Med Surg Exam 3 (Endocrine, GI, Nutrition TPN, Liver, Pancreas)

Upper GI Problems: GERD

"Gastroesophageal reflux disease (GERD): = is a chronic symptom of mucosal damage caused by *reflux of stomach acid into the lower esophagus.* - GERD is NOT a disease but a *syndrome*. - GERD is the most common upper GI problem. - symptoms *(heartburn or regurgitation) at least once a week.* Results when stomach's acidic contents reverses into the esophagus -- esophagus is not made to maintain stomach acid. (Gastric HCl acid and pepsin) Leads to esophageal irritation and inflammation Causes include LES (Lower Esophageal Spincter) incompetence = lets the acid go up from stomach into esophagus, obesity, increased LES pressure (such as lying flat after eating), and smoking, hiatial hernia. Manifestations: Heartburn (pyrosis) Epigastric pain (dyspepsia) - can be GI problems in origin. Press down on it and it will hurt If its acute. Chronic stops hurting. Cough, wheeze, chest pain - acid is in the chest. Usually a clinical diagnosis - diagnoses based on your symptoms, not 1 specific thing. Pain and difficulty swallowing Hypersalivation Complications: - *Esophagitis* — acid will inflame the esophagus - *Barrett's esophagus* — its going to create stomach lining in the esophagus, because there is so much acid here the body replaces the esophagus with stomach lining. This causes cancer. - Dental erosion Management: - *Decrease acidic foods — reduce spicy, citrus foods, no coffee. No tomatoes, alcohol, chocolate*. - Smoking cessation - Stress management - *HOB 30 degrees* - Medications: — *Panoprazole (Protonix)* — PPI ends in prazole. Effective because it decreases acid. Take in morning with nothing in your stomach. Shouldn't take more than 2 weeks because cardiac issues - *Ranitidine (Zantac)* — H2Blocker. H2 receptors in our stomach. By blocking the recpotrs, blocking the acid. Usually twice a day. - *Calcium carbonate* — electrolytes PRN. *geRd = R = Ranitidine (Zantac).* *Pro-tonix = pro Gerd)* Diagnostic Studies: - is a clinical diagnosis based on symtpoms - Endocropy can be used to see incompetent LES - biopsy can happen because of Barrett's esophagus - pH management - Surgical therapy *(antireflux surgery)* is reserved for patients with complications, including esophagitis, medication intolerance, stricture, Barrett's esophagus, and persistent severe symptoms. The goal of surgical therapy is to reduce reflux by enhancing the integrity of the LES. Most surgical procedures are done laparoscopically."

Acute Liver Failure

*Fulminant hepatitis* : *characterized by a rapid onset of severe liver dysfunction in someone with no prior history of liver disease.* *often accompiend by hepatic encephalopathy* most common cause is drugs, usually acetaminophen in combo with alcohol. other drugs: isoniazid, halothane, sulfa-containing drugs, and NSAIDs. *Can be from HBV*. manifestations: jaundice coagulation abnormalities *encephalopathy -- first sign.* Diagnostic Studies: CT or MRI Complications: Renal failure dehydration *Liver transplant is treatment of choice*

Upper GI Problems: Achalasia

"In achalasia, peristalsis of the lower two thirds (smooth muscle) of the esophagus is absent. Achalasia is a rare, chronic disorder. The exact cause is unknown. With achalasia, the pressure in the LES increases along with incomplete relaxation. Esophageal obstruction at or near the diaphragm occurs. Food and fluid accumulate in the lower esophagus. The result is dilation of the esophagus proximal to (above) the tapering affected segment of the lower esophagus There is a selective loss of inhibitory neurons, resulting in unopposed contraction of the LES." Esophageal Varices: "Esophageal varices are dilated, tortuous veins occurring in the lower portion of the esophagus because of portal hypertension. Esophageal varices are a common complication of liver cirrhosis."

Upper GI Problems: N/V

(stomach is the line between the upper and lower GI tract) *Nausea and vomiting*: Has multiple causes: Food poisoning Pregnancy Metabolic disorder (diabetes, Addison's, renal failure) Anesthesia Medications (Chemo, opiods) Which is subjective? = nausea Objective = vomitting Manifestations: Nausea usually begins first Followed by anorexia Regurgitation Retching = nothing comes out because you regurgitate so much. dry heave. Projectile vomiting = if adult does this it its very concerning. indicates brain injury, brain bleed, increased inter cranial pressure. What does emesis tell us? (throw-up) Contents of emesis can indicate a cause of problem Partially digested food = delayed emptying Fecal odor = lower intestinal obstruction Coffee grounds = GI bleed. worry about clotting factor labs. PT ptt. patient looks pale, low BP. Bright red blood = frank blood. bleeding somewhere in the esophagus and comes up. seen in liver failure. Bright red blood means it hasn't been digested in the stomach. could be a mallory-weiss tear. "Those with cyclic vomiting syndrome have recurring episodes of nausea, vomiting, and fatigue that last from a few hours up to 10 days."

Pancreatitis

*= Acute inflammation of pancreas* Pancreatic enzymes spill around pancreas, causing autodigestion and pain Causes include *(gallbladder disease) gallstones* -- more common in women and *alcohol abuse* -- more common in men. 3 F's - fat, female, forty. Risk factors : Smoking *Biliary sludge = mixture of cholesterol crystals and calcium salts.* hypertriglyceridemia trauma viral infections (HIV, mumps) can be idiopathic consuming alcohol Manifestations: *Abdominal pain in LUQ but can be mid-epigastric. commonly radiates to the back and left shoulder. aggravated by eating.* Vomiting due to pain. *Steatorrhea = fat in your stool and looks white or clay colored.* Leukocytosis, hypotension Abdominal tenderness with guarding is common. bowel sounds may be decreased or absent crackles in lungs weight loss *Cullen's sign = discoloration of the abd around the umbillicus* *Turner's sign. = bluish discoloration of the flanks* *S/S of diabetes mellitus* Complications: *Hypotension* *Sepsis* Pulmonary complications - respiration distress; pneumonia, pleural effusion, atelectasis Hemorrhage *Pseudocyst -- when gets inflamed > pancreatic abscess results* Tetany (hypocalcemia) Hypovolemia Infeiciton Type 1 diabetic organ failure coagulation defects Diagnosis : *amylase and lipase levels increased* increased liver enzymes, triglycerides, glucose, and biliruben decreased calcium & mag Labs *CT*/US Treatment: *NPO !!!!* - NG suction to reduce vomiting and gastric acidic contents. *When you eat, it stimulates the pancreas to make digestive enzymes* Pain management. *IVF - lactated ringers.* Oxygen as needed for pulmonary complications when diet resumes = *LOW FAT AND NO ALCOHOL* glucose monitoring/ administer insulin *if shock is present = blood volume replacement. plasma os plasma volume expanders such as dextran or albumin*. prevent infections *surgical therapy related to gallstones = an urgent ERCP plus endoscopic sphincterotomy. followed by laparoscopic cholecystectomy.* percutaneous drainage of pseudocyst and drainig tube left in place. meds: opiods antibiotics: Imipenem H2 blockers: Ranitidine PPI: Omeprazole Pancreatic Enzymes: Pancrelipase -- take with every food. drink 1 glass of water after.

Lower GI: Diarrhea

*= Defined as passing at least 3 liquid stools in a day* ◦Acute diarrhea lasts 14 days or less ◦Chronic diarrhea continues for 30 days or more ◦Typically caused by infectious organism and virus: > *◦E. coli* -- *most common blood diarrhea*. "It is transmitted by undercooked beef or chicken contaminated with the bacteria or in fruits and vegetables exposed to contaminated manure." Traveler's diarrhea. > *◦Giardia* -- *most common intestinal parasite* that causes diarrhea in the US. > *◦Norovirus* -- alter secretion and/or absorption of the enterocytes of the *small intestine without causing inflammation*. > *◦C. Diff* -- impairs absorption by destroying cells, cause inflammation in the colon, and produce toxins that cause damage. "Secretory diarrhea is a common result of bacterial or viral infections. It occurs when ingested pathogens survive in the GI tract long enough to absorb into the enterocytes. " can be from infection, drugs & food intolerance, lactose intolerance, laxatives, large amounts of undigested carbohydrates. "smotic diarrhea results from rapid GI transit that prevents absorption of fluid and electrolytes. Bile salts and undigested fats lead to excessive fluid secretion into the GI tract. Diarrhea from celiac disease and short bowel syn-drome results from malabsorption in the small intestine."

Cholelithiasis

*= Gallstones* *Leads to inflammation (cholecystitis)* Very common in the U.S. -- women over 40 post menopause or young women taking oral contraceptives. Due to bile saturation with cholesterol *Stones that form are made of cholesterol* Passage of stones is incredibly painful *Cholecystectomy (removal of the gallbladder) is common surgical procedure in the U.S.* Care of T-tube. Bile acids (cholesterol solvents) such as *ursodiol and chenodiol* are used to dissolve stones. not usually treated with drugs. *ERCP for stone removal.* *Extracorporeal shock-wave lithotripsy (ESWL) alternative treatment when stones cannot be removed by endoscopic approaches. shock waves are used to break up the stones.*

Cirrhosis

*= end stage of liver disease; scarring of the liver*, extensive degernation and destruction of the liver cells. (hepatocytes) Causes; alcohol induced liver disease Hep C infection "Cardiac cirrhosis includes a spectrum of hepatic derange-ments that result from long-standing, severe, right-sided heart failure." Manifesations : usually found late *Similar to hepatitis but worse* Jaundice Spider angiomas *Palmar eruthema (A red area that blanches with pressure)* Hematologic problems = thrombocytopenia, keuopenia, anemia, coagulation disorders. Endocrine problems = gynecostamia, loss o faxillary and pubic hair, loss of libido, Peripheral Neuropathy *fector hepaticus = fruity, musty breath odor of severe chronic liver disease* Complications: - *Portal HTN* = portal vein connects to esophagus, goes to the liver. Traffic jam in the portal vein, backs up and goes back into the esophagus. Leads to esophageal varices. - *Esophageal varices* = blood vessels ready to pop in esophagus. from portal HTN. - Edema = no albumin that holds everything in place. - Ascites = *manifests by abd distention with weight gain, dehydration, hypokalemia. fluid wave test*. Liver patients are malnourished. Fluid gathers in their belly. *Can get infected = sponatnus bacterial peritonitis (SBP).* - *Hepatic encephalopathy* = Altered mental status due to elevated ammonia > *Asterixis = (flapping tremors)* test for it by flexing the hand up. If ammonia is elevated, the hand will flap. "Patients who are cirrhotic but who have no obvious complications are con sidered to have compensated cirrhosis. Those who have one or more complica-tions of their liver disease have decompensated cirrhosis." Diagnostic Studies: liver function tests enzyme levels - alkaline, AST/ALT, GGT. decreased protein, albumin. increase bilirubin PPt, PT, INR. creatine decrease Hgb Hct ammonia levels Ultrasound elastography (Fibroscan) - liver fibrosis *a liver biopsy***

Hepatitis

*= inflammation of the liver* *Typically caused by viruses :* > Hepatitis A, B, C, D, E Substances can also be causative > *Alcohol, Tylenol, some antibiotic* Manifestations: Symptoms include anorexia, fatigue, and GI alterations Physical exam may reveal *hepatomegaly, jaundice (usually seen in eyes first), lymphadenopathy, and RUQ tenderness (caused by liver inflammation) = acute hepatitis. 1-6 months.* Other manifestations include *dark urine (due to bilirubin) and itching (pruritus)* *tan-green stool* Diagnostic Findings: What labs do you anticipate? > ALT/AST, albumin, PT, ptt, INR, Hepatitis Panel, liver function, blood tests for hepatitis, bilirubin urinary, ammonia. *US abdomen** CT abdomen Liver biopsy How to measure liver = percussion while they hold their breathe or press down below the costal margin, take a deep breathe - Cuff technique Determine how large it is by how low it is below the costal margin. Complications: Liver failure Cirrhosis - scarring of the liver. Usually see this with liver failure. Chronic hepatitis Portal hypertension Hepatocellular carcinoma Chronic hepatitis complications: *Coagulopathy = decreased ability to clot*. INR & PTT goes up. Vitamin K is antidote for Coumadin. INR of 3 of liver failure NOT on Coumadin is abnormal. Plasma has clotting factors, FFP or RBC are given. FFP & Platelets given over half hour, dont need to cross match blood. *Spider angiomas* = a capillary bleeding. Seen on the belly. Gynecomastia Ascites = excess fluid *Hepatic encephalopathy* = AMS associated with ammonia. Major problem is safety. If it gets high enough, go into a coma. Hepatitis treatment: Treat underlying cause if possible/necessary Rest Good nutrition - caloric needs increased. No tylenol, no drinking. Antidote for Tylenol is Acetadote given IV Hepatitis Nutrition: Promote a diet the patient can tolerate Fat may be difficult to tolerate May require vitamin supplements - particular B & K. If fluid/electrolyte problems are severe, may require IV therapy

Upper GI Problems: Gastritis

*= inflammation of the stomach* Causes:— *same causes as GERD* - *Anything that breaks down the gastric mucosa* - *NSAIDs* — shred your stomach. NSAIDS work on cox 1 in stomach lining. Motrin, aspirin. - *Diet* - *H. Pylori* — bacteria that can cause gastric mucosa to breakdown. Treated with antibiotics. - Smoking Manifestations: Acute: - *Cant tolerate food* - Anorexia - Nausea - Vomiting - Epigastric tenderness - *Feeling of fullness* - *Hiccuping, Reflux* -Chronic: - Belching - Heartburn after eating - sour tast in the mouth - *Vitamin B 12 deficiency* > *Chronic has a loss of intrinsic factor.* Intrinsic factor is essential for the absorption of cobalamin in the terminal ileum. Once the body's cobalamin stores in the liver are depleted, a state of cobalamin deficiency exists. Because it is essential for the growth and maturation of red blood cells (RBCs), the lack of cobalamin results in *pernicious anemia and neurologic complications.* - Typically a clinical diagnosis > *H. Pylori is detected via serum sample — can detect through a breathe test. Has to do with levels of CO2 levels you blow off.* > *CBC can detect anemia in chronic gastritis* If acute send you home on meds, if doesn't work they test for H. Pylori endoscopy -- inserted through the mouth into the esophagus, stomach, and duodenum to visual digestive tract. NPO, local anesthetic sprayed in the back of throat. *(soar throat common after)* "Breath, urine, serum, stool, and gastric tissue biopsy tests are available to assess for H. pylori infection. A complete blood count (CBC) may show anemia from blood loss or lack of intrinsic factor. Stools are tested for occult blood. Serum tests for antibodies to parietal cells and intrinsic factor may be done. A tissue biopsy can rule out gastric cancer" Management: - Similar to care for patients with n/v - *Often prescribed PPIs (end in -azole)* - Abx for H. Pylori: — heavy antibiotics that can give you worse n/v. On this antiiobitcs for 4-6 weeks. Compliance is an issue. - Diet management -- food and fluids withheld, followed by clear liquids then solid food. no spicy foods, caffeine, alcohol, and nicotine. - NO SMOKING "Drug therapy: Acute Gastritis - focuses on reducing irritation of the gastric mucosa and providing symptomatic relief. - *H2receptor blockers (e.g., ranitidine, cimetidine (Tagamet) -- watch for confusion) or* - *PPIs (e.g., omeprazole (Priolsec) -- should not have heartburn after administration; lansoprazole) reduce gastric HCl acid secretion* Chronic Gastritis: H.Pylori : Triple Treatment: Triple-drug therapyproton pump inhibitor (PPI) amoxicillin clarithromycin (Biaxin) ^ these meds will kill the bacteria and stop the acid production Quadruple therapy: PPI bismuth tetracycline metronidazole (Flagyl)" Complications: GI bleed, obstruction dehydration pernicious anemia with chronic gastritis due to loss of intrinsic factor (vitamin b 12).

Lower GI: Peritonitis

*= results from a inflammatory process of the peritoneum.* Primary = occurs when blood-borne organism enter the perionteal cavity. *secondary = most common. occurs when abdominal organs perforation or rupture and release their contents (bile, enzymes, and bacteria). Infuse metronidazole (Flagyl) 500 mg IV* "Common causes include a ruptured appendix, perforated gastric or duodenal ulcer, severely inflamed gallbladder, and trauma from gunshot or knife wounds." Intestinal contents irritate the normally STERILE peritoneum. Manifestations: abdominal pain tenderness over the involved area. lie still with shallow breaths "Abdominal dis-tention, fever, tachycardia, tachypnea, nausea, vomiting, and altered bowel habits may be present" Complications: *Hypovolemic shock* sepsis intraabdominal abscess formation paralytic ileus acute respiratory distress syndrome Diagnostic Studies: CBC - WBC hemoconcentration from fluid shifts. Peritoneal aspiration abd xray pertionescopy Treatment: antibiotics NG suction analgesis IV fluid Surgery

Lower GI: Appendicitis

*= the inflammation of the appendix* most common reason for emergency abdominal surgery *most common cause is obstruction of the lumen by accumulated feces.* obstruction results in distention, venous engorgement, and accumulation of mucus and bacteria -- gangrene, perforation, peritonitis Manifestations: *begins with dull periumbilical pain that descends to the RLQ* abd pain most intense at *McBurney's point.* *Rebound tenderness* followed by N/V and anorexia. "The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at McBurney's point (halfway between the umbilicus and right iliac crest). A low-grade fever may develop. Further assessment reveals localized tenderness, rigidity, rebound tenderness, and muscle guarding. Coughing, sneezing, and deep inhalation worsen pain. The patient usually prefers to *lie still, often with the right leg flexed*. Diagnostic Studies: history, physical exam, WBC urinalysis *CT SCAN* Treatment: *Appendectomy* - surgical removal because the appendix can rupture and be fatal. antibiotic and fluid resuscitation are started before surgery. ^ helps prevent dehydration and sepsis. *only use ice packs to the abd. heat packs can cause rupture.* *if rupture occurred = Penrose drain insertion; position client on the right side with legs flexed to facilitate drainage.*

Lower GI: Diverticulosis & Diverticulitis

*Diverticulosis = an outmatching or herniation of the intestinal mucosa. most common in sigmoid colon*. *Diverticulitis = is inflammation of one or more diverticula, that occurs from penetration of fecal matter through the thin-walled diverticula.* diverticula disease covers a spectrum from asyptomatic, uncomplicated diverticulosis to diverticulitis with complications such as perforation, abscess, fistula, and bleeding. diverticula most common in the left descending sigmoid colon *due to lack of dietary fiber intake* Manifestations: *LLQ pain that increase with coughing, straining, lifting.* usually asymtomatic bloating, N/V *flatulence and changes in bowel habits -- blood in stools.* more severe = diverticula bleed & diverticulitis Diverticulitis: Manifestations: *acute pain in LLQ (sigmoid colon)* palpable abd mass N/V infection symptoms Complications: Perforation Abscess Peritonitis Bleeding Diagnositc Studies: discovered during sigmoidoscopy or colonoscopy history/physical *CT scan with oral contrast** XRAY Management: High fiber diet - fruit, vegetables. decreased fat and red meat physical activity colon rest -- oral antibiotics and clear liquid diet if hospitalized -- patient is NPO and given IVF FIRST THEN HIGH FIBER DIET. *surgery = colon resection with anastomosis. then colostomy*

Upper GI Problems: Hiatal hernia

*Hiatal hernia is herniation of a portion of the stomach into the esophagus through an opening, or hiatus, in the diaphragm*. It is also referred to as diaphragmatic hernia and esophageal hernia. Hiatal hernias are the most common abnormality found on xray examination of the upper GI tract. They are common in older adults and occur more often in women. 2 types: Sliding (most common) above the diaphragm or Rolling below the diaphragm Risk factors: "These include obesity, pregnancy, ascites, tumors, intense physical exertion, and heavy lifting on a continual basis. "Surgical approaches to hiatal hernias can include reduction of the herniated stomach into the abdomen, herniotomy (excision of the hernia sac), herniorrhaphy (closure of the hiatal defect), an antireflux procedure, and gastropexy (attachment of the stomach subdiaphragmatically to prevent reherniation)"

Lower GI: Intestinal Obstruction

*Occurs when contents cannot pass through GI tract* ◦*Mechanical obstruction* = Something physically blocks movement through small intestine. Starts with constipation. Gets backed up. Pseudo-obstruction is a mechanical obstruction of the intes-tine without any cause found on radiologic imaging. There are several conditions that are associated with a pseudo-obstruction. These include myocardial infarction, renal failure, Parkinson's disease, trauma, recent major orthopedic surgery, opiate use, and metabolic disturbances (e.g., hypokalemia) ◦*Nonmechanical obstruction* = Caused by absent peristalsis due to altered neuromuscular transmission of the parasympathetic innervation to the bowel. *Muscle of colon doesn't contract to move the stool through.* It may result from a neuromuscular or vascular disorder. *Paralytic ileus (lack of intestinal peristalsis and bowel sounds) is the most common form of nonmechanical obstruction. It occurs to some degree after any abdominal surgery.* It can be difficult to know whether postoperative obstruction is due to paraly-tic ileus or adhesions. One clue is that bowel sounds usually return before postoperative adhesions develop" Manifestations: 4 hallmarks: ◦*Abdominal pain - usually first* ◦*Vomiting* ◦*Distention - firm* ◦*Constipation* ◦What happens to bowel sounds? *bowel sounds are hyperactive, but then become hypoactive.* Diagnosis ◦*CT scan*, abd xray ◦Labs evaluate dehydration, electrolyte disturbances (hypocalemia, hyponatremia) Elevated WBC Management: ◦Bowel rest ◦NPO ◦NG tube - not for feeding, used for suctioning. So always on fluids to replace what we take out. ◦IVF - normal saline, lactated ringers, adding potassium. ◦Pain management - avoid opiods (cause constipation) ◦Surgery - "Partial or total colectomy, colostomy, or ileostomy" or a colonoscopy (non-surgical) can remove. depends. May do a resection — take out chunk that doesn't work. Or colostomy bag and then in 6 months-1 year reverse it. Can do an exploratory laparotomy " A patient with a high small intestinal obstruction is more likely to have metabolic alkalosis. -- projectile vomitting A patient with a low large obstruction is at greater risk for metabolic acidosis. " -- abdominal distention

Hypo-parathyroid

*Often caused by thyroidectomy* Leads to *hypocalcemia* / hyperphosphatemia s/sx of hypoparathyroid are s/sx of hypocalcemia Labs findings include decreased calcium and PTH along with increased phosphate *Treat with calcium and vitamin D* What should be included in their diet? Chovestks sign, trousseau sign are hypocalcemia. tetany. *dont supplement the parathyroid hormone, supplement the calcium and vitamin D.* diet: fish, dairy, tofu, kale, normal levels = 8-10 Treatment — *IV calcium gluconate SLOWLY. Use ECG monitoring* during because high calcium levels can cause hypotension, cardiac dysrhytmias, or cardiac arrest. & vitamin D. *breathe in and out of paper bag to blow off CO2.*

Disorders of Adrenal Cortex: Addison's Disease

*need to ADD hormone* "Adrenocortical insufficiency (hypofunction of the adrenal cortex) may be from a primary cause (Addison's disease) or a secondary cause (lack of pituitary ACTH secretion). MANIFESTATIONS •*Typically caused by an autoimmune disorder, although can also be caused by AIDS, TB, and cancer* •Diagnosis is delayed - s/sx do not appear until late in the disease. don't become evident until 90% of the adrenal cortex is destroyed. •*Anorexia, fatigue, weight loss* •*Hyperpigmentation!* - bronze colored skin ikely due to increased secretion of β-lipotropin. •Orthostatic hypotension, headache, and abdominal pain Addison's disease can be present along with other endocrine conditions. This is known as autoimmune polyglandular syndrome. It is most common in white females. Those with autoimmune adrenalitis often have other autoim-mune disorders such as type 1 diabetes, autoimmune thyroid disease, pernicious anemia, and celiac disease" COMPLICATIONS *ADDISONIAN CRISIS* = •Life threatening event leads to hypotension, tachycardia, and electrolyte imbalances •*Often triggered by stress, sudden withdrawal of steroids, or adrenal surgery* DIAGNOSIS •*ACTH stimulation test* = •Baseline cortisol and ACTH levels obtained •After injection of ACTH, levels rechecked in 30-60 mins. •*People with Addison's have little change in levels (normal people it should increase)* When the response to ACTH test is abnormal, a corticotropin-releasing hormone *(CHR) simulation test may be done*. Patient is given CRH injection and rechecked in 30-60 mins. Those with Addison's disease have high ACTH levels but no cortisol. Other abnormal laboratory findings may include *hyperkalemia*, hypochloremia, *hyponatremia, hypoglycemia*, anemia, and increased BUN levels. *blood cortisol, ACTH, salivaryly and urinary cortisol is decreased* TREATMENT •*Treatment is steroids (Hydrocortisone), prednisone*. -- cannot take with aspirin or antihistamine.; should be taken before 9AM (early morning). *ADDisons = HYDROcortisone* •Treatment is lifelong •*During times of stress dose is INCREASED* Women need androgen replacement with dehydroepiandrosterone *(DHEA)* as their only source of androgen production is the adrenal glands. *Increased salt is added to the diet.* Addisonian Crisis Treatment = Treatment is directed toward shock management and high-dose hydrocortisone replacement. Large volumes of *0.9% saline solution and 5% dextrose* are given to reverse hypotension and electrolyte imbalances until BP returns to normal

Upper GI Problems: Peptic Ulcer Disease

- Peptic Ulcer Disease — *= Breakdown Of GI mucosa due to digestive enzymes. Eats away at the tissue. (Hal and Pepsin)* - Can occur anywhere in the GI tract -- *most common are gastric and duodenal ulcers.* - Can be acute or chronic - Causes include H. Pylori, meds, stress, and lifestyle (including alcohol abuse) H.Pylori Infection likely occurs during childhood with transmission from family members to the child, possibly through a fecaloral or oraloral route." - can only develop in an acid area. Risk factors: - genetics, - smoking, - NSAID use, - diet. - high alcohol and coffee intake. - It is thought that the higher risk of PUD among persons of lower socioeconomic status is due to their having a higher prevalence of H. pylori infection." - The acute ulcer is associated with superficial erosion and minimal inflammation. It is of short duration and resolves quickly when the cause is identified and removed. - A chronic ulcer is one of long duration, eroding through the muscular wall with the formation of fibrous tissue. It is present continuously for many months or intermittently throughout the person's lifetime. Chronic ulcers are more common than acute erosions." Manifestations: - *Pain typically occurs a couple hours after eating. Eating makes it worse because extra acid irritates the ulcer.* as opposed to gastritis, where eating relieves the pain - bloating, nausea, vomiting, - Bleeding - Diagnosis with EGD and biopsy for H. Pylori - Labs will also be followed to r/o anemia or other complications - Not a clinical diagnoses. Something you observe. *perforation = a rigid, boardlike abdomen* Diagnosis Studies: EGD — endoscropy - Moderate sedation. Needs suction, airway stuff. NPO after midnight. "The gold standard for diagnosing H. pylori infection is a biopsy of the antral mucosa with testing for urease (rapid urease testing). Noninvasive tests include serology, stool, and breath testing" complications: - Hemorrhage - Perforation - Gastic Outlet Obstruction = "The aim of therapy for obstruction is to decompress the stomach, correct any existing fluid and electrolyte imbalances, and improve the patient's general state of health. An NG tube is used as described previously. With continuous decompression for several days, the ulcer can begin healing, and the inflammation and edema will subside. Pain relief results from the decompression." Perforated Ulcer — - Left untreated it can continue to eat though tissue lining and eat the organ and into the abdominal cavity. - Life threatening emergency. - *If bleeding into the abdomen — will be distended and hard. Pressure will drop. Have to go to the OR.* - NG tube can be placed to stop the perforation - "Circulating blood volume is replaced with lactated Ringer's and albumin solutions. These solutions substitute for the fluids lost from the vascular and interstitial space as peritonitis develops. Blood replacement in the form of packed RBCs may be necessary." - "Either open or laparoscopic procedures are used for perforation repair" Management — - Stop meds that contribute to the problem - *Resume ASA with enteric coating* - PPis and antibiotics - H2 blockers - *Sucralfate (Carafate) - Mucosal protectant. Carafate for short term management* — dose 5mL. Creates a paste in the stomach and neutralizes the acid thats left. creates a protective barrier against acid and pepsin. administered orally on empty stomach. one hour before meals and at bedtime. - *Misoprostol (Cytotec)*.— Can not be preganant. Citotect is used to give abortions. suppress secretion of gastric acid. therpautic effect = relief of epigastric pain. *the 2 C's (Carafate & Cytotec) are for PUD* - Treat bleeding quickly if ulcer perforates - No smoking "Sucralfate is used for the shortterm treatment of ulcers. It provides cytoprotection for the esophagus, stomach, and duodenum. Sucralfate does not have acidneutralizing capabilities. Since it is most effective at a low pH, give it at least 60 minutes before or after an antacid. Adverse side effects are minimal. It binds with cimetidine, digoxin, warfarin (Coumadin), phenytoin (Dilantin), and tetracycline, reducing their bioavailability" "*Misoprostol is a synthetic prostaglandin analog prescribed to prevent gastric ulcers caused by NSAIDs and aspirin*. It has protective and some antisecretory effects on gastric mucosa. Misoprostol does not interfere with the therapeutic effects of aspirin and NSAIDs. People who require chronic NSAID therapy, such as those with osteoarthritis, may benefit from its use. Since it is teratogenic, it is used with caution in women of childbearing potentia" Surgery: when ulcers don't heal after 12-16 weeks; removal of the stomach: - total gastrectomy - vagotomy - gastric resection - Billroth I/ II Post op Complications : - *Dumping Syndrome* = the rapid emptying of the gastric contents into the small intestine that occurs following gastric resection (avoid sugar, salt, milk). early signs and symptoms = sweating and pallor. - Postpandrial Hypoglycemia - Bile Reflux Gastritis

Aging and the GI tract

-Appetite decreases -- center in brain turns down the volume. dehydrated -Caries and disease lead to teeth loss -Delayed gastric emptying -Xerostomia = dry mouth -Constipation is common but not a result of aging

The pancreas

-Has both exocrine and endocrine function: -Exocrine function: Digestive enzymes excreted through pancreatic duct into duodenum. *contributes to digestion*. -Endocrine function: *Insulin* excreted directly into bloodstream made from the pancreas

Objective data: GI Assessment

-Order of assessment? Inspection, *Auscultation*, Palpation, Percussion On auscultation: use diaphragm, listen for 2 minutes, borborygmi) indicate hyperperistalsis. The bowel sounds are more high pitched (rushes and tinkling) when the intestines are under tension, as in intestinal obstruction. Listen for decreased or absent bowel sounds. A perfectly "silent abdomen" is uncommon." bruite: heard with bell. (low pitched sounds) Precussion: "Air produces a higher-pitched, hollow sound termed tympany. Fluid or masses produce a short, high-pitched sound with little resonance termed dullness." -As you assess the abdomen, recall which organs are in the area being assessed -Special exams: -Murphy test = press in RUQ, take a deep breathe. Looking for gallstones. If positive they are going to guard because it hurts. A positive Murphy's sign is seen in acute *cholecystitis* -Rebound tenderness = usually in *appendicitis*. Press down in RLQ and pain should get better. Tell patient I'm about to suddenly remove my hand, and ask what happens to the pain. -Fluid wave test = test for *ascites* and put hand in the middle of the belly, tap on one side. If the fluid in the belly It will travel onto the other side of the hand. If not, fluid gets stopped by the hand - CVA tenderness — punching kidneys in the back

The Liver

-Largest internal organ -Each lobule is made of hepatocytes, capillaries, and Kupffer cells -Functions include: -Metabolism -Detoxification -Clotting -Blood reservoir -Storage of glucose, vitamins, and albumin *Makes bile* -- consists of water, cholesterol, bile salts, electrolytes, fatty acids, and bilirubin. ALT/AST, bilruben *biliary tract -- consists of the gallbladder and ducts that connect the liver, gallbladder, and duodenum*. The gallbladder is a pear-shaped sac located below the liver. *The gallbladder's function is to concentrate and store bile.* It holds approximately 45 mL of bile. The presence of fat in the upper duodenum triggers the release of cholecystokinin, which causes the gallbladder to contract and release bile.

Clinical Manifestations: Hyper-parathyroid

/sx of hyperparathyroid are s/sx of *hypercalcemia* Complications include *osteoporosis, cardiac problems, and renal failure* Nursing diagnoses?? Patient with hyperparathyroid have hypercalcemia, hypophosphatemia, and elevated PTH. "Loss of appetite, constipation, fatigue, emotional disorders, shortened attention span, and muscle weakness, particularly in the proximal muscles of the lower extremities, are often noted. Complications include osteoporosis, renal failure, kidney stones, pancreatitis, cardiac changes, and long bone, rib, and vertebral fractures" Diagnostic studies — : PTH levels, calcium levels usually higher than 10 , phosphate levels usually less than 3.. "Elevations in other laboratory tests include urine calcium, serum chloride, uric acid, creatinine, amylase (if pancreatitis is present), and alkaline phosphatase (in the presence of bone disease). Bone density measurements may be used to detect bone loss. " "screening *dual-energy x-ray absorptiometry (DEXA) scan should be tested for hypercalcemia*. MRI, CT, and/or ultrasound can detect an adenoma treatment: surgical removal of parathyroid glands -- endoscopy. *Parathyroidectomy*. What complications should the nurse monitor for? > fluid and electrolyte disturbances, hemorrhages > tenanty = muscular spasms = *IV Calcium Gluconate, calcitonin* > Assess calcium, potassium, phosphate, and magnesium levels as well as Chvostek's & Trousseau's sign. > respiratory distress -- position in semi-fowlers > neck dressing for bleeding. If surgery is not warranted (in mild cases), medications include bisphosphonates and calcimimetic agents.: Severe hypercalcemia is managed with *IV sodium chloride solution and loop diuretics such as furosemide (Lasix) to increase the urinary excretion of calcium.* *bisphosphonates = alendronate (Fosamax); IV = pamidronate (Aredia)* *Calcimimetic agents = cincalcet (Sensipar)* patient will have polyuria.

Endocrine Regulation

1. Negative Feedback Loop = *regulates hormone secretion by the hypothalamus and pituitary gland.* Increased amounts of target gland hormones in the bloodstream decrease secretion of the same hormone and other hormones that stimulate its release. relies on the blood level of a hormone or other chemical compound regulated by the hormone (e.g., glucose). It is the most common type of endocrine feedback system and results in the gland decreasing the release of a hormone. Negative feedback similar to functioning of thermostat. Cold air in a room activates the thermostat to release heat Warm air signals the thermostat to turn of the heater. Ex: calcium and parathyroid hormone (PTH) regulation. Low blood levels of calcium stimulate the parathyroid gland to release PTH. PTH acts on the bone, intestine, and kidneys to increase blood calcium levels. The increase blood calcium level then inhibits further PTH release. ex: thyroid 2. Positive Feedback System = increasing hormone levels cause another gland to release a hormone that then stimulates further release of the first hormone. A means to stop the release of the first hormone (e.g., follicle death) is required or its release will continue. The ovarian hormone estradiol operates by this type of feedback. Increased levels of estradiol produced by the follicle during the menstrual cycle result in the production and relates of follicle-stimulating hormone (FSH) but the anterior pituitary. FSH causes further increases in estradiol until the death of the follicle. This results in drop of FSH serum levles. ex: Child birth and breast feeding. 3. Nervous System Regulation = directly affects some endocrine glands. stimulated adrenal gland. pain, fear, sexual excitement, and other stressors can stimulate the nervous system to modulate hormone excretion. When stress is sensed by CNS, the sympathetic nervous system secretes catecholamine (epinephirne) which maximize cardiac and lung function and Visio to deal with the stress more effectively. 4. Circadian Rhytyhm = It is a 24-hour rhythm that can be driven and altered by sleep-wake or dark-light 24-hour (diurnal) cycles. Hormone levels and the responsiveness of target tissues fluctuate predictably during these cycles. Cortisol, produced by the adrenal cortex, rises early in the day, declines toward evening, and rises again toward the end of sleep to peak by morning. Growth hormone (GH), thyroid-stimulating hormone (TSH), and prolactin levels peak during sleep. Reproductive cycles are often longer than 24 hours (ultradian). An example is the menstrual cycle. These rhythms are an important factor when inter-preting laboratory results for hormone levels."

Diabetes Inspidus (DI)

= *Underproduction of ADH. too little.* *fluid volume defecit.* kidneys are not holding onto the water. *excess sodium. HYPERNATREMIA* MANIFESTATIONS •Typically occurs after *head injury or other cranial insult* •*Polydipsia = very thirsty and polyuria* •*LOTS of urine (2 to 20L daily)* •*Urine has low specific gravity* •In response to fluid losses, *patients drink large volumes of water* •Can lead to circulatory collapse if not managed early and aggressively *Dehydration* fatigue, muscle pain/weakness headache tachycardia DIAGNOSIS AND TREATMENT •Water deprivation test •After administration of DDAVP, urine osmolality markedly improves •Maintain hydration!! - dehydration can cause hypotension, tachycardia, and hypovolemic shock. •*Fluid replacement - D5W* •*DDAVP or vasopressin -- if administered by intranasal route, can cause runny or stuffy nose. if given IV -- headache, vulval pain, flushed skin DI = DDAVP* •Monitor hemodynamic stability decreased urine osmaliity and decrease urine specific gravity is expected of DI *LOW URINE, HIGH BLOOD* *water deprivation test:* Before the test, body weight, and urine osmolality, volume, and specific gravity are measured. The patient is deprived of water for 8 to 12 hours measure the patients urine osmaliity every hour, until 3 separate checks show an increase of less than 30. (ensures the pt is dehydrated) at that point, measure blood osmaliity. if blood osmaility is greater than 280, a dose of ADH desmopressin acetate (DDAVP) vasopressin is administered SUBQ. measure the urine osmaility 30-60 mins later after administration of DDVAP urine osmality improves from 100-600 and a significant decrease in urine volume.

Disorders of Adrenal Cortex: Cushing Syndrome

= *have an extra "cushion" of hormone* WHAT IS OUT OF BALANCE? •*Excess corticosteroid exposure (cortisol) ACTH* •*Often caused by steroid administration (prednisone)* •Other causes include adrenal tumors and lung cancer MANIFESTATIONS •What happens when you are on too much prednisone? •Moon face, weight gain, hyperglycemia! •Acne, virilization in females, feminization in men •Menstrual disorders, hirsutism (male pattern hair growth on women) •Gynecomastia, impotence purplish red striae. buffalo hump DIAGNOSIS AND TREATMENT •*Cortisol levels* assessed using late night level and 24-hour urine Three tests are used: (1) *midnight or late-night SALVILARY cortisol* -- preferred over blood and urine for mild cases. *CORTISOL LEVELS ARE LOWEST AT NIGHT -- IF THEY ARE HIGH, THERE IS A PROBLEM* (2) *low-dose dexamethasone DDVAP suppression test* -- blood cortisol levels will decrease and increased ACTH, and (3) *24-hour urine cortisol.* Urine cortisol levels higher than the normal range of 80 to 120 mcg/24 hr indicate Cushing syndrome. Urine levels of 17-ketosteroids may be elevated. CT scan or MRI can indicate a tumor. High or normal ACTH levels indicate Cushing disease *blood cortisol, ACTH, salivaryly and urinary cortisol is increased* •Treat the underlying cause •Surgical removal of pituitary tumor or adrenal glands = *Adrenalectomy* •Radiation •Drugs offered include *ketoconazole* -- These are used cautiously because they are often toxic at the dosages needed to reduce cortisol secretion. *monitor blood pressure* *diet should have lots of potassium because they are hypokalemic* *high glucose, ACTH, and cortisol* *Ketoconazole K = C for Cushing's* 7 dwarfs of curshings = Forgetful, Chubby, Bruisy, Sleepy, Hairy, Angry, & Psycho Cotisol is a response to stress. Cortisol levels highest in morning lowest at night. If elevated at night it is a concern. *Cortisol helps make a BP*

Cholecystitis

= inflammation of the gallbladder Typically associated with obstruction caused by gallstones and biliary sludge Diagnosed with US Labs may show elevated ALT/AST and bilirubin Can cause hepatitis Can cause pancreatitis Manifestations: Abdominal pain - bilary colic in RUQ. occurs 3-6 hours after a high-fat meal, or when the patient lies down. Nausea/vomiting RUQ tenderness - may be referred to right shoulder and scapula. Positive Murphy's sign Rebound Tenderness dark brown bilirubin urine Belching Indigestion Faltulence Complications: gangrenouse cholecystits pancreatitis rupture of gallbladder Diagnostic Studies: *US* Lab test -- WBC, bilirubin, ALT/AST. Management: NPO Advance to a low-fat diet IVF Antiemetics Pain management Antibiotics - can be from an infection Procedures: > ERCP with sweep -- balloon sweep to remove the stones with endoscopy. > Cholecystectomy -- removal of gallbladder. from the belly button. >> main complication = injury o the common bile duct. > Choledocholithotomy - requires incision into the common bile duct to remove the stone.

Lower GI: Gastroenteritis

= the inflammation of the mucous of the stomach and small intestine. sudden diarrhea accompiend by N/V, fever, and abdominal cramping. Caused by Virus's - Norovirus is leading cause of food borne outbreaks of acute gastroenteritis Encourage Pedialyte IV fluid replacement same therapy for diarrhea

Lower GI: Fecal Incontinence

= the involuntary passage of stool. when the normal structures that maintain continence are damaged or disrupted. defecation is a voluntary action when the neuromuscular system is intact. contributing factors: disruption of anal sphincter, damage to anal tissue etc. for women = obstetric trauma is the most common cause of sphincter disruption. diagnostic studies: health history and physical exam. xray CT. treatment: maintain normal constinecny, high fiber diet, increased intake of caffeine free fluids. if dehydrated, give fluid replacements laxatives - psyllium common food triggers = onions, coffee, dried fruit, mushrooms, green vegetables, fruit with peels, spicy foods. antidiarheeal agents Kegel exercises

Hepatitis'

A = fecal-oral route. flu like symptoms and jaundice "It frequently occurs in small out-breaks caused by fecal contamination of food or drinking water. Poor hygiene, improper handling of food, crowded situations, and poor sanitary conditions are contributing factors." Malaise A - risk factors: drug users gay men traveling to developing countries usually seen in fall and winter. A - treatment: Hep A vaccine & hand washing. B = Hep B vaccination. Perinatal from moms to their infants IV drug use long term hemodialysis small cuts exposed to blood, vaginal secretions, semen, saliva. sexual transmission Can live on a dry surface for at least 7 days -- worse than HIV Drug Therapy = *Nucleoside and Nucleotide analogs* "These medications include *lamivudine (Epivir), adefovir (Hepsera), entecavir (Baraclude), telbivudine (Tyzeka), and tenofovir (Viread).*" Interferon = SUBQ C = *No vaccine.* *most common cause of liver failure & disease* can cause acute illness & chronic infection drug users posttransfusion Hep HIV positive people - unprotected sex Percutanously - shared needles Drug Therapy = *(DAA's (Direct Acting Antivirals. - Ribavirin, Simeprevir,grazoprevir, paritaprevir.* Antihistamines for itching and antiemetics for nausea promethazine (Phenergan) & ondansetron (Zofran). HIV meds D = Common in Mediterranean and Middle Eastern areas *Only occurs with Hep B* Infection through blood Hep B injection prevents Hep D E = waterborne virus - bathing, eating, drinking in contaminated waters Travleing Similar to Hep A high mortality rate in pregnant woman

Enteral Nutrition (Tube Feeding)

Also known as tube feeding Administration of nutritionally balanced liquefied food or formula through tube inserted into: Stomach = PEG (Gastronomy) Duodenum Jejunum ^^ Both = J Tube, G-J Tube. Indications include those with: Anorexia Orofacial fractures Head/neck cancer Neurologic or psychiatric condition Burns chemo, radiation therapy. Provides nutrients alone or supplement to oral or parenteral nutrition Easily administered Safer than parenteral More physiologically efficient than parenteral Less expensive than parenteral Variety of formulas Special formulas for patients with diabetes, liver, kidney, and lung disease Concentrations from 1 to 2 cal/mL Osmolarity, amount of protein, sodium, and fat vary Delivery options include: Continuous infusion by pump Cyclic feedings by pump Intermittent by gravity Intermittent bolus by syringe Polyurethane or silicone tube Soft and flexible Radiopaque Placement in small intestine Stylet may be used for placement ↓Likelihood of regurgitation and aspiration when placed in intestine

C. Diff

C. Difficile ◦*Healthcare associated infection causing severe, life threatening, diarrhea* ◦*Often caused by antibiotic misuse* ◦Also seen in immunesuppresed patients - chemotherapy ◦C. Diff microbes have phlanges that allow it to stick to surfaces for up to 70 days soap and water, change gloves. ◦Infection control: ◦PO *Vancomycin* or by enema. all stool softerns, antibiotics, laxatives, and antidiarrheal agents are stopped. ◦*Fecal transplant* - donor transplant, poop is made liquid and sprayed on the inside of patients colon. *For reoccurring C. Diff = antibiotic fidaxomicin (Dificid)*

Clinical Manifestations

Clinical Manifestations •Systemic effects characterized by slowing of body processes •Manifestations variable •Slow onset •Symptoms may be attributed to normal aging in older adult •Cardiovascular system •CV problems may be significant in patients with pre-existing cardiovascular disease •*↓Cardiac contractility and output* •↑Serum cholesterol and triglycerides •Anemia •Respiratory system •Low exercise tolerance •*Shortness of breath on exertion* •Neurologic system •Fatigue and lethargy •Personality and mood changes •*Impaired memory, slowed speech, decreased initiative, and somnolence* •Gastrointestinal system •*Decreased appetite* •Nausea and vomiting •*Weight gain* •*Constipation* •Distended abdomen •Enlarged, scaly tongue •Celiac disease •Integumentary system •Dry, thick, inelastic, cold skin •Thick, brittle nails •Dry, sparse, coarse hair •*Poor turgor of mucosa* •Generalized interstitial edema •*Puffy face* •Decreased sweating •Pallor •Musculoskeletal system •Fatigue, weakness •Muscular aches and pains •Slow movements •Arthralgia •Reproductive system •Prolonged menstrual periods or amenorrhea •Decreased libido, infertility •Other •Increased susceptibility to infection •Increased sensitivity to opioids, barbiturates, anesthesia •*Intolerance to cold* •Decreased hearing •Sleepiness •Goiter The patient is often fatigued, lethargic, and experiences per-sonality and mental changes, including impaired memory, slowed speech, decreased initiative, and somnolence. Many appear depressed. Weight gain is most likely a result of a decreased metabolic rate.

•Myxedema coma

Complications •Myxedema coma •Precipitated by infection, drugs (especially opioids, tran-quilizers, and barbiturates), cold, trauma. alters the physical appearance of the skin and subcutaneous tissues with puffiness, facial and peri-orbital edema, and a masklike affect. medical emergency •Characterized by: •Impaired consciousness •Subnormal temperature, hypotension, hypoventilation •Cardiovascular collapse •*Treated with IV thyroid hormone* Assessment a. Hypotension b. Bradycardia c. Hypothermia d. Hyponatremia e. Hypoglycemia*** f. Generalized edema g. Respiratory failure h. Coma priority = patient airway

Nursing Management : N/V

Complications: — - Electrolyte disturbances — potaasium down, sodium can go up due to dehydration. PH becomes metabolic alkalosis. - ABG Treatment: - *IV fluids* — isotonic fluids, saline. If pressure is low might a bolus than a L of saline over 20 mins at 125 to replace losses. - *NG tube* — if vomiting is caused by an obstruction get an NG tube because need to relieve the pressure on the obstruction. Measure from the nose to the tragus, to zyghpoid process. The more patent the name, is the one you're using. Patient is sitting straight up 90 degrees. Their head must be down to avoid airway. problem: can go into the trachea — start coughing and turn blue. Remove tube immediately. Xray verifies it in correctly. Or test PH, if acidic you're in the stomach. Insert air in the NG tube, then ausuclate and should hear a sound if it in the right spot after X-ray. - *Advance diet slowly* — start with small clear liquids. Advance their diet if they're able to hold it down. Soft bland food next. Crackers toast. If they vomit again they are NPO, meds, then try again. Advancement of diet is entirely up to the nurse. *Water is the initial fluid of choice for oral rehydration*. Have the patient sip small amounts of fluid (5 to 15 mL) every 15 to 20 minutes. Other options include carbonated beverages with the carbonation removed at room temperature and warm tea. Extremely hot or cold liquids are often difficult to tolerate. Broth and sports drinks (e.g., Gatorade) are high in sodium, so give them with caution. Dry toast or crackers may be helpful" "As the patient's condition improves, *provide a diet high in carbohydrates and low in fat*. Items such as a baked potato, plain gelatin, rice, and cereal are ideal. Many patients do not tolerate coffee, spicy foods, highly acidic foods, and those with strong odors. Tell the patient to eat food slowly and in small amounts to prevent overdistending the stomach. *Liquids taken between meals rather than with meals also reduce overdistention.*" NONDRUG THERAPY: peppermint oil, ginger, relaxation, distraction, change in body position, exercise.

Diagnostic Studies: Hypothyroidism

Diagnostic Studies •History and physical examination •TSH and free T4 — TSH helps determine the cause of hypothyroidism *Increase T4 indicates the nurse should call provider before administering levothryoxine (Synthroid)* •*TSH ↑ with primary hypothyroidism — when the defect is in the thyroid* •TSH ↓ with secondary hypothyroidism — when the defect is in the pituitary or the hypothalamus •Thyroid antibodies — suggest an autoimmune origin. Other abnormal labs findings are — elevated cholesterol & triglycerides, anemia and increased creatine kinase.

Diagnostic studies: GI

Diagnostic studies: -Radiologic studies -Upper and lower GI series X-Rays (requires contrast) -Colonoscopy/endoscopy -- visualize GI tract -Capsule endoscopy -- swallowing a camera recorder -Biopsy -Ultrasound -Labs? AST, ALT, amnelazye, lypaize — pancreas , billiruben -- liver

Upper GI Problems: Esophageal diverticula

Esophageal diverticula are saclike outpouchings of one or more layers of the esophagus. They occur in three main areas: (1) above the upper esophageal sphincter (Zenker's diverticu-lum), which is the most common location; (2) near the esophageal midpoint (traction diverticulum); and (3) above the LES (epiphrenic diverticulum) "Typical symptoms include dysphagia, regurgitation, chronic cough, aspiration, and weight loss. Food becomes trapped in the outpouches. This causes tasting sour food and smelling a foul odor. Complications include malnutrition, aspiration, and perforation. Endoscopy or barium studies can easily establish a diagnosis" "There is no specific treatment for esophageal diverticula. Some patients find that they can empty the pocket of food that collects by applying pressure at a point on the neck. The diet may have to be limited to foods that pass more readily (e.g., blenderized foods). Surgical treatment may be necessary if nutrition is disrupted. Treatment by endoscopic stapling diverticulotomy or diverticulostomy is associated with decreased complications compared with the open approaches. The most serious surgical complication is esophageal perforation" Esophageal Strictures: "The most common cause of esophageal strictures (or narrowing) is chronic GERD. The ingestion of strong acids or alkalis, external beam radiation, and surgical anastomosis can also create strictures. Trauma such as throat lacerations and gunshot wounds can lead to strictures because of scar formation. Strictures can result in dysphagia, regurgitation, and ultimately weight loss."

Etiology and Pathophysiology Graves' Disease

Etiology and Pathophysiology Graves' Disease = •Autoimmune disease •Diffuse thyroid enlargement •Excess thyroid hormone secretion •Precipitating factors interact with genetic factors •Women are 5 times more likely than men to develop Graves' disease

Gastic Ulcers & Dudeoenum Ulcers:

Gastric Ulcers: - *Gastric ulcers are more likely than duodenal ulcers to result in obstruction.* H. pylori, medications, and bile reflux are risk factors for gastric ulcers. Alcohol use and smoking are associated with ulcer formation." Manifestations: "In gastric ulcers, the discomfort is generally located high in the epigastrium and *occurs about 1 to 2 hours after meals.* The pain is described as "burning" or "gaseous." If the ulcer has eroded through the gastric mucosa, *food tends to aggravate* rather than alleviate the pain. For some patients, the earliest symptoms are due to a serious complication such as perforation" Dudoenum Ulcers: *most common*. - Although many factors are associated with the development of duodenal ulcers, H. pylori is most common. *H. pylori infection is found in approximately 90% to 95% of patients with duodenal ulcers.*" Mainfestations: "Symptoms of duodenal ulcers occur generally *2 to 5 hours after a meal.* The pain is described as "burning" or "cramplike." It is most often located in the midepigastric region beneath the xiphoid process. Duodenal ulcers can also produce back pain. Antacids alone or in combination with an H2receptor blocker, as well as food, neutralize the acid to provide relief. A characteristic of duodenal ulcer is its tendency to occur continuously for a few weeks or months and then disappear for a time, only to recur some months later." *pain is relieved by food intake**** *pain at night.* Administer meds to treat H. pylori H2 receptos PPI Antacids Surgery

Tube Feeding: Nursing Care

General nursing considerations Daily weights Assess for bowel sounds before feedings Accurate I&O Initial glucose checks = the feedings are straight sugar. Label with date and time started Pump tubing changed q24h Complications: Vomiting Dehydration More calorically dense, less water formula contained Check for high protein content Diarrhea Constipation Gastrostomy or jejunostomy feedings: Two potential problems: > Skin irritation Skin assessment and care > Pulling out of tube Teach patient/family about feeding administration, tube care, and complications Gerontologic Considerations: More vulnerable to complications Fluid and electrolyte balances Glucose intolerance Decreased ability to handle large volumes Increased risk of aspiration Site care Assess the skin around tube daily Monitor bumper tension Apply a dressing until site is healed After healed, wash with soap and water Protective ointment or skin barrier "A protective ointment (zinc oxide, petroleum gauze) or a skin barrier (Karaya, Stoma-hesive) may be used on the skin around the tube"

Gland's Hormones

Hypothalamus = GH Pituitary > Anterior = ACTH, GH, TSH, FSH. > Posterior = Oxytocin, ADH Adrenal = Cortisol, Aldosterone Thyroid = T3 thyrocalcitonin, T4 triiodothyronine, TSH Parathyroid = Parathyroid PTH Pancreas = Insulin & Glucagon Ovareis & Testes: = estrogen, progesterone, testosterone

Hyper-parathyroid

Increased secretion of PTH (ParaThyroid Hormone) leads to leeching of calcium from bones *Associated with long term lithium use as well as as benign tumor* Excess levels of circulating PTH usually lead to *hypercalcemia* and hypophosphatemia and elevated PTH. Why are they at risk for renal calculi? (kidney stones) In the kidneys the excess calcium cannot be reabsorbed, leading to increased urinary calcium levels (hypercalciuria). This urinary calcium, along with a large amount of urinary phosphate, can lead to calculi formation" *Can be prevented by a high fluid intake 4000mL/daily* see a lot with people who take lithium and a tumor on endocrine gland Lithium = given in bipolar disorder. Toxicity is common. People take it for a long time end up hyperparathyroid and hypercalemica Parathyroid hormone leaches calcium from the bone and results in a brittle bone — *osteoporosis*. Risk for injury. *Medicate with phosphorus — bisphosanates — alendronate sodium (Fosamax) have to be seated up right for at least 30 mins. take with water at least 30 mins before breakfast. FOSAMAX = MAX HYPER-PARATHYROID*

Interprofessional Care: Hypothyroidism

Interprofessional Care: •Restoration of euthyroid state as safely and rapidly as possible with hormone therapy. •Low-calorie diet warm enviornment assess for constipation •*Levothyroxine (Synthroid) DURG OF CHOICE* *take at same time each day, in the morning WITHOUT food.* *side effects: insomnia, weight loss, mild heat intolerance* •Start with low dose •Monitor for cardiovascular side effects (chest pain, dysrhythmias), weight loss, nervousness, tremors, insomnia •Increase dose in 4- to 6-week intervals as needed •Lifelong therapy Levothyroxine has a peak of action 1-3 weeks. *LEVO = LEVEL OUT THE HYPOTHYROID* Liotrix is a synthetic mix of t4 and t3 in a 4:1 combination. In contrast, liotrix has a faster onset of action with a peak of 2-3 days. Can be used in acutely ill patients with hypothyroidism.

Lower GI: Irritable Bowel Syndrome (IBS)

Iritable Bowel SYNDROME ◦Chronic abdominal pain and either constipation or diarrhea. *no known organic cause.* ◦May be intermittent ◦*Often has food triggers or history of GI infections. STRESS/ emotional issues.* *ABD pain in LLQ* due to changes in bowel pattern and consistency 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. Psy-chologic stressors (e.g., depression, anxiety, sexual abuse, post-traumatic stress disorder) are associated with development and exacerbation of IBS" ◦Clinical diagnosis - *The ROME III criteria requires pain for at least 3 months that is associated with improvement with defecation, change in stool frequency at onset, or change in the stool appearance at onset* CBC, stools, blood albumin. Hydrogen Breath Test ◦Medications offered are unique to each patient ◦*Bentyl* (Antispadmodic) decrease GI motility and smooth muscle spams, reducing pain and diarrhea. given IM or PO. ◦*Immodium* (synethic opiod-antidiarrheal) that slows intestinal transit for diarrhea. doesn't have a bacteria they are trying to flush out. *IBs = I = Imodium. = B = Bentyl* *COLONOSCOPY IS NORMAL*

Lower GI: Irritable Bowel Disease

Irritable Bowel DISEASE: ◦*Autoimmune disorder causing chronic inflammation of GI tract* ◦*Has a genetic component* - espeically monozygotic twins. ◦Characterized by exacerbations and remissions Exact cause is unknown and no cure. *Classified as Chron's disease or ulcerative colitis:* ◦Crohn's disease can involve any segment of the GI tract from the mouth to the anus but commonly involves the distal ileum and proximal colon.. *manifests with diarrhea that may contain mucus and pus and cramping. NOD2 gene. pain in RLQ* ◦Ulcerative colitis is usually limited to the colon, starts in the rectum and move toward the cecum. . *manifests with bloody diarrhea and abdominal pain - inflammation and breakdown of colon that results in bleeding. electrolyte losses. pain in LLQ* Lifelong thing that can be managed Manifestations: diarrhea weight loss abdominal pain fever fatigue IBD complications ◦Hemorrhage - may lead to anemia. - blood transfusions and iron supplements are used to treat anemia. ◦Strictures ◦Perforation with peritonitis ◦Toxic megacolon ◦*Increased risk for colon cancer* - need colonoscopies younger and more frequently. Ulcerative colitis can eat through the bowel leading to perfuratin, infection, bleeding. Can develop scar tissue inside bowel and becomes a stricture (anything that narrows the lumen) makes the opening of the bowel smaller so its harder to pass matter through. ◦Diagnosed with labs, CT, and colonoscopy Management ◦*5-ASA* - decrease GI inflammation. > ◦*Mesalamine (Pentasa) - mainstay for preventing flare ups.* ◦*Corticosteroids = Prednisone* ◦Biologic medications > ◦*Infliximab (Remicade)* = an infusion. Targets your immune system to stop attacking the bowel. Risk for infection. " 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. " *to determine effectiveness = check frequency and consistent of bowel movements.* *Double P - Prednisone & Pentasa Prevents flare ups* *Infusion Infliximax Remicades IBD immunity* ◦Surgery > ◦*Ileostomy may be temporary or permanent* temporary = a ileal pouch. "Immediately after surgery, ileostomy output initially may be as high as 1500 to 1800 mL/24 hr." after the bowel adapts to it, the average drainage is about 500 mL (2 cups) > frequent complication of ileostomy is fluid and electrolyte imbalances Nutritional Therapy *COLONOSCOPY IS NOT NORMAL* Colonscopy : NPO after midnight Drink the golightly Bowels have to be empty. Moderate sedation

Diarrhea complication

Manifestations: infections that attack the upper GI tract: (Norovirus): usually produce large volume watery stools, cramping and periumbilical pain. low fever or no fever N/V before the diarrhea infections of the colon and distal small bowel (C. diff, salmonella, shigella) : *produce fever and frequent blood diarrhea* with a small volume. Diagnostic Studies: stool cultures -- blood, mucus, WBC, and parasites. stool electrolytes, pH, and osmolality Diarrhea complications: ◦Dehydration ◦Electrolyte problems (hypokalemia) & lose mag. ◦*Metabolic acidosis* Nursing Management: ◦Which labs do you anticipate? ◦If patient ony has diarrhea (no nausea/vomiting), clear liquid diet is indicated > ◦*Pedialyte (Contains glucose and electrolytes)* ◦*Antidiarrheal drugs* may be used > ◦Contraindicated with infectious diarrhea because they prolong exposure to the organism. > If give antidiarrheal, you are holding onto the infectious process. ◦In severe cases, patient may require IV fluids Insoluable fibers can help thicken the stool. pg 931 antidiarheal drugs

Medications —Upper GI N/V

Medications — - *Ondanestron (Zofran)* — tells your *brain* your not nauseous. - *Metocloperamide (Reglan)* — *promotility drug*. Prescind a lot of gastric peritusus. Diabetics get it. *Helps move the food through the tract.* *If you push too fast IV, can have a distonic reaction and the patient goes psycho and HALLUCINATIONS*. Infuse it over 15 minutes. usually administered 30 mins before meals and at bedtime. • Chronic use or high doses carry the risk of tardive dyskinesia. • Tardive dyskinesia is a neurologic condition characterized by involuntary and repetitive movements of the body (e.g., extremity movements, lip smacking). • Tardive dyskinesia may persist after discontinuing the drug." - *Promethazine (Phenergan)* — *helps reduces the secretions and CNS depressant and drowsiness. Anticholinergic. Given rectally, not IV*. Post op n/v and chemo patients. When vomitting is really hard to control. Promethazine Injection: • Do not administer into an artery or under the skin because of the risk of severe tissue injury, including gangrene. • When given IV, it can leach out of the vein and cause serious damage to surrounding tissue. • Deep muscle injection is the preferred route of injection administration. "Dronabinol (Marinol) is an orally active cannabinoid. It is used alone or in combination with other antiemetics for preventing chemotherapyinduced vomiting. Because of the potential for abuse as well as drowsiness and sedation, it is used only when other therapies are not effective."

Administration of PN:

Methods of administration: Central parenteral nutrition is used for long-term support Peripheral parenteral nutrition is used for short-term therapy or special conditions TPN: HAS FAT Central parenteral nutrition through catheter whose tip lies in superior vena cava *Subclavian or jugular vein* Peripherally inserted central catheters (PICCs) Long-term parenteral support It is white from the fat. Must go through a central line. Never peripheral. Very hypertonic that a peripheral IV cant tolerate it. Can be given forever. Central solutions are hypertonic. Large central vein can handle high glucose content ranging from 20% to 50% PPN: NO FAT Peripheral parenteral nutrition: Through peripherally inserted catheter or vascular access device Short-term nutritional support Indications: Protein and caloric requirements not high Risk of central catheter too great Supplement inadequate oral intake Peripheral nutrition PPN is protein, sugar, electrolytes, with NO FAT. Is yellow because multivimans. Is used for short term. Also hypertonic but can handle it. Peripheral solutions are hypertonic. Peripheral vein can handle glucose up to 20%.

Types of Feeding Tubes

Nasogastric and nasointestinal tubes: NG Tube Can clog easily Can be dislodged by vomiting or coughing Can be knotted/kinked in GI tract used for short term (less than 4 weeks) Gastrostomy and jejunostomy tubes: PEG, J-Tube, G-J Tube. May be used when a patient requires tube feedings for an extended time Patient must have intact, unobstructed GI tract Can be placed surgically, radiologically, or endoscopically "The procedure requires IV sedation and local anesthesia. IV antibiotics are given before the procedure" Percutaneous endoscopic gastrostomy (PEG) placement requires esophageal lumen wide enough for endoscope PEG and radiologically placed gastrostomy Fewer risks than surgical placement, lower cost, minimum sedation Gastrostomy tube placement via percutaneous endoscopy Using endoscopy, a gastrostomy tube is inserted through esophagus into stomach and then is pulled through a stab wound made in abdominal wall. can start feedings within 2 hours. Feedings can be started when bowel sounds are present, usually 24 hours after placement placement identified with X-ray. then air and auscultation technqiue. mark the tube of insertion site.

Nursing Implementation Ambulatory Care

Nursing Implementation Ambulatory Care: •Discharge teaching •Monitor hormone balance periodically •Decrease caloric intake •Adequate but not excessive iodine intake •Regular exercise •Avoid environmental temperature •Regular follow-up care •Complete thyroidectomy > •Symptoms of hypothyroidism > •Need for lifelong thyroid hormone replacement ^ AFTER THYROIDECTOMY U BECOME LIFELONG HYPO-THYROIDISM

Nursing Implementation Postoperative Care

Nursing Implementation Postoperative Care •Maintain patent airway •Oxygen, suction equipment, tracheostomy tray in patient's room •*Monitor for laryngeal stridor* = (harsh, vibratory sound) may occur during inspiration and expiration because of edema of the laryngeal nerve. Laryngeal stridor may also be related to tetany from hypocalcemia, which occurs if the parathyroid glands were removed or damaged during surgery •IV calcium readily available (gluconate) Assess every 2 hours during first 24 hours for signs of hemorrhage or tracheal compression •Semi-Fowler's position •Support head with pillows •Avoid neck flexion and tension on suture line •Monitor vital signs and calcium levels •Signs of hypocalcemia •Analgesics •Ambulation •Psychosocial support Assess for signs of tetany secondary to hypoparathyroidism (e.g., tingling in toes, fingers, around the mouth; muscular twitching; appre-hension) and any difficulty in speaking and hoarseness. Monitor Trousseau's sign and Chvostek's sign"

Nutrition

Nutrition is sum of processes by which one takes in and uses nutrients Undernutrition = Poor nourishment because of inadequate diet or disease Normal nutrition Overnutrition = Ingestion of more food than is require Malnutrition Normal Nutrition: Ingestion of a balanced diet Macronutrients= Carbohydrates, fats, proteins Micronutrients = Vitamins, minerals, electrolytes Water Calculating Nutritional Needs: A convenient way to estimate daily calories is based on kilocalories per kilogram (kcal/kg) An average adult requires an estimated 20 to 35 calories per kilogram of body weight per day Need: simple, complex carbs, fats, proteins, vitamins, mineral salts.

Hyperthyroidism Interprofessional Care:

Nutritional Therapy •High-calorie diet (4000 to 5000 cal/day) •Six full meals/day with snacks in between •Protein intake: 1 to 2 g/kg ideal body weight •Increased carbohydrate intake •Avoid highly seasoned and high-fiber foods, caffeine •Dietitian referral Diagnostic Studies Normal values (normal findings vary between laboratory settings) a. T3: 80 to 230 ng/dL b. T4: 5 to 12 mcg/dL c. Thyroxine, free (FT4): 0.8 to 2.4 ng/dL •*↓ TSH and ↑ free thyroxine (free T4)* •Total T3 and T4 •*Radioactive iodine uptake (RAIU)* = Differentiates Graves' disease from other forms of thyroiditis. A small dose of radioactive iodine is given by mouth or intravenously; the amount of radioactivity is measured in 2 to 4 hours and again at 24 hours. Normal values are 3% to 10% at 2 to 4 hours, and 5% to 30% in 24 hours. ^ Elevated values indicate hyperthyroidism. Decreased = hypothyroidism. Goals •Block adverse effects of thyroid hormones •Suppress hormone oversecretion •Prevent complications

Lower GI: Hernia

Occurs when organ protrudes through a weak area of a body cavity ◦Usually the intestine protrudes through a weakness in the abdominal cavity ◦Name of the hernia is based on its anatomical location: ◦Inguinal = most common. ◦Hiatal ◦Umbilical = when the rectus muscle is weak or the umbilical opening fails to close after birth. ◦incisional = due to weakness of the abd was at the site of a previous incision. femoral = easily strangulate - Reduciable hernias = easily return into the abd cavity - Irredudible or Incarcerated = hernias cannot be placed back into the abd cavity and have abd contents trapped in the opening. "Strangulation occurs if the blood supply to the contents trapped in an irreducible hernia becomes compromised. The result is an acute intestinal obstruction." Manifestations: pain -- can worsen with lifting, coughing, straining. if it becomes strangulated -- severe pain and symptoms of a bowel obstruction like vomitting, cramming and distention. Management: history/physical exam US, CT, MRI surgery = laparoscopic surgery; herniorrhaphy Strengthen muscles Wearing a support garment If incarcerated, surgery is required. No heavy lifting 6-8 weeks. measure intake and output for distended bladder scrotal edema after inguinal hernia -- ice bag and elevation encourage deep breathing, but no coughing

PN Nursing Care

PN solutions are prepared by pharmacist or trained technician under strict aseptic techniques: Must be refrigerated until 30 minutes before use Must be labeled with nutrient content, all additives, time mixed, and date and time of expiration!!!!!! because: Tube feeds and parental nutrition tubes are only good for 24 hours. After that its too much of a risk for bacterial growth. Has to get thrown away. Complications of PN: - Refeeding syndrome = When starving you break down muscle, have ketones, electrolytes are holding on for dear life. When you start to feed someone who is malnourished for a long time, you make insulin again. You can wind up with profound electrolyte and fluid disturbances that are life threatening. Seen in WW2 survivors and eating disorders. Its a snydomre — cluster of problems. *The hallmark is a low phosphate level. treatment = stop the feeding. Give the body a chance to readjust and try again*. - Fluid retention and electrolyte imbalances - Hypophosphatemia is hallmark - Patients predisposed by long-standing malnutrition states - Metabolic problems - Hyperglycemia, hypoglycemia, prerenal azotemia, fatty acid deficiency, electrolyte disturbances, hyperlipidemia, mineral deficiencies Nursing Management: Vital signs every 4 to 8 hours Daily weights Blood glucose Check initially every 4 to 6 hours Infusion pump must be used Need to periodically check volume infuse Monitor lab values: > Electrolytes > BUN > CBC > Liver enzymes Dressing changes Site observation key Before starting PN, check label and ingredients against order Examine bag for signs of contamination Discontinue PN solution at end of 24 hours Watch for infection and septicemia Local manifestations Erythema Tenderness Exudate at catheter insertion site Systemic manifestations Fever, chills Nausea/vomiting Malaise Blood and catheter cultures if infection suspected X-ray: To check changes in pulmonary status After PN therapy, daily dressing changes until heals Home nutrition support: Teach the patient and caregiver Catheter or tube care Mixing and handling of solutions and tubing Side effects and complications Discharge planning needed Enternal feedings are clean. Parenteral feedings are sterile. Can see central line infections. Central line care every 3-4 days or when visibly soiled. If suspect an infection take cultures from peripheral and central line. When people go home technique goes from sterile to clean care.

TPN (Total Parental Nutrition)

Parenteral nutrition (PN) *Administration of nutrients directly into the bloodstream* Goal: Meet nutritional needs and allow growth of new body tissue Customized to meet each patient's needs -- based on your labs. good for 24 hours. indications: chronic severe diarrhea or vommitting complicated surgery or trauma GI obstruction intractable diarrhea severe anorexia nervousa severe malabsoprtion short bowel sydnrome GI anormalities and fistula composed of: calories, carbs, fat, protein, elctolytes, trace elements & vitamins. Amount of carbs and fats vary on the patient. has sugar, aminoacids. *TOTAl Parenternal Nutrtion HAS FAT: central line* *PERPHERAL Parenternal Nutrtion does NOT have fat.*

Quads

RUQ: Liver Gallbladder * Cholecytisis RLQ: Appendix Ovaries * Appendicitis LUQ: Spleen Stomach Pancreas * Pancreatitisis LLQ: Colon * Colitis Supra pubic area: lower middle Bladder Uterus * UTI Epigastric: upper middle * Stomach / heart burn pain Flank pain: * kidney pain at costavertebral angel

Treatment: RAI and surgery

Radioactive Iodine Therapy (RAI) •Treatment of choice in nonpregnant adults •Damages or destroys thyroid tissue •Delayed response of up to 3 months •Treated with antithyroid drugs and β-blocker before and during first 3 months of RAI •Given on outpatient basis •Patient teaching •Oral care for thyroiditis/parotiditis •Radiation precautions •Symptoms of hypothyroidism = Although RAI is usually effective, 80% of patients have posttreatment hypothyroidism, resulting in the need for lifelong thyroid hormone therapy. Relief may be obtained with frequent sips of water, ice chips, or a salt and soda gargle three or four times per day. This gargle is made by dissolving 1 tsp of salt and 1 tsp of baking soda in 2 cups of warm water. The discomfort should subside in 3 to 4 days. A mixture of antacid (Mylanta or Maalox), diphenhydramine, and viscous lidocaine can be used to swish and spit, increasing patient comfort when eating. To limit radiation exposure to others, teach the patient receiv-ing RAI home precautions, including (1) using private toilet facilities if possible and flushing two or three times after each use; (2) separately laundering towels, bed linens, and clothes daily at home; (3) not preparing food for others that requires prolonged handling with bare hands; and (4) avoiding being close to pregnant women and children for 7 days after therapy Surgical Therapy •Indications •Large goiter causing tracheal compression •Unresponsive to antithyroid therapy •Thyroid cancer •Not a candidate for RAI •Rapid reduction in T3 and T4 levels *Subtotal thyroidectomy* •Preferred surgical procedure •Involves removal of 90% of thyroid •Can be done using minimally invasive procedures > •*Endoscopic thyroidectomy* = is an appropriate procedure for patients with small nodules (less than 3 cm) and no evidence of cancer > •*Robotic surgery* = is best for those who are not overweight and have small nodules on only one side of the gland. Advantages of endoscopic and robotic procedures over open thyroidectomy include less scar-ring, less pain, and a faster return to normal activity"

Parathyroid function

Regulates *calcium* level in the blood *Parathyroid gland rests on the thyroid* Target organ is the *bone*. *Calcium and phosphorus have a relationship. -- phosphorus eats the calcium.* *Decrease in parathyroid hormone = decrease in calcium*

SIADH

SIADH = *Overproduction of ADH* •Causes include *cancer, medications, and head injury* = fluid retention - *fluid overload, sodium levels decline.* HYPONATREMIA kidneys hold onto the water. problem is in the brain, not the kidneys. •Manifestations: •*Low urine output* •*Increased weight* •*Thirst, Dyspnea On Exerction, fatigue* •As sodium drops, signs of *hyponatremia* progress hypertension tachycardia anorexia, N/V signs of fluid volume overload Mild hyponatermia causes muscle cramps, irritability and headache. Usually falls to 120 or less. Then becomes more severe with vomiting abdominal cramps and muscle twitching. Cerebral edema leading to legarthy, confusion seizures and coma. SIADH DIAGNOSIS AND TREATMENT •Urine and serum osmolality are compared simultaneously •*Serum osmolality is much LOWER than urine (urine is being concentrated despite dilute serum)* *increased urine osmaliity and urine specific gravity indicates SIADH* urine sodium increased *SIA(DH) = DILUTED BLOOD, HIGH URINE* •Treatment includes: •Daily weight •*Fluid restriction (800 - 1000mL daily) -- ice chips, gum*. •*Diuretic -- furosemide (Lasix), Demeclocycline* •Seizure precautions *HOB is flat or elevated no more than 10 degrees.* frequent turning be alert for low urine output with a high specific gravity, a sudden weight gain without edema, or a decreased serum sodium level. Monitor intake and output, vital signs, and heart and lung sounds. Obtain daily weights. Observe for signs of hyponatremia, including seizures, headache, vomiting, and decreased neurologic function"

GI

Structures and function: GI -*Autonomic nervous system controls GI tract* -Perfusion of blood is provided by celiac, superior mesenteric (SMA), and inferior mesenteric arteries (IMA) -Overall function is to provide nutrients -3 steps: -Ingestion -Digestion -Absorption "The GI tract has its own nervous system: *the enteric nervous system (ENS) or intrinsic nervous system*. The ENS system regulates motility and secretion along the entire GI tract. " digestive system consists of mouth, esophagus, stomach, small intestine, large intestine, rectum and anus Omentum — layer of fat and lymph nodes that cover the peritoneal.

Treatment : Drug Therapy

Three primary treatment options •Antithyroid medications •Radioactive iodine therapy (RAI) •Surgery Drug therapy Useful in treatment of thyrotoxic states •Not considered curative > •Antithyroid drugs > •Iodine > •β-Adrenergic blockers Antithyroid Drugs: *Propylthiouracil (PTU) and methimazole (Tapazole) BOTH HAVE 'TH' IN THEM MEANING ITS FOR THRYOID* •*Inhibit synthesis of thyroid hormone* •Improvement in 1 to 2 weeks •Good results in 4 to 8 weeks •Therapy for 6 to 15 months Common side effects: N/V. *medication should be taken with food, consume a high calorie diet, assess client for unexplained bleeding or bruising, report effects such as sore throat, fever, or headaches* An advantage of propylthiouracil is that it achieves the therapeutic goal of being euthyroid more quickly. However, it must be taken three times per day. Methimazole is given in a single daily dose. Iodine •*Potassium iodine (SSKI) and Lugol's solution* •*Inhibit synthesis of T3 and T4 and block their release into circulation* •Decreases vascularity of thyroid gland •Maximal effect within 1 to 2 weeks •*Used before surgery and to treat crisis* Iodine is used with other antithyroid drugs to prepare the patient for thyroidectomy or for treatment of thyrotoxicosis. Because of a reduction in the therapeutic effect, long-term iodine therapy is not effective in controlling hyperthyroidism *Iodine is mixed with water or juice, sipped through a straw, and given after meals.* Assess the patient for signs of iodine toxicity, such as swelling of the buccal mucosa and other mucous membranes, excessive salivation, nausea and vomiting, and skin reactions. If toxicity occurs, discontinue iodine administration and notify the HCP B-Adenergic Blockers — "β-Adrenergic blockers are used for symptomatic relief of thyrotoxicosis. These drugs block the effects of sympathetic nervous stimulation, thereby decreasing tachycardia, nervousness, irritability, and tremors. *Propranolol is usually given first in thyroid storm* is usually given with antithyroid agents. *Atenolol* is the pre-ferred β-adrenergic blocker for use in the hyperthyroid patient with asthma or heart diseas"

Thyrotoxicosis

Thyrotoxicosis = •Physiologic effects/clinical syndrome of hypermetabolism •Results from increased circulating levels of T3, T4, or both •Hyperthyroidism and thyrotoxicosis usually occur together

Tube Feeding Administration

Tube feeding administration Aspiration risk Ensure proper position of tube Maintain head-of-bed elevation Check gastric residual volume Patient position Patient should be sitting or lying with HOB at 30 to 45 degrees HOB remains elevated semi fowlers (45 degrees) for 30 to 60 minutes for intermittent delivery after feeding. Tube position Check gastric residual volumes = If residual volume is high like 150 you put that residual back. Normal is about 100. After you return it, check bowel sounds for motility and turn the feeding off. Every 4 hours during first 48 hours ↑Volume leads to aspiration = the tube displaced from small intestine to stomach. Promotility drugs may be ordered = Reglan X-ray confirmation for new nasal or orogastric tubes Mark exit site of tube Check placement before each feeding/drug administration or every 8 hours with continuous feeds Check insertion length regularly Methods used to check placement Aspiration of stomach contents pH check pH <5, which is indicative of stomach contents Most accurate assessment: x-ray visualization Tube feeding administration Tube patency Flush with water before/after each feeding, drug administration, residual check with 30 mL of warm water & every 4 hours during intermittent feedings. Continuous feedings administered on feeding pump with occlusion alarm To help unclog = warm water and ginger ale using a back and forth motion. Administration of feedings: Pump > Gradually increase rate or volume over 24 to 48 hours Intermittent feedings: > Volume usually 200 to 500 mL per feeding Administer flush water or water boluses as tolerated "Promotility drugs such as erythromycin or metoclopramide improve gastric emptying and may reduce aspiration risk. Feeding tubes may need to be advanced below the ligament of Treitz (jejunostomy) if gastric residual volumes consistently measure more than 500 mL. Do not obtain residual volumes for EN delivered through a jejunostomy tube."

Pancreatic Cancer

Typically diagnosed late Most patients die within 5-12 months of diagnosis 5-year survival rate less than 5% *Whipple procedure is a radical surgery attempting to control the disease = take apart the GI tract that has cancer. Everything is gone and gets rerouted. Overnight they become a type 1 diabetic cos they have no pancreas, no longer making digestive enzymes. Med called Creon — have to take it before meals. & on insulin* *Cancer = Creon* the cause remains unknown. risk factors: chronic pancreatits diabetes melitus age cigarrete smoking family history of pancreatic cancer high-fat diet *exposure to chemicals such as benzidine* Manifestations: *Abd pain (dull, aching) -- upper abd and radiate to the back. related to eating and occurs at night.* anorexia rapid and progressive weight loss nausea jaundice Diagnostic Studies: CT scan PET scan tumor markers Cancer-associated engine 19-9 is elevated *Surgery is more effective treatment -- Whipple.*

Disorders of the Posterior Pituitary Gland:

WHAT IS OUT OF BALANCE? •Antidiuretic hormone! •Responsible for retaining water and sodium •DI = too little ADH •SIADH = too much ADH

Upper GI Problems: Weight Loss Surgery

Weight loss surgery — (*Bariatric Surgery*) BMI grater than 40 Benefits — Alterations of stomach and/or intestines resulting in weight loss. Decreasing the amount of nutrients you are able to abrosb. Only option shown to have long term success Typically reduces incidence of DM, cardiac disease, and improves overall quality of life. Usually requires thorough preop evaluation and clearance Types of surgery — *1. Restrictive* - *= Redues the size of the stomach* resulting in earlier feeling of fullness *Gastric banding and sleeve gastrectomy* — loss of intrinsic factor. sleeve = Loses whole chunk of stomach, losses RBC. Precious anemia with sleeve gastrecomty. *2. Malabsorptive* - (Gastric Bypass) BPD procedure *decreases amount of small intestine* able to decrease absorb nutrients *RYGB* producere restrtics the stomach and connects it to the jejunum. *3. Combo of the 2* *Drugs to try before surgery* - - Orlistat = prevents digestions of fats - Loracaserin = brain curbs hunger - Phentermine-topiramate = suppresses the appetite Complications — Nutrient malabsorption, vitamin defeicient. Diarrhea Constipation — esp. after lap band. Pain — might be when u eat. leak of anastomosis. life threatening emergency dehydration Diet teaching after — Meals must be SMALL No liquid can be taken with meals Diets should be high in protein and low in carbohydrates Vitamin supplements may be needed. — usually liquids. Can have difficulty with absorption and become TPN. abd binder

What is the endocrine system?

What is the endocrine system? Chemical messengers that tell organs what to do *Hormones* are produced by endocrine glands Hormones have *target organs* - hormones deliver a message for the organs to act on Endocrine system is so named because the chemicals are secreted into the bloodstream (internally) glands include the hypothalamus, pituitary, thyroid, parathyroids, adrenals, pancreas, ovaries, testes, and pineal gland What is an exocrine gland? -- secreted to other parts of the body. Glands: Adrenal ■ Hypothalamus ■ Ovaries ■ Pancreas ■ Parathyroid ■ Pituitary ■ Testes ■ Thyroid

Who do the glands talk to?

Who do the glands talk to? •Hypothalamus communicates with Pituitary •Pituitary communicates with Thyroid, Adrenal glands, Kidneys, and reproductive organs •Parathyroid communicates with bone, kidneys, and intestines •Adrenal glands communicate with sympathetic nervous system •Pancreas communicates with liver and cellular tissue

Drug & Chemical Induced Liver Diseases

alcohol consumption !!! "Acute alcoholic hepatitis = is a syndrome of hepatomegaly, jaundice, elevation of liver enzyme tests (AST, ALT, alkaline phosphate), low-grade fever, and possibly ascites and prolonged prothrombin time. These manifestations may improve with ces-sation of alcohol intake." "Chemical hepatotoxicity = is liver injury caused by exposure to certain compounds (e.g., carbon tetrachloride, gold com-pounds). Some agents can cause hepatotoxicity, while others may induce cholestasis, necrosis, or liver cancer" "Drug-induced liver injury (DILI) = is one of the more common causes of jaundice.12 Many medications (prescription, over-the-counter [OTC], diet and herbal supplements) can cause an increase in liver enzymes and, in severe cases, jaundice and acute liver failure." most common is acetaminophen TYLENOL max dose is 4mg/day. elderly is 3mg/day.

Hyperthyroidism

•A sustained increase in synthesis and release of thyroid hormones by thyroid gland •Occurs more often in women •Highest frequency between ages 20 to 40 year •Most common form = *Graves' disease (75%)* •Other causes = Toxic nodular goiter •Thyroiditis •*Excess iodine intake* •Pituitary tumors •Thyroid cancer

Endocrine Dysfunction

•Characterized by a lack of balance between a stimulating hormone and a suppressing hormone •The problem can be either with the stimulating hormone or suppressor •The problem dictates the treatment

Hypothyroidism

•Deficiency of thyroid hormone •Causes general slowing metabolic rate •More common in women than in men Etiology and Pathophysiology •Primary hypothyroidism > •Caused by destruction of thyroid tissue or defective hormone synthesis •Secondary hypothyroidism > •Caused by pituitary or hypothalamic dysfunction (↓ TSH or TRH) Etiology •Iodine deficiency = most common •Atrophy of the gland •Treatment for hyperthyroidism •Drugs •Cretinism if occurs in infancy = thyroid hormone deficiencies during fetal state. Hypothyroidism can be transient and related to thyroiditis or discontinuing thyroid hormone therapy. In the United States, the most common cause of primary hypothyroidism is atrophy of the thyroid gland. This atrophy is the end result of Hashimoto's thyroiditis or Graves' disease. These autoimmune diseases destroy the thyroid gland. Hypothyroidism may also develop after treat-ment for hyperthyroidism, specifically thyroidectomy or RAI therapy. *Drugs such as amiodarone (Cordarone), which contains iodine, and lithium, which blocks hormone production, can cause hypothyroidism*.

Nursing Management: Hypothyroidism

•Most outpatient therapy •Myxedema coma necessitates acute care •Mechanical respiratory support •Cardiac monitoring •*IV thyroid hormone replacement* •Monitoring of core temperature •Patient teaching •Written instructions important •Need for lifelong therapy •*Thyroid medicine in morning on empty stomach* •Side effects of medication •Signs and symptoms of hypothyroidism and hyperthyroidism •Regular follow-up care •*Do not switch brands* •Medication interactions •*Comfortable, warm environment* •Measures to prevent skin breakdown •*Avoid sedatives or use lowest dose possible (diazepam)* •*Measures to minimize constipation* •Relapses occur if treatment is interrupted Tell the patient to immediately contact an HCP if symptoms, such as orthopnea, dyspnea, rapid pulse, palpitations, chest pain, nervousness, or insomnia, are present.

Nursing Implementation Acute Thyrotoxicosis

•Necessitates aggressive treatment •Medications to block thyroid hormone production and SNS •Monitoring for dysrhythmias •Ensuring adequate oxygenation •Fluid and electrolyte replacement Establish trusting relationships •Ensure adequate rest •Calm, quiet room > •Cool room > •Light bed coverings If exophthalmos present: •Apply artificial tears to relieve eye discomfort •Salt restriction and elevate head of bed •Dark glasses •Tape eyelids closed if needed for sleep •ROM of intraocular muscle

Clinical Manifestations: Hyperthyroidism -- Grave's Disease

•Related to effect of thyroid hormone excess > •↑Metabolism > •↑Tissue sensitivity to stimulation by sympathetic nervous system •Goiter > •Inspection: enlarged > •Auscultation: bruits ^ *causes from lack of iodized salt*. ^ overproduction or underproduction of thyroid hormones Ophthalmopathy •Abnormal eye appearance or function •*Exophthalmos* •Increased fat deposits and fluid •Eyeballs forced outward •Cardiovascular system •*Systolic hypertension* •*Bounding, rapid pulse; palpitations* •↑Cardiac output •Cardiac hypertrophy •Systolic murmurs •Dysrhythmias •Angina Respiratory system •Dyspnea on mild exertion •*Increased respiratory rate* GI system •*↑Appetite, thirst* •*Weight loss* •*Diarrhea* •Splenomegaly •Hepatomegaly Integumentary system •Warm, smooth, moist skin •Thin, brittle nails •Hair loss •Clubbing of fingers; palmar erythema •Fine, silky hair; premature graying •Diaphoresis •Vitiligo Musculoskeletal system •Fatigue •Weakness •Proximal muscle wasting •Dependent edema •Osteoporosis Nervous system •*Nervousness, fine tremors* •Insomnia , exhaustion •Lability of mood, delirium •Hyperreflexia of tendon reflexes •Inability to concentrate •Stupor, coma Reproductive system •Menstrual irregularities •Amenorrhea •Decreased libido •Impotence •Gynecomastia in men •Decreased fertility *Intolerance to heat* •Elevated basal temperature •Lid lag, stare •Eyelid retraction •Rapid speech *TSH is LOW, t4 is high.*

Acute Thyrotoxicosis

•Thyrotoxic crisis or thyroid storm •Excessive amounts hormones released •Life-threatening emergency •Death rare when treatment initiated •*Results from stressors* •*Thyroidectomy patients at risk* Manifestations •Severe tachycardia, heart failure •Shock •Hyperthermia •Agitation •Seizures •Abdominal pain, vomiting, diarrhea •Delirium, coma *Fever, Nausea, Tremors, Confusion* Administer antithyroid medications, iodides, propranolol, and glucocorticoids as prescribed. Monitor continually for cardiac dysrhythmias. Administer nonsalicylate antipyretics as prescribed (salicylates increase free thyroid hormone levels). Use a cooling blanket to decrease temperature as prescribed.

Lower GI: Constipation

◦*Characterized by difficult or infrequent stools* ◦*Stool is often hard and/or dry* ◦Must know patient's baseline status to determine ◦Often caused by diet low in fiber or fluid ◦Medications - opiods ◦Laxative withdrawal (especially among the elderly) ◦Medical conditions Manifestations: discomfort in abd absents stools or hard, dry, and difficult to pass. abdominal distentions, bloating, increased flatulence, and increased rectal pressure. Complications: Abdominal pain N/V Hemorrhoids Vasovagal reaction Perforation Diverticulosis Diagnostic Studies: history and physical exam. abd xrays barium enema colonscopy sigmoidscopy treatment: increase dietary fiber - fruits, vegetables, grains. (wheat bran, prunes, bran) fluid intake exerise *laxatives & enemas - Enemas given rectally. Tap water, Castile soap. Turn patient on side and start to infuse enema. Tell patient to hold it for as long as u can 10-15 minutes* radiologic testing defecation is easiest when the person is sitting on a commode with the knees higher than the hips. gravity.