| Colostomy Posted: 27 Sep 2010 05:49 PM PDT 
 Colostomy Definition - Formation of an opening into the colon, brought out onto the abdominal wall as a stoma. The opening can be either permanent or temporary.
Specific Technique Discussion - This procedure is usually performed for lesions in the large intestine caused by cancer, diverticulitis, or obstruction of the large intestine in an area close to the rectum.
- Types of colostomy:
- Temporary colostomy: A temporary colostomy is performed to divert the fecal stream from the distal colon, which may be obstructed by tumor inflammation, or requires being "put-to-test" because of anastomosis or a pouch procedure. A temporary colostomy may be created in the transverse colon or sigmoid colon.
- Permanent colostomy: A permanent colostomy is performed to treat malignancies of the colon. Other indications may include irrevocable rectal strictures, incontinence of bowel, or inflammatory bowel disease. A permanent colostomy can be fashioned similar to a temporary colostomy but most often is an end colostomy.
Position - Supine, with arms extended on arm boards.
Incision Site - Dependent on the segment of colon to be used.
Packs/ Drapes - Laparotomy pack
- Four folded towels
- Transverse Lap sheet
- Minor pack
Instrumentation - Major Lap tray
- Intestinal tray
- Closing tray
- Internal surgical staples
Supplies/ Equipments - Basin set
- Blades
- Needle counter
- Penrose drain
- Internal stapling instruments
- Glass rod and tubing with colostomy pouch
- Solutions – saline, water
- Sutures
- Medications
- Dressings
Procedure - The abdomen is opened in the usual manner and the segment of colon is mobilized.
- The colon can be brought out through the main incision, or through an adjacent site from which a disk of skin and subcutaneous tissue has been excised.
- The underlying rectus fascia muscle and peritoneal layers are incised to accommodate the colon. The appropriate segment is excised between two atraumatic (intestinal) clamps or the internal stapling instrument, which is used to prepare and create the stoma.
- In a loop colostomy, a rod or bridge may be placed under the colon to avoid retraction.
- The abdomen is irrigated with warm saline and closed layers in a routine fashion.
- A colostomy poucj is applied over the stoma.
Perioperative Nurisng Considerations - The colostomy pouch may or may not be applied in surgery.
- A Vaseline gauze may encircle the stoma with a "fluff" type dressing applied.
- If the institution has an "Ostomy Nurse", the application of the colostomy pouch may be delayed until the clinical specialist can work with the patient and family.
image from howstuffworks.com Related posts: - Colostomy Care
- Anastomosis of Small Intestine (Small Bowel Resection)
- Appendectomy
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| Thyrotoxicosis (Thyroid Storm) Posted: 27 Sep 2010 05:42 PM PDT 
 Thyroid Storm Thyroid storm is a life-threatening condition in which patients with underling thyroid dysfunction inhibit exaggerated signs and symptoms of hyperthyroidism. Thyroid storm is precipitated by stressors such as infection, trauma, DKA, surgery, heart failure, or stroke. The condition can result from discontinuation of antithyroid medication or as a result of untreated or inadequate treatment of hyperthyroidism. The excess thyroid hormones increase metabolism and affect the sympathetic nervous system, thus increasing oxygen consumption and heat production and altering fluid and electrolyte levels. Signs And Symptoms - Sudden onset of fever
- Tremors
- Flushing
- Profuse palm sweating
- Tachydysrhythmias
- Extreme restlessness
- Nausea
- Vomiting
- Diarrhea
- Weight loss
- Fatigue
- Muscle weakness
- Atrophy
Physical Examination Vital signs - Systolic hypertension or hypotension
- HR: tachycardia disproportionate to the degree of fever
- RR: >20 breaths/ min
- Temperature >102.2 °F can be higher
Neurologic - Agitated
- Tremulous
- Delirious coma
Cardiovascular - Bounding pulses
- Systolic murmur
- Widening pulse
- Weak thready pulses
Pulmonary - Tachycardia
- Crackles may be present
Gastrointestinal Endocrine - Thyroid may be enlarged or nodular
Acute Care Patient Management Nursing Diagnosis: Decreased cardiac output related to increased cardiac work secondary to increased adrenergic activity; Deficient fluid volume secondary to increased metabolism and diaphoresis. Outcome Criteria - Patient alert and oriented
- Peripheral pulses palpable
- Lung clear to auscultation
- Urine output 30 ml/hr
- Absence of life-threatening dysrhythmias
Patient Monitoring - Continuously monitor ECG for dysrhythmias or HR ? 140 beats/min that can adversely affect cardiac output and monitor for ST segment changes indicative of myocardial ischemia.
- Continuously monitor oxygen saturation with pulse oximetry.
- Continuously monitor pulmonary artery pressure.
- Monitor fluid volume status; measure urine output hourly and determine fluid balance every 8 hours.
Patient Assessment - Assess cardiovascular status; extra heart sounds, complaints of orthopnea or dyspnea on exertion.
- Assess hydration status because dehydration can further decrease circulating volume and compromise cardiac output.
- Assess for pressure ulcer development secondary to hypoperfusion.
Diagnostic Assessment - REVIEW THYROID STUDIES AS AVAILABLE.
- Review serial serum electrolytes, serum glucose, and serum calcium levels to evaluate the patient's response to therapy.
- Review serial ABGs for hypoxemia and acid-base imbalance, which can adversely affect cardiac function.
- Review serial chest radiographs for cardiac enlargement and pulmonary congestion.
Patient Management - Administer dextrose-containing intravenous fluids as ordered to correct fluid and glucose deficits.
- Carefully assess the patient for heart failure or pulmonary edema.
- Dopamine may be used to support blood pressure.
- Provide supplemental oxygen as ordered to help meet increased metabolic demands.
- Once the patient is hemodynamically stable, provide pulmonary hygiene to reduce pulmonary complications.
- If the patient is in heart failure, typical pharmacologic agents for treatment of heart failure may also be indicated.
- Reduce oxygen demands by decreasing anxiety, reduce fever, decrease pain, and limit visitors if necessary.
- Anticipate aggressive treatment of precipitating factor.
- Institute pressure ulcer strategies.
image from aprescriptionfreelife.com Related posts: - Myxedema coma
- Cardiogenic Pulmonary Edema
- Cardiomyopathy
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| Syndrome Of Inappropriate Antidiuretic Hormone (SIADH) Posted: 27 Sep 2010 05:30 PM PDT 
 Syndrome of inappropriate antidiuretic hormone (SIADH) Is a condition that results from failure in the negative feedback mechanism that regulates inhibition and secretion of ADH. It produces excess ADH, resulting hypothermia and hypoosmolality of serum. The kidneys respond by reabsorbing water in the tubules and excreting sodium; thus the patient becomes severely water intoxicated. SIADH is most commonly caused by ectopic production of ADH by malignant tumors. It can be result of CNS disorders, such as Guillain-Barre syndrome, meningitis, brain tumors, and head trauma. Pulmonary-related conditions, such as pneumonia, and positive pressure ventilation can cause SIADH. Pharmacologic agents such as general anesthetics, thiazine diuretics, oral hypoglycemics, chemotherapeutic agents, and analgesics are also associated with SIADH release. Signs And Symptoms Vital signs - BP: Increased or may be normal
- HR: tachycardia
- Temperature: decreased or may be normal
Neurologic - Alert to unresponsiveness
- Seizures
Cardiovascular Pulmonary Gastrointestinal - Cramps
- Decreased bowel sounds
- Vomiting
Muscoloskeletal - Weakness
- Cramps
- Absent deep tension reflexes
Acute Care Patient Management Nursing Dianosis: Excess fluid volume related to excessive amount of antidiuretic hormone secretion. Outcome Criteria - Intake approximates output
- Serum potassium 3.5 to 5 mEq/L
- Serum sodium 135 to 145 mEq/L
- Serum chloride 95 to 105 mEq/L
- Serum osmolality 275 to 295 mOsm/kg
- Urine specific gravity 1.003 to 1.035
- CVP 2 to 6 mm Hg
Patient Monitoring - Monitor pulmonary artery pressures and central venous pressure hourly (if available) or more frequently to evaluate the patient's response to treatment. Both parameters reflect the capacity of the vascular system to accept volume and can be used to monitor fluid volume status.
- Monitor hourly intake and output, and determine fluid balance every 8 hours. Compare serial weights and note rapid (0.5-1 kg/day) changes in weight, suggesting fluid imbalance.
- Continuously monitor ECG for dysrhythmias resulting from electrolyte imbalance.
Patient Assessment - Obtain VS every hour or more frequently until the patient's condition is stable.
- Evaluate hydration status every 4 hours. Note skin turgor on inner thigh or forehead, condition or buccal membranes, development of edema or crackles, and complaints of thirst.
- Assess for pressure ulcer development secondary to edematous state.
Diagnostic Assessment - Review serum sodium and potassium, serum osmolality, urine specific gravity, and urine osmolality to evaluate the patient's response to therapy.
Patient Management - Restrict fluid as ordered, generally <500 mL/day in severe cases and 800 to 1000 mL/day in moderate cases.
- Administer potassium supplements as ordered, assess renal function and ensure adequate urine output before administering potassium.
- As adjuncts to water restriction, demeclocycline may be ordered to inhibit the renal response to ADH in patients with lung malignancies.
- Avoid hypotonic enemas to treat constipation because water intoxication can be potentiated.
- Institute pressure ulcer prevention strategies.
image from medicalimages.allrefer.com Related posts: - Hepatic Failure
- Thyrotoxicosis (Thyroid Storm)
- Acute Peritonitis
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| Myxedema coma Posted: 27 Sep 2010 05:30 PM PDT 
 Severe form of hypothyroidismis Myxedema Coma Myxedema coma is a life-threatening condition in which patients with underlying throid dysfunction exhibit exaggerated manifestations of hypothyroidism. Precipitating factors may include (but are limited to) infection, trauma, surgery, heart failure, stroke, or central nervous system depressants. Hypothyroidism depresses metabolic rate, thus seriously affecting all body system. Signs And Symptoms - Hypothermia
- Hypoventilation
- Decreased mental function
- Fatigue
- Activity intolerance
- Hyporeflexia
- Cardiac or respiratory failure
Physical Examination Vital Signs - BP: hypotension or hypertension
- HR: bradycardia
- RR: bradypnea
- Temperature: hypothermic <95° F (35° C)
Skin - Coarse and dry
- Possibly carotene color
- Preorbital and facial edema
Neurologic - Obtunded, coma or seizures
- Delayed reflexes
Gastrointestinal Endocrine - Thyroid maybe nonpalpable, enlarged, or nodular
Acute Care Patient Management NURSING DIAGNOSIS: Decreased cardiac output related to bradycardia and decreased stroke volume. Outcome Criteria - Patient alert and oriented
- BP 90 to 120 mm Hg
- Mean arterial pressure 70 to 105 mm Hg
- HR 60 to 100 beats/min
- Urine output 30 ml/hr
- Peripheral pulses palpable
Patient Monitoring - Continuously monitor ECG for dysrhythmias or profound bradycardia that can adversely affect cardiac output.
- Continuously monitor pulmonary artery pressure, central venous pressure (if available) and blood pressure.
- Monitor fluid volume status; measure urine output hourly and determine fluid balance every 8 hours.
Patient Assessment - Assess cardiovascular status: note quality of peripheral pulses and capillary refill.
- Observe for increase jugular vein distention and pulsus paradoxus, which may indicate pericardial effusion.
Diagnostic Assessment - Review thyroid studies as available.
- Thyroid stimulating hormone should decline within 24 hours of therapy and should normalize after 7 days of therapy.
Patient Management - Administer intravenous fluids as ordered to maintain BP >90 mm Hg; carefully monitor for fluid overload and development of heart failure.
- Vasopressor agents may be used if hypotension is refractory to volume administration and if thyroid replacement has not had time to act. Carefully monitor the patient for lethal dysrhythmias.
image from nytimes.com Related posts: - Thyrotoxicosis (Thyroid Storm)
- Cardiac Tamponade
- Hypovolemic Shock Patient Care and Monitoring
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