BAH Exam #3 Study Guide PDF

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BAH Exam #3 review ●

Please review your power point, and notes from which include the Gastrointestinal System and Endocrine System

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G-tube placement https://www.youtube.com/watch?v=hSv4FOwZ9kQ&t=129s NG Placement Determine the length of tube to be inserted and mark with tape or indelible ink (measuring the distance from the tip of the nose to the earlobe to the xyphoid process determines the approximate depth of insertion). Inject 10 mL of water from a 30-mL or larger syringe into the tube to aid the guide wire or stylet insertion. Dip the tube with surface lubricant into a glass of water. Doing so activates the lubricant to facilitate passage of the tube into the naris to the GI tract. Have the patient flex the head toward the chest after the tube has passed through the nasopharynx. This closes off the glottis and reduces the risk of the tube entering the trachea. Have the patient mouth breathe and swallow. Give small sips of water or ice chips when possible. Advance the tube as the patient swallows. Rotate the tube 180 degrees while inserting. (Swallowing facilitates passage of the tube past the oropharynx, and rotating the tube decreases friction.)

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Intractable nausea a. Intractable vomiting refers to vomiting that is difficult to control b. It doesn’t lessen with time or traditional treatments c. Intractable vomiting is often accompanied by nausea, when you constantly feel as if you’re about to vomit. d. Caused by: Acute gastroenteritis, gastric obstruction, Gastroparesis, Hyperemesis gravidarum

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CEA CA 19-9 levels and colonoscopy procedure a. Dx testing for the GI b. Sensitive and specific for colorectal and hepatacellular carcinomas c. CEA → carcinoembryonic antigen ■ Can determine stage and extent of disease and pt prognosis for cancer ■ Esp GI and colorectal cancers ■ CEA not normally detected in blood of a healthy person ■ If pt found positive = cancer is present d. CA 19-9 → cancer antigen ■ Protein that exists on surface of certain cells, shed by tumor cells

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Can act as a tumor marker It’s a type of antigen released by pancreatic cancer cells CA 19-9 levels are elevated in most pt with advanced pancreatic cancer Also elevated in conditions such as colorectal, stomach and bile duct cancers e. These tests are screened along with colonoscopy beginning at age 50; done every 10 years ■ Done more often if Familial Adenomatous Polyposis - FAP ■ FAP → genetic, inherited disease that causes polyps to form in colon, rectum, all the way up to duodenum. ■ If polyps are unchecked, they can turn into cancer. Many pts will remove their whole colon to prevent from having colon CA.

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Fecal occult blood testing (FOBT) a. Initial screening for several disorders, most frequently in early cancer detection b. Stool sample collected and tested for blood, ova and parasites and bacteria. Can be assessment of DNA changes which can predispose a client to cancer of the intestine. c. DO NOT perform test if there is hemorrhoidal bleeding d. Indications: Gi bleeding, unexplained diarrhea e. avoid certain foods for 72 hrs bc of false-positive results (red meats, ASA, NSAIDs, turnips, horseradish) or because of false-negatives (vitamin C) f. Preprocedure: ■ Occult blood: provide client with card. Three samples used. Mediation restrictions for 7 days(anticoagulants, NSAIDs), diet restriction (vit c, red meath, chicken, fish) g. Stool for ova & parasite & bacteria: provide a specimen cup. h. Interpretations of findings: at least 3 positive guaiac FOBT confirms GI bleed. Positive finding for blood indicative of GI bleeding (ulcer, colitis,cancer). Positive for ova and parasites =GI parasitic infections, need for broad spectrum antibiotics.

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Esophageal reflux disorder Symptom and treatment. a. Backflow of gastric/duodenal contents into the esophagus b. Incompetent sphincter, pyloric stenosis, motility disorder c. Symptoms ■ Heartburn, dyspepsia (indigestion), regurgitation, dysphagia, esophagitis d. Can lead to dental erosion, ulcerations in pharynx and esophagus, laryngeal damage, pulmonary complications

e. Management: ■ Low fat diet, avoid caffeine, tobacco, beer, milk, peppermint, carbonated drinks ■ No food 2 hours before bed ■ Avoid tight fitting clothes ■ Elevated HOB at least 30 degrees f. TX/Medications: ■ PPI = Proton pump inhibitors ● Pantoprazole (Protonix), omeprazole (Prilosec), lansoprazole (Prevacid), Nexium ■ H2 antagonist ● Famotidine (Pepcid), Ranitidine (Zantac), cimetidine (Tagamet) ■ Antacids ● Tums ● Magnesium ● Aluminum hydroxide ■ Surface agents = Sucralfate ■ Prokinetic agents = metoclopramide (Reglan)

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postoperative day 1 following neck dissection surgery a. Frequent assessment Place in Fowler position Encourage coughing and deep breathing If patient has a tracheostomy b. provide tracheostomy care as required c. Encourage high-density, high-quality intake d. Diet may need to be modified to liquid diet or to soft, pureed, and liquid foods e. Consider patient preferences and cultural considerations in food selection f. Provide oral care before and after eating

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Peptic ulcer Treatment and medication teaching ie suraclfate a. Antacids b. Antibiotics ■ Complete entire med therapy, do not stop even if feeling better c. PPIs ■ Should be used for 4-8 wks for complete peptic ulcer healing ■ High risk pt require maintenance dose for 1 yr d. H2 Antagonists ■ Should be used for 6-8 wks for complete peptic ulcer healing ■ High risk pt require a maintenance dose for 1 yr

e. Sucralfate (prostaglandin analong) → forms protective barrier, binds to surface of the ulcer, prevents digestion by pepsin ■ Take without food but with water ■ Other meds should be taken 2 hrs before or after this med ■ May cause constipation or nausea f. Smoke cessation, Dietary modification g. Surgical management

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Intervention Treatment of dumping syndrome a. Eat smaller meals 5-6x a day b. Avoid fluids with meals c. Increase fiber intake, increase protein, increase carbs d. Limit sugar, dairy e. Can give antidiarrheal drug to slow emptying of food into intestines

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symptoms of early gastric cancer (textbook pg. 1304) a. Poor appetite b. Weight loss c. Abd pain d. N/V e. Heartburn, Indigestion f. Sense of fullness in upper abdomen g. Pain not relieved by antacids, resembles those of benign ulcers h. SX of advanced → similar to peptic ulcer disease; ie dyspepsia, weight loss, early satiety, ab pain above umbilicus, bloating after meals, N/V

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Signs and symptoms of GI bleed a. Black, tarry stool b. Hematemesis c. Rectal bleeding d. Lightheadedness e. SOB f. Hypotension

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TPN administration and discontinuing a. Hypertonic IV bolus solution. Used to prevent or correct nutritional deficiencies and minimize adverse effects of malnutrition. b. Administered through the central line, contains complete nutrition including calories in high concentration of dextrose, lipids, essential fatty acids, electrolytes, vitamins and trace minerals. c. Typically no more than 700 calories/day d. Potential dx: severe BURNS, short bowel syndrome, chronic pancreatitis, diffuse peritonitis e. Pt. weight loss greater than 10% of body weight & NPO for more than 5 days. Muscle wasting, poor tissue healing, burns, bowel disease. f. Obtain labs: electrolytes. Flow rate gradually increases and decreases. g. NEVER STOP ABRUPTLY! Assess vital signs q. 4-8 hr and daily weight. h. Follow sterile procedure. i. Change the tubing and solution bag (EVEN IF NOT EMPTY) every 24 hr. j. Assess capillary glucose q 4-6 hr for 1st 24 hr., k. keep dextrose water at bedside in case solution runs out and next bag not available ■ Hang 10% dextrose solution l. OLDER CLIENTS: increased incidence of glucose intolerance m. pt has to remain on finger sticks for remainder of time they have TPN administered

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Treatment of chronic gastritis a. Can be related to autoimmune disease(pernicious anemia and H. pylori). b. Expect monthly injections of B12 c. Lab tests: ■ CBC (anemia) ■ blood stool antibody/antigen(h. pylori) ■ c13 urea breath test(measures h. pylori) d. Dx procedure: ■ upper endoscopy- maintain NPO 6-8 hr prior, local anesthetic sprayed onto back of throat, monitor indications of perforation(pain, fever, nausea, vomiting, abdominal distention). ■ Monitor I&O. ■ administer IV fluids ■ provide small frequent meals ■ AVOID: alcohol, caffeine, spicy, oily foods. ■ Monitor for indications of gastric bleeding,

e. Medications: ■ Histamine 2 antagonists (end in DINE).(*Famotidine take at night.) → 1 hr before or after administration of antacid bc they decrease effectiveness. Take 1 hr before meals. ■ Antacid: Take on an empty stomach. Wait 1 hr to take other meds. Monitor Magnesium antacids for diarrhea or hypermagnesemia, monitor aluminum for toxicity and constipation. ■ Proton Pump inhibitors (end in AZOLE). Wait 1 hr before eating, do not crush or chew, can take up to 4 hr to see effects. Prostaglandins (Misoprotrol) use contraceptives, do not take if may become pregnant. ■ Anti-ulcer/mucosal barriers (sucralfate) forms protective coating, allow 30 min before/after to give antacid ■ Antibiotics(eliminates H pylori) monitor electrolytes/hydration status. Notify if persistent diarrhea=superinfection of bowel. f. Therp procedures: ■ upper endoscopy(pt with significant bleeding) ■ vagotomy(reduces gastric acid secretion) ■ partial gastrectomy(removal of portion of stomach) g. Complications: ■ gastric bleeding, gastric outlet obstruction, dehydration, pernicious anemia ■ DUMPING SYNDROME( rapid release of metabolic peptides following ingestion of food bolus. ■ Pt will feel fullness, dizzy, sweating, abdominal cramping, diarrhea, can occur 10 min to 3 hr after eating. ■ Instruct to lay down after meals, eat high protein, high-fat, low carb diet, limit liquids during meals, eat small meals

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ulcerative colitis/ acute diverticulitis Symptom and treatment. a. Ulcerative colitis ■ SX: ● affects only the colon, not small intestines ● Abdominal pain usually on left side ● Frequent bloody, watery, diarrhea ● Rectal bleeding ● Intermittent tenesmus (continual or recurrent inclination to evacuate the bowels) ● Weight loss, anorexia, fever, vomiting and dehydration ● Passage of 6 or more liquid stools each day ■ Treatment: ● Medications:

○ Corticosteroids, aminosalicylates ○ Immunomodulators (Remicaede, Humira, Imuran) ○ Bulk hydrophilic agents ○ Antibiotics ● Surgical: ○ Proctocolectomy (removal of colon and rectum) with ileostomy b. Acute diverticulitis ■ Diverticulitis = diverticulum becomes inflamed, causing perforation and possible obstruction, abscess, peritonitis and hemorrhage ■ SX: ● Mild to severe pain in the left lower quadrant ● Constipation ● Nausea, fever, leukocytosis ● Complications → Abscess formation, bleeding, peritonitis ■ Treatment: ● Medical management: rest, oral fluids, analgesic medications ○ Clear liquid diet until inflammation subsides ○ High fiber and low fat diet ○ Hospitalization may be required for significant sx (usually for older pt, immunocompromised or taking corticosteroids) ● Surgical: ○ Acute diverticulitis usually subsides with medical management but immediate surgery necessary for complications (peritonitis, perforation, hemorrhage, obstruction)

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Macrovascular and Microvascular complications of diabetes a. Macrovascular → ■ Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and renal function are considered to be microvascular. ■ Cause of amputations ■ Accelerated atherosclerotic changes ■ CAD, cerebrovascular disease, PVD b. Microvascular → ■ Deals with the small blood vessels → kidneys and eyes ■ Diabetic retinopathy; leads to blindness ■ Nephropathy; leads to renal failure ■ Neuropathy

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Microalbuminuria (urinary albumin excretion of 30-300 mg/day)  disease, a. If your doctor believes you may be at risk for kidney damage or kidney it’s likely that you’ve had or will have a microalbuminuria test. b. It is a m  oderate increase in the level of urine albumin c. occurs when the kidney leaks small amounts of albumin into the urine, in other words, when an abnormally high permeability for albumin in the glomerulus of the kidney occurs d. It is an indicator of insulin resistance and of the increased renal and cardiovascular risk associated with metabolic syndrome. e. Albuminuria is a well-known predictor of poor renal outcomes in patients with type 2 diabetes and in hypertension

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Different between type 1 diabetes and type 2 diabetes patient teaching a. Type 1 - Beta cell destruction is the hallmark of type 1 diabetes b. Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia.Insulin Dependent Diabetes Mellitus. c. Insulin Dependent Diabetes Mellitus (IDDM) is characterized by onset in youth (age 20 or younger), although it may occur at any age. Insulin Dependent d. Diabetes Mellitus has previously been referred to as "juvenile diabetes." e. Insulin Dependent Diabetes Mellitus is characterized by low serum f. insulin levels due to an insulin deficiency. g. Treatment consists of parenteral administration of insulin along with diet therapy. h. Glucose is from absorption of ingested food in the GI tract and formation by liver from food i. glucose from food can’t be stored in liver but stays in bloodstream – post prandal hyperglycemia j. Too much glucose in blood kidneys can”t reabsorb and into urine. Water and electrolytes follow – osmotic diuresis k. Fat breakdown – ketones – acidic l. Can have “honeymoon” period where pancreas can work a little bit before fully quitting m. Type 2: ■ Non insulin dependent DM ■ Insulin production does not stop, but insulin levels may be low, normal, or elevated ■ Impaired beta cell function leads to decreased insulin production ■ Affects 90-95% of diabetics ■ More common at age 30 and obese

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Slow progressive glucose intolerance Treatment: ● Initially treated with diet and exercise ● Insulin and/or antidiabetic agents Patient teaching: Treatment consists of diet therapy, weight control measures, and the use of oral hypoglycemic medications if necessary.

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Treatment for medical emergency for type 1 diabetes a. ABC’s b. Fluid resuscitation c. Replace insulin d. If patient cannot swallow or is unconscious → 25-50 mL 50% dextrose in water IV bolus e. Glucagon 1 mg sub-Q or IM, turn pt onto side, may vomit, monitor airway (takes up to 20 min to work)

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HHS symptoms (Hyperglycemic Hyperosmolar Syndrome) 1. Blood sugar level of 600 milligrams per deciliter (mg/dL) or 33.3 millimoles per liter (mmol/L) or higher 2. Excessive thirst 3. Dry mouth 4. Increased urination 5. Warm, dry skin 6. Fever 7. Drowsiness, confusion 8. Hallucinations 9. Vision loss 10. Convulsions ●

The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration.

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Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Prevention: blood glucose monitoring. Dx and management of diabetes, assess/promote self care management skills

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Sick day rule a. Check blood sugar, eat/drink regularly to prevent dehydration, take diabetes med, be cautious of OTC meds, know when to call your doctor b. The most important  issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur c. Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates d. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.

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Diabetes insipidus testing and monitoring a. Most common disorder of posterior lobe of pituitary gland and characterized by deficiency of ADH(vasopressin). b. Abnormally large volumes of dilute urine are excreted as a result of deficient production of vasopressin c. may occur following surgical tx of brain tumor, secondary to non surgical brain tumors, traumatic brain injury, infections of nervous system, hypophysectomy, failure of renal tubules d. Testing: fluid deprivation test, plasma and urine osmolarity studies are performed ■ Concurrent measurements of plasma levels of ADH and plasma and urine osmolarity as well as trial of desmopressin therapy and IV infusion of hypertonic saline solution ■ If dx confirmed pt carefully assessed for tumors that may be causing the disorder. e. Symptoms: extreme thirst, heavy urination, dehydration, fatigue**can lead to hypernatremia f. Monitoring: ■ physical assessment and pt education are pillars of nursing management. ■ **wear a medical identification bracelet and carry required med info about DI at all times. Eat low sodium diet g. TX: NSAIDs, diuretics, IV fluid replacement, Desmopressin (DDVAP)

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treatment and symptom, what to do in emergency. a. Symptoms: ■ Urine with low specific gravity ■ Increased urine output ■ 2-20 liters of fluid intake daily (thirst) b. Treatment ■ Replace ADH (if not nephrogenic DI) ■ Fluid replacement ■ Correct the cause ■ Desmopressin acetate – oral, sublingual, intranasally, subcutaneously (parenteral form 10X stronger) ■ Early detection of dehydration and maintenance of adequate hydration ■ Lifelong vasopressin therapy with permanent condition ■ Teach patients to weigh themselves daily to identify weight gain

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Type of insulin and life shelf. a. Rapid-Lispro, Humalog, Novolog ■ Onset-Less than 15 minutes ■ Take 10-15min before meal b. Short-Regular, Humulin ■ Onset-30-60 ■ Peak 2-5 hrs ■ Duration 5-8 hrs ■ Take 30 min before meal c. Intermediate-NPH ■ Onset- 1-2 hours ■ Peak 4-12 hours ■ Duration 18-25 hours ■ Used twice daily and combined with rapid or short d. Long-Lantus or Glargine ■ Onset-1-1.5 hours ■ Lasts 20-24 hours

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Adrenal insufficiency - SX and TX a. Sudden drop in corticosteroids due to sudden tumor removal, stress of illness, trauma, surger, or dehydration or abrupt withdrawal of steroid medication. b. Indications include: hypertension, hypoglycemia, hyperkalemia, abdominal pain, weakness and weight loss. c. Nursing interventions: Administer glucocorticoids, insulin with dextrose or loop or thiazide diuretics to treat hyperkalemia, monitor vital signs & glucose levels, monitor ECG. d. Pt education: taper medication, ***during times of stress additional glucocorticoids might be needed to prevent adrenal crisis

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Addison disease NOT ENOUGH CORTISOL a. Addison's disease occurs when adrenal glands are damaged and cannot produce sufficient amounts of cortical hormones. b. Symptoms: fatigue, weight loss, dark pigmentation of mucous membranes and skin, especially knuckles, knees and elbow, hypotension, and low blood glucose, low serum sodium and high serum potassium levels, salt craving, nausea, vomiting, diarrhea c. TX: hydrocortisone by IV, vasopressors if hypotension persists, antibiotics. ■ If adrenal gland does not regain function, pt needs lifelong replacement of corticosteroids and mineralocorticoids to prevent recurrence of adrenal insufficiency.

d. Pt. education: pt should have an emergency kit in the form of corticosteroid in prefilled syringes. ■ Wear medical alert ID band ■ Avoid strenuous activity in hot, humid weather ■ Compliance is lifelong ■ Ensure high carb, high protein diet and adequate salt intake ■ Know warning signs of adrenal crisis

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Addisonian crisis ○ This is when disease progresses ○ SX: Hypotension, weak pulse, rapid respiratory rate, cyanosis, fever, nausea, vomiting, and signs of shock develop. ■ Pt will have pallor, HA, abdomi...