Med Surg Care of AdultsTest 3

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Intervertebral Disk Disease Low Back Pain Gallbladder Disorders Pancreas Disorders Liver/Cirrhosis

What is the second most common pain complaint?

Backache, second only to headache

Why is low back pain a common problem?

1. The lumbar region bears most of the body's weight.
2. Lumbar region is the most flexible region in the spinal column
3. Contains nerve roots that are vulnerable to injury or disease.
4. has an inherently poor biomechanical structure.

Name the risk factors associated with low back pain.

1. lack of muscle tone
2. excess body weight
3. poor posture
4. cigarette smoking
5. stress
6. jobs that require repetitive heavy lifting, vibration, and prolonged periods of sitting

What are the causes of low back pain of musculoskeletal origin?

1. acute lumbosacral strain
2. instability of the lumbosacral bony mechanism
3. osteoarthristis of the lumbosacral vertebrae
4. degenerative disk disease
5. herniation of an intervertebral disk

Acute low back pain lasts:
a. 4 years or more
b. 4 months or less
c. 4 weeks or less
d. 4 days or less

c. 4 weeks or less

What is one diagnostic test that can be done to ascertain the presence of nerve irritation and muscle strain?

the straight-leg raise; this test is positive for lumbar disk herniation when radicular pain occurs

What are some treatments for acute low back pain with muscle spasms (as long as the spasms and pain are not severe)?

One or a combo of:
1. analgesics, such as NSAIDS
2. muscle relaxants (Flexeril)
3. massage and back manipulation
4. alternating use of heat and cold compresses
5. a day or 2 of rest at home for some (no prolonged bed rest)
Avoid activities that aggravate the condition (lifting, bending, prolonged sitting, twisting)

The overall goals for acute low back pain are:

a. have satisfactory pain relief
b. avoid constipation secondary to medication and immobility
c. learn back-sparing practices
d. return to previous level of activity within prescribed restrictions

A cashier complains of low back pain. She is on her feet for most of her 8 hour shifts 5 days a week. What are some instructions she can be given to manage her back problems while at work?

a. Place a foot on a stool while standing behind her register; this will prevent her lower back from straining forward.
b. do not learn forward without bending her knees
c. Shift positions while standing, and move around as much as her job allows.
d. When lifting heavy objects, bend at the knees, stand slowly, and hold the object close to her body.

What are some ways to help prevent low back pain?

1. Maintain a healthy weight
2. Do not sleep in a prone position
3. Sleep on your side with your knees flexed and a pillow between your knees.
4. Avoid smoking and tobacco products
5. Exercise regularly
6. When lifting objects, bend at knees instead of waist, hold object close to your body.
7. Comfortable, flat shoes are best (no heels)
8. Sleep on a firm mattress

What are the primary nursing interventions for acute low back pain?

1. assist pt. in maintaining activity limitations
2. promote comfort
3. educate the patient about the health problem
4. educate about appropriate exercises

Chronic low back pain lasts more than:
a. 3 years
b. 3 months
c. 3 weeks
d. 3 hours

b. 3 months, or if it's a repeated incapacitating episode

True or False: Symptoms of low back pain always appear immediately at the time of the injury.

False: often, symptoms develop later b/c of the gradual increase in paravertebral muscle spasms

True or False: MRI and CT are done immediately if someone experiences acute low back pain, in case there is a serious injury present.

False: MRI and CT are not done unless trauma or systemic disease is suspected.

What are some of the causes of chronic back pain?

1. degenerative disk disease
2. lack of physical exercise
3. prior injury
4. obesity
5. structural and postural abnormalities
6. systemic disease

In what part of the spine is OA usually found in adults over the age of 50?

the lumbar spine

_______ _______ is a narrowing of the vertebral canal or nerve root canals caused by the movement of bone into the space.

spinal stenosis

Pain associated with lumbar spinal stenosis often starts in the low back and then radiates to:
a. the arm and shoulder
b. the chest
c. the buttock and leg
d. the neck

c. the buttock and leg
the pain worsens with walking, or standing without walking

Does pain with chronic low back pain increase or decrease following periods of inactivity?

it increases

True or False: Spinal stenosis is more often acquired through degenerative or traumatic changes to the spine.

True

Younger patients with OA usually have chronic back pain located where?

the thoracic or lumbar spine

What are some treatments used for chronic low back pain?

1. NSAIDS to reduce pain associated w/ ADL
2. Rest and heat compresses in cold, damp weather
3. wt. reduction
4. local heat and cold application
5. exercise and activity throughout day
6. tricyclic antidepressants
7. serotonin reuptake inhibitors
8. surgery is indicated in patients with severe chronic low back pain, those who do not respond to the above measures, and those with neuro deficits

True or False: Degenerative disk disease is a normal process of aging.

True

What is the gelatinous center of an intervertebral disk called?

nucleus pulposus
When this center starts to dry out and shrink, and compression of the nerve roots and cord may occur.

______ ______ can occur due to the damage to the spine by DDD.

bone spurs (osteophytes)

What is another name for a herniated intervertebral disk?

slipped disk

What are some reasons one can get a slipped disk?

1. natural degeneration due to aging
2. repeated stress and trauma to the spine

What are the most common sites for herniated disks?

L4-5 and L5-S1
also at C5-6 and C7

The most common feature of lumbar disk damage is _______________.

low back pain

What type of pain usually indicates disk herniation?

radicular pain that radiates down the buttock and below the knee, along the sciatic nerve.

What are clinical manifestations of ILD?

-Most common is low back pain
-disk herniation-radicular pain that radiates down buttock and below knee, along sciatic nerve
-positive straight-leg raising-test
-reflexes depressed or absent, depending on spinal nerve root invovled
-leg raise and flex foot 90 degrees--back and leg pain reproduced
-paresthesia or muscle weakness in legs, feet, or toes
-bowel or bladder incontinence or impotence from multiple nerve root compression

L3-4

subj. pain--back to buttocks to posterior thigh to inner calf
reflex- patellar
motor function-quadriceps, anterior tibialis
sensation- inner aspect of lower leg, anterior part of thigh

L4-5

subj. pain-- back to buttocks to dorsum of foot and big toe
reflex -- none
motor function-- anterior tibialis, extensor hallucis longus, gluteus medius
sensation- dorsum of foot and big toe

L5-S1

subj. pain-- back to buttocks to sole of foot and heel
reflex -- achilles
motor function-- gastrocnemius, hamstring, gluteus maximus
sensation-- heel and lateral foot

What are diagnostic studies done to identify intervertebral lumbar disk damage?

x-rays (note structural damage)
myelogram, MRI, CO scan localizes damaged site.
epidural venogram or diskogram may be necessary
EMG of extremities determines severity of nerve irritation

How long is ILD managed with conservative therapy?
a. at least 4 months
b. at least 4 weeks
c. up to 4 years
d. surgery is done right away

b. at least 4 weeks

What types of therapy are first tried to manage ILD?

1. limit spinal movement with a brace, corset or belt
2. local heat or ice
3. ultrasound or massage
4. traction
5. transcutaneous electrical nerve stimulation (TENS)
6. Drug therapy (NSAIDS, short-term opioids, muscle relaxants)
7. epidural corticosteroid injections

After symptoms of ILD subside when damaged area has healed over, patients should:

1. do back strengthening exercises twice a day; this is encouraged for a lifetime
2. be taught principles of good body mechanics
3. discouraged from extreme flexion and torsion

Surgical therapy for ILD is indicated when:

1. problem is not responding to conservative tx
2. patient is in consistent pain
3. persistent neurologic deficit
* sometimes patients do not improve after surgery, and sx may actually worsen

How are IDET and radiofrequency discal nucleoplasty similar and how are they different?

They are similar in that a needle is inserted into the affected disk.
With the IDET, however, a wire is sent through, and heated, which denervates nerve fibers, and partially melts the annulus, which causes the body to generate new reinforcing proteins.
With radiofreq. discal nucleoplasty, instead of a heating wire inserted, a radiofrequency probe is inserted, which generates energy that breaks up molecular bonds in the gel in nucleus; this decompresses the disk and relieves pressure on both the disk and surrounding nerve roots

Another name for Interspinous process decompression is? It is indicated when?

X Stop--indicated when pain is due to spinal stenosis; it pushes the spinal cord open by pressing against parts of either side of vertebrae---made of titanius and fit into mount placed on vertebrae in lower back

What is the most common and tradition type of surgery for ILD?

a laminectomy
it's a surgical excision of part of posterior arch or vertebrae to gain access to part of or entire protruding disk to remove it.
minimal hospital stay is required, usually

What does a diskectomy do?

helps to maintain bony stability of spine

Is percutanous laser diskectomy an inpatient or outpatient procedure?

Outpatient; a tube is passed through retroperitoneal soft tissues to lateral border of disk with local anesthesia and aid of fluroscopy, and a laser is used on the damaged portion (minimal blood loss)

What type of disk is surgically placed in the spine through a small incision below the umbilicus after the damaged disk is removed?

A charite disk (associated with DDD)--an artificial disk; it's made up of high-density core sandwiched between two cobalt-chromium end plates

When is a spinal fusion done?

When unstable bony mechanism is present. The spine is stabilized by creating a fusion of continuous vertebrae with a graft or donor bone; metal plate, rods or screws may be implanted at time of surgery as well to increase stability and decrease vertebral movement.

What is the main goal postop spinal surgery?

To maintain proper spinal alignment

What should be done when turning a patient postop spinal surgery?

1. Logroll patient to turn
2. Place pillows under thighs of each leg when supine and between legs when side-laying
3. Reassure patient that proper technique for turning is being used when they express fear of turning and movement may increase pain or damage to spine.
4. Make sure sufficient staff are available to move patient

What is the most common disorder of the biliary system?

Cholelthiasis (stones in the gallbladder)

What are the two types of gallstones?

1. Cholesterol
2. Pigmented, or calcium

What is cholecystitis?

Inflammation of the gallbladder

Cholecystitis is most commonly associated with:
a. alcoholism
b. gallstones or biliary sludge
c. trauma
d. none of the above

b. gallstones or biliary sludge

Why are small stones more likely to cause problems than large gallstones?

B/c small stones are able to move about, and can get lodged in ducts.

Name some manifestations of acute cholecysitis.

1. indigestion
2. moderate to severe pain
3. fever
4. jaundice
5. N & V
6. restlessness
7. diaphoresis

What are the sx of chronic cholecystitis?

1. Hx. of fat intolerance
2. dyspepsia
3. heartburn
4. flatulence

What are some diagnostic studies used to diagnose gallstones and cholecystitis?

H & P
Ultrasound
ERCP
Percutaneous transhepatic cholangiography
Liver function studies
WBC count
Serum bilirubin

With an acute episode of cholecystitis, the focus of treatment is on:
a. control of pain
b. control of possible infection
c. maintenance of fluid and electrolyte balance
d. all of the above

d. all of the above

Where does most digestion occur?
a. the mouth
b. the stomach
c. the duodenum
d. the transverse colon

c. the duodenum

If bile is blocked in the gallbladder, this leads to malabsorption of which vitamins? (Select all that apply).
a. Vitamin A
b. Vitamin B
c. Vitamin C.
d. Vitamin D
e. Vitamin E.
f. Vitamin K.

a, d, e, and f
Vitamins A, D, E, and K are all fat soluble vitamins; bile is needed for the digestion of fats, and if the bile is not available, the fat soluble vitamins cannot be digested properly.

Name the "5 F's" that are high risk factors for developing a gallbladder disorder.

1. fat (overweight or obese)
2. fertile (pregnancy, hormone replacement therapy, or BC pills)
3. fair (caucasian)
4. female
5. flatulent

______ is a product of broken down hemoglobin, and is found in bile.

Bilirubin

A chronic progressive disease of the liver is ______.

cirrhosis

The single most common cause of cirrhosis is:
a. long-term, excessive ETOH use
b. Hepatitis B
c. Hepatitis C
d. NAFLD

a. long-term, excessive ETOH use
the others listed are also causes of cirrhosis, along with biliary cirrhosis and cardiac cirrhosis

What is the first change in the liver with excessive alcohol intake? Continued abuse of alcohol?

Fatty liver--fat accumulation in liver cells (this is due to the liver not functioning as well, and not breaking down fats).
If ETOH continues, then the fatty tissue begins to scar over, and the liver hardens.

True or False: The onset of cirrhosis is easily noticeable, because it usually sets in very quickly.

False; the onset is insidious.

Name the early symptoms of cirrhosis of the liver.

GI disturbances:
-anorexia
-dyspepsia
-flatulence
-N & V
-change in bowel habits (diarrhea or constipation)
-abd. pain (heavy, dull pain in the RUQ)
Other early manifestations:
-fever
-lassitude (lack of energy)
-wt. loss
-enlargement of liver and spleen (liver is often palpable in cirrhosis patients)

What are the late signs of cirrhosis of the liver?

-Jaundice (pruritus can occur with biliary tract obstruction)
-peripheral edema
-ascites
-skin lesions (spider angiomas, palmar erythema)
-endocrine disorders
-hematologic disorders (spenomegaly from backup of blood from portal vein, and bleeding tendencies due to lowered production of hepatic clotting factors)
-peripheral neuropathy (due to deficiencies in thiamine, folic acid and B12)

Name the neurologic sx of liver cirrhosis.

-hepatic encephalopathy
-peripheral neuropathy
-asterixis

Name the integumentary sx of liver cirrhosis.

-jaundice
-spider angiomas
-palmar erythema
-Purpura
-petechiae
-caput medusae

Name the gastrointestinal sx of liver cirrhosis.

-anorexia
-dyspepsia
-N & V
-Change in bowel habits (diarrhea or constipation)
-dull abd. pain RUQ
-esophageal and gastric varices
-gastritis
-hematemesis
-hemorrhoidal varices

Name reproductive sx of liver cirrhosis.

-amenorrhea
-testicular atrophy
-gynecomastia
-impotence

Name hematologic manifestations of liver cirrhosis.

-anemia (macro anemias)
-thrombocytopenia
-leukopenia
-coagulation disorders
-splenomegaly

Metabolic manifestations of liver cirrhosis

-hypokalemia
-hyponatremia
-hypoalbuminemia

Cardiovascular manifestations of liver cirrhosis?

-fluid retention
-peripheral edema
-ascites

azotemia is....

the build up of nitrogenous waste products (urea) in the blood that are usually excreted in the urine.

The obstruction of the normal blood flow through the portal system results in:

Portal hypertension

Portal hypertension is characterized by: (select all that apply):
a. gastric and esophageal varices
b. ascites
c. systemic hypertension
d. gallstones
e. splenomegaly

a, b, c, and e

What is the most life-threatening complication of cirrhosis of the liver?

Bleeding esophageal varices
pg. 1075 Lewis

______ is the accumulation of serous fluid in the peritoneal or abdominal cavity.
a. portal hypertension
b. ascites
c. esophageal varices
d. gastric varices

b. ascites

True or False: A paracentesis can permanently remove fluid from the abdomen.

False: A paracentesis is only a temporary measure, because the fluid tends to reaccumulate. The procedure is reserved for patients with impaired respiration or abdominal pain caused by severe ascites.

True or False: In compensated or end-stage liver disease, AST and ALT levels may be normal.

True

What are some diagnostic tests done for cirrhosis?

-H & P
-Lab tests:
liver function
Serum electrolytes
CBC
PTT
Serum albumin
Stool for occult blood
Analysis of ascitic fluid
-Liv, er biopsy

What is the goal of treatment in cirrhosis?

Main goal is to slow down the progress of the disease. Rest can help this.
Also:
admin of B-complex vitamins
-avoid ETOH
-avoid aspirin, acetaminophen, and NSAIDS

Which drugs are used to treat esophageal and gastric varices?

Octreotide (Sandostatin)
Vasopressin (VP, Terlipressin)
Nitroglycerine (NTG)
B-adrenergic blockers

What is the #1 therapeutic goal for esophageal and gastric varices?

Avoidance of bleeding and hemorrhage.

Name some surgical ways that esophageal and gastric varices can treated.

1.Endoscopic sclerotherapy (sclerosing agent, Scleromate, is introduced through an endoscopy, and it obliterates the distended veins) Used for both acute and chronic bleeding.
2. Endoscopic ligation or banding (a small rubber band or a clip is slipped around the based of the varix) Used for acute bleeds
3. Balloon tamponade (mechanically compresses the varices to stop bleeding. Usually use Sengstaken-Blakemore tube.

Name some supportive measures used during an acute variceal bleed.

1. Give fresh frozen plasma and packed RBC's
2. Vitamin K
3. histamine receptor blockers (Tagamet, Zantac) and proton pump inhibitors (Protonix)
4. Lactulose to prevent hepatic encephalopathy from breakdown of blood and the release of ammonia in the intestine. Neomycin, and antibiotic to prevent bacterial infection.

True or False: Shunting procedures need to be done immediately after the first major bleeding episode of esophageal varices.

False: shunting is usually reserved for after the 2nd major bleeding episode

True or False: Protein restriction is needed for all cirrhosis patients.

False: Protein restriction is rarely justified in patients, unless they have hepatic encephalopathy; in this case the protein would be lowered.

Why would you want a patient to assume a kneeling position when you are measuring abdominal girth with ascites? (select the best answer).
a. this encourages the patient to not stay in the same position all day.
b. this will allow the fluid to drain towards their feet, providing some relief to their abdomen
c. the fluid will drain to the most dependent part of the abdomen, and this provides the best measurement of abdominal girth.
d. none of the above

c. the fluid will drain to the most dependent part of the abdomen, and this provides the best measurement of abdominal girth.
pg. 1081, last paragraph Lewis

Why must a patient void before having a paracentesis?

This prevents puncture of the bladder

True or False: Acute pancreatitis can be life-threatening.

True

What are the primary etiologic factors in acute pancreatitis? What is the most common cause in the United States?

biliary disease (most common in women)
and
alcoholism (most common in men)
In the U.S.:
1. gallstones
2. alcoholism

How does autodigestion of the pancreas occur?

1. Trypsin is activated prematurely in the pancreas, rather than in the intestine.
2. The common bile duct or the ampulla of vater is obstructed
3. there is a reflux of of bile into the pancreatic duct

What is the predominant manifestation of acute pancreatitis?
a. fever
b. ascites
c. abdominal pain
d. chest pain

c. abdominal pain-pain is usually in the LUQ, but can also be in the midepigastrium.

What is the difference between Grey Turner's sign and Cullen's sign?

Grey Turner's sign is a bluish discoloration found on the flank, and Cullen's sign is a bluish discoloration of the periumbilical.

What is the leading indication for a liver transplant?
a. cirrhosis caused by chronic alcoholism
b. liver disease r/t chronic viral hepatitis
c. hepatic encephalopathy
d. esophageal varices hemmorrhage

b. liver disease r/t chronic viral hepatitis

Choose the contraindication for a liver transplant:
a. severe pulmonary hypertension
b. morbid obesity
c. obstructed splanchic blood flow
d. all of the above

d. all of the above

True or False: Rejection of the organ after a transplant is less of a problem with liver transplant than kidney transplant.

True; liver seems to be less susceptible to rejection than the kidneys.

What is considered to be GERD?

Persistent reflux that occurs more than 2 times per week

How can you tell the difference between GERD-related chest pain and cardiac pain?

GERD-related chest pain is relieved with antacids, whereas cardiac pain is not.

Should patients with GERD drink milk?

Milk can help with heartburn, but milk should normally be avoided, esp. at bedtime, due to the fact that it increases gastric acid secretions.

What does drug therapy for GERD focus on?

1. decreasing volume and acidity of reflux
2. improving LES function
3. Increasing esophageal clearance
4. protecting the esophageal mucosa.

Which is more effective in healing esophagitis, PPIs or H2 receptor blockers?

PPIs

What are the most common and effective types of drugs for tx of GERD?

PPIs-Proton pump inhibitors
Histamine (H2) receptor blockers

Give some examples of PPIs.

Prilosec
Nexium
Protonix
Prevacid
Aciphex
These decrease gastric HCl secretion

Give some examples of H2 receptor blockers.

Tagamet
Zantac
Pepcid
Axid

How do cholinergic drugs help GERD?

They increase LES pressure, and increase gastric emptying.--however, they also increase HCl acid formation.

Name two types of surgery that can be done for GERD.

Nissen fundoplication
Toupet fundoplication
In the Nissen, the fundus of the stomach is wrapped around the lower portion of the esophagus to reinforce the LES, and repair the defective barrier.

True or False: Antacids produce quick and long-term relief of heartburn.

False; relief is quick, but it's short-lived. They act by neutralizing HCl acid

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