Bariatric Flashcards
(46 cards)
1
Q
Addison Disease Definition and etiology
A
primary adrenal insufficiency; insufficent cortisol and aldosterone due to destruction, partial or complete to adrenal glands
2ndary could be caused 2/2 decr ATCH release caused by a pituitary tumor or prolonged striod use. 2dary is more common but we will focus on primary
Etio:autoimmune reaction, infection, metastized cancer, CMV, tuberculosis, and hemmorage
2
Q
Addison Disease Risk fxs, gender and age
A
Surgery, pregnancy accident injury or trauma, infection, sweating overexertion during physical activity or failure to take steroid therapy in persons who have chronic adrenal insufficiency Slightly higher in women 40-60 years
3
Q
Addison Disease Clinical Presentation:
A
- Cortisol mobilizes nutrients, modifies the body’s response to inflammation, stimulates the liver to raise blood sugar and helps to control the amount of water in the body.
- Hypoglycemia can ensue
- weak, exhausted, hypotensive, anorexia, weight loss, nausea and vomiting, Emotional disturbance and poor stress mgmt and darkenign of the skin
- Aldosterone regulates salt and water levels which affects blood volume and blood pressure.
- decr can cause hypotension, decr CO, dehydration,
- Addisonian crisis, can progress quickly to hypovolemic shock (e.g., hypotension, tachycardia, and loss of consciousness) from rapid fluid loss
4
Q
Addison Disease diagnostic dx
A
-blood and urine tests. Cortisone and alodsterone should incr with ATCH synthetic admin
5
Q
Addison Disease med mgmt
A
- replacing fluids, electrolytes, glucose and cortisol
- synthetically manufactured corticosteroids and mineralocorticoids
6
Q
Addison Disease Physical TherapyTests and Measures and Implications for evaluation
A
- check vitals, stress can increase the risk for Addisonian crisis
- get baseline for ROM, MMT and areobic state
- proper dose of replacement medication is taken every day
- focus on strength
- CONTRA- aqua therapy; hot and humid
7
Q
Grave’s Disease Definition and Etiology
A
Autoimmune condition and a form of hyperthyroidism with an increase in t4 production; primary role to regulate metabolism
- makes up of 85% of hyperthyroiodism cases
- thyroid gland; stimulation of metabolism, therefore, causes hypermetabolism and increased sympathetic nervous system activity
8
Q
Grave’s Disease risk fxs gender and age
A
- Immunologic and genetic factors
- more common in women with a family history of thyroid conditions
- psoriatic arthritis, rheumatoid arthritis, and Sjögren Syndrome
- 4 times as likely to affect women than it is to affect men-
- 20-50 yrs
9
Q
Grave’s Disease Clinical presentation
A
- symmetric enlargement of the thyroid
- nervousness, heat intolerance, sweating, diarrhea, tremor, and palpitations, dramatic weight loss despite an increase in appetite
- exophthalmos, afrib
10
Q
Grave’s Disease dx tests
A
Radioactive iodine uptake
- blood tests to test TSH
11
Q
Grave’s Disease Med MGMT
A
Antithyroid medication, radioactive iodine (first-line therapy for those over 18 and not prego), and partial or subtotal thyroidectomy
12
Q
Grave’s Disease Physical TherapyTests and Measures and Implications for evaluation and prax
A
exercise intolerance and reduced exercise capacity should be looked out for 2/2 weakness and myopathy
- watch vitals and cardio signs bc of unpredictable cardio signs
- watch for signs/ be observant of possible signs of hypoparathyroidism, which include tetany, muscle twitching, and numbness and tingling around mouth, fingers, or toes
- address bone mineral density and poor nutrition
- cardiopulmonary rehabilitation should be a focus
13
Q
Gastric Bypass definition and description of procedure
A
- caloric restriction through a significant reduction in stomach capacity via medical procdure
- “Roux-en-Y” is the gold standard
- stomach is either stapled or transected into a smaller “gastric pouch” of anywhere from 15-30 mL
14
Q
Gastric Bypass Characteristics for Qualification
A
- Weight 100 pounds or 100% above desirable weight
- BMI >40 kg/m2
- BMI >35 kg/m2with medical comorbidities
- Failure of nonsurgical attempts at weight reduction
- Absence of endocrine disorders that can cause massive obesity
- Psychological stability-Basic understanding of how obesity surgery causes weight loss
- Realization that surgery itself does not guarantee weight loss
- Absence of alcohol and drug abuse
- Commitment to post-op follow-up
15
Q
Gastric Bypass Risk Fxs
A
- Nephrolithiasis (kidney stones)
- Hepatic failure
- Cholelithiasis (gall bladder stones)
- Malnutrition (vitamin and mineral deficiencies)
- Reflux
- Small bowel obstruction
- Hemorrhage
- Iron-deficiency anemia
- Gastric prolapse
- Postoperative bleeding
- Postoperative leaking
- Atelectasis; pneumonia
- Pulmonary embolism
- Significant decrease in bone health
- Death
16
Q
Gastric Bypass Clinical Presentation: Signs/symptomsBefore and After Procedure
A
Before -Hypertension (BP above 120/80) -BMI >35 kg/m2 -Presence of diabetes mellitus (A1C of >6.5% or fasting blood sugar test of >126 mg/dL glucose on two separate occasions) -Presence of sleep apnea -Decreased activity tolerance -Decreased quality of life After -Malnutrition of protein -Severe/mild iron deficiency anemia -Nausea/vomiting -Hair loss from iron/folate/vitamin B12deficiencies -Diarrhea/bad fecal odor
17
Q
Gastric Bypass Dx tests
A
- blood tests
- phych test
- BMI
- nutrition consult
- DxA scan for bone mineral density
18
Q
Gastric Bypass med mgmt
A
- multi vitamin for mal nutrition
- constant lab work ups every 3 months
- re- do of sx if it was outeaten
19
Q
Gastric Bypass Physical TherapyTests and Measures and Implications for evaluation and prax
A
- sense effects of sx dont happen over night help pt get back to activity goals and monitor activity tolerance
- tend to suffer from increased heat intolerance, so err on the side of caution to reports of excessive sweating and “over-heating” to avoid heat stroke/exhaustion
- high risk of bone fractures
- low intensity short duration
- moderate aerobic exercise of at least 150 min/week and strength training 2-3 times/week can have a positive effect on bone mineral density
- strengthen core and rpevent incision site adhesions
- With Ex Rx **
- Increased heat intolerance
- Need for equipment modifications to fit body size
- Reported pain as obesity tends to increase risk of LBP and joint pain
- Selection of appropriate footwear as obesity can lead to poor foot mechanics
20
Q
Cushing’s Definition and Etiology
A
exposure of excessive glucocorticoids for extended periods of time due to injection or tumors causing endogenous overproductions
- Hyperfunction of the adrenal glands from an adenoma,also with carcinomas in rarity.
oExcessive corticosteroid medications, like those suffering from inflammation, chronic allergy or even MSK disorders involving pain.
- excess ATCH
-uncontrolled type 2 diabetes, hypertension, or early-onset osteoporosis.
21
Q
Cushing’s Risk Fxs gender and age
A
- Chronic use of corticosteroids
- Genetics
- Females> men
18-25
22
Q
Cushing’s clinical presentation
A
- “moon-face” in which the face enlarges and becomes rounded with washed out jaw/cheek lines
- increased truncal obesity and specific supraclavicular and cervicodorsal (buffalo hump) fatty enlargements.
- hyperglycemia, hypertension, proximal muscle wasting and bone mineral density (BMD) loss resulting in osteoporosis
- Mental changes like memory loss, poor concentration and “steroid psychosis”
23
Q
Cushing’s Diagnostic tests
A
- 24-hour urinary cortisol test
- Lowdose dexamethasone suppression test –Measures response of ACTH by adrenal glandfollowing dexamethasone
- Late-night salivary cortisol test; nomral are low levels at night
- MRI of pituitary
24
Q
Cushing’s Med MGMT
A
-Surgery, chemotherapy, radiation or otherdrugs aimed at inhibiting, or lessening cortisol in the body
25
Cushings Physical TherapyTests and M and measures and Implications for evaluation and best prax
muscle and bone wasting, poor energy conservation and even mentation status changes can be mgmt's be emdurace, strength or balance interventions
- Cortisol is an immunosuppressant; underlying infections can sometimes go unnoticed
- delay wound healing, education on care and general principles to increase wound healing
- do nto overload 2/2 osteoporosis
26
Gastric band Definition of procedure
help patients who are morbidly obeselose weight
-small adjustable band around the patient’s upper stomach, in an effort to create a smaller stomach pouch in order to restrict food intake
-
27
Gastric band Qualifications to have procedure completed
18 years of age or older
-Have been overweight for 5 years or more
[BMI= 40 kg/m2 or higher and/or 100 pounds overweight and/or weigh two times as much as your ideal recommended weight
- BMI= 35 kg/m2 or higher and have at least one obesity related comorbidity (ex. Type 2 Diabetes, HTN)3BMI= 30 kg/m2 and you are paying privately.
-Unsuccessful non operative weight loss attempts.
-Currently do not suffer from any other disease that affects weight loss.
-Not currently pregnant.
-Mental health clearance with alcohol or illegal substance dependence
- You are prepared to make major changes in eating habits and living a healthy lifestyle
28
Gastric band procedure risks
```
Band erosion and Infection
Gastric band slippage
Esophageal dilation
Food trapping
Stomach stenosis
Gastric pouch dilation
Band or port leak
Hiatal hernia
Abdominal pain
DVT/GERD
Ineffective weight loss and weight regain
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29
Gastric band Clinical Presentation-Signs and symptoms before and after procedure
- obesity
-obstructive sleep apnea,
hypertension,
pressure sores or ulcers from being bed bound,
obesity induced lymphedema
- mineral defiiciency; poor wound healing
-pharma issues; constripation dizzyness
30
Gastric band Dx tests
- Chest X Ray Electrocardiogram (EKG) Cardio echocardiogram
- Complete blood count, Chemistry Panel
- Ultrasound on gallbladder to look for gallstones and stomach
- Lipid Panel
- Thyroid function tests
- Treadmill stress test
- Pulmonary function tests
- GI Evaluation
- Psychiatric screens(Depression and anxiety)
- Sleep apnea studies
- Nutritional screening(Vitamin Deficiency screen, eating habits)
31
Gastric band Med MGMT
- Site band infection-removal of the infected port or band and antibiotics are administered to the patient for 7 to 10 days after surgery
- activity tolerance its tracked with monthly visits following 1 yr post sx
- lab values, skin integirty, activity status are monitored
32
Gastric band Physical Therapy tests and measures and implications for evaluation and best prax
- 2 to 5 days in acute care hospital
- therefore measure activity baseline and practice mobiltiy fo safe discharge to home
- Exercise History and Attitude Questionnaire, which provides an assessment of the patients prior level of activity and helps highlight the patients interest and beliefs towards exercise
- DET The Dionne’s Egress test - mobility safety
- RED FLAGS gastric leak, and dehydration, DVT, PE
- 150 mins per week of moderate intensity or 75 minutes of vigorous intensity is the minimum
- 200-300 mins of moderate intensity per week is the recommended amount of activity to maintain long term weight los
- ID potential barriers; lack of equipment, support
33
Sleeve Gastrectomy Definition and Description of procedure
- limits the size of your stomach by 80%, hormones also help reduce weight
- Repair of hiatal hernia if present. -
Posterior portion of the stomach is mobilized from lesser sac
-French Bougie is placed within the gastric sleeve that is left after removal of portion of stomach, which provides the new reduced stomach with structure and prevents leakage.
34
Sleeve Gastrectomy Characteristics for qualifications to have procedure performed.
- BMI ≥40 or a BMI of≥35 with a related comorbidity such as musculoskeletal issues, hypertension, or diabetes mellitus,
- unsuccesful attempts at weight loss
- cleared mental status
35
Sleeve Gastrectomy Risks of the procedure
Early complications
1.Excessive bleeding, Infection, Adverse reactions to anesthesia, Blood clots, Lung or breathing problems, Leaks from the surgical site within the stomach. 2.Hemorrhage,
Late complications:
1. Gastrointestinal obstruction, hernias, hypoglycemia, vomiting
2. Stricture- narrowing of passage to or from stomach which may present 2/2 edema (dysphagia, nausea, and vomiting). Tx: only needing surgery if unable to resolve on its own.
3. GERD
4. Nutritional Deficiencies(malnutrition)
36
Sleeve Gastrectomy Clinical presentation: signs/symptoms before and after procedure
Before:
presents with with other comorbidities such as: gastroesophageal reflux disease, heart disease, high blood pressure, high cholesterol, obstructive sleep apnea, type 2 diabetes, history of stroke, and infertility
After, the pt may have diarehhea, lose stoll or be constipated, weight loss doesnt happen till about 2 years
Comorbidities may also still be present
37
Sleeve Gastrectomy Diagnostic Tests/screens
```
1.
A complete history and physical to determine obesity related co-morbidities, causesof obesity, BMI, weight loss history, commitment to lifestyle changes, and possible surgical risk.
2.Routine labs.
3.Nutrient screening.
4.Cardiopulmonary evaluation.
5.GI evaluation.
6.Endocrine evaluation.
7.Nutrition evaluation by registered dietician.
8.Behavioral evaluation
```
38
Sleeve Gastrectomy Med MGMT
- first seven days a sugar-free noncarbonated liquids diet will be required, progression to purred foods
- multivitamin supplementation for life
- Diarrhea may be caused 2/2 flora imbalance and can be tx'd by probiotics or flagyl if C-Diff or antibiotic-associated diarrhea is suspected.
- drink more H2o if constipated
- dysphagia- eat slowly, chew
- regualr check up to monitor weight loss and S,E
39
Sleeve Gastrectomy Physical therapy tests and measures and implications for evaluation and best prax: 5As
- Exercise before and after operation to decrease post-op complications
- mild ex 20min x 4/week
- Balloon blowing to increase lung capacity.
- Improvement of aerobic conditioning with walking, swimming, or bike riding.
- Increase in strength with use of light weights or resistance bands
After
- Day 1 walking, then progressing to actives mentioned above to improve aerobic capacity
- Eventually patient can work up to 5-7 days a week of 45-60 minutes sessions at moderate intensity(40-60% heart rate reserve
5 A's
1. Assess: Tailor advice for PT by assessing their willingness to make change, potential barriers to change, goals. Barriers may include musculoskeletal conditions, lack of education,
2. Advise: Educate- benefits of physical activity even after surgery, develop realistic expectations, what SE arent okay: nausea, or shortness of breath, set expectations for discomfort, soreness, tenderness. Aerobic exercise in bouts of 10 minutes or longer with a goal of 60 minutes per day.
3. Agree: Collaboration with the patient on goals, type, duration, intensity, and frequency of exercise to increase likelihood of compliance.
4. Assist: Provide more resources or printed info to help increase the benefit and compliance, online support groups, or tools for self-monitoring
5. Arrange: Follow-up appointments with the patient one or two weeks after evaluation to provide further reinforcement and accountability.
40
Biliopancreatic Diversion with Duodenal Switch: Definition and Description of Procedure
- Combines a sleeve gastrectomy (removal of between 60%-80% of the stomach) with an intestinal bypass, in which the end of the small intestine is connected to the duodenum near the pyloric valve
- reduces caloric intake by reduction stomach and time in the small intestine for lesss nutrient absorbtion
- Stomach is removed (often 80%) creating a small tube (GSleeve)
- small intesitine (jejunum) is cut out with the distal end of illieum attached to the duodenum
41
Biliopancreatic Diversion with Duodenal Switch: Characteristics for Qualification
A BMI over 40, or, alternatively, being more than 100 pounds overweight
A BMI over 35 with multiple lifestyle related comorbidities (Diabetes Mellitus Type II, Hypertension, Severe Sleep Apnea, CAD, Heart Disease, or liver disease)
Failure of conservative care and lifestyle changes to have any lasting effect on weight loss.
If BMI over 50 then consider other forms of Bari Sx
42
Biliopancreatic Diversion with Duodenal Switch: Risk fxs
During surgery,
- GI leaks and bleeds, Arterial bleeds
- General complications of anesthesia: vomiting, nausea, nerve injury, cardiorespiratory distress, and pain1
- in very rare cases, accidental splenectomy
After:
*pneumonia,
* infection/sepsis
*orthostatic hypotension
*post-surgery atelectasis
* DVT / PE
*Reoperation
Following surgery, long term effects, such as:
- Decreased lean body mass (due to decreased protein absorption)
- Nutrient deficiencies, such as anemia
- Bowel obstructions
- Reoperation
-Liver and other organ failure (related to nutrient deficiencies)
- Nausea and abdominal cramping (Dumping Syndrome)
- Increase risk of fracture and osteoporosis
- Formation of gallstones or kidney stones
43
Biliopancreatic Diversion with Duodenal Switch:
Prior to Sx pt eill rpestn with co-morbs 2/2 obesity
after:
-Tenderness around abdomen
- Osteopenia or Osteoporosis4
- Anemia 2/2 decreased Vitamin B12, causing fatigue, orthostatic hypotension, and reduced energy levels
- Vitamin D deficiency, which can affect hormone levels, energy levels, and mood
- Vitamin A deficiency, which can cause blindness and reduce the function of the immune system
- Vitamin B deficiencies (particularly B12), which can cause fatigue, anemia, and weakness
- Hypotension/Hypoglycemia
-Improved mood and quality of life scores
Weightloss
- Improved functional mobility due to weight loss
- Reduced complaints of pain
44
Biliopancreatic Diversion with Duodenal Switch:
- Echocardiogram and Electrocardiogram
- Full blood work, including CBC (complete blood count)
- Liver function test
- Exercise stress test
- Endoscopy
- Requirement of cessation of smoking, steroids, or any drug that could compromise immune system/ recovery
- Nutritional counseling
- Psychiatric screening
45
Biliopancreatic Diversion with Duodenal Switch: Med MGMT
- reducing or eliminating current medications for metabolic syndromes, with the addition of supplements to avoid nutrient deficiencies
- no NSAIDS
- Opiods by mouth
- Heparin day of Sx
- lifeuse of multivitamin
- monitor and continue lipidemia meds and HTN meds
- gallstone prevention
-
46
Biliopancreatic Diversion with Duodenal Switch: Physical TherapyTests and Measures and Implications for evaluation and best prax
- Anthropometric measurements,
- vitals
- CV itness assessment
- Strength, ROM, ect
- psychometric properties
- RED FLAG: Vomiting after BPD-DS, dependent or independent of food =stomach or duodenum ulcer
- Fever, pain radiating to the back, a sudden increase in abdominal pain, and rapid heart rate are all indicative of peritonitis
- Low intensity aerobic exercise, often in bouts of 5 or 10 minutes, progressing to a total of 150 minutes per week of moderate intensity exercise
- resistance training: 2-3x per week for 25-35 minutes
