ANCC Review Guide

• Health People 2010 – to improve access to comprehensive, quality, primary care services. Goals: o Increase the quality and years of healthy life o Eliminate health disparities among Americans • Health People 2020 - The program is an initiative that develops evidence-based practice objectives designed to improve the health of all Americans. These objectives are targeted to be followed over a 10-year period 4 foundational healthcare measures 1. General health status 2. Health-related quality of life & well-being 3. Determinants of Health – aim to create social & physical environments that promote good health for all 4. Reduce Health Disparities • Electronic Medical Record (EMR) – Pros: allows for sharing of health information between healthcare entities & with patients, thereby reducing the cost of care, improving care efficiency, avoiding readmission and decreasing duplicate testing. Cons: the potential for data loss in the event of computer or system failure • Medicaid - a government health insurance program for low-income individuals funded by federal & state entities and administered by the state. * Varies from state-to-state. • Medicare – federally funded health insurance program for those 65yrs, those with severe disability no matter income level, or those with ESRD. Qualifying conditions: US citizen, non US citizens after 5 years of permeant residence in the US, veterans are eligible after 65yrs. A. Medicare Part A covers medically necessary inpatient care and supplies; skilled nursing facility B. Medicare Part B covers nursing home/custodial care (ADL’s), home health services, durable medical equipment, out patient care & preventative services (i.e. 1 mammogram every 12 months) in women 40 and older. Part B DOES NOT cover eyeglasses or routine dental care. • The Barthel Index is a measurement of ability to perform ADL’s C. Medicare Part C – HMO D. Medicare Part D covers prescriptions • A single payer healthcare system refers to a system where in essence the government runs a nationwide insurance plan that pays for all healthcare costs of its members. • Peer Review / 360 degree Evaluation – employees rate other employees in the same job classification, through the use of established criteria. The system has the potential to offer honest & specific feedback that allows the individual to make improvements or adjustments to meet objectives and performance standards • Fidelity – Loyalty & dedication; keeping a promise • Beneficence – promote good & prevent harm • Non-Maleficence – To do no harm • Justice - right to fair and equitable treatment • Autonomy – The right of patients to make clinical decisions about their medical care, assuming the patient is rational & can make informed decisions about care • Veracity – The duty to be truthful • Utilitarianism – produces the greatest good for the greatest number of people PROFESSIONAL PRACTICE – 17% (30 QUESTIONS) Policies & Practice Standards • State Nurse Practice Act (NPA) – approved by vote through the processes of each individual states legislature. The Act delineates the legal scope of practice within the geographical boundaries of the jurisdiction. The purpose of the Nurse Practice Act is to protect the public. • State Board of Nursing (BON) – determines laws governing nurse practitioner authority; has the authority to develop administrative rules or regulations that clarify the NPA & make scope of practice interpretations more specific. The state BON rules and regulations must be consistent with the legislature. • Indian Health Care Improvement Act of 2010 – part of patient protection & affordable Care Act. Only Native American enrolled as members of a federally recognized tribe can be eligible for health care services. Services obtained under the IHS must be prioritized with life threatening illness or injuries being given the highest priority. IHS formulary drug list may not include all drugs & medicines. • Emergency Medical Treatment & Labor Act (EMTALA) – designated to prevent inappropriate transfers and “patient dumping” for indigent patients. Requires hospitals to assess & treat patients regardless of ability to pay and provides specific provision for when transfers are allowed. • The Genetic Information Nondiscriminatory ACT (GINA) – prohibits the use of genetic information in employment & health care insurance decisions. • Health Information Technology for Economic & Clinical Health Act of 2009 (HITECH) – healthcare providers would be offered financial incentives for demonstrating meaningful use of EHR until 2015 after which penalties may be levied for failing to demonstrate such use. *** CMS announced in mid 2015 that it will delay final penalties until 2017** Meaningful Use – to implement clinical decision support (CDS) rule relevant to specialty or high clinical priority (i.e. abnormal vitals signs appear in red) Clinical Decision Support (CDS) – provides clinicians, staff, patients & other individuals with knowledge and person-specific information, intelligently filtered & presented at appropriate times to enhance health & healthcare. CDS encompass a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts & reminders to care providers and patients; clinical guidelines; conditions specific order sets; focused patient data report summaries; documentation templates; diagnostic support; contextually relevant reference information. • Affordable Care Act of 2010 – expands healthcare coverage using a variety of mechanisms on the state & federal level. 㾎 Only US citizens can purchase health insurance through the online market place 㾎 Expands Medicaid as well as subsidies available for low income individuals who cannot afford individual plans. Subsidies are based on the state you live in, # of adults, children & ages, and annual incomes. 㾎 Tax penalties for individuals who do not get health coverage • The Patient Protection & Affordable Care Act (PPACA)- federal legislation that principally reforms health reimbursement systems and establishes an individual mandate requiring people to have health insurance. • Consensus Model for Advanced Practice Registered Nurse (APRN) – a multifaceted proposal established by the National Counsel of the state BON in conjunction with numerous professional organizations. Advocates for the APRN title, independent prescriptive authority & establishes certain minimum standards for NP’s. ***NP’s are not required to have collaborating physician supervision under the consensus model. • Medical Home Model – Medical home is the phrase assigned to a model aimed at reorganizing the delivery of primary healthcare. The purpose of the model is to improve healthcare in America by transforming how primary care is organized & delivered. In addition, to providing comprehensive care, patients & their families are encouraged to be active participants in care. The patient-centered medical home concept is designed to meet the increase demands of both access to and management of healthcare thereby improving patient outcomes. • IOM (5) Core Competencies of effective healthcare providers & leaders 1. patient-centered care 2. Work in interprofessional teams 3. Employ evidence-based practices 4. Apply quality improvement 5. Utilize informatics (integrate information technology into care) • National Institute of Medicine (6) Quality Aims (PPEEET) 1. Patient Safety – care should be as safe for patients in healthcare facilities as in their homes 2. Patient Centeredness- the system of care should revolve around the patient, respect patient preferences & put the patient in control 3. Effectiveness – the science & evidence behind healthcare should be applied and serves a standard of care in healthcare delivery 4. Efficiency – service & care should be cost effective and waste should be removed from the system 5. Timeliness – There should be no waits or delays in the delivery of healthcare or health services to patients 6. Equity – Unequal treatment should be a fact of the past • National Practitioner Data Bank (NPDB) – a national databank of medical malpractice claims & specifically defined adverse actions associated with healthcare care providers. Any state licensure or certification action is also a reportable item. • Prescriptions for Controlled Substances – must include the following: 1. date of issue 2. patient’s name & address 3. practitioner’s name, address & DEA 4. drug name, dosage form, quantity, direction for use 5. # or refills 6. manual signature **prescriptions for scheduled II controlled substances may be telephoned to pharmacy but must be followed up with a written prescription within 7 days** Prescriptions for schedule III-V may be written, oral or transmitted by fax. • American Telemedicine Association Practice Guidelines – providers shall follow federal, state & local regulatory & licensure requirements related to their scope of practice and shall abide by state board & specialty training requirements. Providers shall ensure that the patient is physically located in a jurisdiction in which the provider is duly licensed and credentialed. Providers shall practice within the scope of their licensure and shall observe all applicable state and federal legal & regulatory requirements. • Criteria to Hospice Admission The patient must give consent Have a life expectancy 6mos Agree to not use life-sustaining equipment in the event of a life-threatening situation • State Reportable to Department of Health • 5 diagnoses: Gonorrhea, Chlamydia, Syphilis, HIV, TB • Criminal acts & injury from dangerous weapons • Animal bites • Suspected and/or actual child or elder abuse Elder abuse, also know as elder mistreatment, involves the physical abuse, emotional abuse, financial abuse, sexual abuse, neglect, and self-neglect inflicted upon an elderly individual. Abandonment or neglect is the most common elder abuse ***Domestic violence is NOT state reportable*** PROFESSIONAL PRACTICE – 17% (30 QUESTIONS) FRAMEWORKS/MODELS • The Swiss Cheese Model (James Reason) – systems approach to understanding errors. Declares humans are fallible & errors ae to be expected even in the best organizations. The holes represent opportunities for the process to fail. • Kotters 8-Step Change Model 1. Create a sense of urgency 2. Build a guiding coalition - assembling a group with the power & energy to lead and support a collaborative change effort (i.e. NP’s creating a task force to address scope of practice concerns) 3. Form a strategic mission & initiative 4. Enlist a volunteer army 5. Enable action by removing barriers 6. Generate short-term wins 7. Sustain acceleration 8. Institute change • Lewin’s Change Model 1. 1st Stage (Unfreezing) “reason for the change” – where barriers to change should be assessed. Dissatisfaction with the status quo is identified, bench mark operations are identified and internal barriers, driving forces & resistant forces to performance are understood. Unfreezing involves formulating a plan to modify or eliminate an existing practice that is the target of change. 2. 2nd Stage (Driving forces) – redesigning organizational roles, responsibilities/relationships, training for newly required skills, promoting supporters, removing resisters. The change phase is the actual modification of practices, beliefs, or thoughts surrounding the targeted change. 3. 3rd Stage (refreezing) – involves aligning pay/reward systems, re-engineering measurement/control systems & creating new organizational structure to support the change. Refreezing is the establishment of the new practice as a habit or standard procedure. • Family Developmental Theory Framework (Duvall & Miller) Examines and analyzes the basic changes & developmental tasks common to most families during their life cycle The stages and developmental tasks illustrate common family behaviors that may be expected at specific times in the family life cycle (Stages: beginning families, families w/ children, aging families) Families change over time because of the influence of environmental factors • The Health Belief Model (HBM) – conceptual framework for understanding health behavior. The premise of this model is that individuals are motivated to take positive health actions because they want to avoid negative health consequences. Self efficacy – confidence in one’s ability to take action Perceived Susceptibility – one’s opinion of chances of getting a condition Perceived Severity – one’s opinion of how serious a condition is & how serious its consequences are Perceived health benefits - one’s belief in efficacy of the advised action to reduce risk or seriousness of impact. Perceived Barrier’s – one’s opinion of tangible & psychological costs of the advised action. INDEPENDENT PRACTICE – 46% (81 QUESTIONS) CULTURAL COMPETENCY Cultural differences in the perception of illness Chinese – perceive illness as the result of a disruption between yin & yang Hispanics – perceive illness as an imbalance between the individual & the environment Africans – view illness as the “Will of God” Haitians - incorporate older traditional beliefs, feel that illness is a punishment Native Americans – believe that illness is punishment; Shamans “cure” the illness by performing rituals & using herbal medicines Collectivistic Cultures (China, Korea, Japan, & middle eastern cultures) – emphasize family & work goals above individual needs or desires. Characterized by lifelong ties to family & older adults and hierarchical figures being highly respected. Loyalty - values the needs of a group or a community over individual needs. Elders are highly respected in the Asian population and family members are expected to care for their elders. Chinese Women partake in a “sitting month” for a period of time after childbirth. During this time, they avoid cold foods, cold water and cold conditions in order to restore the energy in their bodies that were lost during the blood loss associated with childbirth. Amish Culture & Community welfare and government assistance are not acceptable. Medical bills and expenses are paid by the community. (An individual is not solely responsible for his own medical bills) Cancer & related illnesses are real and should be treated appropriately Individualistic Cultures (North American cultures) – focus on the individual. Personal accomplishments, values or productivity & self-expression are characteristic. Native Americans respect is communicated through avoidance of eye contact (can be interpreted as an intrusion into the spirit). Avoiding loud volume when speaking (stern or loud speaking is considered to be aggressive) Allowing for silence during conversation (felt to be disrespectful to interrupt someone’s conversation). Greet with light handshake. Mexicans Emphasizes the mother as the health care decision maker. Fathers are usually in charge of everything else besides health care decision making Families are very close and patients often bring many family members to their appointments Hispanics (Latino’s) Yerba burna (mint tea) is commonly used for headaches in Hispanic cultures & is safe in usual quantities Stress levels can be very high when Latino patients come to the US. (Emotional distress may present with headaches or other somatic complaints). Respect is a normative Latino cultural value along with kindness, friendliness & modesty It is considered respectful to address elders as Senor/Senora INDEPENDENT PRACTICE – 46% (81 QUESTIONS) • Confidence interval – specified probability of the parameter being estimated. A small confidence interval implies a very precise range of values. RESEARCH TERMS • Standard Deviation – the average amount of deviation of values from the mean • Reliability – the degree to which an assessment tool produces stable & consistent results • Validity – the degree in which a variable measure what it is intended to measure • Level of Significance – (P-value) the probability level of which the results of statistical analysis are judged to indicate a statistically significant difference between 2 groups P – Value – the alpha used in statistical analysis establishes level of significance for outcomes being evaluated. 0.05 is the benchmark used to interpret p –values. P-values 0.05 indicates there is a greater than 5% chance that the study outcome is due to random chance & thus non-significant. 0.05 is statistically significant meaning – 95% chance that the results did not occur by chance. • Perfect Correlation – a measure of interdependence of 2 random variables that range in value from -1 to +1 -1 indicates perfect negative correlation 0 absence of correlation +1 perfect positive correlation • Evidence Base Practice (EBP) – integration of best research evidence with clinical expertise & patient values to guide medical decision making. The 4 A’s 1. Asking a focus question is the 1st step in seeking an evidence-based answer PICO a) Patient/Population/Problem b) Intervention/Exposure c) Comparison/Control d) Outcome 2. Acquiring the best evidence you can find 3. Appraising the evidence 4. Applying to patient care • Experimental – includes experimental manipulation of variables utilizing randomization & a control group to test the effects of the intervention or experiment 1. Quasi-experimental – manipulation of variable but lacks comparison group or randomization • Non Experimental – includes (2) broad categories of research. 1. Descriptive – aims to describe situation, experience & phenomena as they exist 2. Expost-facto/ correlational Research – aims to examine relationships among variables • Qualitative – includes case studies, open-ended questions, field observations, participant observations & ethnographic studies where observation & interview techniques are used to explore phenomena through detailed descriptions of people, events, situations or observed behavior. Research bias is a potential problem. Calls into question the generalizability of the findings. Produces very rich data through no other means • Systemic Reviews & Meta Analysis – A systematic review or meta analysis offer the highest level of strength of evidence in research. Systemic reviews & meta analysis are often found together within the same publication, but they are distinct entities. Systematic review – refers to a literature search & summarization process. Provides a comprehensive review of all relevant studies on a particular clinical or health related question/topic. Created after reviewing and combining all the information from both published and unpublished studies and then summarizing the findings. Meta-analysis - refers to the application of statistical techniques to analyze this process. A subset of systematic reviews; a method for systematically combining pertinent qualitative and quantitative study data from several selected studies to develop a single conclusion that has the greatest statistical power. • Order of Evidence Strength 1. Systematic Review / Meta- Analysis – reviews of multiple studies and articles, which summarize the findings of the group 2. Randomized Controlled double-blinds – the best design to determine the benefit/risk of an intervention. Consists of subjects who are randomly assigned to treatment or non-treatment groups. They represent a high level of relevance 3. Cohort Studies (longitudinal study, quasi-experiment)) – follows individuals with a particular condition over a period of time. It is the best design to obtain valid information about the prognosis of a condition. 4. Case-Control Studies (observational study) – compares patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcome (control), looks back retrospectively 5. Cross sectional study (observational study) –analyzes data from a population, or a representative subset, at a specific point in time. (causal effects of independent and dependent variables; the best design to evaluate a diagnostic test) 6. Case Reports – a review of one patient’s case, treatments and outcomes 7. Editorials/Opinions 8. Animal Research 9. Vitro Research • SMART CRITERIA - Developing specific, measureable objectives requires time, orderly thinking, and a clear picture of results expected from program activities. The more specific your objectives, the easier it will be to demonstrate success. SPECIFIC (clear & precise) “ What exactly are we going to do, for whom?” MEASURABLE (able to be evaluated) “Is it quantifiable and can we measure it?” APPROPRIATE (consistent with the goal & priorities of the overall program) “Will this objective have an effect on the desired goal or strategy” REASONABLE (can be realistically achieved given available resources) “Can we get it done in the proposed time frame with the resources and support we have available?” TIMED (will be collected within a specified timeline) “When will this objective be accomplished?” FOUNDATONS OF ADVANCED PRACTICE – 37% (64 QUESTIONS) PSYCHOSOCIAL DISORDERS • Bupropion (Wellbutrin) is an atypical antidepressant that increases the risk of seizures. Contraindications are seizures, anorexia nervosa, & bulimia, abrupt alcohol withdrawal, sedatives, certain head injuries • Side effects of SSRIs: weight gain, dry mouth, sexual dysfunction, insomnia and headache • Patients taking MAOI’s should not also take SSRI’s (i.e. Prozac, Paxil, Zoloft), d/t the possibility of developing Serotonin Syndrome • Serotonin Syndrome: severe anxiety, restlessness, confusion, and muscle twitching • SSRI’s are antidepressants • Depression – to meet the criteria for depression, 5 symptoms must be present for at least 2 weeks • In SAD CAGES – Interest (loss of interest), sleep disturbances, Appetite changes, Depressed mood, Concentration difficulties, Activity (agitation or irritation), Guilty feelings or low self- esteem, energy loss, and suicidal ideation. • Risk Factors for SUICIDE 1. Elderly white males (especially after the death of a spouse) 2. Past history of suicide attempt 3. Family history of suicide 4. Plans for use of a lethal weapon 5. Female gender have attempt rate, but males have a higher success rate 6. Personal history or bipolar or depression • Alzheimer’s Disease (10) signs 1. Memory loss that disrupts daily life 2. Challenges in planning or problem solving 3. Difficulty completing familiar tasks 4. Confusion with time or place 5. Trouble understanding visual images or spatial relationships 6. New problems with words or speaking/writing 7. Misplacing things and loosing the ability to retrace steps 8. Decreased or poor judgment 9. Withdrawal from work/social activities 10. Changes in mood and personality DERMATOLOGICAL DISORDERS • BLEPHARITIS – treated with warm compress and topical antibiotics • ACNE VULGARIS • First-line treatment includes OTC medicated soap and water w/ topical antibiotic gels • Next step tx would be initiation of tetracycline • Accutane would be the final step of therapy • Staphylococcus Auras infections IMPETIGO – classic honey-colored crust on the edges of pus-filled sores, which are commonly found around the nose and mouth Hidradenitis Suppurativa – inflammatory condition of the skin where large abscess develop. Commonly found in the apocrine glands in the axilla and /or groin that causes painful nodules under the skin. These abscesses tend to open and drain fluid and pus. Significant scarring of the skin may result from these outbreaks. • Group A Beta-hemolytic streptococcus infections Cellulitis Folliculitis – inflammatory condition of the pilosebaceous follicle. Erysipelas – bacterial infection of the skin’s outer layer • LYME DISEASE ▪ Caused by Borrelia burgdorferi ▪ Erythema Migrans - characteristic rash of early Lyme disease usually appearing 7-10 days after a tick bite The rash appears either as a single expanding red patch or a central spot surrounded by the clear skin that is ringed by a red rash (bull’s eye) Doxycycline 100mg BID for 14-21 days is the recommended treatment for adults • CANDIDAL INTERTIGO More common in the obese & women with pendulous breasts Found in areas where skin rubs against skin (under breasts, groin areas, stomach folds) More common in warm in humid weather (summer) • SQUAMOUS CELL CARCINOMA Primarily found on sun-exposed areas such as the rim of the ear, face, scalp, lips & mouth Actinic keratoses – initial skin characteristics presenting as a small, sandpaper-like growth *crusted or scaly patch with a red inflamed base; non-healing ulcer, or just crust Any non-healing ulcers require further evaluation. • BASAL CELL CARCINOMA * Most common type of skin cancer • MELANOMA The skin cancer with highest mortality (65% of skin cancer deaths) • TINRA VERSICOLOR (Sunspots) Infection of the skin (stratum corneum layer) Caused by dermatophytes (fungi) of the tinea family. RESPIRATORY DISORDERS • Acute Otitis Media – Amoxicillin is first-line therapy. Augmentin is used with increased risk for resistance due to recent antibiotic use in the last 30days • MONONUCLEOSIS (EBV) Member of the herpes virus family Clinical diagnosis TRIAD of fever, lymphadenopathy, & pharyngitis. Other: hepatosplenomegaly, malaise & abdominal discomfort Atypical lymphocytes Diagnostic test: Mono Spot • EMPHYSEMA – characterized by having a barrel-shaped chest, pursed-lip breathing, and dyspnea when at rest. • VIRAL BRONCHITIS – airway clears with coughing, no fever • ACUTE BRONCHITIS – tx includes Bactrim, Azithromycin, Doxycycline • SINUSITIS – purulent discharge in addition to sinus tenderness, headaches, and fever may be present • PNEUMONIA – fever, purulent sputum, and lung consolidation. Cases of PNA may be presumed based on clinical symptoms and most patients are effectively treated empirically with broad spectrum antibiotics. • Tonsil assessment 1+ barely visible outside the tosillar pillar 2+ tonsils between the tosillar pillar and the uvula 3+ tonsils touch the uvula 4+ tonsils touch each other CARDIOLOGY • S1 heart sound is caused by closure of the atrioventricular valves (mitral valve & tricuspid valve) • S2 heart sound caused by closure of the semilunar valves or AP valves (aortic & pulmonic valves) • S2 is physiologically split in about 90% of people & is common in young athletes This heart sound is heard best in the 2nd intercostal space left upper sternal border (pulmonic area) • S3 heart sounds are best heard with the bell of the stethoscope at the apex of the heart and the client in the left lateral position. • For individuals with cholesterol 200 screening is recommended every 5 years • HYPERTENSION • According to JNC 7, normal BP should be 120/80 • The most current recommendation for BP goal is 130/80 in patients with diabetes • Smoking cessation is highly recommended in patient with HTN to reduce the risk of secondary coronary disease and renal damage • Thiazide diuretics (HCTZ) are recommended as initial therapy for uncomplicated HTN either alone or in combination with other agents by the JNC-7 guidelines. • First line drugs for Blood Pressure management is an ACI or ARB for diabetics since they help alleviate microalbuminuria and may reduce the risk of the development of other forms of end-organ damage such as retinopathy. JNC 7 has adopted microalbuminuria or estimated glomerular filtration rate less than 60ml/min as one of the major cardiovascular risk factors. • If patient develops ACE inhibitor-induced angioedema, the safest option is to avoid both ACE & ARB and move to HCTZ if the patient has good renal function. HCTZ can increase lipoproteins • ACE-inhibitor induced angioedema is a serious, even life threatening, condition which is characterized by severe swelling of the lips, tongue, and upper airway. The safest option is to avoid both ACE inhibitors and ARBs in those who have had angioedema (similarity in mechanism of action) and move onto HCTZ if the patient has good renal function. • According to JNC-8 guidelines, an ACE and ARB should not be given together. • Beta blockers may be indicated only if target blood pressure cannot be achieved using first-line therapy drugs alone or in combination. • Low-does aspirin therapy may be recommended for those with diabetes who are at immediate risk of cardiovascular disease (younger patients with at least one risk factor, older patients with no risk factors, or patients with a 10-year risk of 5-10%). • Clinical eye findings found in patients with chronic HTN: AV nicking, cooper wire arterioles (arteriole constriction), flame-shape hemorrhages, cotton-wool spots, papilledema (swelling of the optic disc) • SYSTOLIC MURMURS: mitral valve regurgitation, severe tricuspid regurgitation and aortic stenosis result in systolic murmurs ** Mnemonic: MR. ASS is the MVP • DIASTOLIC MURMURS: mitral stenosis and aortic regurgitation resulting from valvular disease cause diastolic murmurs. ** Mnemonic: MS. ARD GASTROENTESTINAL DISORDERS (PEDS) • GASTROENTERITIS Monitor for dehydration in children oral hydration therapy: for mild – moderate (50ml/hr) Severe 100ml/hr Continue breastfeeding and formula *Avoid anti-motility drugs (the organisms need to clear the system) Drug of choice * Bactrim (Salmonella requires supportive management) Child needs (2) neg stool cultures to return to school • GERD **present in 85% of preemies; resolves by 18mos Vomiting, belching, frequently clearing throat Abdominal US – r/o pyloric stenosis Labs: CBC r/o anemia & infection Management: small frequent meals, frequent burping, add weight to formula (cereal) Drug of choice: H2 antagonist, GI referral • PYLORIC STENOSIS Present is younger infants 3wks – 4months Characteristic features: blue eyes, blonde hair, flat feet (pes planus) Projectile vomiting, palpable pyloric mass, peristaltic waves Diagnostic test: Abdominal US “string sign” narrow pyloric channel Management: refer to surgery • INTERUSSUSCEPTION Cause: Rotavirus vaccine Bilious vomiting, sausage shape mass in RUQ, Progressive distention tenderness (acute abdomen) **Currant jelly stools Refer to surgery • HIRSCHSPRUNGS (Aganglionic Mega Colon) More common in males Failure to pass meconium, jaundice, infrequent bowel movements, progressive abdominal distention Referral to GI • NEUROBLASTOMA Arises from the adrenal glands Urine catecholamines Abdominal US or CT GASTROENTESTINAL DISORDERS • APPENDICITIS: patients present with RLQ pain • Blumberg’s Sign or rebound tenderness: the examiner palpates the abdominal wall. (+) if pain is elicited with the removal of pressure. Assesses peritonitis or appendicitis • Markle’s Sign: found when there is abdominal pain with running. Pain in the RLQ of the abdomen is elicited by having the patient drop from standing on the toes to heels, with a jarring landing; found in acute appendicitis • McBurney’s Sign: tenderness on gentle pressure at the point (McBurney’s point) on the right side of the abdomen 2/3 of the way from the navel to the boney prominence on the front of the hip. Reliable sign for appendicitis. • Other sings: psoas (pain with leg elevation), Rovsing (palpation on left abdomen produces rebound pain on the right), Obturator (pain with internal rotation of the hip) • The presentation of fever & malaise with RLQ rebound tenderness is consistent with acute appendicitis and should be referred to ER for further assessment d/t potential for rupture. CT scan is the diagnostic test of choice. IV fluids and antibiotics are standardly given in the inpatient setting. • **Sudden absence of pain in a patient previously presenting with pain indicates surgical emergency; high risk for rupture • CHOLECYSTITIS • Murphy’s Sign: a maneuver during physical exam as part of the abdominal examination of the edge of the gallbladder. The patient is asked to breathe in, and with the examiner’s palpation, if the patient winces with a “catch” in the breath, the test is (+) for cholecystitits. • Ultrasound is the GOLD STANDARD diagnostic exam • DIVERTICULITIS • Patients present with mild to moderate pain in the LLQ. • Most common in older females, high incidence in those with low fiber diet • Acute abdomen is an EMERGENT condition. (*air under the diaphragm on x-ray is consistent with peritonitis) • Differentiates from Ulcerative colitis in that “bloody diarrhea” establishes diagnosis of UC. • BOWEL OBSTRUCTION • Indicated by dilated loops of bowel on x-ray • Common causes: fecal impaction, adhesions, volvulus (children) • S:S high pitched or tinkling bowel sounds, inability to pass gas • Referral - NGT, IV fluids, antibiotics, GI/Surgical consult PEPTIC ULCER DISEASE H. PYLORI • an infection of the GI tract leading to chronic inflammation; common cause of ulcer formation • Diagnostic test: Endoscopy with tissue biopsy • Combination therapy is used in treatment: (2) antibiotics and (1) PPI ex. Metronidazole, Amoxicillin, and Omeprozole • Sucralfate ia a cytoprotective agent that coats the lining of the stomach; does not have an effect on stomach acid. It can be used following combination therapy. Sucralfate needs to be taken 2 hrs apart from other medications and necessitates an acidic environment DUODENAL ULCERS • Common in the 30-55 yo age range. Occurring more often in men than women. • With this ulcer pain (gnawing) is relieved with eating. • Classic pain occurs 2-3 hours after meals and may awake the patient from sleep. • 90% of these ulcers are caused by H. Pylori GASTRIC ULCERS • Common in 55 to 65 yo age range. • Misoprostol (Cytotec) is a synthetic prostaglandin E1 analog used to prevent gastric ulcers. **should be avoided in pregnant patients as it stimulates uterine contraction and induce abortion. • GERD (Reflux Disease) • H2 blockers are first line approach for treatment (i.e “tidine” = Rantidine). This drug group inhibits stomach acid production. Is taken 30-60mins before eating to inhibit acid production. • PPI’s are used before eating or at night inhibiting the stomach’s production of gastric acid. Taken before meals. • Consider EGD in long time standing GERD to r/o Barrett’s esophagus; precursor to Esophageal Ca • Elevate HOB, smoking cessation, weight loss, Avoid caffeine & spices • HEPATITIS • Patients may present with fatigue, anorexia, nausea, headaches, weight loss, pruritus, & RUQ pain. Hepatosplenomegaly may be present. Elevated ASL/ALT 500 – 2000 IU/L (*normal 35-40) • Supportive: rest during active phase, increased fluids, No/LOW protein diet • Vit K for prolonged pT • Avoid medication processed by the liver (Tylenol), Alcohol