Lippincott’s Pharmacology Chapter 1

Passive Diffusion
High conc. -> low
majority of drugs work this way
does not involve carrier, is not saturable, and shows a low structural specificity

Facilitated Diffusion
involves carrier proteins
High conc -> low
no energy required, an be saturated, may be inhibited by compounds that compete for the carrier

Active Transport
Shows saturation kinetics for the carrier
drugs closely resemble naturally occurring metabolites that are actively transported across cell membranes
may be competitively inhibited

exo/endocytosis
B12 is absorbed by endocytosis; some neurotransmitters (e.g., norepinephrine) are stored in vesicles and released by exocytosis

Distribution equilibrium
when the permeable form of a drug achieves an equal concentration in all body water space

P-glycoprotein
a multidrug transmembrane transporter protein responsible for transporting various molecules , including drugs, across cell membranes; in areas of high expression, it reduces drug absorption

bioavailability
the fraction of administered drug that reaches the systemic circulation

bioequivalence
when two related drugs show comparable bioavailability and similar times to achieve peak blood concentrations

therapeutic equivalence
when two similar drug products that are pharmaceutically equivalent with similar clinical safety profiles

Pharm – General Principles of Pharmacology

What are the four (4) types of names assigned to drugs?
1) Chemical name
2) Generic name
3) Official name
4) Trade name (brand name)

What are the three (3) key features of a drug’s chemical name?
1) Exact chemical makeup of the drug
2) Placement of the atoms or molecular structure
3) No capitalization

What are the four (4) key features of a drug’s generic name?
1) Non-proprietary
2) Name given to drug before it becomes official
3) May be used in all countries by all manufacturers
4) No capitalization

What are the two (2) key features of a drug’s official name?
1) Name listed in “The United States Pharmacopeia National Formulary”
2) May not be the same as the generic name

What are the four (4) key features of a drug’s trade name (brand name)?
1) Name is registered by the manufacturer and is followed by the trademark symbol
2) Can be used only by the manufacturer
3) Any given drug may have several trade names
4) First letter of the name is capitalized

What is the largest category of drugs?
Prescription

Prescription drugs require a prescription by a ________.
Licensed health care provider

Prescription drugs are also called ________ drugs.
Legend

Prescriptions must have 1) the ________ of the drug, 2) the ________ of the drug, 3) the ________ of administration, 4) the ________ of administration, and 5) the ________.
1) name
2) dose
3) number of times
4) route
5) amount to be dispensed

Non-prescription drugs may be obtained without a ________.
Prescription

What is another name for non-prescription drugs?
OTC (over the counter)

Name two general conditions under which risks may be associated with non-prescription drugs.
1) When directions are not followed
2) When adverse reactions occur

What is a controlled substance?
A controlled substance is a drug or chemical whose use, ownership, or manufacture is regulated by law — particularly the federal Controlled Substances Act.

Drugs, substances, and certain chemicals used to make drugs are classified into ________ distinct categories or schedules.
Five

Drugs, substances, and certain chemicals used to make drugs are classified into distinct categories or schedules depending upon 1) ________ and 2) ________.
1) the drug’s acceptable medical use
2) the drug’s abuse or dependency potential

The schedule numbering for controlled substances ranges from ________ to ________.
I to V

A schedule V drug has a [higher or lower] potential for abuse or dependency than a schedule I drug.
Lower

What are the two key features of a schedule I drug?
1) High abuse potential
2) No accepted medical use in the U.S.

What are the two examples of a schedule I substance listed in the PowerPoint presentation?
1) Heroin
2) LSD

Schedule II substances are characterized by potential for abuse with ________ physical or psychological ________.
Severe
Dependence

Schedule III substances have [more or less] abuse potential than schedule II substances.
Less

Schedule III substances are characterized by ________ physical or psychological dependence.
Moderate

Non-barbiturate sedatives, non-amphetamine stimulants, and limited amounts of certain narcotics are examples of schedule ________ drugs
III

Schedule III substances have [more or less] abuse potential than schedule IV substances.
More

Schedule IV substances are characterized by ________ dependence.
Limited

What are the two (2) general categories the PowerPoint presentation gives as examples of schedule IV substances?
1) Sedatives and anxiety agents
2) Non-narcotic analgesics

Schedule ________ substances are characterized by limited abuse potential.
V

Anti-________ and anti-________ medications are categorized as schedule V substances because they contain small amounts of ________.
(Anti)-tussives
(Anti)-diarrheals
Narcotics

Drugs taken by mouth (except liquids) go through how many phases?
Three

Drugs taken by ________ (except liquids) go through three (3) phases.
Mouth

The three (3) phases of drugs taken my mouth (except liquids) are:
1) Pharmaceutic phase
2) Pharmacokinetic phase
3) Pharmacodynamic phase

The ________ phase involves the dissolution of the drug.
Pharmaceutic

Drugs must be in ________ to be absorbed.
Solution

Liquid drugs and ________ drugs do not go through the pharmaceutic phase because they are already in solution.
Parenteral

________ administration involves the esophagus, stomach, and small and large intestines (i.e., the gastrointestinal tract).
Enteral

Oral, sublingual (dissolving the drug under the tongue), and rectal are ________ methods of administration.
Enteral

________ administration literally means to avoid the gut (gastrointestinal tract) and refers to any route of administration outside of or beside the alimentary tract.
Parenteral

________ tablets do not dissolve until reaching the small intestine.
Enteric-coated

Metabolic activities of the drug within the body after it is administered relate to the ________ phase.
Pharmacokinetic

The pharmacokinetic phase relates to how many different features or actions of the drug?
Six (6)

The six drug features or actions that figure into pharmacokinetics are:
1) Bioavailability
2) Absorption
3) Distribution
4) Metabolism
5) Excretion
6) Drug half-life

Mnemonic: BAD MED

Absorption is the process by which a drug ________.
Becomes available for use in the body

In ________ absorption, a carrier molecule moves the drug across a membrane.
Active

Passive absorption occurs when the drug moves from an area of ________ concentration to ________ concentration. This transport mechanism is known as ________.
Higher
Lower
Diffusion

________ is a method of absorption in which cells engulf the drug particle, causing movement across the cell.
Pinocytosis

________, ________, and ________ affect the rate of absorption.
Route of administration
Solubility of the drug
Certain body conditions

What are the two (2) PowerPoint examples of body conditions that affect the rate of absorption?
1) Lipodystrophy
2) Food in the stomach

Whether a drug is ________ soluble or ________ soluble can affect its rate of absorption.
Water
Lipid

IV, IM, SC, and PO are examples of ________, which affects the rate of absorption.
Route of administration

________ is the fraction of the drug that reaches systemic circulation chemically unchanged.
Bioavailability

Protein binding refers to the fact that drugs travel in the system circulation bound to ________ and are ________ when bound to protein.
Albumin
Inactive

Protein molecules release the drug, which diffuses through the tissue, interacts with receptors, and produces the desired ________.
Therapeutic effect

________ drug levels must be maintained in order for the drug to be effective.
Therapeutic

If the drug level [increases or decreases], the drug will not produce the desired effect.
Decreases

If the drug level increases, ________ symptoms may occur.
Toxic

________ is the chemical reaction that occurs in the liver and converts a drug to an inactive compound.
Biotransformation

The ________ effect applies to drugs that are absorbed in the small intestines and are transported to the liver via portal circulation. There they are metabolized by the liver before release into the circulatory system.
First-pass

The first-pass effect applies to drugs that are absorbed in the ________ and are transported to the liver via portal circulation. There they are metabolized by the liver before release into the circulatory system.
Small intestines

The first-pass effect applies to drugs that are absorbed in the small intestines and transported to the ________ via portal circulation. There they are metabolized by the ________ before release into the circulatory system.
Liver
Liver

The first-pass effect can ________ the bioavailability of a drug.
Decrease

The first-pass effect can decrease the ________ of a drug.
Bioavailability

Only ________ drugs undergo the first-pass effect.
PO

________ refers to elimination of a drug from the body.
Clearance

In the process of excretion, the ________ renders the drug inactive and the ________ excretes the inactive compounds.
Liver
Kidney

Some drugs are excreted by the kidney unchanged and without ________ involvement.
Liver

What are the six (6) PowerPoint examples of routes of excretion?
1) Kidney
2) Sweat
3) Breast milk
4) Respiratory
5) Feces
6) Bile

The ________ phase refers to drug actions and effects on the body.
Pharmacodynamic

As part of a drug’s pharmacodynamics, primary and secondary effects may alter the cellular ________ or the cellular ________.
Environment
Function

Alteration in ________ function can increase or decrease physiologic function.
Cellular

Physical changes in the cellular environment include what three (3) alterations listed in the PowerPoint?
1) Osmotic pressure
2) Lubrication
3) Absorption

________ refers to the intended effect of the drug on the body.
Therapeutic response

________ are drugs that bind with a receptor to produce results.
Agonists

Drugs that bind with a receptor and prevent another molecule from binding to the same receptor and producing some result are called ________
Antagonists

What are the six (6) main categories of drug reactions?
1) Toxic reactions
2) Drug tolerance
3) Drug idiosyncrasy
4) Allergic drug reactions
5) Adverse drug reactions
6) Cumulative drug effect

Mnemonic: Tall Talking Idiots Alert Comatose Advisors
Tolerance, Toxic, Idiosyncrasy, Allergic, Cumulative, Adverse

Adverse reactions are often called ________ when they are mild.
Side effects

________ reactions are often called side effects when they are mild.
Adverse

Allergic reactions can be called ________ reactions.
Hypersensitivity

________ can be called hypersensitivity reactions.
Allergic reactions

________ may prompt the body to produce antibodies against what it perceives as an antigen.
Allergic reactions

Allergic reactions may prompt the body to produce ________ against what it perceives as an ________.
Antibodies
Antigen

________ is an extremely serious allergic reaction and can be life-threatening if not recognized and treated immediately.
Anaphylactic shock

Anaphylactic shock is an extremely serious ________ and can be life-threatening if not recognized and treated immediately.
Allergic reaction

________ refers to any abnormal or unusual drug reaction of unknown cause and with no predictability.
Drug idiosyncrasy

________ refers to decreased response to a drug requiring increase in dosage.
Tolerance

[Increased or decreased] response to drug requiring [increase or decrease] in dosage is referred to as tolerance, which is a sign of ________.
Decreased
Increase
Drug dependence

________ refers to increased response to a drug because of decreased metabolism and excretion (usually secondary to ________ or ________ disease).
Cumulative effect
Liver
Kidney

Cumulative effect refers to [increased or decreased] response to a drug because of [increased or decreased] metabolism and excretion (usually secondary to liver or kidney disease).
Increased
Decreased

________ refers to poisoning of the system secondary to overdose of chemical resulting in elevated blood concentration.
Toxic reaction

Toxic reaction refers to poisoning of the system secondary to ________ of chemical resulting in ________ blood concentration.
Overdose
Elevated

________ refers to a genetically caused abnormal response to a drug.
Pharmacogenetic reaction

What are the two (2) main types of drug interactions from the PowerPoint?
1) Drug-drug
2) Drug-food

What are the three (3) basic types of drug-drug reactions?
1) Additive drug reaction
2) Synergistic drug reaction
3) Antagonistic drug reaction

________ is the term used when two or more drugs are taken at the same time and the action of one plus the action of the other results in an action as if just one drug had been given. This could be represented by 1+1= 2. An example would be a barbiturate and a tranquilizer given together before surgery to relax the patient.
Additive drug reaction

________ occurs when two drugs are taken together that are similar in action, such as barbiturates and alcohol, which are both depressants, resulting in an effect that is exaggerated out of proportion to that of each drug taken separately at the given dose. This could be expressed by 1+1= 5. An example might be a person taking a dose of alcohol and a dose of a barbiturate. Normally, taken alone, neither substance would cause serious harm in this example, but if taken together, the combination could cause coma or death.
Synergistic drug reaction

________ occurs when two drugs given together have an opposite effect on the body. This could be expressed by 1+1=0. An example might be the use of a tranquilizer to stop the action of LSD. Some stimulants will counteract the effects of depressants and thus are used to treat overdoses of barbiturates and narcotics.
Antagonistic drug reaction

What are the five (5) chief factors influencing drug response?
1) Age
2) Weight
3) Gender
4) Disease
5) Route of administration

________ refers to taking of multiple drugs and creates potential for ________
Polypharmacy
Interactions

Polypharmacy is often practiced by ________, who have more conditions for which to be medicated.
the elderly

Polypharmacy increases the possibility of ________ reactions.
Adverse

Oral Pathology – Exam 1

Lichen

Primitive plants composed of symbiotic algae and fungi

Grow on tree trunks or rocks

Pathology: any of various skin diseases characterized by patchy eruptions of small, firm papules

Lichen Planus
Chronic immunologically-mediated disease
Oral lesions; +/- lesions on skin, other mucosae
Oral lesions more persistant than skin lesions
Middle age onset
Slight greater predilection in females over males

Lichen Planus – Skin Lesions
Most on flexor surfaces
Plaques or papules
Purple, flat-topped with white (Wickham’s) striae
Pruritic
Wax and wane and often subside in 2 years
Oral Lichen Planus – Types
White adherent
Erosive (e.g. desquamative gingivitis)
Vesiculobullous
White Adherent Lesions
Reticular striae
Plaques
Papules
White Adherent Lesions – Reticular Type
Asymptomatic
Interlacing white lines
Bilateral and symmetrical
Buccal mucosa > tongue > gingivae, lips, etc.
White Adherent Lesions – Plaques

Tongue and buccal mucosa

*The most common site for plaque is the dorsum of the tongue

Erosive Lichen Planus
E.g. Desquamative gingivitis (slide 120)
Symptomatic
Atrophy, erythema around central ulceration
Peripheral radiating white striae
Rare malignant transformation
Thick fibrinous exudate gives an appearance suggesting a bulla
Erosive Lichen Planus – Clinical Differential Diagnosis
Hypersensitivity reactions:
Systemic (e.g. drugs)
Local or contact (e.g. amalgam, cinnamon)Lupus erythematosus

Chronic ulcerative stomatitis

Oral graft-versus-host disease

Lichen Planus – Management
******
In general, monitor for iatrogenic candidiasis
Reticular Type
No treatment needed after diagnosis
Clinical monitoring
Erosive
Topical corticosteroids
Systemic immunosuppressive, if necessary
Monitor for potential dysplasia, SCC
Oral Lichen Planus – Histology
Orthokeratosis or parakeratosis
Uneven acanthosis (diffuse epidermal hyperplasia)
Rete ridges prominent, sharp (“saw tooth”), or absent (due to lymphocyte “remodeling” rete ridges)
T-LYMPHOCYTE zone in UPPER LAMINA PROPRIA (immediately below the epithelium)
Loss of basal cells (lymphocytes attack basal cell layer; apoptotic bodies left behind)
Immunofluorescence non-specific: shaggy fibrinogen band along BMZ
Oral Lichen Planus – Histology, cont’d.
Colloid, cytoid or Civette bodies (apoptotic basal cells are eosinophilic degenerating keratinocytes)
Lichen mucositis may have similar features
“Lichen Mucositis”
Lesions with clinical and/or histological resemblance to classical lichen planus
May exhibit some variation from classical features*See slide 24 for picture

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Pemphigus – Types
Vulgaris
Vegetans
Foliaceus
Erythematosus
Paraneoplastic
Drug induced*Foliaceus and erythematosus do not affect the oral cavity

Pemphigus Vulgaris – Clinical Features
Autoimmune vesiculobullous mucocutaneous disease
Appears first in mouth in some cases
Childhood to old age, but most occur between 30-50 years old
Pemphix (Greek) = bubble or blister
Skin lesions appear as flaccid blisters*Autoantibody against Desmoglein 3 triggers response and destroys epithelial cells

*See slides 26-28 for pictures

Pemphigus Vulgaris – Clinical Features
Oral mucosa:
Positive Nikolsky signOral lesions:
Painful
Vesicles rupture rapidly
Ulcers with irregular outlines
Spread peripherally and coalesce

Positive Nikolsky Sign
Pemphigus vulgaris
Paraneoplastic pemphigus
Pemphigoid (all types)
Bullous lichen planus
Erythema multiforme
Epidermolysis bullosa
Hypersensitivity reactions*May not be demonstrable in all cases

Pemphigus Vulgaris – Histology
Autoantibodies against desmoglein 3
Acantholysis (“acantho” = prickle)
Suprabasilar cleft with tombstone basal cells:
Cleft contains Tzanck cells (float off into space)*Basal cells lose attachment to the cells above them, but remain attached to the basement membrane

Pemphigus Vulgaris – Diagnosis

Exfoliative cytology: acantholytic round epithelial (Tzanck) cells

Histology: suprabasilar cledft with tombstone basal cells (cleft contains Tzanck cells)

DIF: Labelled Igs attached to autoantibodies against desmoglein 3 around epithelial cells in specimen (creates fishnet pattern)

IIF: Labelled CIRCULATING AUTOANTIBODIES to desmoglein 3 create same pattern on animal mucosa

Pemphigus Vulgaris – Management
Diagnosis ASAP
Prescriptions by experienced physician
Systemic corticosteroids
Other immunosuppressive agents
Monitor for iatrogenic candidiasis
Monitor disease by indirect immunofluorescence: circulating Igs correlate with disease activity
Serious drug side effects
10% fatal due to treatment
Systemic Corticosteroid Side Effects
Diabetes mellitus
Adrenal suppression
Weight gain
Osteoporosis
Peptic ulcers
Severe mood swings
Increased susceptibility to infections
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Perilesional Biopsy – Chronic Blisters, Erosions and Ulcers

Perilesion = tissue around the lesion

Diagnosis of immunologically-mediated ulcerative conditions (e.g. PV, MMP, BP, LP, LE)

Biopsy specimen should include perilesional (clinically normal) tissue

One-half in 10% formalin for routine H & E stain
Other half in Michel’s (preservative) solution

Incubated with FLUORESCIN-LABELED KNOWN PREPARED ANTIBODY against tissue-bound autoantibody or tissue antigen (C3, fibrinogen)

Bound fluorescin emits bright yellow-green light when tissue is exposed to UV light

Direct Immunofluorescence

Identifies factors in fresh (or preserved) patient tissue

Patient tissue incubated with F-LABELED KNOWN, PREPARED ANTIBODY against:
Tissue bound autoantibody (in PV, MMP, BP, LE)
PV: autoantibody to desmoglein 3
Tissue antigen (C3, fibrinogen)
Foreign (e.g. viral) antigen

Bound fluorescein emits bright yellow-green light when tissue is exposed to UV light

Indirect Immunofluorescence

Identifies circulating autoantibody in patient’s serum

Monkey mucosa is incubated with patient’s serum

Autoantibody in serum attaches to corresponding structure in the mucosa

F-LABELED KNOWN PREPARED ANTIBODY against the antibody is incubated with tissue section

Bound fluorescein emits bright yellow-green light when tissue is exposed to UV light

Pemphigus Vegetans
Variant of pemphigus vulgaris (less serious form)
Oral involvement in a few cases
Acantholytic bullae followed by epithelial hyperplasia and intraepithelial abscess
Pustular vegetations may look verrucous
Many eosinophils present
Vegetans type may occur in lull in pemphigus vulgaris
Can spontaneously remit
Paraneoplastic Pemphigus
Mucocutaneous disease associated with lymphoma (or benign lymphoprolifierative disease)
May appear before lymphoma diagnosis
Sudden onset of multiple vesiculobullous lesions on skin and mucosae
Also seen in erythema multiforme
Paraneoplastic Pemphigus, cont’d.
Cicatricial conjunctivitis in some cases
Skin lesions papular and pruritic (like lichen planus)
Lips resemble erythema multiforme (crusting)
Corticosteroids controls this disease but make malignancy worse
Paraneoplastic Pemphigus – Pathogenesis
Tumor causes host lymphocytes to release IL-6
IL-6 stimulates Igs against basement membrane antigens
Cytotoxic T lymphocytes presentThis multifaceted immunologic attack produces a variety of clinical, histologic and immunologic changes

Paraneoplastic Pemphigus – Histology

Lichenoid mucositis with subepithelial cleft or intraepithelial cleft

Some cases are only lichenoid

DIF: Weak deposition of immunoreactions (IgG and C); between epithelial cells and/or linear deposits at the basement membrane zone

IIF (using patient serum and epithelium from rat bladder): Igs between epithelial cells against desmogleins 1 and 3; Igs in BMZ against desmoplakin I and II, BPAG-1, etc.

***REVIEW CASES***
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Mucous Membrane Pemphigoid – Clinical Features
Chronic vesiculobullous disease
Most often affects females greater than 40 years old
Vesicles rupture: painful ulcers may persist for months
Positive Nikolsky sign
Usually exclusive to the mucous membrane of the oral mucosa; much lesser extent in the skin
Causes desquamative gingivitis
Desquamative Gingivitis
Gingivae red, edematous and glazed
Superficial ulceration or desquamation/peeling
Occurs more on the buccal gingiva than the lingual
Vesiculobullous conditions: MMP, ELP, PV, CUS, EBA, SLE, drug reactions, LIgA, paraneoplastic pemphigus
Mucous Membrane Pemphigoid – Clinical Features, cont’d.

Conjunctival involvement may lead to scarring

Symblepharon
Ankyloblepharon
Entropion

Symblepharon
Adhesions between bulbar and palpebral conjunctivae
Ankyloblepharon
Adhesion of ciliary edges of eyelids to each other
Entropion
Scarring may cause eyelids to turn inward
Mucous Membrane Pemphigoid – Histology
Subepithelial cleft
Entire epithelium lifts off the surface; looks like “unzipping”
Separation of epithelium from connective tissue at the BMZ results in vesicle formation
Subepithelial Vesicles in Oral Vesiculo-Ulcers
Pemphigoid (all types)
Epidermolysis bullosa (some types)
Linear IgA disease
Angina bullosa hemorrhagica
Dermatitis herpetiformis
Mucous Membrane Pemphigoid – Immunofluorescence
Homogeneous linear fluorescence at BMZ on DIF (IgG, C3, etc.)
See a definite line along the basement membrane zoneCIRCULATING IGs IN ONLY 5-30% OF CASES (this is IIF)

Mucous Membrane Pemphigoid – Pathogenesis and Histology
AUTOANTIBODIES (IgG etc.) TO BMZ ANTIGENS:
Hemidesmosome: BPAG (230kd) in plaque (in BP and MMP); BPAG2 (180kd) TRANSMEMBRANE PROTEIN (in MMP); Integrin alpha-6, beta-4 (in MMP)
Lamina lucida: LAMININ (EPILIGRIN) IN ANCHORING FILAMENTS (in MMP)Binding of IgG triggers reaction involving C and PMNs

Weakens basement membrane

Homogenous linear fluorescence at BMZ in DIF

Circulating Igs in only 5-30% of cases

Mucous Membrane Pemphigoid – Management

Removal of drug-induced disease

Ophthalmic consult

Topical corticosteroids:
Increase potency as necessary

Systemic:
Corticosteroids
Steroid sparing immunosuppressives
Tetracycline or minocycline
Dapsone

Bullous Pemphigoid – Clinical Features
Most common autoimmune blistering disease
Occurs in older people (60-80)
Starts with pruritus
Multiple tense bullae on normal or erythematous skin
Bullous Pemphigoid – Clinical Features, cont’d.
Bullae rupture, producing crust
Heal without scars
Oral lesions uncommon
Clinical course shorter than MMP
Bullous Pemphigoid – Histology
Subepithelial cleavage
Antigens: BP180 and BP230
Eosinophils within bullae
DIF positive in 90-100% of cases
IIF positive in 50-90% of cases
Titers don’t correlate with disease activity
Bullous Pemphigoid – Management
Removal of drug-induced disease
Systemic immunosuppresive agents
Lower doses of prednisone than for pemphigus
Better prognosis
Spontaneous remission in 2 to 5 years in some
Mortality due to treatment in older patients
Systemic Lupus Erythematosus – Pathogenesis
Antibodies against host cell antigens:
Nuclear (seem to do the most damage)
Cytoplasmic
Cell surfaceGenetic, environmental and hormonal factors trigger:
Increased B cell function
Abnormal T cell activity

*Patients most often die from renal failure

Discoid Lupus Erythematosus
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Organs Involved
Skin and oral only
Symptoms
NO
Serology
NO DETECTABLE ANTIBODIES
Histopathology
Basal cell loss
Lymphocytes at interface and perivascular
Keratosis
DIF
Granular/linear basement membrane deposits of IgG and C3
Systemic Lupus Erythematosus
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Organs Involved
Skin, oral, heart, kidneys, joints
Symptoms
Fever, malaise, weight loss
Serology
Positive ANA
Anti-DNA antibodies
Histopathology
Similar to discoid
DIF
Similar to discoid
Systemic Lupus Erythematosus – Clinical Features
Young adult females
Erythematous cutaneous rash (“butterfly” pattern on face)
Fever, weight loss, malaise
Glomerulonephritis
Damage to: joints, heart, lungs
Oral Lesions – LE
White plaques +/- ulceration
Erythema
Erosions
Ulcers
Desquamative gingivitis*Classical lesion: central red area or ulcer with white spots and peripheral radiating white lines

*Oral lesions may occur in SLE and CCLE

Systemic Lupus Erythematosus – Laboratory Abnormalities
Hematologic changes:
Anemia
Leukopenia
ThrombocytopeniaReduced serum complement concentration

ANTINUCLEAR ANTIBODIES

SLE – Antinuclear Antibodies

IIF is the most common technique to detect ANAs

Pattern of nuclear fluorescence suggests type of antibody

Homogenous/diffuse: antibodies to chromatin, histones and ds-DNA

Rim: antibodies to ds-DNA

Speckled: antibodies to non-DNA antigens (histones and RNP):
Sm
RNP
SS-A (Ro)
SS-B (La)

Nucleolar: antibodies to nucleolar RNP

Lupus Erythematosus – Histology
Hyperkeratosis:
Follicle keratin plugging in skin in CCLE, but nor in SLEAlternating epithelial atrophy/acanthosis

Basal cell degeneration (apoptotic bodies)

Subepithelial edema (+/- vesicles)

Thick PAS + BMZ

Lupus Erythematosis – Histology, cont’d.

Subepithelial, perivascular and adnexal lymphocytes

Intense inflammation in superficial lamina propria; inflammatory cells in deeper connective tissue (perivascular tissue)

See bulging of rete ridges due to attacking lymphocytes

*See zone of lymphocytes attacking the basal cells
*Looks like lichen planus, until you see deeper perivascular inflammation

Lupus Erythematosus – Histology, cont’d.
IF shows shaggy, granular-linear deposits in BAND along mucocutaneous BMZ:
IgG (IgM and IgA), C3 and fibrinogen
Band along BMZ is LUPUS BAND TEST
Positive in clinically normal skin in SLE (not CCLE)*In patients with CCLE, will only see the bands in the lesions; in SLE patients, will see the bands even in normal skin

Systemic Sclerosis
Probable autoimmune pathogenesis
Occurs much more in females than males
Insidious onset
INCREASED COLLAGEN (produces a mask-like facies)
Microstomia
Sclerodactyly (fingers with tightly bound skin)
Systemic Sclerosis – Scleroderma
Fibrosis of lungs, heart, kidneys, GI tract
Fibrosis also causes atrophy of the ramus, coronoid process or condyle; PDL space around mandibular molar is widened (with intact lamina dura)
Interstitial pulmonary disease, which leads to pulmonary hypertension and heart failure
Localized Scleroderma

Morphea

The cutaneous alteration (from a limited form of scleroderma) called en coup de sabre because the lesion resembles a scar that might result from a cut with a sword

Raynaud’s Phenomenon

Arterial insufficiency of acral parts SECONDARY to another disorder that causes arterial narrowing (e.g. SLE, systemic sclerosis, etc.)

Claudication (limping), color and temperature changes

Chronic ulcerations and eventual gangrene

See breakdown and resorption of digits (fingers may be fixed in a claw-like position; shortening may occur from acro-osteolysis; ulcerated fingertips)

Raynaud’s Disease
Vasospasm and its consequences are primary (increased response to stimuli has no known cause
Systemic Sclerosis – Diagnosis

Histology

Rheumatoid factor (antibody against Fc fragment of human IgG)

ANAs (including Anto-Scl-70; Scl-70 is a centromere antigen)

Systemic Sclerosis – Management

D-penicillamine inhibits collagen formation

Surgery (esophageal dilation)

Calcium channel blockers (increase peripheral blood flow and reduce Raynaud’s)

ACE inhibitors (reduce hypertension if kidneys severely affected)

Oral hygiene instruction

Poor long-term prognosis

CREST

Mild form of systemic sclerosis

C: calcinosis cutis
R: Raynaud’s phenomenon
E: esophageal dysfunction
S: sclerodactyly
T: telangiectasia

Mostly affects 50-70 year old females

Erythema Multiforme
Vesiculo-ulcerative mucocutaneous disease
Mostly affects the lips
Occurs in young adults
Occurs in males more than females
Prodrome: fever, malaise, headache
Abrupt onset; usually resolves in four weeks
Recurrence linked to HSV
Erythema Multiforme – Pathogenesis
Self-limiting hypersensitivity reaction
Precise mechanism unknown
Possible involvement of both cell-mediated and humoral immune systems
Ag-Ab complexes target small mucocutaneous vessels
Some drugs may cause EM: Sulfas, Penicillin, Dilantin, Barbiturates, Iodines, Salicylates
Erythema Multiforme – Clinical
Usually acute, self-limited
Some cases chronic or recurring acute
Headache, fever, lymphadenopathy
Target skin lesions (concentric erythematous rings)
Skin macules, papules, vesicles, bullae, etc
Oral ulcers
Erythema Multiforme – Oral Lesions
Painful
Aphthous-type ulcers
Multiple superficial extensive ulcers
Bullae soon rupture*Destruction of epithelium that is superficial, but deeper than pemphigus vulgaris

Erythema Multiforme – Types
Minor
Major
Stevens Johnson syndrome (oral, eye and genital lesions)
*These three may overlapToxic epidermal necrolysis (usually caused by drugs; patients look like they have extensive burns)

Erythema Multiforme – Histology
Necrotic keratinocytes
Spongiosis
Vesicles in epithelium may extend to the subepithelium
Necrosis of vesicle roof
Interface infiltrate lymphohistiocytic
Perivascular inflammation
IF nonspecific*Histology is characteristic but not pathognomonic

Erythema Multiforme – Management
Eliminate triggers (antiviral agents in cases triggered by HSV)
Early corticosteroids (topical, systemic)
Rehydrate
TEN (toxic epidermal necrolysis): burn unit, avoid corticosteroids, pooled IgGs (blocks Fas ligand, which caused epithelial destruction)
Reactive Arthritis (Reiter’s Syndrome)
Abnormal immune reaction to microbial antigen (STD or dysentery)
See 1-4 weeks after exposure
Acute onset of triad: non-specific urethritis, conjunctivitis, arthritis
Skin lesions in some (histology is psoriasiform)
Reactive Arthritis (Reiter’s Syndrome), cont’d.
Oral in less than 20% of cases:
Ulcers (RAU)
Papules
Erythema migrans?Most affects young adult males

HLA-B27 phenotype

Lasts weeks to months with recurrences

NSAIDS for arthritis

Lange Q&A Surgery

Def high-output renal failure
BUN continues to rise with urine output >1000-1500

Mild-to-moderate renal insufficiency

Severe renal failure
Oliguric renal failure

How long can the kidneys tolerate ischemia?
30-90 minutes

Do vasopressors help with shock?
No, they aggravate the deleterious effects of shock

Hyperkalemia manifests with ____ or ____ signs
GI or cardiovascular

What are the GI signs and symptoms of hyperkalemia
Nausea, vomiting, intestinal colic, and diarrhea

T/F abdominal distension as a result of paralytic ileus is due to hypokalemia?
True.

What are the CV signs and symptoms of hyperkalemia
ECG is useful to monitor potassium levels.

Hyperkalemia = peaked T waves, ST segment depression, widened QRS complex, and heart block

When would you see Osborne (J) waves?
Seen in hypothermia

What is given to counteract the effect of potassium on the myocardium?
Calcium gluconate

How do you get metabolic acidosis with normal anion gap?
Loss of bicarbonate (e.g. small bowel fistula, pancreatic fistula, or diarrhea) and gain of chloride

What are some causes of SIADH?
Head injury
CNS disorders
Neoplastic diseases
Idiopathic

What are some signs of SIADH?
Impaired water excretion, oliguria, hyponatremia, significantly decreased serum osmolality, and increased urinary osmolality

When does hyponatremia cause CNS symptoms?
When serum sodium <130 mEq/L

What are some of the signs/symptoms of moderate hyponatremia?
Muscle twitching and increased tendon reflexes

What are some signs/symptoms of severe hyponatremia?
Convulsions, loss of reflexes, and hypertension

What is the sodium deficit?
(normal serum sodium − observed serum
sodium) × 0.6 × (total body weight)

How should the sodium deficit be corrected?
Half of the sodium deficit should be administered over 12-18 hours

The composition of intestinal fluid is closest to that of ____
Plasma

What ions does normal saline, 3% saline, and half normal saline have?
Na, Cl

How do you calculate pH based on changes in CO2?
Every change of 10 mmHg from 40 mmHg changes pH by 0.08 from 7.4.

What are the most common signs of zinc deficiency?
Skin lesions (scaly, hyperpigmented lesions)
Hypogonadism
Diminished wound healing
Immunodeficiencies

What are the effects of toxic megacolon?
Massive dilatation
Perforation
Fecal peritonitis
Death

Surgical Procedures end in "-plasty"

Punctoplasty
A surgical procedure to restore the proper drainage of tears when the Lacrimal punctum gets blocked in one or both the eyes

Trabeculoplasty
A laser treatment for glaucoma.

Otoplasty
Surgical and non-surgical procedures for correcting the deformities and defects of the pinna (external ear); and for reconstructing a defective, or absent external ear, consequent to congenital conditions (e.g. microtia, anotia, etc.) and trauma (blunt, penetrating, blast).

Rhinoplasty
A nose job, is a plastic surgery procedure for correcting and reconstructing the form, restoring the functions, and aesthetically enhancing the nose, by resolving nasal trauma (blunt, penetrating, blast), congenital defect, respiratory impediment, and a failed primary rhinoplasty.

Septoplasty
A corrective surgical procedure done to straighten the nasal septum, the partition between the two nasal cavities.

Angioplasty
The technique of mechanically widening narrowed or obstructed arteries, the latter typically being a result of atherosclerosis.

Uvulopalatoplasty
A surgical procedure performed with the aim of reducing or eliminating snoring.

Palatoplasty
A surgical procedure used to correct or reconstruct the palate in a person with a cleft palate.

Urethroplasty
A repair of an injury or defect within the walls of the urethra.

Pyeloplasty
The surgical reconstruction or revision of the renal pelvis to drain and decompress the kidney.

Phalloplasty
Penis enlargement; the construction or reconstruction of a penis, or the artificial modification of the penis by surgery, often for cosmetic purposes.

Scroplasty
Reparative or plastic surgery of the scrotum.

Vaginoplasty
A reconstructive plastic surgery and cosmetic procedure for the vaginal canal and its mucous membrane, and of vulvo-vaginal structures that might be absent or damaged because of congenital disease (e.g. vaginal atresia) or because of an acquired cause (e.g. childbirth physical trauma, cancer).

Clitoroplasty
A term for the surgical creation of a clitoris, in transsexual and transgender women (as part of sex reassignment surgery), or restoration in the case of procedures reversing the damage caused by female genital cutting.

Labiaplasty
A plastic surgery procedure for altering the labia minora (inner labia) and the labia majora (outer labia), the folds of skin surrounding the human vulva.

Tuboplasty
A number of surgical operations that attempt to restore patency and functioning of the Fallopian tube(s) so that a pregnancy could be achieved.

Fimbrioplasty
A plastic or reconstructive surgery to repair the fimbria that may be damaged or causing a blockage within the fallopian tubes.

Acromioplasty
An arthroscopic surgical procedure of the acromion (a small piece of the surface of the bone).

Khyphoplasty
A type of surgery to repair compression fracture to vertebra, often from osteoporosis.

Mentoplasty
Chin augmentation using surgical implants to alter the underlying structure of the face by reduction, providing better balance to the facial features.

Arthroplasty
An orthopedic surgery where the articular surface of a musculoskeletal joint is replaced, remodeled, or realigned by osteotomy or some other procedure.

Rotationplasty
A type of autograft wherein a portion of a limb is removed, while the remaining limb below the involved portion is rotated and reattached.

Mammoplasty
A group of surgical procedures, the goal of which is to reshape or otherwise modify the appearance of the breast.

Abdominoplasty
A cosmetic surgery procedure used to make the abdomen more firm. The surgery involves the removal of excess skin and fat from the middle and lower abdomen in order to tighten the muscle and fascia of the abdominal wall.

Hernioplasty
Hernia repair; a surgical operation for the correction of a hernia

Frenuloplasty
The surgical alteration of a frenulum when its presence restricts range of motion between interconnected tissues.

Z-plasty
A versatile plastic surgery technique that is used to improve the functional and cosmetic appearance of scars.

Oscheoplasty
Reparative or plastic surgery of the scrotum.

Genioplasty
Chin augmentation using surgical implants to alter the underlying structure of the face by addition, providing better balance to the facial features.

Gastrointestinal Disorders NCLEX 3000

A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when administering an enema?
1. Assist the client into the left-lateral Sims’ position., 2. Lubricate the distal end of the rectal catheter., 6. Be sure to keep the solution container below 18″ above bed level.
A client is recovering from a small-bowel resection. To relieve pain, the physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours. How soon after administration should meperidine’s onset of action occur?
2. 15 to 30 minutes

A client seeks medical attention after developing acute abdominal pain. Which action by the nurse would help ensure accurate auscultation of the client’s bowel sounds?
2. Making sure the client’s bladder is empty before auscultating
A 68-year-old male is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:
3. onto the bedpan.
The nurse is teaching a group of middle-aged men about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention:
4. alcohol abuse and smoking.
A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained:
4. until three fecal cultures are negative for Shigella.
The nurse is teaching a client about malabsorption syndrome and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the:
2. small intestine.
A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do?
4. Sign the consent only if she sees the client sign it.
Locate the abdominal quadrant where the nurse would expect to palpate the liver.
The liver is located in the right upper abdominal quadrant.
Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease?
1. To keep gastric pH at 3.0 to 3.5
After taking an antacid, the client asks the nurse where antacids act in the body. How should the nurse respond?
4. Stomach
A client is admitted to the health care facility with nausea, vomiting, and abdominal cramps and distention. Which test result is most significant?
4. Serum potassium level of 3 mEq/L
When caring for a client with hepatitis B, the nurse should monitor closely for the development of which finding associated with a decrease in hepatic function?
4. Irritability and drowsiness
The nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?
3. “Maintain a high-carbohydrate, low-fat diet.”
The nurse is assessing a client who complains of abdominal pain, nausea, and diarrhea. When examining the client’s abdomen, which sequence should the nurse use?
2. Inspection, auscultation, percussion, and palpation
When caring for a client who has had constipation for 4 days, what should be the nurse’s primary client care concern?
1. Promoting defecation
Which food should be included in a client’s diet during the first 6 to 8 weeks after ileostomy surgery?
4. Banana
When preparing a client for a hemorrhoidectomy, the nurse should take which action?
1. Administer an enema as ordered.
A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant?
4. A client with bilateral blindness
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin sulfate (Mycifradin). The rationale for neomycin use in this client is to:
2. decrease the intestinal bacteria count.
A client is preparing to undergo abdominal paracentesis. Which nursing interventions should be performed before the procedure?
1. Explain the procedure to the client., 2. Make sure informed consent was obtained., 3. Instruct the client to void.
A client with recent onset of epigastric discomfort is scheduled for an upper GI series (barium swallow). When teaching the client how to prepare for the test, which instruction should the nurse provide?
4. “Avoid eating or drinking anything for 6 to 8 hours before the test.”
A nurse is assigned the care of six clients and has the aid of a nursing assistant. Which task is appropriate for the nurse to delegate to the nursing assistant?
1. Measuring and recording nasogastric tube output
What is the primary nursing diagnosis for a client with a bowel obstruction?
1. Deficient fluid volume
A nurse is irrigating an open wound of the abdomen. In which direction should she arrange for the irrigation solution to flow through the wound?
4. From the top inside of the wound, through the wound, and then out
Which condition is most likely to have a nursing diagnosis of Deficient fluid volume?
2. Pancreatitis
After checking the client’s chart for possible contraindications, the nurse is administering meperidine (Demerol), 50 mg I.M., to a client with pain after an appendectomy. Which type of drug would contraindicate the use of meperidine?
3. A monoamine oxidase (MAO) inhibitor
The nurse is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?
1. Hanging the irrigation bag 24″ to 36″ (60 to 90 cm) above the stoma
A nurse is assigned to care for four clients. Which client should a nurse assess first?
1. A postoperative client who just returned from surgery and is vomiting
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?
3. Monitoring the client’s weight every day
Which infections require contact precautions?
1. Clostridium difficile, 3. Methicillin-resistant staphylococcus aureus
The nurse is monitoring a client receiving paregoric to treat diarrhea for drug interactions. Which drugs can produce additive constipation when given with an opium preparation?
2. Anticholinergic drugs
A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer:
2. phytonadione (Mephyton).
While preparing a client for cholecystectomy, the nurse explains that incentive spirometry will be used after surgery primarily to:
1. increase respiratory effectiveness.
A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:
2. anorexia, nausea, and vomiting.
A client who has just been diagnosed with hepatitis A asks, “How could I have gotten this disease?” What is the nurse’s best response?
4. “You may have eaten contaminated restaurant food.”
A client with mild diarrhea, fever, and abdominal discomfort is being evaluated for inflammatory bowel disease (IBD). Which statement about IBD is true?
1. Diarrhea is the most common sign of IBD.
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?
1. Atrophy of the gastric mucosa
A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects this client’s stools to be:
3. black and tarry.
A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client’s nasogastric (NG) tube has stopped draining. How should the nurse respond?
1. Notify the physician.
A client undergoes a barium swallow fluoroscopy that confirms gastroesophageal reflux disease (GERD). Based on this diagnosis, the client should be instructed to take which action?
2. Avoid caffeine and carbonated beverages., 4. Stop smoking., 5.Take antacids 1 hour and 3 hours after meals.
A client with severe abdominal pain is being evaluated for appendicitis. What is the most common cause of appendicitis?
2. Obstruction of the appendix
The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action:
1. destroys the odor-proof seal.
A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone (Maalox TC) by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently?
2. It has a short duration of action.
The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should:
3. collect the specimen in a sterile container.
A nurse is caring for a client with an ileostomy. What is the most common complication of this procedure?
1. Peristomal skin irritation
When preparing a client, age 50, for surgery to treat appendicitis, the nurse assists in formulating a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
2. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix
A client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency department. His wife reports that he has been “spitting up blood.” A Mallory-Weiss tear is suspected, and the nurse begins taking a client history from the client’s wife. The question by the nurse that demonstrates her understanding of Mallory-Weiss tearing is:
1. “Tell me about your husband’s alcohol usage.”
For a client with cirrhosis, deterioration of hepatic function is best indicated by:
2. difficulty in arousal.
As part of a routine screening for colorectal cancer, a client must undergo fecal occult blood testing. Which foods should the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period?
2. Red meat,. 3. Turnips, 4. Horseradish
A client is in the late stage of cirrhosis. When planning the client’s diet, the nurse should focus on providing increased amounts of:
4. carbohydrate.
When collecting data on a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:
1. a canker sore of the oral soft tissues.
Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?
1. Change the tube feeding solutions and tubing at least every 24 hours.
After undergoing a liver biopsy, the client should be placed in which position?
2. Right lateral decubitus position
During a client-teaching session, which instruction should the nurse give to a client receiving kaolin and pectin (Kaopectate) for treatment of diarrhea?
4. “Drink 8 to 13 8-oz glasses (2 to 3 L) of fluid daily.”
A nurse is working with a nursing assistant, who is given the task of calculating three clients’ intake and output at the end of the shift. When the nurse reviews the nursing assistant’s work, she discovers inaccuracies in the nursing assistant’s results. What should the nurse do?
4. Ask the nursing assistant to show her how she determined the results.
A 32-year-old male client with appendicitis is experiencing severe abdominal pain. An abdominal X-ray film reveals intraperitoneal air. The nurse should prepare the client for:
1. surgery.
The nurse must administer an enema to an adult client. The appropriate distance for inserting an enema into an average-sized adult is:
2. 3″ to 4″.
A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note:
1. yellow sclerae.
A client with cirrhosis is ordered to have a daily measurement of his abdominal girth. Identify the anatomical landmark where the tape measure should be placed when obtaining this measurement.
Abdominal girth should be measured at the umbilicus to obtain the most accurate measurement.
When a client resumes oral feedings after having gastric resection, the nurse watches for early manifestations of dumping syndrome. The vasomotor disturbances associated with this syndrome usually occur how soon after eating?
2. 5 to 30 minutes
While palpating a client’s right upper quadrant, the nurse would expect to find which of the following structures?
4. Liver
The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
4. drink liquids only between meals.
Which diagnostic test would be used first to evaluate a client with acute upper GI bleeding?
1. Endoscopy
After admission for acute appendicitis, a client undergoes an appendectomy. He complains of moderate postsurgical pain for which the physician prescribes pentazocine (Talwin), 50 mg by mouth every 4 hours. How soon after administration of this drug can the nurse expect the client to feel relief?
2. 15 to 30 minutes
A nurse approaches a client with an 0800 dose of his scheduled pancreatin. The client states, “I’m not going to take that medicine. It makes me nauseated.” What should the nurse do first?
3. Instruct the client about the benefit of taking the medication.
When planning care for a client with a small-bowel obstruction, the nurse should consider the primary goal to be:
3. maintaining fluid balance.
The nurse is developing a plan of care for a client with hepatitis A. What is the main route of transmission of this hepatitis virus?
2. Feces
As a result of a viral infection, a client develops gastroenteritis. The physician prescribes kaolin and pectin mixture (Kaopectate), 60 ml by mouth after each loose bowel movement, up to eight doses daily. The client asks the nurse how soon the medication will take effect. How should the nurse respond?
2. Within 30 minutes
A 58-year-old client with osteoarthritis is admitted to the hospital with peptic ulcer disease. Which findings are commonly associated with peptic ulcer disease?
2. History of nonsteroidal anti-inflammatory drug (NSAID) use, 3. Epigastric pain that’s relieved by antacids, 5. Nausea and weight loss
A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?
4. “I’ll eat frequent, small, bland meals that are high in fiber.”
A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client’s stoma appears dusky. How should the nurse interpret this finding?
1. Blood supply to the stoma has been interrupted.
To verify the placement of a gastric feeding tube, the nurse should perform at least two tests. One test requires instilling air into the tube with a syringe and listening with a stethoscope for air passing into the stomach. What is another test method?
1. Aspiration of gastric contents and testing for a pH less than 6
A client comes to the emergency department complaining of acute GI distress. When obtaining the client’s history, the nurse inquires about his family history. Which disorder has a familial basis?
3. Ulcerative colitis
The physician orders morphine for a client who complains of postoperative abdominal pain. For maximum pain relief, when should the nurse anticipate administering morphine?
1. Before the pain becomes severe
A client with cholecystitis is receiving propantheline bromide (Pro-Banthine). The client is given this medication because it:
3. inhibits contraction of the bile duct and gallbladder.
A 72-year-old client seeks help for chronic constipation. This is a common problem for elderly clients due to several factors related to aging. Which of the following is one such factor?
2. Decreased abdominal strength
The nurse is performing an assessment on a client who has developed a paralytic ileus. The client’s bowel sounds will be:
2. hypoactive.
While a client is being prepared for discharge, the nasogastric (NG) feeding tube becomes clogged. To remedy this problem and teach the client’s family how to handle it at home, what should the nurse do?
1. Irrigate the tube with cola
A 53-year-old client undergoes colonoscopy for colorectal cancer screening. A polyp was removed during the procedure. Which nursing interventions are necessary when caring for the client immediately after colonoscopy?
3. Observe the client closely for signs and symptoms of bowel perforation., 4. Monitor vital signs frequently until they’re stable., 5. Inform the client that there may be blood in his stool and that he should report excessive blood immediately.
The nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse’s actions is to avoid:
2. aspiration.
One day after undergoing a traditional cholecystectomy, a client is scheduled to stand at the bedside and walk. What should a nurse teach the client to do before standing and walking for the first time after surgery?
2. Flex her legs when moving to a sitting position.
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
2. Positioning the client on the side with the knees flexed
When evaluating a client for complications of acute pancreatitis, the nurse would observe for:
2. decreased urine output.
A client with gastroenteritis is admitted to an acute care facility with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:
2. enteric precautions must be continued.
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:
1. increasing fluid intake to prevent dehydration.
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
2. “Avoid coffee and alcoholic beverages.”
A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and ranitidine (Zantac). Before the client is discharged, the nurse should provide which instruction?
3. “Avoid aspirin and products that contain aspirin.”
A client with amebiasis, an intestinal infection, is prescribed metronidazole (Flagyl). When teaching the client about adverse reactions to this drug, the nurse should mention:
1. metallic taste.
A client who can’t tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must stay alert for:
1. diaphoresis, vomiting, and diarrhea.
A client comes to the emergency department with suspected cholecystitis. Which data collection findings are characteristic of this diagnosis?
1. Transient epigastric pain radiating to the back and right shoulder, 2. Burning in the chest after eating fried foods, 3. Flatulence, 4. Nausea
Which outcome indicates effective client teaching to prevent constipation?
4. The client reports engaging in a regular exercise regimen.
A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?
4. The client touches the altered body part.
A client who is about to undergo gastric bypass surgery calls the nurse into the room. The client says she’s concerned that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best?
2. “I’m not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so.”
Which of the following is a warning sign of colon cancer?
3. Rectal bleeding
A client who received an inhalation anesthetic during GI surgery experiences severe shivering postoperatively. In addition to providing extra blankets, the nurse should:
3. provide oxygen as prescribed.
A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary?
3. Standard precautions
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
1. auscultate bowel sounds.
An 86-year-old client with a history of atrial fibrillation takes 5 mg of warfarin (Coumadin) daily. Warfarin therapy makes the client at risk for which complications?
2. Hemorrhage, 3. Hepatitis, 5. Hematuria
An elderly client with Alzheimer’s disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for:
3. aspiration.
The nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
2. Increased urine output
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should:
3. wear gloves when caring for the client and wash her hands after touching the client.
The physician prescribes lactulose (Cephulac), 30 ml by mouth three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:
4. level of consciousness (LOC).
A client with left hemiparesis is having difficulty handling eating utensils. A nurse asks the physician to request a consult with which discipline?
4. Occupational therapy
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?
1. Acute pain related to biliary spasms
A client with abdominal pain secondary to a malignant mass in the colon is receiving fentanyl (Duragesic) by transdermal patch. His current patch expires in 48 hours and he reports a pain level of 8 on a 1-to-10 scale. What should a nurse do?
3. Notify the client’s physician.
A client is receiving a cleansing enema. During the procedure, the client reports abdominal cramping. What should the nurse do?
1. Lower the fluid bag so that the instillation slows.
The nurse is teaching an elderly client about good bowel habits. Which statement by the client would indicate to the nurse that additional teaching is required?
2. “I need to use laxatives regularly to prevent constipation.”
Which medication should the nurse expect to administer to a client with constipation?
4. Docusate sodium (Colace)
A client is undergoing an extensive diagnostic workup for a suspected GI problem. The nurse discovers that the client has a family history of ulcer disease. Which blood type also is a risk factor for duodenal ulcers?
4. Type O
Alterations in hepatic blood flow resulting from a drug interaction also can affect:
4. metabolism and excretion.
A client with Crohn’s disease is admitted to a semiprivate room late in the afternoon. The next day, the client reports that he was not able to sleep during the night because the hallway lights bothered him. He asks that he be moved to a bed next to a window. What should the nurse do?
3. Move him to the next available window-side bed.
The nurse is caring for a client with cirrhosis. Which data collection findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?
3. Purpura and petechiae
A client with peptic ulcer disease is prescribed aluminum-magnesium complex (Riopan). When teaching about this antacid preparation, the nurse should instruct the client to take it with:
2. water.
The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the client’s response, the surgeon should collaborate with which health team member?
4. Enterostomal nurse
A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When monitoring TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause:
1. hyperglycemia.
A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?
3. Ineffective breathing pattern
One year ago, a client was diagnosed with cirrhosis of the liver caused by alcohol abuse. Since then, he has been noncompliant with the prescribed protein-restricted diet. After a friend finds him semiconscious at home, the client is admitted to the hospital. When initial laboratory test results show an elevated ammonia level, he’s diagnosed with hepatic encephalopathy. The physician prescribes lactulose (Cephulac), 200 g diluted in 700 ml of tap water, given as a retention enema every 4 hours. For which other condition is lactulose prescribed?
4. Constipation
A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client?
1. Relieving abdominal pain
A client with acute diarrhea is prescribed paregoric, 5 ml by mouth up to four times daily, until the diarrhea subsides. The client asks the nurse how soon the medication will start to work after the first dose is taken. How should the nurse respond?
3. “Within 1 hour”
A client who has been treated for diverticulitis is being discharged on oral propantheline bromide (Pro-Banthine). The nurse should instruct the client to take the drug at which times?
3. 30 minutes before meals and at bedtime
The nurse should expect to administer which vaccine to the client after a splenectomy?
3. Pneumovax 23
The nurse caring for a client with small-bowel obstruction would plan to implement which nursing intervention first?
4. Administering I.V. fluids
A client is scheduled for bowel resection with anastomosis involving the large intestine. Because of the surgical site, the nurse assists in formulating the nursing diagnosis of Risk for infection. To complete the nursing diagnosis statement, which “related-to” phrase should be added?
2. Related to the presence of bacteria at the surgical site
While obtaining a client’s medication history, the nurse learns that the client takes ranitidine (Zantac), as prescribed, to treat a peptic ulcer. The nurse continues gathering medication history data to assess for potential drug interactions. The nurse should instruct the client to avoid taking a drug from which class with ranitidine?
1. Antacids
A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, “No.” What should the nurse do next?
2. Provide the client with information about an advance directive.
A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Discharge teaching should include which instruction?
1. “Continue to take antacids, even if your symptoms subside.”
One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond?
1. “Atropine decreases salivation and gastric secretions.”
The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should:
3. irrigate the NG tube gently with normal saline solution.
A client is admitted with suspected cirrhosis. During assessment, the nurse is most likely to detect:
2. muscle wasting.
A client with hepatitis C develops liver failure and GI hemorrhage. The blood products that would most likely bring about hemostasis in the client are:
4. cryoprecipitate and fresh frozen plasma.
Following a liver transplant a client develops ascites. The nurse should teach the client to:
2. brace the abdomen with a pillow during coughing.

Florida Board of PT Laws and Rules

Endorsement
licensure granted by the board persuant to the provisions of 486.081 or 486.087

Practitioner of record
458 md
459 osteopathic
460 chiropractor
461 podiatrist
466 dentist

Board of PT practice # of members
7

Board of PT practice members
5 PTs (at least 4 years) – 1 may be a full time faculty member
2 never been licensed health care practioners

Board of PT practice terms
4 years

How many times can you fail boards?
5 times
3 attempts and then educational training required then 2 more attempts allowed

Requirements for temporary license (5)
1. application for permit
2. graduate of US PT school
3. application for licensure
4. proof of malpractice insurance
5. documentation of supervising therapist
–must pass laws and rules?

temporary license supervising therapist requirements
licensed at least 6 months. DIRECT supervision. cosign all records.

Temporary permit voiding
1. if does not pass NPTE
2. within 6 months

Reactivation of a license rules
1. fee no greater than 200
2. CEU requirements not greater than 10 hours for each year
3. Has practiced 4 years in another state
4. PAsses NPTE exam

Continuing education requirements
24 hours
12 can be online
2 prevention of medical errors (no more than 3)
1 HIV/AIDS (no more than 3)
no more than 5 hours of risk management

Reasons to miss board meeting
court order, subpeona, death of family member, illness, hospitalization of immediate family
Cannot miss more than 3 consecutive board meetings unless excused.

Florida Statutes
PT – Chapter 486
other 456

Florida administrative code
64b17

Probable cause panel
2 people – designate chair (2 members or 1 current and 1 past member)

application fees:
licensure by endorsement
licensure by NPTE
Laws and rules exam
Initial licensure
unlicensed activity fee
biennial fee for active
biennial fee for inactive
retired status fee
delinquent status fee
reactivate license
change of status
licensure by endorsement 100
licensure by NPTE 100
Laws and rules exam 25
Initial licensure 75
unlicensed activity fee 5
biennial fee for active 75
biennial fee for inactive 50
retired status fee 50
delinquent status fee 55
reactivate license 50
change of status 40

How many years must you have passed the NPTE and laws and rules to receive license?
within 5 years

Replication for license exam? laws and rules?
DOH form #DOH-MQA 1143

Requirements for reactivation of inactive license (4)
1. 10 hours of CE (no more than 6 at home)
2. Medical errors precention for each biennium
3. 2 hours specifically related to laws and rules within 1 year prior to reactivation
4. proof of 24 hours of CE including med errors in the preceding biennium which the licensee held active license

Spouses of military
Exempt from licensure renwal when out of state due to spouse’s duties. Must document status and tell board within 6 mo of return. If at second half of biennium then exempt from CE.

Program plan
establishment of objectives (goals) and specific remediation techniques

Releasing info to a 3rd party not in actual care
Written consent from patient or legally authorized personnel

Inquiries of patient prognosis from PTA
direct to PT

Acute care PTA
PT will be readily and physically available for consultation to the PTA

PTA employed under who needs general supervision by PT? under who needs direct?
general: board certified orthopedic physician or physiatrist, chiropractic physician certified in PT
direct: any other physician than stated above.

Min qualifications for perform electromyography (4)
1. must be trained
2. formal education
3. 200 hours of testing human subjects under direct supervision
4. present evidence of 100 tests of neurologically involved patients

Change of address
notify within 60 days

Death of PT
1. medical records must be available for 2 years after death
2. must be published in newspaper at least 1 month after death

TErmination or relocation of PT
1. 2 years medical records be available
2. Notice in newspaper no less than 4 times over 4 weeks
3. SIgn placed outside office no less than 30 days prior to relocation

Costs of duplicating medical records
first 25 pages $1/page
over 25 = .25c/page
reasonable costs of reproducing xrays

Unable to practice with reasonable skill
1,000 3 years probation PRN eval

Obtain license with bribery
500 2 years probation

Guilt of crime relating to PT
1500 6 months probation

Treatment other than PT
1000 1 year probation

failure to maintain acceptable standards
1000 letter of concern

unlawful fee splitting
1000 and/or 1 year probation

negligent filing or false report
1000 up to min 2 years probation

offer practice beyond scope
2500 and/or 1 year probation

improper use of laser device
2000 and/or 1 year probation

Failure to comply with HIV/AIDS
1000 and letter of concern

Failure to report health care violator
letter of concern

Improper delegation
1000 and/or 6 months probation

+ drug screen
500 and/or 2 years probation

Citations
requirement that subject correct violation within 60 days.
Issued within 6 months after the filing of the complaint

citation violations: 8
Advertising discounted services 200
Failure to turn over patient records 100
Obtaining license by bad check 100
Failing to report conviction 250
Failure to satisfy CE 300-1000
Failure to notify change of address 250
Failure to comply with audit of CE 250
Failure to pay fees 150

Failure to complete CE fines
>9 hours 300
9-16 hours 600
>16 1000

Reinstatement of license when for definite period
upon expiration

Reinstatement of license when ability to engage in safe practice
compliance with terms of final order and show ability to practice safely

early Reinstatement of license when definite or indefinite –
petition with documentation of compliacne with final order and plan

To show safety compliance
10 hours of CE/year
submission of mental or physical exam
completion of substance treatment program

How long to correct violation?
15 days

HIV/AIDS requirement
1 clock hour – online – first renewal of licensure
modes of transmission, infection control, clinical management, prevention, florida law on AIDS

Medical errors requirement
2 contact hours – can be at home – each biennium
medical documentation and communication, CI and indications for PT management, pharmacological components of PT and pt management. Study of root cause analysis,. error reduction and prevention, patient safety

1 contact hour
50 minutes

1 CEU
10 contact hours = 500 minutes

CE approved 6
College/university 1 credit = 1 contact hour
APTA sponsored courses
FPTA sponsored courses
Florida board meetings (50min = 1 contact hour)
Probable cause council (5 hours)
Laws and rules exam (2 hours)

Excuses for not getting CEs 3
illness, courses not available, economic/tech/legal hardships

Notify department for missing board meeting 456
5 days prior unless proof of emergency

Who can limited licenses provide services to? 456
indigent, underserved or critical need populations within the state

Who can challenge the validity of the examination? 456
Those that score 10% below min score

Examination in another language 456
Must pay costs of translation and allow 6 months. 15 or more applicants must want the translation.

Penalty for theft or reproduction of exam 456
3rd degree felony

Delinquent business license 456
must reapply within 6 months

Prescription labeling 456
Must have name of practioner and license number on prescription. Name of practioner on bottle

Financial interest disclosure 456
1. tell pt about existence of financial interest
2. name and address of the entity
3. Pts right to obtain items/services
4. 2 alternative sources
5. post copy of disclosure and terms
Violation is 1st degree misdemeanor

Kickbacks 456
prohibited

Legislative intent
every PT meets min requirements for safe practice

Physical therapy definition
a person who is licensed and who practices PT in accordance with the provisions of this chapter 486

Practice of PT definition
performance of assessment and treatment of human beings or the prevention with physical, chemical or other properties of air, electricity, exercise, massage and performance of acupuncture when no penetration of skin occures, radiant eneerfy (ultraviolet, visible and infrared rays), ultrasound, water. Implement plan of treatment.

Direct acces # of days
21

sexual misconduct
prohibited.

Grounds for denial of license
1. illness or use of drugs
2. fraud in PT or deceit in obtaining license
3. convicted or guilty of crime related to PT
4. failure to maintain acceptable standard of practice
5. treating by other mens other than PT
6. dividing transferring assigning rebating or refunding fees received for services
7. having license revoked or suspended in antoher stat
8. violating order from disciplinary hearing
9. filing false report
10.practicing beyond scope
11. viiolating 456

If you vilate any provisions what penalty is it
first degree misdemeanor
1. practice without active license
2. use a license which is suspended or revoked
3. otain license fraudulently
4. use name PT unless licensed
5. make false oath or affirmation
6. conceal info relating to violations

Injunctive relief
any person or the department in the name of the state may apply for injunctive relief int he court to enjoin any person from committing any act in violation of this chapter

Practitioner disclosure of confidential info: immunity 456
shall not be civilly or criminally liable for the disclosure of confidential info to a sexual partner or needle sharing partner under the following circumstances:
1. if patient discloses the persons info
2. the practitioner recommends the pt notify the partner and hte patient refuses
3. adivses the partner reasonably and in good faith

treatment programs for impaired practitioners 456
?

Block 3 – Pharmacology – Gastrointestinal Drugs

Emesis
Pathogenesis
1. Vagal afferents from stomach and small intestine
2. Blood-borne (chemotherapy, opioids, ipecac)
3. Higher brain centers (fear, anticipations, memory)
4. Sensory input (sight, smell, pain)
5. Vestibular apparatus
-All of these converge on one center of the brain to induce this symptom (chemoreceptor trigger zone, or CTZ)
-Employs serotinin, dopamine, muscarinic receptors, histamine, and neurokinin NTs and receptors for signaling (targets of treatment)

Emesis
Treatment
-Serotonin receptor antagonists
-Glucocorticoids
-Substance P/Neurokinin-1 antagonists
-Benzodiazepines
-Dopamine antagonists
-Butyrophenones
-Metoclopramide

Motion Sickness
Treatment
-Scopolamine
-Antihistamines

Emetics
Gastrointestinal Drugs
-Ipecacuanha
-Apomorphine

Ulcers
Treatment
-H2 receptor antagonists
-Cholinergic antagonists
-Antacids
-Proton pump inhibitors
-Protective agents (bismuth, sucralfate)
-Promotility agents
-Antibiotics

H2 Blockers
Gastrointestinal Drugs
-Cimetidine
-Ranitidine
-Famotidine
-Nizatidine

-tidine
Mechanism
-Reversible block of histamine H2-receptors; results in decreased H+ secretion by parietal cells

-tidine
Clinical Use
-Peptic ulcer, gastritis, mild esophageal reflux, ZE syndrome
-However, only treats the symptoms, not the underlying disease pathology

Cimetidine
Toxicity
-Potent inhibitor of P-450 (multiple drug interactions; prolongs other drug half-lives)
-Antiandrogenic effects (prolactin release, gynecomastia, impotence, decreased libido in males)
-Crosses BBB (confusion, dizziness, headaches) and placenta

Cimetidine, Ranitidine
Toxicity
-Decreased renal excretion of creatinine

Propantheline, Isopropamide, Scopolamine
Clinical Use
-Decrease acetylcholine stimulated acid secretion and motility along the GI tract (rarely used alone)

Proton Pump Inhibitors
Gastrointestinal Drugs
-Omeprazole
-Lansoprazole
-Esomeprazole
-Pantoprazole
-Dexlansoprazole

-prazole
Mechanism
-Irreversibly inhibit H+/K+ ATPase in stomach parietal cells; results in decreased H+ secretion

-prazole
Clinical Use
-Peptic ulcer
-Gastritis
-Esophageal reflux
-Zollinger-Ellison syndrome
-Can be taken just once a day (advantage over histamine-receptor antagonists)

-prazole
Toxicity
-Increased risk of Clostridium difficile infection
-Pneumonia
-Hip fractures
-Decreased serum Mg2+ w/ long-term use
-Hypertrophy of gastrin producing cells; can potentially cause tumors (only animal studies at high doses)

Bismuth, Sucralfate
Mechanism
-Bind to ulcer base, providing physical protection and allowing HCO3- secretion to re-establish pH gradient in the mucous layer

Bismuth, Sucralfate
Clinical Use
-Increase ulcer healing
-Traveler’s diarrhea

Misoprostol
Mechanism
-PGE1 analog
-Increases production and secretion of gastric mucous barrier; results in decreased acid production

Misoprostol
Clinical Use
-Prevention of NSAID-induced peptic ulcers
-Maintenance of a patent ductus arteriosus
-Induction of labor (ripens cervix)

Misoprostol
Toxicity
-Diarrhea
-Contraindicated in women of child-bearing potential (abortifacient)

Octreotide
Mechanism
-Long-acting somatostatin analog

Octreotide
Clinical Use
-Acute variceal bleeds
-Acromegaly
-VIPoma
-Carcinoid tumors

Octreotide
Toxicity
-Nausea
-Cramps
-Steatorrhea

Antacids
Toxicity
-Can affect absorption, bioavailability, or urinary excretion of other drugs by altering gastric and urinary pH or by delaying gastric emptying (change in pH can affect bioavailability of other drugs)
-Hypokalemia
-Aluminum hydroxide also stimulates mucus secretion

Aluminum Hydroxide
Toxicity
-Constipation (“minimum amount of feces”) and hypophosphatemia
-Proximal muscle weakness
-Osteodystrophy
-Seizures

Magnesium Hydroxide
Toxicity
-Diarrhea (“M”ust “g”o to the bathroom)
-Hyporeflexia
-Hypotension
-Cardiac arrest

Calcium Carbonate
Toxicity
-Hypercalcemia
-Rebound acid increase (b/c gastrin release is stimulated)
-Can chelate and decrease effectiveness of other drugs (i.e tetracyclines)

Infliximab
Mechanism
-Monoclonal antibody to TNF-alpha

Infliximab
Clinical Use
-Crohn’s disease
-Ulcerative colitis
-Rheumatoid arthritis

Infliximab
Toxicity
-Infection (including reactivation of latent TB)
-Fever
-Hypotension

Sulfasalazine
Mechanism
-Combination of sulfapyridine (anti-bacterial) and 5-aminosalicyclic acid (anti-inflammatory)
-Activated by colonic bacteria

Sulfasalazine
Clinical Use
-Ulcerative colitis
-Crohn’s disease

Sulfasalazine
Toxicity
-Malaise, nausea
-Sulfonamide toxicity
-Reversible oligospermia (semen w/ low sperm concentration)

Ondansetron
Mechanism
-5-HT3 (type 3 serotonin) receptor antagonist
-Powerful central-acting anti-emetic
(At a party feeling queasy? Keep “on danc”ing w/ this drug)

Ondansetron
Clinical Use
-Control vomiting post-op and in patients undergoing cancer chemotherapy (first drug approved to do so)
-Often combined w/ dexamethasone (corticosteroid); makes drug more efficacious

Ondansetron
Toxicity
-Headache
-Constipation

Glucocorticoids
Mechanism = unknown; possibly anti-swelling effects

Clinical Use = anti-emetic, but not currently approved by FDA for nausea and vomiting relief alone; often used on combination w/ Ondansetron

Aprepitant
Mechanism = Substance P/neurokinin 1 antagonists; blocks these receptors in the chemoreceptor-trigger zone

Clinical Use = anti-emetic; prevents post-operative nausea/vomiting and; however, takes long time to act and effects last for weeks

Metoclopramide
Mechanism
-Dopamine-2 receptor antagonist
-Increases resting tone, contractility, LES tone, and motility of GI tract smooth muscle
-Does not influence colon transport time

Metoclopramide
Clinical Use
-Diabetic and post-surgery gastroparesis
-Anti-emetic
-GERD (helps to empty stomach to prevent acid build up)

Metoclopramide
Toxicity
-Increased parkinsonian effects
-Restlessness, drowsiness, fatigue, depression, nausea, diarrhea
-Interaction w/ digoxin and diabetic agents
-Contraindicated in patients w/ small bowel obstruction or Parkinson’s disease

Lorazepam
Clinical Use
-Benzodiazepam
-Used in combination regimens to suppress chemotherapy-induced nausea and vomiting
-Sedates, suppresses anticipatory emesis, and produces anterograde amnesia (patient won’t remember what made them nauseous)

Phenothiazines
Mechanism
-Dopamine antagonists; blocks dopamine-2 receptors in CTZ

Clinical Use
-Anti-emetic in surgery, cancer chemotherapy, and toxins

Toxicity = enter CNS and cause extrapyramidal (movement disorders), anti-cholinergic effects, hypotension, and extreme sedation

Haloperidol, Droperidol
Mechanism
-Butyrophenones; blocks dopamine-2 receptors in CTZ

Clinical Use
-Anti-emetic in surgery, cancer chemotherapy, and toxins

Toxicity = enter CNS and cause extrapyramidal (movement disorders), anti-cholinergic effects, hypotension, and extreme sedation; may cause prolonged QT interval (slow conduction)

Cannabinoids
Clinical Use
-Dronabinol and nabilone; related to medical marijuana
-Anti-emetic mechanism unclear
-Potential for abuse

Scopolamine
Mechanism
-CNS muscarinic antagonist

Toxicity
-Dry mouth, blurred vision, sedation

Scopolamine
Clinical Use
-Motion sickness

Ipecacuanha
Clinical Use
-Emetic drug to induce vomiting in conscious patients

Apomorphine
Clinical Use
-Derivative of morphine
-Emetic drug that induces vomiting by acting on the CTZ (induces dopamine receptors)

Domperidone
Mechanism = peripheral dopamine-receptor antagonist; regulates the motility of gastric and small intestine smooth muscle

Clinical Use = short-term relief of GERD

Laxatives
Gastrointestinal Drugs
-Bulk forming
-Emollient
-Osmotic/Saline
-Stimulant
-Peripherally-acting opioid antagonists

Toxicity = electrolyte imbalances (can cause arrhythmia in elderly)

Bulk Forming
Mechanism
-Laxative
-High fiber; absorbs water to increase bulk, which distends bowel to initiate reflexive bowel activity
-Includes psyllium and methylcellulose

Bulk Forming
Indications
-Acute and chronic constipation
-Irritable bowel syndrome
-Diverticulosis

Emollient
Mechanism
-Laxative
-Softens and lubricates stool; promotes more water and fat in the stools
-Includes docusate salts (stool softener) and mineral oil (lubricant)

Emollient
Indications
-Acute and chronic constipations
-Fecal impaction
-Facilitation of bowel movements in anorectal conditions (want stool smooth)

Osmotic Laxatives
Gastrointestinal Drugs
-Magnesium hydroxide (saline)
-Magnesium citrate (saline)
-Polyethylene glycol (hyperosmotic)
-Lactulose (hyperosmotic)

Magnesium Hydroxide, Magnesium Citrate, Polyethylene Glycol
Mechanism
-Laxative
-Provide osmotic load to draw water out into the GI tract (former two drugs by generating salt gradient)

Magnesium Hydroxide, Magnesium Citrate, Polyethylene Glycol
Clinical Use
-Chronic constipation
-Diagnostic and surgical preps

Magnesium Hydroxide, Magnesium Citrate, Polyethylene Glycol, Lactulose
Toxicity
-Diarrhea
-Dehydration
-May be abused by bulimics

Lactulose
Mechanism
-Laxative
-Provide osmotic load to draw water out into the GI tract
-Gut flora degrade it into metabolites (lactic and acetic acid), which promotes nitrogen excretion as NH4+

Lactulose
Clinical Use
-Constipation
-Treatment of hepatic encephalopathy

Stimulant
Mechanism
-Laxative
-Increases peristalsis via intestinal nerve (however, can cause severe cramps)
-Includes Senna, Bisacodyl

Stimulant
Indications
-Acute constipation
-Diagnostic and surgical preps

Peripherally-acting Opioid Antagonists
Mechanism
-Blocks entrance of opioid into bowel (thus, treats constipation caused by opioids); allows bowel to function properly w/ opioid use (strict regulations)
-Includes Methylnaltrexone and Alvimopan

Diarrhea
Treatment
-Adsorbents
-Anticholinergics
-Opioid preparations (i.e. Loperamide)
-Intestinal flora modifiers

Adsorbents
Mechanism
-Anti-diarrheal
-Coats the walls of the GI tract
-Bind to causative bacteria or toxin, which is then eliminated through the stool
-Includes Bismuth subsalicylate, activated charcoal, and aluminum hydroxide

Anticholinergics
Mechanism
-Anti-diarrheal, anti-motility
-Decrease intestinal muscle tone and peristalsis of GI tract, resulting in slowed movement of fecal matter
-Includes belladonna alkaloids (atropine, hyoscyamine)

Opiates
Mechanism
-Anti-diarrheal, anti-motility
-Decrease bowel motility and relieve rectal spasms
-Increases transit time through the bowel, allowing more time for water and electrolytes to be absorbed and relieves pain of rectal spasms
-Includes paregoric, opium tincture, codeine, loperamide, diphenoxylate

Intestinal Flora Modifiers
Mechanism
-Anti-diarrheal
-Probiotics or bacterial replacement drugs
-Bacterial cultures of Lactobacillus organisms work by supplying missing bacteria to the GI tract, suppressing the growth of diarrhea-causing bacteria

CH 5 – Nursing Process & Critical Thinking

ACTUAL NURSING DIAGNOSIS
Human responses to health conditions / life processes that exist in an individual, family, or community. It is supported by defining characteristics that cluster in patterns or related cues or inferences.

ASSESSMENT
A systemic, dynamic process by which the nurse, through interaction with the client, significant others, & health care providers, collects & analyzes data about the client.

BIOGRAPHIC DATA
Relating to the facts and events of a person’s life.

CASE MANAGEMENT
(Now a certified nursing specialty) Refers to the assignment of a health care provider to a pt so that the care of that pt is overseen by one individual.

CLINICAL PATHWAY
A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, high-cost cases. (Synonyms: critical paths, multdisciplinary action plans, action plans, care maps.)

COLLABORATIVE PROBLEM
Certain physiologic complications that nurses monitor to detect onset or changes in status. Use of physician-prescribed & nursing-prescribed interventions. EX: Potential Complication: hypoglycemia.

CUE
Synonym for subjective & objective data.

DATABASE
A large store or bank of information. (From which the nursing diagnosis can be identified).

DEFINING CHARACTERISTICS
Cues that tell how the diagnosis is manifested — The clinical cues, signs, & symptoms that furnish evidence that the problem exists.

DIAGNOSE
To identify the type & cause of a health condition. (ANA def. – a clinical judgment about the client’s response to actual or potential health conditions or needs, The diagnosis provides the basis for determination of a plan of care to achieve expected outcomes.)

EVALUATION
A determination made about the extent to which the established outcomes have been achieved. — Review pt-centered goals, Reassess pt to gather data about pts actual response to nursing interventions, Compare the actual outcome with desired outcome, Make critical judgment as to whether outcome was achieved.

GOAL (STATEMENT)
A statement about the purpose to which an effort is directed.

IMPLEMENTATION
Established plan is put into action to promote outcome achievement. — 5th phase of nursing process — Includes: ongoing activities of data collection, prioritization, performance of nursing interventions, & documentation.

MANAGED CARE
A health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame.

MEDICAL DIAGNOSIS
The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory test, & procedures.

NANDA
North American Nursing Diagnosis Association – approved official definitions of a nursing diagnosis that are still in current use.

NURSING DIAGNOSIS
Clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. — Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

NURSING INTERVENTION
Those activities that should promote the achievement of the desired pt outcome — May include activities that the nurse selects to resolve a nursing diagnosis, to monitor for the development of a risk problem, or to carry out physician orders.

NURSING PROCESS
Serves as the organizational framework for the practice of nursing. — A systematic method by which nurses plan & provide care for pts. — Consists of 6 dynamic & interrelated phases: assessment, diagnosis, outcome identification, planning, implementation, & evaluation.

NURSING-SENSITIVE OUTCOMES
The results or outcomes of nursing interventions. These outcomes or indicators are influenced by nursing & can be used to judge effectiveness of care & determine best practices.

OBJECTIVE DATA (SIGNS)
Observable & measurable data that can be recorded. EX: rash, lesions, puffy eyes, crying, slurred speech, temperature elevation.

OUTCOME (Desired Pt Outcome)
States the behaviors that the pt will be able to perform rather than the nurse will do. — 2 functions: 1.) Guide the selection of interventions — 2.) Establishes the measuring standard that is used to evaluate the effectiveness of the nursing interventions.

PLANNING
Nurse establishes priorities of care, selects & converts nursing interventions into nursing orders, and communicates the plan of care using standardized languages or recognized terminology to document the plan.

PROBLEM
Any health care condition that requires diagnostic, therapeutic, or educational action. —

RISK NURSING DIAGNOSIS
Human responses to health conditions / life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that are present that are known to contribute to the development of a problem.

STANDARDIZED LANGUAGE
A structured vocabulary that provides nurses with a common means of communication.

SUBJECTIVE DATA (SYMPTOMS)
Verbal statements provided by the pt. EX: nausea, fatigue, anxiety.

SYNDROME NURSING DIAGNOSIS
Used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances. CURRENT: Post-trauma, Rape-trauma, Risk for disuse, Impaired environmental interpretation, Relocation stress.

VARIANCE
When a pt does not achieve the projected outcome. — Exit — Are examined by members of the interdisciplinary team to determine whether the failure to achieve the outcome was a system, provider, or pt problem. — Analysis is used to promote continuous quality improvement.

WELLNESS NURSING DIAGNOSIS
Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement.

NURSING
The protection, promotion, and optimization of health & abilities, prevention of illness and injury, alleviation of suffering through the diagnosis & treatment of human response, & advocacy in the care of individuals, families, communities, & populations.

FOCUS ASSESSMENT
Is advisable when a pt is critically ill, disoriented, or unable to respond — Gathers info about a specific health problem —

PRIMARY SOURCES OF DATA
The patient.

SECONDARY SOURCES OF DATA
Include family members, significant others, medical records, diagnostic procedures, nursing literature, & other health care team members.

2 BASIC METHODS OF COLLECTING DATA
Pt Interview. & physical examination.

PT INTERVIEW DATA
Health history, biographic data, information about the reason the pt is seeking health care, history of present illness, family history, environmental history, psychosocial history, followed by review of systems.

DATA CLUSTERING
Occurs when related cues are grouped together, attention being focused on health concerns. (Also assists in identification of the nursing diagnosis).

GUIDELINES FOR SIGNIFICANT CUES
1.) Deviations from population norms — 2.) Any change in the pts usual health status — 3.) Developmental delays — 4.) Dysfunctional behavior — 5.) Changes in usual behavior

NURSING DIAGNOSIS COMPONENTS
1.) Nursing diagnosis title/label — 2.) definition of the title/label — 3.) Contributing /etiologic /related factors — 4.) defining characteristics.

RISK FACTORS
Those circumstances that increase the susceptibility of a pt to a problem.

4 TYPES OF NURSING DIAGNOSIS
1.) Actual nursing diagnosis — 2.) Risk — 3.) Syndrome — 4.) Wellness

PT OUTCOME STATEMENT
Provides a description of the specific, measurable behavior (outcome criteria) that the pt will be able to exhibit in a given time frame following the interventions.

Nursing Interventions/Tx GI

Oral Cancer
1.Airway management
2•Cough Enhancement
3•Aspiration Precautions
Medical:
1. Oral examination for lesions &Palpation of cervical nodes
2•Biopsy of oral lesions which do not heal in two weeks
3•Surgical resection
4•Radiation Therapy
5•Chemotherapy
6•Combination of above 3

GERD Diagnosis (3)
-Rule out cardiac pain
-Diagnosis demonstrated reflux
1. 24-hour ambulatory pH monitoring (most accurate method of dx) (small catheter placed into distal esophagus that continuously monitors and records pH while client keeps a diary of activities and symptoms
2. Endoscopy/esophagogastroduodenoscopy (EGD) (requires conscious sedation)
3. Esophageal manometry: water filled catheter inserted through nose or mouth and slowly withdrawn while LES pressure and peristalsis measurements are recorded
-Labs

GERD Teaching (9)
1•Avoid foods & medication that reduce LES tone
2•Avoid eating within 3 hours of bedtime or lie flat after eating
3•Avoid restrictive clothing
4•Avoid large meals
5•Elevate HOB 6-12 inches for sleeping
6•Smoking cessation
7•Caffeine in moderation
8•Consult with dietician for weight loss
9•Avoid heavy lifting & straining or working bent-over

GERD Surgery tx

done if medical doesn’t work

1. Laparoscopic NissenFundoplication- done by laproscopy-A portion of the gastric fundus is wrapped around the sphincter area of the esophagus.
2. Nissen Fundoplication
3. Hill Repair
4. Belsy Repair (Mark IV)
5. Angelchic Prosthesis

Hiatal Hernia tx
1.Lifestyle Modification
Weight loss, small frequent meal, Avoid eating 2-3 hours before bedtime or lying down after meals, Avoid straining and vigorous exercise, Smoking cessation, Elevate HOB
2. Medications: Antacids, Histamine H 2-receptor antagonist, & Proton Pump Inhibitors

Hiatal Hernia surgery

done if severe, non-responsive, & if ulceration/necrosis is suspected

Surgery similar to that done for GERD-
-NissenFundoplication most common: fundus of stomach is brought up and wrapped around esophagus; stitched into place providing a one-way valve to control reflux; may be done laparascopically
-Complications include hemorrhage, infection, dysphagia, obstruction, perforation, fistula, pulmonary embolus

Achalasia tx
Aimed at relief of symptoms
•Elevate HOB
•Pain relief-Antacids, H2 receptor antagonists, and Proton pump inhibitors
•Calcium channel blockers and nitrates reduce LES pressure
•Botox injections to esophagus -Inhibits contraction of smooth muscle (90% improve, but requires repeated dosing; long-term effects are unknown)

Achalasia dx
-Barium Swallow: visualizes the esophagus and will show dilation with a narrowing at the terminal esophagus (hallmark)
-CXR: shows a distorted and dilated tubular esophagus, the absence of a gastric bubble, and occasionally a tubular mediastinalmass next to the aorta.
-Endoscopy: to evaluate the appearance of esophageal mucosa
-Manometry: usually reveals increased LES pressure and incomplete sphincter relaxation when swallowing

Achalasia Surgery
1. Esophageal dilation of LES- Usually done on outpatient basis, Local anesthesia used, 75% success rate
2. Esophagomyotomy -enlarging the LE sphincter by incising the circular muscle fibers down to the mucosa

Esophageal Tumors dx
-Esophagogastroduodenoscopy (EGD) with biopsy
-Bronchoscopy to determine metastasis to trachea

Esophageal tumor tx
1.Nutrition consult due to malnourishment or risk for malnourishment.
2.Speech pathologist consult to assist with oral exercise for improved swallowing.
3.Radiation therapy is used for inoperable tumors to manage symptoms or to provide palliation of symptoms by shrinking tumor.
4.Chemotherapy either alone or in combination with radiation and/or surgery.

Esophageal tumor surgery
1-Esophagectomy-removal of all or part of the esophagus and replacement with a Dacron graft or a portion of colon or small intestine
2-Esophagogastrostomy-resection of a portion of the esophagus and anastomosis of remaining portion to stomach
3-Palliative gastrostomy done for purpose of feeding client

Zenker Diverticulum tx/dx
Diagnosis: Esophagogastroduodenoscopy (EGD)

•Collaborate with Dietician for best food options
•Semisoft meals, small, frequent meals
•Sleep with HOB elevated
•Avoid being supine for at least 2 hours after eating
•Avoid excessive exercise after meals
•Avoid tight clothing
•Limit stooping and bending
•Surgical removal of diverticulum
-NPO for several days to promote healing
-IV fluids and possible tube feedings
-NG tube placement

Gastritis Acute tx (7) & Chronic (4)
Directed toward identification of and removing the cause and treating the symptoms
1.NPO until N/V abate
2.Bland diet progressing to regular diet as tolerated
3.Administer medications as ordered
4.Antiemetic for n/v
5.Antacids, H2 receptor antagonists, Proton Pump Inhibitor for gastric pain
6.Anti-diarrheal if a problem with diarrhea
7.Replacement IV fluids if dehydration is a problem

Chronic same as acute but add
1.R/O Gastric Cancer
2•Vitamin B12
3•Treat H. pylori
4•Stress reduction techniques

PUD tx
Treatment similar regardless of location
1. Medications
-Antimicrobials: Clarithromycin(Biaxin), Metronidazole(Flagyl), Amoxicillin(Amoxil), Tetracycline(Sumycin)
-PPI or H2 blocker
-Antacids or Bismuth
-Coating agents
-Gastrointestinal Prostaglandin-misoprostol(Cytotec)
2. Dietary modification
-Small frequent meals
-Avoid irritants/foods that promote gastric secretion, such as caffeine, milk, coffee, alcohol
3.Lifestyle modification
-Smoking cessation
-Stress reduction
-Exercise

PUD Complication: Hemorrhage tx (11)
Goal: Stop acute bleeding & prevent re-bleeding
1.Maintain airway, breathing, & circulation.
2.Cool saline lavage via NG tube
3.Endoscopic therapy via EGD for:
4.Thermal contact using a heater probe or multielectrocoagulation
5.Injection of bleeding site with diluted epinephrine
6.Laser therapy
7.Clipping vessel with mechanical clip
8.Suppression of gastric acid (H2-receptor antagonists, PPI, antacids)
9. Replace volume/fluids to maintain vascular, cellular, and intracellular perfusion (NS, LR)
10•Promote rest-Bedrest with limited visitors
11•Monitor VS, UOP, & kidney function, and neurological status
-Foley/hourly urine
-BUN/Creatinine
-Frequent neuro checks

PUD Complications: Perforation tx (5)
1•Keep NPO
2•Fluid/electrolyte replacement
3•Antimicrobial
4•Nasogastric suction
5•Emergency Surgery
-Hemigastrectomy
-Pyloroplasty
-Peritoneal Cavity flushing with antimicrobial and Normal Saline

PUD complications: Obstruction tx ()
1•Nasogastric suctioning
2•IV maintenance of fluid & electrolyte balance
3•Surgical Treatment
-Gastric resection-removal of portion of stomach involved
-Vagotomy-cutting of Vagus nerve to eliminate PSN stimulation of gastric secretion
-Pyloroplasty-pylorus in incised and re-sutured to relax muscle and enlarge opening from stomach to duodenum to increase rate of gastric emptying

Stress Ulcer tx (5)
1.Prevention is best! Monitor patients at high risk & prophylactic measures
2. Remember its painless
3. Admin Meds: Antacids, H2 Blockers, PPI, Coating Agents
4-Hemorrhage care
•Gastric lavage
•Vasoconstrictive meds-Vasopressin(Pitressin) drip
•Electrocoagulation
•Vagotomy
•Gastrectomy

ZES tx
1.Therapy aimed @ suppression of acid secretion (PPI or/and H2 receptor antagonists)
2.Tumor Removal
3.Aggressive disease may be treated with chemotherapy

Gastric Cancer tx (4)
Treatment depends on stage of disease
1•Little effective medical treatment available
2•Primary treatment is surgical resection (usually palative)-Gastrectomy (Partial/Total), Vagotomy, Pyloroplasty
3•Combination of radiation and chemotherapy after surgery may be used
4•TPN for nutrition

Dumping Syndrome tx (6)
1.Decrease amount of food eaten at one time
2.Eat high protein, high fat, low carbohydrate, dry diet
3.Eat 5-6 small meals per day
4.Minimize roughage (Fiber)
5.Eat in semi-recumbent position or lie down after meals
6.Avoid fluids 1 hour before meals and for 2 hours after meals

IBS tx (5)
No specific test to diagnose
1.Diet modification
•Restrict foods which irritate condition
•Dairy
•Grains
•Sorbitol/Fructose/Lactose (1st 2 are irritants, 3rd can have intolerance)
2.Stress relief
3.Manage psychosocial impact
4.Monitor analgesic use
5. Meds
-Constipation dominate: Bulk forming laxatives (Metamucil-psyllium) at mealtime w/8 oz H20
-Diarrhea dominate: antidiarrheals (Lomotil-difenoxin/atropine, Imodium-loperamide)
-Pain dominate: Anticholinergics or antispasmodics (Bentyl-dicyclomine, Pro-Banthine-propantheline)
-Tricyclic Antidepresants
-Postprandial discomfort: take meds 30-45 minutes prior to eating

Abd Hernia tx
1.Strengthening exercises
2•Weight control
3•Mechanical reduction by a truss which is a pad made with firm material, held in place by a belt.
4. Surgery

Intestinal Obstruction tx (11)
1•NPO-bowel rest
2•NG suction
-Low continuous decompression
-Replacement of NG output with IVF
3•Treatment of primary disease
-Barium enema to dislodge intussusception
4•Disempaction if mechanical empaction
5•Fluid & Electrolyte replacement (K)
6•TPN
7•Mouth care
8•Pain management (not opiods until dx)
9•Broad spectrum antibiotics
10•Insertion of an intestinal tube to decompress and/or break up obstruction
-Miller-Abbott
-Cantor Tube
11.Sugery: Exploratory Laparoscopy/Laparotomy•Bowel resection•Primary resection and anastomosis•Temporary colostomy/ileostomy•Lysis of Adhesions

Hemorrhoids tx
1•Prevent constipation:
-Diet high in fiber to avoid constipation, Avoid prolonged sitting, Ample fluids (water), Stool softeners, Mineral oil,Exercise
2•Relieve pain
-Sitz baths 3-4x day, Witch hazel compresses, OTC preparations- locally – temporary pain relief
•Ice pack
•Bulk laxatives
•Topical anesthetics

hemorrhoids surgery

Complications: Infection, Stricture formation, Hemorrhage, Urinary retention d/t rectal spasms

•Sclerotherapy- Injecting a sclerosing agent between and around tissue and veins to cause formation of scar tissue
•Ligation-used for internal hemorrhoids-hemorrhoids are tied off with rubber bands and in 8-10 days area sloughs.
•Cryosurgery- (freezing) not common now leads to necrosis and sloughing of hemorrhoids
•Laser-hemorrhoids are burned off with laser
•Hemorrhoidectomy-Vein is excised and is left open to heal by granulation or is closed with sutures

Appendicitis tx
No medical treatment for appendicitis
Surgical intervention, removal of appendix, within 24-48 hrs. of onset of symptoms
Delay usually results in rupture of appendix and subsequent peritonitis
Surgery may be small incision or by laparoscope

Peritonitis tx (11)
1.Maintain fluid and electrolyte balance
IV fluids
Replacement electrolytes
NG tube or long intestinal tube to reduce pressure within the bowel
2.Infection control
IV antibiotic therapy with potent broad-spectrum agents
3.surgery may have to be delayed until stable:
-Surgery will Repair perforated organ as soon as possible
-Irrigate abdominal cavity with antibiotic solution to reduce bacterial count
-Wound may be packed open or drain in place so that infection can be treated
4. Bedrest in Semi-fowlers position
5. TC & DB
6. Assess respiratory status, VS
7.Strict I & O, wt, hydration
8.Assess pain, IV, NG Tube
9.Assess GI function
10.Wound Care
11.Post-Op Care

Gastroenteritis tx (8)
1. IV fluids
2.Monitor I&O, Daily wts
3.NPO, advance as tolerated
4.Water only does not replace electrolytes
5.HOLD Anticholinergics and antiemetics
6.Antibiotics (Cipro, Septra, Bactrim)
7.Rectal Care
8.Health Teaching

Ulcerative Colitis dx (5)
1.Stool Samples
2.CBC/Electrolytes: Hgb & Hct Decrease, Increased WBC
Increased ESR, Hyponatremia and hypokalemia, Hypoalbuminemia
3.CT Scan of Abdomen
4.Lower GI Series
With or without contrast (Barium) and air
5.Colonoscopy (most definitive test)

Ulcerative Colitis tx(8)
1.Maintain Remission
2.Diarrhea Management (atropine sulfate (Lomotil), loperamide (Imodium)
3.Diet Therapy
4.No Smoking
5.Rest
6.Meds- Aminosalicylates, Corticosteroids, Immunomodulatory Agents
7.Prevent Complications
8.Surgical Management
-Total protocolecotmy with permanent ileosstomy
-Total colectomy with ileoanal anastomosis; ileoanal reservoir

Crohns tx (3)
1.Drug Therapy
-Antibiotics: Metronidazole (Flagyl), Rifaximin (Xifaxan)
-Immunosupressive (Immuron)
-Biological Agents: Infliximab (Remicaide), Adalimumab (Humira), Etanercept (Embrel)

2.Manage Complication of Fistula (abnormal tract from intestine to skin or intestine to intestine)
3. Surgical Management: bowel resection, total colectomy and ileostomy

IBD: Crohns & CUC Nursing management (12)
1.Maintaining Normal Elimination patterns
2.Relieving pain
3.Maintaining Fluid Intake, Measures to promote fluid an electrolyte balance,TPN or Parenteral Nutrition
4.Promoting rest
5.Reducing Anxiety, Incorporate Stress reduction into lifestyle, Enhancing Coping Measures
6.Preventing Skin Breakdown
7.Understanding of Disease
8.Post surgical care – ileostomy, colostomy or colectomy
9.Nutritional management-Bland, low-residue(during flares), high protein, high vitamin diet, Foods to avoid
10.Medication Regimen
11.Measures to treat exacerbation of symptoms
12.Management, complications and interventions

Diverculitis tx (6)
1.Rest
2. Diet : Clear liquid until inflammation subsides, low fiber diet during acute episodes then High-fiber, low fat diet (Avoid seeds and nuts)
3.Monitor I&O: Adequate fluid intake 10 glasses/d
4.Drug Therapy:
-Antibiotics broad spectrum (Flagyl)
-IV’s
-Anticholenergics (Pro-Banthine)
-Opiod analgeisics
-Antispasmodics
5. NG Tube
6.Surgical Management: One Stage resection, Two stage resection

Cholecytis tx (8)
1.Diet:
-Avoid high-fat or high volume meals
-NGT – decompression of stomach
-Chronic: Low-fat diet to decrease stimulation to gallbladder
2.Drug therapy:
-Opioid analgesics (Demerol) relieve abd pain and spasm, morphine
-Antispasmotic agents: (Bentyl) to relax smooth muscle
-Antiemetics: (Tigan) to relieve n/v
-IV antibiotics: Ampicillin, cephalosporins, aminoglycosides
-anticholinergic medications
3. Fluid and electrolyte balance; rehydrate with IV fluids
Withhold food/fluids for N/V
4.Monitor for complications
5.Endoscopy
6.Dissolution: UDCA: ursodiol, Dissolves cholesterol
7.ESWL (extracorporeal shock wave lithotripsy)
Can have no pancreatic or liver involvement, Conscious sedation, general anesthesia or epidural
Recurrence is High
8.Surgery

choleliathisis
(Gall stones)
1.Diet therapy:Low fat,Obst bile flow decreases fat soluble vitamins (A, D, E, & K), Avoidance of large meal after fasting
2. Drug therapy:
-Opioid analgesics
-Antispasmotic or anticholinergics (Bentyl)
-Antiemetics
-Bile acid therapy – dissolve gallstones: Chenodeoxycholic acid (Chenix), Ursodeoxycholic acid (ursodiol) Reduce cholesterol stones by unsaturating bile
3.Fluid and electrolyte balance: NPO, IV fluid hydration
Careful progression of diet
4.Extracorporeal Shock wave lithotripsy-Noninvasive, outpatient, Lithotriptor generates powerful shock waves to shatter the stones, Approximately one hour; 1500 shocks, Stones are then secreted via intestines, RUQ pain is common, resolving in 2 days
5.Surgical:Cholecystotomy, Choledocholithotomy, Cholecystectomy