Gastrointestinal Diseases

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Diagnostic Procedures

Upper GI tract study (Barium swallow)

Pre procedure

• examination of Upper GI under fluoroscopy after intake of barium sulfate

• NPO after midnight prior to the day of the test

Post-Procedure

•laxative (may be prescribed)

• increase oral fluids

• monitor passage of barium stools                           

Lower GI tract study (Barium enema)

    fluoroscopic and radiographic examination of large intestine after rectal instillation of barium sulfate.

PreOp:

• low residue diet for 1-2 days before

• clear liquid and laxative the evening before the test

• NPO midnight prior to the day of the test

• cleansing enemas on morning of test

PostOp:

• same as Upper GI.

•Notify Physician if no bowel movement within 2 days.

UGI Endoscopy

Direct visualization of esophagus , Stomach and duodenum

•Obtain written consent

•NPO for 6-8 Hours

•Anticholinergic (ATSO4) as ordered ,To reduce Mucus secretions

•Sedatives ,Narcotics,Tranquilizers, To relax the Client (diazepam, Meperidine HCL)

•Remove dentures bridges, To prevent airway obstruction

•Local spray anesthetic on the posterior pharynx-Instruct not to swallow saliva .

Colonoscopy

Fiberoptic endoscopic study of large intestine

• patient side-lying / knee-chest position.

PreOp:

•  Cleansing of colon

• Clear liquid diet on noon day before the test

• NPO midnight of test

• Midazolam IV for sedation

PostOp:

• Bed rest until alert.

• Monitor for signs of perforation.

• Report any bleeding.

Cholecystography, Cholangiography

• Involves visualization of structures with use of a dye.

• Always ask about allergies to iodine or seafood.

Fecal Analysis

Stool for Occult Blood  (guiac stool exam)

•Detect GI bleeding

•Increase fiber diet 48 to 72 hours

•No red meats , poultry ,fish ,turnips ,horse radish

Stool for Ova and parasites

•Send fresh warm stool specimen

•Stool culture

•Sterile test tube /cotton tipped applicator

Stool for lipids

•Assess steatorrhea

•Increase fat diet, No alcohol for 3 days

•72 hour stool specimen (store on ice)

Measures secretion of HCL and pepsin

•NPO for 12 hours

•NGT is inserted , connected to suction

•Gastric contents collected every 15 minutes to 1 hour

  

Stomatitis

•An inflammation of the mucous lining in the mouth.

•Can be caused by poor oral hygiene, poorly fitted dentures, immunocompromised, mouth burns from hot food or drinks, medications (especially chemotherapy), infections or allergic reactions, exposure to radiation.

Assessment

•Burning sensation

•Canker sores(small sores or ulcers  that are painful) = cold sores = virus

•Excessive salivation

•Halitosis (unpleasant odor of the breath) 

•Xerostomia (abnormal dryness of the mouth due to insufficient secretions) – often with radiation

•Erythema of the mucous membranes

•White patches = thrush à candidiasis

Screening & Diagnosis:

•Medical History – may disclose dietary deficiency, allergic reaction & systemic disease.

•Physical examination – (+)apthous ulcers (well circumscribed oral lesions w/ white centers & reddish rings around the periphery.

•Scraping of the lining of the mouth – (+) infectious causative agent

Treatment:

•Antibiotics : tetracycline (Sumycin®) , chlorhexidine gluconate (PerioGard®, Peridex®)

•Anti-fungal: nystatin suspension, clotrimazole (Mycelex Troches®)

•Analgesics/topical anesthetics: lidocaine, benzocaine (Americaine®, Anbesol®), sulcrafate, orabase

•Antiviral: acyclovir (Zovirax®)

Implementation

•Instruct patient regarding good oral hygeine

•Avoid foods that are irritating

•Adequate fluid intake

Gastroesophageal Reflux

•A condition in which stomach acid bile flows back into the esophagus.

•It results from inability of the lower esophageal sphincter (LES) to close fully, thus allowing stomach contents to flow freely into the esophagus.

Assessment

•Heartburn

•Chest pain, especially at night while lying down

•Dysphagia

•Regurgitation of food or sour liquid

•Cough, hoarseness, voice changes

Implementation

•low-fat, high-fiber diet, avoid caffeine, tobacco, carbonated beverages.

• avoid eating and drinking 2 hours before bedtime.

• elevate head of bed

• avoid cholinergics which delay stomach emptying

• Instruct regarding meds: antacids, H2 receptor antagonists.

Esophagitis

•(inflammation –esophagus)

•Inflammation of the lining of esophagus.

•Caused by an infection or irritation of the esophagus (due to backflow of acid fluid from the stomach/GERD, vomiting, surgery, medications).

Assessment

•dysphagia (difficult/painful swallowing)

•heartburn

•esophageal pain

•acid regurgitation

•belching

Screening & Diagnosis:

•Physical examination – reveals tachypnea, thrush in the oropharynx, & dental erosions

•Upper GI x-ray w/ barium – esophageal motility abnormalities, esophageal strictures, gastric outlet obstruction.

•Biopsy (sample of esophageal tissue is removed then sent to the lab. to be examined under the microscope)

•Esophagogastroduodenoscopy (EGD) – reveals irritated, inflamed & eroded areas

Implementation

•Small frequent meals

•elevate head of bed 4 to 8 inches

• no meals 2 hours before bedtime

•Avoid irritating foods

Medications

• Antacids

•H2 recptor antagonist

•Proton pump inhibitor

Hiatal Hernia

•Sliding hernia: gastroesophageal junction and part of stomach slide upwards.

•Paraesophageal hernia: part of stomach turns adjacent to esophagus

  Assessment

•Heartburn

•Belching

•Substernal/epigastric pressure or pain after eating & when lying down

•Hiccups

•Dysphagia, feeling of fullness

Diagnosis: Chest X-ray or Barium swallow

                                                  Barium swallow images for hiatal hernia

Implementation:

• If asymptomatic – no treatment necessary

• Small frequent meals

• Elevate head of bed to reduce acid reflux

• Avoid activities that increase abdominal pressure:

•(lifting heavy objects, bending over, etc)

  

Medications

•Antacids

•Antiemetics

•Histamine receptor Antagonist

•Gastric Acid secretion Inhibitors

  

AVOID

•Anticholinergics

•Xanthine derivatives

•Ca-channel blockers

•Diazepam

Implementation

•Small frequent meals

•Elevate head of the bed

•Avoid factors that increases abdominal pressure

  

Surgery
NissenFundoplication (Gastric wrap Around)

Postop care

•Facilitate airway clearnce

•Semi-fowlers position

•Reinforce DBCT exercise

•Drainage from NG tube returns to yellowish green within first 8 to 12 hours post op

•Oral fluids after peristalisis returns

•Small frequent meals

•Avoid gas forming food

Peptic ulcer disease

GASTRITIS

Diffuse or localized inflammation of the gastric mucosa

Acute gastritis

Short –term inflammatory process due to ingestion of chemical agents or food products that irritate and erode gastric mucosa

Chronic gastritis

Type A

Autoimmune in nature

Atrophic gastritis, gastric Ca , pernicious anemia

 Type B

Asociated with helicobacter pylori

  

Assessment

•Anorexia

•Heartburn

•Nausea and vomitting

•Sour taste in the mouth

•Belching

•Epigastric pain

Implementation

•Assess for GI bleeding

•Small frquent meals

•Avoid irritating foods

•Avoid smoking

  

Gastric Ulcer 

•Normal or decreased acid production

•Decreased mucosal resistance

•Chronic NSAID use

•Pain gets worse after meals

                                                              Gastric ulcer pics  

Duodenal Ulcer

May be asymptomatic

Pain ( midepigastric)

Meds for gastritis, GERD, PUD.

Antacids:

• Aluminum hydroxide (Amphogel)

• Bismuth subsalicylate (Pepto-Bismol)

• Calcium carbonate (Tums)

• Magnesium hydroxide (Milk of Magnesia)

GI protectors

• Misoprostol (Cytotec)

• Sucralfate (Carafate)

H2 Receptor Antagonists

•Cimetidine (Tagamet)

•Ranitidine (Zantac)

•Famotidine (Pepcid)

Antimicrobials

• Amoxicillin (Amoxil)

• Clarithromycin (Biaxin)

• Metronidazole (Flagyl)

• Tetracycline (Achromycin

Proton Pump Inhibitors

• Omeprazole (Prilosec)

• Iansoprazole (Prevacid)

SURGERY

Vagotomy

•Resection  of the vagus nerve

•Decreased cholinergic stimulation

Pyloroplasty

•Surgical dilation of the pyloric sphincter

•Improves gastric emptying of the acidic chyme

Antrectomy

•Removal of 50 % of the lower part of the stomach

Types

•Billroth I   ( gastroduodenostomy)

•Billroth II  ( Gastrojejunostomy  )

Subtotal gastrectomy with bilroth1/bilroth 2

Total gastrectomy

Potential complication following surgery

•Respiratory ( Atelectasis)

•Bleeding

•Dumping syndrome

DUMPING SYNDROME

Early signs and symptoms ( 5 to 30 min p.c.)

•Weakness

•Tachycardia

•Dizziness

•Diaphoresis

•Pallor

•Feeling of fullness or discomfort

•Nausea

•Explosive diarrhea

Esophageal Varices

•Elevated portal vein pressure

•Tortous dillated thin walled veins

Assessment

•Asymptomatic

•If massive bleeding ( signs of shock)

Medication

•Vassopressin ( pitressin)

•Betablockers

•Nitrates

Implementation

•Assess vital signs

•Assist patient to avoid straining and vomitting

•Assess for bleeding

•assist with Sengstaken tube

Sengstaken blakemoreTube

•To compress esophageal varices

Liver Cirrhosis

•Chronic, degenerative liver disease manifested by diffuse destruction & fibrotic regeneration of hepatic cells that leads to anatomic alteration & partial/complete occlusion of blood in the liver.

Types

•Laennec’s cirrhosis

•Biliary cirrhosis

•Postnecrotic cirrhosis

•Cardiac cirrhosis

Assessment

• Fatigue
•  nausea, vomiting
•  itchy skin, jaundice
•  spider angiomas
• palmar erythema
•  nosebleeds, GI bleeds, bruises
•  ascites
•   esophageal varices - CNS: lethargy

Analysis:

•altered thought process

•bleeding risk

•Impaired skin integrity

•Altered nutrition

Implementation

•Check skin, gums and stool for bleeding

•Avoid aspirin, NSAIDS, alcohol

•Monitor weight

•Monitor abdominal circumference

If ascites interferes with breathing- - high fowler’s

Hepatitis

A	Contaminated Water/food/shellfish	-2-6 weeks incubation - 0% become chronic
B	Blood transfusions Sexual contact Parenteral	-2-6 months incubation -10% become chronic
C	Blood transfusions Sexual contact Parenteral	- 1-2 months incubation
D	Only in patients with hepatitis B parenteral	incubation period: 21 to 140 days
E	Fecal oral	incubation period: 15 to 65 days

Assessment:

PREICTERIC:

• nonspecific: fatigue, anorexia, malaise, weakness

• low grade fever

ICTERIC

•Jaundice

•Pruritus

•Brown-colored urine

•Lighter-colored stools

•Decrease in preicteric phase symptoms

POSTICTERIC

•Energy level increase

•GI symptoms are minimal to absent

•Pain subsides

•Serum bilirubin & enzyme levels return to normal

Treatment:

•Diet therapy: high-calorie, moderate-protein, low fat

•Activity – rest

Medications

•Interferon alpha (IM or SC injection)

•lamivudine (Ephivir HBV)

•ribavirin  (Rebetol®)

•Vitamins & minerals

•Vaccines for preventive measures (only for hepa A  & B – 3 series shots)

•Herbal medicines: licorice root

Implementation

• Provide bed rest

• Provide high-calorie diet

• Monitor for signs of GI bleeding

•Limit visitors/ isolation procedures if infectious

Cholecystitis

•Inflammation of the gallbaldder

•Associated with cholelithiasis

Assessment

•Nausea and vomitting

•Belching

•Indigestion

•+ murphy’s sign

•Pain right upper quadrant

Dissolution therapy 

•  Ursodiol(Actigall)
•  Chenodiol (Chenix)

Analgesics: meperedinehydrochloride(Demerol)

Anti-emetics: promethazine (Phenergan, Prorex, Anergan)

Surgical

•Cholecystectomy – removal of the gallbladder

•Choledochotomy – incision of the common bile duct to remove the stone

Postoperative:

 Monitor T-tube drainage(up to 500 ml in 24 hours is normal) 

Pancreatitis

Acute or chronic inflammation of the pancreas wherein there is abnormal pancreatic enzyme activation in the pancreas

Acute Pancreatitis	Chronic Pancreatitis
•         Pain midepigastric          Left upper quadrant •         Tachycardia •         Increased temperature •         Abdominal distention & rigidity •         ↓ Bowel sounds •         Nausea & vomiting •         Cold clammy skin •         Mild jaundice •         Cullen’s sign – discoloration of the abdomen and periumbilical area •         Turner’s sign -  bluish discoloration of the flanks	•         Reoccurring abdominal pain & tenderness •         steatorrhea & foul smelling stools •         Left upper quadrant mass •         Weight loss •         Muscle wasting •         Jaundice

Blood chemistry – reveal ↑ amylase, bilirubin, lipase, trypsinogen, alkaline phosphatase glucose, ↓ calcium

Medications

•Analgesics: acetaminophen (Tylenol®), tramadol (Ultram®)

•Antibiotics: imipenem and cilastatin (Primaxin®)

•Pancreatic enzymes: pancrelipase (Lipancreatin®)

•H2 blockers: cimetidine (Tagamet®), ranitide (Zantac®)

Diet therapy: low-fat, low-protein, high-carbohydrate, small frequent feedings with restricted

Implementation

•Monitor vital signs, assess level of pain.

•Maintain NPO and provide NG tube suction if vomiting in acute phase

•Follow dietary recommendations & restrictions

•Instruct patient about the importance of avoiding alcohol and smoking cessation.

APPENDICITIS (epityphlitis)

•Inflammation of the appendix caused by an obstruction of the narrow appendiceal lumen secondary to impacted fecal material, kinking infectious swelling fibrous over growth or lymph node swelling.

•Occurs in all age groups but rare in infants.

Types:

•Simple appendicitis

•Gangrenous appendicitis

•Perforated appendicitis

Assessment

•(+) Rebound tenderness

•(+) Rovsing’s sign

•(+) Psoas sign  

•(+) Obturator sign

•Low-grade fever

•Nausea & vomiting

•Loss of appetite

•Inability to pass gas

Medication

Antibiotics : cefuroxime, metronidazole

Surgical

•Appendectomy – surgical removal of the appendix to decrease the risk of perforation.

•Laparoscopic surgery – remove appendix using a pencil-thin tube; provides less scarring & faster recovery.

Implementation

• maintain bed rest

• keep client NPO

• semi-fowler’s position

•monitor for signs of perforation and systemic infection

Postoperative:

• monitor vital signs

• monitor fluid intake and output

• monitor bowel sounds

• monitor dressing for drainage or signs of infection

 DIVERTICULOSIS

A condition when multiple diverticula exist without symptom or inflammation.

Diverticulitis

An inflammation of one or more diverticula

Assessment

•Lower left side abdominal pain

•Abdominal tenderness

•Change in bowel

•Vomiting

•Bloating

•Anorexia

•Trace (occult) blood in the stool

•Urinary frequency from pressure

•Low grade-fever

Diagnosis

•Physical examination & digital rectal exam

•Hemooccult or guaiac testing Complete blood count - ↑ WBC, RBC loss

•Abdominal x-ray/ CT scan

• Barium enema

•Colonoscopy or sigmoidoscopy

Medications

•Opioid Analgesics: meperedine(Demerol®), pentazocine (Talwin ®)

•Antispasmodics: propantheline bromide(Pro-Banthine®), oxyphencyclimine(Daricon®)

•Antibiotics: metronidazole (Flagyl®), clindamycin (Cleocin®), cefoxitin (Mefoxin®)

•Bulk preparation: psyllium(Metamucil)

•Stool softener: docusate(colace)

Surgical

•Bowel resection with primary anastomosis

•Temporary or permanent colostomy

  

Implementation

•Bed rest during acute phase

•NPO during acute phase

•Administer medications as ordered

•Instruct to avoid straining

•Increase fluid intake

•Dietary modification

•Provide colostomy care ( if present)

Inflammatory bowel diseases

	Ulcerative colitis	Chron’s disease
Pathology And location	•         mucosal ulceration •         begins at rectum and progresses towards ileocecal junction •         Involves entire colon up to ileum	transmural thickening granulomas •         Ileum, ileocolic colon
Assessment	•         Abdominal cramping: left lower quadrant •         Abdominal distention •         Nausea & vomiting •         Fatigue •         Bloody purulent stool •         Fever •         Tenesmus •         Weight loss, •          anorexia •           •	•         Diarrhea •         Possible steatorhhea •         Weight loss + malabsorption à deficiencies •         Diffuse abdominal tenderness •         Abdominal pain & cramping •         Fever •           •

Medication

•Anti-inflammatory: sulfasalazine (Azulfidine),mesalamine (Asacol, Rowasa), olsalazine, salicylate

•Corticosteroids: budesonide (Entocort EC), methylprednisolone, prednisone

•Antibiotics: metronodazole (Flagyl),ciprofloxacin (Cipro)

•Immune system suppresors : azathiophrine(Imuran), mercaptopurine (Purinethol), methotrexate, (rheumatrex)

•Anti-diarrheals: psyllium powder (Metamucil), loperamide(Imodium)

Surgery

•Total proctocolectomy/ Ileostomy

•Kock ileostomy

  

Watch for dehydration

• Monitor stool frequently and consistency

• During acute phase NPO

• Watch signs of gastrointestinal obstruction

• Dietary modification

Colostomy

•is a surgical procedure that involves connecting a part of the colon onto the anterior abdominal wall

-Cancer

-Ulcerative Colitis, Chrons

-Diverticulitis
Congenital conditions: Hirschprung's disease, rectal atresia, and megacolon

-Bowel Obstruction

-Traumatic Injury

•Permanent Ostomy
Constructed when the rectum, colon, or the bladder have been removed

•Temporary Ostomy

 Considered temporary if it is going to be reversed

An ileostomy is astoma that has been constructed by bringing the end of the small intestine (the ileum) out onto the surface of the skin..

Colostomy care:

•Remove pouch when 1/3 full

•Cleanse stoma with soft cloth and water or mild soap

•Dry skin thoroughly before applying pouch

•Use skin barrier powder or paste to protect from fecal drainage.

•Irrigation of stoma: be gentle – never force catheter

•Allow client to verbalize feelings about colostomy

Fluid and electrolyte and acid base balance

Fluids and Electrolytes

Body is 60% fluids

ICF=40%       

ECF=20% (Intravascular=5%; Interstitial=15%)

Solvent – the medium (usually water) that contains some particles.

Solutes – particles that are dissolved in solvent :salts, sugars, amino acids.

Electrolytes

•Chemical compounds in solution that have the ability to conduct an electrical current

Break into charged particles called ions

•Positively charged CATIONS

•Negatively charges : ANIONS

FUNCTIONS OF ELECTROLYTES

•Promote neuromuscular irritability

•Maintain body fluid volume and osmolality

•Distribute body water between fluid compartments

Function of Body Water

ECF

•Maintains blood volume

•Transport system to and from the cell

ICF

•Internal aqueous medium for cellular chemical function

MOVEMENTS OF FLUIDS BETWEEN COMPARTMENTS

•Diffusion

•Osmosis

•Active Transport

•Hydrostatic Pressure

•Colloid Osmotic Pressure

•Filtration

Types of solution

Crystalloids: Intravenous Fluids

1.Isotonic (equal osmolality with plasma)

   0.9% NaCL,Ringer’s Solution,Lactated Ringer’s, D5H20

2.Hypotonic (lower osmolality than plasma)

0.45% NaCL

3.Hypertonic (higher osmolality than plasma)

D5.9% NSS, D5.45% NSS, D10 H20,D5LR

Colloidal Solution

Aminosol 5%

Dextran 40

              INTRAVENOUS THERAPY

Purpose:

1.Maintenance of fluid & electrolyte balance

2.Replacement of fluid & electrolyte loss

3.Provision of nutrients

4.Provision of a route for medications

Average Fluid Intake

1.         Drink = 1,500ml/day.

2.         Food = 800 ml/day.

3.            Oxidation = 300 ml/day.

Average Fluid Loss

1.         Urine = 1,500 ml/day.

2.         Lung = 400 ml/day.

3.         Skin = 600 ml/day.

4.         Feces = 100ml/day.

Fluid Volume Deficit

An imbalance in fluid volume in which there is loss of fluid from the body not compensated for by an adequate intake of water.

•Excess Water Loss = FLUID VOLUME DEFICIT

Example: Simple Dehydration : water and electrolytes are lost in the same proportion

. Assessment

•Dry mucous   membranes

•Concentrated urine, ↓urine output

•Thready,↑PR,↑RR

•Orthostatic hypotension

•↓ BP

•Flat neck veins

•↓ CVP

•Diminished  peripheral pulse

•Dry skin

 Implementation

• fluid replacement

• weigh client daily

• monitor intake and output

• monitor urine specific gravity

Fluid Volume Excess

•           fluid intake or fluid retention exceeds the body’s fluid needs.

•           Also called overhydration or fluid overload

•           Excess Water Intake/Retention = FLUID VOLUME EXCESS

           

Example : Overhydration

1. Assessment

•Lethargy

•Confusion

•Muscle cramps

•Diarrhea

•Delirium

•Weakness

•Seizure

•Rapid PR

•↑Urinary output

•Nausea and vomiting

Nursing Interventions:

•Monitor vital signs, daily weight, and hemodynamic status.

•Monitor I & O.

•Monitor electrolyte levels & body system status.

•Prevent further fluid overload then restore normal fluid balance.

•Administer prescribed diuretics.

•  Report warning signs of hypervolemia.

SODIUM

Normal Value : 135-145 mEq/L

Common Food Sources : table salt, soy sauce, cured meats, dairy products (milk, cheese, butter), ketchup, canned food, snack food (chips, crackers). Note: instant oatmeal has salt.

Hyponatremia

 sodium level below 135 mEq/L

Causes:

1.            Increased sodium excretion.

2.            Inadequate sodium intake.

3.Dilution of serum sodium 

Assessment

•Nausea & vomiting

•Lethargy

•Confusion

•Muscle cramps

•Diarrhea

•Delirium

•Weakness

•Seizure

•Rapid PR

•↑Urinary output

Implementation

•Assess neurological status.

•Monitor electrolyte results and I & O accurately

•Administer IV fluids

•Increase oral sodium intake.

•Maintain seizure precautions.

•If hypovolemia: IV saline fluids; If hypervolemia: diuretics.

•If taking Lithium, monitor lithium levels because hyponatremia can cause decrease in lithium excretion and result in toxicity.

B. Hypernatremia  - sodium level exceeding 145 mEq/L

Causes:

1.            Decreased sodium excretion – corticosteroids, renal failure, Cushings Synd.

2.            Increased sodium intake – excess ingestion or IV fluids with sodium.

3.            Decreased water intake – NPO, Low fluid intake.

4.            Increased water loss – fever, diaphoresis.

Symptoms

           decreased contractility and output of heart

-            hypervolemia : pulmonary edema

-            spontaneous muscle twitching later weakness.

-           ** Altered mental/ cerebral functioning is the most common manifestation.

-            Increased urine specific gravity, decreased urine output.

Implementation

•Gradual replacement of water (in excess of sodium)

•ADH replacement, vasopressin administration (for patients with diabetes insipidus)

•Medications:

•Diuretics

•Diet therapy

•↓ Na+

           

POTASSIUM

Normal value = 3.5 – 5.1 mEq/L

Common food sources: avocado, raisins, pork, beef, cantaloupe, spinach, bananas, fish, oranges, strawberries, mushrooms, carrots, potatoes, tomatoes.

** Potassium is the major cation of the intracellular fluid. Small changes in extracellular potassium concentrations are very significant.

A. Hypokalemia

 - level below 3.5 mEq/L

Causes

1.            Potassium Loss – use of meds such as diuretics, Conns Synd (increase in aldosterone), vomiting, diarrhea.

2.            Inadequate intake

3.            Intracellular shift – alkalosis, hyperinsulinism, TPN feedings.

4.         Dilution of serum potassium – water intoxication, IV fluids with low K.

Assessment

•          Thready, weak pulse

•          Cardiac arrhythmias, ECG : ST depression

•          Shallow respiration

•          Anxiety, lethargy, confusion

•          Muscle weakness

•          Decreased GI motility, nausea, vomiting. 

•          Decreased urine specific gravity, increased output.

Implementation

•monitor ECG

•Oral or IV potassium

•Fluids to increase urinary output

•IV fluids

B. Hyperkalemia

- level exceeding 5.1 mEq/L

Causes

1.         Excess intake – overingestion of foods or meds, rapid infusion.

2.            Decreased excretion – potassium-sparing diurectics, renal failure.

3.            Extracellular shift – tissue damage, acidosis, vigorouse drawing of blood destroying RBC’s

Assessment

•           irregular heart rate, dysrhythmias; slow, weak pulse, decreased BP

•           ECG : tall T waves, widened QRS complexes, prolonged PR interval.

•           Skeletal muscle weakness, may lead to respiratory failure.

•           Early: muscle twitching, cramps, paresthesias.

•           Late: profound muscle weakness, paralysis.

•           Increased GI motility, diarrhea.

Implementation

•          monitor VS, affected systems, place on cardiac monitor.

•          Discontinue IV potassium or oral potassium supplements.

•          Restrict K in diet.

•          K excreting diuretics.

•          IV  glucose with insulin to move excess K into cells.

CALCIUM

Normal levels : 8.6 to 10.0 mg/dl

Plays an important role in excitable tissues : heart, muscle, nerves.

Common food sources : yogurt, milk, rhubarb, collard greens, cheese, tofu, spinach, broccoli, green beans, carrots

A. Hypocalcemia

- level below 8.6 mg/dl

Causes

1.            Inadequate absorption – low oral intake, lactose intolerance, malabsorption syndromes such as Crohns disease, celiac sprue, low intake of vit. D, ESRD.

2.            Increased excretion – renal failure, diarrhea, wound drainage.

3.            Conditions that decrese serum levels – alkalosis, medications, acute pancreatitis, **hyperphosphatemia, disease or removal of parathyroid glands.

Assessment

•          Decrease heart rate and contractility

•          Hypotension, diminished pulses.

•          Irritable skeletal muscles: twitching, cramps

•          Hyperactive deep tendon reflexes.

•          +Trousseau’s and Chvostek’s sign.

  

Implementation

• monitor VS and systems affected.

•Oral calcium or IV supplements

•Meds that increase calcium : aluminum hydroxide reduces phosphorus causing increase in calcium; vitamin D aids in absorption.

•Quiet environment, seizure precautions.

B. Hypercalcemia

 - level beyond 10 mg/dl.

Causes

1.            Increased absorption – excess oral intake of calcium or vit.D.

2.            Decreased excretion – renal failure, thiazide diuretics.

3.            Increased bone resorption – malignancy, immobility, hyperparathyroid/thyroid

4.            Hemoconcentration – dehydration

Assessment

•     Increased heart rate early but   bradycardia in late stage.

•           Increased BP, bounding pulses

•           Weak respiration, muscle weakness

•           Disorientation, lethargy, coma.

•           Formation of renal calculi

•           Decreased GI motility, anorexia, nausea.

Implementation

-           monitor VS, systems affected, cardiac monitor.

-            Discontinue oral or IV solutions with calcium, vit. D

-           IV normal saline to restore balance

-           Severe: dialysis

 •  

MAGNESIUM

Normal value: 1.6 – 2.6 mg/dl

Common food sources: green leafy vegetables, avocado, white tuna, milk, yogurt, oats

-           As calcium goes, so does magnesium. Hypocalcemia frequently accompanies hypomagnesemia, so signs are similar and interventions also aim to restore normal serum calcium level.

-            Monitor for reduced deep tendon reflexes when administering magnesium since reduced DTR’s suggest hypermagnesemia.

PHOSPHORUS

Normal value: 2.7 – 4.5 mg/dl

Common food sources: fish, pork, beef, chicken, organ meats, nuts.

   A decrease in phosphorus is accompanied by increase in calcium. Inverse relationship. Problems that occur in hyperphosphatemia center on the hypocalcemia that results when serum phosphorus levels increase. 

Acid – is a proton donor (HCL, Sulfuric,phosphoric ,carbonic acids

            A strong acid is the one that highly dissociate and produces a high concentration   

            Of hydrogen ions

Base – a hydrogen ion acceptor.They bind free hydrogen ions,reducing their concentration

Buffer – a substance that reduces the change in free hydrogen ion concentration of a solution on the addition of an acid or base

Acid Base Balance

The body has two main defense mechanisms against too much acid:

(There are other mechanisms but these are the important ones.

1. Respiratory

- if too much H2CO3 is produced by the above reactions, the lungs can remove it in the form of CO2.

- inability to remove CO2 due to hypoventilation causes acidosis.

- removal of too much CO2 by hyperventilation causes alkalosis.

2. Metabolic

- the kidneys can supply (recover) additional buffer base HCO3 to compensate for acidosis.

 - inability of the kidneys to recover HCO3 causes acidosis.

Drawing Arterial Blood Gases

1.         Obtain vital signs.

2.            Determine if arterial line is in place so arterial puncture is not necessary.

3.         Do Allen Test for determining patency of collateral circulation

a.         Apply direct pressure over the clients ulnar and radial arteries simultaneously.

b.         While pressure is applied, ask the client to open and close the hand repeatedly; the hand should blanch.

c.         Release pressure from the ulnar artery while compressing the radial artery and assess the color of the extremity distal to the pressure point.

d.         If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen.

4.         Draw into heparinized syringe.

5.         Must be sterile.

6.         Discard if in contact with room air.

7.         Keep on ice, transport to lab immediately.

8.         Apply pressure to puncture site for 5 to 10 minutes.

9.         On the lab form always record the clients temperature and any oxygen being received.

Analyzing Arterial Blood Gases

Normal Values

pH: 7.35-7.45

PCO2: 35-45 mmHg

HCO3: 22-27 mEq/L

PO2: 80-100 mmHg

step 1 - examine pH

if low, indicates acidosis --
if high, indicates alkalosis --
if normal, check to see if borderline (may be compensation)

step 2 - examine CO2

if high, indicates respiratory acidosis (with low pH)
if low, indicates respiratory alkalosis (with high pH)
if normal, check for compensatory problem

step 3 - examine HCO3

üif high, indicates metabolic alkalosis (with high pH)
if low, indicates metabolic acidosis (with low pH)
if normal, check for compensatory condition

step 4 - check PO2 levels

üif low, indicates an interference with ventilation process (should evaluate the patient)
if normal, indicates patient is getting enough oxygen

step 5 - check signs/symptoms of patient

üThis analysis is for the patient whose respiratory status is fairly stable clinically, but acid/base balance is questionable. Following is a step-by-step account of how to analyze ABG if the prime concern is oxygenation.

pH 7.51, pCO2 40, HCO3- 31:

            a.            Normal

            b.            Uncompensated metabolic alkalosis

            c.            compensated respiratory acidosis

            d.            Uncompensated respiratory alkalosis

pH 7.33, pCO2 29, HCO3- 16:

            a.            Uncompensated respiratory alkalosis

            b.            Uncompensated metabolic acidosis

            c.            Compensated respiratory acidosis

            d.            Uncompensated metabolic acidosis

           

pH 7.40, pCO2 40, HCO3- 24:

            a.            Normal

            b.            Uncompensated metabolic acidosis

            c.            Compensated respiratory acidosis

            d.            Compensated metabolic acidosis

pH 7.12, pCO2 60, HCO3- 29:

            a.            Uncompensated metabolic acidosis

            b.            Uncompensated respiratory acidosis

            c.            Compensated respiratory acidosis

            d.            Compensated metabolic acidosis

pH 7.48, pCO2 30, HCO3- 23:

            a.            Uncompensated metabolic alkalosis

            b.            Uncompensated respiratory alkalosis

            c.            Compensated respiratory alkalosis

            d.            Compensated metabolic alkalosis

pH 7.62, pCO2 47, HCO3- 30:     

            a.            Uncompensated metabolic alkalosis

            b.            Uncompensated respiratory alkalosis

            c. compensated respiratory alkalosis

            d. compensated metabolic alkalosis

NCLEX audio format test (with cardio sounds for download)

The Nclex exam has adapted a new nclex format which is the audio type of question you could get Heart sounds , breath sounds. Some of my students already had this type of questions and a lot of them got heart sounds. So I would

suggest is for you to study cardiac auscultations















Cardio Sounds for download
Cardio sounds download

Medical emergency ( BLS)

Basic Life Support

· Includes the recognition of signs of sudden cardiac arrest (SCA). Heart attack, stroke, and foreign- body airway obstruction (FBAO); cardiopulmonary resuscitation; and de-fibrillation with an automated external defibrillator (AED).
Check for Response
· The rescuer should ensure the scene is safe, the rescuer should check for response.
· To check for response, tap the victim on the shoulder and ask, “Are you all right?” If the victim is responsive but is injured or needs medical assistance, leave the victim and call 911.
· Then return as soon as possible after calling for help, recheck the victim’s condition.

Activate the emergency medical services (EMS) system

· For one rescuer who finds an unresponsive adult, the rescuer should activate the EMS system (911), get an AED (if available), and return to the victim to provide CPR, and defibrillation if needed.
· If 2 or more rescuers are present, one rescuer should begin the steps of CPR while a second rescuer activates the EMS system and gets the AED.
· If the emergency occurs in a facility with an established medical response system, notify that system instead of the EMS system.
· If phoning for help, the rescuer should be prepared to the dispatcher’s questions about location, what happened, number & condition of victims, type of aid provided. ( Note: The caller should hang up only when instructed to do so by the dispatcher & should then return to the victim to provide CPR)

Open the Airway and Check Breathing

· To prepare for the CPR, place the victim on a hard surface in a face up position (supine).
· If an unresponsive victim is face down (prone), roll the victim to a supine position.
· If a hospitalized patient with an advanced airway, the health care provider may attempt CPR with the patient in a prone position.
· Healthcare Provider: should use the head tilt-chin lift maneuver to open the airway of a victim without evidence of head or neck trauma. If a healthcare provider suspects a cervical spine injury, use a jaw thrust without head extension.
· Check breathing: Determine breathlessness and maintain open airway. Place ear over mouth, observing chest. Look, listen, feel for breathing. (5-10 seconds)

                                                             

                                                                   

                                                   

Give Rescue Breaths

· Give 2 rescue breaths, each over 1 second, with enough volume to produce visible chest rise
o Mouth-to-Mouth Rescue Breathing
§ Open the victim’s airway, pinch the victim’s nose, and create an airtight mouth-to-mouth seal.
§ Give 1 breath over 1 second, take a regular breath, and give a second rescue breath over 1 second.
o Mouth-to- Barrier Devise Breathing
§ Barrier devices are available in 2 types: face shields and face mask
§ Face shields are clear plastic or silicone sheets that reduce direct contact between the victim and rescuer but do not prevent contamination of the rescuer’s side of the shield.
§ Masks used for mouth-to-mask breathing should contain a 1-way valve that directs the rescuer’s breath into the patient while diverting the patient’s exhaled air away from the rescuer.
§ If oxygen is available, healthcare providers should provide it at a minimum flow rate of 10 to 12 L/min.

o Mouth- to- Nose and Mouth- to-Stoma Ventilation
§ Mouth-to-nose ventilation is recommended if it is impossible to ventilate through the victim’s mouth.
§ A mouth-to-stoma rescue breath is recommended to a victim with a tracheal stoma who requires rescue breathing. An alternative is to create a tight seal over the stoma with a round pediatric face mask.

Pulse Check for Healthcare Providers

· Determine pulselessness, in adult feel for carotid pulse for 5-10 seconds and maintain an open airway. For infant feel for brachial pulse, maintaining head-tilt.
· For two-rescuer CPR, one person assesses while other rescuer assumes proper position for external chest compressions.

                                                       

Chest Compressions

· Increases the intrathoracic pressure and directly compresses the heart.
· The victim should lie supine on a hard surface, with the rescuer kneeling the victim’s thorax.
· Correct hand placement for chest compression is crucial. The rescuer should place the heel of the hand on the lower half of the sternum, between the nipples and then place the heel of the second hand on top of the first so that the hands are overlapped and parallel.
· For adult, the rate of compression is 100 per minute at a depth of 1 ½ to 2 inches (4 -5cm), then allow the chest to return to its normal position. Perform 5 complete cycles; then reassess the victim.
· For infant, place 2 fingers on the sternum, 1 finger’s width below line and with a depth of 1/3-1/2. For neonates use chest encirclement technique.
· Recommended compression-ventilation ratio is 30:2. Give cycles of 30 compressions and 2 breaths for adults, one or two rescuers. For infant or child use 30:2 for single rescuer and 15:2 for 2 rescuers.
· Reevaluate the patient’s pulse every 2 minutes and every 5 cycles thereafter. If pulse returns but not breathing, continue with rescue breathing only.

Defibrillation

· All BLS providers should be trained to provide defibrillation.
· Defibrillation is not recommended for infants <1 year of age.
· If shockable, resume CPR immediately for 5 cycles. Check rhythm every 5 cycles.
· Continue until ALS providers take over or victim starts to move.
· Use adult pads ages 8 and above.

to watch video on cpr and defibrillation click on this

Ethics

Ethics – The branch of philosophy concerned with distinction between right and wrong based on body of knowledge

Morality – Behavior in accordance with custom or tradition

Nurse Practice Act – A series of statutes that have been enacted by each state legislature to regulate the practice of nursing in that state


Standards of care – Are guidelines that identify what the client can expect to receive in terms of nursing care

Contracts – Nurse are responsible for carrying out the terms of a contractual agreement with the employing agency and client
• Hospital staffing
• Floating

Good Samaritan Law – Encourage health care professional to assist in emergency situations without fear of being sued for the care provided


Legal risk areas
Good Samaritan Law – Encourage health care professional to assist in emergency situations without fear of being sued for the care provided

False imprisonment – Occurs when a client is not allowed to leave a health care facility when there is no legal justification to detain the client
Defamation – Is a false communication or a careless disregard for the truth that causes damage to one’s reputation

Informed Consent – Is the client’s approval to have his or her body touched by a specific individual

Client privacy – Client right to protection against unreasonable and unwarranted interference into private affairs


Confidentiality – A special relationship exist between the nurse and client , in which information discussed will not be shared with a third party
Medical records
•Client has the right to read the medical records
•Only staff members directly involved in care has legitimate access to a clients record

Patient Self determination act – Right to identify written direction about the care that they wish to receive in the event that they become incapacitated and are unable to make health care decisions
• Advanced directive
• Durable power of attorney
• DNR