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2021 Care and Management of Adults > Unit 2 > Flashcards

Unit 2 Flashcards

1
Q

ileocecal valve

A

valve at junction of ileum of small intestine, cecum of colon (inferior), and ascending colon (superior)

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2
Q

appendix

A
  • vermiform appendix
  • worm-shaped tube connected to posterior aspect of cecum
  • 1-8 in (avg 3 in)
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3
Q

GI health Hx

A
  • age
  • gender
  • family Hx
  • culture
  • travel
  • SDOH
  • Hx of GI d/o, surgery, meds
    • ASA
    • NSAIDs
    • laxatives
    • enemas
    • suppositories
    • herbals
  • health habits
    • exercise
    • smoking
    • tobacco
    • stress
  • nutrition
    • typical diet
    • allergies
    • wt loss/gain
    • eating habit changes
    • ETOH
    • caffeine
  • bowel patterns, concerns
  • presenting Sx
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4
Q

GI physical assessment

A
  1. inspection
  2. auscultation
  3. percussion
  4. light palpation
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5
Q

abd assessment landmarks

A
  • xiphoid process
  • costal margin
  • abd midline
  • umbilicus
  • rectus abdominis muscle
  • anterior superior iliac spine
  • inguinal ligament
  • symphysis pubis
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6
Q

GI labs

A
  • CBC: signs of bleed
  • liver
    • PT: clotting factors r/t fxn
    • LFT: fxn
    • CMP: fxn, albumin, BMP
  • BMP:electrolytes, renal fxn
  • pancreas fxn: amylase, lipase
  • FOBT
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7
Q

FOBT

A

fecal occult blood test

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8
Q

GI imaging

A
  • EGD
    • esophagus, stomach, duodenum
    • prep
      • NPO for 6-8 hr before
      • avoid blood thinners, NSAIDs
    • check gag reflex before D/C of NPO
  • ERCP
    • pancreas, liver, gallbladder, bile duct
    • exam and Tx of obstruction
  • colonoscopy/sigmoidoscopy
    • prep
      • clear liquids 1 day, NPO 4-6 hr before
      • avoid blood thinners and NSAIDs several days
      • avoid red, orange, purple drinks
      • bowel cleanse (go-lytely no appropriate for OA)
    • post: monitor for bleeding, pain (perf)
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9
Q

IBD

A

inflammatory bowel dz

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10
Q

acute inflammatory bowel dz

A
  • appendicitis
  • gastroenteritis
  • peritonitis
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11
Q

chronic inflammatory bowel dz

A
  • ulcerative colitis
  • Crohn’s dz
  • diverticulitis
  • celiac dz
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12
Q

appendicitis

A
  • obstruction of lumen of appendix
  • fecalith → infection in appendix wall
  • at risk: adolescents, young adults
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13
Q

fecalith

A

mass of hardened fecal matter

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14
Q

appendicitis assessment

A
  • Hx of illness and complete pain assessment
    • abd pain → N/V → anorexia
    • cramping pain in epigastric or periumbilical area
  • light palp @ McBurney’s point
    • guarding
    • muscle rigidity
    • rebound tenderness
  • lab: possibly ↑ WBCs w/ shift to left
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15
Q

McBurney’s point

A
  • exterior landmark for appendix
  • about 1/3 of the way between the ASIS and umbilicus and 1-2 in above ASIS
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16
Q

ASIS

A

anterior superior iliac spine

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17
Q

appendicitis interventions

A
  • hospitalization
  • NPO to prep for possible surgery
  • pain management
  • surgery
    • appendectomy when indicated (lap preferred)
    • exploratory lap
      • Dx not definitive
      • high risk for complications
  • post-op care including splinting to cough
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18
Q

peritonitis

A
  • contamination of peritoneum by bacteria or chemicals
  • acute inflammatory process
    • local rxn → diffuse pertonitis
    • peristalsis slows or stops
    • fluid accumulates in intestine @ 7-8 L/day
    • → septicemia → septic shock → death
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19
Q

peritoneum

A
  • serous membrane
  • forms closed sac
  • encloses peritoneal cavity, potential space between layers of peritoneum
  • contains ~50 mL sterile fluid
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20
Q

etiology of pertonitis

A
  • bacterial: gains entry via perf
    • appendicitis
    • diverticulitis
    • PUD
    • external penetrating wound
    • gangrenous gall bladder
    • bowel obstruction
    • ascending from genital tract
    • surgery
    • CAPD
  • chemical
    • bile leakage
    • pancreatic enzymes
    • gastric acid
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21
Q

peritonitis assessment

A
  • Hx
  • S/Sx
    • abdomen
      • rigid, board-like
      • often rebound tenderness
      • distention
      • ↓ bowel sounds
    • GI
      • inability to pass flatus or stool
      • anorexia
      • N/V
    • systemic/CV
      • high fever
      • tachycardia
      • dehydration from fever
    • GU: ↓ UOP
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22
Q

Dx of peritonitis

A
  • labs
    • WBC ≤ 20,000/μL, ↑ neutrophils
    • blood cultures to Dx septicemia, ID organism
    • fluid: H&H
    • renal: BUN, Cr
  • imaging to check for air/fluid in abd cavity
    • abd X-ray
    • US
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23
Q

peritonitis interventions

A
  • assess VS frequently, monitor for signs of shock
  • O2 PRN
  • monitor I&O
  • NGT for decompression
  • possible surgery to find/repair cause
  • restore fluid volume PRN
  • abx as ordered
  • manage pain
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24
Q

signs of septic shock

A
  • hypotension
  • ↓ pulse pressure
  • tachycardia
  • fever
  • skin changes
  • tachypnea
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25
Q

gastroenteritis

A
  • inflammation of mucous membranes of stomach and/or small bowel
  • trigger: bacterial or viral (most common) infection
  • most cases self-limiting, ~ 3 days
  • risk for
    • fluid and electrolyte imbalance
    • impaired nutrition
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26
Q

most common foodborne dz

A

norovirus

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27
Q

gastroenteritis assessment

A
  • Hx: recent restaurant visit (24-36 hr) or travel
  • S/Sx
    • ill appearance
    • N/V → abd cramping, diarrhea
    • signs of dehydration
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28
Q

gastroenteritis interventions

A
  • prevent spread
    • handwashing
    • sanitizing surfaces
  • self-manage @ home unless severe
  • oral fluid replacement w/ Gatorade, Powerade, or Pedialyte
  • avoid antiemetics/antidiarrheals, or any drug that suppresses gastric motility
  • abx may be needed for bacterial infection
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29
Q

UC

A

ulcerative colitis

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30
Q

Most UC pts are diagnosed at what ages?

A

most Dx @ 15-35 y/o​

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31
Q

UC patho

A
  • inflammation of rectosigmoid colon, can extend to whole colon
  • priodic remissions and exacerbations
  • mucosa →
    • hyperemic
    • edematous
    • reddened
    • bleed w/ small erosions
    • possible abscesses → tissue necrosis
      • → edema, mucosal thickening → partial bowel obstruction
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32
Q

UC complications

A
  • abscesses
  • hemorrhage (perf)
  • tosic megacolon
  • malabsorption
  • nonmechanical bowel obstruction
  • fistulas
  • colorectal CA (Hx > 10 yrs)
  • extraintestinal complications
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33
Q

extraintestinal complications of UC

A
  • arthritis
  • hepatic and biliary dz
  • oral and skin lesions
  • ocular d/o
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34
Q

assessment of UC

A
  • fam Hx of IBD
  • nutrition Hx and habits
  • bowel elimination pattern
  • onset of Sx
  • VS
  • abd distention, pain
  • psychosocial assessment
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35
Q

UC clinical presentation

A
  • abd distension
  • blood and mucus in stool
  • lower abd colicky pain relieved w/ defecation
  • malaise
  • fatigue
  • anorexia
  • wt loss
  • extraintestinal manifestations
  • fever
  • anemia
  • dehydration
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36
Q

UC severity scale

A
  • mild: < 4 stools/day, non-bloody
  • moderate: > 4 stools/day, w/ or w/o blood
  • severe: > 6 bloody stools/day
  • fulminant: > 10 bloody stools/day
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37
Q

fulminant

A

coming on suddenly and with great severity

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38
Q

labs for UC

A
  • similar to those for Crohn’s dz
  • ↓ H&H: chronic blood loss
  • ↓ Na+, K+, and Cl-: diarrhea and malabsorption
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39
Q

imaging for UC

A
  • MRE
    • NPO 4-6 hr before
    • contrast used
  • colonoscopy
    • bowel prep very uncomfortable for UC/CD pts
    • frequent scopes recommended in 10+ yr Hx of UC d/t high CA risk
  • barium enema w/ air contrast
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40
Q

MRE

A

magnetic resonance enterography

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41
Q

UC interventions

A
  • meds: similar to those for Crohn’s
    • 5-ASAs
    • corticosteroids
    • antidiarrheals
    • BRMs (refractory, severe complications)
  • nutrition
    • bowel rest: NPO w/ TPN
    • avoid
      • caffeine
      • ETOH
      • some veggies, high-fiber foods
      • lactose
      • nuts
      • carbonated drinks
  • surgeries
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42
Q

surgical management of UC

A
  • temp or perm ileostomy: prior abd surgery or abd scar may r/o lap
  • RPC-IPAA
  • total proctocolectomy w/ perm ileostomy
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43
Q

RPC-IPAA

A

restorative proctocolectomy w/ ileal pouch-anal anastomosis

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44
Q

restorative proctocolectomy w/ ileal pouch-anal anastomosis

A
  • RPC-IPAA
  • two-stage procedure to manage UC
  • Stage 1
    • colon and rectum removed and temp ileostomy placed
    • internal pouch created from last part of small intestine and connected to anus, which remains intact
  • Stage 2: ileostomy reversal
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45
Q

Crohn’s disease

A
  • chronic inflammatory bowel dz
  • sites affected
    • small intestine, usually terminal ileum
    • colon
    • both
  • remission-exacerbation cycles
  • severe malabsorption by small intestine more common than in UC
  • inflammation → bowel wall thickening
    • fibrosis/scar tissue → strictures and obstruction
    • ulcerations → risk for fistula
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46
Q

CD

A

Crohn’s Disease

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47
Q

CD clinical presentation

A
  • varies by individual
  • diarrhea, possibly w/
    • steatorrhea
    • bright red blood
  • abd pain, RLQ, constant
  • fever w/ abscess, inflammation, or fistula
  • wt loss
  • fluid/electrolyte imbalance
  • anemia (blood loss + ↓ folic acid, B12)
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48
Q

psychosocial considerations for IBD

A
  • chronicity: self-management is important
  • requires lifestyle changes for pt and fm
  • level of anxiety
  • coping skills
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49
Q

labs for Crohn’s

A
  • inflammation: ↑ C-reactive protein, ESR
  • blood loss: ↓ H&H, albumin
  • diarrhea, fistula: ↓ K+, Mg2+
  • enterovesical fistula or pyuria: ↑ WBCs in urine
  • CMP
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50
Q

imaging for CD

A
  • purpose: to determine motility, bleeding, ulcerations, stenosis, fistulas
  • types
    • MRE
    • abd/pelvic X-ray
    • US
    • CT
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51
Q

enterovesical fistula

A
  • opening from bladder to intestine
  • possible w/ IBD (esp. CD)
  • → WBCs in urine
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52
Q

pyuria

A
  • pus in urine
  • → WBCs in urine (UA)
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53
Q

CD drug therapy

A
  • 5-ASAs
  • BRMs/mAbs
  • abx as ordered
  • glucocorticoids
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54
Q

5-ASA drugs

A
  • aminosalicylates
  • used to ↓ inflammation in bowel in IBD
  • routes
    • rectal suppository or enema
    • PO
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55
Q

Glucocorticoids may mask S/Sx of _____.

A

infection

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56
Q

nutrition therapy for CD

A
  • exacerbations may require bowel rest (NPO + TPN)
  • avoid GI stimulants (caffeine, ETOH)
  • 3,000 kcal/day to promote fistula healing
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57
Q

Skin care is important for pts w/ _____, who may require _____ to capture drainage.

A
  • pts w/ fistulas
  • pouches to capture drainage
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58
Q

surgical management of CD

A
  • fistula repair or resection
  • small bowel resection
  • stricturoplasty
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59
Q

pt education for CD

A
  • rest during periods of exacerbation
  • ↓ stress, esp. if it’s a trigger
  • proper nutrition
  • wound/skin care w/ fistula (return demo)
  • S/Sx of infection
  • consult home health, SW, case management, dietician
  • support groups
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60
Q

post-op care for CD

A
  • pain mgmt
    • explore nonpharm options
    • goal: acceptable level of comfort for pt
  • watch for GI bleed
    • stool color/consistency
    • H&H
    • VS
  • altered body image
  • home health may be necessary
  • psychosicial considerations
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61
Q

stoma assessment

A
  • healthy: pink or red, moist
  • unhealthy
    • bleeding, leaking
    • itching, painful
    • swelling/bulging
    • pale or purple
    • dry
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62
Q

skin care for ileostomy

A
  • crucial to logevity of device
  • keep clean, dry
  • have properly fitting wafer
  • wound care team
  • pt teaching w/ return demo
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63
Q

pt education for ileostomy

A
  • avoid foods that cause gas or are high in fiber
  • pt should ID well-tolerated foods
  • get enough salt and water in diet
  • find ostomy system that works best
  • skin and stoma care
  • ostomy care
  • S/Sx of unhealthy stoma
    • stoma changes
    • ↑/↓ in stool output
    • severe abd pain
  • meds
    • avoid enteric-coated or capsules
    • NO laxatives or enemas
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64
Q

diverticulitis

A
  • inflammation and infection of bowel mucosa
  • etiology: bacteria, food, or fecal matter become trapped in one or more diverticula
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65
Q

diverticula

A

pouch-like herniations in intestinal wall

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66
Q

celiac dz

A
  • chronic inflammation of small intestine mucosa
  • autoimmune w/ genetic, environmental factors
  • → bowel wall atrophy, malabsorption
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67
Q

immune dz pts at higher risk for celiac dz

A
  • T1DM
  • RA
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68
Q

manifestations of celiac dz

A
  • (Sx vary by person)
  • anorexia
  • wt loss
  • abd pain, distention
  • diarrhea or constipation
  • steatorrhea
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69
Q

atypical manifestations of celiac dz

A
  • malnutrition
    • osteoporosis
    • Fe-deficiency anemia
    • protein-calorie malnutrition
  • joint pain, inflammation
  • lactose intolerance
  • migraine
  • epilepsy
  • depression
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70
Q

management of celiac dz

A
  • only Tx option is gluten-free diet
  • intestinal mucosa generally heal in 2 yrs
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71
Q

pt education for celiac dz

A
  • avoid gluten-containing products
    • wheat, other grains processed in wheat facility
    • gluten can also be in additives, drugs, or cosmetics
  • supplemental nutrition needed
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72
Q

noninflammatory intestinal d/o

A
  • obstruction
  • IBS
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73
Q

IBS

A

irritable bowel syndrome

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74
Q

intestinal obstruction

A
  • complete or partial
  • mechanical: physically blocked by object outside, inside, or in wall of intestine
  • nonmechanical (paralytic ileus): ↓ or absent peristalsis; neuromuscular disturbance
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75
Q

complications of bowel obstruction

A
  • fluid/electrolyte and acid-base imbalances
  • severe hypovolemia → AKI
  • risk for peritonitis w/ ↓ blood flow to intestine
  • sepsis
  • GI bleed
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76
Q

etiology of mechanical bowel obstruction

A
  • adhesions
  • tumor
  • complications of appendicitis
  • hernias
  • fecal impaction
  • strictures d/t inflammation or radiation Tx
  • intussusception
  • volvulus
  • fibrosis
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77
Q

etiology of nonmechanical bowel obstruction

A
  • POI
  • peritonitis
  • intestinal ischemia
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78
Q

POI

A

post-op ileus

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79
Q

volvulus

A

loop of intestine twists around itself and the mesentery that supplies it → obstruction

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80
Q

intestinal fibrosis

A
  • excessive scarring in intestines → obstruction or stricture
  • occurs in IBD
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81
Q

Sx of bowel obstruction

A
  • pain and/or cramping, maybe sporadic
  • vomiting possible
  • bile, mucus in vomitus
  • obstipation
  • diarrhea (diarrhea partial obstruction)
  • abd distention
  • auscultation
    • borborygmi above
    • sounds absent below
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82
Q

borborygmi

A

rumbling, gurgling bowel sounds

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83
Q

obstipation

A

failure to pass flatus

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84
Q

interventions for bowel obstruction

A
  • assess
    • VS
    • wt
    • abd
  • NPO until able to pass flatus, stool
  • NGT for decompression
  • disimpaction and/or enemas for lower fecal impaction
  • IV fluid replacement PRN
  • monitor electrolytes, fluid status
  • frequent oral care
  • surgery for complete mechanical obstruction
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85
Q

IBS

A

irritable bowel syndrome

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86
Q

irritable bowel syndrome

A
  • functional GI d/o
  • S/Sx: chronic or recurrent diarrhea, constipation, and/or abd pain and bloating
  • 3 types
    • IBS-C
    • IBS-D
    • IBS-A
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87
Q

IBS etiology

A
  • environmental: caffeine, carbonation, dairy
  • immunologic
  • genetic
  • hormonal
  • stress-related
  • infectious agents can be biomarkers for IBS
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88
Q

assessment for IBS

A
  • GI Hx
    • Sx and exacerbations, including flatulence, bloating, distention
    • nutrition
    • drugs
  • pain, often in LLQ
  • physical
    • usually stable wt
    • bowel sounds
      • hypo w/ C
      • hyper w/ D
  • labs normal
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89
Q

interventions for IBS

A
  • ambulatory care mgmt
  • self-mgmt
    • ↓ stress
    • general health education
    • ↑ dietary fiber, 30-40 g/day
    • 64-80 oz water/day
    • drug therapy
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90
Q

drug therapy for IBS

A
  • (depends on main Sx)
  • IBS-C: bulk-forming laxative (Metamucil)
  • IBS-D: antidiarrheal (Imodium)
  • others
    • muscarinic receptor antagonists to ↓ motility
    • probiotics
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91
Q

abd hernia etiology

A
  • etiology
    • weakness in abd muscle wall allows abd organs/structures to protrude
    • congenital or acquired via ↑ intra-abd pressure
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92
Q

types of abd hernias

A
  • indirect/direct inguinal
  • femoral
  • umbilical
  • incisional
  • epigastric
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93
Q

management of abd hernia

A
  • nonsurgical or surgical
  • reducible or irreducible
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94
Q

hernia strangulation

A
  • protruding abd structure is tightly trapped → gangrene
  • requires prompt surgery
  • nonsurgical reduction contraindicated, will severely compromise Tx and outcome
  • signs
    • N/V
    • fever
    • sudden pain that intensifies quickly
    • hernia bulge that turns red, purple, or dark
    • inability to move bowels or pass flatus
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95
Q

hemorrhoids

A
  • swollen or distended anorectal veins
  • prolapse of veins d/t ↑ intra-abd pressure
  • can be internal or external
  • common
  • significant if painful d/t thrombosis and bleeding
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96
Q

prevention of hemorrhoids

A
  • ↑ fluids
  • ↑ fiber
  • avoid straining during BM
  • exercise regularly
  • maintain healthy wt
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97
Q

Tx of hemorrhoids

A
  • nonpharm
    • cold packs
    • tepid sitz baths 3-4x/day
  • drugs
    • OTC topical
      • anesthetics
      • steroids
    • stool softeners
  • diet ↑ fiber and fluids
  • surgical: hemorrhoidectomy
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98
Q

hemorrhoidectomy

A
  • surgical removal of hemorrhoids
  • type depends on
    • degree of prolapse
    • presence of thrombi
    • health of pt
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99
Q

biliary system

A
  • parts
    • liver
    • gallbladder
    • pancreas
  • fxn: secrete enzymes for digestion in stomach and small intestine
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100
Q

gallbladder

A
  • pear-shaped, hollow organ
  • in RUQ inferior to liver
  • holds bile
  • bile flow
    • liver common hepatic duct → gallbladder
    • fat digestion triggers gallbladder ctx
      • → cystic + common hepatic
      • → common bile cystic + common hepatic
      • → common bile duodenum
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101
Q

cholecystitis

A
  • inflammation of gallbladder
  • acute or chronic
  • two types
    • calculous: d/t gallstones: most common
    • acalculous: w/o gallstones
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102
Q

cholelithiasis

A
  • formation of gallstones when bile salts precipitate in gallbladder
  • stones calcified or non
  • asymptomatic unless bile flow is obstructed
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103
Q

acute calculous cholecystitis

A
  • gallstones obstruct
    • cystic duct (most common)
    • gallbladder neck
    • common bile duct
  • → bile backup into gallbladder
  • →
    • irritation
    • inflammation
    • impaired circulation
    • edema
    • gallbladder distension
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104
Q

types of gallstones

A
  • pigmented/calcified
  • cholesterol
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105
Q

acute acalculous cholecystitis

A
  • inflammation of gallbladder w/o calculi
  • etiology: changes in filling or emptying of gallbladder (biliary stasis)
    • ↓ blood flow to gallbladder
    • anatomic issues
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106
Q

chronic cholecystitis

A
  • repeated episodes of gallbladder inflammation
  • often associated w/ calculi
  • outcomes
    • scarring, further gallbladder dysfunction
    • pancreatitis
    • cholangitis
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107
Q

bile obstruction →

A
  • infection
  • ↑ bilirubin
  • chronic liver dz
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108
Q

risk factors for cholecystitis

A
  • female gender
  • age
  • obesity
  • high-fat diet
  • rapid wt loss
  • malabsorption syndromes
  • HRT
  • contraceptives
  • genetics
  • PG
  • anatomical obstruction
  • prolonged TPN
  • ethnicity/race
    • Native American
    • Mexican
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109
Q

subjective data for cholecystitis

A
  • RUQ pain, often radiating to rt shoulder
  • rebound tenderness
  • can present as general abd pain
  • Sx after ingesting fatty food
    • N/V
    • belching
    • flatulance
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110
Q

objective data for cholecystitis

A
  • fever
  • tachycardia
  • dehydration (fever, vomiting)
  • jaundice/icterus
  • dark urine
  • clay-colored stools
  • steatorrhea
  • dyspepsia
  • eructation
  • flatulence
  • pruritus
  • OA: may not have fever or pain
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111
Q

labs for cholecystitis

A
  • ↑ WBCs
  • biliary obstruction: ↑ ALP, AST, LDH, and bilirubin
  • pancreatic involvement: ↑ amylas, lipase
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112
Q

diagnostics for cholecystitis

A
  • US (best intially)
  • abd X-ray, CT: shows only calcified stones
  • HIDA scan: traces bile flow to determine patency
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113
Q

HIDA scan

A
  • hepatobiliary iminodiacetic acid scan
  • used to trace flow of bile in cholecystitis Dx
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114
Q

ERCP

A

endoscopic retrograde cholangiopancreatography

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115
Q

MRCP

A

magnetic resonance cholangiopancreatography

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116
Q

magnetic resonance cholangiopancreatography

A
  • MRCP
  • oral/IV contrast used
  • detailed imaging of hepatobiliary and pancreatic structures
  • less invasive, safer that ERCP
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117
Q

endoscopic retrograde cholangiopancreatography

A
  • ERCP
  • direct visualization of liver, gallbladder, bile ducts, and pancreas
  • invasive
  • allows for therapeutic procedures
    • sphincterotomy
    • gallstone removal
    • stent placement
    • balloon dilation
    • Bx
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118
Q

ERCP with sphincterotomy

A
  • cholecystitis
    • a small cut made in papilla of Vater to enlarge opening of bile and/or pancreatic ducts
    • goals: improve drainage or remove stones in ducts
  • pancreatitis caused by gallstones
    • opening created in sphincter of Oddi
    • pacreatic duct sphincter enlarged if needed
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119
Q

nonsurgical management of cholecystitis

A
  • dietary
    • high fiber
    • low fat
    • small, frequent meals
  • drug therapy
  • ESWL
  • percutaneous transhepatic biliary drain w/ cholecystostomy
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120
Q

surgical management of cholecystitis

A
  • cholecystectomy: removal of gallbladder
  • lap chole: gold standard Tx
  • open: for severe obstruction
  • NOTES: new MIS procedure
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121
Q

lap chole

A
  • laparoscopic cholecystectomy
  • process
    • abd insufflated using 3-4 L CO2
    • trocars puncture abd, laparoscope inserted
    • bile aspirated, stones crushed
    • gallbladder removed via umbilical port
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122
Q

insufflated

A

blow air or gas into a cavity

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123
Q

MIS

A

minimally invasive surgery

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124
Q

NOTES

A

natural orifice transluminal endoscopic surgery

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125
Q

NOTES cholecystectomy

A
  • flexible scope passed through natural orifice to furth minimize size/number of incisions necessary
  • decreases post-op complications, and possibly pain
  • routes: mouth, vagina, anus
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126
Q

traditional/open cholecystectomy

A
  • for severe biliary obstruction
  • rarely done
  • biliary ducts explored to ensure patency
  • drain may be placed to reduce post-op fluid accumulation
    • JP
    • T-tube
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127
Q

classes of drugs used for cholecystitis

A
  • pain
    • opioids for acute pain
    • ketorolac for mild-moderate pain
  • N/V: antiemetics
  • inflammation/infection: IV abx
  • stones: bile acids
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128
Q

opioids for cholecystitis

A
  • for acute biliary pain
  • drugs
    • morphine sulfate
    • hydromorphone
  • may cause sphincter of Oddi spasm
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129
Q

ketorolac for cholecystitis

A
  • for mild to moderate biliary pain
  • NSAID
  • risk for GI bleed
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130
Q

bile acids for cholecystitis

A
  • to dissolve cholesterol-based stones in pts who cannot or will not undergo surgery
  • compounds naturally produced in body
  • drugs: take w/ food or milk
    • ursodiol
    • chenodiol
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131
Q

ESWL

A

extracorporeal shock wave lithotripsy

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132
Q

ESWL for cholelithiasis/cholecystitis

A
  • breaks up small, cholesterol-based stones
  • good when surgery is contraindicated
  • requirements
    • average/normal wt
    • good gallbladder fxn
  • process
    • pt lays on fluid-filled pad
    • shock waves delivered via pad
  • possible results
    • spasms
    • stone movement
    • pain, discomfort
  • meds: possible UDCA to further break up fragments
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133
Q

UDCA

A
  • ursodeoxycholic acid
  • bile acid
  • sometimes used after ESWL to break up remaining fragments
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134
Q

JP drain

A
  • Jackson-Pratt
  • surgical drain with flexible bulb that uses gentle mechanical suction to remove accumulating fluid
  • expected course
    • diminishing amounts of serosanguineous
    • color: red → light pink/yellow
    • removal when drainage < 25 mL/day x2 days
  • monitor and document output closely
  • abx to prevent infection
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135
Q

T-tube management

A
  • expected course
    • sanguineous/serosanguineous → bile color
    • ≤ 400 mL in first 24 hr, then ↓
    • removal in 1-3 wks
  • no drainage + N/V could mean obstruction
  • monitor
    • and record color, amount
    • insertion site for inflammation, infection, leakage
    • color of stools (white/clay = no bile)
    • VS
    • skin color
    • pain level
    • tolerance of diet/intake
  • pain meds, abx
  • ​report immediately
    • ​abd pain + fever + jaundice = bile peritonitis
    • output 500 mL/24 hr
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136
Q

T-tube

A
  • surgical drain placed in common bile duct after surgery and exploration
  • prevents buildup of bile d/t postop swelling/inflammation
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137
Q

pt education for cholecystitis

A
  • preop/postop info baseed on procedure
  • dietary: avoid fatty and gas-causing foods
  • post-op
    • lap chole: early ambulation to expel CO2
    • incision/drain care
    • S/Sx of dehiscence or evisceration
    • resume activity gradually
    • open chole: no heavy lifting for 4-6 wks
    • drain: showers, not baths, until removed
  • S/Sx of infection, when to see provider
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138
Q

complications of cholecystitis and Tx

A
  • bile duct obstruction
  • gallbladder rupture
  • peritonitis
  • post-cholecystectomy syndrome
  • hepatic CA
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139
Q

post-cholecystectomy syndrome

A

manifestations of gallbladder dz after removal

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140
Q

pancreas anatomy

A
  • shape: elongated, tapered
  • position
    • retroperitoneal, posterior to stomach
    • close to liver, near L1, L2 vertebrae
    • head on right (larger end)
      • in curve of duodenum
      • connected by pancreatic duct
    • tail on left (smaller), near spleen
    • head lies in curve of duodenum, connected by pancreatic duct
  • composition: 2 types of glands
    • 95% exocrine by mass
    • 1-2% endocrine
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141
Q

exocrine glands of pancreas

A
  • makes up 95% of pancreas by mass
  • secrete enzymes to break down starches, proteins, and fats
  • activated by presence of food small intestine
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142
Q

endocrine glands of pancreas

A
  • 1-2% of pancreas by mass
  • consists of islets of Langerhans
  • primary d/o associated w/ these glands: DM
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143
Q

substances secreted into duodenum by exocrine pancreas

A
  • alkali: HCO3
  • enzymes
    • proteases
      • trypsinogen
      • chymotrypsinogen
    • amylase
    • lipase
    • other enzymes
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144
Q

HCO3

A
  • bicarbonate
  • alkaline/base
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145
Q

role of bicarbonate in digestion

A
  • secreted from pancreatic duct cells → lumen → duodenum
  • neutralizes HCl from stomach
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146
Q

substances secreted by endocrine pancreas

A
  • insulin
  • glucagon
  • somatostatin
  • pancreatic polypeptide
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147
Q

pancreatitis

A
  • inflammation of pancreas
  • etiology: not always known; possibilities are
    • obstructions
    • ETOH
    • autimmune dz
  • acute or chronic
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148
Q

acute pancreatitis

A
  • inflammation of pancreas →
    1. ↑ duct pressure
    2. → duct rupture
    3. → enzymes released in pancreas
    4. → autodigestion of pancreatic tissue
    5. → inflammation, pain, fibrosis
  • untreated → NHP
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149
Q

NHP

A
  • necrotizing hemorrhagic pancreatitis
  • result of untreated pancreatitis
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150
Q

necrotizing hemorrhagic pancreatitis

A
  • result of untreated pancreatitis
  • involves these processes
    • diffuse bleeding of pancreatic tissue
    • scarring
    • tissue death
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151
Q

chronic pancreatitis

A
  • → permanent damage
  • almost always result of ETOH abuse
  • several types
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152
Q

How does ETOH affect the pancreas?

A

↑ enzyme production

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153
Q

types of chronic pancreatitis

A
  • chronic calcifying: usually r/t ETOH abuse
  • chronic obstructive: usually r/t cholelithiasis
  • autimmune
  • idiopathic
  • hereditary
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154
Q

pancreatitis risk factors

A
  • ETOH and drug toxicity
  • stones in common bile duct
  • genetics
  • cystic fibrosis
  • trauma
  • postop manipulation
  • OA
  • viral infection
  • autoimmunity
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155
Q

symptoms of pancreatitis

A
  • sudden onset of pain
    • possible locations
      • LUQ radiating to back
      • mid-epigastric
      • left flank
      • left shoulder
    • descriptions
      • boring
      • gnawing
      • stabbing
    • often relieved by bending abd
    • worse when lying down
  • N/V, w/ no relief of pain
  • wt loss
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156
Q

signs of pancreatitis

A
  • blood seeping into tissues
    • Cullen’s sign
    • Turner’s sign
  • jaundice
  • absent or hypoactive bowel sounds
  • hyperglycemia
  • abd guarding
  • tachycardia
  • fever
  • ascites
  • possible
    • palpable mass
    • paralytic ileus
    • pleural effusion
  • steatorrhea
  • dark urine
  • clay-colored stool
  • polyuria
  • polydipsia
  • polyphagia
  • hypocalcemia →
    • MSK tetany
    • Trousseau’s sign
    • Chvostek’s sign
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157
Q

Cullen’s sign

A
  • blood seeping into tissues → periumbilical discoloration
  • blue/gray
  • most often a sign of hemorrhagic pancreatitis
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158
Q

Turner’s sign

A
  • blood seeps into tissues → ecchymosis on flanks
  • most often a sign of hemorrhagic pancreatitis
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159
Q

Trousseau’s sign

A
  • hand spasm occurs when BP cuff inflated
  • indicates hypocalcemia
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160
Q

Chovstek’s sign

A
  • face twitches when facial nerve is tapped
  • indicates hypocalcemia
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161
Q

diagnostics for pancreatitis

A
  • CT w/ contrast: reliable, accurate
  • abd X-ray and/or US: to look for gallstones
  • ERCP
  • HIDA scan
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162
Q

nonsurgical management of pancreatitis

A
  • pharm Tx
  • ERCP w/ sphincterotomy
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163
Q

surgical management of pancreatitis

A
  • cholecystectomy
  • endoscopic pancreatic necrosectomy + NOTES
  • pancreaticojejunostomy
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164
Q

pharm Tx of pancreatitis

A
  • pain: opioids
    • morphine
    • hydromorphone
    • NOT meperidine (sz, esp. in OA)
  • inflammation/infection: abx
    • imipenem
    • usu. for necrotizing
    • monitor for S/Sx of infection, sz
  • acid reduction
    • H2 blocker: ranitidine
    • PPI: omeprazole
  • digestive aid: pancrelipase
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165
Q

pancrelipase

A
  • digestive aid used for pancreatitis
  • give w/ every food/snack
  • drink full glass of water
  • can sprinkle capsule contents on nonprotein foods
  • take after antacid or H2 blocker
  • wipe and rinse mouth to prevent breakdown
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166
Q

cholecystectomy for pancreatitis

A

for pancreatitis caused by cholecystitis and cholelithiasis

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167
Q

longitudinal pancreaticojejunostomy (Roux-en-Y)

A
  • reroutes pancreatic secretion drainage into the jejunum
  • Roux-en-Y: anastamosis technique used in LPJ
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168
Q

Roux-en-Y

A
  • anastamosis technique
  • used in several surgeries
    • pancreaticojejunostomy
    • pancreatic head resection
    • Tx of lesion in pancreatic head
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169
Q

surgical Tx for pancreatitis

A
  • cholecystectomy
  • endoscopic pancreatic necrosectomy and NOTES
  • pancreaticojejunostomy
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170
Q

LPJ

A

longitudinal pancreaticojejunostomy

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171
Q

dietary considerations for pancreatitis

A
  • NPO/gut rest until pain resolves
  • TPN or J-tube feedings if condition not severe
  • J-tube contraindicated if pt has paralytic ileus
  • restarting solid food
    • bland
    • high-protein
    • low-fat
    • small, frequent meals
    • no caffeine
  • may need dietary consult
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172
Q

TPN

A

total parenteral nutrition

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173
Q

PPN

A

peripheral parenteral nutrition

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174
Q

nursing care of pancreatitis pts

A
  • give meds as ordered: analgesics, abx, antiemetics
  • position for comfort
    • fetal
    • side-lying
    • HOB elevated
    • sitting leaned forward
  • monitor
    • BG, give insulin as ordered
    • hydration: I&O, labs, orthostatic BP
  • give IV fluids, electrolytes as ordered
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175
Q

total parenteral nutrition

A
  • hypertonic IV solution
  • only give in central line
  • complete nutrition
  • usually
    • ≤ 700 kcal/day
    • ↑ glucose concentration
  • can be given w/ lipids, ≤ 30% concentration
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176
Q

peripheral parenteral nutrition

A
  • ≤ 10% dextrose
  • given via PIV
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177
Q

types of IV solutions

A
  • isotonic
  • hypotonic
  • hypertonic
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178
Q

isotonic IV solution

A
  • NS
  • osmolarity ≈ plasma
  • solution stays in intravasular space
  • expands intravascular compartment, ↑ fluid volume
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179
Q

hypotonic IV solutions

A
  • 1/2 NS
  • osmolarity lower than plasma
  • draws fluid out of intravascular compartment
  • hydrates cells and interstitial compartment
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180
Q

hypertonic IV solutions

A
  • TPN, 3% NS
  • osmolarity higher than that of plasma
  • draws fluid into intravascular compartment from cells, interstitial compartment
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181
Q

TPN Rx must be verified by _____ _____.

A

another RN

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182
Q

pancreatitis labs

A
  • cell injury
    • ↑ serum amylase
    • ↑ serum lipase
    • ↑ serum trypsin
    • ↑ serum elastase
  • cell injury/↓ insulin release: ↑ serum glucose
  • fat necrosis: ↓ Mg2+ and Ca2+
  • hepatobiliary involvement
    • ↑ bilirubin (obstruction)
    • ↑ ALT
    • ↑ AST
  • inflammation: ↑ WBCs, ESR
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183
Q

things to monitor when administering TPN

A
  • I&O +
    • daily wt
    • PO nutrient intake
  • labs
    • prealbumin
    • albumin
    • glucose
    • electrolytes
    • CBC
  • infection
    • fever, chills
    • ↑ WBCs
    • redness @ catheter insertion
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184
Q

allergies to check for before giving TPN

A
  • soybeans
  • safflower
  • eggs (lipid solution)
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185
Q

TPN administration

A
  • use
    • micron filter
    • IV pump
    • strict asepsic technique
  • rate
    • start slowly
    • increase to goal rate gradually
    • NEVER catch up by increasing rate
    • NEVER STOP SUDDENLY
    • taper to D/C
  • if next bag unavailable, use destrose solution
  • change bag and tubing Q24H
  • TOTAL INCOMPATIBLE
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186
Q

What other meds or solutions can be added to TPN?

A

none

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187
Q

How often should TPN bag and tubing be changed?

A

Q24H

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188
Q

When administering TPN with lipids, where should the lipids be connected?

A

distal to the filter

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189
Q

If TPN is unavailable, what solutions should be used in its place and why?

A

D10W or D20W

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190
Q

metabolic complications of TPN

A
  • hyper- or hypoglycemia
  • electrolyte imbalances
  • dehydration
  • fluid overload
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191
Q

mechanical complications of TPN admin

A
  • catheter misplacement
  • embolus
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192
Q

How can TPN cause dehydration?

A

hyperosmolar diuresis from hyperglycemia

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193
Q

What indicates fluid overload from TPN?

A

wt gain > 1 kg/day + edema

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194
Q

types of complications from TPN

A
  • metabolic
  • mechanical
  • infectious (→ sepsis)
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195
Q

adjunct orders for TPN

A
  • sliding scale or IV insulin for hyperglycemia
  • dextrose for hypoglycemia
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196
Q

Why must TPN be tapered?

A

to avoid rebound hypoglycemia

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197
Q

You should notify the provider if a pt on TPN gains >.___ kg/day.

A

1 kg/day

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198
Q

pt education for pancreatitis

A
  • S/Sx
  • proper diet
  • importance of med adherence, esp. if chronic
  • ETOH cessation
  • management of complications
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199
Q

complications of pancreatitis

A
  • hypovolemia
  • left pleural effusion → pneumonia
  • DIC
  • multi-system organ failure
  • T2DM or T1 if pancreas is destroyed
  • paralytic ileus
  • pancreatic abscess
  • pancreatic pseudocyst
  • pancreatic CA
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200
Q

hypovolemia w/ pancreatitis

A
  • cause: third-spacing
  • → hypovolemic shock
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201
Q

third-spacing

A

too much fluid moves intravascular → interstitial

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202
Q

S/Sx of hypovolemic shock

A
  • restlessness
  • anxiety
  • agitation
  • confusion
  • weakness
  • lightheadedness
  • tachycardia
  • appearance: stable → critically ill
  • AMS
  • UOP < 30 mL/hr
  • ↑ cap refill
  • gooseflesh
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203
Q

nursing care of paralytic ileus 2/2 pancreatitis

A
  • may require prolonged NGT for decompression
  • assess for passage of flatus
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204
Q

Pancreatic abscess occurs with _____ pancreatitis.

A

necrotizing

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205
Q

pancreatic abscess considerations

A
  • must be drained
  • abx not effective alone
  • ↑ mortality d/t easy spread to other organs
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206
Q

pancreatic pseudocyst considerations

A
  • can rupture and cause
    • hemorrhage
    • abscess
    • fistula
  • Tx
    • may resolve on its own
    • surgical removal
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207
Q

pancreatic CA overview

A
  • devastating
  • low 5-year survival
  • often found late
    • well-developed
    • aggressive
  • very painful; pt often has vague abd pain
  • common Tx: Whipple
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208
Q

Whipple procedure

A
  • pancreaticoduodenectomy
  • removal of
    • head of pancreas
    • parts of stomach
    • duodenum
    • gallbladder
    • bile duct
  • sometimes used as Tx for pancreatic CA
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209
Q

cirrhosis

A

chronic, irreversible inflammation and scarring of liver tissue

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210
Q

cirrhosis →

A
  • loss of normal cellular fxn
  • development of nodules and fibrous tissue
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211
Q

causes of cirrhosis

A
  • chronic ETOH use
  • drugs
  • toxins
  • hepatitis
  • NAFLD
  • gallbladder dz
  • CV dz
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212
Q

What types of hepatitis cause cirrhosis?

A
  • viral
    • most common: B and D
    • second most common: C
  • autoimmune
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213
Q

NAFLD

A

non-alcoholic fatty liver dz

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214
Q

non-alcoholic fatty liver dz

A
  • NAFLD
  • associated w/
    • obesity
    • metabolic syndrome
    • DM
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215
Q

types of cirrhosis

A
  • post-necrotic
  • Laennec’s (alcoholic)
  • biliary/cholestatic
  • compensated
  • decompensated
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216
Q

cause of post-necrotic cirrhosis

A
  • hepatitis
  • drugs
  • toxins
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217
Q

causes of biliary/cholestatic cirrhosis

A
  • biliary obstruction
  • AID
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218
Q

compensated cirrhosis

A

performs necessary fxn despite scarring

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219
Q

decompensated cirrhosis

A

obvious manifestations of liver failure

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220
Q

cirrhosis complications

A
  • portal HTN
  • ascites
  • esophageal varices
  • coagulation problems
  • jaundice
  • encephalopathy
  • hepatorenal syndrome
  • spontaneous bacterial peritonitis
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221
Q

portal HTN

A

↑ > 5 mm Hg in portal vein

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222
Q

portan HTN cause

A
  • ↑ resistance of blood flow in portan vein
  • obstruction prevents normal blood flow
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223
Q

cirrhosis → portal HTN →

A
  • (blood rerouted to nearby vessels)
  • esophageal varices
  • ascites
  • splenomegaly
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224
Q

acute mgmt of bleeding esophageal varices

A
  • hemodynamic resuscitation
  • octreotide
  • blanding, sclerotherapy
  • prophylactic abx
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225
Q

chronic mgmt of esophageal varices

A
  • beta blockers
  • endoscopic variceal ligation
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226
Q

ascites

A

collection of free fluid in peritoneal cavity

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227
Q

ascites causes

A
  • ↑ pressure from portal HTN
  • Na+ retention → renin-angiotensin activation
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228
Q

ascites process

A
  • plasma protein accumulates in peritoneal fluid
    • → ↓ plasma protein in blood + ↓ albumin production
    • → ↓ osmotic pressure in vessels
    • → fluid shift to abd
    • → hypovolemia + edema
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229
Q

Bleeding esophageal varices are an _____.

A

emergency

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230
Q

esophageal varices cause

A
  • ↑ pressure in portal vein
  • → blood flow backup into esophagus
  • → fragile, thin-walled veins in esophagus become tortuous
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231
Q

signs of bleeding esophageal varices

A
  • hematemesis
  • melena
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232
Q

cause of bleeding in esophageal varices

A
  • spontaneous
  • anything that ↑ pressure
  • damage to esophagus
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233
Q

splenomegaly cause

A
  • (blood flow backup into spleen)
  • portal hypertension
  • CHF
  • splenic vein obstruction
  • etc.
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234
Q

splenomegaly process

A
  • spleen enlargment
  • → platelet destruction
  • → ↑ risk for bleed
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235
Q

Thrombocytopenia caused by _____ may be the first clinical sign of _____ dysfunction.

A
  • caused by splenomegaly
  • liver dysfunction
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236
Q

Cirrhotic liver does not produce enough _____.

A

bile

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237
Q

bile fxn

A

helps w/ absorption of fat-soluble vitamins

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238
Q

↓ bile production → ↓ vitamin ___ absorption, which is necessary for production of _____ _____

A
  • vitamin K
  • clotting factors
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239
Q

hepatocellular jaundice

A
  • liver cells do not effectively excrete bilirubin
  • → excess bilirubin in circulation
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240
Q

intrahepatic obstructive jaundice

A
  • causes
    • edema
    • fibrous tissue
    • scarring of channels, ducts
  • interferes w/ bile and bilirubin excretion
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241
Q

medical term for jaundice

A

icterus

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242
Q

types of jaundice

A
  • hepatocellular
  • intrahepatic obstructive
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243
Q

PSE

A
  • portal-systemic encephalopathy
  • AKA hepatic encephalopathy
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244
Q

portal-systemic encephalopathy

A
  • AKA hepatic encephalopathy, PSE
  • complex cognitive syndrome
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245
Q

characteristics of PSE

A
  • AMS
  • speech problems
  • mood changes
  • sleep disturbances
  • later
    • altered LOC
    • impaired thinking
    • impaired neuromuscular fxn
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246
Q

hepatic encephalopathy

A
  • acute or insidious
    • etiology unknown, but unclear link to ↑ serum ammonia
  • 4 stages
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247
Q

Stage I hepatic encephalopathy

A
  • subtle changes in
    • thinking
    • personality
    • behavior
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248
Q

Stage II hepatic encephalopathy

A
  • ↑ Sx of
    • confusion
    • disorientation
    • asterixis
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249
Q

asterixis

A
  • abnormal muscle tremor
  • involuntary jerking movements
  • esp. in hands, but also seen in tongue, feet
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250
Q

Stage III hepatic encephalopathy

A
  • marked confusion
  • stupor
  • hyperreflexia
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251
Q

Stage IV hepatic encephalopathy

A
  • unresponsive
  • unarousable
    • Babinski
  • fetor hepaticus
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252
Q

fetor hepaticus

A

mousy odor in the breath of people with severe liver impairment

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253
Q

Babinski sign in adults

A
  • dorsiflexion of the great toe when the sole of the foot is stimulated
  • in adults, could indicate
    • lesion of the pyramidal (corticospinal) tract
    • hepatic encephalopathy
    • other neurological conditions
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254
Q

potential factors in development of hepatic encephalopathy

A
  • high-protein diet
  • infection
  • hypovolemia
  • hypokalemia
  • constipation
  • GI bleed
  • drugs
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255
Q

Hepatorenal syndrome may occur after what 2 conditions?

A
  • GI bleed + clinical deterioration
  • onset of hepatic encephalopathy
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256
Q

hepatorenal syndrome signs

A
  • sudden ↓ of UOP: < 500 mL/24 hr
  • ↑ BUN
  • ↑ Cr
  • ↓ Na+ excretion
  • ↑ urine osmolarity
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257
Q

possible cause of spontaneous bacterial peritonitis

A
  • ​abnormally low protein levels
  • bacteria from bowels → ascitic fluid
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258
Q

S/Sx of spontaneous bacterial peritonitis

A
  • possibly none
  • fever
  • chills
  • abd pain/tenderness
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259
Q

Dx of spontaneous bacterial peritonitis

A
  • WBC count
  • ascitic fluid culture
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260
Q

cirrhosis assessment Hx

A
  • demographic data
  • lifestyle
    • ETOH, drug, toxin exposure
    • illicit drugs
    • OTC meds
    • sexual Hx
    • needle exposures
    • travel
    • close-quarter living
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261
Q

S/Sx of early or compensated cirrhosis

A
  • vague Sx
    • fatigue
    • wt change
    • GI Sx
    • abd pain
  • labs
    • thrombocytopenia
    • abnormal LFTs
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262
Q

S/Sx of advanced cirrhosis

A
  • jaundice
  • petechiae
  • ecchymoses
  • spider angiomas on
    • nose
    • cheeks
    • thorax
    • shoulders
  • ascites
  • edema
    • peripheral
    • sacral
  • vitamin deficiency, esp. K
  • hepatomegaly
  • splenomegaly
  • fetor hepaticus
  • asterixis
  • neurological dysfunction
  • gynecomastia
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263
Q

3 important things to monitor in cirrhosis

A
  • abd girth
  • daily wt
  • neurological fxn
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264
Q

lab assessment for liver dz

A
  • may normalize w/ ↑ deterioration
    • AST
    • ALT
  • LDH
  • biliary obstruction
    • GGT
    • ALP
  • bilirubin
  • ↑
    • PT/INR
    • ammonia
  • ↓
    • serum protein
    • albumin
    • platelets
    • RBCs
    • H&H
    • WBC
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265
Q

elimination assessment for liver dz

A
  • urine: ↑ urobilirubin
  • stool
    • ↓ urobilinogen conc. r/t biliary obstruction
    • clay-colored or light
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266
Q

diagnostics for liver dz

A
  • imaging: hepatomegaly, splenomegaly, ascites, lesions/masses
    • X-ray
    • CT
    • MRI
  • Bx
  • US: liver visualization, portal vein blood flow
  • EGD
    • visualization of esophageal varices, bleeding
    • ulceration
  • ERCP
    • contrast to view sphincter of Oddi, biliary tract
    • remove stones if necessary
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267
Q

nursing priority for liver dz

A

remove excess fluid

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268
Q

nutrition therapy for liver dz

A

Na+ restriction

vitamin, electrolyte replacement

IV vitamins for late-stage liver dz

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269
Q

meds for liver dz

A
  • diuretics
  • abx
  • propranolol
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270
Q

paracentesis

A
  • removal of excess ascitic fluid
  • at bedside or in IR
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271
Q

Tx for fluid volume excess

A

respiratory support for hepatopulmary syndrome

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272
Q

respiratory support for hepatopulmary syndrome

A
  • ↑ abd pressure r/t ascites
  • prevents thoracic expansion
  • monitor
    • SpO2
    • respiratory effort
    • daily wt
  • elevate
    • HOB
    • edmatous limbs
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273
Q

drug therapy for intact esophageal varices

A
  • beta blockers
    • ↓ HR
    • ↓ hepatic venous pressure gradient
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274
Q

drug therapy for bleeding esophageal varices

A
  • vasopressin
    • ↓ blood flow
    • ↑ vasoconstriction
  • octreotide
    • ↓ secretion of
      • gastrin
      • serotonin
      • peptides
    • → ↓ GI blood flow
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275
Q

EVL

A

endoscopic variceal ligation

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276
Q

Tx for bleeding esophageal varices

A
  • EVL
  • EST
  • SB tube
  • TIPS
  • others
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277
Q

EST

A

endoscopic sclerotherapy

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278
Q

goals of EVL

A
  • ↓ bleeding
  • ↓ blood supply to varices
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279
Q

endoscopic sclerotherapy

A
  • goal: stop bleeding
  • process: catheter injects sclerosing agent into vein
  • complications: ulceration of mucosa → further bleeding
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280
Q

Sengstaken-Blakemore tube

A
  • procedure
    • in mouth or nare → stomach
    • balloon inflated to apply pressure to bleeding varices
  • complications
    • aspiration
    • asphyxia
    • esophageal perf
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281
Q

SB tube

A
  • Sengstaken-Blakemore tube
  • used to stop esophageal bleeding
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282
Q

TIPS

A
  • transjugular intrahepatic portal-systemic shunt
  • Tx for bleeding esophageal varices
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283
Q

transjugular intrahepatic portal-systemic shunt

A
  • TIPS
  • to treat bleeding esophageal varices
  • performed in IR
  • US-guided placement of stent in portal vein
  • follow-up to ensure patency
284
Q

NGT placement in Tx of bleeding esophageal varices

A

as needed to monitor for further bleeding

285
Q

possible transfusions for esophageal varices bleed

A
  • pRBCs
  • FFP
  • albumin
  • platelets
286
Q

labs for esophageal varices bleed

A
  • PT/INR
  • PTT
  • platelets
287
Q

nursing priority for hepatic encephalopathy

A
  • SERUM AMMONIA
  • liver can’t convert → remains in circulation → brain
  • also produced by GI bacteria
    • moderate-protein diet
    • drug therapy
288
Q

drug Tx for hepatic encephalopathy

A
  • laxative: lactulose
  • abx: ↓ GI bacteria
    • rifaximin
    • metronidazole
    • vancomycin
289
Q

pt education for liver dz

A
  • nutrition
    • follow diet
    • supplements
    • vitamin/electrolyte replacement
  • meds
    • avoid all OTCs
    • supply of lactulose
  • ETOH abstinence
  • Fm education: S/Sx of
    • encephalopathy
    • fluid shift/retention
    • bleeding
290
Q

hepatitis etiology

A
  • exposure to causative source → inflammation, necrosis
  • causes
    • viral strains A-E
    • other viral hepatitis
    • toxin- and drug-induced
    • secondary infection
      • Epstein-Barr
      • herpes
      • varicella-zoster
      • CMV
291
Q

hep A

A
  • enterovirus
  • prognosis
    • generally recoverable
    • more severe in OA
  • destroyed by bleach and very high temps
292
Q

hep B

A
  • composed of antigens
  • circulates in blood
  • prognosis
    • most adults clear infection, become immune
    • others become carriers
293
Q

hep B S/Sx

A
  • fever
  • anorexia
  • N/V
  • RUQ pain
  • dark urine
  • light stool
  • jaundice
  • joint pain
294
Q

hep B transmission

A
  • unprotected sex
  • needles
    • sharing
    • accidental sticks
    • transfusions
    • hemodialysis
  • close person-person contact w/ open wound
295
Q

hep A transmission and S/Sx

A
  • transmission: fecal-oral
    • hand-hand
    • food/water contamination
  • S/Sx: flu-like
296
Q

hep C

A
  • HCV
  • most common hep virus
  • most are unaware of infection
297
Q

hep C transmission

A
  • blood-blood
  • needles
    • IV needle sharing
    • accidental sticks
    • tattoo equipment
  • blood
    • blood products
    • organ transplant
298
Q

hep C prognosis

A

untreated → chronic liver inflammation/scarring → cirrhosis

299
Q

hep D

A
  • defective RNA → needs HBV to replicate
  • prognosis: usually becomes chronic dz
300
Q

hep D transmission

A
  • parenteral
  • IV needle sharing
  • sexual contact
301
Q

hep E

A
  • geographical prevalence
    • Asia
    • Africa
    • Middle East
    • Mexico
    • Central and South America
    • only among international travelers in U.S.
  • prognosis: generally self-limiting, not chronic
302
Q

hep E manifestations

A

similar presentation to hep A

flu-like Sx

303
Q

hepatitis complications

A
  • fulminant hepatitis
  • chronic hepatitis
304
Q

fulminant hepatitis

A
  • severe acute hepatitis
  • failure of liver cells to regenerate
  • progression of necrosis
  • can be fatal
305
Q

chronic hepatitis

A
  • inflammation > 6 mo
  • etiology
    • generally HBV or HCV
    • also w/ combo infections and HIV
  • → cirrhosis, liver CA
306
Q

health promotion and maintenance for hepatitis

A
  • vaccines
    • HAV
    • HBV
  • HAV
    • proper handwashing
    • avoid contaminated food/water
  • HBV
    • avoid unprotected, risky sexual contact
    • exposure to blood or bodily fluids
307
Q

expected hepatitis labs

A
  • ↑ ALT
  • ↑ AST
308
Q

drug usage → hepatitis

A
  • OTC
  • prescribed
  • illicit
309
Q

assessment for hepatitis

A
  • LFTs
  • drug usage
  • ingestion of shellfish or contaminated water
  • sexual activity
  • living quarters
  • travel Hx
310
Q

physical assessment for hepatitis

A
  • malaise
  • N/V
  • pruritis
  • abd pain
  • jaundice
  • arthralgia
  • myalgia
  • stool and urine changes
311
Q

psychosocial assessment for hepatitis

A
  • emotions/coping
  • depression
  • fm involvement
  • cost
  • fear of infecting others
312
Q

diagnostic labs for hep A

A
  • current inflammation: ImM
  • previous infection: IgG
313
Q

diagnostic labs for hep B

A
    • HBSAB: antibody present
      • recovery and immunity
      • vaccinated
314
Q

diagnostic lab for hep C

A

ELISA

315
Q

diagnostic lab for hep D

A

+delta-antigen

316
Q

liver Bx for hepatitis looks for

A

characteristics and changes to liver

317
Q

hepatitis Tx

A
  • liver rest, recovery
  • small, frequent meals
  • drugs (HBV and HCV)
    • antivirals
    • immunomodulators
  • prevent spread
318
Q

nutrition for hepatitis recovery

A
  • ↑ carb and kcal
  • moderate fat and protein
  • vitamin supplements
  • no ETOH, drugs
319
Q

steatosis

A
  • accumulation of fats in and around hepatic cells
  • NAFLD
  • non-alcoholic steatohepatitis
320
Q

non-alcoholic steatohepatitis

A

fatty liver dz

321
Q

causes of NAFLD

A
  • DM
  • obesity
  • ↑ lipids
322
Q

steatohepatitis

A
  • fatty liver dz
  • degenerative changes in liver cells 2/2 fat deposits in hepatocytes
  • generally asymptomatic
  • may be found in liver Bx or imaging
323
Q

Tx for fatty liver dz

A
  • Tx of underlying cause
  • monitor LFTs
  • meds: lipid-lowering agents
324
Q

liver trauma

A
  • injury or assault to liver
  • common cause: steering wheel in MVA
  • complication: blood loss, hypovolemic shock
    • Tx: blood products
    • monitor coags
325
Q

hepatic CA

A
  • primary or metastatic
  • main cause: cirrhosis 2/2 chronic HBV and HCV
326
Q

liver CA early Sx

A

asymptomatic

327
Q

later Sx of liver CA

A
  • wt loss
  • anorexia
  • RUQ pain
328
Q

lab for liver CA

A

AFP tumor marker

329
Q

AFP tumor marker

A
  • alpha-fetoprotein tumor marker
  • indication of liver CA
330
Q

Tx for liver CA

A
  • tumor resection
  • hepatic artery embolization
  • radiofrequency ablation
  • chemo
  • transplant
  • palliative care (late stages)
331
Q

tumor resection for liver CA

A
  • only available long-term Tx
  • most tumors not resectable
332
Q

hepatic artery embolization for liver CA

A
  • causes cell death by ischemia in hepatic artery, which feeds most tumors
  • most hepatic cells fed by portal vein
  • IR procedure
  • catheter guided by angiogram injects blocking agent into artery feeding tumor
333
Q

transplant for liver CA

A
  • indication: end-stage dz w/o response to conventional Tx
  • exclusions
    • severe cardiac or respiratory dz
    • metastatic tumors
    • inability to follow instructions/self-manage
334
Q

liver donation

A
  • most donors trauma victims
  • liver preserved ≤ 8 hr
335
Q

liver transplant complications

A
  • acute graft rejection
  • infection
336
Q

acute graft rejection after liver transplant

A
  • usually POD 4-10
  • S/Sx
    • tachycardia
    • fever
    • RUQ pain
    • ↑ jaundice
  • → multi-organ failure
  • prophylaxis: immunosuppressants
337
Q

infection after liver transplant

A
  • common
    • pneumonia
    • wound infection
    • UTI
  • opportunistic
  • in month after surgery
  • S/Sx
    • fever
    • foul-smelling drainage
338
Q

normal stool description

A
  • medium to dark brown
  • strong-smelling
  • pain-free to pass
  • passed 1-2x daily
  • consistent in characteristics
339
Q

changes in stool that could mean a problem

A
  • smell
  • frequency
  • firmness
  • color
340
Q

minimum number of stools/wk

A

3

341
Q

what makes stool brown?

A

bilirubin from breakdown of RBCs

342
Q

The color of stool is affected by what 4 factors?

A
  • foods ingested
  • meds
  • amount of bile
  • presence of blood
343
Q

possible stool colors

A
  • brown
  • green
  • yellow
  • grey/clay
  • red
  • black
344
Q

green stool causes

A
  • green foods
  • diarrhea: ↓ time for chemical changes to bilirubin
345
Q

yellow stool cause

A
  • (undigested fat)
  • d/o of
    • liver
    • pancreas
    • gallbladder
  • celiac dz
  • giardiasis
  • stress
  • diet
346
Q

grey/clay stool cause

A
  • (↓ bile)
  • hepatobiliary dz
347
Q

red stool causes

A
  • also dark red, maroon
  • diet: red veggies or food dye
  • lower GI bleed
348
Q

black stool causes

A
  • not sticky + odorless
    • bismuth
    • Fe supplements
  • tarry + sticky + foul-smelling
    • AKA melena
    • upper GI bleed
349
Q

BMP

A
  • basic metabolic panel
  • glucose
  • electrolytes
    • Ca2+
    • Na+
    • K+
    • Cl-
  • CO2
  • BUN
  • Cr
350
Q

CMP

A
  • comprehensive metabolic panel
  • BMP+
    • total bilirubin
    • total protein
    • albumin
    • liver enzymes
      • ALT
      • AST
      • ALP
351
Q

Guaiac-based tests may yield _____ _____ results.

A

false positive

352
Q

foods to avoid before guaiac test

A
  • red meat
  • raw fruits and veggies
353
Q

meds to avoid before guaiac test

A
  • x7 days before
  • NSAIDs
  • anticoagulants
354
Q

FIT

A

fecal immunochemical test

355
Q

fecal immunochemical test

A
  • FIT, iFOBT
  • type of FOBT that does not require pt prep
  • also screening for colon CA
  • detects blood from lower GI
356
Q

Fat is normally absorbed in the _____ ______.

A

small intestine

357
Q

malabsorption of fat →

A
  • steatorrhea
  • fatty stools
  • yellow
358
Q

When does gag reflex typically return after EGD?

A

30-60 min

359
Q

SE of ERCP

A
  • instilled air → colicky abd pain + flatulence
  • severe
    • bleeding
    • perf
    • sepsis
    • pancreatitis
360
Q

sedation for endoscopic upper GI procedures

A
  • medazolam
  • fentanyl
  • propofol
361
Q

most common indications for ERCP

A
  • Dx and Tx of conditions of pancreas or bile ducts
  • indications
    • abd pain
    • wt loss
    • jaundice
    • CT or US showing stones or massess
362
Q

ERCP is sometimes used _____ or _____ gallbladder surgery to assist with that operation.

A

before or after

363
Q

In suspected or known pancreatic dz, _____ helps determine the need for surgery or the best _____ to use.

A
  • ERCP helps
  • best procedure
364
Q

GoLYTELY bowel prep for lower GI scope

A
  • solution is best chilled
  • watery stool starts ~1 hr after starting
  • do not give to OA
365
Q

At what age should healthy adults start having colonoscopies, and how often?

A
  • 50 yo
  • Q10yrs
366
Q

What are indications for having colonoscopies more often than every 10 yrs?

A
  • fm Hx of CA
  • polyps
367
Q

general manifestations and results of IBD

A
  • nutritional deficits
  • altered bowel elimination
  • infection
  • pain
  • fluid/electrolyte imbalances
368
Q

most common cause of RLQ pain

A

appendicitis

369
Q

slow appendix inflammatory process →

A

abscess

370
Q

rapid appendix inflammation process →

A

peritonitis

371
Q

pain pattern for appendicitis

A

anywhere in abd, esp. periumbilical or epigastric → more severe → McBurney’s point

372
Q

Clinical presentation of appendicitis is notoriously _____, and differential Dx is often _____, because it can mimic other ______ abd conditions.

A
  • presentation inconsistent
  • Dx challenging
  • severe abd conditions
373
Q

most common Sx of appendicitis

A

abd pain

374
Q

Vomiting that precedes abd pain suggests _____ _____.

A

intestinal obstruction

375
Q

pt positioning to relieve appendicitis pain

A
  • lying down
  • hips flexed
  • knees drawn up
  • keeping still
376
Q

duration of Sx in appendicitis

A
  • < 48 hr in ~80% of adults
  • > 48 hr w/ perf or in OA
377
Q

lapartomy nursing considerations

A
  • may need
    • wound drain
    • wound vac
    • NGT (decompression)
  • meds
    • abx
    • opioids
  • prevent complications: early ambulation
    • VTE
    • atelectasis
    • pneumonia
378
Q

laparotomy has more potential complications in

A
  • OA
  • chronic dz
379
Q

laparotomy

A

surgical opening of abd

380
Q

Peritoneum is the _____ and most _____ serous membrane in the body.

A
  • largest
  • most complex
381
Q

parietal peritoneum

A
  • outer layer of peritoneum
  • attached to abd wall
382
Q

visceral peritoneum

A
  • inner layer of peritoneum
  • wrapped around organs in intraperitoneal cavity
383
Q

mesentery

A
  • double layer of visceral peritoneum
  • encloses the peritoneal cavity
384
Q

peritoneal cavity

A
  • enclosed by mesentery
  • serous fluid-filled
    • ~ 50 mL
    • prevents friction during peristalsis
385
Q

The abd cavity is normally _____.

A

sterile

386
Q

Peritonitis is a _____-_____ infection of the lining of the abd cavity.

A

life-threatening

387
Q

Peritonitis is the dominant cause of postop ____ 2/2 infection.

A

death

388
Q

norovirus transmission and incubation

A
  • transmission
    • fecal-oral
      • person-person
      • contaminated food/water
    • airborne via vomiting
  • incubation: 1-2 days
389
Q

ORT

A

oral rehydration therapy

390
Q

similarities between UC and Crohn’s

A
  • often develop in teens and young adults, but possible at any age
  • affect the sexes equally
  • Sx are similar
  • unknown causes
    • similar contributing factors
    • both AIDs
391
Q

difference between UC and Crohn’s

A
  • UC affects innermost lining of colon
  • Crohn’s occurs in all layers of bowel
392
Q

indeterminate colitis

A
  • ~10% of IBD
  • has features of UC and Crohn’s
393
Q

physical features of Crohn’s

A
  • fat wrapping bowel
  • fissures into mucosa and muscle
  • muscle hypertrophy
  • cobblestone appearance of mucosa
394
Q

physical features of UC

A

ulceration within mucosa

395
Q

UC puts pts, esp. OA, at risk for what health complications?

A
  • fluid/electrolyte imbalance
  • dehydration
  • hypokalemia → dysrhythmias
  • cellular changes → ↑ risk of colon CA
396
Q

UC etiology

A
  • exact cause unknown
  • factors
    • genetic
    • immunologic (AID)
    • environmental
397
Q

What parts of the large intestine does UC mainly affect?

A
  • rectum
  • rectosigmoid colon
  • may also spread to entire colon
398
Q

ileocecal valve landmark

A

about halfway between umbilicus and anterior iliac spine

399
Q

toxic megacolon

A

paralysis of colon → dilation → colonic ileus + possible perf → peritonitis and/or gangrene

400
Q

malabsorption →

A
  • anemia
  • malnutrition
  • bone loss
401
Q

Fistulas are more common in the _____ form of chronic IBD.

A

Crohn’s

402
Q

IBD-associated fistulas can occur anywhere, but are commonly found between the _____ and colon.

A

bladder

403
Q

A bladder-colon fistula leads to _____ and _____.

A
  • pyuria
  • fecaluria
404
Q

fecaluria

A

feces in the urine

405
Q

pyuria

A
  • > 10 WBCs per high-powered microscopic urinary field
  • detected in UA
406
Q

other conditions developed by IBD pts

A
  • polyarthritis
  • episcleritis
  • uveitis
  • aphthae
  • renal calculi
  • gallstones
  • vitamin-deficiency anemia
  • erythema nodosum
  • Sweet’s syndrome
407
Q

polyarthritis

A

inflammation of > 1 joint, and usually > 4

408
Q

EIMs

A

extraintestinal manifestations

409
Q

extraintestinal manifestations

A

conditions in other parts of the body that IBD patients can develop during active dz

410
Q

erythema nodosum

A

tender, red nodular rash on the shins that typically occurs with another illness

411
Q

episcleritis

A

inflammation of the subconjunctival layers of the sclera

412
Q

uveitis

A
  • nonspecific term for any intraocular inflammatory d/o
  • uveal tract (iris, ciliary body, and choroid) usually involved
  • other parts of the eye, including retina and cornea, may be involved
413
Q

Sweet’s syndrome

A
  • AKA acute febrile neutrophilic dermatosis
  • distinctive eruption of tiny bumps that enlarge
  • often tender to the touch
  • on back, neck, arms or face
414
Q

tenesmus

A
  • urgent sensation to defecate, even though bowels already empty
  • may involve straining, pain, and cramping
415
Q

mild UC presentation

A

may be asymptomatic

416
Q

moderate UC presentation

A
  • mild abd pain
  • nausea
  • possibly ↑ CRP and ESR
417
Q

severe UC presentation

A
  • fever
  • tachycardia
  • anemia
  • abd pain
  • ↑ CRP and ESR
418
Q

fulminant UC presentation

A
  • ↑ Sx of severe
  • may need transfusion
  • possible colonic distention
419
Q

CRP

A

C-reactive protein

420
Q

C-reactive protein

A
  • protein made by liver
  • sent into bloodstream as response to inflammation
  • interpretation
    • low levels expected
    • ↑ levels can mean
      • serious infection
      • other d/o
421
Q

ESR

A

erythrocyte sedimentation rate

422
Q

erythrocyte sedimentation rate

A
  • measures how quickly RBCs settle to bottom of test tube of blood
  • normal: slowly
  • ↑ rate: inflammation
423
Q

barium enema w/ air contrast for IBD

A
  • shows
    • differences between UC and Crohn’s
    • complications
    • depth of dz involvement
424
Q
A
425
Q

benefits of rectal/enema route in 5-ASA Tx

A
  • ↓ systemic exposure
  • targets colon
426
Q

examples of 5-ASAs

A
  • sulfasalazine
  • mesalazine
  • olsalazine
  • balsalazide
427
Q

immunomodulators

A
  • drugs that alter a pt’s immune response
  • not effective alone
  • synergistic effect w/ corticosteroids: ↓ steroids needed
428
Q

CWOCN

A

certified wound, ostomy, and continence nurse

429
Q

Parenteral _____ are given within 1 hr of GI ostomy.

A

abx

430
Q

acute coronary syndrome

A
  • ACS
  • any circumstance that suddenly impairs blood flow through the coronary arteries
431
Q

ACS

A

acute coronary syndromes

432
Q

coronary artery disease

A
  • CAD
  • narrowing of the coronary arteries, usually as a result of atherosclerosis
433
Q

CAD

A

coronary artery disease

434
Q

atherosclerosis

A
  • most common form of arteriosclerosis
  • marked by cholesterol-lipid-calcium deposits in walls of arteries that may restrict blood flow
435
Q

arteriosclerosis

A
  • disease of the arterial vessels marked by thickening and loss of elasticity in the arterial walls
  • “hardening of the arteries”
436
Q

angina

A
  • ↓ blood flow and O2 to heart muscle → oppressive chest pain or pressure
  • usually precipitated by exercise
437
Q

myocardial infarction

A

death of myocardial tissue d/t ischemia

438
Q

preload

A
  • end-diastolic stretch of a heart muscle fiber
  • at bedside: estimated by measuring CVP or pulmonary capillary wedge pressure
439
Q

afterload

A
  • force that impedes the flow of blood out of the heart
  • primarily composed of
    • peripheral vasculature pressure
    • aortic compliance
    • mass and viscosity of blood
440
Q

heart failure

A

inability of the heart to circulate blood effectively enough to meet the body’s metabolic needs

441
Q

acute heart failure

A
442
Q

ejection fraction

A
  • percentage of the blood emptied from the ventricle during systole
  • normal: 50-70%
443
Q

chronic heart failure

A
444
Q

systolic heart failure

A
445
Q

diastolic heart failure

A
446
Q

endocarditis

A

infection or inflammation of the heart valves or of the lining of the heart

447
Q

rheumatic endocarditis

A

valvular inflammation and dysfunction (esp. mitral insufficiency) occurring during acute rheumatic fever

448
Q

colloquial terms for meds used to treat CV disease

A
  • blood thinners
  • antihypertensives
  • heart medication
449
Q

antiplatelet

A

agent that destroys or inactivates platelets, preventing them from forming blood clots

450
Q

anticoagulant

A

agent that prevents or delays blood coagulation

451
Q

antithrombotic

A

interfering with or preventing thrombosis

452
Q

rivaroxaban

A
  • class
    • anticoagulant
    • antithrombotic
    • factor Xa inhibitor
  • action: inactivates cascade of coagulation by blocking active site on factor Xa
453
Q

beta blocker

A

blocks action of epinephrine on CV system

454
Q

ACE inhibitor

A
  • antihypertensive
  • action
    • blocks conversion of precursor angiotensin I to vasoconstrictor angiotensin II
    • systemic vasodilation
455
Q

ARB

A

angiotensin II receptor antagonist

456
Q

antiotensin II receptor antagonist

A
  • antihypertensive
  • action
    • blocks aldosterone-secreting and vasoconstrictor effects of angiotensin II
    • ↓ BP, ↓ risk of death from CV dz
457
Q

atrioventricular heart valves

A
  • tricuspid
  • mitral
458
Q

semilunar heart valves

A
  • pulmonic
  • aortic
459
Q

S1

A
  • “lub”
  • corresponds with
    • closure of AV valves (mitral)
    • ventricular ctx
    • beginning of systole
  • loudest at apex
460
Q

S2

A
  • “dub”
  • corresponds with
    • closure of semilunar valves (aortic)
    • beginning of diastole
  • loudest at base
461
Q

heart auscultation sequence

A
  • rate, rhythm
  • high-pitched/normal sounds
    • w/ diaphragm
    • S1, S2
  • low-pitched/extra sounds
    • w/ bell
    • S3, S4
    • murmurs
462
Q

peripheral vascular inspection

A
  • ​color
  • temp
  • hair
  • edema
  • nailbeds
463
Q

peripheral vascular palpation

A
  • cap refill
  • palpate pulses
    • feel w/ fingertips
    • compare bilaterally
    • note
      • rate
      • rhythm
      • amplitude/intensity
      • quality
464
Q

pulse intensity scale

A
  • (0-4+)
  • 0: no palpable pulse
  • 1+: faint
  • 2+: diminished
  • 3+: normal
  • 4+: bounding
465
Q

types of impaired myocardial perfusion, or CAD

A
  • chronic ischemic heart dz
  • acute coronary syndromes
466
Q

types of chronic ischemic heart dz

A
  • stable angina
  • variant (Prinzmetal’s) angina
467
Q

types of acute coronary syndromes

A
  • unstable angina
  • myocardial infarction
468
Q

types of myocardial infarction

A
  • NSTEMI
  • STEMI
469
Q

NSTEMI

A

non-ST segment elevation myocardial infarction

470
Q

STEMI

A

ST segment elevation myocardial infarction

471
Q

alterations in cardiac fxn

A
  • HF
  • valvular dz/dysfunction
472
Q

HF

A

heart failure

473
Q

CHD

A

coronary heart dz

474
Q

coronary artery dz

A
  • CAD
  • atherosclerosis in coronary artery → ↓ blood flow to area it supplies
  • untreated →
    • angina
    • MI
475
Q

patho of CAD

A
  • progressive
    • endothelial damage → deposits → vessel narrowing
    • can → thrombus formation
    • blockage grows → occlusion → tissue death
  • begins early in life
476
Q

progression of heart dz

A

atherosclerosis → CAD → angina → MI

477
Q

LDL

A
  • low-density lipoproteins
  • less desirable lipoproteins
478
Q

HDL

A
  • high-density lipoproteins
  • highly desirable lipoproteins
479
Q

non-modifiable CAD risk factors

A
  • genetics: gene variation can → extremely ↑ LDL
  • ↑ age
  • sex: male > female
  • T1DM
480
Q

modifiable CAD risk factors

A
  • smoking
  • diet
  • obesity
  • T2DM
  • HTN
  • physical inactivity
  • hyperlipidemia
  • hypertriglyceridemia
  • metabolic syndrome
481
Q

chronic ischemic heart dz

A

blood flow ↓ → ischemia in affected myocardium

482
Q

acute coronary syndromes

A

partial or total occlusion of coronary arteries

483
Q

S/Sx + descriptions of angina pectoris

A
  • description
    • tightness
    • heaviness
    • vise-like
    • “elephant on chest”
  • S/Sx
    • pain radiating to left
      • arm
      • hand
      • jaw
      • shoulder
    • nausea
    • fatigue
    • lightheadedness
484
Q

etiology of angina pectoris

A
  • partially occluded coronary arteries →
    • ­↑ in myocardial O2 demand
    • ↓ in myocardial O2 supply
485
Q

Each type of angina has different _____, _____, and _____.

A

pattern, signs, and symptoms

486
Q

stable angina trigger

A

predictable degree of exertion or emotion

487
Q

Stable angina has a stable pattern of _____, _____, _____, and _____ factors.

A
  • onset
  • duration
  • severity
  • relieving factors
488
Q

typical pattern of stable angina

A
  • begins gradually and peaks over a period of minutes as activity continues
  • activity → CP
  • rest → relief
489
Q

relieving factors for stable angina

A
  • rest
  • nitro
  • both
490
Q

variant angina pattern

A
  • occurs during periods of rest, often at night
  • not related to
    • physical activity
    • HR
491
Q

cause of variant angina

A

coronary artery spasm

492
Q

classic present Sx of CAD

A

angina

493
Q

other Sx of CAD

A
  • nausea
  • dizziness
  • SOB
  • anxiety
  • feeling of impending doom
494
Q

possible presentation of CAD in women

A
  • unusual fatigue
  • sleep disturbance
  • SOB
  • indigestion
  • anxiety
  • chest discomfort: aching, tightness, pressure
495
Q

percentage of CAD presentations in women that include chest discomfort

A

30%

496
Q

What outward signs can be normal in CAD?

A
  • wt
  • VS
  • all signs
497
Q

possible signs of CAD

A
  • hypo- or hypertension
  • peripheral edema
  • cyanosis or pallor
  • diaphoresis
  • dyspnea
  • vomiting
  • EKG changes
  • abnormal heart sounds, rate, and/or rhythm
498
Q

Signs of CAD depend on the condition’s _____.

A

severity

499
Q

anginal equivalents

A

Sx suggesting cardiac ischemia w/o CP

500
Q

What populations are more likely to experience anginal equivalents?

A
  • women
  • diabetics
  • OA
501
Q

other sites where pain may be felt during cardiac ischemia other than the chest

A
  • jaw
  • arm
  • upper back
502
Q

anginal equivalent S/Sx

A
  • dyspnea
  • fatigue
  • lightheadedness
  • dizziness
  • pain in jaw, arm, upper back
  • women: upper arm weakness
503
Q

types of acute coronary syndromes

A
  • unstable angina
  • MI
    • NSTEMI
    • STEMI
504
Q

unstable angina

A
  • unpredictable CP
    • w/ rest or minimal activity, possibly at night
    • occurs with ↑ frequency and severity
  • nitro doesn’t help
  • requires immediate medical attention
505
Q

MI

A

myocardial infarction

506
Q

cause of MI

A

complete or near-complete occlusion of coronary artery

507
Q

patho of MI

A

occlusion of coronary artery ­→ ↓ O2 delivery ­→ cell death

508
Q

MI is the _____ cause of death in America and the end result of untreated or _____ treated _____.

A
  • leading cause of death
  • ineffectively treated CAD
509
Q

cardiac biomarkers

A
  • cardiac-specific: troponin I
  • non-specific
    • CK-MB
    • myoglobin
510
Q

protocol for cardiac biomarker lab draws

A
  • Q6H
  • multiple draws show trends
511
Q

Cardiac biomarkers may be _____ on arrival at the hospital, then _____.

A
  • negative on arrival
  • then increase
512
Q

troponin I

A

cardiac-specific muscle protein useful in lab Dx of heart attack

513
Q

troponin I levels

A
  • ↑ injury = ↑ numbers
    • ­Normal: < 0.04 ng/mL
    • ­Elevated: 0.04 – 0.39
    • ­Probable MI: ≥ 0.40
    • ­↑ after heart cath
  • ↑ 7-14 hrs after Sx onset​
514
Q

CK-MB

A

creatinine kinase-muscle/brain

515
Q

creatinine kinase-muscle/brain

A

more cardiac-specific than myoglobin and other forms of CK

516
Q

CK-MB levels

A
  • normal: 5-25 IU/L
  • MI
    • ↑ 3-6 hrs after CP onset
    • peak: 12-18 hrs
517
Q

myoglobin

A
  • O2-binding protein
  • released after damage to heart or any skeletal muscle
518
Q

myoglobin levels

A
  • normal: 25-72 ng/mL
  • MI
    • detected within 2 hrs after
    • sensitive indicator: second sample is x2 if drawn within 2 hrs of first sample
519
Q

MI diagnostics

A
  • EKG
  • EST
  • TEE
  • transthoracic echo
  • heart cath and angio
520
Q

EKG/ECG

A

electrocardiogram

521
Q

electrocardiogram for suspected MI

A
  • 12-lead
  • easiest and most effective test
  • for every pt w/ CP
522
Q

signs EKG can show in pt w/ CP and possible MI

A
  • heart rhythm
  • blood flow or ischemia
  • heart attack
  • thickened heart muscle
523
Q

How does an EKG show a heart attack?

A
  • ↓ blood flow → depolarization changes
  • manifests as abnormal changes in ST segment and T wave
  • ischemia/injury to different regions show on different leads
524
Q

EST

A

exercise stress test

525
Q

exercise stress test

A
  • exercise + EKG
  • evaluates myocardial perfusion
526
Q

pt prep for EST

A
  • don’t eat, smoke, or drink caffeine for several hrs
  • hold CV meds for 24 hrs
  • wear comfy clothes, shoes
527
Q

CAD stress test findings

A
  • ­normal ECG at rest
  • ­abnormalities w/ ↑ O2 demand (activity)
528
Q

EST procedure

A
  • pt exercises
    • per strict protocol
    • w/ continuous EKG
  • if myocardial ischemia suspected
    • test immediately stopped
    • Tx administered
529
Q

indications of myocardial ischemia during EST

A
  • angina
  • ST segment depression ≥ 1 mm
  • BP
    • failure to ↑ systolic BP to ≥ 120 mm Hg
    • ­sustained ↓ of ≥ 10 mm Hg with progressive ↑ in exercise
530
Q

pharm stress test

A

induces CV stress with meds that dilate coronary vessels

531
Q

pharm stress test indication

A

exercise contraindicated d/t arthritis, amputation, etc.

532
Q

meds used for pharm stress test

A
  • dobutamine
  • adenosine
  • dipyridamole
533
Q

diagnostics used during pharm stress test

A
  • EKG +
    • echo
    • nuclear testing (tracer injection)
534
Q

myocardial perfusion imaging

A

nuclear testing (tracer injection) often used during pharm stress test to detect CAD

535
Q

MPI

A

myocardial perfusion imaging

536
Q

echocardiography

A

US used to assess functional structures of heart

537
Q

issues that can be detected with echocardiography

A
  • structural valve abnormalities
  • atrial and ventricular chamber size
  • diameter of great vessels
  • heart wall motion
538
Q

TEE

A

transesophageal echocardiogram

539
Q

transesophageal echocardiogram

A

transducer is guided down esophagus to allow for visualization of heart w/o ribs or lungs in the way

540
Q

cardiac cath

A
  • thin catheter inserted into artery and threaded into coronary arteries
  • +angio: visualize presence/degree of blockage
541
Q

cardiac cath with angio

A
  • catheter threaded into coronary arteries
  • radiopaque contrast injected
  • fluoroscopy used to visualize presence/degree of blockage
542
Q

Heart cath is an _____ procedure that uses IV _____.

A
  • invasive procedure
  • IV contrast
543
Q

Before a heart cath w/ angio, always ask about what allergies?

A
  • iodine or shellfish allergies
  • previous rxn to contrast
544
Q

pot-cath VS monitoring

A
  • Q15Min x4
  • Q30Min x2
  • Q1H x4
  • Q4H
545
Q

post-cath nursing care

A
  • monitor VS frequently (per protocol)
  • ensure pt lies flat w/ extremity straight for prescribed time
  • neurovascular checks as prescribed; assess affected limbs together
  • continuous telemetry, pulse ox
  • antiplatelet/antithrombotic or thrombolytic therapy
  • monitor UOP
  • administer IVF
  • sheath removal
546
Q

Pts are commonly expected to lie flat for ___-___ hrs after heart cath, or _____ with closure device.

A
  • 4-6 hrs
  • shorter
547
Q

neurovascular checks after heart cath

A
  • body area: distal to catheter insertion site
  • purpose: to ensure sensation and pulse are present
548
Q

5 Ps of neurovascular checks

A
  • pulses
  • parethesias
  • pain
  • pallor
  • paralysis
549
Q

criteria for diagnosing chronic ischemic heart dz

A
  • based on Hx and Sx patterns
  • ECG changes only during EST
  • no ↑ cardiac enzymes
550
Q

diagnosing acute coronary syndromes

A
  • Hx
  • presence of unstable angina
  • Sx consistent w/ partially occluded arteries
  • no ↑ serum biomarkers
  • possible, but not necessary: ST segment depression, T wave inversion
551
Q

diagnosing MI

A
  • ST segment and/or T wave changes, depending on type
  • ↑ enzymes
  • cell necrosis and infarction distal to occlusion
552
Q

non-ST segment elevation myocardial infarction

A
  • NSTEMI
  • partial coronary artery blockage
  • less damaging to heart
  • depressed ST segment or T wave inversion
  • ↑ serum cardiac enzymes
553
Q

ST segment elevation myocardial infarction

A
  • STEMI
  • complete coronary artery blockage
  • more damaging to heart
  • elevated ST segment of ≥ 1 mm
  • ↑ serum cardiac enzymes
554
Q

behaviors to promote for CAD prevention

A
  • healthy, balanced diet
  • ­↓ in BP
  • ­↓ in fat intake
  • ­wt loss
555
Q

CAD prevention meds

A
  • antiplatelet/antithrombotic therapy
    • ASA
    • heparin
    • enoxaparin
556
Q

Treat all _____ _____ like _____ _____ until Dx is complete.

A
  • all chest pain
  • like myocardial infarction
557
Q

nursing assessment for CP presentation

A
  • general
    • pain
    • N/V
  • focused cardiopumonary
    • VS
    • heart and lung sounds
    • peripheral pulses
    • skin color, temp, and moisture
  • look for
    • SOB
    • diaphoresis during pain
558
Q

impaired myocardial perfusion nursing interventions

A
  • immediate 12-lead EKG (10 min)
  • continuous tele + pulse ox
  • start IV
  • HOB @ 30°
  • MONA meds as ordered
  • additional Tx dictated by
    • EKG
    • labs
    • risk to pt
559
Q

MONA med administration for impaired myocardial perfusion

A
  • immediate: ~325 mg nonenteric-coated ASA
  • O2
  • nitroglycerin
  • morphine
560
Q

nitroglycerin

A
  • vasodilator
  • prevents coronary artery spasm
  • ↓ preload and afterload to ↓ O2 demand
561
Q

nitroglycerin administration

A
  • routes
    • sublingual (tab or spray)
    • TD
  • dosage: 0.4 mg
    • Q5Min ≤ 3x until CP relieved
    • if no relief, explore other options
562
Q

most common SE of nitroglycerin

A
  • orthostatic hypotension
  • HA
563
Q

morphine for impaired myocardial perfusion

A

↓ CP where nitro is not successful

564
Q

When giving morphine for impaired myocardial perfusion, watch for what SE?

A
  • hypotension, esp. w/ vasodilator
  • respiratory depression
565
Q

beta blockers for impaired myocardial perfusion

A
  • metoprolol and others
  • action
    • ↓ HR and afterload (↓ BP)
      • ­→ ↓ myocardial O2 demand
    • can ↓ infarct size in acute MI
566
Q

SE to watch for when giving beta blocker for impaired myocardial perfusion

A
  • orthostatic hypotention
  • severe bradycardia
567
Q

Ca channel blocker for impaired myocardial perfusion

A
  • diltiazem, verapamil, and others
  • NOT nifedipine
  • action
    • dilates coronary arteries
    • ↑ O2 supply to myocardium
568
Q

antiplatelet for impaired myocardial perfusion

A
  • ASA, clopidogrel
  • action
    • inhibits platelet aggregation
    • ↓ risk of clot formation
569
Q

nursing implications for angina

A
  • chronic: teach about lifestyle changes
  • acute: considered acute MI until proven otherwise
570
Q

NSTEMI treatment

A
  • draw cardiac enzymes
  • anticoagulation therapy
  • ↓ workload of heart
  • monitor pt closely
  • may need surgical Tx
571
Q

anticoag for NSTEMI

A
  • heparin + ASA or clopidogrel
  • rationale
    • heparin prevents new clots
    • ASA or clopidogrel ↓ platelet aggregation
572
Q

monitoring a pt w/ NSTEMI

A
  • continuous tele and pulse ox: dysrhythmias
  • S/Sx of cardiogenic shock
573
Q

candidates for surgical Tx of NSTEMI

A
    • signs of HF
  • v-tach
  • hemodynamic instability
  • persistent CP
  • persistent/recurrent ST deviation
574
Q

STEMI treatment

A
  • optimal
    • activate cath lab (≤ 90 min)
    • IV access, x2 if done quickly
    • nitro 0.4 mg
    • IV nitrates
    • IV morphine
  • not near cath lab
    • transfer within 120 min?
    • if not, tPA (≤ 30 min)
    • other possible meds
      • beta blocker
      • Ca channel blocker
575
Q

cath lab goal time

A
  • door → balloon inflation in ≤ 90 min
  • ≤ 60 min even better
576
Q

reperfusion in cath lab for STEMI pt

A
  • restores blood flow to affected myocardium
  • won’t reverse damage
  • stops or limits future damage
577
Q

getting IV access for STEMI pt

A
  • get x2 if possible, but don’t delay Tx
  • draw blood for enzymes now if possible
578
Q

IV nitrates for STEMI pt

A
  • usually starts at 5-10 mcg/min
  • gradually increase until CP relieved
579
Q

IV morphine for STEMI pt

A
  • for refractory or severe pain
  • dosage
    • 2-4 mg IV push
    • repeat Q5-10Min
580
Q

fibrinolytic therapy

A

given for STEMI if within 12 hrs after Sx onset

581
Q

time goal for tPA for STEMI pt

A

door to needle in 30 min

582
Q

disadvantages of tPA

A
  • can re-occlude
    • will begin to c/o CP again
    • small pieces travel distal, occlude smaller vessel
  • compared to heart cath
    • ­↑ reperfusion outcomes
    • ­↓ complications and death
583
Q

other possible meds with tPA

A
  • beta blockers
  • Ca channel blockers
584
Q

focus of invasive Tx for ACS

A

restore blood flow to prevent further damage

585
Q

types of invasive Tx for ACS

A
  • percutaneous transluminal coronary angioplasty (PTCA)
  • directional coronary atherectomy (DCA)
  • intracoronary stents
  • transcatheter aortic valve replacement (TAVR)
  • coronary artery bypass graft (CABG)
586
Q

PTCA

A

percutaneous transluminal coronary angioplasty

587
Q

DCA

A

directional coronary atherectomy

588
Q

TAVR

A

transcatheter aortic valve replacement

589
Q

CABG

A

coronary artery bypass graft

590
Q

PTCA procedure

A
  • done during heart cath w/ coronary angiogram
  • balloon-tipped catheter
    • inserted into blocked artery
    • inflated several times to open vessel
591
Q

PTCA is good for blockages that are _____ and stable.

A

smaller

592
Q

DCA procedure

A
  • done during heart cath
  • excises and removes plaque in blocked artery
  • rotating blade shaves blockage material and stores it in cone
593
Q

DCA is good for _____- to _____-sized vessels in the prosimal or middle portions.

A

medium- to large-sized

594
Q

intracoronary stent placement

A
  • done during heart cath
  • inserted on tip of balloon cath
  • balloon inflated, then deflated to leave stent in place
595
Q

Intracoronary stents are a _____-term solution than PTCA.

A

longer-term

596
Q

heart cath complications

A
  • artery dissection
  • cardiac tamponade
  • hematoma
  • allergic rxn
  • external bleed at insertion site
  • retroperitoneal bleed
  • embolism
  • restenosis of vessel
  • AKI
597
Q

nursing care for heart cath-associated hematoma

A
  • palpate thoroughly all around insertion site
  • feels like hard knot under skin
  • intervention: pressure x15 min
598
Q

retroperitoneal bleed

A
  • possible complication of heart cath procedure
  • happens with femoral insertion
  • blood pools in posterior abd cavity
599
Q

TAVR procedure

A
  • to treat symptomatic aortic valve stenosis
  • via cardiac cath
  • new valve expands, pushes old valve leaflets aside
  • new valve takes over blood flow regulation
600
Q

indication for TAVR

A

pt not candidate for open-heart surgery because of dz, comorbidities, etc.

601
Q

CABG indication

A

reperfusion by other methods not viable options

602
Q

CABG procedure

A
  • open-heart surgery
  • uses veins from other parts of body to replace blocked artery or arteries
603
Q

vessels commonly used for CABG

A
  • saphenous vein
  • internal mammary/thoracic veins
  • radial artery
  • gastroepiploic artery
604
Q

post-CABG care

A
  • pt → ICU
  • monitor VS closely and meet surgeon’s parameters
  • measure chest tube output closely
  • frequent labs
  • extubate ASAP
  • after stable/extubated, walk and move as much as possible
  • many pts D/C home within 4 days
605
Q

What’s the optimal time frame for extubation after CABG?

A

4-8 hrs

606
Q

MI complications

A
  • dysrhythmias
  • cardiogenic shock
  • HF + pulmonary edema
607
Q

post-CABG dysrhythmias

A
  • SVT
  • frequent PVCs
  • v-tach
  • v-fib
608
Q

SVT

A

supraventricular tachycardia

609
Q

PVC

A

premature ventricular contraction

610
Q

HF and pulmonary edema as complications of CABG

A
  • cause: ↓ functionality of myocardium
  • usually manifests wks later
  • pt education: warning signs, importance of follow-up
611
Q

cardiogenic shock after CABG

A

not common COD, but possible

612
Q

signs of cardiogenic shock

A
  • hypotension
  • diaphoresis
  • tachycardia
613
Q

Tx for cardiogenic shock

A
  • vasopressors
  • O2
  • other Tx as ordered
  • until heart recovers
614
Q

nursing implications of MI

A
  • stabilize pt during acute phase
  • monitor for complications
  • promote energy conservation
  • educate pt on lifestyle changes
  • prep for rehab
615
Q

etiology of HF

A

changes in heart fxn due to intrinsic or extrinsic factors

616
Q

HF is often _____, in which acute _____ are the cause of hospitalization.

A
  • chronic
  • exacerbations
617
Q

HF patho

A
  • progressive dz → cardiac remodeling
  • left ventricle dilates, hypertrophies, and becomes more spherical
618
Q

main types of HF

A
  • left-sided
  • right-sided
  • high-output
619
Q

two main types of left-sided heart failure

A
  • systolic
  • diastolic
620
Q

normal ejection fraction

A

50-70%

621
Q

ejection fraction in left-sided systolic HF

A

< 40%

622
Q

possible causes of right-sided HF

A
  • left ventricular failure
  • less common
    • right ventricular MI
    • COPD
    • pulmonary HTN
623
Q

left-sided systolic HF

A
  • heart can’t contract hard enough
  • ↑
    • preload
    • afterload (d/t peripheral resistance)
  • ↓
    • contractility
    • ejection fraction
    • cardiac output
    • BP
    • UOP
624
Q

S/Sx of left-sided diastolic HF are similar to those of systolic dysfunction except what?

A
  • no S/Sx of ↓ cardiac output
  • ejection fraction > 40%
625
Q

right-sided HF

A
  • ventricle can’t empty completely
  • ↑ venous volume + pressure → peripheral edema
626
Q

left-sided diastolic HF

A

ventricle can’t relax enough to fill completely during diastole

627
Q

high-output HF

A

cardiac output remains ≥ normal

628
Q

etiology of high-output HF

A
  • ­↑ metabolic needs
  • usually in hyperkinetic conditions
    • septicemia
    • high fever
    • anemia
    • hyperthyroidism
629
Q

HF risk factors

A
  • HTN
  • CAD
  • cardiomyopathy
  • substance abuse
  • valvular dz
  • congenital defects
  • cardiac infections and inflammatory states
  • dysrhythmias
  • DM
  • smoking/tobacco use
  • family Hx
  • obesity
  • severe lung dz
  • sleep apnea
  • hyperkinetic conditions
630
Q

types of valvular heart dz

A
  • stenosis
  • regurgitation
631
Q

valve stenosis patho

A
  • valve leaflets thicken, stiffen, or fuse together
    • ­→ ↓ blood flow and ↑ resistance
    • ­→ pressure backup
632
Q

major types of valve stenosis

A
  • mitral
  • aortic
633
Q

valve regurgitation patho

A
  • valves don’t close completely
    • ­→ backflow into chamber
    • ­→ pressure backup
634
Q

major types of valve regurgitation

A
  • mitral
  • aortic
  • valvular prolapse
635
Q

mitral valve stenosis

A
  • narrowing of valve between LA and LV
  • → slow LA filling time
636
Q

mitral valve stenosis S/Sx

A
  • pulmonary problems first
    • crackles
    • SOB
  • ↑ HR can → CO drop
637
Q

mitral valve stenosis risk factors

A
  • rheumatic fever
  • female sex
638
Q

aortic valve stenosis patho

A
  • valve hardens
    • → restricted flow to aorta
    • → pressure backup to LV
    • → LV hypertrophy
  • → ­cannot ↑ CO for ↑ demand
639
Q

aortic valve stenosis risk factors

A
  • rheumatic fever
  • aging
640
Q

mitral regurgitation patho

A
  • mitral valve can’t close completely
    • → ­blood flows back into LA → ­↓ SV
    • → ­LA works hard, hypertrophies
  • ­can →
    • left-sided HF
    • right-sided HF
641
Q

SV

A

stroke volume

642
Q

stroke volume

A

volume of blood pumped from LV per beat

643
Q

mitral regurgitation risk factors

A
  • aging
  • infective endocarditis
  • rheumatic fever
644
Q

left-sided HF subjective data

A
  • difficulty breathing
    • dyspnea
    • orthopnea
    • paroxysmal nocturnal dyspnea
  • non-productive cough
  • fatigue, weakness
  • dizziness
  • angina
645
Q

right-sided HF subjective data

A
  • fatigue
  • tight feeling in extremities
  • nausea d/t liver congestion
646
Q

paroxysmal nocturnal dyspnea

A

severe SOB and coughing that occur at night

647
Q

left-sided HF objective data

A
  • respiratory
    • wheezes
    • crackles
    • tachypnea
    • pink, frothy sputum
  • CV
    • tachycardia
    • palpitations
    • weak peripheral pulses
    • cool extremities
    • S3, S4
    • pallor
  • other
    • oliguria, nocturia
    • ↓ LOC
648
Q

right-sided HF objective data

A
  • CV
    • JVD
    • dependent edema (esp. hands)
    • enlarged liver, spleen
      • ↑ LFTs
      • ascites
      • anorexia
  • GU
    • nighttime polyuria
    • wt gain
649
Q

oliguria

A

abnormally small amounts of urine

650
Q

labs for HF

A
  • chem panel
  • CBC
  • BNP
  • ABGs
  • LFTs
651
Q

CBC can show what for suspected HF?

A
  • severe anemia and/or infection
  • anemia can cause or aggravate HF
652
Q

BNP

A

brain natriuretic peptide

653
Q

ABGs for suspected HF

A
  • can show any acid-base imbalances or hypoxemia
  • usually only done for resp. distress
654
Q

brain natriuretic peptide

A
  • AKA B-type, BNP
  • hormone secreted by left ventricular cardiomyocytes 2/2 stretching and hard work w/ ↑ blood volume
  • most specific test for HF
    • level indicates severity
    • abnormal: > 100 pg/mL
655
Q

HF diagnostics

A
  • ECG
  • CSR
  • echo
  • CVP
656
Q

EKG can help detect what factors → HF?

A
  • heart dz
  • MI
  • enlarged heart
  • dysrhythmias
657
Q

echo for HF

A
  • most useful diagnostic
  • can differentiate HF w/ or w/o preserved left ventricular systolic fxn
658
Q

CVP

A

central venous pressure

659
Q

central venous pressure

A
  • pressure in vena cava near RA
  • estimates RA pressure
660
Q

measures assessed via CVP in critically ill pts

A
  • preload of RV, which regulates SV
  • volume status
661
Q

CVP is used to guide _____ _____.

A

fluid resuscitation

662
Q

normal CVP

A

0-6 mm Hg

663
Q

↑ CVP = possible Dx of

A

right-sided HF

664
Q

reasons other than right-sided HF that CVP can be ↑

A
  • ↑ in venous blood volume
  • ↓ in venous compliance
665
Q

HF pharm treatments

A
  • O2
  • diuretics
  • ACE inhibitors
  • beta blockers
  • digoxin
  • vasodilators (nitro)
  • morphine
666
Q

non-pharm treatments for HF

A
  • elevate HOB
  • Na+ restriction
  • ↓ activity level, stress
  • VAD
667
Q

VAD

A

ventricular assist device

668
Q

ventricular assist device

A
  • requires open-heart surgery
  • for right, left (LVAD), or both ventricles
  • indication: ventricular dysfunction
    • end Tx for those who are not transplant candidates
    • rarely: temporary unti heart recovers
669
Q

diuretics for HF

A
  • for ↓ of FVE
  • often w/ ACE inhibitor and beta blocker
  • types
    • thiazide: for mild Sx
    • loop: for more severe Sx
  • multiples used together if necessary
670
Q

ACE inhibitors for HF

A
  • captopril, lisinopril
  • relaxes blood vessels to ↓ BP
  • often used w/ beta blocker and diuretic
671
Q

Hold ACE inhibitor if systolic BP is below ___ mm Hg.

A

100 mm Hg

672
Q

beta blockers for HF

A
  • carvedilol, atenolol, propranolol
  • block effects of epinephrine: ­↓ HR + ↓ force + vasodilation ­→ ↓ BP
  • usually used w/ ACE inhibitor and diuretics
  • may not work as well in OA or those of African descent
673
Q

digoxin toxicity level

A

> 2 ng/mL

674
Q

digoxin therapeutic level

A

0.5-2 ng/mL

675
Q

digoxin toxicity S/Sx

A
  • fatigue
  • dysrhythmias
  • visual disturbances
676
Q

preventing digoxin problems

A
  • brady: hold for apical pulse < 60/min
  • hypokalemia: check K+ before admin
  • toxicity: check drug levels and hold per protocol
677
Q

digoxin action

A
  • affects Na+ and K+ inside heart cells to ↓ strain
  • ↓ ventricular rate + improved strength → better filling
678
Q

O2 admin for HF

A
  • admin oxygen per order or protocol
  • maintain SpO2 ≥ 90% (except in advanced COPD)
679
Q

nursing actions for HF

A
  • oxygenation
    • O2 therapy (≥ 90%)
    • high Fowler’s or on pillows
    • arms on pillows (chest expansion)
    • reposition, cough, and deep breathe Q2H
    • check ABGs
    • help pt group activities to conserve energy
  • fluid/electrolyte balance
    • monitor I&O, daily wt
    • report wt gain of > 3 lbs
    • may require ↑ diuretic dosage
    • maintain Na+ restriction
    • check electrolytes
680
Q

types of inflammatory d/o of the heart

A
  • pericarditis
  • myocarditis
  • rheumatic endocarditis
  • infective endocarditis
681
Q

How is the heart damaged in inflammatory d/o?

A

extended inflammatory response often → destruction of healthy tissue

682
Q

pericarditis

A

inflammation of pericardium

683
Q

etiology of pericarditis

A
  • commonly follows resp. infection
  • MI
684
Q

pericarditis findings

A
  • CV
    • chest pressure/pain
      • relieved when sitting, leaning forward
      • worse on inspiration
    • pericardial friction rub
    • ↑ cardiac enzymes
  • resp.
    • coughing
    • SOB
685
Q

myocarditis

A

inflammation of myocardium

686
Q

etiology of myocarditis

A
  • virus
  • fungus
  • bacteria
  • inflammatory dz, e.g. Crohn’s
687
Q

myocarditis findings

A
  • tachycardia
  • murmur
  • friction rub
  • cardiomegaly
  • CP
  • dysrhythmias
688
Q

rheumatic endocarditis

A
  • complication of rheumatic fever → lesions in heart
  • preceded by Group A betahemolytic streptococcal pharyngitis
689
Q

rheumatic endocarditis findings

A
  • CV
    • CP
    • tachycardia
    • friction rub
    • murmur
  • SOB
  • joint pain
  • rash on trunk, extremities
  • fever
690
Q

infective endocarditis etiology

A
  • organisms
    • staphylococci
    • streptococci
    • fungi
    • other
  • most common in
    • structural malformation
    • cardiac devices
    • prosthetic heart valves
    • IV substance use
  • other causes → bacteremia → endocarditis
    • dental procedures,
    • body piercing
    • tattooing
691
Q

infective endocarditis findings

A
  • fever
  • flu-like manifestations
  • murmur
  • petechiae
  • splinter hemorrhages
  • + blood culture
692
Q

inflammatory cardiac d/o risk factors

A
  • non-modifiable
    • congenital defects
    • heart valve replacement
    • immune suppression
    • rheumatic fever, other infections
    • school-age children w/ long duration of strep
  • modifiable
    • malnutrition
    • overcrowding
    • lower socioeconomic status
693
Q

inflammatory cardiac d/o diagnostics

A
  • ECG
    • rheumatic fever: heart block
    • pericarditis: ST elevation in almost all leads
  • echo
    • inflamed heart layers
    • pericardial effusion
694
Q

labs for inflammatory cardiac d/o

A
  1. cultures: blood, throat
  2. CBC: WBC count
  3. cardiac enzymes: ↑ in pericarditis
  4. ESR, CRP: ↑ inflammation
695
Q

nursing priorities for inflammatory cardiac d/o

A
  • assess
    • heart sounds for murmur, friction rub, or muffle
    • pain
  • review labs
    • ABGs
    • SaO2
    • CXR
  • monitor
    • VS for fever
    • ECG
  • meds
    • abx
    • antipyretics
  • bed rest
696
Q

inflammatory heart d/o that cause fever

A
  • infective endocarditis
  • rheumatic endocarditis
697
Q

inflammatory cardiac d/o that causes heart lesions

A

rheumatic endocarditis

698
Q

inflammatory heart d/o that cause chest pressure/pain

A
  • pericarditis
  • myocarditis
  • rheumatic endocarditis
699
Q

findings for infective endocarditis that don’t happen with other inflammatory heart d/o

A
  • flu-like manifestations
  • petechiae
  • splinter hemorrhages
    • blood cultures
700
Q

S/Sx of rheumatic endocarditis that don’t apply to other inflammatory heart d/o

A
  • joint pain
  • rash on trunk and extremities
  • recent infection w/ Group A betahemolytic strep pharyngitis
701
Q

What sound can be auscultated in pericarditis, myocarditis, and rheumatic endocarditis, but not infective endocarditis?

A

friction rub

702
Q

In which of these inflammatory cardiac d/o will a heart murmur not be present?

pericarditis

myocarditis

rheumatic endocarditis

infective endocarditis

A

pericarditis

703
Q

relieving and worsening factors for chest pain/pressure in pericarditis

A
  • relief: sitting, leaning forward
  • worsening: on inspiration
704
Q

Which inflammatory heart d/o causes cardiomegaly and dysrhythmias?

A

myocarditis

705
Q

Which 2 inflammatory cardiac d/o cause SOB?

A
  • pericarditis
  • rheumatic endocarditis
706
Q

What 2 inflammatory cardiac d/o cause tachycardia?

A
  • myocarditis
  • rheumatic endocarditis
707
Q
A

2021 Care and Management of Adults (3 decks)

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