NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Gastrointestinal System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Complications

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Portal Hypertension

Focus topic: Medical–Surgical Nursing

Definition: The result of altered liver structure that impedes normal hepatic blood flow and increases portal pressure.

Characteristics
A. Obstruction of portal circulation causes portal hypertension and congestion of the spleen, pancreas, and gastrointestinal tract.
B. As the body compensates for increased pressure in the hepatic system, collateral circulation increases.

Assessment
A. Two major conditions result from portal hypertension.

  • Evidence of increased collateral circulation: hemorrhoids, veins observable on abdomen, esophageal varices that bleed easily.
  • Weight gain and abdominal distention from ascites.

B. Assess for respiratory complications due to severe ascites.
C. Assess for abdominal pain (may be indication of infection or bleeding).

Implementation
A. Provide general nursing care for cirrhosis
B. Provide specific care for management of edema.

  • Skin care to prevent breakdown.
    a. Use lanolin-based products to soften skin.
    b. Guard against cutting or scratching skin.
  • Dietary control: negative sodium balance to reduce fluid retention, diuretics (Lasix [furosemide], Edecrin [ethacrynic acid]) with potassium supplements, vitamin supplements of B complex, C, folate, and K.
  • Monitor intake and output; weigh daily.

C. Provide care for ascites.

  • Prevent complications associated with ascites (e.g., respiratory impairment, infection).
  • Restrict fluids and sodium intake.
  • Position client in high-Fowler’s to maximize respiratory capability.
  • Weigh daily and measure abdominal girth to estimate status of fluid accumulation.
  • Monitor use of diuretics (used with sodium restriction); is successful in 90% of clients with ascites.
  • Assist with paracentesis (will be avoided as long as possible due to the danger of precipitating shock, hypovolemia, or hepatic coma).
    a. Removal of fluid will relieve pressure on the diaphragm, stomach, or umbilical hernia.
    b. Because of high protein concentration in the ascitic fluid, IV infusion of saltpoor albumin may be administered over 24 hours.

Medical–Surgical Nursing

Characteristics
A. Increased blood ammonia levels.

  • Normally, ammonia is formed in the intestines from the breakdown of protein and is converted by the liver to urea.
  • In liver failure, ammonia is not converted into urea, and blood ammonia concentrations increase.

B. Any process that increases protein in the intestine, such as gastrointestinal hemorrhage and high protein intake, will cause elevated blood ammonia.
C. Other factors involved in high ammonia levels.

  • Electrolyte and acid–base imbalances.
    Alkalosis increases toxicity of NH3.
  • Constipation.
  • Infectious diseases.
  • Medications: sedatives, narcotic analgesics, central nervous system depressants.
  • Shunting of blood into systemic circulation without passing through the hepatic sinusoids.

Assessment
A. Assess for mental changes as blood ammonia level increases.

  • Impaired memory, decreased attention, concentration, and rate of response.
  • Personality changes: untidiness, confusion, and inappropriate behavior.

B. Assess for depressed level of consciousness and flapping tremor (liver flap) upon dorsiflexion of hand; also called asterixis (involuntary hand flapping), constructional apraxia (inability to reproduce simple two- or three-dimensional figures.
C. Evaluate disorientation and eventual coma.

Implementation
A. Temporarily decrease protein from diet because ammonia cannot be converted to urea for excretion.

  • Protein is restricted to 60–80 g/day.
  • Sodium intake may be restricted to less than 2 g/day to decrease fluid retention, especially ascites
  • High-calorie, moderate-fat diet recommended.

B. Give client bile salts to assist with the absorption of vitamin A. Vitamin K may be given to reduce risk of bleeding.
C. Give folic acid and ferrous sulfate (iron) to treat anemia.
D. Administer antibiotics (Neomycin) to destroy intestinal bacteria and to reduce the amount of ammonia.
E. Administer lactulose to reduce blood ammonia—acidifies colon contents, resulting in retention of ammonium ion and decreased ammonia absorption.

  • Two or three stools/day indicates lactulose is working.
  • Watery diarrhea indicates drug overdose.

F. Give enemas and/or cathartics to empty bowel and to reduce ammonia absorption.
G. Give salt-poor albumin to maintain osmotic pressure by increasing serum protein.
H. Use cation-exchange resins to remove toxic substances from the bowel.
I. Correct fluid and electrolyte imbalances.
J. Weigh daily to monitor for ascites and edema.
K. Measure and record intake and output.
L. Observe, measure, and record neurologic status daily.

  • Test ability to perform mental tasks.
  • Keep samples of handwriting.

M. Avoid depressants, which must be detoxified by the liver. Use agents, such as a benzodiazepine, that are excreted through the kidneys.
N. Prevent complications—pressure ulcers, thrombophlebitis, or pneumonia.
O. With coma, utilize same nursing skills as with the unconscious client.

Medical–Surgical Nursing: Cholecystitis and Cholelithiasis

Focus topic: Medical–Surgical Nursing

Definition: Cholecystitis, either acute or chronic, is an inflammation of the gallbladder; cholelithiasis refers to stones in the gallbladder, formed of cholesterol (the most common) or pigment; choledocholithiasis refers to stones in the common bile duct.

Characteristics
A. Risk factors: cholesterol gallstones—age, race or ethnicity, obesity, estrogen, rapid weight loss, genetic predisposition, cholesterol-lowering drugs, and bile acid malabsorption; pigment gallstones— chronic liver disease, obstruction, or biliary infection.
B. Diagnostic procedures.

  • Serum bilirubin is elevated.
  • Gallbladder x-ray test.
  • IV cholangiogram.
  • Ultrasound determines gallstones.
  • Complete blood count (CBC); if WBC elevated, indicates infection or inflammation.

Assessment
A. Laboratory values.

  • Serum amylase elevated—may indicate pancreatic involvement of stones in common bile duct; alkaline phosphatase, bilirubin increased.
  • WBC count elevated—indicates inflammation and/or infection.

B. Differentiate between cholecystitis and cholelithiasis.
C. Assess for cholecystitis.

  • Epigastric distress—eructation after eating.
  • Pain—localized in right upper quadrant because of somatic sensory nerves.
    a. Murphy’s sign: Client cannot take a deep inspiration when assessor’s fingers are pressed below hepatic margin.
    b. Pain begins 2–4 hours after eating fried or fatty foods and persists 12–18 hours.
  • Nausea, vomiting, and anorexia.
  • Low-grade fever.
  • Jaundice due to hepatocellular damage (seen in 25% of clients).
  • Weight loss.
  • Elevated serum bilirubin and alkaline phosphatase.

D. Assess for cholelithiasis.

  • Pain—excruciating, upper right quadrant—radiates to right shoulder (biliary colic).
  • Pain is sudden, intense, and paroxysmal—occurs with contraction of gallbladder. Lasts 30 minutes to 5 hours.
  • Nausea and vomiting.
  • Jaundice due to obstruction and/or hepatocellular damage.
  • Intolerance to fat-containing foods.

E. Observe for biliary obstruction.

  • Jaundice—yellow sclera.
  • Urine—dark orange and foamy.
  • Feces—clay-colored.
  • Pruritus.

Implementation
A. Provide relief from vomiting.

  • Position nasogastric tube and attach to low suction. Tube reduces distention and eliminates gastric juices that stimulate cholecystokinin.
  • Provide good oral and nasal care; assure patency and flow of gastric secretions.

B. Maintain fluid and electrolyte balance.

  • Monitor intravenous fluids; record intake and output (I&O).
  • Observe serum electrolyte levels; watch for signs of imbalance.

C. Monitor drug therapy.

  • Administer broad-spectrum antibiotics in presence of positive culture.
  • Chenodeoxycholic acid—bile acid dissolves cholesterol calculi (60% of stones).
  • Actigal (ursodiol) and Chenix (chenodiol) reduce cholesterol content of stones, so they gradually dissolve; disadvantages are cost and long duration.
  • Nitroglycerin or papaverine to reduce spasms of duct.
  • Synthetic narcotics (Demerol, Dolophine [methadone]) to relieve pain. Morphine sulfate may cause spasm of sphincter of Oddi and increase pain.
  • Questran/Benadryl (diphenhydramine) to relieve pruritus.

D. Provide low-fat diet to decrease gallbladder stimulation; avoid alcohol and gas-forming foods.
E. Maintain bed rest.

Nonsurgical Management
A. Extracorporeal shock-wave lithotripsy: shock waves that disintegrate stones in the biliary system.

  • Ultrasound is used for stone localization before the lithotripter sends waves through a water bag upon which the client is lying.
  • Analgesics and sedatives are given to reduce pain during procedure.
  • Oral-dissolution medication follows to dissolve stone fragments.
  • Postprocedure—monitor for biliary colic, results from gallbladder contractions.

B. Cholesterol stones removed through dissolution therapy. For high-risk clients—oral medications to decrease size or dissolve stones.
C. Stone removal by instrumentation.

Surgical Management
A. Laparoscopic cholecystectomy is treatment of choice: removal of gallbladder through small puncture hole in abdomen.

  • Laser dissects gallbladder.
  • Discharged day of surgery—normal activities resumed in 2–3 days.

B. Cholecystectomy: removal of gallbladder after ligation of the cystic duct and vessels.

  • Common bile duct may be explored.
  • A Penrose drain is usually inserted for drainage following procedure.

C. Choledochostomy: opening into the common bile duct for removal of stones.

  • T-tube inserted to maintain patency of the duct; connected to drainage bottle to collect excess bile.
  • Purpose is to decompress biliary tree and allow for postoperative cholangiogram.

Implementation
A. Position client in low- to semi-Fowler’s to facilitate bile drainage
B. Maintain skin integrity following surgery.

  • Change position frequently; relieve pressure points.
  • Protect skin around incision site from bile seepage.
    a. Change dressings frequently.
    b. Use skin protectant or drainage pouches to prevent bile drainage from skin contact.

C. Prevent respiratory complications (the most common postoperative complication).

  • Turn, cough, and deep-breathe every 2 hours.
  • Use incentive spirometer every 2 hours.
  • Auscultate for abnormal breath sounds.
  • Observe for signs of respiratory distress.
  • Ambulate and activate as early as allowed.

D. If nasogastric tube was inserted to relieve distention and increase peristalsis, irrigate tube every 4 hours and prn.

E. If T-tube inserted.

  • Place client in Fowler’s position to facilitate drainage.
  • Keep tube below level of wound to promote bile flow and prevent back flow.
  • Measure amount and record character and color of drainage (may be up to 500 mL for first 24 hours).
  • Clamp tube before eating.
  • Protect skin around incision and cleanse surrounding area.

F. Prevent wound infections; clients tend to be obese—healing is often delayed.
G. Prevent thrombophlebitis.

  • Encourage range of motion.
  • Ambulate early.
  • Provide antiembolic stockings.

H. Provide diet: low fat, high carbohydrate, and high protein.

  • Instruct client to maintain diet for at least 2 or 3 months postoperatively.
  • May require continued use of vitamin K as dietary supplement.

I. Prepare client for T-tube removal.

  • As T-tube is clamped, observe for
    a. Abdominal discomfort and distention.
    b. Chills and fever; nausea.
  • Unclamp tube if any nausea or vomiting.

Medical–Surgical Nursing: Acute Pancreatitis

Focus topic: Medical–Surgical Nursing

Definition: An inflammation of the pancreas with associated escape of pancreatic enzymes into surrounding tissue.

  • Characteristics
    A. Etiology.
    Inflammation is caused by the digestion of the organ from the very enzymes it produces— trypsin, elastase, and lipase.
  • The most common precipitating factor in the United States is alcoholic indulgence.
  • Eighty percent of clients with pancreatitis have biliary tract disease with blocking of ampulla of Vater by gallstones.
  • May be caused as a result of Deltasone (prednisone) or thiazide therapy.
  • May be a complication of viral or bacterial disease, peptic ulcer, trauma, etc.

B. Pathology.

  • Cholecystitis with reflux of bile components into the pancreatic duct.
  • Spasm and edema of ampulla of Vater following inflammation of the duodenum.

Assessment
A. Assess for acute interstitial pancreatitis.

  • Constant epigastric abdominal pain radiating to the back and flank. More intense in supine position. Aggravated by fatty meal, alcohol, or lying in the recumbent position.
  • Nausea, vomiting, abdominal distention, paralytic ileus, and weight loss.
  • Low-grade fever.
  • Severe perspiration; anxiety.
  • Possible jaundice.

B. Laboratory values.

  • Elevation of WBC—20,000 to 50,000.
  • Elevated serum lipase (rises within 2–12 hours) and amylase (5–40 times); bilirubin and alkaline phosphatase elevated (due to compression of common duct) and transient elevation in glucose.
  • Urine amylase elevated.
  • Abnormal low serum levels in calcium, sodium, and magnesium—due to dehydration, binding of calcium in areas of fat necrosis.

C. Assess for acute hemorrhagic pancreatitis.

  • Pancreatic enzymes erode major blood vessels, causing hemorrhage into the pancreas and retroperitoneal tissues.
    a. Cullen’s sign: gray–blue discoloration of the abdominal area may be seen in intraabdominal hemorrhage.
    b. Turner’s sign: bruising of the skin of the loin.
  • Enzymatic digestion of the pancreas.
  • Severe abdominal, back, and flank pain.
  • Ascites.
  • Shock.

Implementation
A. Assess pain (using a standard pain scale) and take actions to alleviate pain.

  • Give analgesic medication as ordered (pain and anxiety increase pancreatic secretions).
  • Avoid opiates (morphine), which may cause spasms of sphincter of Oddi.
  • Give anticholinergic medication—atropine, to decrease vagal stimulation.

B. Reduce pancreatic stimulus.

  • Client is NPO to eliminate chief stimulus to enzyme release. TNA may be initiated.
  • Nasogastric tube to low suction to remove gastric secretions and air if nausea, vomiting, or ileus present.
  • Drugs to reduce pancreatic secretion.
    a. Sodium bicarbonate to reverse metabolic acidosis. Histamine H2 antagonists may be used to neutralize hydrochloric acid secretion.
    b. Diamox (acetazolamide) to prevent carbonic anhydrase from catalyzing secretion of bicarbonate into pancreatic juice.
    c. Regular insulin to treat hyperglycemia.
  • Diet to avoid pancreatic secretion: low fat, low protein, high carbohydrate; no spicy foods, alcohol, or caffeine; parenteral feedings if NPO.

C. Take vital signs every 15–30 minutes during acute phase; assess cardiovascular status.
D. Prevent or treat infection (and possible sepsis) with broad-spectrum antibiotics.
E. Replace and maintain fluids and electrolytes.

  • Treat hypocalcemia with neuromuscular irritability with calcium gluconate IV. (Signs—nausea, vomiting, tetany, abdominal pain, positive Chvostek’s sign.)
  • Treat hypokalemia—potassium is a major component in pancreatic juice. (Signs—muscle weakness, hyporeflexia, hypotension, apathy or irritability, arrhythmias.)
  • Treat hypomagnesemia (less than 1.4 mg/dL)—can be life-threatening.
  • Blood and plasma administration may be necessary to maintain circulatory volume.

F. Aggressive respiratory care to prevent acute respiratory distress syndrome (ARDS).

  • Atelectasis, effusion may be caused by elevation of the diaphragm.
  • Hypoxemia may occur.
  • Monitor arterial blood gases or ventilator if ordered.

G. Reduce body metabolism.

  • Oxygen for labored breathing.
  • 2. Bed rest; Fowler’s position for maximum chest expansion.
  • Cool, quiet environment.

H. Provide client and family instruction.

  • Discuss pathology of disease.
  • Give rationale for treatment.
  • Instruct client to avoid alcohol, coffee, heavy meals, and spicy foods.
  • Stress importance of follow-up with physician.
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Medical–Surgical Nursing: Chronic Pancreatitis

Focus topic: Medical–Surgical Nursing

Definition: Chronic fibrosis of the pancreatic gland—irreversible process of obstruction of ducts and destruction of secreting cells, following repeated attacks of acute pancreatitis.

Etiology
A. Alcohol abuse most common.
B. Other causes: hyperparathyroidism, malnutrition, and trauma.

Assessment
A. Assess for pain—persistent epigastric and left upper quadrant pain radiating to upper left lumbar region.
B. Check for anorexia, nausea, vomiting, constipation, and flatulence.
C. Evaluate disturbances of protein and fat digestion.

  • Malnutrition.
  • Weight loss from decreased intake due to fear of pain.
  • Abdominal distention with flatus and paralytic ileus.
  • Foul, fatty stools (steatorrhea) caused by a decrease in pancreatic enzyme secretion.

D . Laboratory values.

  • Elevated serum amylase and lipase (indicates decreased pancreatic enzyme excretion).
  • Increased glucose and lipids.
  • Decreased calcium, potassium.

E. Assess for hyperglycemia with symptoms of diabetes.
F. Evaluate fecal fat in stool specimens; x-ray often shows pancreatolithiasis and mild ileus, indicating fibrous tissue and calcification.

Implementation
A. Provide low-protein, low-fat, high-carbohydrate diet. Suggest bland and low-gas-forming foods in small, frequent feedings.
B. Administer drug therapy.

  • Antacids (Maalox) to neutralize acid secretions.
  • Histamine antagonists Zantac and Tagamet to decrease hydrochloric acid production so pancreatic enzymes are not activated.
  • Proton-pump inhibitors (Prilosec) may be given to neutralize or decrease gastric secretions.
  • Anticholinergics (atropine, Pro-Banthine [propantheline bromide]) to decrease vagal stimulation, GI motility, and inhibit pancreatic enzymes.
  • Administer pancreatic enzyme replacements, such as Viokase (pancreatin) and Cotazym (pancrelipase), with meals or snacks to aid digestion. Dose depends on degree of malabsorption or maldigestion. Monitor for side effects.
  • Narcotic analgesics (such as morphine sulfate) are used to control pain.

C. Report diabetic symptoms—insulin or oral hypoglycemic agents will be administered; monitor blood glucose levels to control hyperglycemia and prevent insulin shock.
D. Monitor for potential complications: pseudocyst, ascites, or pleural effusion, GI hemorrhage, biliary tract obstruction. Surgical treatment is done for specific complications and to relieve constant pain.

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