MEDICAL SURGICAL 2 RLE

PREPARED BY: LEGAD RYAN KENT, SN

NOTE : this reviewer made and created by my effort also the content of this reviewer serves as guide
and all are module based.

SESSION 1

HYPERALEMENTATION OR PARENTERAL NUTRITION - is a form of nutritional support that supplies

PROTEIN, CARBS,FATS,ELECTROLYTES,VITAMINS,MINERALS AND FLUID via IV route.

TOTAL PARENTERAL NUTRITION PERIPHERAL PARENTERAL NUTRITION

 hyperosmolar solution exceeding 10%  Lower concentration

dextrose/5% protein  Same components as TPN but dextrose is
 administered through CVC-central venous less than 10%/5% protein
catheter

TPN short term use or less than 4 weeks - location (subclavian and jugular vein are commonly used

TPN long period use greater than 4 weeks or permanent catheter -location (peripherally-inserted central
catheter (PICC) -a tunnelled catheter or an implanted vascular accesss(port-a cath)

 change the parenteral solution container and tubing every 24hours to decrease the risk of
microbial growth
CYCLIC INFUSIONS
-client received 24hours volume of TPN over 10-14 period
-CYCLING or the interruption of infusion used for clients receiving home infusion therapy
-increased freedom because nutrition is delivered during the sleeping hours and client is able to
continue with ADL during off hours
COMPLICATIONS OF TPN
1. INFECTION - prevention(aseptic technique)
2. FLUID Overload - hyperosmolar solution is rapidly infused into the circulatory system,
CHF,RENAL INSUFFIENCY are RISK. MONITOR FLUID BALANCE THROUGH SERUM
ELECTROLYTES DAILY AND I/O MESUSREMENTS
3. METABOLIC COMPLICATIONS - client experience hyperglycemia. BLOOD GLUCOSE IS
MONITORED ATLEAST ONCE A DAY OR MORE FREQUENTLY
PURPOSES OF ADMINISTERING TPN
a. provide parenteral nutritional support to malnourished clients
b. provide parenteral nutritional support to clients requiring bypass of GI tract for
prolonged periods
c. provide parenteral nutritional support to clients who have excessive metabolic
needs due to trauma,cancer,or hypermetabolic states
INDICATIONS
 a. insufficient oral or enteral intake severe burns, malnutrition, short bowel
syndrome, AIDS, sepsis,cancer
b. impaired ability to ingest or absorb food orally or enterally - paralytic ileus,
crohns disease, short gut,postradiation enteritis,high-output enterocutaneous
fistula
c. the patient is unwilling or unable to ingest adequate nutrients orally or
enterally- major psychiatric illness
d. preoperative and postoperative nutritional needs are prolonged - extensive
bowel surgery, acute pancreatitis
SIDE NOTE FOR TPN
1. Solutions with more Tha 10% dextrose must be infused directly into
subclavian or internal jugular vein rapidly dilute the solution to prevent
thrombophlebitis
2. Cover the lipids or TPN bag with sheet against the light unless the bag is
light protected
3. Monitor blood glucose every 6 hours on neonate patient
4. Monitor V/S every 4 hours
5. Monitor electrolytes,BUN and glucose
6. ADULTS - 500ml intra lipid over 4-6 hours ( 1.0ml/min)
7. CHILDREN - up to 1g/kg over 4 hours ( 0.1ml/min)

SESSION 2

GASTROINTESTINAL INTUBATION

PURPOSES OF GI INTUBATION

a. To decompress the stomach and remove gas and fluids

b. To lavage the stomach and remove ingested toxins or other harmful materials
c. To diagnose disorders of GI motility and other disorders
d. To administer medications and feeding
e. To compress a bleeding site
f. To aspirate gastric contents for analysis
NASOGASTRIC TUBE
-Ng is introduced through the nose into the stomach often before and after surgery at the
bedside
-used to administer medication for up to 4 weeks to give feeding or to remove fluid ND gas
from the upper GI tract by the process of DECOMPRESSION
-commonly used the LEVIN TUBE AND GASTRIC SUMP TUBE
-LEVIN TUBE has single lumen and is made of plastic or [Link] tube is connected to low
intermittent suction(30-40mmHg)
-GASTRIC SUMP(SALEM) - tube is radiopaque (easily seen on x-ray),clear plastic, double
lemn NG tube
INDICATIONS
a. Evaluation of upper GI bleeding
b. Aspiration of gastric fluid content
c. Identification of the esophagus and stomach on a chest radiograph
d. Administration of radiographic contrast to the GI tract
e. Identification of cancer cell
ENTERIC TUBE
-used for providing NUTRIENTS. Inserted in duodenum called nasoduodenal and placed
jejunum call nasojejunal tube
MEASUREMENT - from nostril to the tip of the ear/earlobe to the xiphoid process
FORMULA
-chemical composition of the nutrient source PROTEIN , CARBS AND FATS
ADMINISTRATION METHOD
BOLUS FEEDING - administered by gravity into the stomach,requires 10-15 mins to
complete
INTERMITTENT GRAVITY DRIP - administering feedings over 30 mins at designated
intervals and COMMONLY USED IN PATIENT AT HOME
CONTINOUS FEEDING - feedings incrementally over long period
CYCLING FEEDING - alternative to the continous infusion method ,given 80-18 hours.
INFUSED AT NIGHT TO AVOID INTERRUPTION THE PATIENT LIFESTYLE
SIDENOTE
 aspirated fluid is re-administered to the patient
 200ml or greater is generally considered as concern for risk of aspiration
 To ensure patency and to decrease the chance of bacterial growth,crusting or
occlusion of the tube atleast 30-50ml of water or NS is administered
 Any water or normal saline used to irrigate these tubes must be recorded as fluid
intake
 Tube is flushed with 30-50ml of water after medication administration and recorded
as fluid intake
 Medication should not be mixed with the fedding formula
 Patients with NG tubing experience diarrhea or constipation
 Dumping syndrome also leads to diarrhea
 Aspiration pneumonia occurs when regurgitated stomach contents or enteral
feedings from improperly position
SESSION 3 : MANAGEMENT OF THE PATIENT WITH INTESTINAL AND RECTAL
DISORDERS "STOMA CARE"
- Stoma is a word of Greek means mouth or opening
A stoma is an opening on the abdomen that can be connected to either your
digestive or urinary system to allow waste (urine or feces) to diverted out of your
body
 THE MOST COMMON UNDERLYING CONDITIONS RESULTING IN THE NEED FOR STOMA
SURGERY ARE : COLECTERAL CANCER, BLADDER CANCER, ULCERATIVE COLITIS , CROHNS
DISEASE AND ETC.
Colostomy - surgical procedure that brings one end of the large intestine out through
the abdominal wall
 formed any section of the large bowel
 common site for colostomy is SIGMOID COLON
 Semi-solid or formed stool
 Positioned in the LEFT ILIAC FOSSA
 Stomas formed higher up along the colon will produce a slightly more liquid stool
COLOSTOMIES CAN EITHER BE PERMNENT (END) OR TEMPORARY (LOOP)
a. PERMANENT (END) - most commonly formed stoma, often formed following removal of rectal
cancer ,END-section bowel
b. TEMPORARY (LOOP) - may formed to divert fecal output to allow healing of a surgical join or
repair or to relieve an obstruction bowel injury , LOOP COLOSTOMY IS LARGER THAN END
COLOSTOMY
ILEOSTOMY
 formed when a section of ileum is brought out onto the abdominal wall
 Positioned at the end of the ileum on the RIGHT ILIAC FOSSA
UROSTOMY/ ILEAL CONDUIT
 Ileal conduit is the most common form of urostomy: the colon(colonic conduit)may also
be used
 a section of bowel is isolated along with its mesentry vessels and the remaining ends of
the bowel are anostomosed to restore continuity
INDICATIONS
a. To collect feces or urine in an appropriate appliance
b. to achieve and maintain patient comfort and security
c. to support psychological adaptation and independence
ONE OR TWO PIECE SYSTEMS
 ONE PIECE SYSTEM - pouch attached to an adhesive wafer that is removed
completely when pouched is [Link] is an easier system for an ostomate
with dexterity problems such as arthritis or Peripheral neuropathy
 TWO PIECE SYSTEM - comprises wafer onto which a pouch is clipped or stuck . It
can be used with sore and sensitive skin because when pouch is removed the
flange is left intact and so the skin is left undisturbed
SIDE NOTES
 suitable time for irrigation is preferably after meal
 should perform same time each day

SESSION 4 : FASTING PLASMA GLUCOSE (FBS)

-NORMAL VALUES - 70 to 110mg (at least 8 hours fasting)

-FEMALES AND CHILDREN - 40mg lead to brain damage

-MALES - less than 50 lead to brain damage

-ALL PATIENTS - great rthan 400mg/D/L lead to coma

PURPOSE

a. To screen for diabetes and Pre diabetes

b. To monitor drug and dietary theraphy in the patient with DM
c. To monitor hyperglycemia and hypoglycemia
INC/HIGH FBS - insulin resistance or diabetes
DEC/LOW FBS - indicates could be diabetes medication
FACTORS CAN AFFECT BLOOD GLUCOSE LEVELS
a. too much food such as meal or snack with more carbs than usual
b. not being active
c. not enough insulin or oral diabetes medication
d. side effect from other psychotic and steroids medications
FACTORS RELATING TO FOOD THAT CAN TRIGGER SIGNIFICANT RISES
 eating large meals
 consuming sugary foods and drinks
 eating foods with simple carbs such as bread and sweet snacks
THIS MEANS THAT FASTING BLOOD SUGAR DEPENDS ON THREE FACTORS
a. the content of a person's last meal
b. the size of their previous meal
c. their body's ability to produce and respond to insulin

TESTING

a. CONVENTIONAL BLOOD SUGAR TEST - traditional home glucose monitoring

b. HEMOGLOBIN A1C ( HbA1C) - measures how the body is managing blood sugar over
time ,usually the last 2-3months
SIDE NOTES
 blood sugar tends to peak an hour after eating and declines after that
 INSULIN - makes it possible to store and release irt as necessary
 TYPE 1 DM ( insulin dependent ) - do not produce insulin because their body attacks its
insulin-producing cells
 TYPE 2 DM (insulin independent ) - do not respond well to insulin in their body and later
may not make enough insulin
 Instruct patient to fast 12-14hours before TEST (FBS) with old diabetic meds
SESSION 5: RANDOM GLUCOSE TEST
 one method for measuring the amount of glucose or sugar circulating in a person's
blood
 You may eat and drink before a random glucose test
 200mg/ DL sign that you have diabetes
 values depending on the last time you ate,(within 1-2hours after the start of meal
expect 180 but if before meal expect 80-130)
 TYPE 2 symptoms is difficult to detect first and accounts approximately 90-95% of all
cases in adults and 5-10% in women with GDM and diagnose with type 2 DM
 poorly controlled diabetes leads to CUSHING DISEASE AND OTHER ILLNESS
 STEROID can cause HYPERGLYCEMIA
 hyperglycemia-S/S-blurred vision,thirst and fruity breath, fatigue,N/S , Inc
urination(3Ps)
 hypoglycemia-S/S- anxiety,confusion,tachycardia,parethesia, tremors,diaphoresis,
dizziness or lightheadedness,pale face,tingling lips
 UNCONTROLLED/UNTERATED DM CAN AFFECT OTHER ORGANS SUCH AS
DIABETIC NEUROPATHY (brain) ,DIABETIC NEPHROPATHY (kidney) , DIABETIC
RETINOPATHY ( eyes)
REASONS FOR TESTING
 POLYURIA
 POLYDIPSIA
 POLYPHAGIA
 UNEXPLAINED WEIGHT LOSS
 EXTREME FATIGUE OR TIREDNESS
 BLURRED VISION
 SLOW HEALING OF CUTS AND BRUISES

THIS FACTORS MAY INCREASE A PERSON'S BLOOD GLUCOSE LEVELS

 eating too much foods
 low level of physical activity
 medication side effect
 illness
 stress
 pain
 menstruation
 dehydration
THE FOLLOWING MAY DECREASE A PERSONS BLOOD GLUCOSE LEVELS
 eating small or no food
 drinking alcohol
 meds side effect
 intense physical activity or exercise
SESSION 6 : 2 HOURS POSTPRANDIAL BLOOD GLUCOSE

 PBBS is a glucose test done on the blood that helps determine the type of sugar also known as
glucose after a certain meal
 This test measures blood glucose exactly 2hours after you start eating a meal
 Blood glucose will be normal within 2hours. In diabetic patients glucose level will remain
elevated
 Screening test for DM
 If glucose level is greater than 140 and less than 200 then GTT is advised
 If level after 2hours = 200 DM is confirm and advised HBA1C for further evaluation
 NORMAL <120
WHY IS GLUCOSE-PPBS test is done
 to detect and diagnose diabetes
 to diagnose diabetes during pregnancy
 to monitor the treatment efficacy in diabetic patients
 as part of preventive health check-up
 if a patient has family history of diabetes
 if a patient has diabetes associated diseases
 SESSION 7: CRANIOTOMY

 involves opening the skull to gain access to intracranial structures

 Procedure performed to remove tumor,relieve elevated ICP, evacuate a blood clot , and
control hemorrhage
PURPOSES OF CRANIOTOMY
 To diagnose
 to remove brain tumor
 to treat brain tumor
INDICATIONS FOR CRANIOTOMY
 Surgical removal of a tumor or blood clot or draining of abscess within the
[Link] injury following trauma is one of the commonest infications of
craniotomy
 CLIIPING OF AN ANEURYSM - dilated artery with weakened walls that is life
threatening and by clipping it reduces the blood flow and decrease the size and
prevent its potential to burst
 REMOVAL OF AN ARTERIOVENOUS MALFORMATION - abnormal communication
between artery and vein that results to bleeding
 SURGERY FOR EPILEPSY - some cases of epilepsy doesn't not respond to meds and
needed for surgery
 VENTRICULAR SHUNTING - a procedure performed to reduce pressure in the skull
due to excess fluid accumulation
CRANIAL SURGICAL APPROACHES
SUPRATENTORAL CRANIOTOMY
site : above tentorium
incision location : behind hairline
NI : maintain HOB 35 to 45 degree with neck in neutral ailment
Position ; avoid positioning on operative side
INFRATENTORAL CRANIOTOMY

Site: below tentorium,brain stem

Incision location : nape of the neck around occipital lobe

NI : maintain neck in straight alignment . AVOID FLEXION OF THE NECK

TRANSSPHENOIDAL CRANIOTOMY

SITE : Sella turcica

Incision location : beneath the upper lip to gain access into the nasal cavity

NI : maintain nasa packing in place. INSTRUCT patient to avoid blowing nose, provide frequent oral care ,
KEEP HOB
 TEST DONE PRIOR TO CRANIOTOMY

 CT SCAN , MRI AND ANGIOGRAPHY

 BLOOD TEST ( hemoglobin level, blood group, BUN AND CREATININE AND PTT
 URINE TEST
 ECG
 CHEST X-RAY
MEDICATION ADMINISTERED PRIOR SURGERY
 ANTI-SEIZURE "PAM AND LAM"
 CORTICOSTEROIDS " PREDNISONE"
 ANTIBIOTIC
 BLOOD THINNER ( aspirin) should stop 1 month before surgery
RISK ASSOCIATED WITH CRANIOTOMY
 HEADACHE
 LEAKAGE OF CSF
 BLEEDING AND HEMATOMA
 SPASM OF VESSELS
 AIR EMBOLISM
 DI
 SEIZURES
 DAMAGE TO CRANIAL NERVE
 RESPIRATORY PROBLEMS

SESSION 8 : INTRACRANIAL PRESSURE MONITORING

- diagnostic test that helps your doctor determine if high or low CSF

-test measures the pressure in your head directly using small pressure - sensitive probe that is inserted
through the skull

-NORMAL ICP is 5 to 15mmHg

PURPOSES

 To identify increased pressure early in its course

 to quantify the degree of elevation
 to initiate appropriate treatment
 to provide access to CSF for sampling and drainage
 to evaluate the effectiveness of treatment
INDICATIONS OF ICP MONITORING
 TRAUMATIC HEAD INJURY
 INTRACEREBRAL HEMORRHAGE
  SUBARACHNOID HEMORRHAGE
 HYDROCEPHALUS
 MALIGNANT INFARCTION
 CEREBRAL EDEMA
 CNS INFECTIONS
 HEPATIC ENCEPHALOPATHY

DEVICES USED TO MONITOR ICP

VENTRICULOSTOMY - A fine bore catheter inserted into latetal ventricle usually in the nondominant
hemisphere of the brain

-used to drain the ventricle blood

-key words " ventricle or ventricular"

SUBARACHNOID BOLT ( SCREW) - hollow device inserted through skull and dura matter into the cranial
SUBARACHNOID space

EPIDURAL MONITOR - epidural monitor uses a pneumonic flow sensor that functions on nonelectrical
basis, DISADVANTAGE is the inability to widraw CSF for analysis

FIBEROPTIC MONITOR - transducer-tipped catheter is becoming widely used alternative to standard

intraventricular,SUBARACHNOID and subdural system

-used in conjunction with a CSF drainage device

INTRACRANIAL PRESSURE WAVES

 waves of high pressure and troughs of relatively normal pressure indicate changes in ICP ,
waveform are captured and recorded on an oscilloscope
A WAVES ( Plateau wave) - transient, paroxysmal, recurring elevations of ICP that may last 5-
20mins and range in amplitude from 50-100mmHg
-cerebral ischemia, brain damage
B WAVES - shorter 30seconds to 2mins with smaller amplitude up to 50mmHg
-seen in patients with depressed consciousness,they may precede the appearance of A
WAVES
-seen in patients with intracranial hypertension, and decreased intracranial compliance
C WAVES - small,rhythmic oscillations with frequencies of approximately 6 per minute
-they appear to be related to rhythmic variations of the Systemic arterial blood pressure and
respirations