, and polyps can be immediately removed and sent to the laboratory for examination. People at average risk of CRC should have a colonoscopy every 10 years beginning at age 50. Persons at risk need earlier and more frequent screening Those with first-degree relative in whom CRC was diagnosed before age 60 Those with two first-degree relatives with CRC Persons at risk should begin screening earlier and have screening done more often. African Americans should have their first colonoscopy at age 45. Those who have a first-degree relative who developed CRC before age 60 or have two first-degree relatives with CRC should have a colonoscopy every 5 years beginning at age 40 or 10 years earlier than when the youngest relative developed cancer. Those who have one first-degree relative who had CRC after age 60 should have a colonoscopy every 10 years beginning at age 40. Tissue biopsies confirm diagnosis Additional laboratory studies are then needed CBC to check for anemia Liver function tests Note: liver function test results may be normal even when metastasis has occurred. Carcinoembryonic antigen (CEA) Complex glycoprotein Sometimes produced by colorectal cancer cells May be used to monitor for disease recurrence after surgery or chemotherapy NOT a good screening tool because of a large number of false positives CEA levels may also be increased in non-colon carcinomas (e.g., gastric, pancreatic, lung carcinoma, breast, and thyroid carcinoma) as well as some non-neoplastic conditions such as IBD, pancreatitis, cirrhosis, COPD, and smokers. CT scan or MRI of the abdomen Helpful in detecting Liver metastases Retroperitoneal and pelvic disease Depth of penetration of tumor in bowel wall

Nursing Diagnoses - DM

Ineffective health management Risk for unstable blood glucose levels Risk for injury Risk for peripheral neurovascular dysfunction

Three phases of PD cycle

Inflow (fill) Dwell (equilibration) Drain Called an exchange The three phases are called an exchange. For manual PD, a period of about 30 to 50 minutes is required to complete an exchange.

DementiaClinical Manifestations

Initial symptoms are related to changes in cognitive function Family members often report Memory loss Mild disorientation Trouble with words and numbers Often it is a family member, in particular the spouse, who reports the patient's declining memory to the HCP.

Photodynamic therapyeosph CA

Inject IV porfimer (Photofrin), which is absorbed by cancer tissue Light transmitted through an endoscopic fiber reacts with porfimer, starting a reaction that destroys cancer cells In photodynamic therapy, the patient receives an IV injection of porfimer sodium (Photofrin), which is a photosensitizer. Although most tissues absorb porfimer, cancer tissue absorbs it to a greater degree. The HCP directs light towards the cancerous area using a fiber passed through an endoscope. The light reacts with porfimer, starting a reaction that destroys the cancer cells. Must avoid direct sunlight 4 weeks after

Clinical Manifestations CRC

Insidious onset Symptoms often do not appear until disease is in advanced stages Change in bowel habits Unexplained weight loss Vague abdominal pain Weakness and fatigue Physical findings may include the following: Early disease: Nonspecific findings (fatigue, anorexia, weight loss) or none at all. Weakness and fatigue may occur from iron-deficiency anemia from GI bleeding. More advanced disease: Abdominal tenderness, abdominal distension, rectal pain, palpable abdominal mass, hepatomegaly, ascites.

Medical Alert - DM

Instruct the patient to carry medical identification at all times that indicates that he or she has diabetes. Police, paramedics, and many private citizens are aware of the need to look for this identification when working with sick or unconscious persons. Every person with diabetes is encouraged to wear a MedicAlert bracelet or necklace. An identification card can supply valuable information, such as the name of the HCP, the type of diabetes, and the type and dose of insulin or OA.

DementiaClinical Manifestations

Onset of dementia depends on cause Gradual and progressive over time Neurologic degeneration Abrupt Vascular dementia tends to be abrupt or progress in a stepwise pattern

Genetic Link DM

Insulin resistance Decreased insulin production by pancreas Inappropriate hepatic glucose production Altered production of hormones and cytokines by adipose tissue (adipokines) Research continues on role of brain, kidneys, and gut in type 2 diabetes Metabolic abnormalities have a role in the development of type 2 diabetes. It is likely multiple genes are involved. 1. This is because insulin receptors are unresponsive to the action of insulin and/or insufficient in number. insulin receptors = skeletal muscle, fat, and liver cells. insulin is not properly used = glucose into the cell is impeded =hyperglycemia. 2. Decrease in the ability of the pancreas to produce insulin, as the β-cells become fatigued from the compensatory overproduction of insulin or when β-cell mass is lost. The underlying reason why the β-cells fail to adapt is unknown. It may be linked to the adverse effects of chronic hyperglycemia or high levels of circulating free fatty acids. In addition, the α cells of the pancreas increase production of glucagon. 3. Inappropriate glucose production by the liver. Instead of properly regulating the release of glucose in response to blood levels, the liver does so in a haphazard way that does not correspond to the body's needs at the time. 4. Altered production of hormones and cytokines by adipose tissue (adipokines). Adipokines secreted by adipose tissue appear to play a role in glucose and fat metabolism and are likely to contribute to the pathophysiology of type 2 diabetes. Adipokines are thought to cause chronic inflammation, a factor involved in insulin resistance, type 2 diabetes, and cardiovascular disease. The two main adipokines believed to affect insulin sensitivity are adiponectin and leptin. 5. Finally, the brain, kidneys, and gut also have roles in the development of type 2 diabetes, and scientists are continuously learning more about metabolic factors in the development of type 2 diabetes.

Metabolic SyndromeEtiology and Pathophysiology

Insulin resistance related to excessive visceral fat Increased prevalence of coronary artery disease Hypertension Increased risk for clotting Abnormal cholesterol levels The main underlying risk factor for metabolic syndrome is insulin resistance related to excessive visceral fat.

Drug TherapyChronic Hepatitis B

Interferon Naturally occurring immune protein Antiviral, antiproliferative, and immune modulating effects Pegylated interferon (PegIntron, Pegasys) given subcutaneously Side effects Flu-like symptoms, depression Interferon is a naturally occurring immune protein made by the body during an infection to recognize and respond to pathogens. It has antiviral, antiproliferative, and immune modulating effects. Pegylated interferon (PegIntron, Pegasys) is given by subcutaneous injection. The numerous side effects with interferon therapy, including flu-like symptoms (e.g., fever, malaise, fatigue), make adherence to therapy challenging for some patients. Patients receiving interferon should have blood counts and liver function tests performed every 4 to 6 weeks. Depression is a side effect of interferon. Patients need to be screened for depression and other mood disorders before starting interferon treatment and monitored frequently while on therapy.

Psychologic Factors IBS

Interventions that help patients cope Cognitive behavior therapy Stress management techniques Acupuncture Hypnosis Regular exercise Decreases bloating and constipation Reduces symptoms of anxiety and depression

What nutritional recommendations can you advise D.B. to incorporate?

Keep a food diary to identify foods that he is not tolerating well. Limit cold foods and high-fat foods, and replace dairy with yogurt until it is clearer just what foods he is not tolerating well.

Alzheimer's DiseaseHealth Promotion

Keep your brain healthy Avoid harmful substances Challenge your mind Exercise regularly Stay socially active Avoid trauma to the brain Keep your brain healthy Take care of mental health Treat diabetes Take care of your heart Get enough sleep Get the right fuel

Clinical ManifestationsRespiratory System CKI

Kussmaul respirations Dyspnea may occur with Fluid overload Pulmonary edema Uremic pleuritis Respiratory infections With severe acidosis, the respiratory system may attempt to compensate with Kussmaul breathing, which results in increased carbon dioxide removal by exhalation (see Chapter 16). Dyspnea may occur as a manifestation of fluid overload, pulmonary edema, uremic pleuritis (pleurisy), pleural effusions, and respiratory infections (e.g., pneumonia).

DELIRIUM LABS

Laboratory tests Electrocardiogram (ECG) Urinalysis Liver and thyroid function tests Oxygen saturation level Lumbar puncture Laboratory tests to explore the cause Serum electrolytes Blood urea nitrogen level Creatinine level Complete blood count (CBC) Drug and alcohol levels Drug and alcohol levels may be obtained. If unexplained fever or nuchal rigidity is present, and meningitis or encephalitis is suspected, a lumbar puncture may be performed. Drug and alcohol levels may be obtained. If unexplained fever or nuchal rigidity is present, and meningitis or encephalitis is suspected, a lumbar puncture may be performed.

Acute PancreatitisDiagnostic Studies

Laboratory tests Serum amylase level Serum lipase level Liver enzyme levels Triglyceride levels Glucose level Bilirubin level Serum calcium level The primary diagnostic tests for acute pancreatitis are serum amylase and lipase measurements. The serum amylase level is usually elevated early and remains elevated for 24 to 72 hours. Serum lipase level, which is also elevated in acute pancreatitis, is an important test because other disorders (e.g., mumps, cerebral trauma, renal transplantation) may increase serum amylase levels. increase in liver enzymes, triglycerides, glucose, and bilirubin levels decrease in calcium level. CT = best imaging test for pancreatitis = pseudocysts and abscesses. ERCP is can be used, although ERCP can cause acute pancreatitis in some cases. Additional studies include endoscopic ultrasonography (EUS), magnetic resonance cholangiopancreatography (MRCP), and angiography. Chest x-rays = atelectasis and pleural effusions.

Laboratory tests- Cholecystitis

Laboratory tests ↑ WBC count ↑ Serum bilirubin level ↑ Urinary bilirubin level ↑ Liver enzyme levels ↑ Serum amylase level Laboratory tests may reveal an increased WBC count as a result of inflammation. Both the direct and indirect bilirubin levels may also be elevated, as is the urinary bilirubin level if an obstructive process is present. Serum enzymes, such as alkaline phosphatase, ALT, and AST, may be elevated. The serum amylase level is increased if there is pancreatic involvement.

Chronic ComplicationsDiabetic Retinopathy - Treatment

Laser photocoagulation Most common Laser destroys ischemic areas of retina Vitrectomy Aspiration of blood, membrane, and fibers inside the eye Drugs to block action of vascular endothelial growth factor (VEGF) Laser photocoagulation = destroys the ischemic areas of the retina that produce growth factors that encourage neovascularization. vitreous hemorrhage and retinal detachment of the macula = vitrectomy. Vitrectomy = aspiration of blood, membrane, and fibers from the inside of the eye Iluvien (fluocinolone acetonide intravitreal implant) is used to treat retinopathy. It is an injectable micro-insert that provides sustained treatment through continuous delivery of corticosteroid fluocinolone acetonide for 36 months. Iluvien is injected in the back of the patient's eye with an applicator that uses a 25-gauge Research has identified the importance of vascular endothelial growth factor (VEGF) in the development of diabetic retinopathy. Drugs injected into the eye that block the action of VEGF and reduce inflammation are currently being studied for their effectiveness in treating retinopathy.

Drain

Lasts 15 to 30 minutes May be facilitated by gently massaging abdomen or changing position Ultrafiltration during PD depends on osmotic forces The cycle starts again with the infusion of another 2 L of solution. Dialysis solutions vary, and the choice of the exchange volume is primarily determined by the size of the peritoneal cavity. A larger person may require a 3-L exchange volume without any difficulty, whereas an average-size person typically uses a 2-L exchange. Smaller exchange volumes are used for patients with a smaller body, pulmonary compromise (the added pressure of the large volume may precipitate respiratory difficulty), or inguinal hernias. Dialysis solutions vary, and the choice of the exchange volume is primarily determined by the size of the peritoneal cavity. A larger person may require a 3-L exchange volume without any difficulty, whereas an average-size person typically uses a 2-L exchange. Smaller exchange volumes are used for patients with a smaller body, pulmonary compromise (the added pressure of the large volume may precipitate respiratory difficulty), or inguinal hernias. Ultrafiltration (fluid removal) during PD depends on osmotic forces; with dextrose being the most commonly used osmotic agent in PD solutions. It is relatively safe and inexpensive, but is associated with high rates of peritoneal glucose absorption leading to problems with hypertriglyceridemia, hyperglycemia, and long-term peritoneal membrane dysfunction.

Diabetes Mellitus causes

Leading cause of Adult blindness End-stage renal disease Nontraumatic lower limb amputations Major contributing factor Heart disease Stroke The risk for stroke is also two to four times higher among people with diabetes. diabetes have hypertension and high cholesterol levels.

Nigrostriatal Disorder in Parkinsonism

Left-sided view of the human brain shows the substantia nigra and the corpus striatum (shaded area) lying deep within the cerebral hemisphere. Nerve fibers extend upward from the substantia nigra, divide into many branches, and carry dopamine to all regions of the corpus striatum.

Interprofessional Care - gerd

Lifestyle modifications Avoiding triggers Maintain appropriate weight Smoking cessation Stress management Most patients with GERD can successfully manage this condition through lifestyle modifications and drug therapy. These long-term approaches require patient teaching and compliance with therapies. With regard to triggers, give particular attention to diet and drugs that may affect the LES, acid secretion, or gastric emptying. Nutritional therapy Avoid foods that decrease LES pressure or irritate the esophagus Small, frequent meals Avoid late evening meals Drink fluids between meals decrease LES pressure include chocolate, peppermint, tomatoes, coffee, and tea. tomato-based products, orange juice, cola, red wine =irritate the esophagus. Increased saliva production by chewing gum/oral lozenges small frequent meals

Hiatal HerniaInterprofessional Management

Lifestyle modifications Eliminate alcohol Elevate head of bed Stop smoking Avoid lifting/straining Reduce weight, if appropriate Use antisecretory agents and antacids Conservative therapy for hiatal hernia is similar to that for GERD. Surgical Therapy Provide acceptable lower esophageal sphincter (LES) pressure Prevent movement of gastroesophageal junction Surgical Therapy Reduction of herniated stomach Herniotomy Excision of hernia sac Herniorrhaphy Closure of hiatal defect Antireflux procedure Gastropexy Attachment of stomach subdiaphragmatically to prevent reherniation Laparoscopically performed techniques are standard antireflux surgeries Nissen Toupet Thoracic or abdominal approach

Metabolic SyndromeNursing/Interprofessional Management

Lifestyle modifications are first-line interventions Reduce LDL cholesterol Stop smoking Lower blood pressure Reduce glucose levels For long-term risk reduction, weight should be decreased, physical activity increased, and healthy dietary habits established. Weight reduction and maintenance of a lower weight should be the first priority in those with abdominal obesity and metabolic syndrome. low in saturated fats and should promote weight loss.

Fats DM

Limit saturated fats to < 7% of total calories Limit cholesterol to < 200 mg/day Minimize trans fat Healthy fats come from plants Olives, nuts, avocados Dietary fat provides energy, carries fat-soluble vitamins, and provides essential fatty acids. The ADA recommends limiting saturated fat to less than 7% of total calories. Less than 200 mg/day of cholesterol and limited trans fats are also recommended as part of a healthy meal plan. Decreasing fat and cholesterol intake assists in reducing the risk for cardiovascular disease.

DiabetesAlcohol

Limit to moderate amount 1 drink/day for women; 2 drinks/day for men Inhibits gluconeogenesis by liver Can cause severe hypoglycemia Blood glucose levels must be monitored Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver. This can cause severe hypoglycemia in patients on insulin or oral hypoglycemic medications that increase insulin secretion. Create a trusting environment where patients feel comfortable being honest about their use of alcohol because its use can make blood glucose more difficult to manage. Moderate alcohol consumption can be safely incorporated into the meal plan if the person is monitoring blood glucose levels and if the patient is not at risk for other alcohol-related problems. Moderate consumption is defined as one drink per day for women and two drinks per day for men. A patient can reduce the risk for alcohol-induced hypoglycemia by eating carbohydrates when drinking alcohol. On the other hand, mixed drinks often contain sweetened mixers and can lead to elevated blood glucose levels. To decrease the carbohydrate content, recommend using sugar-free mixes and drinking dry, light wines.

G.O. is very upset. He has many questions about his diagnosis and upcoming surgery. What interventions are appropriate to help alleviate his stress?

Listen to his concerns and questions. Talk to him about the procedure and what he can expect following surgery. Elicit information about his support system and encourage him to have those people close by and available during this time.

Diagnostic Studiescirrhosis

Liver enzyme tests Total protein, albumin levels Serum bilirubin, globulin levels Cholesterol levels Prothrombin time Ultrasound elastography (Fibroscan) Liver biopsy In cirrhosis, there are abnormalities in most of the liver function tests. Enzyme levels, including alkaline phosphatase, AST, ALT, and γ-glutamyl transpeptidase (GGT), are initially elevated because of their release from inflamed liver cells. However, in end-stage liver disease, AST and ALT levels may be normal due to the death and loss of hepatocytes. Patients with cirrhosis will also have decreased serum total protein and albumin, increased serum bilirubin and globulin levels, and prolonged prothrombin time. Alterations in fat metabolism abnormalities are reflected by decreased cholesterol levels. Although a liver ultrasound study may be able to detect the presence of cirrhosis. it is not a reliable diagnostic test for cirrhosis. Ultrasound elastography (Fibroscan) is a non-invasive test that is used to quantify the degree of liver fibrosis. A liver biopsy, which may be done to identify liver cell changes, is the gold standard for a definitive diagnosis of cirrhosis. A liver biopsy may be done to identify liver cell changes and alterations in the lobular structure. Differential analysis of ascitic fluid may help confirm the cause of cirrhosis.

Three surgical options in rectal cancer

Local excision Abdominal-perineal resection (APR) with a permanent colostomy Low anterior resection (LAR) to preserve sphincter function In rectal cancer, the location and size of the tumor determines the course of treatment. Local excision may be an option. If the tumor is in the distal rectum (1-2 cm from the anorectal junction) and the sphincters cannot be preserved, the patient will undergo an abdominal-perineal resection (APR). An APR involves removing the entire rectum with the tumor, and the patient will have a permanent colostomy. The perineal wound may be closed around a drain or left open with packing to allow healing by granulation. Complications that can occur include delayed wound healing, hemorrhage, persistent perineal sinus tracts, infections, and urinary tract and sexual dysfunction. If the tumor is in the mid or proximal rectum, it may be possible to preserve the sphincters. In this situation, a low anterior resection (LAR) can be done. A LAR involves removing the rectum and anastomosing the colon to the anal canal. A temporary ileostomy or colostomy may be done to divert stool and allow time for the anastomosis to heal, usually about 8-12 weeks. Then the ostomy can be "taken down" and the ends of the colon surgically reconnected. A LAR is increasingly common because of advancements in laparoscopy and stapling techniques. End-to-end anastomosis stapling involves less tissue (less than 5 cm from anus) and more secure with less leakage.

Nursing Assessment - Objective Data hep

Low-grade fever Jaundice Rash Hepatomegaly Splenomegaly Abnormal laboratory values

Expected Outcomes Hep

Maintain food and fluid intake adequate to meet nutritional needs Avoid alcohol and other hepatotoxic agents Demonstrate gradual increase in activity tolerance Perform daily activities with scheduled rest periods Expected outcomes are that the patient with hepatitis will Maintain food and fluid intake adequate to meet nutritional needs Avoid alcohol and other hepatotoxic agents Demonstrate gradual increase in activity tolerance Perform daily activities with scheduled rest periods

Acute illness - DM

Maintain normal diet if able Increase noncaloric fluids Continue taking antidiabetic medications If normal diet not possible, supplement with CHO-containing fluids while continuing medications Food intake is important during times of stress and illness because the body requires extra energy to deal with the stress of the illness. If patients are able to eat normally, they can continue with their regular meal plan while increasing the intake of noncaloric fluids, such as water, sugar-free gelatin, and other decaffeinated beverages, and continue taking oral agents, nonisulin injectable agents, and insulin as prescribed. When illness causes patients to eat less than normal, they can continue to take oral hypoglycemic medications, noninsulin injectable agents, and/or insulin as prescribed while supplementing food intake with carbohydrate-containing fluids, such as low-sodium soups, juices, and regular sugar-sweetened decaffeinated soft drinks. It is important to tell the patient to contact a HCP if he or she is unable to keep down food or fluid.

Nursing ManagementEvaluation cirrhosis

Maintenance of food/fluid intake to meet needs Maintenance of skin integrity Normalization of fluid balance Treatment for substance abuse Expected outcomes are that the patient with cirrhosis will: Maintain food and fluid intake adequate to meet nutritional needs Maintain skin integrity with relief of edema and pruritus Experience normalization of fluid balance as a result of medical and nursing interventions Acknowledge and get treatment for a substance abuse problem

HemodialysisSettings and Schedules

Majority treated in a community-based center Dialyzed for 3 to 4 hours 3 days per week Other schedule options Short daily HD Long nocturnal HD Home HD The patient receiving long nocturnal HD has the advantage of sleeping while dialyzing. Each nocturnal treatment lasts 6 to 8 hours, and the patient dialyzes up to six times per week. HD allows greater freedom in choosing dialysis times = 2 1/2 to 3 hours per session 5 to 6 days per week.

G.O. is going to have abdominal surgery for his stage I tumor. What is the priority care before surgery?

Make sure his hypertension is managed. Regarding his current condition, he needs patient teaching and emotional support.

Nutritional Therapy - PD

Malnutrition and constipation can be serious consequences Patients with dysphagia and bradykinesia need food that is easily chewed and swallowed Cut food into bite-sized pieces before it is served, and serve it on a warmed plate to preserve its appeal. Eating more numerous small meals is less exhausting than eating fewer large meals each day Provide ample time to avoid frustration Levodopa can be impaired by protein and vitamin B6 ingestion

Hiatal HerniHiatal HerniaEtiology and Pathophysiologya

Many factors involved Structural changes occur with aging Weakening of muscles in diaphragm Increased intraabdominal pressure Obesity Pregnancy Heavy lifting Other factors that increase intraabdominal pressure are ascites, tumors, intense physical exertion, and heavy lifting on a continuous basis.

Planning - PD

Maximize neurologic function Maintain independence in activities of daily living (ADLs) for as long as possible Optimize psychosocial well-being The overall goals are that the patient with PD will (1) maximize neurologic function, (2) maintain independence in activities of daily living for as long as possible, and (3) optimize psychosocial well-being.

Esophageal CancerChemotherapy and radiation therapy

May be given concurrently for palliation Sometimes radiation started before surgery Many different chemotherapy combinations used Concurrent radiation and chemotherapy are used for palliation of symptoms, especially dysphagia, as well as to increase survival. Common combination regimens are carboplatin and paclitaxel (Taxol), cisplatin and 5-fluorouracil (5-FU), ECF (epirubicin [Ellence], cisplatin, and 5-FU), DCF (docetaxel [Taxotere]), cisplatin, and 5-FU, cisplatin with capecitabine (Xeloda), and oxaliplatin and either 5-FU or capecitabine. Other chemotherapy drugs that have been used include bleomycin, mitomycin, methotrexate, vinorelbine (Navelbine), topotecan, and irinotecan (Camptosar). (Chemotherapy is discussed in Chapter 15.)

Radiation therapy

May be used As an adjuvant to surgery and chemotherapy As palliative therapy for metastasis To reduce tumor size To provide symptomatic relief Some patients may receive radiation therapy as an adjuvant to surgery and chemotherapy or as a palliative measure for those with metastatic cancer. As a palliative measure, the primary objective is to reduce tumor size and provide symptomatic relief. Radiation therapy is described in Chapter 15.

Inflammatory Bowel Disease Description

May occur at any age Commonly occur during teenage years and early adulthood Second peak in sixth decade Occur more commonly in people of white and Ashkenazic Jewish origin Many have a family member with disorder IBD occurs more commonly in people of white and Ashkenazic Jewish origin than in other racial and ethnic groups. Many people with IBD have a family member with the disorder.

DiabetesNutritional Therapy: Type 1 DM

Meal planning Based on usual food intake and preferences Balanced with insulin and exercise patterns Day-to-day consistency makes it easier to manage blood glucose levels More flexibility with rapid-acting insulin, multiple daily injections, and insulin pump People with type 1 diabetes base their meal planning on usual food intake and preferences balanced with insulin and exercise patterns. The patient coordinates insulin dosing with eating habits and activity pattern in mind. Day-to-day consistency in timing and amount of food eaten makes it much easier to manage blood glucose levels, especially for those individuals using conventional, fixed insulin regimens. Patients using rapid-acting insulin can adjust the dose before each meal based on the current blood glucose level and the carbohydrate content of the meal. Intensified insulin therapy, such as multiple daily injections or the use of an insulin pump, allows considerable flexibility in food selection, and can be adjusted for alterations from usual eating and exercise habits.

Balloon tamponade

Mechanical compression of varices Sengstaken-Blakemore tube Minnesota tube Linton-Nachlas tube Balloon tamponade may be used when acute esophageal or gastric variceal hemorrhage that cannot be controlled on initial endoscopy. Balloon tamponade controls the hemorrhage by mechanical compression of the varices. Different types of tubes are available. The Sengstaken-Blakemore tube has two balloons, gastric and esophageal, with three lumens: one for the gastric balloon, one for the esophageal balloon, and one for gastric aspiration. Two other types of balloons include the Minnesota tube (a modified Sengstaken-Blakemore tube with an esophageal suction port above the esophageal balloon), and the Linton-Nachlas tube. See next slide for figure.

Metabolic Syndrome

Medical problems will develop over time if the condition remains unaddressed. Patients with this syndrome are at a higher risk of developing heart disease, stroke, diabetes, renal disease, and polycystic ovary syndrome. Patients who have metabolic syndrome and smoke are at an even higher risk.

MyPlate for People With Diabetes

MyPlate was developed by the U.S. Department of Agriculture (USDA) to represent national nutrition guidelines for people with or without diabetes. This simple method helps the patient visualize the amount of vegetables, starch, and meat that fills a 9-in plate. The recommendation is that each meal has one half of the plate filled with nonstarchy vegetables, one fourth filled with a starch, and one fourth filled with a protein (www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate). An 8-ounce glass of nonfat milk and a small piece of fresh fruit complete the meal.

Hepatitis B Virus (HBV) - At-risk populations

Men who have sex with men Household contact of chronically infected Patients undergoing hemodialysis Health care and public safety workers Transplant recipients Sexual transmission is a common mode of HBV transmission. Men who have sex with men (especially those practicing unprotected anal intercourse) are at risk for HBV infection. It is generally believed that casual encounters such as hugging, kissing, and sharing utensils do not transmit the disease. Other at-risk individuals include those who live with chronically HBV-infected persons, patients undergoing hemodialysis, health care personnel, and public safety workers. Organ and tissue transplantation is another potential source of infection. However, in some patients with acute hepatitis B, there is no readily identifiable risk factor.

Type 2 Diabetes MellitusEtiology and Pathophysiology

Metabolic syndrome increases risk for type 2 diabetes Elevated glucose levels Abdominal obesity Elevated BP High levels of triglycerides Decreased levels of HDLs Individuals with metabolic syndrome are at an increased risk for the development of type 2 diabetes. three of the five components is considered to have metabolic syndrome.

Biguanides

Metformin (Glucophage) Reduces glucose production by liver Enhances insulin sensitivity Improves glucose transport May cause weight loss Used in prevention of type 2 diabetes The most widely used oral diabetes agent is metformin, the only medication in the biguanide class available in the United States. Metformin is the most effective first line treatment for type 2 diabetes. The primary action of metformin is to reduce glucose production by the liver. It also enhances insulin sensitivity at the tissue level and improves glucose transport into the cells. In addition, it has beneficial effects on plasma lipids. Because it may cause moderate weight loss, metformin may be useful for people with type 2 diabetes and prediabetes who are overweight or obese. It is also used in the prevention of type 2 diabetes in those with prediabetes who are younger than 60 and have risk factors such as hypertension or a history of gestational diabetes.

Continual Renal Replacement Therapy (CRRT)

Method for treating AKI Means by which uremic toxins and fluids are removed Acid-base status/electrolyte are adjusted slowly and continuously The principle of CRRT is to dialyze patients in a more physiologic way (over 24 hours), just like the kidneys. CRRT is contraindicated = life-threatening = uremia (hyperkalemia, pericarditis) Can be used in conjunction with HD life-threatening manifestations of uremia that require rapid treatment Infusion of replacement fluid determined by degree of fluid and electrolyte imbalance Replacement fluid infused into the infusion port before the hemofilter allows for greater clearance of urea and can decrease filter clotting. The use of the infusion port located after the filter dilutes intravascular fluid, decreasing the concentration of unwanted solutes such as BUN, creatinine, and potassium. Can be continued as long as 30 to 40 days Hemofilter should be changed every 24 to 48 hours Ultrafiltrate should be clear yellow Specimens may be obtained for evaluation of serum chemistries. If the ultrafiltrate becomes bloody or blood tinged, suspect a possible rupture in the filter membrane Treatment needs to be terminated to prevent blood loss. Specific nursing interventions Obtain weights Monitor and document laboratory values daily Assess hourly Intake and output Vital signs Hemodynamic status Care for site to prevent infection Although reductions in central venous pressure and pulmonary artery pressure are expected, there should be little change in mean arterial pressure or cardiac output. Assess and maintain the patency of the CRRT system. Care for the patient's vascular access site to prevent infection. Once the patient's AKI is resolved or there is a decision to withdraw treatment, CRRT is discontinued and the needle(s) removed. Continuous venovenous hemofiltration (CVVH) Slow continuous ultrafiltration (SCUF) Continuous venovenous hemodialysis (CVVHD) Continuous venovenous hemodiafiltration (CVVHDF) Various types of CRRT are available (Table 46-14). CRRT most commonly uses the venovenous approaches of continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF). Vascular access for CRRT is achieved through the use of a double-lumen catheter (as used in HD [Fig. 46-10]) placed in the jugular or femoral vein. Various types of CRRT are available (Table 46-14). CRRT most commonly uses the venovenous approaches of continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF). Vascular access for CRRT is achieved through the use of a double-lumen catheter (as used in HD [Fig. 46-10]) placed in the jugular or femoral vein.

Waist-to-hip ratio (WHR)

Method of describing distribution of subcutaneous and visceral adipose tissue Waist measurement/hip measurement WHR <0.8 optimal WHR >0.8 at risk for health complications describing the distribution of both subcutaneous and visceral adipose tissue. The ratio is calculated by using the waist measurement divided by the hip measurement.

Chronic ComplicationsFoot Complications

Microvascular and macrovascular diseases increases risk for injury and infection Sensory neuropathy and PAD are major risk factors for amputation clotting abnormalities, impaired immune function, autonomic neuropathy Smoking increases risk Sensory neuropathy and peripheral artery disease (PAD) are risk factors for foot complications. In addition clotting abnormalities, impaired immune function, and autonomic neuropathy also have a role. Smoking is deleterious to the health of lower extremity blood vessels and increases the risk for amputation. Sensory neuropathy → loss of protective sensation → unawareness of injury Monofilament screening Peripheral artery disease ↓ Blood flow, ↓ wound healing, ↑ risk for infection Sensory neuropathy is a major risk factor for lower extremity amputation in the person with diabetes. Loss of protective sensation (LOPS) often prevents the patient from being aware that a foot injury has occurred. Because the primary risk factor for lower extremity amputation is LOPS, annual screening with a monofilament is important. This is done by applying a thin, flexible filament to several spots on the plantar surface of the foot and asking the patient to report if it is felt. Insensitivity to a monofilament has been shown to greatly increase the risk for foot ulcers that can lead to amputation. PAD increases the risk for amputation by causing a reduction in blood flow to the lower extremities. Signs of PAD include intermittent claudication, pain at rest, cold feet, loss of hair, delayed capillary filling, and dependent rubor (redness of the skin that occurs when the extremity is in a dependent position). Management includes reduction of risk factors, particularly smoking, cholesterol intake, and hypertension. Bypass or graft surgery is indicated in some patients. Patient teaching to prevent foot ulcers Proper footwear Avoidance of foot injury Skin and nail care Daily inspection of feet Prompt treatment of small problems Diligent wound care for foot ulcers Neuropathic arthropathy (Charcot's foot) Casting can be done to redistribute the weight on the plantar surface of the foot. Neuropathic arthropathy = Charcot's foot, results in ankle and foot changes that ultimately lead to joint dysfunction and footdrop.

Chronic ComplicationsDiabetic Retinopathy

Microvascular damage to retina Most common cause of new cases of adult blindness Nonproliferative: more common Proliferative: more severe Diabetic retinopathy = microvascular damage to the retina as a result of = hyperglycemia, presence of nephropathy, and hypertension in patients with diabetes. Diabetic retinopathy = most common cause adult blindness. Retinopathy can be classified as nonproliferative or proliferative. Nonproliferative Partial occlusion of small blood vessels in retina causes microaneurysms Proliferative Involves retina and vitreous humor New blood vessels formed (neovascularization): very fragile and bleed easily Can cause retinal detachment nonproliferative retinopathy = most common form, partial occlusion of the small blood vessels in the retina causes microaneurysms to develop in the capillary walls. The walls of these microaneurysms are so weak that capillary fluid leaks out, causing retinal edema and eventually hard exudates or intraretinal hemorrhages. Proliferative retinopathy, the most severe form, involves the retina and the vitreous humor. When retinal capillaries become occluded, the body compensates by forming new blood vessels to supply the retina with blood, a pathologic process known as neovascularization. These new vessels are extremely fragile and hemorrhage easily, producing vitreous contraction. Eventually light is prevented from reaching the retina as the vessels become torn and bleed into the vitreous cavity. The patient sees black or red spots or lines. If these new blood vessels pull the retina while the vitreous contracts, causing a tear, partial or complete, retinal detachment will occur. If the macula is involved, vision is lost. Without treatment, more than half of patients with proliferative diabetic retinopathy will be blind. Glaucoma = neovascularization. Cataracts develop at an earlier age type 1 diabetes = eye examined with dilation within 5 years after the onset of diabetes, Q1yr The best approach to the management of diabetes-related eye disease is to prevent it by maintaining healthy blood glucose levels and managing hypertension.

Alzheimer's DiseaseMild Cognitive Impairment

Mild cognitive impairment (MCI) 2nd stage in spectrum of AD Problems with memory, language, other cognitive functions Noticeable to others Show up on tests Do not meet criteria for dementia To the casual observer, an individual with MCI may seem fairly normal. However, the person with MCI is often aware of a significant change in memory, and family members may observe changes in the individual's abilities 10%-20% of people > age 65 have MCI High risk for developing AD 15% of people with MCI develop AD Drug therapy currently not available Between 10% and 20% of people 65 years old and older have MCI and are at high risk of developing AD. Some individuals with MCI show no progression and do not go on to develop AD, but an estimated 15% of people with MCI eventually do. No drugs have been approved for the treatment of MCI. Primary treatment of MCI is currently based on careful monitoring know 10 warnign signs

Acute PancreatitisPathophysiology mild/severe

Mild pancreatitis Edematous or interstitial Severe pancreatitis Necrotizing Endocrine and exocrine dysfunction Necrosis, organ failure, sepsis Rate of mortality: 25% mild pancreatitis - also known as edematous or interstitial pancreatitis or severe pancreatitis - necrotizing pancreatitis). severe pancreatitis = decreases in pancreatic endocrine/exocrine function, high risk for developing pancreatic necrosis, organ failure, septic

DiabetesCarbohydrates

Minimum of 130 g/day Fruits, vegetables, whole grains, legumes, low-fat dairy All benefit from including dietary fiber Nutritive and nonnutritive sweeteners may be used in moderation Carbohydrates include sugars, starches, and fiber. Carbohydrates provide important sources of energy, fiber, vitamins, and minerals and are therefore important to all people, including those with diabetes. Foods containing carbohydrates from whole grains, fruits, vegetables, and low-fat dairy are part of a healthy meal plan. The recommended dietary allowance for carbohydrates is a minimum of 130 g/day. All individuals benefit from including dietary fiber as part of a healthy meal plan. The current recommendation for the general population is 25 to 30 g/day. Nutritive and nonnutritive sweeteners may be included in a healthy meal plan in moderation. Nonnutritive sweeteners include the sugar substitutes saccharine, aspartame, sucralose, neotame, and acesulfame-K.

Ileostomy

Monitoring of Stoma viability Mucocutaneous juncture Peristomal skin integrity Postoperative care after surgical procedures for IBD is similar to that described in the general nursing care plan for the postoperative patient (see eNursing Care Plan 19-1 on the website for Chapter 19). If an ileostomy is formed, you need to monitor stoma viability, the mucocutaneous juncture (the area where the mucous membrane of the bowel interfaces with the skin), and peristomal skin integrity. Your patient should return from surgery with a clear ileostomy pouch in place. Replace pouches if feces leak onto the skin. Output may be as high as 1500-1800 mL per 24 hours Observe for Fluid and electrolyte imbalance Hemorrhage Abdominal abscess Small bowel obstruction Dehydration If an NG tube is used, remove it when bowel function returns. Initial drainage will be liquid Transient incontinence of mucus from manipulation of anal canal Kegel exercises Perianal skin care Over a period of days to weeks, the proximal small bowel adapts and increases fluid absorption. Then, feces will thicken to a paste-like consistency and the volume decrease. Patients, especially those with Crohn's disease, are at risk for developing a bowel obstruction during the first 30 days postoperatively. Transient incontinence of mucus is a result of intraoperative manipulation of the anal canal. Initial drainage through the ileoanal anastomosis will be liquid. Have the patient start Kegel' s exercises about 4 weeks after surgery to strengthen the pelvic floor and sphincter muscles. Perianal skin care is important to protect the epidermis from mucous drainage and maceration. Instruct the patient to gently clean the skin with a mild cleanser, rinse well, and dry thoroughly. A moisture barrier ointment and a perineal pad may be used.

Diagnostic TestsPD

No specific tests exist Diagnosis based on history and clinical features Requires presence of TRAP = Asymmetric onset = Confirmation = + response to antiparkinsonian drugs (levodopa or dopamine agonist).

Esophageal DiverticulaInterprofessional Care

No specific treatment Applying pressure at a point on neck to empty pocket of food Diet may need to be limited to foods that are blenderized Surgery Endoscopic or open approach Open approach Significant morbidity Endoscopic stapling diverticulotomy or diverticulostomy Decreased complications complication is perforation of the esophagus.

Dawn Phenomenon

Morning hyperglycemia present on awakening May be due to release of counterregulatory hormones in predawn hours Growth hormone and cortisol The Dawn phenomenon is also characterized by hyperglycemia that is present on awakening. Two counterregulatory hormones (growth hormone and cortisol) which are excreted in increased amounts in the early morning hours may be the cause of this phenomenon. The Dawn phenomenon affects a majority of people with diabetes and tends to be most severe when growth hormone is at its peak in adolescence and young adulthood. Careful assessment is required to document the Somogyi effect or Dawn phenomenon because the treatment for each differs. The treatment for Somogyi effect is less insulin in the evening. The treatment for Dawn phenomenon is an increase in insulin or an adjustment in administration time. Ask the patient to measure and document bedtime, nighttime (between 2:00 and 4:00 AM), and morning fasting blood glucose levels on several occasions. If the predawn levels are less than 60 mg/dL (3.3 mmol/L) and signs and symptoms of hypoglycemia are present, the insulin dosage should be reduced. If the 2:00 to 4:00 AM blood glucose level is high, the insulin dosage should be increased. In addition, counsel the patient on appropriate bedtime snacks.

Acute PancreatitisInterprofessional Care - Drug Therapy

Morphine Antispasmodics (e.g., dicyclomine [Bentyl]) ↓ Vagal stimulation, motility, pancreatic outflow (↓ volume and concentration of bicarbonate and enzyme secretion); contraindicated in paralytic ileus Carbonic anhydrase inhibitor (acetazolamide [Diamox]) ↓ Volume and bicarbonate concentration of pancreatic secretion Antacids Neutralization of gastric hydrochloric (HCl) acid secretion; ↓ production and secretion of pancreatic enzymes and bicarbonate Proton pump inhibitors (omeprazole [Prilosec]) ↓ HCl acid secretion (HCl acid stimulates pancreatic activity)

Interprofessional Care:Drug Therapy Cholecystitis

Most common = Analgesics/Morphine Anticholinergics Atropine Fat-soluble vitamins (A, D, E, K) Bile salts If the patient has chronic gallbladder disease or any biliary tract obstruction, fat-soluble vitamins (A, D, E, and K) may need to be given. Bile salts may be administered to facilitate digestion and vitamin absorption. Cholestyramine may be given for pruritus Given in powdered form, mixed with milk or juice Monitor for side effects (nausea/vomiting, diarrhea or constipation, skin reactions) This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Because cholestyramine may bind with other medications, check drug- to- drug interactions prior to administering.

Etiology and Pathophysiology cirrhosis

Most common causes in United States are chronic hepatitis C and alcohol-induced liver disease Other causes Extreme dieting, malabsorption, obesity Environmental factors Genetic predisposition Any chronic liver disease, including excessive alcohol intake and NAFLD, can cause cirrhosis. extreme dieting, malabsorption, and obesity. Approximately 20% of patients with chronic hepatitis C and 10% to 20% of those with chronic hepatitis B will develop cirrhosis. Chronic inflammation and cell necrosis from viral hepatitis can result in progressive fibrosis and, ultimately, cirrhosis. Chronic hepatitis combined with alcohol ingestion has a synergistic effect in accelerating liver damage. Biliary cirrhosis Primary biliary cirrhosis (PBC) Primary sclerosing cholangitis (PSC) Cardiac cirrhosis right HF Primary sclerosing cholangitis is a chronic inflammatory condition affecting the liver and bile ducts that is frequently found in men. Cardiac cirrhosis includes a spectrum of hepatic derangements that result from long-standing, severe right-sided heart failure. It causes hepatic venous congestion, parenchymal damage, necrosis of liver cells, and fibrosis over time. tx = manage HF

Deep Brain Stimulation - PD

Most common surgical treatment Reversible and programmable ↓ Increased neuronal activity produced by DA depletion Reduces dyskinesia and medications DBS procedures reduce the increased neuronal activity produced by DA depletion.

Etiology and Pathophysiology - Cholecystitis

Most commonly associated with obstruction from stones or sludge Acalculous cholecystitis Prolonged immobility, fasting, prolonged parenteral nutrition, diabetes Bacteria or chemical irritants Adhesions, neoplasms, anesthesia, opioids Cholecystitis = obstruction caused by gallstones or biliary sludge. When cholecystitis occurs in the absence of obstruction (acalculous cholecystitis), Acalculous cholecystitis = prolonged immobility and fasting, prolonged parenteral nutrition, and diabetes mellitus. Bacteria reaching the gallbladder via the vascular or lymphatic route, or chemical irritants in the bile, can also produce cholecystitis. Escherichia coli, streptococci, and salmonellae are common causative bacteria. Other etiologic factors include adhesions, neoplasms, anesthesia, and narcotics. Inflammation Confined to mucous lining or entire wall Gallbladder is edematous and hyperemic May be distended with bile or pus Cystic duct may become occluded Scarring and fibrosis after attack

Thiazolidinediones

Most effective in those with insulin resistance Improve insulin sensitivity, transport, and utilization at target tissues Examples Pioglitazone (Actos) Rosiglitazone (Avandia) Rarely used because of adverse effects Sometimes referred to as insulin sensitizers, these agents include pioglitazone (Actos) and rosiglitazone (Avandia). They are most effective for people who have insulin resistance. These agents improve insulin sensitivity, transport, and utilization at target tissues. Because they do not increase insulin production, thiazolidinediones do not cause hypoglycemia when used alone. However, these drugs are rarely used today because of their adverse effects. Rosiglitazone is associated with adverse cardiovascular events (e.g., myocardial infarction) and can be obtained only through restricted-access programs. Pioglitazone can worsen heart failure and is associated with an increased risk of bladder cancer.

Recovery hep

Most patients recover completely with no complications Most cases of acute hepatitis A resolve Some HBV and majority of HCV result in chronic hepatitis Most patients with acute viral hepatitis recover completely. .

Osmosis

Movement of fluid from an area of lesser concentration of solutes to area of greater concentration Glucose is added to the dialysate and creates an osmotic gradient across the membrane, pulling excess fluid from the blood.

Esophageal CancerNursing Implementationacute/postop

NG tube with bloody drainage for 8-12 hours Changes gradually to greenish yellow NG tube should not be repositioned or reinserted without surgeon's approval Turning and deep breathing every 2 hours Assessment of drainage, maintenance of the tube, and providing oral and nasal care are nursing responsibilities. Turning, coughing, and deep breathing every 2 hours Incentive spirometer use Because of the location of the surgery and the general condition of the patient, place emphasis on prevention of respiratory complications. Cardiac dysrhythmias may result from the proximity of the pericardium to the surgical site. Other complications that can occur following esophagectomy include esophageal anastomotic leaks, fistula formation, interstitial pulmonary edema, and acute respiratory distress due to disruption of the mediastinal lymph nodes. Positioned in semi-Fowler's or Fowler's Should be maintained at least 2 hours after eating Monitor for complications Turning, coughing, and deep breathing every 2 hours Incentive spirometer use Positioned in semi-Fowler's or Fowler's Should be maintained at least 2 hours after eating Monitor for complications Because of the location of the surgery and the general condition of the patient, place emphasis on prevention of respiratory complications. Cardiac dysrhythmias may result from the proximity of the pericardium to the surgical site. Other complications that can occur following esophagectomy include esophageal anastomotic leaks, fistula formation, interstitial pulmonary edema, and acute respiratory distress due to disruption of the mediastinal lymph nodes. Because of the location of the surgery and the general condition of the patient, place emphasis on prevention of respiratory complications. Cardiac dysrhythmias may result from the proximity of the pericardium to the surgical site. Other complications that can occur following esophagectomy include esophageal anastomotic leaks, fistula formation, interstitial pulmonary edema, and acute respiratory distress due to disruption of the mediastinal lymph nodes. May require long-term follow-up care after surgery A permanent feeding gastrostomy may be required. The patient usually has fears and anxieties about a diagnosis of cancer. Referral to palliative care or home health nurse may be needed. Needs encouragement and assistance in maintaining nutrition May need referral to palliative care or home health nurse

Acute PancreatitisInterprofessional Care - Nutritional Therapy

NPO status initially Enteral versus parenteral nutrition Monitor triglycerides if IV lipids given Small, frequent feedings when able High-carbohydrate No alcohol Supplemental fat-soluble vitamins Depending on the severity of the pancreatitis, enteral feedings via nasojejunal tube are initiated. Because of infection risk, parenteral nutrition is reserved for patients who cannot tolerate enteral nutrition. Suspect intolerance to oral foods when the patient reports pain, has increasing abdominal girth, or has elevations in serum amylase and lipase levels.

For more active and aggressive forms of MS

Natalizumab (Tysabri) Alemtuzumab (Lemtrada) Mitoxantrone (Novantrone) Dimethyl fumarate (Tecfidera) AE natalizumab = increased risk of progressive multifocal leukoencephalopathy = fatal viral infection of the brain. Mitoxantrone = serious effects = cardiotoxicity, leukemia, and infertility.

Necrobiosis Lipidoidica Diabeticorum

Necrobiosis lipoidica diabeticorum usually appears as red-yellow lesions, with atrophic skin that becomes shiny and transparent, revealing tiny blood vessels under the surface. This condition is uncommon and occurs more frequently in young women. It may appear before other clinical signs or symptoms of diabetes. Because the thin skin is prone to injury, special care must be taken to protect affected areas from injury and ulceration.

Chronic ComplicationsDiabetic Neuropathy

Nerve damage due to metabolic derangements of diabetes Reduced nerve conduction and demyelinization Sensory or autonomic Diabetic neuropathy is nerve damage that occurs because of the metabolic derangements associated with diabetes mellitus. Screening for neuropathy begins in patients with type 2 diabetes at the time of diagnosis and 5 years after diagnosis in patients with type 1 diabetes. The pathophysiologic processes of diabetic neuropathy are not well understood. Several theories exist, including metabolic, vascular, and autoimmune factors. The prevailing theory is that persistent hyperglycemia leads to an accumulation of sorbitol and fructose in the nerves that causes damage by an unknown mechanism. The result is reduced nerve conduction and demyelinization. Ischemia in blood vessels damaged by chronic hyperglycemia that supply the peripheral nerves is also implicated in the development of diabetes-related neuropathy. Neuropathy can precede, accompany, or follow the diagnosis of diabetes. The two major categories of diabetes-related neuropathy are sensory neuropathy, which affects the peripheral nervous system, and autonomic neuropathy. Each of these types can take several forms. This can lead to the loss of protective sensation in the lower extremities, and, coupled with other factors, this significantly increases the risk for complications that result in a lower limb amputation. Sensory neuropathy Loss of protective sensation in lower extremities Major risk for amputation Distal symmetric polyneuropathy Most common form Affects hands and/or feet bilaterally Loss of sensation, abnormal sensations, pain, and paresthesias The most common form of sensory neuropathy is distal symmetric polyneuropathy, which affects the hands and/or feet bilaterally. This is sometimes referred to as stocking-glove neuropathy. Characteristics of distal symmetric polyneuropathy include loss of sensation, abnormal sensations, pain, and paresthesias. The pain, which is often described as burning, cramping, crushing, or tearing, is usually worse at night and may occur only at that time. The paresthesias may be associated with tingling, burning, and itching sensations. The patient may report a feeling of walking on pillows or numb feet. At times the skin becomes so sensitive (hyperesthesia) that even light pressure from bed sheets cannot be tolerated. Complete or partial loss of sensitivity to touch and temperature is common.

Hepatic encephalopathy

Neurotoxic effects of ammonia Abnormal neurotransmission Astrocyte swelling Inflammatory cytokines Liver unable to convert increased ammonia Ammonia crosses blood-brain barrier Hepatic encephalopathy is a neuropsychiatric manifestation of liver disease. The pathogenesis of hepatic encephalopathy is multifactorial and includes the neurotoxic effects of ammonia, abnormal neurotransmission, astrocyte swelling, and inflammatory cytokines. A major source of ammonia is the bacterial and enzymatic deamination of amino acids in the intestines. The ammonia that results from this deamination process normally goes to the liver via the portal circulation and is converted to urea, which is then excreted by the kidneys. When blood is shunted past the liver via the collateral vessels or the liver is so damaged that it is unable to convert ammonia to urea, the levels of ammonia in the systemic circulation increase. The ammonia crosses the blood-brain barrier and produces neurologic toxic manifestations. Changes in neurologic and mental responsiveness Impaired consciousness and/or inappropriate behavior Sleep disturbances, trouble concentrating, coma Clinical manifestations of encephalopathy are changes in neurologic and mental responsiveness, impaired consciousness, and/or inappropriate behavior, ranging from sleep disturbances to lethargy to deep coma. Changes may occur suddenly because of an increase in ammonia in response to bleeding varices or infection, or it may arise gradually as blood ammonia levels slowly increase. A grading system is often used to classify the stages of hepatic encephalopathy: 0 to 4, 4 being most advanced. A characteristic manifestation of hepatic encephalopathy is asterixis (flapping tremors). This may take several forms, the most common involving the arms and hands. Asterixis Flapping tremors Most common in arms and hands Difficulty in moving pen left to right Apraxia Fetor hepaticus Musty, sweet odor of patient's breath is asterixis (flapping tremors). involving the arms and hands. Impairments in writing involve difficulty in moving the pen or pencil from left to right and apraxia (inability to construct simple figures) Fetor hepaticus (musty, sweet odor of the patient's breath) occurs in some patients with encephalopathy.

Nissen Fundoplication

Nissen fundoplication for repair of hiatal hernia. A, Fundus of stomach is wrapped around distal esophagus. B, The fundus is then sutured to itself.

Alzheimer's DiseaseInterprofessional Care

No cure No treatment exists to stop the deterioration of brain cells in AD Interprofessional care is aimed at Controlling undesirable behavioral manifestations Providing support for family caregiver Nothing stops or really slows the progression of the disease.

Interprofessional Care - PD

No cure for PD Interprofessional care is aimed at symptom management

Alzheimer's DiseasePreclinical Stage

No current treatment successfully modifies the progression of AD Early intervention is a future goal Modify disease before Plaques and tangles have formed Symptoms emerge Ongoing research A long lag exists between pathologic changes in the brain and manifestations of AD. Once plaques and tangles have formed in sufficient quantity, it may be too late to intervene to prevent the disease or its progression. The model for early intervention is seen in other diseases. Examples include removing polyps to prevent colon cancer, controlling blood glucose in diabetes before the disease progresses to heart and kidney disease, and treating cardiac risk factors before a person has a myocardial infarction.

Alzheimer's DiseaseDiagnostic Studies

No definitive diagnostic test exists for AD Diagnosed by exclusion Made once all other possible conditions causing cognitive impairment have been ruled out Comprehensive patient evaluation Complete health history Physical examination Neurologic assessment Mental status assessment Laboratory tests Brain imaging tests CT MRI PET Help detect early changes in disease process Enable monitoring of treatment response A CT or an MRI scan may show brain atrophy in the later stages of the disease, although this finding occurs in other diseases and can also be seen in persons without cognitive impairment. Positron emission tomography (PET) scanning can be used to differentiate AD from other forms of dementia. Definitive diagnosis of AD usually requires an autopsy Biomarkers are promising, but more research is indicated Level of β-amyloid accumulation in the brain Injured or degenerating nerve cells A definitive diagnosis of AD usually requires examination of brain tissue and the presence of neurofibrillary tangles and neuritic plaques at autopsy. Biomarkers = diagnosis of Alzheimer's dementia (1) biomarkers showing the level of β-amyloid accumulation in the brain and (2) biomarkers showing that nerve cells in the brain are injured or actually degenerating. Biomarkers include CSF neurochemical markers β-amyloid and tau proteins Plasma levels are not diagnostic Imaging biomarkers Volumetric MRI and PET Brain volume correlates with neurodegeneration Biomarkers include (1) cerebrospinal fluid (CSF) neurochemical markers: β-amyloid and tau proteins and (2) imaging biomarkers: volumetric MRI and PET. The level of tau in the CSF is an indication of neurodegeneration. (Plasma levels of tau or β-amyloid are not of any value in diagnosing AD.) In AD, multiple brain structures atrophy and the volume of the brain correlates with neurodegeneration. PET determines brain metabolism using glucose tracers. , detect amyloid. Neuropsychologic testing can help document degree of cognitive impairment Mini-Cog Mini-Mental State Examination (MMSE) Also used to determine a baseline from which to evaluate change over time

Diagnostic Studies MS

No definitive diagnostic test for MS MRI of brain and spinal cord = plaques, inflammation, atrophy, and tissue breakdown and destruction Cerebral spinal fluid (CSF) analysis = ince Immunoglobulin G (igG) and Presence of oligoclonal banding Evoked potential responses are often delayed in persons with MS because of decreased nerve conduction from eye and ear to brain Evidence of at least 2 inflammatory demyelinating lesions in at least 2 different locations within CNS Damage or an attack occurring at different times (usually >1 month apart) All other possible diagnoses must have been ruled out If evidence exists for only one lesion, or only one clinical attack has occurred, the HCP will monitor the patient for another attack or for an attack at a different site in the CNS.

Etiology and Pathophysiology GERD

No one single cause Results when defenses of lower esophagus are overwhelmed by reflux of acidic gastric contents into lower esophagus HCl acid and pepsin secretions in refluxate cause irritation and inflammation (esophagitis) Intestinal proteolytic enzymes and bile salts add to irritation The degree of inflammation depends on the amount and composition of gastric reflux and on the ability of the esophagus to clear the acidic contents. Incompetent LES Primary factor in GERD Results in ↓ pressure in distal portion of esophagus Gastric contents move from stomach to esophagus Can be due to certain foods (caffeine, chocolate) and drugs (anticholinergics) Predisposing factors Incompetent lower esophageal sphincter (LES) Decreased LES pressure Increased intraabdominal pressure Hiatal hernia LES acts as an antireflux barrie = lets gastric contents move from the stomach to the esophagus when the patient is supine or has an increase in intraabdominal pressure. Decreased LES pressure can be due to certain foods and drugs. In an obese person the intraabdominal pressure is increased, which can exacerbate GERD.

Interprofessional Care IBS

No single therapy has been found to be effective for all patients with IBS Consider predominant symptom pattern Diarrhea Constipation Pain Treatment may include dealing with Dietary changes Psychologic factors Medications that Regulate stool output Reduce pain/discomfort Patients may benefit from keeping a diary to help identify any factors that trigger the IBS symptoms Specific symptoms Diet Episodes of stress

Nutritional Therapy hep

No special diet required Emphasis on well-balanced diet that patient can tolerate Adequate calories are important during acute phase Fat content may need to be reduced Vitamins B-complex and K IV glucose or enteral nutrition During acute viral hepatitis, adequate calories are important because the patient usually loses weight. If fat content is poorly tolerated because of decreased bile production, it should be reduced.

interprofessional Care - Health Promotion: Hepatitis C

No vaccine to prevent HCV Screen all persons born between 1945 and 1965 No postexposure prophylaxis; baseline and follow-up testing (1) screening of blood, organ, and tissue donors; (2) use of infection control precautions; and (3) modifying high-risk behavior. The CDC does not recommend IG or antiviral agents (e.g., interferon) for post-exposure prophylaxis for HCV infection (e.g., needle-stick exposure from an infected patient). Following an acute exposure (e.g., needle stick), the person should have anti-HCV testing done. For the person exposed to HCV, baseline anti-HCV and ALT levels should be measured. Follow-up testing for anti-HCV and ALT should be done at 4 to 6 months. Testing for HCV RNA may be performed at 4 to 6 weeks.

Normal Glucose and Insulin Metabolism

Normal glucose and insulin metabolism. Insulin binds to receptors along the cell walls of muscle, adipose, and liver cells. Glucose transport proteins (GLUT 4) then attach to the cell wall and allow glucose to enter the cell where it is either stored or used to make energy. Normal glucose and insulin metabolism. Insulin binds to receptors along the cell walls of muscle, adipose, and liver cells. Glucose transport proteins (GLUT 4) then attach to the cell wall and allow glucose to enter the cell, where it is either stored or used to make energy.

Alzheimer's DiseaseClinical Manifestations

Normal memory decline does not interfere with ADLs Recent memory loss Remote memory loss Interference with ADLs With time and progression of AD, memory loss includes both recent and remote memory and ultimately affects the ability to perform self-care. As the disease progresses ↓ Personal hygiene ↓ Concentration and attention Unpredictable behavior Delusions and hallucinations Changes are not under control of patient Ongoing loss of neurons in AD can cause a person to act in altered or unpredictable ways. Behavioral manifestations of AD (e.g., agitation, aggression) result from changes that take place within the brain. They are neither intentional nor controllable by the individual with the disease. Some patients develop delusions and hallucinations. Additional cognitive impairments Dysphasia Apraxia Visual agnosia Dysgraphia Inability to recognize family and friends Wandering With progression of AD, additional cognitive impairments are noted. These include dysphasia (difficulty comprehending language and oral communication) apraxia (inability to manipulate objects or perform purposeful acts) visual agnosia (inability to recognize objects by sight) dysgraphia (difficulty communicating via writing) Later stages Unable to communicate Cannot perform activities of daily living (ADLs) Patient becomes unresponsive and incontinent Total care is required Retrogenesis Process where degenerative changes occur in the reverse order in which they were acquired Developmental stages in children

Drug therapy cirrhosis

Not specific for cirrhosis Used to treat symptoms and complications of advanced liver disease There is no specific drug therapy for cirrhosis. However, a number of drugs are used to treat symptoms and complications of advanced liver disease.

Nursing Implementation - obesity

Obesity is one of most challenging health problems Treatment = understanding their weight history, deciding on a plan that is best for them Help obese patients explore and deal with their negative experiences. HCPs are often reluctant to counsel patients about obesity for a variety of reasons. These include the following: (1) time constraints are a factor during appointments, (2) weight management may be viewed as professionally unrewarding, (3) reimbursement for weight management services is difficult to obtain, and (4) many HCPs do not feel knowledgeable about giving weight loss advice. An "ideal" BMI is not necessary and may not be realistic Modest weight loss of 3% to 5% can have clinical benefits Greater weight loss produces greater benefits Average weight loss programs result in a 10% reduction of body weight Explore motivation - it is key Requires a short-term energy deficit Focus on the reasons for wanting to lose weight to help patients develop strategies for weight loss. A multicomponent approach for weight loss needs to be used that includes nutritional therapy, exercise, behavior modification, and for some, drugs or surgical intervention.

Acute PancreatitisInterprofessional Care

Objectives include Relief of pain Prevention or alleviation of shock ↓ Pancreatic secretions Correction of fluid/electrolyte imbalance Prevention/treatment of infections Removal of precipitating cause

HemodialysisVascular Access Sites

Obtaining vascular access is one of most difficult problems Types of access Arteriovenous fistulas and grafts Temporary vascular access A subcutaneous arteriovenous fistula (AVF) is usually created in the forearm or upper arm with an anastomosis between an artery and a vein (usually cephalic or basilic) (Figs. 46-8, A, and 46-9). In some situations when immediate vascular access is required, percutaneous cannulation of the internal jugular or femoral vein is performed.

Esophageal Diverticula

Occur in 3 main areas Zenker's diverticulum Most common location Above the upper esophageal sphincter Traction diverticulum Near esophageal midpoint Epiphrenic diverticulum Above the LES Esophageal diverticula are saclike outpouchings of one or more layers of the esophagus. (See next slide for figure.) Pharyngeal pouches (Zenker's diverticula) occur most commonly in older adult patients (older than 60 years).

Alzheimer's DiseaseBehavioral Problems

Occur in most patients with AD These problems include Repetitiveness Delusions Hallucinations Agitation Aggression Behavioral problems occur in about 90% of patients with AD. Problems Altered sleep patterns Wandering Hoarding Resisting care Can be unpredictable and challenging Often lead to placement of patients in institutional care settings Behavior is unpredictable. Can be challenging for caregiver. Caregivers need to be aware that these behaviors are not intentional and are often difficult to control. Behavioral problems are often the reason that patients are placed in institutional care settings. Assess patient's Physical status Environment Move patient or remove stimulus Reassure patient about safety Rely on mood and behavior rather than verbal communication Don't ask patient "why" When these behaviors become problematic, you must plan interventions carefully. Check the patient for changes in vital signs, urinary and bowel patterns, and pain that could account for behavioral problems. Then assess the environment to identify factors that may trigger behavior disruptions. Do not ask the confused or agitated patient challenging "why" questions. The person with AD cannot think logically. If the patient cannot verbalize distress, validate his or her mood. Rephrase the patient's statement to validate its meaning. Closely observe the patient's emotional state. Nursing strategies to address difficult behaviors Redirection Distraction Reassurance Do not threaten to restrain patient or call HCP Exhaust options before using drugs Use reality orientation to orient to time, place, and person. Ways to distract the agitated patient may include providing snacks, taking a car ride, sitting on a porch swing or rocker, listening to favorite music, watching videotapes, looking at family photographs, or walking. Use of repetitive activities, songs, poems, music, massage, aromas, or a favorite object can be soothing to patients. A calming family member can be asked to stay with the patient until the patient becomes calmer. Monitor the patient frequently, and document all interventions. The use of positive nurse actions can reduce the use of chemical (drug therapy) restraints. Disruptive behaviors have been treated with antipsychotic drugs (Table 59-11). Before these drugs are used, all other measures of treating behavioral issues should be exhausted. Sundowning Specific type of agitation Patient becomes more confused and agitated in late afternoon or evening May be due to disruption of circadian rhythms Behaviors related to sundowing include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Other possible causes include fatigue, unfamiliar environment and noise (especially in an acute care setting), medications, reduced lighting, and sleep fragmentation. Nursing interventions for sundowning Create a quiet, calm environment Maximize exposure to daylight Evaluate medications Limit naps and caffeine Consult health care provider on drug therapy When a patient has sundowning, remain calm and avoid confrontation. Assess the situation for possible causes of the agitation. Nursing interventions that may be helpful include (1) creating a quiet, calm environment; (2) maximizing exposure to daylight (open blinds and turn on lights during the day); (3) evaluating medications to determine if any could cause sleep disturbance; (4) limiting naps and caffeine; and (5) consulting with the HCP regarding drug therapy. Management of sundowning can be challenging for you, the patient, and the family.

Colorectal Cancer

Of cancers that affect both men and women 2nd leading cause of cancer-related deaths 3rd most common form of cancer More common in men Highest mortality rates among African American men and women Risk of disease increases with age Of cancers that affect both men and women, colorectal cancer (CRC) is the second leading cause of cancer-related deaths and is the third most common cancer in men and women. The risk of CRC increases with age, with about 90% of new CRC cases detected in people older than 50. However, although the incidence of CRC in people over 50 years is decreasing due to increased screening efforts to detect precancerous lesions, the number of cases in people aged 20 to 49 years is rising and expected to continue to do so.

Tremor - PD

Often first sign Initially minimal More prominent at rest Aggravated by Emotional stress ↑ Concentration Occurs during voluntary movement, has more rapid frequency, is familial The hand tremor is described as "pill rolling" because the thumb and forefinger appear to move in a rotary fashion as if rolling a pill, coin, or other small object. Tremor can also involve the diaphragm, tongue, lips, and jaw, but rarely causes shaking of the head. benign essential tremor = diagnosed as PD.

Episodes of hypomobility - PD

Often occur within 3-5 years Off episodes Combination carbidopa, levodopa, entacapone Apomorphine (Apokyn) Needs to be taken with an antiemetic drug Hypomobility manifests in inability to rise from a chair, to speak, or to walk. Off-episodes can occur toward the end of a dosing interval with standard medications (so-called end-of-dose wearing off) or at unpredictable times (spontaneous "on/off"). The injectable DA receptor agonist apomorphine (Apokyn) is also used to improve movement in hypomobility episodes = needs to be taken with an antiemetic drug (e.g., trimethobenzamide [Tigan]) = causes severe n/v = serotonin (5-HT3) receptor antagonist class = [Zofran])

Acute PancreatitisNursing Assessment -Possible diagnostic findings:

Possible diagnostic findings: ↑ Serum amylase/lipase levels Leukocytosis Hyperglycemia Hypocalcemia Abnormal findings on ultrasonography/CT scans Abnormal findings on ERCP

Planning - DM

Overall Goals Active patient participation Few or no hyperglycemia or hypoglycemia emergencies Maintain normal blood glucose levels Prevent or minimize chronic complications Adjust lifestyle to accommodate diabetes plan with a minimum of stress The overall goals are for the patient with diabetes mellitus to (1) engage in self-care behaviors to actively manage his or her diabetes, (2) experience few or no hyperglycemia or hypoglycemia emergencies, (3) maintain blood glucose levels at normal or near-normal levels, (4) prevent or minimize chronic complications related to diabetes, and (5) adjust lifestyle to accommodate the diabetes plan with a minimum of stress. The patient with diabetes needs to safely and effectively fit diabetes into life, rather than living life around diabetes.

Nursing ManagementPlanning CKI

Overall Goals Demonstrate knowledge and ability to comply with therapeutic regimen Participate in decision making Demonstrate effective coping strategies Continue with activities of daily living within physiologic limitations

Planning - obesity

Overall Goals Modify eating patterns Participate in a regular physical activity program Achieve and maintain weight loss to a specified level Minimize or prevent health problems First assess a patient's willingness to change and potential for change. If people are not ready for change, offer them the opportunity to return for further discussion when they are ready to discuss their weight again and make lifestyle changes.

Nursing ManagementPlanning CRC

Overall Goals Normal bowel elimination patterns Quality of life appropriate to disease progression Relief of pain Feelings of comfort and well-being

Interprofessional Care CKI

Overall Goals Preserve existing kidney function Reduce risks of CV disease Prevent complications Provide for patient's comfort Early recognition, diagnosis, and treatment can prevent the progression of kidney disease. Every effort is made to detect and treat potentially reversible causes of kidney failure (e.g., HF, dehydration, infections, nephrotoxins, urinary tract obstruction, glomerulonephritis, renal artery stenosis). Conservative Therapy Correction of extracellular fluid volume overload or deficit Nutritional therapy Erythropoietin therapy Calcium supplementation, phosphate binders Conservative Therapy Antihypertensive therapy Measures to lower potassium Adjustment of drug dosages to degree of renal function

Ambulatory Care DM

Overall goal is to enable patient or caregiver to reach an optimal level of independence in self-care activities Increased risk for other chronic conditions Successful interaction with interprofessional team Because diabetes is a complex chronic condition, a great deal of patient contact takes place in outpatient and home settings. The major goal of patient care in these settings is to enable the patient or caregiver to reach an optimal level of independence in self-care activities. Unfortunately, many patients with diabetes face challenges in reaching these goals. Diabetes increases the risk for other chronic conditions that can affect self-care activities. These include visual impairment, lower extremity problems that affect mobility, and other functional limitations related to stroke. Successful management of diabetes requires ongoing interaction among the patient, the caregiver, and the health care team. Assess patient's ability to perform SMBG and insulin injection Use assistive devices as needed Assess patient/caregiver knowledge and ability to manage diet, medication, and exercise Teach manifestations and how to treat hypoglycemia and hyperglycemia Important nursing functions are to assess the ability of patients and caregivers in performing activities such as SMBG and insulin injection. Assistive devices for self-administration of insulin include syringe magnifiers, vial stabilizers, and dosing aids for the visually impaired. In some cases, referrals are made to help the patient achieve the self-care goal. These may include an occupational therapist, a social worker, a home health aide, or a dietitian. Assessment of the patient must include an evaluation of his or her ability to safely manage this therapy. This includes the ability to understand the interaction of medication, diet, and activity and to be able to recognize and treat the symptoms of hypoglycemia appropriately. If the patient does not have the cognitive skills to do these things, identify and teach another responsible person. Emotional support and encouragement to deal with this chronic disease is important. Frequent oral care Foot care Inspect daily Avoid going barefoot Proper footwear How to treat cuts Travel needs Medication, supplies, food, activity The potential for infection necessitates diligent skin and dental hygiene practices. Because of the susceptibility to periodontal disease, encourage daily brushing and flossing in addition to regular visits to the dentist. When dental work is done, have the patient inform the dentist that he or she has diabetes. Teach patients regarding the importance of informing dentists and other health care professionals of their diagnosis. Routine care should include regular bathing, with particular emphasis given to foot care. Advise patients to inspect their feet daily, avoid going barefoot, and wear shoes that are supportive and comfortable. If cuts, scrapes, or burns occur, treat them promptly and monitor them carefully. Patients should wash the area, apply a nonabrasive or nonirritating antiseptic ointment, and cover the area with a dry, sterile pad. Teach patients to notify the HCP immediately if the injury does not begin to heal within 24 hours or if signs of infection develop. Travel for a patient with diabetes requires advance planning. Being sedentary for long periods of time may raise the person's glucose level. Encourage the patient to get up and walk at least every 2 hours to prevent the risk for deep vein thrombosis and to prevent elevation of glucose levels. Teach the patient to have a full set of diabetes care supplies in the carry-on luggage when traveling by plane, train, or bus. This includes blood glucose monitoring equipment, insulin and/or oral medications, and syringes or insulin pens. When equipment such as syringes, lancing devices, insulin vials or pens, and insulin pumps are taken onto a commercial airliner, it is a good idea to have the professional printed pharmaceutical labels that accompany them. A letter from the prescribing HCP indicating medical necessity may prevent delays at security checkpoints. Notify screeners if an insulin pump is used so they can inspect it while it is on the patient's body, rather than removing it. For patients who use insulin, OAs, or noninsulin injectable agents that can cause hypoglycemia, keep snack items and a quick-acting carbohydrate source for treating hypoglycemia in the carry-on luggage. Keep extra insulin available in case a bottle breaks or is lost. For longer trips, carry a full day's supply of food in the event of canceled flights, delayed meals, or closed restaurants. If the patient is planning a trip out of the country, it is wise to have a letter from the HCP explaining that the patient has diabetes and requires all the materials, particularly syringes, for ongoing health care. When travel involves time changes such as traveling coast to coast or across the International Date Line, the patient can contact the HCP to plan an appropriate insulin schedule. During travel, most patients find it helpful to keep watches set to the time of the city of origin until they reach their destination. The key to travel when taking insulin is to know the type of insulin being taken, its onset of action, the anticipated peak time, and mealtimes.

Alzheimer's DiseasePlanning

Overall goals for patients Maintain functional ability as long as possible Be maintained in a safe environment with a minimum of injuries Have personal care needs met Have dignity maintained Overall goals for caregivers Reduce caregiver stress Maintain personal, emotional, and physical health Cope with long-term effects of caregiving

Nursing Implementation - PD

PD is a chronic degenerative disorder with no acute exacerbations Focus teaching and nursing care Maintenance of good health Encouragement of independence Avoidance of complications such as contractures and falls Promote physical exercise and a well-balanced diet Limit consequences from decreased mobility Physical therapy Occupational therapy Promotion of physical exercise and a well-balanced diet are major concerns for nursing care. Exercise can limit the consequences of decreased mobility, such as muscle atrophy, contractures, and constipation. The American Parkinson Disease Association (www.apdaparkinson.org) publishes a series of booklets and videotapes with helpful exercises that can be used by family members and health care professionals. A physical therapist may be consulted to design a personal exercise program aimed at strengthening and stretching specific muscles. Overall muscle tone and specific exercises to strengthen the muscles involved with speaking and swallowing should be included. Although exercise will not halt the progress of the disease, it will enhance the patient's functional ability. An occupational therapist can also assist the patient with strategies to increase self-care measures, including eating and dressing.

Maestro Rechargeable System

Pacemaker-like electrical pulse generator, wire leads, and electrodes implanted in abdomen Sends intermittent electrical pulses to vagus nerve which is involved in regulating stomach emptying and signaling feelings of emptiness or fullness to brain obese patients + failed at least one supervised weight management program within the past five years and who have either a BMI of 40 to 45 kg/m2 or a BMI of 35 to 39.9 kg/m2 and one or more obesity-related conditions (e.g. diabetes, high blood pressure, sleep apnea, etc.). External controllers allow the patient to charge the device and allow HCPs to adjust the device's settings in order to provide optimal therapy. The system is approved for use in obese patients who have failed at least one supervised weight management program within the past five years and who have either a BMI of 40 to 45 kg/m2 or a BMI of 35 to 39.9 kg/m2 and one or more obesity-related conditions (e.g. diabetes, high blood pressure, sleep apnea, etc.).

Alzheimer's DiseasePain Management

Pain should be recognized and treated promptly Monitor patient's responses Patients can have difficulty communicating complaints May exhibit changes in behavior Because of difficulties with oral and written language associated with AD, patients may have difficulty expressing physical complaints, including pain. Pain can result in alterations in the patient's behavior, such as increased vocalization, agitation, withdrawal, and changes in function.

Type 2 Diabetes MellitusEtiology and Pathophysiology

Pancreas continues to produce some endogenous insulin but Not enough insulin is produced OR Body does not use insulin effectively Major distinction In type 1 diabetes there is an absence of endogenous insulin In type 2 diabetes, the pancreas usually continues to produce some endogenous (self-made) insulin. However, the body either does not produce enough insulin or does not use it effectively, or both. The presence of endogenous insulin is a major distinction between type 1 and type 2 diabetes. (In type 1 diabetes, endogenous insulin is absent.)

Nursing Assessment - Subjective Data Hep

Past health history Hemophilia Exposure to infected persons Ingestion of contaminated food or water Ingestion of toxins Past blood transfusion (before 1992) Other risk factors Medications Acetaminophen, OTC, or herbal medications Subjective Data: Functional Health Patterns IV drug and alcohol abuse Distaste for cigarettes (in smokers) High-risk sexual behaviors Weight loss, anorexia, nausea/vomiting RUQ abdominal discomfort Urine and stool color Fatigue/arthralgias/myalgia Exposure to high-risk groups Obtain the following health information from the patient: Past health history: hemophilia; exposure to infected persons; ingestion of contaminated food or water; exposure to benzene, carbon tetrachloride, or other hepatotoxic agents; crowded, unsanitary living conditions; exposure to contaminated needles; recent travel; organ transplantation; exposure to new drug regimens, hemodialysis, transfusion of blood or blood products before 1992, HIV status (if known) Medications: use and misuse of acetaminophen, new prescription, over-the-counter, or herbal medications or supplements

Alzheimer's DiseaseClinical Manifestations

Pathologic changes precede clinical manifestations by 5 to 20 years Early warning signs of AD Memory loss that affects job skills Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or ↓ judgment Problems with abstract thinking Early signs of AD Misplacing things Changes in mood or behavior Changes in personality Loss of initiative Categorized Mild Moderate Severe Progression Highly variable from person to person Ranges from 3 to 20 years

Teaching DM

Patient teaching Nutritional therapy Drug therapy Exercise Self-monitoring of blood glucose Diabetes is a chronic disease that requires daily decisions about food intake, blood glucose monitoring, medication, and exercise. The major types of glucose-lowering agents (GLAs) used in the treatment of diabetes are insulin, oral agents (OAs), and nonisulin injectable agents.

Self-Monitoring of Blood Glucose patient teaching

Patient teaching How to use, calibrate When to test Before meals Two hours after meals When hypoglycemia is suspected During illness Before, during, and after exercise Because errors in monitoring technique can cause errors in management strategies, comprehensive patient teaching is essential. Initial instruction should be followed up with regular reassessment. Review the instructions that accompany each product for how to use that particular glucose monitor. Teach patients to use and interpret calibration and control solutions. Control solution should be used when a blood glucose meter is first used, when a new bottle of strips are used, or if there is a reason to believe that the readings are not correct. People with type 1 diabetes often test their blood glucose before meals. This is because many patients use insulin pumps or multiple daily injections and base the insulin dose on the carbohydrates in a meal or make adjustments if the premeal value is above or below target. Checking blood glucose 2 hours after the first bite of food helps a person determine if the bolus insulin dose was adequate for that meal. Teach patients to monitor blood glucose whenever hypoglycemia is suspected so that immediate action can be taken. During times of illness, check blood glucose levels at 4-hour intervals to determine the effects of the illness on glucose levels. Teach the patient to monitor blood glucose before and after exercise to determine the effects of exercise on blood glucose levels. This is especially important in a patient with type 1 diabetes. A patient who is visually impaired, cognitively impaired, or limited in manual dexterity needs careful evaluation of the degree to which SMBG can be performed independently. Nurses preparing patients for discharge from the hospital, and those working in home health and outpatient settings may need to identify caregivers who can assume this responsibility. Adaptive devices are available to help patients with certain limitations. These include talking meters and other equipment for the visually impaired.

Planning hep

Patient will Have relief of discomfort Be able to resume normal activities Return to normal liver function without complications

Blood Glucose Monitors

Patients who perform SMBG use portable blood glucose monitors. A wide variety of blood glucose monitors are available Disposable lancets are used to obtain a small drop of capillary blood (usually from a finger stick) that is placed in a reagent strip. After a specified time, the monitor displays a digital reading of the blood glucose value. The technology of SMBG is a rapidly changing field; newer and more convenient systems are introduced on an ongoing basis. Alternative blood sampling sites Data uploaded to computer Continuous glucose monitoring Displays glucose values with updating every 1 to 5 minutes Helps identify trends and track patterns Alerts to hypoglycemia or hyperglycemia Some systems allow the user to collect blood from alternative sites such as the forearm or palm. Alternate site use is not recommended when blood glucose readings change rapidly, during pregnancy, or when symptoms of low blood glucose levels are present. The data from some glucose monitors can be uploaded to a computer and reviewed by HCPs, allowing for more frequent and efficient adjustment of the plan of care if needed. Continuous glucose monitoring (CGM) systems provide another route for monitoring glucose. Using a sensor inserted subcutaneously under the skin, the systems display glucose values continuously, updating values every 1 to 5 minutes. CGM assesses interstitial glucose, which lags behind blood glucose by up to 20 minutes. The patient inserts the sensor by using an automatic insertion device. Data are sent from the sensor to a transmitter, which displays the glucose value on either an insulin pump or a pagerlike receiver. The continuous glucose monitor can be used with or without an insulin pump. CGMs assist the patient and HCP to identify trends and patterns in glucose levels and are useful for the management of insulin therapy or when continuous blood glucose readings are clinically important. The patient is alerted to episodes of hypoglycemia and hyperglycemia, thus allowing corrective action to be quickly taken. Both systems still require finger-stick measurements and the use of a blood glucose monitor to calibrate the sensor and to make treatment decisions. The MiniMed® 530730G with Enlite® (A) delivers insulin through a thin plastic tubing to an infusion set, which has a cannula (B) that sits under the skin. Continuous glucose monitoring occurs through a tiny sensor (C) inserted under the skin. Sensor data are sent continuously to the insulin pump through wireless technology giving a more complete picture of glucose levels, which can lead to better treatment decisions and improved health.

CKD-MBD

Phosphate binders Should be administered with each meal Side effect: constipation Avoid aluminum preparations Supplementing vitamin D Calcitriol Serum phosphate level must be lowered before calcium or vitamin D is administered Because bone disease (osteomalacia) is associated with excess aluminum, aluminum preparations should be used with caution in patients with kidney disease. Do not use magnesium-containing antacids = depends on the kidneys for excretion. Active vitamin D is available as oral or intravenous calcitriol (Rocaltrol, Calcijex), intravenous paricalcitol (Zemplar), and oral or IV doxercalciferol (Hectorol) and can reduce the elevated levels of PTH. Controlling secondary hyperparathyroidism Calcimimetic agents Cinacalcet (Sensipar) ↑ Sensitivity of calcium receptors in parathyroid glands Subtotal or total parathyroidectomy Cinacalcet (Sensipar), a calcimimetic agent, is used to control secondary hyperparathyroidism. Calcimimetics mimic calcium and increase the sensitivity of the calcium receptors in the parathyroid glands. As a result, the parathyroid glands detect calcium at lower serum levels and decrease PTH secretion. subtotal or total parathyroidectomy may be performed to decrease the synthesis and secretion of PTH

D.B. has had no prior GI problems. Further assessment reveals: His father has ulcerative colitis. D.B. is anxious about his symptoms. He has not attended college classes since his symptoms began.

Physical assessment findings: Heart rate and temperature are elevated Bowel sounds are hyperactive Height 6 ft Weight 140 pounds

HemodialysisDialyzers

Plastic cartridge that contain thousands of parallel hollow tubes or fibers Fibers are semipermeable membranes The blood is pumped into the top of the cartridge and is dispersed into all of the fibers. Dialysis fluid (dialysate) is pumped into the bottom of the cartridge and bathes the outside of the fibers. When the dialyzed blood reaches the end of the thousands of semipermeable fibers, it converges into a single tube that returns it to the patient.

Acute PancreatitisComplications - Systemic complications

Pleural effusion Atelectasis Pneumonia ARDS Hypotension Thrombi, pulmonary embolism, DIC Hypocalcemia: tetany (bp are twich, muscle tightness) systemic complications = pulmonary (pleural effusion, atelectasis, pneumonia, and acute respiratory distress syndrome [ARDS]) and cardiovascular (hypotension). pulmonary complications = passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels. Enzyme-induced inflammation of the diaphragm = atelectasis caused by reduced diaphragm movement. Trypsin = activate prothrombin and plasminogen, incr intravascular thrombi, pulmonary emboli, and disseminated intravascular coagulation Tetany = hypocalcemia = calcium and fatty acids during fat necrosis.

Acute Intervention CRC

Postoperative care Sterile dressing changes, care of drains, and patient and caregiver teaching about stoma Management differs depending on type of wound Type of management is individualized Patients with more extensive surgery (e.g., APR) may have an open wound and drains (e.g., Jackson-Pratt, Hemovac) and a permanent ostomy. Postoperative care includes sterile dressing changes, care of drains, and patient and caregiver teaching about the ostomy. Postoperative care Drainage must be assessed for amount, color, and consistency Wound should be examined regularly Record bleeding, excessive drainage, and odor Monitor suture line for infection Help with pain control Be aware of phantom sensations Provide sexual dysfunction education A patient who has open and packed wounds requires meticulous care. Reinforce dressings and change them frequently during the first several hours postoperatively when drainage is likely to be profuse. Carefully assess all drainage for amount, color, and consistency. The drainage is usually serosanguineous. Examine the wound regularly and record bleeding, excessive drainage, and unusual odor. Use aseptic technique with dressing changes. Some patients experience phantom rectal pain or still feel as if they need to have a bowel movement. This is normal and often subsides over time. Be astute in distinguishing phantom sensations from perineal abscess pain. Consult with a wound, ostomy, and continence nurse (WOCN) if available. Ostomy care is discussed in depth in the next section. If the patient's wound is closed or partially closed, assess the incision for suture integrity and signs and symptoms of wound inflammation and infection. Examine the drainage for amount, color, and characteristics. Observe the skin around the drain for signs of inflammation, and keep the area around the drain clean and dry. Monitor for edema, erythema, and drainage around the suture line, as well as fever and an elevated WBC count. Sexual dysfunction is a possible complication after APR. The likelihood of sexual dysfunction depends on the surgical technique used. The surgeon should discuss the possibility with the patient. Members of the interprofessional care team should be available to address the patient's questions and concerns. Erection, ejaculation, and orgasm involve different nerve pathways, and a dysfunction of one does not mean complete sexual dysfunction. The WOCN is an important source of information concerning sexual dysfunction resulting from an APR.

Postoperative caregerd

Postoperative care goals Prevent respiratory complications Maintain fluid/electrolyte balance Prevent infection Since most procedures are performed laparoscopically, the risk of respiratory complications is reduced. If an open high abdominal incision is used, respiratory complications can occur. Respiratory assessment Respiratory rate/rhythm Pulse rate/rhythm Signs of pneumothorax Dyspnea Chest pain Cyanosis When peristalsis returns, only fluids given initially Solids added gradually Normal diet gradually resumed Patient must avoid gas-forming foods and must chew foods thoroughly First month after surgery, patient may report mild dysphagia; should resolve after edema subsides

Clinical Manifestations Electrolyte/Acid-Base Imbalances CKI

Potassium Hyperkalemia Most serious electrolyte disorder in kidney disease Fatal dysrhythmias When serum potassium level reaches 7 to 8 mEq/L (7 to 8 mmol/L) Hyperkalemia = breakdown of cellular protein, bleeding, and metabolic acidosis. Sodium Dilutional hyponatremia may occur = Edema, HNT, HF restricted to 2 g/day. Calcium and phosphate alterations Magnesium alterations Hypermagnesemia Related to ingestion of magnesium absence of reflexes, decreased mental status, cardiac dysrhythmias, hypotension, respiratory failure Hypermagnesemia - milk of magnesia, magnesium citrate, antacids containing magnesium Metabolic acidosis Kidneys' impaired ability of to excrete excess acid (primary ammonia) Defective reabsorption and regeneration of bicarbonate Plasma bicarbonate level usually falls to approximately 16 to 20 mEq/L (16 to 20 mmol/L) The average adult produces 80 to 90 mEq of acid per day. This acid is normally buffered by bicarbonate. plasma bicarbonate level, which is an indirect measure of acidosis, usually falls to a new steady state at approximately 16 to 20 mEq/L (16 to 20 mmol/L).

Complications - Hepatic encephalopathy

Potentially life-threatening spectrum of neurologic, psychiatric, and motor disturbances Results from liver's inability to remove toxins Hepatic encephalopathy results from the liver's inability to remove toxins (especially ammonia) from the blood.

Drug TherapyAmylin Analog

Pramlintide (Symlin) Slows gastric emptying, reduces postprandial glucagon secretion, increases satiety Used concurrently with insulin Subcutaneously in thigh or abdomen before meals Watch for hypoglycemia Pramlintide (Symlin) is the only available amylin analog. Amylin, a hormone secreted by the β-cells of the pancreas in response to food intake, slows gastric emptying, reduces glucagon secretion, and increases satiety. Pramlintide is used in addition to mealtime insulin in patients with type 1 or type 2 diabetes who have elevated blood glucose levels on ideal insulin therapy. It is used only concurrently with insulin and is not a replacement for insulin. Pramlintide is administered before major meals subcutaneously into the thigh or abdomen. It cannot be injected into the arm because absorption from this site is too variable. The drug cannot be mixed in the same syringe with insulin. The concurrent use of pramlintide and insulin increases the risk of severe hypoglycemia during the 3 hours after injection. Severe hypoglycemia is possible, especially in patients with type 1 diabetes. Patients should be instructed to eat a meal with at least 250 calories and keep a form of fast-acting glucose on hand in the event that hypoglycemia develops. When pramlintide is used, the bolus dose of insulin should be reduced.

Levodopa - PD

Precursor of DA Can cross blood-brain barrier Converted to DA in the basal ganglia Carbidopa inhibits an enzyme that breaks down levodopa before it reaches brain Levodopa with carbidopa (Sinemet) = primary treatment The net result of the combination of levodopa and carbidopa is that more levodopa reaches the brain, and therefore less drug is needed. However, levodopa has many side effects and drug interactions. Prolonged use often results in dyskinesia (abnormal or impaired voluntary movement) and "off/on" periods when the medication will unpredictably start or stop working.

Esophageal CancerNursing Management

Progressive dysphagia Types of substances causing dysphagia Odynophagia Burning, squeezing pain while swallowing Pain Choking Heartburn Hoarseness Cough Anorexia Weight loss Regurgitation Chronic pain Imbalanced nutrition: less than body requirements Risk for aspiration Anxiety and grieving

Interprofessional Care:Transhepatic Biliary Catheter

Preoperative or palliative When endoscopic drainage fails Inserted percutaneously and attached to drainage bag Replace fluids lost with electrolyte-rich drinks The transhepatic biliary catheter can be used preoperatively in biliary obstruction and in hepatic dysfunction secondary to obstructive jaundice. The catheter is inserted percutaneously and allows for decompression of obstructed extrahepatic bile ducts so that bile can flow freely. After placement of the catheter into the obstructed duct internally, the external catheter is connected to a drainage bag. The skin around the catheter insertion site should be cleansed daily with an antiseptic. Observe for = bile leakage, abdominal pain, n/, fever or chills

Inflow

Prescribed amount of solution infused through established catheter over about 10 minutes After solution infused, inflow clamp closed The amount of solution is usually 2 L. The flow rate may be decreased if the patient has pain.

Esophageal and gastric varices

Prevent bleeding/hemorrhage Avoid alcohol, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) Screen for presence with endoscopy Nonselective β-blocker The main therapeutic goal for esophageal and gastric varices is to prevent bleeding and variceal rupture by reducing portal pressure. The patient who has esophageal and/or gastric varices should avoid ingesting alcohol, aspirin, and nonsteroidal antiinflammatory drugs (NSAIDs). All patients with cirrhosis should have upper endoscopy (EGD) to screen for the presence of varices. The diagnosis of esophageal or gastric variceal bleeding needs to be made by endoscopic examination as soon as possible. Patients with varices at risk of bleeding and are generally started on a nonselective β-blocker (nadolol [Corgard] or propranolol [Inderal]) to reduce the incidence of hemorrhage. β-blockers decrease high portal pressure, which decreases the risk for rupture. If bleeding occurs, stabilize patient, manage airway, provide IV therapy and blood products Drug therapy Octreotide Vasopressin Endoscopic therapy Band ligation Sclerotherapy When variceal bleeding occurs, the first step is to stabilize the patient and manage the airway. IV therapy is initiated and may include administration of blood products. Management that involves a combination of drug therapy and endoscopic therapy is more successful than either approach alone. Drug therapy for bleeding varices may include the somatostatin analog octreotide (Sandostatin) or vasopressin (VP). The main goal of drug therapy is first to stop the bleeding and identify the source and apply interventions to prevent bleeding. IV administration of octreotide or VP produces vasoconstriction of the splanchnic arterial bed, decreases portal blood flow, and decreases portal hypertension. Currently, octreotide is more widely used in this setting because of its limited side effect profile when compared with VP. At the time of endoscopy, band ligation or sclerotherapy of varices may be used to prevent re-bleeding. Endoscopic variceal ligation (EVL or "banding") is placement of a small rubber band (elastic O-ring) around the base of the varix (enlarged vein). Sclerotherapy involves injection of a sclerosing solution into the swollen veins through an injection needle that is placed through the endoscope.

Classification of Body Weight and Obesity

Primary obesity Secondary obesity An important part of your patient assessment is to determine and classify a patient's body weight.

What to teach a patient with PD

Problems secondary to bradykinesia can be alleviated by thinking stepping over a line on the floor Lifting toes when stepping Get out of a chair by using arms and placing the back legs on small blocks Remove rugs and excess furniture Simplify clothing from buttons and hooks Use elevated toilet seats Use an ottoman to elevate legs = dependent ankle edema. caregiver burden/strain satin nightwear and/or satin sheets beneficial.

Chronic Ulcerative ColitisSurgical Therapy

Procedures for chronic ulcerative colitis Total protocolectomy with ileal pouch/anal anastomosis Total protocolectomy with permanent ileostomy Can be performed laparoscopically Because ulcerative colitis affects only the colon, a total proctocolectomy is curative. Ulcerative colitis can be cured with a total colectomy, inasmuch as the colon and rectum are not necessary for survival. Total proctocolectomy with ileal pouch/anal anastomosis (IPAA) Most commonly used surgical procedure for ulcerative colitis

Interprofessional Care CRC

Prognosis and treatment correlate with pathologic staging of disease TNM system Prognosis worsens with Greater size and depth of tumor Lymph node involvement Metastasis The most commonly used staging system is the tumor-node-metastasis (TNM) staging.

Insulin peaks

Rapid acting - lispro/aspart Peak 1hr Short acting - regular (Humulin R/Novolin R) Peak 2-3hr Intermediate - Novolin N/Humulin N (NPH) Peak 6-14 Long acting - glargine (lantus) No peak

Insulin DM

Promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell Cells break down glucose to make energy Liver and muscle cells store excess glucose as glycogen Skeletal muscle and adipose tissue are considered insulin-dependent tissues Insulin promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell. Cells break down glucose to make energy, and liver and muscle cells store excess glucose as glycogen.

Nutritional Therapy cirrhoiss

Protein supplements for protein-calorie malnutrition Low-sodium diet for patient with ascites and edema Seasonings to make food more palatable Collaborate with a dietitian

Drug Alert gerd

Proton pump inhibitors Long-term use or high doses of PPIs may increase the risk of fractures of hip, wrist, and spine Associated with increased risk of C. difficile infection in hospitalized patients Long-term use of PPIs has been associated with decreased bone density, chronic hypochlorhydria, and increased risk of pneumonia

Clinical ManifestationsIntegumentary System CKI

Pruritus Itching may be intense Leads to bleeding or infection Urea crystalizes on skin Uremic frost is an extremely rare condition in which urea crystallizes on the skin; this is usually seen only when BUN levels are extremely elevated (e.g., over 200 mg/dL).

Ambulatory Care CRC

Psychologic support Managing changes that result from cancer and cancer treatment Ostomy rehabilitation Psychologic support for the patient and caregiver dealing with the diagnosis of cancer is important. Discuss the patient's feelings about his or her prognosis and future screening. Patients need much emotional support because recurrent cancer is painful, debilitating, and demoralizing. The special needs of the cancer patient are discussed in Chapter 15. You may need to address issues surrounding palliative care, end-of-life issues, and hospice (see Chapter 9). Patients with CRC need to know how to manage changes that are the result of the cancer and cancer treatment. Those who had sphincter-sparing surgery may experience diarrhea and incontinence of feces and gas. They may need antidiarrheal drugs or bulking agents to control the diarrhea, but overuse can result in constipation. A consult with a dietitian or WOCN may help patients and caregivers understand how to manage food and fluid options. Ostomy rehabilitation, including teaching and ongoing support, should be available for all ostomy patients. Patients with skin changes from incontinence and/or radiation therapy will need assistance in managing these conditions.

Hepatitis E Virus (HEV)

RNA virus Transmitted via fecal-oral route Most common mode of transmission: drinking contaminated water Occurs primarily in developing countries Few cases in United States Hepatitis E virus (HEV) is an RNA virus transmitted via the fecal-oral route. The usual mode of transmission is via drinking contaminated water. Hepatitis E infection occurs primarily in developing countries, with epidemics reported in India, Asia, Mexico, and Africa. Only a few cases of HEV have been reported in the United States, and these cases have been primarily in persons who had recently traveled to an HEV-endemic area.

Hepatitis A Virus (HAV)

Ranges from mild to acute liver failure Not chronic Incidence decreased with vaccination RNA virus transmitted via fecal-oral route Contaminated food or drinking water Hepatitis A is a self-limiting infection that can cause a mild flu-like illness and jaundice. In more severe cases, it can cause acute cause acute liver failure. It does not result in a chronic (long-term) infection. Hepatitis A virus (HAV) is a ribonucleic acid (RNA) virus that is transmitted primarily through the fecal-oral route. It frequently occurs in small outbreaks caused by fecal contamination of food or drinking water. Poor hygiene, improper handling of food, crowded situations, and poor sanitary conditions are contributing factors. Transmission occurs between family members, institutionalized individuals, and children in day care centers. Foodborne hepatitis A outbreaks are usually due to food contaminated by an infected food handler. In the United States, the incidence of hepatitis A viral infection has declined since vaccination was recommended for at-risk persons and children (at the age of 1 year).

Somogyi effect

Rebound effect in which an overdose of insulin causes hypoglycemia Release of counterregulatory hormones causes rebound hyperglycemia Hyperglycemia in the morning may be due to the Somogyi effect. A high dose of insulin produces a decline in blood glucose levels during the night. As a result, counterregulatory hormones (e.g., glucagon, epinephrine, growth hormone, cortisol) are released, stimulating lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia. The danger of this effect is that when blood glucose levels are measured in the morning, hyperglycemia is apparent and the patient (or the HCP) may increase the insulin dose. If a patient is experiencing morning hyperglycemia, checking blood glucose levels between 2:00 AM and 4:00 AM for hypoglycemia will help determine if the cause is the Somogyi effect. The patient may report headaches on awakening and may recall having night sweats or nightmares. A bedtime snack, a reduction in the dose of insulin, or both can help to prevent the Somogyi effect.

Wearable Artificial Kidney (WAK)

Recently developed and approved for use Miniaturized dialysis machine Connects to patient via catheter Designed to filter blood in ESRD Can run continuously The wearable artificial kidney (WAK) has recently been developed and is approved for use to improve the quality of life of an ESRD patient. resembles a tool belt. run continuously on batteries weighs about 10 pounds

Bowel symptoms CRC

Rectal bleeding is most common Alternating constipation and diarrhea Change in stool caliber Narrow, ribbonlike Sensation of incomplete evacuation Obstruction Right-sided lesions are more likely to bleed and cause diarrhea. Left-sided tumors are usually detected later. They are usually associated with a change in bowel habits and could present with bowel obstruction

Acute PancreatitisPlanning

Relief of pain Normal fluid and electrolyte balance Minimal to no complications No recurrent attacks

Nursing Management:Planning Cholecystitis

Relief of pain and discomfort No complications postoperatively No recurrent attacks of cholecystitis or cholelithiasis

Exercise - MS

Relieve spasticity Improve coordination Train patient to substitute unaffected muscles for impaired muscles Neurologic dysfunction = physical and speech therapies. Exercise decreases spasticity, increases coordination, and retrains unaffected muscles to substitute for impaired ones.

Hepatic encephalopathy

Reduce ammonia formation Lactulose (Cephulac), which traps ammonia in gut Rifaximin (Xifaxan) antibiotic Prevent constipation Treatment of precipitating cause Lower dietary protein intake Control GI bleeding Remove blood from GI tract The goal of management of hepatic encephalopathy is the reduction of ammonia formation. Ammonia formation in the intestines is reduced with lactulose (Cephulac). This drug traps ammonia in the gut. It can be given orally, as an enema, or through a nasogastric (NG) tube. The laxative effect of the drug expels the ammonia from the colon. Antibiotics such as rifaximin (Xifaxan) may also be given, particularly in patients who do not respond to lactulose. Constipation should be prevented, and regular and frequent bowel movements are necessary to minimize the ammonia buildup. Control of hepatic encephalopathy also involves treatment of precipitating causes (see Table 43-11). This includes lowering ones dietary protein intake, preventing and controlling GI bleeds and, in the event of a bleed, removing the blood promptly from the GI tract to decrease the protein accumulation in the gut.

Nursing Management:Nursing ImplementationPostoperative care Cholecystitis

Referred pain to shoulder pain from CO2 Sims' position Deep breathing, ambulation, analgesia Clear liquids Discharged same day The CO2 can irritate the phrenic nerve and diaphragm, causing some difficulty in breathing. Placing the patient in the Sims' position (left side with right knee flexed) helps move the gas pocket away from the diaphragm. If the patient has a T-tube, you need to maintain bile drainage and monitor T-tube function and drainage. The T-tube is usually connected to a closed gravity drainage system. If the Penrose or Jackson-Pratt tube or the T-tube is draining large amounts of bile, it is helpful to use a sterile pouching system to protect the skin.

Fructosamine

Reflects glycemia in previous 1-3 weeks Autoantibodies Fructosamine is another way to assess glucose levels. Fructosamine is formed by a chemical reaction of glucose with plasma protein. It reflects glycemia in the previous 1 to 3 weeks. Fructosamine levels may show a change in blood glucose levels before A1C does. Islet cell autoantibody testing is ordered primarily to help distinguish between autoimmune type 1 diabetes and diabetes due to other causes.

Most common sites of metastasis CRC

Regional lymph nodes Liver Lungs Bones Brain Because venous blood leaving the colon and rectum flows through the portal vein and the inferior rectal vein, the liver is commonly a site of metastasis. The cancer spreads from the liver to other sites, including the lungs, bones, and brain. CRC can also spread directly into adjacent structures.

During acute exacerbations ibs

Regular diet may not be tolerated Liquid enteral feedings are preferred High in calories and nutrients Lactose free Easily absorbed Regular foods are reintroduced gradually Liquid enteral feedings are preferred over parenteral nutrition because atrophy of the gut and bacterial overgrowth occur when the GI tract is not used. Restarting regular foods gradually will to help identify food intolerances or sensitivities. Foods that trigger exacerbations vary Food diary helps identify problems for individuals Lactose intolerance High-fat foods Cold foods High-fiber foods There are no universal food triggers for IBD, but some may find that certain foods cause diarrhea. A food diary helps to identify problem foods to avoid. Because many patients with IBD are lactose intolerant, avoiding milk and milk products improves symptoms. Lactose-intolerant patients can use yogurt as a substitute. High-fat foods, cold foods and high-fiber foods (cereal with bran, nuts, raw fruits with peels) may trigger diarrhea.

Clinical ManifestationsClinical Manifestations cirrhosis

Relatively few symptoms in early stage disease Blood tests may be normal- compensated cirrhosis fatigue or an enlarged liver. Late manifestations Result from liver failure and portal hypertension Jaundice, peripheral edema, ascites Skin lesions, hematologic disorders , endocrine disturbances , and peripheral neuropathies Late manifestations result from liver failure and portal hypertension (Fig. 43-5). Jaundice, peripheral edema, and ascites develop gradually. Other late manifestations include skin lesions, hematologic disorders, endocrine disturbances, and peripheral neuropathies (Fig. 43-6). In the advanced stages, the liver becomes small and nodular. Liver function is dramatically diminished. Jaundice Decreased ability to conjugate and excrete bilirubin Overgrowth of connective tissue in liver compresses bile ducts Leads to obstruction Increase in bilirubin in vascular system May be minimal or severe Jaundice results from decreased ability to conjugate and excrete bilirubin into the small intestines There is an overgrowth of connective tissue in the liver, which compresses the bile ducts and leads to an obstruction. This results in an increase in the bilirubin in the vascular system, and jaundice occurs. The jaundice may be minimal or severe, depending on the degree of liver damage. Skin lesions Due to increase in circulating estrogen caused by inability of liver to metabolize steroid hormones Spider angiomas (teleangiectasia or spider nevi) Palmar erythema Various skin manifestations are commonly seen in cirrhosis because of an increase in circulating estrogen as a result of the damaged liver's inability to metabolize steroid hormones. Spider angiomas (telangiectasia or spider nevi) are small, dilated blood vessels with a bright red center point and spiderlike branches. They occur on the nose, cheeks, upper trunk, neck, and shoulders. Palmar erythema (a red area that blanches with pressure) is located on the palms of the hands. Both of these lesions are due to an increase in circulating estrogen as a result of the damaged liver's inability to metabolize steroid hormones. Hematologic disorders Thrombocytopenia Leukopenia Anemia Coagulation disorders Hematologic problems include thrombocytopenia, leukopenia, anemia, and coagulation disorders. Thrombocytopenia, leukopenia, and anemia are thought to be caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension). Overactivity of the enlarged spleen results in increased removal of blood cells from circulation. Anemia can result from inadequate RBC production and survival, poor diet, poor absorption of folic acid, and bleeding from varices. The coagulation problems result from the liver's inability to produce prothrombin and other factors essential for blood clotting. Manifestations of coagulation problems (bleeding tendencies) include epistaxis, purpura, petechiae, easy bruising, gingival bleeding, and heavy menstrual bleeding. Secondary to decreased metabolism of hormones Gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence and loss of libido (men) Amenorrhea or vaginal bleeding Hyperaldosteronism in both sexes The liver plays an important role in the metabolism of hormones, such as estrogen, and testosterone. Aldosterone, an important hormone associated with fluid balance, can also be altered. liver fails to metabolize aldosterone adequately = hyperaldosteronism Peripheral neuropathy Dietary deficiencies of thiamine, folic acid, and cobalamin (vitamin B12) Sensory and motor symptoms Sensory symptoms may predominate

Open (incisional) cholecystectomy

Removal of gallbladder through right subcostal incision T-tube inserted into common bile duct Allows excess bile to drain

Endoscopic mucosal resection (EMR)

Removes superficial lesions or submucosal neoplasms Radiofrequency ablation used to kill cancer cells Option for some small, very early stage cancers

Hepatorenal syndrome

Renal failure with azotemia, oliguria, and intractable ascites No structural abnormality of kidneys Portal hypertension → vasodilation → renal vasoconstriction Treat with liver transplantation Hepatorenal syndrome is a type of renal failure with azotemia, oliguria, and intractable ascites. In this syndrome, the kidneys have no structural abnormality.

Delirium Drug Therapy

Reserved for those patients with severe agitation Interferes with needed medical therapy Puts patient at increased risk for falls and injury Used when nonpharmacologic interventions have failed Drug therapy is used cautiously because many of the drugs used to manage agitation have psychoactive properties. Dexmedetomidine (Precedex) for sedation Neuroleptics Haloperidol (Haldol) Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Short-acting benzodiazepines Dexmedetomidine (Precedex), an α-adrenergic receptor agonist, has been used in ICU settings for sedation. side effects antipsychotics = hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of the face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects. Short-acting benzodiazepines (e.g., lorazepam [Ativan]) can be used to treat delirium associated with sedative and alcohol withdrawal = may worsen delirium caused by other factors and must be used cautiously.

Interprofessional Care cirrhoiss

Rest Administration of B-complex vitamins Avoidance of alcohol Minimization or avoidance of aspirin, acetaminophen, and NSAIDs The goal of treatment is to slow the progression of cirrhosis to prevent and treat any complications. Conservative therapy includes: Rest Administration of B-complex vitamins Avoidance of alcohol Minimization or avoidance of aspirin, acetaminophen, and NSAIDs Ascites Sodium restriction Albumin Diuretics Tolvaptan (Samsca) Management of ascites is focused on sodium restriction, diuretics, and fluid removal. The amount of sodium restriction is based on the degree of ascites. Patients may be encouraged to limit sodium intake to 2 g/day. Patients with severe ascites may need to restrict their sodium intake to 250 to 500 mg/day. Very low sodium intake can result in reduced nutritional intake and subsequent problems associated with malnutrition. The patient is usually not on restricted fluids unless severe ascites develops. Accurately assess and monitor fluid and electrolyte balance. Albumin infusion may be used to help maintain intravascular volume and adequate urinary output by increasing plasma colloid oncotic pressure. Diuretic therapy is an important part of management. Often a combination of drugs that work at multiple sites of the nephron is more effective than a single agent. Spironolactone (Aldactone) is an effective diuretic, even in patients with severe ascites. Spironolactone is also an antagonist of aldosterone and is potassium sparing. A high-potency loop diuretic, such as furosemide (Lasix), is frequently used in combination with a potassium-sparing drug. Tolvaptan (Samsca), a vasopressin-receptor antagonist, is used to correct hyponatremia, which is often seen in patients with cirrhosis. It causes an increase in water excretion, resulting in an increase in serum sodium concentrations. Ascites Paracentesis Transjugular intrahepatic portosystemic shunt (TIPS) Peritoneovenous shunt A paracentesis is a sterile procedure in which a catheter is used to withdraw fluid from the abdominal cavity. Used to diagnose a medical condition or relieve pain, pressure, or difficulty breathing. In the patient with cirrhosis, this procedure is reserved for the person with impaired respiration or abdominal discomfort caused by severe ascites who does not respond to diuretic therapy. It is only a temporary measure of palliation because the fluid tends to re-accumulate rapidly. TIPS is used to alleviate ascites that does not respond to diuretics. Peritoneovenous shunt is a surgical procedure that provides continuous reinfusion of ascitic fluid into the venous system. Its use has almost been eliminated because of the high rate of complications.

Acute PancreatitisNursing Assessment - Objective Data

Restlessness, anxiety, low-grade fever Flushing, diaphoresis Discoloration of abdomen/flank Cyanosis Jaundice Decreased skin turgor Dry mucous membranes Tachypnea Basilar crackles Tachycardia Hypotension Abdominal distention/tenderness Diminished bowel sounds

Bariatric Surgical Procedures

Restrictive bariatric surgery reduces either the size of the stomach, which causes the patient to feel full quicker, or the amount allowed to enter the stomach. In these surgeries digestion is not altered so the risk of anemia or cobalamin deficiency is low. The most common restrictive surgeries include adjustable gastric banding and sleeve gastrectomy.

Clinical Manifestations CKD

Result of retained substances Urea Creatinine Phenols Hormones Electrolytes Water Uremia Syndrome in which kidney function declines to the point that symptoms occur in multiple body systems, when GFR is ≤ 15 mL/min

Other Specific Types of Diabetes

Results from injury to, interference with, or destruction of β-cell function in the pancreas Diabetes occurs in some people because of another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels. Cushing syndrome, hyperthyroidism, recurrent pancreatitis, cystic fibrosis, hemochromatosis, and the use of parenteral nutrition. corticosteroids (prednisone), thiazides, phenytoin (Dilantin), and atypical antipsychotics (e.g., clozapine [Clozaril]).

Dietary Changes IBS

Review with the patient foods that are high in FODMAPs Teach patients to follow a low FODMAP diet FODMAPs are carbohydrates (sugars) that are found in foods Not all carbohydrates are considered FODMAPs FODMAPs in diet are Fructose Lactose Fructans Galactans Polyols The FODMAPs in the diet are: Fructose (fruits, honey, high fructose corn syrup [HFCS], etc) Lactose (dairy) Fructans (wheat, garlic, onion, inulin etc) Galactans (legumes such as beans, lentils, soybeans, etc) Polyols (sweeteners containing isomalt, mannitol, sorbitol, xylitol, stone fruits such as avocado, apricots, cherries, nectarines, peaches, plums, etc) Eliminate gas-producing foods Brown beans Brussels sprouts, cabbage, cauliflower, raw onions Grapes, plums, raisins This is very helpful in patients whose primary symptoms are abdominal distention and increased flatulence. Yogurt may be better tolerated than milk products Lactobacillus bacteria Probiotics may be used Increase dietary fiber for those with constipation If dairy products tend to cause symptoms, yogurt may be the best option because of the lactobacillus bacteria it contains. Some patients benefit from certain probiotic combinations. For those with constipation, encourage an intake of enough dietary fiber to produce soft, painless bowel movements.

Stages of dementia

Reyburgs stages of alzheimers 1 = no impairment 2 = mild cognition decline - forgetting recent events, miss placing things, word finding: subtle changes 3 = mild impairment: effects daily living, try to hide it, probs with organization, pt knows and tries not to let others know 4 = mild alzheimers: math is hard, memory declines, sequential tasks (cooking/driving) 5 = moderate alzheimers: cog decline, need assists, disoriented (wrong season for clothing), can still do ADLs but it is harder 6 = moderately/severe alzheimers: lack of awareness, don't remember names/past, need help with basic tasks (ADLs) 7 = severe: limited speech, lack of motor skills, decr movement (eating, swallowing, walking), need around the clock care Complications: pneumonia, falls

Colorectal Cancer Etiology and Pathophysiology

Risk factors No single risk factor accounts for most cases of CRC Highest risk in those with first-degree relatives with CRC and people with IBD About 1/3 of cases of CRC occur in patients with a family history of CRC About 30% to 50% of people with CRC have an abnormal KRAS gene (oncogene) Unlike some other cancers, no single risk factor accounts for most cases of CRC. The risk is highest in those with first-degree relatives with CRC and people with IBD. About one third of cases of CRC occur in patients with a family history of CRC. Hereditary forms of CRC, including FAP and hereditary nonpolyposis colorectal cancer (HNPCC) syndrome (Lynch syndrome), account for 5% to 10% of those cases. About 30% to 50% of people with CRC have an abnormal KRAS gene. The KRAS gene, which is primarily involved in regulating cell division, belongs to a class of genes known as oncogenes. When mutated, oncogenes have the potential to cause normal cells to become cancerous. Factors that ↓ the risk of CRC Physical exercise Diet high in fruits, vegetables, and grains Long-term use of NSAIDS Adenocarcinoma is most common type of CRC About 85% arise from adenomatous polyps Tumors spread through walls of colon into musculature and into lymphatic and vascular systems As the tumor grows, the cancer invades and penetrates the muscularis mucosae. Eventually tumor cells gain access to the regional lymph nodes and vascular system and spread to distant sites. Approximately 85% of CRCs arise from adenomatous polyps. As the tumor grows, the cancer invades and penetrates the muscularis mucosae.

Complications - Cirrhosis

Risk factors include Male gender Alcohol consumption Concomitant fatty liver disease Excess iron deposition in liver Patients with metabolic syndrome In some patients, co-infection with HIV may also cause complications or require modification of treatment.

Alzheimer's DiseaseSafety

Risks Injury from falls Ingesting dangerous substances Wandering Injury to others and self with sharps Burns Inability to respond to crisis Minimize risks in home environment Assist caregiver in assessing home environment for safety risks Implement all possible safety strategies Supervision As the patient's cognitive function declines over time, the patient may have difficulty navigating physical spaces and interpreting environmental cues. Teach the caregiver to take the following steps: Have stairwells well lit. Handrails should be graspable. Tack down carpet edges. Remove throw rugs and extension cords. Use nonskid mats in tub or shower. Install handrails in bath and by commode. Wandering is major concern Observe for precipitating factors or events Patient can be registered with Medical Alert + Safe Return GPS Wandering may be related to loss of memory or to side effects of drugs, or it may be an expression of a physical or emotional need, restlessness, curiosity, or stimuli that trigger memories of earlier routines. When someone with AD is discovered missing, every second counts. To assist caregivers with locating them, the Alzheimer's Association and the MedicAlert Foundation have created an alliance to offer MedicAlert + Alzheimer's Association SafeReturn. The Safe Return program includes identification products (e.g., bracelet, necklace, wallet cards), a national photo/information database, a 24-hour toll-free emergency crisis line, local chapter support, and wandering behavior education and training for caregivers and families. Tracking devices such as a global positioning system (GPS) can also be used to detect and find people who wander. These devices can be placed in shoes, sewn into pockets, worn as a bracelet or pendant, or clipped to a belt.

Combination of Restrictive and Malabsorptive Surgery

Roux-en-Y surgical procedure (RYGB) Has low complication rates Excellent patient tolerance Food bypasses 90% of the stomach, duodenum, and a small segment of jejunum most common bariatric procedure = gold standard among bariatric procedures. This procedure involves creating a small gastric pouch and attaching it directly to the small intestine using a Y-shaped limb of the small bowel. improvement or reversal of diabetes, normalization of BP, decreased total cholesterol and triglycerides, decr gastroesophageal reflux disease (GERD), and decr sleep apnea.

Nursing Management:Nursing Implementation Cholecystitis

Screen for predisposing factors Teaching for at-risk ethnic groups Early detection of chronic cholecystitis Manage with low-fat diet

Behavior Modification obesity

Self-monitoring: Show what and when foods are eaten Stimulus control: Separate events that trigger eating from the act of eating Rewards: Non-food incentives for weight loss Self-monitoring may involve keeping a record of the type and time food was consumed and how the person was feeling when eating. Stimulus control is aimed at separating events that trigger eating from the act of eating. Praise your patient's successes, even small ones, at every opportunity. Changing existing behaviors is difficult.

D.V. eats irregularly and often in a hurry. She is anxious about her symptoms and worried that she may have colon cancer because her grandmother died of cancer.

She has a very stressful lifestyle. She denies any blood in stool or diarrhea. There is no change in body weight, and appetite is good.

Peritoneal DialysisEffectiveness of Chronic PD

Short training program Advantages Simplicity Home-based program Increasing patient participation No need for special water systems Equipment set-up is relatively simple Learning self-management skills = accomplished in a 3- to 7-day training program. Mortality rates are about equal between in-center HD patients and PD patients After about 2 years, mortality rates for patients receiving PD increase

Protein DM

Should make up 15% to 20% of total calories High-protein diets not recommended The amount of daily protein in the diet for people with diabetes and normal renal function is the same as for the general population. • 15% to 20% of total calories. • High-protein diets are not recommended for weight loss for people with diabetes.

Glucagonlike Peptide-1 Receptor Agonists

Simulate glucagonlike peptide-1 (GLP-1) Increase insulin synthesis and release Inhibit glucagon secretion Slow gastric emptying Increases satiety Exenatide (Byetta), exenatide extended-release (Bydureon), liraglutide (Victoza), albiglutide (Tanzeum), and dulaglutide (Trulicity) simulate glucagonlike peptide-1 (GLP-1) (one of the incretin hormones), which is found to be decreased in people with type 2 diabetes. These drugs increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, slow gastric emptying, and reduce food intake by increasing satiety. These drugs may be used as monotherapy or adjunct therapy for patients with type 2 diabetes who have not achieved optimal glucose levels on OAs. These drugs are administered using a subcutaneous injection in a prefilled pen. In contrast to exenatide, which is given twice a day, and liraglutide, which is given once daily, dulaglutide, albiglutide, and Bydureon are given once every 7 days. The delayed gastric emptying that occurs with these medications may affect the absorption of oral medications. Advise patients to take fast-acting oral medications at least 1 hour before injecting a GLP-1 agonist drug.

Mechanisms of Action of Type 2 Diabetes Drugs

Sites and mechanisms of action of type 2 diabetes drugs. DDP-4, Dipeptidyl peptidase; GLP-1, glucagon-like peptide-1. Panc, adipose, muscle, stomach, small intestine, live, kidney

Alzheimer's DiseaseGenetic Link

Small percentage of people < 60 years old develop AD Early-onset: <60 years old Late-onset: >60 years old When AD develops in someone younger than 60 years old, it is referred to as early-onset AD. AD that becomes evident in individuals older than 60 years old is called late-onset AD.

Interprofessional Care:Nutritional Therapy Cholecystitis

Small, frequent meals with some fat Diet low in saturated fat High in fiber and calcium Reduced-calorie diet if patient is obese Avoidance of rapid weight loss After laparoscopic cholecystectomy Liquids first day Light meals for several days After incisional cholecystectomy Liquids to regular diet after return of bowel sounds May need to restrict fats for 4-6 weeks The amount of fat in the postoperative diet depends on the patient's tolerance of fat. A low-fat diet may be helpful if the flow of bile is reduced (usually only in the early postoperative period) or if the patient is overweight.

What does G.O. need to know about how smoking can affect his health?

Smoking actually increases G.I. motility and may influence his nutrition and dietary regimen and tolerance. He needs to know that this adds risk to his existing cardiovascular condition. He needs information about smoking cessation.

Esophageal CancerTargeted therapy

Some esophageal cancers have too much HER-2 protein Trastuzumab (Herceptin) Angiogenesis inhibitors block vascular endothelial growth factor (VEGF) Ramucirumab (Cyramza) Trastuzumab (Herceptin) is a drug that targets the HER-2 protein and kills the cancer cells. (This drug is discussed in Chapter 51). Ramucirumab (Cyramza), an angiogenesis inhibitor, binds to the receptor for vascular endothelial growth factor (VEGF), a compound that stimulates blood vessel growth. This prevents VEGF from binding to the receptor and signaling the body to make more blood vessels. This can help slow or stop the growth and spread of cancer.

HeRO Graft(Hemodialysis Reliable Outflow)

Special bridge access Used when other access options are exhausted Two pieces Reinforced tube to bypass blockages Dialysis graft anastomosed to an artery It consists of two pieces: a reinforced tube to bypass blockages in veins and a dialysis graft anastomosed to an artery to be accessed for HD (Fig. 46-8, C). The HeRO graft is placed under the skin, like both a fistula and standard graft. The HeRO Graft bypasses the venous system to provide blood flow directly from a target artery to the heart.

Chronic ComplicationsMicrovascular Angiopathy

Specific to diabetes and includes Retinopathy Nephropathy Dermopathy Usually appear 10 to 20 years after diagnosis Microvascular = thickening of the vessel membranes in the capillaries and arterioles in response to conditions of chronic hyperglycemia. They differ from the macrovascular complications in that they are specific to diabetes. microangiopathy = found throughout the body = the eyes (retinopathy), the kidneys (nephropathy), and the skin (dermopathy). Microvascular changes = type 2 diabetes = clinical manifestations = until 10 to 20 years later.

Alzheimer's DiseaseNursing Assessment

Subjective Data Past health history Medications Health perception-health management Nutritional-metabolic Elimination (incontinence) Subjective Data Activity-exercise Sleep-rest pattern Cognitive-perceptual Objective Data Disheveled appearance Neurologic Early, middle, late Useful questions for the patient and informant are, "When did you first notice the memory loss?" and "How has the memory loss progressed since then?"

DiabetesExchange lists

Starches, fruits, milk, meat, vegetables, fats, free foods Consistent CHO diet USDA MyPlate method Diabetes exchange lists are another method for meal planning. Instead of counting carbohydrates, the individual is given a meal plan with specific numbers of helpings from a list of exchanges for each meal and snack. The exchanges are starches, fruits, milk, meat, vegetables, fats, and free foods. The patient chooses foods from the various exchanges based on the prescribed meal plan. This method may be easier for some patients than carbohydrate counting. It also encourages a well-balanced meal plan. Another advantage is that this approach helps the patient limit portion sizes and overall food intake, an important component of weight management. Whenever possible, include family members and caregivers in nutrition education and counseling, particularly the person who cooks for the household. However, the responsibility for maintaining a healthy eating plan still belongs to the person with diabetes. Reliance on another person to make health decisions interferes with the patient's ability to develop self-care skills, which is essential in the management of diabetes. Foster independence, even in patients with visual or cognitive impairment. It is also important to discuss traditional foods with the patient. Individualize food choices to take into account the patient's preferences and foods that are culturally appropriate. In an acute health care facility, the nutritional needs of the diabetic patient vary slightly from the normal meal plans. Previously, standardized calorie-level meal patterns were used, but new systems are now being used, such as the consistent carbohydrate diabetes meal plan. Under this system, meal plans are created with consistent carbohydrate content. For example, breakfast contains the same amount of carbohydrates every day.

Dyslipidemia CKI

Statins (HMG-CoA reductase inhibitors) Most effective for lowering LDL level atorvastatin (Lipitor) Fibrates (fibric acid derivitives) Used to lower triglyceride levels gemfibrozil

Nursing ManagementNursing Assessment cirrhosis

Subjective Data Past health history Hepatitis NASH Chronic biliary obstruction and infection Severe right-sided heart failure Anticoagulants, aspirin Subjective Data: Functional Health Patterns Chronic alcoholism Weakness, fatigue Anorexia, weight loss Dyspepsia Nausea and vomiting Gingival bleeding Subjective Data: Dark urine Decreased output Light-colored or black stools Flatulence Change in bowel habits Dry, yellow skin Bruising RUQ or epigastric pain Numbness, tingling Pruritus Impotence Amenorrhea Objective Data Fever, cachexia, wasting of extremities Icteric sclera, jaundice Petechiae, ecchymoses Spider angiomas, palmar erythema Alopecia, loss of axillary and pubic hair Peripheral edema Shallow, rapid respirations Epistaxis Abdominal distention, ascites Distended abdominal wall veins Palpable liver and spleen Foul breath Hematemesis; black, tarry stools Hemorrhoids Altered mentation Asterixis Gynecomastia Testicular atrophy Impotence Loss of libido Amenorrhea, vaginal bleeding Anemia, thrombocytopenia, leukopenia ↓ Serum albumin and potassium levels Abnormal liver function studies ↑ INR ↑ Ammonia and bilirubin levels Abnormal findings on abdominal ultrasonography or MRI

Subjective DM

Subjective Data Past health history Viral infections, trauma, infection, stress, pregnancy, chronic pancreatitis, Cushing syndrome, acromegaly, family history of diabetes Medications Insulin, OAs, corticosteroids, diuretics, phenytoin Recent surgery Subjective Data Malaise Obesity, weight loss or gain Thirst, hunger, nausea/vomiting Poor healing Dietary compliance Constipation/diarrhea Frequent urination, bladder infections Nocturia, urinary incontinence Muscle weakness, fatigue Abdominal pain, headache, blurred vision Numbness/tingling, pruritus Impotence, frequent vaginal infections Decreased libido Depression, irritability, apathy Commitment to lifestyle changes

Nursing Management: CholecystitisNursing Assessment Subjective

Subjective Data Past health history: obesity, multiparity, infection, cancer, extensive fasting, pregnancy Medications: use of estrogen or oral contraceptives Surgery or other treatments: previous abdominal surgery Weight loss, anorexia Indigestion, fat intolerance Nausea and vomiting, dyspepsia Chills Clay-colored stools Steatorrhea Flatulence Dark urine Pain - URQ - to back/scapula Pruritus

Objective Data DM

Sunken eyeballs, history of vitreal hemorrhages, cataracts Dry, warm, inelastic skin Pigmented skin lesions, ulcers, loss of hair on toes, acanthosis nigricans Kussmaul respirations Hypotension Weak, rapid pulse Dry mouth Vomiting Fruity breath Altered reflexes, restlessness Confusion, stupor, coma Muscle wasting Serum electrolyte abnormalities Fasting blood glucose level of 126 mg/dL or higher Oral glucose tolerance test and/or random glucose level exceeding 200 mg/dL Leukocytosis ↑ Blood urea nitrogen, creatinine ↑ Triglycerides, cholesterol, LDL, VLDL ↓ HDL Hemoglobin A1C value > 6.0% Glycosuria Ketonuria Albuminuria Acidosis

Acute PancreatitisInterprofessional Care - Conservative Therapy

Supportive care Aggressive hydration Pain management IV morphine, antispasmodic agent Management of metabolic complications Oxygen, glucose levels Minimizing pancreatic stimulation NPO status, NG suction, decreased acid secretion, enteral nutrition if needed However, atropine and other anticholinergic drugs should be avoided when paralytic ileus is present because they can decrease GI mobility, thus further exacerbating to the problem. Other medications that relax smooth muscles (spasmolytics), such as nitroglycerin or papaverine, may be used. It is important to reduce or suppress pancreatic enzymes to decrease stimulation of the pancreas and allow it to rest. This is accomplished in several ways. First, the patient is on NPO status. Second, NG suction may be used to reduce vomiting and gastric distention and to prevent gastric acidic contents from entering the duodenum. Supplemental O2 is used to maintain O2 saturation greater than 95%. In patients with severe pancreatitis, serum glucose levels are closely monitored for hyperglycemia. With resolution of the pancreatitis, the patient will resume oral intake. For the patient with severe acute pancreatitis in whom oral intake is not resumed, enteral nutrition support may be initiated. Shock Plasma or plasma volume expanders (dextran or albumin) Fluid/electrolyte imbalance Lactated Ringer's solution If shock is present, blood volume replacements are used. Plasma or plasma volume expanders such as dextran or albumin may be given. Fluid and electrolyte imbalances are corrected with lactated Ringer's solution or other electrolyte solutions. Central venous pressure readings may be used to assist in determining fluid replacement requirements. Ongoing hypotension Vasoactive drugs: dopamine Prevent infection Enteral nutrition Antibiotics Endoscopically or CT-guided percutaneous aspiration Vasoactive drugs such as dopamine may be used to increase systemic vascular resistance in patients with ongoing hypotension. The inflamed and necrotic pancreatic tissue is a good medium for bacterial growth. In patients with acute necrotizing pancreatitis, infection is the leading cause of morbidity and mortality. Therefore, it is important to prevent infections. Because many of the organisms come from the intestine, enteral feeding reduces the risk of necrotizing pancreatitis. It is important to monitor the patient closely so that antibiotic therapy can be instituted early if necrosis and infection occur. Endoscopically or CT-guided percutaneous aspiration with Gram stain and culture may be performed.

Surgical therapy - gerd

Surgical therapy reserved for those with complications Failure of conservative therapy Medication intolerance Barrett's metaplasia Esophageal stricture and stenosis Chronic esophagitis Nissen and Toupet fundoplications

Esophageal CancerClinical Manifestations

Symptom onset is late Progressive dysphagia is most common symptom Initially with only meat, then with soft foods, and eventually with liquids The onset of symptoms is usually late relative to tumor growth. At diagnosis, the majority of patients have advanced disease. Progressive dysphagia may be described as a substernal feeling as if food is not passing. Pain develops late Substernal, epigastric, or back areas Increases with swallowing May radiate to neck, jaw, ears, shoulders Weight loss Regurgitation of blood-flecked esophageal contents The pain may radiate to the neck, jaw, ears, and shoulders. Weight loss is fairly common. When esophageal stenosis (narrowing) is severe, regurgitation of blood-flecked esophageal contents is common. If tumor is in upper third of esophagus Sore throat Choking Hoarseness

COPDEnd-of-Life Considerations

Symptoms can be managed, but COPD cannot be cured End-of-life issues and advanced directives are important topics for discussion Palliative care, end-of-life and hospice care are important in advanced COPD

Clinical Manifestations - GERD

Symptoms of GERD Heartburn (pyrosis) Burning, tight sensation felt beneath lower sternum, spreading upward to throat or jaw Felt intermittently more than twice a week = GERD. It may occur after ingesting food or drugs that decrease the LES pressure or directly irritate the esophageal mucosa. Dyspepsia Regurgitation Described as hot, bitter, or sour liquid coming into throat or mouth Discomfort from dyspepsia is felt mainly around the midline. GERD-related chest pain Described as burning, squeezing Radiating to back, neck, jaw, or arms Can mimic angina More common in older adults with GERD Relieved with antacids GERD= mimic angina. Heartburn occurring more than once a week, rated as severe, is associated with dysphagia, or occurring at night and waking patient Otolaryngologic symptoms include Hoarseness Sore throat Globus sensation (Lump in throat) Hypersalivation Choking Wheezing Coughing Dyspnea Nocturnal discomfort and coughing with loss of sleep

LINX Reflux Management System - gerd

Titanium beads with a magnetic core strung together and implanted laparoscopically into LES A LINX system is a ring of small, flexible magnets enclosed in titanium beads and connected by titanium wires. Once implanted laparoscopically into the LES, the ring provides strength to a weakened LES. Under resting (nonswallowing) conditions, the magnetic attraction between the beads helps keep a weak LES closed to prevent reflux. When the individual swallows, the force of pressure associated with the movement of the fluids or foods overwhelms the magnetic forces so that the fluid or food passes to the stomach. AE: difficulty swallowing, vomiting, nausea, chest pain, and pain when swallowing food. Cannot have MRI

Tenckhoff Catheter

The catheter is about 24 inches (60 cm) long and has one or two Dacron cuffs. The cuffs act as anchors and prevent the migration of microorganisms into the peritoneum. The tip of the catheter rests in the peritoneal cavity and has many perforations spaced along the distal end of the tubing, allowing fluid movement through the catheter. The technique for catheter placement varies. It is usually placed surgically so that the catheter can be directly visualized, minimizing potential complications.

Alzheimer's DiseaseDiagnostic Studies

The clock drawing test can be used as part of the Mini-Cog or by itself to assess cognitive function. Many students of a younger generation are not familiar with an analog clock.

Diagnostic Studies 1-4 DM

The diagnosis of diabetes mellitus is made using one of four methods. These methods and their criteria for diagnosis are as follows: 1. Hemoglobin A1C level of 6.5% or higher. 2. Fasting plasma glucose (FPG) level of 126 mg/dL (7.0 mmol/L) or higher. 3. Two-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during an OGTT, with a glucose load of 75 g. 4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher. If a patient presents with a hyperglycemic crisis or clear symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) with a random plasma glucose level of 200 or higher, repeat testing is not warranted. Otherwise, criteria 1 through 3 should be confirmed by repeat testing to rule out laboratory error. It is preferable for the repeat test to be the same test used initially. For example, if a random blood glucose test showed elevated blood glucose levels, the same test should be used again when the person is retested.

What patient teaching is important for D.B.?

The importance of rest and diet management, perianal care, action and side effects of drugs, symptoms of recurrence of disease, when to seek medical care, and use of diversional activities to reduce stress.

Appearance of Patient with PD

The posture is that of a slowed "old man" image, with the head and trunk bent forward and the legs constantly flexed. Postural instability is common. Patients may complain of being unable to stop themselves from going forward (propulsion) or backward (retropulsion). Assessment of postural instability = "pull test." = examiner stands behind the patient, gives a tug backwards on the shoulder, which causes patients to lose their balance and fall backward.

Serologic Events in HAV Infection

The virus is present in feces during the incubation period, so it can be carried and transmitted by persons who have undetectable, subclinical infections. The greatest risk of transmission occurs before clinical symptoms appear. HAV is found in feces 2 weeks or more before the onset of symptoms and up to 1 week after the onset of jaundice. It is present only briefly in blood. Anti-HAV (antibody to HAV) immunoglobulin M (IgM) appears in the serum as the stool becomes negative for the virus. Detection of hepatitis A IgM indicates acute hepatitis. Although not commonly assessed clinically, hepatitis A IgG indicates past infection. IgG antibody provides lifelong immunity. Hepatitis A vaccination and thorough hand washing are the best measures to prevent outbreaks.

Interprofessional CareChronic Hepatitis B

To ↓ viral load , liver enzyme levels, and rate of disease progression Prevent cirrhosis, portal hypertension, liver failure, and cancer Drug therapy for chronic HBV infection is focused on decreasing the viral load and liver enzyme levels and in turn slowing the rate of disease progression. Long-term goals are preventing of cirrhosis, portal hypertension, liver failure, and hepatocellular cancer. Current drug therapies for chronic HBV do not eradicate the virus but work well to suppress viral replication and prevent complications of hepatitis B. First-line therapies now include primarily nucleoside and nucleotide analogs and occasionally interferon therapy.

Nutritional Therapy - obesity

There are no "magic" diets Bulk to prevent constipation Sufficient protein No one diet is superior for weight loss. A supervised diet plan may be prescribed that limits calories to a total of 800 or less per day (very-low-calorie diet), but this is not sustainable on a long-term basis. These diets should only be provided by trained professionals in a medical care setting. Persons on low-calorie and very-low-calorie = monitoring = severe energy restriction diet that includes adequate amounts of fruits and vegetables, provides enough bulk to prevent constipation, and meets daily vitamin A and vitamin C requirements. Lean meat, fish, and eggs provide sufficient protein and the B-complex vitamins. Fad diets tend to restrict one category of food = discouraged. The ability to adhere to a diet and degree of weight loss strongly depends on the patient's motivation. A moderately obese person will obviously attain his or her goal more easily than a person with extreme obesity. The obese patient must recognize the advantages of weight loss and weight control. You can assist by helping the patient track eating patterns with a diet diary. Setting a realistic and healthy goal, such as losing 1 to 2 lb/wk, should be mutually agreed on at the beginning of a weight loss program. Trying to lose too much too fast usually results in a sense of frustration and failure for the patient. You can help patients understand that losing large amounts of weight in a short period causes skin and underlying tissue to lose elasticity and tone. Slower weight loss offers better cosmetic results. Remind the patient that plateaus are normal occurrences during weight reduction. A weekly check of body weight is a good method of monitoring progress. Daily weighing is not recommended. There is no clear consensus on the number of meals to be eaten when a person is on a diet. Calorie density is important 2/3 or more of a person's diet should be plant-source foods 1/3 from animal protein 1 portion of animal protein = 3 ounces 1 portion of chopped vegetables = ½ cup Another aspect of the American diet that needs to be considered is which foods contribute the most calories—animal sources, fruits, grains, or vegetables. Two thirds or more of an individual's diet should be plant-source foods, and the other one third or less should be from animal protein.

Acute Care CRC

There is no difference in surgical outcome between those who undergo preoperative cleansing and those who do not Post-op care is similar to care of patient after a laparotomy Depending on your practice setting and surgeon preference, you may see patients undergoing a preoperative bowel cleansing routine prior to elective bowel surgeries. In the past, many patients underwent a cleansing routine with polyethylene glycol solutions (e.g., MiraLAX, GoLYTELY), enemas and/or laxatives to reduce bacterial counts. Little evidence supports this practice. There is no difference in surgical outcome between those who underwent a preoperative cleansing routine and those who did not. Nursing care for the patient after a colon resection is similar to care of the patient after a laparotomy. If enough healthy bowel remained that the surgeon could reconnect the bowel ends, normal bowel function is maintained and routine postoperative care is appropriate.

Accurate Diagnosis IBD

Thorough history Symptoms Past health history Family history Drug history Diet history Ask patients to describe any psychosocial factors such as stress and anxiety that may have been experienced or are currently a concern Determine if and how IBS symptoms interfere with school, work, or fun Complete physical examination Diagnostic tests Used selectively to rule out other disorders Colorectal cancer IBD Endometriosis Malabsorption disorders

Delirium

Three most common cognitive problems in adults Delirium (acute confusion) Dementia Depression These problems often occur together Depression is often mistaken for dementia in older adults, and, conversely, dementia for depression. Manifestations of depression = sadness, difficulty thinking and concentrating, fatigue, apathy, feelings of despair, and inactivity. When dementia and depression occur together (as happens in many patients with dementia), the intellectual deterioration can be extreme. State of temporary but acute mental confusion Common problem Life-threatening syndrome Often preventable and/or reversible Delirium affects as many as 50% of people older than 65 years who are hospitalized, and as many as 80% of patients in an ICU.

Total Portal Division after TIPS

Total portal diversion after transjugular intrahepatic portosystemic shunt (TIPS). A, Portal venogram before TIPS shows filling of large esophageal varices (arrows). B, After insertion of a TIPS, flow to varices is eliminated. Intrahepatic portal vein flow is now reversed, with the direction of intrahepatic flow toward the TIPS. Procedure: A catheter is placed in the jugular vein and then threaded through the superior and inferior vena cava to the hepatic vein. The wall of the hepatic vein is punctured, and the catheter is directed to the portal vein. Stents are positioned along the passageway, overlapping in the liver tissue and extending into both veins. This procedure reduces portal venous pressure and decompresses the varices, thus controlling bleeding. TIPS does not interfere with a future liver transplantation. TIPS is contraindicated in patients with severe hepatic encephalopathy, hepatocellular carcinoma, severe hepatorenal syndrome, and portal vein thrombosis.

Interprofessional Care:Cholelithiasis

Treatment dependent on stage of disease Oral dissolution therapy Ursodeozycholic acid (ursodiol [Actigall]) Chenodeozycholic acid (chenodiol) Bile acids (cholesterol solvents) such as ursodeoxycholic acid (ursodiol [Actigall]) and chenodeoxycholic acid (chenodiol) are used to dissolve stones. However, the gallstones may recur. ERCP with sphincterotomy Visualization Dilation Placement of stents Open sphincter of Oddi, if needed Stones removed with basket or allowed to pass in stool ERCP with endoscopic sphincterotomy (papillotomy) may be used for stone removal. ERCP allows for visualization of the biliary system, dilation (balloon sphincteroplasty), as well as the placement of stents and sphincterotomy. The endoscope is passed to the duodenum = electrodiathermy knife = stone is commonly left in the duodenum to pass naturally in the stool. When a stent is placed, it is generally removed or changed after a few months.

Esophageal CancerInterprofessional Care

Treatment depends on location and spread Poor prognosis Usually not diagnosed until advanced Best results with multimodal therapy The treatment of esophageal cancer depends on the tumor's location and whether invasion or metastasis is present. Esophageal cancer usually has a poor prognosis because it is often not diagnosed until the disease is advanced. The best results are obtained with a multimodal approach, including surgery, endoscopic ablation, chemotherapy, and radiation therapy. Depending on the location and cancer spread, only chemotherapy and radiation may be used. Palliative therapy consists of restoring swallowing function and maintaining nutrition and hydration.

Delirium Nursing/Interprofessional Mgmt

Treatment is important since many cases are potentially reversible Your role in caring for a patient with delirium Prevention Early recognition Treatment Patient groups at risk include those with neurologic disorders (e.g., dementia, stroke, CNS infection, Parkinson's disease), sensory impairment, and older age. risks - surgery, hospitalization in an ICU, and untreated pain

HemodialysisProcedure

Two needles placed in fistula or graft One needle is placed to pull blood from circulation to HD machine Other needle is used to return dialyzed blood to the patient Heparin is added to prevent clotting HD = 14- to 16-gauge Dialyzer/blood lines primed with saline solution to eliminate air Terminated by flushing with saline to return all blood to patient To terminate the treatment, a saline solution is used to return the blood in the extracorporeal circuit back to the patient through the vascular access. Before beginning treatment Assess fluid status, condition of vascular access, and temperature Difference between last postdialysis weight and present predialysis weight determines ultrafiltration During treatment Take vital signs every 30 to 60 minutes

Hiatal Hernia type 1

Two types 1. Sliding Stomach slides through hiatal opening in diaphragm when patient is supine, goes back into abdominal cavity when patient is standing upright Most common type The junction of the stomach and esophagus is above the diaphragm, and a part of the stomach slides through the hiatal opening in the diaphragm. This occurs when the patient is supine. The hernia usually goes back into the abdominal cavity when the patient is standing upright.

Hiatal Hernia - type 2

Two types 2. Paraesophageal or rolling Fundus and greater curvature of stomach roll up through diaphragm, forming a pocket alongside the esophagus Paraesophageal junction remains in normal position Acute paraesophageal hernia is a medical emergency

DiabetesExercise

Type/amount Minimum 150 minutes/week aerobic Resistance training three times/week Benefits ↓ Insulin resistance and blood glucose Weight loss ↓ Triglycerides and LDL , ↑ HDL Improve BP and circulation Regular, consistent exercise is an essential part of diabetes and prediabetes management. The ADA recommends that people with diabetes engage in at least 150 minutes per week (30 minutes, 5 days per week) of a moderate-intensity aerobic physical activity. The ADA also encourages people with type 2 diabetes to perform resistance training three times a week, in the absence of contraindications. Exercise decreases insulin resistance and can have a direct effect on lowering blood glucose levels. It also contributes to weight loss, which decreases insulin resistance. The therapeutic benefits of regular physical activity may result in a decreased need for diabetes medications in order to reach target blood glucose goals in people with type 2 diabetes. Regular exercise may also help reduce triglyceride and LDL cholesterol levels, increase HDL levels, reduce blood pressure, and improve circulation. Start slowly after medical clearance Monitor blood glucose Glucose-lowering effect up to 48 hours after exercise Exercise 1 hour after a meal Snack to prevent hypoglycemia Do not exercise if blood glucose level > 300 mg/dL and if ketones are present in urine Any new exercise program for patients with diabetes can be started after medical clearance. Patients start slowly with gradual progression toward the desired goal. Patients who use insulin, sulfonylureas, or meglitinides are at increased risk for hypoglycemia when physical activity is increased, especially if the patient exercises at the time of peak drug action or if food intake has not been sufficient to maintain adequate blood glucose levels. This can also occur if a normally sedentary patient with diabetes has an unusually active day. The glucose-lowering effects of exercise can last up to 48 hours after the activity, so it is possible for hypoglycemia to occur for that long after the activity. It is recommended that patients who use medications that can cause hypoglycemia schedule exercise about 1 hour after a meal or that they have a 10- to 15-g carbohydrate snack and check their blood glucose level before exercising. Small carbohydrate snacks can be taken every 30 minutes during exercise to prevent hypoglycemia. Patients using medications that place them at risk for hypoglycemia should always carry a fast-acting source of carbohydrate, such as glucose tablets or hard candies, when exercising. Although exercise is generally beneficial to blood glucose levels, strenuous activity can be perceived by the body as a stress, causing a release of counterregulatory hormones that result in a temporary elevation of blood glucose. In a person with type 1 diabetes who has hyperglycemia and ketones, exercise can worsen these conditions. Teach these patients to delay activity if the blood glucose level is over 250 mg/dL and ketones are present in the urine. If hyperglycemia is present without ketosis, it is not necessary to postpone exercise.

Viral Hepatitis

Types of viral hepatitis A B C D E There are several types of viral hepatitis: A, B, C, D, and E. They differ in their modes of transmission and clinical manifestations. The different types of viral hepatitis have similar clinical manifestations, but their modes of transmission and disease course vary (Table 43-1).

Diagnostic Studies - Cholecystitis

Ultrasound is commonly used to diagnose gallstones. ERCP allows for visualization of the gallbladder, cystic duct, common hepatic duct, and common bile duct. Bile taken during ERCP is sent for culture to identify possible infecting organisms. Percutaneous transhepatic cholangiography = needle into gallbladder duct, followed by injection of contrast materials, after ultrasonography indicates a bile duct blockage.

Alzheimer's DiseaseEating and Swallowing Difficulties

Undernutrition is a problem in moderate and severe stages Loss of interest in food Decreased ability to self-feed (feeding apraxia) Co-morbid conditions Nutritional deficiencies can result. In long-term care facilities, inadequate assistance with feeding may add to the problem. When chewing and swallowing become difficult, use Pureed food Thickening liquids Nutritional supplements Quiet and unhurried environment Easy-grip utensils Distractions at mealtimes, including the television, should be avoided. Low lighting, music, and simulated nature sounds may improve eating behaviors. Offer liquids frequently Finger foods may allow self-feeding Short-term possibilities Nasogastric (NG) feedings Percutaneous endoscopic gastrostomy (PEG) tube For the long term the NG tube is uncomfortable and may add to the patient's agitation. A percutaneous endoscopic gastrostomy (PEG) tube provides another option. PEG tubes can be problematic, since patients with AD are particularly vulnerable to aspiration of feeding formula and tube dislodgment. The potential positive outcomes to be gained from nutritional therapies are considered in light of overall outcome goals and potential adverse effects of the specific therapy.

Chronic ComplicationsSkin Problems - DM

Up to two thirds of persons with diabetes develop skin problems. Diabetes-related dermopathy = most common diabetic skin lesion = reddish-brown and round or oval patches, scaly and then flatten out and become indented, on the shins but can also be found on the front of the thighs, forearm, side of the foot, scalp, and trunk. Acanthosis nigricans = insulin resistance, velvety light brown to black skin thickening seen predominantly on flexures, axillae, and the neck. Necrobiosis lipoidica diabeticorum = red-yellow lesions, atrophic skin that becomes shiny and transparent, revealing tiny blood vessels under the surface.

Alzheimer's DiseaseElimination Problems

Urinary and fecal incontinence during middle to late stages Habit or behavioral retraining may ↓ episodes Constipation may relate to immobility, dietary intake, ↓ fluids Urinary and fecal incontinence lead to an increased risk of urinary tract infection and the need for increased nursing care. The combination of aging, other health problems, and swallowing difficulties may increase the risk of complications associated with the use of mineral oil, stimulants, osmotic agents, and enemas.

PD - assessment of drugs

Use of only one drug is preferred Fewer side effects Dosages are easier to adjust Combination therapy is often required as disease progresses Excessive dopaminergic drugs can lead to paradoxic intoxication Paradoxic intoxication results in aggravation rather than relief of symptoms.

Surgical Therapy - PD

Used in patients Unresponsive to drug therapy Have developed severe motor complications Surgical procedures fall into three categories: DBS - Deep brain stimulation Ablation - Destruction Transplantation - of fetal neural tissue

Drug Therapy - obesity

Used only in conjunction with calorie reduction diet, exercise, and behavior modification Drugs should be reserved for those whose BMI > 30 kg/m2 or adults with a BMI of > 27 kg/m2 who have at least one weight-related condition, such as hypertension, type 2 diabetes, or dyslipidemia. Appetite-suppressing drugs Sympathomimetic amines suppress appetite by stimulating the CNS through increased norepinephrine Amphetamines Higher abuse potential Not recommended or approved by the FDA Nonamphetamines Nonamphetamines are not usually recommended for weight loss because of the potential for abuse. If used, these drugs should only be used short term (for 3 months or less). Nonamphetamines include phentermine (Adipex-P, Fastin, Ionamin), diethylpropion (Tenuate), phendimetrazine (Bontril), and benzphetamine (Didrex). Adverse effectts of these drugs include palpitations, tachycardia, overstimulation, restlessness, dizziness, insomnia, weakness, and fatigue.

(Basal) Background Insulin

Used to manage glucose levels in between meals and overnight Long-acting (basal) Insulin glargine (Lantus) and detemir (Levemir) Released steadily and continuously with no peak action for many people Administered once or twice a day Do not mix with any other insulin or solution In addition to mealtime insulin, people with type 1 diabetes use a long-acting basal or intermediate-acting (background) insulin to maintain blood glucose levels in between meals and overnight. Insulin glargine (Lantus) and detemir (Levemir) are long-acting insulins that are released steadily and continuously and, for many people, does not have a peak of action. The action time for glargine and determir varies. Although they can be used for once-daily subcutaneous administration, detemir is often given twice daily. Because they lack peak action time, the risk for hypoglycemia from this type of insulin is greatly reduced.

Chemotherapy CRC

Used to shrink a tumor before surgery An adjuvant treatment following colon resection for stage III and high-risk stage II tumors Palliative treatment for nonresectable colorectal cancer 5-Fluorouracil (5-FU) plus folinic acid Leucovorin is used alone or in combination with oxaliplatin (Eloxatin) or irinotecan (CPT-11) Eloxatin is preferred if patients can tolerate side effects Current chemotherapy protocols include varying doses of 5-fluorouracil (5-FU) and folinic acid (leucovorin) alone or in combination with oxaliplatin (Eloxatin) or irinotecan (CPT-11). The preferred protocol includes oxaliplatin. It is omitted if patients have too many side effects. An alternative protocol combines levamisole (Ergamisol) with 5-FU. Oral fluoropyrimidines (e.g., capecitabine [Xeloda]) in combination with oxaliplatin are an alternative to 5-FU/folinic acid therapy.

CVVHD and CVVHDF

Uses dialysate Dialysis fluid is attached to distal end of hemofilter As in hemodialysis, diffusion of solutes and ultrafiltration via hydrostatic pressure and osmosis occur. This is an ideal treatment for a patient who needs both fluid and solute control but cannot tolerate the rapid fluid shifts associated with HD.

Esophageal StricturesEtiology and Pathophysiology

Usually develop over a long time Result in = Dysphagia, Regurgitation, Weight loss Causes include GERD: most common cause Ingestion of strong acids or alkalis External beam radiation Surgical anastamosis Trauma Strictures can result in dysphagia, regurgitation, and ultimately weight loss.

Clinical Manifestations - Cholecystitis

Vary from severe to none at all Pain more severe when stones moving or obstructing Steady, excruciating Tachycardia, diaphoresis, prostration May be referred to shoulder/scapula Residual tenderness in RUQ Occur 3-6 hours after high-fat meal or when patient lies down Cholelithiasis may produce severe symptoms or none at all. Many patients have "silent cholelithiasis." The severity of symptoms depends on whether the stones are stationary or mobile and whether obstruction is present. This sometimes produces severe pain, which is termed biliary colic even though the pain is rarely colicky. The pain can be excruciating and accompanied by tachycardia, diaphoresis, and prostration. The severe pain may last up to an hour, and when it subsides, there is residual tenderness in the RUQ . The attacks of pain frequently occur 3 to 6 hours after a high-fat meal or when the patient lies down.

Clinical ManifestationsMetabolic Disturbances CKI

Waste product accumulation As GFR ↓, BUN and serum creatinine levels ↑ BUN level ↑ - protein intake, fever, corticosteroids, and catabolism N/V, lethargy, fatigue, impaired thought processes, and headaches occur Serum creatinine clearance determinations (calculated GFR) are considered more accurate indicators of kidney function than BUN or creatinine. Altered carbohydrate metabolism = impaired glucose metabolism Mild to moderate hyperglycemia and hyperinsulinemia may occur. diabetes + uremia may require less insulin than before the onset of CKD Excretion of insulin dependent on kidneys Insulin dosing must be individualized Many patients with uremia develop dyslipidemia, with elevated levels of very-low-density lipoproteins (VLDLs), normal or decreased levels of low-density lipoproteins (LDLs), and decreased levels of high-density lipoproteins (HDLs). Most patients with CKD die from CV disease.

Ultrafiltration

Water and fluid removal Results when there is an osmotic gradient or pressure gradient across membrane Excess fluid moves into dialysate In PD, excess fluid is removed by increasing the osmolality of the dialysate (osmotic gradient) with the addition of glucose. In HD, the gradient is created by increasing pressure in the blood compartment (positive pressure) or decreasing pressure in the dialysate compartment (negative pressure). Extracellular fluid moves into the dialysate because of the pressure gradient. The excess fluid is removed by creating a pressure differential between the blood and the dialysate solution with a combination of positive pressure in the blood compartment or negative pressure in the dialysate compartment.

Body mass index (BMI)

Weight (kg)/Height (m2) Underweight = BMI <18.5 kg/m2 Normal = BMI 18.5-24.9 kg/m2 Overweight = BMI 25-29.9 kg/m2 Obese = BMI >30 kg/m2 Extremely obese = BMI > 40 kg/m2

Biquanides

Withhold if patient is undergoing surgery or radiologic procedure with contrast medium Day or two before and at least 48 hours after Monitor serum creatinine Contraindications Renal, liver, cardiac disease Excessive alcohol intake Patients who are undergoing surgery or any radiologic procedures that involve the use of a contrast medium are instructed to temporarily discontinue metformin before surgery or the procedure and to not resume taking metformin until 48 hours after the surgery or the procedure and after their serum creatinine has been checked and is normal. Do not use in patients with kidney disease, liver disease, or heart failure. Lactic acidosis is a rare complication of metformin accumulation. Do not use in people who drink excessive amounts of alcohol. Take with food to minimize GI side effects.

Acute PancreatitisNursing Implementation

Wound care Observation for paralytic ileus, renal failure, mental changes Respiratory infections are common, which causes the patient to take shallow, guarded abdominal breaths. Measures to prevent respiratory infections include turning, coughing, and deep breathing (TCDB) and assuming a semi-Fowler's position. Other important assessments are observation for signs of paralytic ileus, renal failure, and mental changes. Determine the blood glucose level to assess damage to the β-cells of the islets of Langerhans in the pancreas. If patients have surgery to drain necrotic fluid or treat a cyst, they may require special wound care for an anastomotic leak or a fistula. To prevent skin irritation, use measures such as skin barriers (e.g., Stomahesive Paste, Karaya Paste, or Colly-Seel Disc), pouching, and drains. In addition to protecting the skin, pouching also enables a more accurate determination of fluid and electrolyte losses and increases patient comfort. Sterile pouching systems are available. Consult with a clinical specialist or wound, ostomy, and continence nurse (WOCN).

G.O. is a 65-year-old man who is admitted for a colon resection following a diagnosis of colorectal cancer. At time of admission, he complains of constipation, bloody stools, abdominal pain, and weight loss. He is 6 feet 1 inch tall and weighs 200 lb. He smokes 1 pack of cigarettes/day. G.O. has a history of coronary artery disease and hypertension. He reports taking antihypertensive medication and 81 mg of aspirin daily. G.O. wants to know how he got colon cancer. What risk factors does he have?

age smoking male gender

Drug Therapy for Obesity

orlistat (Xenical, Allī [low-dose form available over-the-counter]) = Blocks fat breakdown and absorption in intestine. Inhibits the action of intestinal lipases, resulting in undigested fat excreted in feces. lorcaserin (Belviq) = Selective serotonin (5-HT) agonist, Suppresses appetite and creates a sense of satiety. bupropion/naltrexone (Contrave) = bupropion: antidepressant, naltrexone: opioid antagonist phenteramine/topiramate (Qsymia) = phentermine: sympathomimetic anorectic., topiramate: antiseizure drug that induces satiety. liraglutide (Saxenda) = Glucagon-like peptide 1 (GLP-1) agonist., Induces satiety

Endoscopic Sphincterotomy

endoscope - mouth and stomach until duodenum opposite the common bile duct. widening the duct mouth by incising the sphincter muscle, the physician advances a basket = snags the stone.

Colonic J-pouch

or coloplasty create an alternative reservoir that replaces rectum as a reservoir for stool The anal sphincters remain Temporary colostomy allows for healing Another option if the anal sphincters remain is for the surgeon to create an alternative reservoir with either a colonic J-pouch or coloplasty. A colonic J-pouch is created by folding the distal colon back on itself and suturing it to form a pouch. The pouch replaces the rectum as a reservoir for stool. The patient has a temporary ostomy to allow the J-pouch sutures time to heal before stool enters it. A coloplasty is made by slitting the side of a section of colon a short distance proximal to the anus, stretching the colon transversely to make it wider, and then suturing it closed in the new widened position. Patients with sphincter-sparing procedures may experience urgency and frequency, especially after meals. Symptoms should improve as the new pouch stretches. When the tumor is not resectable or metastasis is present, palliative surgery can control hemorrhage or relieve a malignant bowel obstruction.

Nursing Management:Nursing Diagnoses Cholecystitis

• Acute pain related to surgical procedure • Ineffective health management related to lack of knowledge of diet and postoperative management

Acute illness and surgery

↑ Blood glucose level secondary to counterregulatory hormones Frequent monitoring of blood glucose Ketone testing if glucose level exceeds 240 mg/dL Report glucose levels exceeding 300 mg/dL twice or moderate to high ketone levels Increase insulin for type 1 diabetes Type 2 diabetes may necessitate insulin therapy Both emotional and physical stress can increase the blood glucose level and result in hyperglycemia. Because stress is unavoidable, certain situations may require more intense management, such as extra insulin and more frequent blood glucose monitoring, to maintain glycemic goals and avoid hyperglycemia. Acute illness, injury, and surgery are situations that may evoke a counterregulatory hormone response, resulting in hyperglycemia. Even common illnesses such as a viral upper respiratory infection or the flu can cause this response. Encourage patients with diabetes to check blood glucose at least every 4 hours during times of illness. Acutely ill patients with type 1 diabetes whose blood glucose value is greater than 240 mg/dL (13.3 mmol/L) should also check urine for ketones every 3 to 4 hours. Teach patients to report glucose levels exceeding 300 mg/dL for twice in a row or the presence of moderate to high urine ketone levels to the HCP. A patient with type 1 diabetes may need an increase in insulin to prevent DKA. Elevated blood glucose levels can lead to poor healing and infection. Insulin therapy may be required for a patient with type 2 diabetes to prevent or treat hyperglycemia symptoms and avoid an acute hyperglycemia emergency. In critically ill patients, insulin therapy may be started if the blood glucose is persistently greater than 180 mg/dL. These patients have a higher targeted blood glucose goal, which is usually 140 to 180 mg/dL.

Three types of bronchodilators

β2-Adrenergic agonists Methylxanthines Anticholinergics β-Adrenergic agonists (SABAs) Examples: albuterol, pirbuterol Effective for relieving acute bronchospasm Onset of action in minutes and duration of 4 to 8 hours They are known as rescue medications. These drugs act by stimulating β-adrenergic receptors in the bronchioles, thus producing bronchodilation. They also increase mucociliary clearance. DRUG ALERT: Use with caution in patients with cardiac disorders, since both SABAs and LABAs may cause elevated BP and heart rate, central nervous system stimulation or excitation, and increased risk of dysrhythmias. β-Adrenergic agonists Prevent release of inflammatory mediators from mast cells Not for long-term use β2-Adrenergic agonists are also useful in preventing bronchospasm precipitated by exercise and other stimuli because they prevent the release of inflammatory mediators from mast cells. If used frequently, inhaled β2-adrenergic agonists may produce tremors, anxiety, tachycardia, palpitations, and nausea. The use of SABAs should be limited to less than two times weekly. In other words, regularly scheduled, daily, or chronic use of inhaled SABA is not recommended for long-term control of asthma. SABA inhalers should last for months. Use of long-term bronchodilators with inhaled corticosteroids or other medications can achieve this goal if prescribed and used properly. Long-acting β2-Adrenergic Agonist Drugs Salmeterol (Serevent) and formoterol (Foradil) Added to daily ICSs Decrease the need for SABAs Never used as monotherapy Combination ICS and LABA available LABAs are added to a daily dose of ICSs for long-term control of moderate to severe persistent asthma (i.e., step 3 or higher for long-term control) and prevention of symptoms, particularly those at night. LABAs should never be used as monotherapy for asthma and should only be used if the patient is on ICS. Tell patients that these drugs should not be used to treat acute symptoms or to obtain quick relief from bronchospasm. Teach the patient that these drugs are used only once every 12 hours. Combination therapy using an ICS and LABA is available in several inhalers (e.g., fluticasone/salmeterol [Advair] and budesonide/formoterol (Symbicort). The combinations are more convenient, improve adherence, and ensure that patients receive the LABA together with an ICS. Methylxanthines (e.g., theophylline) Less effective long-term bronchodilator Alleviates early phase of attacks but has little effect on bronchial hyperresponsiveness Narrow margin of safety They are used only as an alternative therapy for step 2 care in mild persistent asthma. It is a bronchodilator with mild antiinflammatory effects, but the exact mechanism of action is unknown. main problem with theophylline= interaction with other drugs/ side effects. Anticholinergic drugs Block action of acetylcholine Promote bronchodilation Short-acting drugs used for severe acute asthma exacerbation Anticholinergic drugs affect the muscles around the bronchi (large airways). Anticholinergic drugs are less effective than equivalent doses of SABAs in asthma. However, they are more effective in COPD patients.

GERD and Hiatal HerniaGerontologic Considerations

↑ Incidence with age Older patients may take medications known to ↓ LES pressure Other agents can irritate the esophageal mucosa (medication-induced esophagitis) First indication may be esophageal bleeding or respiratory complications Hiatal hernia = weakening of the diaphragm, obesity, kyphosis, and other factors (e.g., wearing girdles) that increase intraabdominal pressure. decrease LES pressure = nitrates, calcium channel blockers, antidepressants Other agents such as NSAIDs and potassium can irritate the esophageal mucosa. Older adults may be asymptomatic or have less severe symptoms. The first indication may be a serious problem such as esophageal bleeding secondary to esophagitis or respiratory complications (e.g., aspiration pneumonia) related to aspiration of gastric contents. Eliminate dietary factors (caffeine-containing beverages and chocolate) Elevation of head of bed on blocks Laparoscopic procedures reduce risk associated with surgical repair elimination of dietary factors, such as caffeine-containing beverages and chocolate, and elevating the head of the bed on block

Meglitinides

↑ Insulin production from pancreas Rapid onset: ↓ hypoglycemia Taken 30 minutes to just before each meal Should not be taken if meal skipped Examples Repaglinide (Prandin) Nateglinide (Starlix) Like the sulfonylureas, repaglinide (Prandin) and nateglinide (Starlix) increase insulin production from the pancreas. However, because they are more rapidly absorbed and eliminated than sulfonylureas, they are less likely to cause hypoglycemia. When they are taken just before meals, pancreatic insulin production increases during and after the meal, mimicking the normal blood glucose response to eating. Instruct patients to take meglitinides any time from 30 minutes before each meal right up to the time of the meal. These drugs should not be taken if a meal is skipped.

Sulfonylureas

↑ Insulin production from pancreas Major side effect: hypoglycemia Examples Glipizide (Glucotrol) Glyburide (Glynase) Glimepiride (Amaryl) Sulfonylureas include glipizide (Glucotrol, Glucotrol XL), glyburide (DiaBeta, Glynase), and glimepiride (Amaryl). The primary action of the sulfonylureas is to increase insulin production from the pancreas. Therefore, hypoglycemia is the major side effect of sulfonylureas.

Rigidity - PD

↑ Resistance to passive motion when limbs are moved through their ROM Jerky quality Rigidity is the increased resistance to passive motion when the limbs are moved through their range of motion. Parkinsonian rigidity is typified by a jerky quality (cogwheel rigidity) = intermittent catches in the passive movement of a joint. Sustained muscle contraction Sustained muscle contraction = rigidity = muscle soreness pain in the head, upper body, spine, or legs. Slowness of movement = rigidity = inhibits the alternating contraction and relaxation in opposing muscle groups (e.g., biceps and triceps).

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COPDAging

= gradual loss of the elastic recoil, stiffening of the chest wall, gas exchange alteration, decrease in exercise tolerance. lungs = rounded and smaller. number of functional alveoli decr

Pathogenesis of MS

A, Normal nerve cell with myelin sheath. B, Normal axon. C, Myelin breakdown. D, Myelin totally disrupted; axon not functioning.

Nursing ManagementNursing ImplementationCOPD

Abstain from or stop smoking. nurses who smoke should reevaluate their own smoking behavior and its relationship to their health. Early detection of small-airway disease Early diagnosis and treatment of respiratory tract infection avoid sick, hand-washing techniques, exercise regularly, healthy weight. Influenza and pneumococcal pneumonia Genetic counseling with AAT deficiency = planning to have children. Ambulatory Care = Most important aspect is teaching Pulmonary rehabilitation Activity considerations Sexual activity Sleep Psychosocial considerations Pulmonary rehabilitation (PR) is designed to reduce symptoms and improve quality of life Includes exercise training, smoking cessation, nutrition counselling, and education Pulmonary rehabilitation can be done in an inpatient or outpatient setting, or in home settings. Works best if the patient starts it when COPD is in the moderate stage. A mandatory component of any pulmonary rehabilitation program is exercise that focuses on the muscles used in ambulation. In PR an interprofessional team works together to individualize the treatment plan for COPD patients. Physical therapists or nurses who have experience in pulmonary care are often responsible for the management of pulmonary rehabilitation centers. A large part of your role is to teach patients self-management of their disease. Activity considerations Exercise training leads to energy conservation In upper extremities, it may improve muscle function and reduce dyspnea Frequently the patient has already adapted alternative energy-saving practices for ADLs. Alternative methods of hair care, shaving, showering, and reaching may need to be explored. An occupational therapist may help with ideas in these areas. Activity considerations Modify ADLs to conserve energy Hair care, shaving, showering O2 during activities of hygiene Walk 15 to 20 minutes a day at least 3 times a week with gradual increases Adequate rest should be allowed If the patient uses home O2 therapy, O2 should be used during activities of hygiene because these are energy consuming. Walking or other endurance exercises (e.g., cycling) combined with strength training are likely the best intervention to strengthen muscles and improve the patient's endurance. Activity considerations Exercise-induced dyspnea should return to baseline within 5 minutes after exercise Some patients benefit from using their β2-adrenergic agonist approximately 10 minutes before exercise. The nurse should instruct the patient to wait 5 minutes after completion of exercise before using the β2-adrenergic agonist to allow a chance to recover. During this time, slow, pursed lip breathing should be used. Psychosocial considerations Healthy coping is a challenge May feel guilt, depression, anxiety, loneliness from social isolation, denial, and frustration from increased dependence People with COPD frequently have to deal with many lifestyle changes that may involve decreased ability to care for themselves, decreased energy for social activities, and loss of a job. It is important to convey a sense of understanding and caring to the patient. The patient with COPD may benefit from stress management techniques (e.g., massage, muscle relaxation). Teach patients about the treatment and disease, which can give them a sense of control of their disease and complex treatment regimens, and include the patient's caregiver in the teaching. Support groups at local American Lung Association chapters (such as the Better Breathers Club), hospitals, and clinics can also be helpful. Sexual activity Plan when breathing is best Use slow, pursed lip breathing Refrain after eating or drinking alcohol Choose less stressful positions Use O2 if prescribed The nurse will need to first assess the patient related to sexuality and concerns of functioning. Ask open-ended questions to determine if the patient wants to discuss any of these concerns, such as "How has your breathing problem affected how you see yourself as a woman or man?" or "How does your shortness of breath affect your desire for intimacy with your partner?" Erectile dysfunction can occur with COPD as with many chronic diseases. Using an inhaled bronchodilator before sexual activity can help ventilation. Sleep Adequate sleep is extremely important Can be difficult because of medications, postnasal drip, or coughing Nasal saline sprays, decongestants, or nasal steroid inhalers can help The hyperinflation of the lungs and the reduction in ventilation can result in severe drops in O2 saturation (down to 60% or less) during sleep. This leads to a strain on the heart. In addition, hypercapnia may develop with more frequent awakening. The net result is poor quality of sleep and awakening unrefreshed and fatigued. If the patient is prescribed O2 therapy, it should be used as it will help decrease insomnia.

Chest physiotherapy indicated for

Excessive, difficult-to-clear bronchial secretions Retained secretions in artificial airway Lobular atelectasis from mucous plug CPT consists of postural drainage, percussion, and vibration. CPT should be performed by an individual who has been properly trained. Contraindications for CPT include situations that involve head, neck, chest, or back instability and/or injury; anatomic deformity; severe spasticity; mental limitations; or in which the patient cannot tolerate the position for other reasons. CPT complications = fractured ribs, bruising, hypoxemia, and discomfort to the patient.

MS Pathophysiology

Activated T cells migrate to CNS, disrupting blood-brain barrier Likely the initial event in development of MS Subsequent antigen-antibody reaction leads to demyelination of axons

COPD Description

Airflow limitation not fully reversible Usually progressive Abnormal inflammatory response of lungs, primarily caused by cigarette smoking and other noxious particles or gases COPD exacerbations and other coexisting illnesses or co-morbidities contribute to the overall severity of the disease. Definitions previously included chronic bronchitis and emphysema Chronic bronchitis is an independent disease Emphysema is a pathologic term that explains only one of several structural abnormalities in COPD Chronic bronchitis, the presence of cough and sputum production for at least 3 months in each of 2 consecutive years, is an independent disease that may precede or follow the development of airflow limitation. Emphysema is the destruction of the alveoli, and is a pathologic term that explains only one of several structural abnormalities in COPD patients.

Triggers of AsthmaNose and Sinus Problems

Allergic rhinitis and nasal polyps Large polyps need to be removed Sinus problems are usually related to inflammation of the mucous membranes Most patients with asthma have a history of allergic rhinitis, and treatment usually improves the symptoms of asthma. Acute and chronic sinusitis, especially allergic rhinosinusitis, may worsen asthma.

Obstructive Sleep Apnea

Also called obstructive sleep apnea-hypopnea syndrome (OSAHS) Partial or complete upper airway obstruction during sleep Apneic period may include hypoxemia and hypercapnia - longer than 10 seconds. Hypopnea is shallow respirations (30% to 50% reduction in airflow). Airflow obstruction in OSA occurs because of (1) narrowing of the air passages with relaxation of muscle tone during sleep and/or (2) the tongue and the soft palate falling backward to partially or completely obstruct the pharynx (Fig. 7-4). Each obstruction may last 10 to 90 seconds. Apnea and arousal cycles occur repeatedly. Apneic episodes occur most often during REM sleep when airway muscle tone is lowest. Smokers are more likely to have OSA. OSA is more common in men than in women until after menopause, when the prevalence of the disorder is the same in both genders. Women with OSA have higher mortality rates. OSA patients with excessive daytime sleepiness have increased mortality.

Gerontologic Considerations: Asthma

An increased number of older adults are diagnosed with asthma. costly medications, nonadherence to medical regimen, and difficulty accessing the health care system.

A patient is admitted to the emergency department with a severe exacerbation of asthma. Which finding is of most concern to the nurse? Unable to speak and sweating profusely PaO2 of 80 mm Hg and PaCO2 of 50 mm Hg Presence of inspiratory and expiratory wheezing Peak expiratory flow rate at 60% of personal best

Answer: A Rationale: During a severe exacerbation of asthma the patient may not be able to speak (or may speak in words, not sentences) because of difficulty breathing; the patient may also be perspiring profusely. Other indicators of severe asthma include absence of wheezing because of limited airflow; arterial blood gas results with decreased PaO2 (< 80 mm Hg) and increased PaCO2 (> 48 mm Hg); and peak expiratory flow rate at or below 40% of personal best.

The nurse reviews the arterial blood gases of a patient. Which result would indicate the patient has later stage COPD? pH 7.32, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18 mEq/L pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25 mEq/L pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35 mEq/L

Answer: A Rationale: In later stage COPD, the patient will have a low or low normal pH, a high normal or above normal PaCO2, and a high normal or above normal HCO3-. This indicates compensated respiratory acidosis, as the patient has chronically retained CO2 and the kidneys have conserved HCO3- to increase the pH to near or within the normal range.

Common manifestations of MS

Motor problems Sensory problems Cerebellar problems Emotional problems - frontal lobe Average life expectancy after the onset of symptoms is more than 25 years. Death usually occurs as the result of infectious complications (e.g., pneumonia) of immobility or because of an unrelated disease.

An older adult patient in the hospital complains of sleep deprivation. Which intervention may improve sleep patterns for this patient? Decrease noise and dim the lights at bedtime. Administer an opioid pain medication to induce sleep. Set the room temperature at 78 degrees F to induce drowsiness. Offer to give the patient a back massage until he falls asleep.

Answer: a Rationale: Hospital noise and bright lights can cause sleep difficulties. Although adequate pain management improves the duration and quality of sleep, opioid medications alter sleep and place the patient at risk for sleep-disordered breathing. Although backrubs are a good method to promote relaxation, the nurse cannot really afford the time to spend extended periods of time giving this patient a backrub.

Triggers of AsthmaDrugs and Food Additives

Asthma triad: Nasal polyps, asthma, and sensitivity to aspirin and NSAIDs Wheezing develops in about 2 hours. β-Adrenergic blockers ACE inhibitors sensitivity to Salicylic acid = in (OTC) drugs and some foods, beverages, and flavorings. NSAID/asprin = wheezing in 2hrs β-Adrenergic blockers in oral form (e.g., metoprolol [Toprol]) or topical eye drops (e.g., timolol [Timoptic]) may trigger asthma as the result of bronchospasm. Angiotensin-converting enzyme (ACE) inhibitors (e.g., lisinopril [Prinivil]) may produce cough in susceptible individuals, thus making asthma symptoms worse. Avoidance diets = not recommended until allergy been demonstrated

1st symptoms may include MS

Blurred or double vision Red-green color distortion Blindness in one eye (each eye on different side of the brain so its opposite)

Bowel and bladder MS

Bowel and bladder function = sclerotic plaque is located in areas of the CNS that control elimination. constipation rather than fecal incontinence. A common problem in patients with MS is a spastic (uninhibited) bladder = small capacity for urine, and its contractions are unchecked = urgency and frequenc, dribbling or incontinence. A flaccid (hypotonic) bladder indicates a lesion in the reflex arc = large capacity for urine= no sensation/desire to void, no pressure, and no pain = urinary retention, need urodynamic studies.

Respiratory and physical therapy COPD

Breathing retraining Effective coughing Chest physiotherapy Percussion Vibration Postural drainage The main types of breathing exercises are (1) pursed lip breathing (PLB) and (2) diaphragmatic breathing. diaphragmatic breathing with COPD = increase the work of breathing and dyspnea. forced expiratory technique = huff coughing Chest physiotherapy (CPT) = excessive bronchial secretions, difficulty clearing them (e.g., cystic fibrosis, bronchiectasis). Airway clearance devices High-frequency chest wall oscillation The Vest Airway clearance devices include the Flutter, Acapella, and TheraPEP Therapy System.

COPDInterprofessional Care drugs

Bronchodilators = Relax smooth muscle in the airway, Improve ventilation of the lungs ↓ Dyspnea and ↑ FEV1, Inhaled route is preferred. Medications are given in a stepwise fashion according to the level of airflow obstruction determined from spirometry (FEV1) and symptoms. Commonly used bronchodilators β2-Adrenergic agonists Anticholinergics Methylxanthines Albuterol or ipratropium may be used as single agents, but combining bronchodilators improves their effect and decreases the risk of adverse effects. These two agents (albuterol and ipratropium) can be nebulized together (DuoNeb) or delivered by one MDI (Combivent Respimat). moderate COPD = long-acting bronchodilator + short-acting rescue bronchodilator, such as salmeterol or formoterol. long-acting theophylline = controversial because it interacts with many drugs. In COPD patients with FEV1 < 60% Inhaled long-acting anticholinergic (LABA) Inhaled corticosteroids (ICS) In patients with severe COPD and chronic bronchitis rofumilast (Daliresp) The addition of inhaled corticosteroid (ICS) to long-acting bronchodilator therapy is often prescribed in COPD patients with FEV1<60%. ICS combined with long-acting β2-adrenergic agonists (e.g., fluticasone/salmeterol [Advair]) are more effective than single-drug therapy in reducing exacerbations and improving lung function. Some patients are on triple therapy with salmeterol/fluticasone (Advair) and tiotropium (Spiriva). Roflumilast (Daliresp) is an oral medication used to decrease the frequency of exacerbations in patients with severe COPD and the presence of chronic bronchitis. This drug is a phosphodiesterase inhibitor, which is an antiinflammatory drug that suppresses the release of cytokines and other inflammatory mediators, and inhibits the production of reactive oxygen radicals. Azithromycin (Zithromax) Phosphodiesterase inhibitor Roflumilast (Daliresp) Combivent Respimat (ipratropium and albuterol) azithromycin (Zithromax) - antibiotic = prevent recurrent COPD exacerbations. Roflumilast (Daliresp) is an oral medication used to decrease the frequency of exacerbations in severe COPD antiinflammatory drug Respimat simplifies coordination between activation of the medication and inhalation without propellant, and it is independent of inspiratory flow

Etiology and Pathophysiology MS

Cause is unknown factors include infection, smoking, physical injury, emotional stress, excessive fatigue, pregnancy, poor state of health Genetic component The disease develops in a genetically susceptible person as a result of environmental exposure, such as an infection. Having a first-degree relative with MS increases a person's risk of developing the disease. Common genetic factors have also been found in families with more than one affected member. Primary neuropathologic condition is an autoimmune process orchestrated by activated T cells Initially, attacks cause damage to myelin sheaths of neurons in brain and spinal cord Nerve fiber is not affected Patient may complain of noticeable impairment of function Transmission of nerve impulses still occurs, but it is slowed. myelin can regenerate = symptoms will disappear = remission. With ongoing inflammation, myelin loses ability to regenerate Nerve impulse transmission is disrupted w/o myelin = permanent loss of nerve function

COPD Exacerbations

Classic signs of exacerbation include an increase in dyspnea, sputum volume, and/or sputum purulence. severity = patient's medical history before the exacerbation, other diseases, current symptoms, ABGs, and laboratory tests. Patients may also have nonspecific complaints of malaise, insomnia, fatigue, depression, confusion, decreased exercise tolerance, increased wheezing, or fever without other causes. Associated with poorer outcomes Primary causes Bacterial and viral infections Signs of severity Use of accessory muscles Central cyanosis usually have 1-2 a year As the severity of COPD increases, exacerbations of COPD are associated with poorer outcomes. The primary causes of exacerbations are bacterial or viral infections. Signs of severity include use of accessory muscles, central cyanosis, development of edema in the lower extremities, unstable blood pressure, right-sided heart failure, and altered alertness.

COPDClassification

Classified as Mild Moderate Severe Very severe FEV1/FVC ratio of less than 70% = COPD severity of obstruction (as indicated by FEV1) determines the stage of COPD. management = based on symptoms, classification, and exacerbation history.

COPDInterprofessional Care complications

Complications of oxygen therapy Combustion CO2 narcosis O2 toxicity Absorption atelectasis Infection "No Smoking" sign should be prominently displayed on the patient's door. CO2 Narcosis - with hypercapnia are given oxygen to breathe. Arterial carbon dioxide tension (PaCO2) increases sharply and progressively with severe respiratory acidosis, somnolence, and coma Venturi masks may be used to have tighter regulation of the maximal FIO2 that is administered. With nasal cannulas, the oxygen flow rate is generally increased by 1 L per minute at a time. The goal is a pulse oxygen saturation (SpO2) of at least 90% or a PaO2 of at least 60 mmHg. Pulmonary O2 toxicity may result from prolonged exposure to a high level of O2 (PaO2). Absorption atelectasis - When high concentrations of O2 are given, nitrogen is washed out of the alveoli and replaced with O2. airway obstruction occurs = O2 is absorbed into blood= alveoli collapse. Infection - hazard of O2 administration, Heated nebulizers that provide constant humidity support bacterial growth = Pseudomonas aeruginosa.

Effective coughing

Conserve energy Reduce fatigue Facilitate removal of secretions Huff coughing Airway clearance techniques (ACTs) huff cough = patient is breathing deeply from the diaphragm. Place the patient's hands on the lower, lateral chest wall and then ask the patient to breathe deeply through the nose. You should feel the patient's hands move outward, which represents a breath from the diaphragm.

Breathing retraining

Decreases dyspnea, improves oxygenation, and slows respiratory rate Diaphragmatic (abdominal) breathing Pursed lip breathing - Prolongs exhalation and prevents bronchiolar collapse and air trapping, Teach patients to use "just enough" positive pressure

Diagnostic Studies asthma

Detailed history and physical exam Spirometry Peak expiratory flow rate (PEFR) Chest x-ray Underdiagnosis of asthma is common. The peak expiratory flow rate (PEFR) measured by the peak flow meter (at home or in a health care setting) is an aid to diagnose and monitor asthma. Spirometry (measured in a health care setting) is usually normal between asthma attacks if the patient has no other underlying pulmonary disease. decrease in forced vital capacity (FVC), FEV1, PEFR, and FEV1 to FVC ratio (FEV1/FVC). Chest x-ray is usually normal for asymptomatic patients Oximetry Allergy testing Blood levels of eosinophils Oximetry may be measured as a baseline and then to determine the patient's ability to oxygenate during an attack. Allergy skin testing may be of some value to determine sensitivity to specific allergens. However, a positive skin test does not necessarily mean that the allergen is causing the asthma attack. On the other hand, a negative allergy test does not mean that the asthma is not allergy related. An elevated serum eosinophil count and elevated serum IgE levels are highly suggestive of atopy (genetic predisposition to develop an allergic response), which may be a risk factor for a person's asthma.

COPD Clinical Manifestations

Diagnosis is considered with patients over 40 years of age, and after 20 pack-years of cigarette smoking. Clinical manifestations develop slowly chronic intermittent cough = morning = may or may not be productive of small amounts of sticky mucus. Dyspnea= progressive, usually occurs with exertion, and is present every day. Patients usually ignore the symptoms and rationalize that, "I'm getting older" and "I'm out of shape." change behaviors to avoid dyspnea, such as by taking the elevator. late stages of COPD = dyspnea may be present at rest = more alveoli overdistended, increasing amounts of air are trapped = flattened diaphragm = breathing from partially inflated lungs. Dyspnea usually prompts medical attention Occurs with exertion in early stages Present at rest with advanced disease Causes chest breathing Use of accessory and intercostal muscles Inefficient breathing May experience wheezing and chest tightness become chest breather = relying on the intercostal and accessory muscles = hard Wheezing and chest tightness = but may vary by time of day or from day to day, especially in patients with more severe disease. Wheezes = laryngeal area Chest tightness, which often follows activity, may feel similar to muscular contraction. Characteristically underweight with anorexia Chronic fatigue, weight loss Paroxysmal coughing may be so severe that patient faints or fractures ribs Physical examination findings Prolonged expiratory phase Wheezes Decreased breath sounds ↑ Anterior-posterior diameter (barrel chest) Tripod position Pursed lip breathing The patient may need to breathe louder than normal for auscultated breath sounds to be heard. pursed lip breathing, accessory muscles = neck Polycythemia and cyanosis Increased production of red blood cells Bluish-red color of skin Hemoglobin concentrations may reach 20 g/dL (200 g/L) or more hypoxemia (PaO2 <60 mm Hg or O2 saturation <88%) hypercapnia (PaCO2 >45 mm Hg). Polycythemia develops as a result of increased production of red blood cells as the body attempts to compensate for chronic hypoxemia. may have lowered hemoglobin/hematocrit = anemia. Edema in the ankles = right-sided heart involvement (cor pulmonale).

Obstructive Sleep Apnea Clinical manifestations

Frequent arousals during sleep Insomnia Excessive daytime sleepiness Witnessed apneic episodes Snoring Morning headache Irritability The patient's bed partner may complain about the patient's loud snoring. Morning headaches are related to hypocapnia or increased BP that causes vasodilation of cerebral blood vessels.

Triggers of AsthmaGastroesophageal Reflux Disease

GERD more common in persons with asthma Reflux may trigger bronchoconstriction as well as cause aspiration Asthma medications may worsen GERD symptoms β2 agonists (orally), = treat asthma = relax the lower esophageal sphincter = allowing stomach contents to reflux = aspirated into the lungs.

Planning COPD

Goals Prevention of disease progression Ability to perform ADLs Relief from symptoms No complications related to COPD Goals Knowledge and ability to implement long-term regimen Overall improved quality of life

Postural drainage

Gravity assists in bronchial drainage Commonly ordered 2 to 4 times per day Percussion, vibration, and postural drainage assist in bringing secretions into larger, more central airways. use with huff coughing

peak flow resluts

Green Zone Usually 80% to 100% of personal best Remain on medications Yellow Zone Usually 50% to 80% of personal best Indicates caution Something is triggering asthma. Red Zone 50% or less of personal best Indicates serious problem Definitive action must be taken with health care provider

COPDInfection

HIV Tuberculosis Severe recurring respiratory tract infections in childhood = reduced lung function and increased respiratory symptoms in adulthood People who smoke and HIV = incr risk COPD. tb = risk factor for COPD development.

Percussion

Hands in a cuplike position to create an air pocket Air-cushion impact facilitates movement of thick mucus If it is performed correctly, a hollow sound should be heard A thin towel should be placed over the area to be percussed, or the patient may choose to wear a T-shirt or hospital gown. No percussion over Kidneys Sternum Spinal cord Bony prominences Tender or painful area Trendelenburg not for patient with = chest trauma, hemoptysis, heart disease, pulmonary embolus, head injury

Asthma Definition

Heterogenous disease clinical manifestations + reversible expiratory airflow limitation + bronchial hyperresponsiveness Related to patient (e.g., genetic factors) Related to environment (e.g., pollen) Male gender is a risk factor in children (but not adults) Obesity is also a risk factor Genetics-inherited component is complex Immune response-hygiene hypothesis Allergens Exercise-induced asthma (EIA) or exercise-induced bronchospasm (EIB) Air Pollutants Atopy, the genetic predisposition to develop an allergic (immunoglobulin E [IgE]-mediated) response to common allergens, is a major risk factor for asthma. Allergens: May be seasonal or year-round depending on exposure to allergen Cockroaches Furry animals Fungi Pollen Molds Typically, EIA occurs after vigorous exercise, not during it (e.g., jogging, aerobics, walking briskly, climbing stairs). Airway obstruction may occur as the result of changes in the airway mucosa caused by hyperventilation that occurs during exercise with either cooling or rewarming of air and capillary leakage in the airway wall. Air Pollutants: Can trigger asthma attacks Cigarette or wood smoke Vehicle exhaust Concentrated pollution

COPDDiagnostic Studies

History and physical exam Diagnosis confirmed by spirometry - airflow obstruction/severity of COPD. FEV1/FVC ratio <70% Increased residual volume The patient is given a short-acting bronchodilator, and post-bronchodilator values are compared to a normal reference value. A diagnosis of COPD is made when the forced expiratory volume in one minute/forced vital capacity (FEV1FVC) ratio is less than 70% along with the appropriate symptoms. The value of FEV1 provides a guideline for the degree of severity of COPD. FEV1 can be expressed as a percentage compared with a normal reference value (% predicted). The lower the FEV1 the sicker the patient. Chest x-ray 6-minute walk test COPD Assessment Test (CAT) Clinical COPD Questionnaire (CCQ) Chest x-rays = NOT diagnostic = show a flat diaphragm = hyperinflated lungs. exercise-induced hypoxemia = 6-minute walk test with pulse oximetry O2 88% or lower when at rest = qualify for supplemental oxygen. Echocardiogram or multigated acquisition (MUGA) (cardiac blood pool) scan An echocardiogram or multigated acquisition (MUGA) (cardiac blood pool) scan can be used to evaluate right- and left-sided ventricular function. Sputum for culture and sensitivity may be obtained if the patient is hospitalized for an acute exacerbation and has not responded to antibiotic therapy. ABG typical findings in later stages ↑ PaCO2 ↑ Bicarbonate level found in late stages of COPD ↓ pH ↓ PaO2 ABGs are usually assessed in the severe stages (FEV1 less than 50%) and monitored in patients hospitalized with acute exacerbations. In early stages = normal or only slightly decreased PaO2 and a normal PaCO2.

Obstructive Sleep Apnea Complications can result in

Hypertension Cardiac changes Poor concentration/memory Impotence Depression Diagnosis is based on PSG Complications untreated sleep apnea = hnt, dysrhythmias, arteriosclerosis, hf, and cardiovascular-related mortality. PSG = patient's chest and abdominal movement, oral airflow, nasal airflow, SpO2, ocular movement, and heart rate and rhythm are monitored. A diagnosis of sleep apnea requires documentation of apneic events or hypopneas of at least 10 seconds' duration. OSA is defined as more than 5 apnea/hypopnea events per hour accompanied by a 3% to 4% decrease in oxygen saturation. Severe apnea can be associated with apneic events of more than 30 to 50 per hour of sleep.

Nutritional therapy

Increased inflammatory mediators Increased metabolic rate Lack of appetite Weight loss altered taste caused by chronic mouth breathing, excessive sputum, fatigue, anxiety, depression, increased energy needs, numerous infections, and side effects of polypharmacy. To decrease dyspnea and conserve energy Rest at least 30 minutes before eating Avoid exercise for 1 hour before and after eating Use bronchodilator High-calorie, high-protein diet is recommended Eat five to six small meals to avoid bloating and early satiety Underweight patients with emphysematous COPD may need 25 to 45 kcal/kg and 1.2 to 1.9 g of protein per kilogram to even maintain their weight. Sensations of bloating = swallowing air while eating, side effects of medication (especially corticosteroids and theophylline), and the abnormal position of the diaphragm relative to the stomach in association with hyperinflation of the lungs. Avoid Foods that require a great deal of chewing Exercises and treatments 1 hour before and after eating Gas-forming foods

Nursing ManagementNursing Diagnoses asthma

Ineffective airway clearance Anxiety Deficient knowledge Nursing diagnoses for the patient with asthma may include, but are not limited to, the following: Ineffective airway clearance related to bronchospasm, excessive mucus production, tenacious secretions, and fatigue Anxiety related to difficulty breathing, perceived or actual loss of control, and fear of suffocation Deficient knowledge related to lack of information and education about asthma and its treatment

Nursing ManagementNursing Diagnoses COPD

Ineffective breathing pattern Ineffective airway clearance Impaired gas exchange Imbalanced nutrition: Less than body requirements Risk for infection

High-frequency chest wall oscillation

Inflatable vest that vibrates the chest Works on all lobes More effective than CPT A high-frequency pulse generator delivers air to the vest, which vibrates the chest, dislodging mucus from the airways.

Classification of Asthma

Intermittent Mild persistent Moderate persistent Severe persistent evere or life-threatening asthma.

Nutritional Problems KEY POINTS

Lewis: Medical-Surgical Nursing, 10th Edition Chapter 39 Nutritional Problems KEY POINTS NUTRITIONAL PROBLEMS • Nutrition is the sum of processes by which one takes in and uses nutrients. Nutrition is important for energy, growth, and maintenance and repair of body tissues. • Nutritional problems can occur in all age groups, cultures, ethnic groups, and socioeconomic classes and across all educational levels. • The essential components of the basic food groups are carbohydrates, fats, proteins, vitamins, and minerals. • A person's daily caloric requirements are influenced by body type, age, gender, medication usage, physical activity, and the presence or absence of disease. SPECIAL DIETS • Certain vegetarian diets exclude red meat, poultry, and fish from the diet. • ♣ Vegans eat only plant food. • ♣ Lacto-ovo-vegetarians eat plant food and may include dairy products and eggs. • Vegetarians can have vitamin or protein deficiencies without a well-planned diet. • Vegans must supplement with cobalamin (vitamin B12). • CULTURALLY COMPETENT CARE: NUTRITION • People have unique cultural heritages that may affect eating customs and nutritional status. • Acculturation, the extent to which immigrants adopt attributes of a new culture, can influence dietary practices. • It is important to know whether the patient eats "traditional foods" associated with the culture. • Consideration of cultural beliefs is very important when planning dietary changes and monitoring acceptance of dietary changes. MALNUTRITION • Malnutrition is a deficit, excess, or imbalance of the essential components of a balanced diet. • Undernutrition describes a state of poor intake because of inadequate diet or diseases that interfere with normal appetite and assimilation of ingested food. • Overnutrition refers to the ingestion of more food than is required for body needs, as in obesity. • Three etiologies of adult malnutrition are starvation-related malnutrition, chronic disease-related malnutrition, and acute disease or injury related-malnutrition. • Many factors contribute to the development of malnutrition, including socioeconomic status, cultural influences, psychologic disorders, medical conditions, and food-drug interactions. • ♣ Malnutrition is a common consequence of illness, injury, surgery, and hospitalization. • ♣ Malabsorption syndrome is the impaired absorption of nutrients from the gastrointestinal (GI) tract. • ♣ Inflammation affects nutrient metabolism and is an important component of nutritional status. • Malnutrition affects body composition and functional status. • Clinical manifestations of malnutrition range from mild (e.g., excessively dry skin, rashes, hair loss) to emaciation and death. • A diet history of foods eaten over a period of time (e.g., a few days) provides insight about a patient's dietary habits and knowledge of good nutrition. • Malnutrition is diagnosed by changes in body composition, including weight loss, functional measurements (e.g., handgrip strength), and laboratory studies, including serum protein and electrolyte levels, used in conjunction with the physical examination. • Anthropometric measurements (e.g., skinfold thickness, midarm circumference) may be used to assess nutritional status. NURSING MANAGEMENT: MALNUTRITION • As a nurse, you initiate the nutrition screening process. • The Joint Commission requires nutrition screening for all patients within 24 hours of admission. If the nutrition screening identifies an at-risk patient, a full nutritional assessment and referral to a dietitian is indicated. • Care for the patient with imbalanced nutrition revolves around the common nursing diagnoses of imbalanced nutrition, self-care deficit, deficient fluid volume, risk for impaired skin integrity, and activity intolerance. • Overall goals for a patient with malnutrition are that the patient will achieve an ideal body weight, consume a specified number of calories, and have no adverse consequences. GERONTOLOGIC CONSIDERATIONS: MALNUTRITION • Older adults are particularly vulnerable to malnutrition. The prevalence of malnutrition in older adults based on the Mini-Nutritional Assessment tool ranges from approximately 6% in community-dwelling older adults to 50% in rehabilitation settings. • Older hospitalized adults with malnutrition are more likely to have poor wound healing, pressure ulcers, infections, decreased muscle strength, postoperative complications, and increased morbidity and mortality. • Risk factors for malnutrition include dietary, economic, psychosocial, and physiologic factors. TYPES OF SPECIALIZED NUTRITION SUPPORT Oral Feeding • High-calorie, high-protein oral supplements may be used in a patient who is nutritionally deficient. • If oral supplementation is not adequate, further nutritional support may be necessary. Enteral Nutrition • Enteral nutrition (EN), also known as tube feeding, is nutritionally balanced liquefied food or formula provided through the GI tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity. • EN is used in a wide variety of patient conditions. • EN may be delivered through orogastric, nasogastric, nasointestinal, nasojejunal, gastrostomy, or jejunostomy tubes. • Procedures for EN therapy include the following: • ♣ Positioning patient with head elevated at least 30 degrees • ♣ Flushing feeding tubes to maintain patency • ♣ Checking tube position on insertion and prior to feeding • ♣ Monitoring for aspiration • ♣ Using sterile, liquid EN formula with closed systems • ♣ Monitoring nutrition status and tolerance of EN • Older patients, especially those with diabetes, may be more susceptible to problems of hyperglycemia in response to the high carbohydrate load of some EN formulas. • The older adult is also at increased risk for aspiration caused by gastroesophageal reflux disease (GERD), delayed gastric emptying, hiatal hernia, or diminished gag reflex. Parenteral Nutrition • Parenteral nutrition (PN) refers to the administration of nutrients by a route other than the GI tract (e.g., the bloodstream). PN may be administered through central or peripheral veins. • Central parenteral nutrition is the delivery of a nutritionally adequate hypertonic solution consisting of glucose, crystalline amino acids, fat emulsion, minerals, and vitamins using a central venous route. • Peripheral parenteral nutrition (PPN) is administered through a peripherally inserted catheter or vascular access device, which uses a large vein. PPN is not appropriate to meet long-term nutrition needs and is rarely used in the acute care setting. • All PN solutions are prepared by a pharmacist or a trained technician using strict aseptic techniques under a laminar flow hood. • Because PN solutions are excellent media for microbial growth, it is essential to follow proper aseptic techniques. • Blood levels of glucose, electrolytes, and urea nitrogen; a complete blood count; and hepatic enzyme studies are monitored a minimum of three times per week until stable and then weekly as the patient's condition warrants. • Dressings covering the catheter site are changed according to institutional protocol, ranging from every other day to once a week. • Refeeding syndrome is characterized by fluid retention and electrolyte imbalances including hypophosphatemia, hypokalemia, and hypomagnesemia. • Catheter-related infection and septicemia can occur in patients receiving PN through both peripherally and centrally placed lines. Local manifestations of infection include erythema, tenderness, and exudate at the catheter insertion site. • Home PN or EN is an accepted mode of nutritional therapy for the person who does not require hospitalization but who requires continued nutrition support.

Obesity KEY POINTS

Lewis: Medical-Surgical Nursing, 10th Edition Chapter 40 Obesity KEY POINTS CLASSIFICATIONS OF BODY WEIGHT AND OBESITY • Primary obesity is excess calorie intake for the body's metabolic demands. Secondary obesity can result from chromosomal and congenital anomalies, metabolic problems, or central nervous system (CNS) lesions and disorders. • • The degree to which a patient is classified as underweight, healthy (normal) weight, overweight, or obese can be assessed by using body weight, a body mass index (BMI) chart, waist circumference, or waist-to-hip ratio. • • Individuals with fat located primarily in the abdominal area (apple-shaped body) are at a greater risk for obesity-related complications than those whose fat is primarily located in the upper legs (pear-shaped body). Epidemiology of Obesity • Obesity is the most common nutritional problem, with over one third of the U.S. population obese. Etiology and Pathophysiology • Obesity is an abnormal increase in the proportion of fat cells. Weight gain, in which the body is moving toward an overweight or obese state, is characterized predominantly by adipocyte hypertrophy and hyperplasia. • • The cause of obesity involves significant genetic/biologic susceptibility factors that are highly influenced by environmental and psychosocial factors. • Health Risks Associated With Obesity • Obesity is a significant risk factor for cardiovascular disease and hypertension in both men and women. • • Many patients with type 2 diabetes are obese. • • Obesity can lead to a number of medical problems, including osteoarthritis, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, nonalcoholic steatohepatitis, and cancer. • • Obesity in older adults can exacerbate age-related declines in physical function and lead to frailty and disability. ' NURSING AND INTERPROFESSIONAL MANAGEMENT: OBESITY • Measurements used with the obese person may include skinfold thickness, height, weight, and BMI. • • The overall goals for the obese patient include the following: Modifying eating patterns Participating in a regular physical activity program Achieving weight loss to a specified level Maintaining weight loss at a specified level Minimizing or preventing health problems related to obesity • Obesity is considered a chronic condition that necessitates day-to-day attention to lose weight and maintain weight loss. The management should include lifestyle changes revolving around a combination of diet and behavior modification, exercise, and occasionally medication. • • Motivation is an essential ingredient for successful achievement of weight loss. • • Restricted food intake is a cornerstone for any weight loss or maintenance program. Persons on low-calorie and very-low-calorie diets need frequent professional monitoring because the severe energy restriction places them at risk for multiple nutrient deficiencies. • • Exercise is an important part of a weight control program. Exercise should be done daily, preferably 30 to 60 minutes a day. • • Useful basic techniques for behavioral modification include self-monitoring, stimulus control, and rewards. • • Patients trying to lose weight often find support groups useful. • • Drug therapy for obesity includes orlistat (Xenical, Allī), lorcaserin (Belviq), bupropion/naltrexone (Contrave), phenteramine/topiramate (Qsymia), and liraglutide (Saxenda). SURGICAL THERAPY • Bariatric surgery can be classified as restrictive, malabsorptive, or combination of restrictive and malabsorptive surgeries. • • Bariatric surgery is currently the only treatment that has been found to have a successful and lasting impact for sustained weight loss for individuals with extreme obesity. • Wound infection is one of the most common complications after surgery. Early ambulation following surgery is important for the obese patient. Late complications following bariatric surgery include anemia, vitamin deficiencies, diarrhea, and psychosocial problems. • When obese patients have surgery they are likely to suffer from other comorbidities including diabetes, altered cardiorespiratory function, abnormal metabolic function, hemostasis, and atherosclerosis that place them at risk for complications related to surgery. METABOLIC SYNDROME • Metabolic syndrome is a collection of risk factors that increase an individual's chance of developing cardiovascular disease and diabetes mellitus. • • The signs of metabolic syndrome are impaired fasting blood glucose, hypertension, abnormal cholesterol levels, and obesity. • • Lifestyle therapies are the first-line interventions to reduce the risk factors for metabolic syndrome.

Upper Gastrointestinal Problems KEY POINTS

Lewis: Medical-Surgical Nursing, 10th Edition Chapter 41 Upper Gastrointestinal Problems KEY POINTS NAUSEA AND VOMITING • Nausea and vomiting are the most common manifestations of gastrointestinal (GI) diseases. Nausea is a feeling of discomfort in the epigastrium with a conscious desire to vomit. Vomiting is the forceful ejection of partially digested food and secretions (emesis) from the upper GI tract. • Nausea and vomiting are found in a wide variety of GI disorders, as well as pregnancy, infectious diseases, central nervous system disorders, cardiovascular problems, metabolic disorders, side effects of drugs, and psychologic factors. • Vomiting can occur when the GI tract becomes overly irritated, excited, or distended. It can be a protective mechanism to rid the body of spoiled or irritating foods and liquids The color of the emesis aids in identifying the presence and source of bleeding. • Drugs that treat nausea and vomiting include anticholinergics, antihistamines, phenothiazines (e.g., chlorpromazine [Thorazine], prochlorperazine [Compazine]), butyrophenones, metoclopramide (Reglan), serotonin receptor antagonists (e.g., ondansetron [Zofran]), dexamethasone, and cannabinoids. • The patient with severe or prolonged vomiting is at risk for dehydration and acid-base and electrolyte imbalances. The patient may require IV fluid therapy with electrolyte and glucose replacement until able to tolerate oral intake. Pulmonary aspiration is a concern when vomiting occurs in the patient who is older, is unconscious, or has other conditions that impair the gag reflex. • Older patients are more likely to have cardiac or renal insufficiency that places them at greater risk for life-threatening fluid and electrolyte imbalances caused by vomiting. ORAL CANCER • Head and neck squamous cell carcinoma is an umbrella term for cancers of the oral cavity, pharynx, and larynx. Most of the oral malignant lesions occur on the lower lip. • Risk factors for oral cancer include tobacco use, excess alcohol intake, a diet low in fruits and vegetables, chronic irritation such as from a jagged tooth or poor dental care, and human papillomavirus (HPV)-associated oropharyngeal cancer. • Common manifestations include leukoplakia, erythroplakia, ulcerations, a sore that does not heal and bleeds easily, and a rough patch. Sore throat and voice changes may occur. • Surgery is the most effective treatment, especially for early stage disease. Radiation therapy may be used alone to treat small cancers or when lesions cannot be removed. Chemotherapy can shrink lesions before surgery, decrease metastasis, sensitize cancer cells to radiation, or treat distant metastases. • The overall goals are that the patient with cancer of the oral cavity will have a patent airway, be able to communicate, have adequate nutritional intake to promote wound healing, and have relief of pain and discomfort. GASTROESOPHAGEAL REFLUX DISEASE • Gastroesophageal reflux disease (GERD) is a syndrome, not a disease, in which there are chronic symptoms or mucosal damage resulting from reflux of gastric contents into the lower esophagus. • Predisposing conditions include hiatal hernia, incompetent lower esophageal sphincter (LES), decreased esophageal clearance (ability to clear liquids or food from the esophagus into the stomach) resulting from impaired esophageal motility, and decreased gastric emptying. • Symptoms vary by person. Heartburn and dyspepsia are the most common manifestations. • A complication of GERD is Barrett's esophagus (esophageal metaplasia), which is considered a precancerous lesion that increases the patient's risk for esophageal cancer. • Most patients with GERD are successfully managed with lifestyle modifications and drug therapy. • ♣ Drug therapy for GERD focuses on improving lower esophageal sphincter (LES) function, increasing esophageal clearance, decreasing volume and acidity of reflux, and protecting the esophageal mucosa. • ♣ Medications used include proton pump inhibitors, histamine receptor antagonists, and antacids. • Provide patient and caregiver teaching about avoiding factors that cause acid reflux. This includes dietary treatment, elevating the head of the bed 6 to 8 inches, losing weight (if indicated), avoiding tobacco, and stress management. HIATAL HERNIA • Hiatal hernia is the herniation of a portion of the stomach into the esophagus through an opening in the diaphragm. • Predisposition to hiatal development includes structural changes and factors that increase intraabdominal pressure, including obesity, pregnancy, ascites, tumors, intense physical exertion, and heavy lifting on a continual basis. • Complications that may occur with hiatal hernia include GERD, esophagitis, hemorrhage from erosion, stenosis, ulcerations of the herniated portion of the stomach, strangulation of the hernia, and regurgitation with tracheal aspiration. • Conservative treatment of hiatal hernia is similar to that of GERD. • Surgical repair can be performed laparoscopically. ESOPHAGEAL CANCER • The cause of esophageal cancer is unknown. Important risk factors include smoking, excessive alcohol intake, Barrett's metaplasia, central obesity, and diet low in fruits, vegetables, and vitamins A, B2, and C. • Most patients present with progressive dysphagia, accompanied by pain and weight loss. • Treatment depends on location of tumor and stage at time of diagnosis. A variety of surgical procedures may be done in combination with chemotherapy and radiation. • Palliative care consists of restoring swallowing function and maintaining nutrition and hydration. OTHER ESOPHAGEAL DISORDERS • Diverticular outpouchings can occur in the esophagus. Some patients can be managed with conservative therapy. Surgery is indicated in those with nutritional disruptions. • In achalasia, peristalsis is absent in the lower portion of the esophagus. The exact cause is unknown. Goals of treatment are to relieve dyspepsia and regurgitation and improve esophageal emptying. • Esophageal varices are dilated veins in the lower esophagus. STOMACH CANCER • Stomach cancer probably begins with a nonspecific mucosal injury as a result of infection (H. pylori), autoimmune-related inflammation, or repeated exposure to irritants (e.g., bile, antiinflammatory agents, tobacco use). Smoking and obesity both increase risk. • Stomach cancer often spreads to adjacent organs before any distressing symptoms occur. Manifestations include weight loss, lack of appetite, abdominal pain, indigestion, and symptoms related to anemia. • Treatment depends on the location of the tumor and stage at time of diagnosis. A variety of surgical procedures may be done in combination with adjuvant chemotherapy, radiation therapy, and targeted therapy. • The nursing role in the early detection of stomach cancer focuses on identifying the patient at risk because of specific disorders such as pernicious anemia and achlorhydria. • Goals of care for a patient with stomach cancer include that the patient will experience minimal discomfort, achieve optimal nutritional status, and maintain a degree of well-being appropriate to disease stage.

Surgical therapy

Lung volume reduction surgery (LVRS) Remove diseased lung to enhance performance of remaining healthy lung tissue =decreased airway obstruction and increased room for remaining normal alveoli to expand, allow the diaphragm to return to its normal shape, allowing the patient to breathe more efficiently. Lung volume reduction surgery is being explored as a therapy that can be performed via a bronchoscope (BLVR). Bronchoscopic lung volume reduction surgery One-way valves are placed in the airways leading to the diseased parts of the lung. Collapses a certain segment of the lung Similar result as LVRS The valves let air out, but not in. This collapses a certain segment of the lung and has a similar result as LVRS. Bullectomy Bullae are large air sacs that form from destroyed alveoli One or more large bullae are removed to improve lung function The bullae are usually resected via thoracoscope. Lung transplantation Single lung—Most common because of donor shortages

Triggers of Asthma Respiratory Infections

Major precipitating factor of an acute asthma attack ↑ Inflammation and hyperresponsiveness of tracheobronchial system Viral-induced alterations of epithelial cells, increased inflammatory cell accumulation, edema of airway walls, and exposure of airway nerve endings contribute to altered airway function.

Long-term O2 therapy (LTOT) at home improves COPD

Mental status Exercise intolerance Chronic O2 therapy at home reduces, hct, Pulmonary hypertension ppl think = will become "addicted" to O2 and are very reluctant to use it. reevaluated every 30 to 90 days during 1st yr therapy and annually after that, as long as the patient remains stable. Short-term home O2 therapy (1 to 30 days) = hypoxemia persists after discharge from the hospital.

Sleep ApneaNursing and Interprofessional Mgmt

Mild Sleep Apnea Sleeping on one's side Elevating head of bed Avoiding sedatives and alcohol 3 to 4 hours before sleep Weight loss Oral appliance Excessive weight worsens sleep apnea = pressure of adipose tissue in the neck and on the chest restrict ventilation. Oral appliances bring the mandible and the tongue forward to enlarge the airway space, thereby preventing airway occlusion. Severe Sleep Apnea (>15 apnea/hypopnea events/hr) CPAP Poor compliance BiPAP Surgery Uvulopalatopharyngoplasty (UPPP or UP3) Genioglossal advancement and hyoid myotomy (GAHM) CPAP, a nasal mask is attached to a blower, which is adjusted to maintain sufficient positive pressure (5 to 25 cm H2O) in the airway during inspiration and expiration to prevent airway collapse. To ensure successful adherence to CPAP treatment, patients needs to be involved in the selection of the mask and device before the start of therapy. For those with difficulty with CPAP, bilevel positive airway pressure (BiPAP) can deliver a higher inspiration pressure and a lower pressure during expiration. UPPP involves excision of the tonsillar pillars, uvula, and posterior soft palate to remove obstructing tissue. GAHM involves advancing the attachment of the muscular part of the tongue on the mandible.

Patient Teaching Related to Drug Therapy asthma

Nebulizers are small machines used to convert drug solutions into mists. Inhalation of the mist can be done through a face mask or mouthpiece held between the teeth. They are usually used for severe asthma or for individuals who have difficulty with the MDI inhalation. Using an MDI (Metered-dosed Inhaler) with a spacer is easier and improves inhalation of the drug DPI (dry powder inhaler) requires less manual dexterity and coordination One of the major problems with metered-dose drugs is the potential for overuse, that is, using them much more frequently than prescribed (>2 canisters/month) rather than seeking needed medical care.

nursing outcomes asthma

Nursing Outcomes Describe the disease process and treatment regimen Demonstrate correct administration of inhaled drugs Express confidence in ability for long-term management of asthma Nursing Outcomes Maintain clear airway with removal of excessive secretions Experience normal breath sounds and respiratory rate Report decreased anxiety with increased control of respirations

Multiple Sclerosis onset

Onset usually between 20 and 50 years of age Can affect people of any age Symptoms 1st appear ages 30-35 Disease more progressive when diagnosed at age > 50 Affects women 2-3 times more often

Nursing ManagementPlanning asthma

Overall Goals Have minimal symptoms Maintain acceptable activity levels Maintain >80% of personal best PEFR Overall Goals Few or no adverse effects of therapy No acute exacerbations of asthma Adequate knowledge to participate in and carry out plan of care

Flutter mucus clearance device

Provides positive expiratory pressure (PEP) treatment Produces vibration in lungs to loosen mucus for expectoration Handheld device The Flutter has a mouthpiece, a high-density stainless steel ball, and a cone that holds the ball. When the patient exhales through the Flutter, the steel ball moves, which causes oscillations (vibrations) in the airways and loosens mucus. The patient must be upright, and the angle at which the Flutter is held is critical.

TheraPEP Therapy System

Provides sustained PEP while simultaneously delivering aerosols The pressure indicator provides visual feedback TheraPEP has a mouthpiece attached to tubing connected to a small cylindric resistor and a pressure indicator. The pressure indicator provides visual feedback about the pressure that the patient needs to hold in an exhalation to receive the PEP.

Triggers of AsthmaEmotional Stress

Psychologic factors can worsen the disease process Extreme emotional expressions Attacks can trigger panic and anxiety Extreme emotional expressions (e.g., crying, laughing, anger, fear) can lead to hyperventilation and hypocapnia, which can cause airway narrowing.

COPDGerontologic Considerations

Reduced lean body mass and decreased respiratory muscle strength may increase dyspnea and lower exercise tolerance COPD complicated by co-morbidities Cardiovascular disease Serious infections Osteoporosis Psychologic problems Impaired cognition Lung cancer hypertension meds in elder = worsen COPD

COPDEtiology

Risk factors Cigarette smoking Occupational chemicals and dust Air pollution Severe recurring respiratory infections α1-antitrypsin deficiency α1-antitrypsin deficiency (an autosomal recessive disorder) is a risk factor for developing COPD. Some degree of emphysema has been thought to occur as a person ages. It is caused by changes in the lung structure and the respiratory muscles, even in a nonsmoker.

Complications asthma

Severe and life-threatening exacerbations Respiratory rate >30/min Dyspnea at rest, feeling of suffocation Pulse >120/min PEFR is 40% at best Usually seen in ED or hospitalized Severe asthma exacerbations occur when the patient is dyspneic at rest and the patient speaks in words, not sentences, because of the difficulty breathing. Accessory muscles in the neck are straining to try to lift the chest wall, and the patient is often agitated. The peak flow (peak expiratory flow rate [PEFR]) is 40% of the personal best or less than 150 L. Life-threatening asthma Too dyspneic to speak Perspiring profusely Drowsy/confused PEFR <25% Require hospital care and often admitted to ICU The breath sounds may be very difficult to hear, and no wheezing is apparent as the airflow is exceptionally limited. Peak flow is less than 25% of the personal best.

COPD Exacerbations treatment

Short-acting β2 - agonists with or without short-acting anticholinergics are preferred for those who are breathless. Drug administration via metered dose inhaler or nebulizer is equal in effect, although sicker patients often prefer the nebulizer. - corticosteriods Antibiotic use remains somewhat controversial. However, the presence of green or purulent sputum (as opposed to white sputum) is one the best ways to determine if antibiotics are needed. Supplemental oxygen therapy may be used for inpatients and titrated by ABG measurement.

Nonprescription Combination Drugs asthma

Should be avoided in general Epinephrine can also increase heart rate and blood pressure Ephedrine stimulates CNS and cardiovascular system

Methods of Oxygen AdministrationLow Flow

Simple face mask. Non re-breather face mask (mask with oxygen reservoir bag and one-way valves which aims to prevent/reduce room air entrainment) Nasal prongs (low flow)

Sleep-Disordered Breathing (SDB)

Snoring Apnea Hypopnea Obstructive sleep apnea (OSA) The term sleep-disordered breathing (SDB) indicates abnormal respiratory patterns associated with sleep, including snoring, apnea (temporary cessation of respiration), and hypopnea (temporary restriction of respiration without full cessation) with increased respiratory effort leading to frequent arousals. SDB results in frequent sleep disruptions and alterations in sleep architecture. Obstructive sleep apnea is the most commonly diagnosed SDB problem.

Interprofessional Care asthma

The level of control is determined by the patient's current peak flow or FEV1. In addition, any exacerbations or adverse effects of treatment will determine the level of control. Intermittent and persistent asthma Avoid triggers of acute attacks Pre-medicate before exercising Short-term (rescue or reliever) medication Long-term or controller medication Patients in all classifications of asthma require a short-term (rescue or reliever) medication. Short-acting β2-adrenergic agonists (SABAs) (e.g., albuterol [ProAir HFA, Proventil HFA, Ventolin HFA]) are the most effective class of drugs used as rescue or reliever medications. Patients with persistent asthma must be on a long-term or controller medication (see Table 28-6). Inhaled corticosteroids (ICSs) (e.g., fluticasone [Flovent]) are the most effective class of drugs to treat the inflammation. For any classification of asthma, in a "rescue plan" patients are instructed to take 2 to 4 puffs of albuterol every 20 minutes 3 times to gain rapid control of symptoms. Moderate exacerbation: Relief is provided with the SABA delivered as in the mild exacerbation, and oral corticosteroids are needed. The patient's symptoms may persist for several days even after the corticosteroids are started. Assessment during acute exacerbation Respiratory and heart rate Use of accessory muscles Percussion and auscultation of lungs PEFR to monitor airflow obstruction ABGs Pulse oximetry During an acute attack, the person sits forward to maximize the diaphragmatic movement with prominent wheezing, a respiratory rate higher than 30 breaths/minute, and pulse greater than 120 beats/minute. Accessory muscles in the neck are straining to lift the chest wall, and the patient is often agitated (from hypoxemia). Percussion of the lungs indicates hyperresonance. Auscultation of the lungs indicates inspiratory or expiratory wheezing. As the episode resolves, coughing produces thick, stringy mucus. During an acute attack of asthma, bedside PEFR may be used to monitor airflow obstruction. Serial PEFR results, oximetry, and measurement of ABGs provide information about the severity of the attack and the response to therapy. Obtaining a PEFR during a severe asthma attack is usually not possible. However, if it can be obtained, and it is less than 200 L/min, it indicates severe obstruction in all but very small adults. Acute asthma exacerbations O2 given via nasal cannula or mask to achieve a PaO2 of at least 60 mm Hg or O2 saturation greater than 90% Continuous oxygen monitoring with pulse oximetry Bronchodilator treatment Short-acting β2-adrenergic agonists (SABAs) The mainstay of bronchodilator treatment is inhalation of short-acting β2-adrenergic agonists (SABAs) such as albuterol (Tables 28-6 and 28-8). Corticosteroids are used for patients who do not initially respond to SABA alone. Severe and life-threatening exacerbations Most therapeutic measures are the same as for acute episode Inhaled ipratropium is used in conjunction with SABA In patients with severe exacerbations, inhaled ipratropium (Atrovent) is used in conjunction with SABA. Combivent = both ipratropium and albuterol. Severe and life-threatening exacerbations "Silent chest" Severely diminished breath sounds Absence of wheeze after patient has been wheezing Patient is obviously struggling Life-threatening situation Severe and life-threatening exacerbations Requires ED and possible ICU IV magnesium sulfate 100% oxygen Hourly or continuous nebulized SABA IV corticosteroids

Nursing ManagementNursing Implementation asthma

The patient can take 2 to 4 puffs of a short-acting β2-adrenergic agonists (SABA) every 20 minutes 3 times as a rescue plan. Depending on the response (e.g., alleviation of symptoms or improved peak flow), continued SABA use and/or oral corticosteroids may be a part of the home management plan at this point. Louder wheezing may actually occur in the airways that are responding to the therapy as airflow in the airways increases. ↓ patient's anxiety and sense of panic = Stay with patient, Position comfortably, Use "talking down" = you gain eye contact with the patient. pursed-lip breathing,= maintaining positive pressure Seek medical attention for bronchospasm or when severe side effects occur Physical exercise (e.g., swimming, walking, stationary cycling) within the patient's limit of tolerance is also beneficial and may require pretreatment with an SABA (as noted previously). Patients with asthma frequently do not perceive changes in their breathing. Therefore peak flow monitoring, when done correctly, can be a reliable, objective measurement of asthma control

Drug Therapy asthma

Three types of antiinflammatory drugs Corticosteroids Leukotriene modifiers Monoclonal antibody to IgE Corticosteroids (e.g., beclomethasone, budesonide) Suppress inflammatory response Inhaled form is used in long-term control Systemic form to control exacerbations and manage persistent asthma ICSs are first-line therapy for patients with persistent asthma requiring step 2-6 therapy 1 to 2 weeks before maximum therapeutic effects can be seen. Corticosteroids Reduce bronchial hyperresponsiveness Decrease mucous production Are taken on a fixed schedule Women/postmenopausal = calcium and vitamin D, weight-bearing exercise. Oropharyngeal candidiasis, hoarseness, and a dry cough are local side effects of inhaled drug Leukotriene modifiers or inhibitors (e.g., zafirlukast, montelukast, zileuton) Block action of leukotrienes—potent bronchoconstrictors Leukotriene modifiers or inhibitors Have both bronchodilator and antiinflammatory effects Not indicated for acute attacks Used for prophylactic and maintenance therapy Leukotrienes are inflammatory mediators produced from arachidonic acid metabolism Leukotrienes are potent bronchoconstrictors, and some also cause airway edema and inflammation, thus contributing to the symptoms of asthma. One advantage of leukotriene modifiers is that they are administered orally. Leukotriene modifiers can successfully be used as add-on therapy to reduce (not substitute for) the doses of ICS. Anti-IgE (e.g., Xolair) ↓ Circulating IgE levels Prevents IgE from attaching to mast cells, preventing release of chemical mediators Subcutaneous administration every 2 to 4 weeks The drug has a risk of anaphylaxis, and patients must receive the medication in a health care provider's office, where this emergency can be handled.

Clinical Manifestations asthma

Unpredictable and variable Recurrent episodes of wheezing, breathlessness, cough, and tight chest May be abrupt or gradual Lasts minutes to hours Expiration may be prolonged. Inspiration-expiration ratio of 1:2 to 1:3 or 1:4 Bronchospasm, edema, and mucus in bronchioles narrow the airways Air takes longer to move out This produces the characteristic wheezing, air trapping, and hyperinflation. Most common manifestations Cough Shortness of breath (dyspnea) Wheezing Chest tightness Variable airflow obstruction frequency nocturnal awakenings due to cough, wheezing, or dyspnea = indicator for the severity of asthma Cough variant asthma Cough is only symptom Bronchospasm is not severe enough to cause airflow obstruction cough= nonproductive or with secretions which may be thick, tenacious, white, gelatinous mucus

Nursing ManagementHealth Promotion asthma

Use dust covers Use scarves or masks for cold air Avoid aspirin and NSAIDs Washing bedclothes in hot water or cooler water with detergent and bleach has some effect on allergen levels. Nonselective β-blockers = contraindicated = inhibit bronchodilation. Selective β-blockers = should be used with caution. Fluid intake of 2 to 3 L every day

Acapella

Vibrates lungs to shake free mucous plugs Improves clearance of secretions Faster and more tolerable than CPT It can be used in virtually any setting, as patients are free to sit, stand, or recline. The patient may also inhale through it, and nebulizers can be attached to the Acapella.

Motor manifestations MS

Weakness or paralysis of limbs, trunk, and head Spasticity of muscles Scanning speech Muscles are chronically affected. muscle weakness in the extremities as well as problems with coordination and balance. may even affect walking or standing. MS can cause partial or complete paralysis in the worst cases. speech impediments, tremors, and dizziness. Hearing loss

COPDPathophysiology

airflow limitation, air trapping, gas exchange abnormalities, mucous hypersecretion, and, in severe disease, pulmonary hypertension with systemic features. Gas exchange abnormalities = hypoxemia and hypercarbia (increased CO2) air trapping worsens and alveoli = destroyed, bullae (large air spaces in the parenchyma) and blebs (air spaces adjacent to pleurae) can form. Bullae and blebs are not effective in gas exchange, since they do not contain the capillary bed that normally surrounds each alveolus. Therefore a significant ventilation-perfusion (V/Q) mismatch and hypoxemia result.

Methods of Oxygen AdministrationHigh Flow

consists of a heated, humidified high-flow nasal cannula that can deliver up to 100% heated and humidified oxygen at a maximum flow of 60 LPM via nasal prongs or cannula. An air/oxygen blender can provide precise oxygen delivery independent of the patient's inspiratory flow demands.

COPDGender

greater in men than women Now almost equal - reflecting the changing patterns of cigarette smoking. Women may be more susceptible to the adverse effects of smoking.

COPDAsthma

pathologic and functional overlap between asthma and COPD Older adults may have components of both diseases Patients with COPD may have asthma. Asthma may be a risk factor for the development of COPD.

How Sleep Apnea Occurs

predisposed to obstructive sleep apnea (OSA) has a small pharyngeal airway. During sleep pharyngeal muscles relax = airway to close. Lack of airflow results in repeated apneic episodes. CPAP = continuous positive airway pressure splints the airway open, preventing airflow obstruction.