Exam 5 Unit IX/VIII Nursing Care of Patients with Problems of Digestion, Peptic Ulcer

Peptic Ulcers

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Answer: 3 3. Limit the fluids taken with meals. Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrojejunostomy (Billroth II procedure). Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. Test-Taking Strategy: Eliminate options 1 and 4 first because these measures are comparable or alike and will promote gastric emptying. From the remaining options, select the measure that will delay gastric emptying.

542. The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal. 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high-Fowler's position during meals.

Answer: 4 4. Assessing for the return of the gag reflex Rationale: The nurse places highest priority on assessing for return of the gag reflex. This assessment addresses the client's airway. The nurse also monitors the client's vital signs and for a sudden increase in temperature, which could indicate perforation of the gastrointestinal tract. This complication would be accompanied by other signs as well, such as pain. Monitoring for sore throat and heartburn are also important; however, the client's airway is the priority. Test-Taking Strategy: Note the strategic words, highest priority. Use the ABCs—airway, breathing, and circulation. The correct option addresses the airway.

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? 1. Monitoring the temperature 2. Monitoring complaints of heartburn 3. Giving warm gargles for a sore throat 4. Assessing for the return of the gag reflex

Answer: B Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the mid-epigastric area and spreading over the abdomen, which becomes rigid and boardlike. Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. A RBC count of 3.9 and Hg of 11 is not an emergency. In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Early ambulation and leg exercises are appropriate postoperative interventions. Mild pain is a common postoperative complication of a gastrectomy and can be controlled by narcotic pain medication.

After completing assessment rounds, which finding would the nurse report to the physician immediately? A. A male client with a diagnosis of chronic gastritis with a RBC of 3.9 and Hg of 11 B. A female client with a diagnosis of peptic ulcer complaining of abdominal pain, and a boardlike, rigid abdomen C. A female client following a Billroth II procedure who insists on getting out of bed and performing leg exercises D. A male client day 1 s/p gastrectomy complaining of abdominal pain rating 5 out of 10

Answer: C Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

CASE STUDY Case Study: Episode 1 Follow this patient throughout the chapter. Mrs. Sharon Taylor is a 37-year-old graphic designer. Over the last several months, she has had increased episodes of a burning sensation near the midline in the epigastrium and back. Her pain has been alleviated after eating. Mrs. Taylor has had recent episodes of pain waking her up a few nights a week. Mrs. Taylor schedules a visit to her advanced practice registered nurse (APRN). As she describes the pain pattern to her provider, the provider gathers additional information. On the basis of her history, the provider refers Mrs. Taylor to an internist who orders an endoscopy. The provider explains that the endoscopy allows visualization of the esophageal, gastric, and duodenal mucosal linings, as well as allowing tissue samples to be obtained for biopsy during the procedure ... Case Study: Episode 2 The endoscopy is performed at an outpatient clinic near Mrs. Taylor's home 2 weeks after visiting her APRN. The endoscopy reveals several peptic ulcers. A tissue sample is taken from Mrs. Taylor's stomach lining. The tissue sample is positive for H pylori, a gram-negative bacterium that infects the stomach ... Case Study: Wrap-up Mrs. Taylor's treatment of the peptic ulcers and infection includes two antibiotics, a PPI, and bismuth salts. She is instructed to take the entire course of her medications and to follow up with the internist in 6 months for a repeated endoscopy. The provider explains that failure to be compliant with the medication regimen may cause antibiotic resistance and persistent infection. The nurse is monitoring Mrs. Taylor, who has been diagnosed with a peptic ulcer. Which assessment finding most likely indicates perforation of the ulcer? A. Bradycardia B. Numbness in the legs C. Sudden and severe epigastric pain D. Nausea and vomiting

Barium enema

Description Visual of colon Rationale Persistent diarrhea Bloody stools Fistulas Special Considerations Barium related Fecal impaction Administer ↑ fluid intake Laxative NPO 8-12 hours prior to study Significance of Findings Polyps Tumors Inflammatory bowel diseases Intussusception

Colonoscopy

Description Visualization of colon from anus to cecum Rationale Colon cancer screening +Fecal occult blood testing Abnormal sigmoidoscopy Lower gastrointestinal bleeding Family history of familial nucleus polyposis Special Considerations Bowel prep 24 hours prior to colonoscopy NPO 6-8 hours prior to study Significance of Findings Colon cancer Benign polyps Crohn's disease Diverticular disease arteriovenous malformations

Esophagogastroduodenoscopy

Description Visualization of the esophagus, stomach, and duodenum Rationale Suspected upper gastrointestinal bleeding, dysphagia Epigastric pain Special Considerations Monitor return of gag reflex Vital signs NPO 8-10 hours prior to study Significance of Findings Peptic ulcers Helicobacter pylori infection Gastritis Hiatal hernia Esophageal • Varices • Strictures • Tumors

Surgical Procedure/Pyloroplasty

Pyloroplasty • Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation In this procedure the surgeon enlarges the pyloric stricture by incising the pylorus longitudinally and sutures the incision transversely.

Answer: D D. Both A and B are correct A. Producing mucus to lubricate and protect the mucosal layer of the GI tract wall B. Secretion of fluids and enzymes to aid in digestion and absorption of nutrients

The basic functions of the secretory glands of the gastrointestinal tract include which of the following? A. Producing mucus to lubricate and protect the mucosal layer of the GI tract wall B. Secretion of fluids and enzymes to aid in digestion and absorption of nutrients C. To promote absorption of proteins, fats, and carbohydrates in the stomach D. Both A and B are correct

Answer: D Rationale: No special preparation is needed for the blood test for H pylori. Answer A is incorrect because the patient is not NPO before the test. Answer B is incorrect because glucose is not administered before the test. Answer C is incorrect because it refers to preparation for the breath test.

The healthcare provider has ordered a blood test for H pylori. How does the nurse prepare the patient for this diagnostic test? A. Instructing the patient not to consume food or liquids after midnight B. Giving an oral suspension of glucose 1 hour before the test C. Explaining that a small dose of radioactive isotope will be used D. Telling the patient that no special preparation is needed

Answer: B Rationale: H. pylori infections can remain active for life, if not treated appropriately. Elimination of this organism allows ulcers to heal more rapidly and remain in remission longer. Two or more antibiotics are given concurrently to increase the effectiveness of therapy and to lower the potential for bacterial resistance. The antibiotics are also combined with a proton pump inhibitor or an H2-receptor antagonist.

The healthcare provider prescribes a combination of antibiotics for a patient with a peptic ulcer. The patient asks you why these types of medications are being given. What is the nurse's best response? A. "It will increase mucus production in your stomach." B. "The combination of antibiotics will help to rid the stomach of the H. pylori bacteria." C. "This medication will help buffer the gastric acid in your stomach." D. "It is used only as a prophylactic to prevent colonization of bacteria in the stomach."

Answer: C Rationale: With a gastric ulcer, pain is triggered or worsened by eating, when there is increased acid content of the stomach, which erodes the lesion and stimulates the exposed nerve endings. Pernicious anemia occurs with chronic gastritis. Constipation and hypertension are not manifestations of gastric ulcers.

The nurse correlates which clinical manifestation to the pathophysiology of a gastric ulcer? A. Pernicious anemia B. Constipation C. Acute epigastric pain after eating D. Hypertension

Answer: D Rationale: A peptic ulcer is an interruption of the integrity of the gastric lining; perforation is the most dangerous complication of this process. Inflammation, infection, and possibly shock can occur.

The nurse identifies which nursing diagnosis as the highest priority for the patient admitted with PUD and possible perforation? A. Acute pain B. Ineffective health maintenance C. Nausea D. Impaired tissue integrity (GI)

Answer: B Rationale: Cigarette smoking may predispose people to peptic ulcer disease, including duodenal ulcers, and may interact with H. pylori and NSAIDs to increase mucosal injury. Smoking also impairs ulcer healing and increases ulcer recurrence. Burning epigastric pain is aggravated by fasting and improved with food or antacids with duodenal ulcers. There is no evidence that bland foods impact peptic ulcer disease.

The nurse incorporates which information into the teaching plan for a patient diagnosed with a duodenal ulcer? A. "You will probably have increased pain after eating." B. "Smoking cigarettes can make the PUD worse." C. "Antacids are not usually effective for the pain." D. "Eating bland foods will aid in healing."

Answer: A Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The nurse is monitoring for the early clinical manifestations of dumping syndrome. Which findings are consistent with this complication? A. Sweating and pallor B. Bradycardia and indigestion C. Double vision and chest pain D. Abdominal cramping and pain

Answer: A Rationale: Erosive or stress-induced gastritis is a severe form of acute gastritis that is a complication of conditions such as shock, severe trauma, or major surgery most likely due to inadequate gastric mucosal blood flow during periods of intense physiologic stress. Adequate mucosal blood flow is important to maintain the mucosal barrier and to buffer any back-diffused hydrogen ions. When blood flow is inadequate, these processes fail and mucosal breakdown occurs.

The nurse recognizes which gastric disorder as a complication of inadequate mucosal perfusion secondary to intense physiological stress? A. Erosive gastritis B. Chronic gastritis C. Duodenal ulcers D. Esophageal reflux

Answer: B Rationale: Gastritis and peptic ulcer hemorrhage are the most common causes of upper GI tract bleeding. Hemorrhage is the most common complication and may be manifested by hematemesis or melena. Large quantities of blood may be lost quickly, so immediate correction of blood loss may be required to prevent hemorrhagic shock. Defining characteristics of fluid volume deficit related to gastrointestinal bleeding include hypotension, tachycardia, decreased skin turgor, weakness, decreased urinary output, pallor, and diaphoresis.

Which nursing diagnosis is most appropriate for a patient admitted for acute GI bleed related to acute gastritis? A. Imbalanced nutrition: less than body requirements B. Risk for deficient fluid volume C. Acute pain D. Deficient knowledge

Answer: B B. Gastrointestinal hormones stimulate glands that will directly secrete enzymes into the digestive tract.

Which of the following statements is true regarding digestion and absorption? A. Gastrointestinal hormones function in the digestive tract to facilitate the absorption of essential nutrients. B. Gastrointestinal hormones stimulate glands that will directly secrete enzymes into the digestive tract. C. The regulation of secreted enzymes is controlled by the hypothalamus via trophic hormones. D. Pepsin, an enzyme that mediates protein digestion, is secreted by the salivary glands.

Stress Ulcers

• Acute gastric mucosal lesions • Associated with major surgery, head injury, burns, respiratory failure, shock and sepsis • Associated with lengthy hospital stays • Bleeding is principal manifestation • Exact etiology is unknown Stress ulcers are acute gastric mucosal lesions occurring after an acute medical crisis or trauma. Bleeding caused by gastric erosion is the principal manifestation of acute stress ulcers.

Nursing Diagnosis ulcer

• Acute pain • Chronic pain • Disturbed Sleep Pattern • Imbalance Nutrition: less than body requirements • Ineffective Health Maintenance • RC: Hemorrhage • • Potential for gastrointestinal bleeding • RC: Peritonitis

Types of Surgical Procedures for bleeding

• Antrectomy/ Subtotal Gastrectomy • • Lower half of stomach (antrum) makes most of the acid • • Removing this portion (antrectomy) decreases acid production • Subtotal gastrectomy • • Removes ½ to 2/3 of stomach

Diet Therapy ulcer

• Bland diet may assist in relieving symptoms (no research that supports this) • Avoid substances that increase gastric acid secretion • • Coffee, both caffeinated and decaffeinated • Avoid bedtime snacks • Avoid alcohol and tobacco • Follow a diet you can tolerate Diet therapy for PUD is a controversial issue. There is no scientific evidence that diet therapy promotes healing. Most clients are instructed to follow a diet that they can tolerate.

Post-op Complications

• Bleeding • • Occurs at the anastomosed site • • First 24 hours and post-op days 4-7 • Duodenal stump leak • • Severe abdominal pain • • Bile stained drainage on dressing • Gastric retention • • Will need NGT • Dumping Syndrome • • Prevalent with sub total gastrectomies • • Early-30 minutes after meals • • Late - 1 ½ -3 hours after meals • • Vertigo, tachycardia, syncope, sweating, pallor, palpitations, weakness, diarrhea • Anemia • • Rapid gastric emptying decreases absorption of iron • Malabsorption of fat • • Decreased acid secretions, decreased pancreatic secretions, increased upper GI mobility Observe for any bleeding, monitor vital signs and post surgery hemoglobin and hematocrit. If gastric retention occurs once ng tube is removed, it will have to be put back in.

Minimize Dumping Syndrome

• Decrease CHO intake • Eat slowly • Avoid fluids during meals • Increase fat and protein • Eat small, frequent meals

Non-surgical Management of GI Bleed

• Endoscopic Therapy • Acid suppression • Nasogastric tube placement and saline lavage Endoscopic therapy: thermal contact using a heater probe or microelectrocoagulation, ejection of the bleeding site with diluted epinephrine, laser therapy, and clipping the bleeding vessel with a mechanical clip Acid Suppression: aggressive acid suppression is used to prevent rebleeding. Acid suppressive agents are used to stabilize the clot that has formed within the ulcer crater. They work by decreasing acid formation in the stomach. They include the H2 receptor antagonists and the proton pump inhibitors. NG tube placement with saline lavage: 50-200 mls of saline inserted and then saline is withdrawn along with the blood. Repeated until return is light pink or clear and without clots.

General Peptic Ulcer Symptoms

• Epigastric tenderness • • Gastric: epigastrium; left of midline • • Duodenal: mid to right of epigastrium • Sharp, burning, aching, gnawing pain • Dyspepsia (indigestion) • Nausea/vomiting • Belching

Key Features of Gastrointestinal Bleeding

• G.I. • • Coffee-ground vomitus • • Tarry stools • • • Melena (occult blood) • • Nausea • Cardiovascular • • Decreased blood pressure • • Increased weak and thready pulse • • Decreased Hgb/Hct • Neuro • • Vertigo, dizziness, syncope, lightheadedness • Older adult • • Acute confusion

Risk Factors Peptic ulcer

• Gender • • Duodenal: are increasing in older women • Genetic factors • • More likely if family member has Hx • Lifestyle • • Smoking • • Acidic drinks • • Alcohol • • Medications • • • ASA, NSAIDS • H. Pylori infection • • 90% have this bacterium • • Passed from person to person (fecal-oral route or oral-oral route) • Age • • Duodenal 30-55 • • Gastric over 55-70 H. Pylori produces substances that damage the gastric mucosa. Urease produced by H. pylori catalyzes the hydrolysis of urea to ammonia. Hydrogen ions are then released in response to the presence of ammonia and contribute further to gastric mucosal damage.

Complications of Peptic Ulcers

• Hemorrhage • • Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wall • • Coffee ground vomitus or occult blood in tarry stools • Perforation • • An ulcer can erode through the entire wall • • Bacteria and partially digested food spill into peritoneum=peritonitis • Narrowing and obstruction (pyloric) • • Swelling and scarring can cause obstruction of food leaving stomach repeated vomiting, nausea and bloating • Intractable disease Hemorrhage: With massive bleeding the patient vomits bright red or coffee ground blood. Minimal bleeding from ulcers is manifested by occult blood in a tarry stool (melena). Manifestations of hemorrhage may include dizziness, feeling lightheaded, change in vital signs (hypotension and tachycardia), and nausea. The nurse should be alert to these signs as they are an indication of hemorrhage. Perforation: Gastric and duodenal ulcers can perforate or bleed. Perforation occurs when the ulcer becomes so deep that the entire thickness of the stomach or duodenum is worn away. The gastroduodenal contents may then empty into the peritoneal cavity. Symptoms of perforation are sudden, sharp pain, the abdomen is tender, rigid, and boardlike. The patient assumes the fetal position, knees to chest. Client can become acutely ill within hours. Peforation is considered a surgical emergency and can be life threatening. If this occurs the physician needs to be notified immediatley.

Diagnostic Tests ulcer

• Major diagnostic test for peptic ulcer disease is Esophagogastrodeuodenoscopy (EGD) • • Endoscopic procedure • • • Visualizes ulcer crater • • • Ability to take tissue biopsy to R/O cancer and diagnose H. pylori • • Barium swallow • • • X-ray that visualizes structures of the upper GI tract • • Urea Breath Testing • • • Used to detect H.pylori • • • Client drinks a carbon-enriched urea solution • • • Excreted carbon dioxide is then measured The major diagnostic test for PUD is EGD. A barium examination of the GI tract can be used to establish a duodenal ulcer. If perforation is suspected the health care provider usually requests an upright abdomen series to demonstrate free air in the peritoneum. Do not use barium where free air is a possibility. Urea breath testing has been used to detect H. pylori. Patient must be NPO the night before the test. The client drinks a carbon-enriched urea solution. The presence of H.pylori causes the bacteria to break down the solution and release carbon dioxide, which the client exhales in a collection container for analysis. The carbon dioxide excreted in the breath is then measured and compared to a baseline measurement to determine the presence of H. pylori.

Stomach Defense Systems

• Mucous layer • • Coats and lines the stomach • • First line of defense • Bicarbonate • • Neutralizes acid • Prostaglandins • • Hormone-like substances that keep blood vessels dilated for good circulation • • Thought to stimulate mucus and bicarbonate production The gastric mucosal barrier overlies the epithelium. The secretion of mucous and bicarbonate provides a first line of defense in maintaining a near normal pH on the gastric epithelium and protects the mucosal barrier against acid. Gastromucosal prostalglandins increase the barrier's resistance to ulceration. When a break in the mucosal barrier occurs, hydrochloric acid injures the epithelium

Postoperative Care bleeding/ulcer

• NG tube • • care and management • • keep track of out put • Monitor for post-operative complications • Pain Management The postoperative plan of care is similar for all of the gastric operative procedures. These patients will have NG tubes in place and attached to low wall suction. Ensure the patency of these tubes. Irrigation or repositioning of the NG tube is not done after gastric surgery unless specifically ordered by the doctor.

Etiology peptic ulcer

• PUD primarily associated with NSAID use and infection with H. Pylori • Certain drugs may contribute to cause, alter gastric secretion and penetrate the barrier: • • Theophylline - Theo-Dur • • Caffeine - stimulates hydrochloric acid production • • Corticosterioids - associated with an increased incidence of PUD NSAID's break down the mucosal barrier and disrupt the mucosal protection and cause depletion of endogenous prostoglandins. Recent research has shown that most peptic ulcers are caused by Helicobacter Pylori (H. pylori) which is a gram negative bacterium.

Duodenal Ulcers

• Pain occurs 2-3 hours after meals; often awakens client between 1 and 2 am • Pain relieved by ingestion of food • Very little risk for malignancy Most duodenal ulcers occur in the first portion of the duodenum. With this type of ulcer the pain occurs 2-4 hours after meals, pain wakes up the patient, the pain is relieved with the administration of food and there is very little risk for malignancy.

Gastric Ulcers

• Pain occurs 30-60 minutes after meals; at night rarely • Pain is made worse by the ingestion of food • May be malnourished • Risk for malignancy • Deep and penetrating and usually occur on the lesser curvature of the stomach Acid, pepsin, and H. pylori infection play an important role in the development of gastric ulcers. When a break in the mucosal barrier occurs, hydrochloric acid injures the epithelium. Gastric ulcers may then develop. With a gastric ulcer the pain occurs 1-2 hours after meals and does not usually wake the patient from sleep. Food worsens the pain. There is an increased risk for malignancy and these ulcers are deep and penetrating and usually occur on the lesser curvature of the stomach.

Drug Therapy for Peptic Ulcer Disease

• Proton pump inhibitors • • Suppress acid production • • Prilosec, Prevacid, Protonix, Nexium • H2-Receptor Antagonists • • Block histamine-stimulated gastric secretions • • Zantac, Pepcid, Axid • Antacids • • Neutralizes acid and prevents formation of pepsin (Maalox, Mylanta, Amphogel) • • Give 2 hours after meals and at bedtime • Prostaglandin Analogs • • Reduce gastric acid and enhances mucosal resistance to injury • • Cytotec • Mucosal barrier fortifiers • • Forms a protective coat • • • Carafate/Sucralfate • Antimicrobials • • Biaxin, Amoxil, Flagyl Hyposecretory drugs produce a reduction in gastric acid secretions. Your proton pump inhibitors have emerged as the drug class of choice for treating clients with acid-related disorders. These drugs suppress acid production. They include Prilosec ,Previcid, Protonix, and Nexium. Your H2 receptor antagonists block histamine stimulated gastric secretions. Antacids neutralizes acid and prevents formation of pepsin. The prostoglandin analogs reduce gastric acid and enhance mucosal resistance to injury. The drug Carafate acts as a mucosal barrier by forming a protective coating. These drugs are all listed in Chart 59-3 pages 1286-1287. A side effect of antacids is constipation. Instruct your client to take antacids 1-3 hours after meals.

Surgery Management of GI Bleed

• Required under these conditions 1. Perforated and overflowed into the abdomen 2. Scarred or swelled so that there is obstruction 3. Acute bleeding 4. Non-responsive to medications • Intractable ulcers

Peptic Ulcer Disease

• S - 75 yr old admitted with UGI bleed B - COPD, CAD, HTN, PUD A - vs 98.4, 96, 22, 110/70 R - admit to Memorial 6E • What orders do you anticipate receiving? • • Labs • • Meds • • Diet • • Activity • Admission nursing assessment? • What are signs/symptoms of GI bleed? • A partial gastrectomy is scheduled • • What Pre-op care are you expected to give? • • • Teaching • • • Checklist • She returns after a large wedge re-section of stomach. NGT in place to LIS, EBL in OR 120mls • • What do you need in report from the PACU nurse? • • How will you manage the NGT? • She turns on her call light and says "I'm leaking" on examination of the incision you note a dehiscence. • • Next action includes? • • How will you document this?

Peptic Ulcers Defined

• Ulcerated lesion in the mucosa of the stomach or duodenum • Types • • Gastric • • Duodenal Peptic ulcer is a mucosal lesion of the stomach or duodenum. The term peptic ulcer is used to describe both gastric and duodenal ulcers. PUD results when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin.

Types of Surgical Procedures

• Vagotomy • Cuts vagus nerve • Eliminates acid-secretion stimulus A vagotomy eliminates the acid-secreting stimulus to gastric cells and decreases the responsiveness of parietal cells.

Urea Breath Testing

• • • Used to detect H.pylori • • • Client drinks a carbon-enriched urea solution • • • Excreted carbon dioxide is then measured -- has been used to detect H. pylori. Patient must be NPO the night before the test. The client drinks a carbon-enriched urea solution. The presence of H.pylori causes the bacteria to break down the solution and release carbon dioxide, which the client exhales in a collection container for analysis. The carbon dioxide excreted in the breath is then measured and compared to a baseline measurement to determine the presence of H. pylori.

Endoscopic procedure

• • • Visualizes ulcer crater • • • Ability to take tissue biopsy to R/O cancer and diagnose H. pylori

Barium swallow

• • • X-ray that visualizes structures of the upper GI tract -- can be used to establish a duodenal ulcer. If perforation is suspected the health care provider usually requests an upright abdomen series to demonstrate free air in the peritoneum. Do not use barium where free air is a possibility. Description More thorough view of the esophagus Rationale Dysphagia Special Considerations Barium related Fecal impaction Administer ↑ fluid intake Laxative NPO 8-12 hours prior to study Significance of Findings Strictures Stenosis Varices Muscular weakness Tumors

Answer: 4 4. A rigid, board-like abdomen Rationale: Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and boardlike. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. Test-Taking Strategy: Focus on the subject, perforation. Option 2 can be eliminated easily because it is not related to perforation. Eliminate option 1 next because tachycardia rather than bradycardia would develop if perforation occurs. From the remaining options, note the strategic words, most likely, to help direct you to the correct option.

540. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? 1. Bradycardia 2. Numbness in the legs 3. Nausea and vomiting 4. A rigid, board-like abdomen

Answer: 3 3. Pain relieved by food intake Rationale: A frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or "hungry" pain that often localizes in the midepigastric area. The client with duodenal ulcer usually does not experience weight loss or nausea and vomiting. These symptoms are more typical in the client with a gastric ulcer. Test-Taking Strategy: Eliminate options 1 and 2 because they are comparable or alike; if the client is vomiting, weight loss will occur. Next, think about the symptoms of duodenal and gastric ulcer. Choose the correct option over option 4, knowing that the pain does not radiate down the right arm and that a pattern of pain-food-relief occurs with duodenal ulcer.

547. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer? 1. Weight loss 2. Nausea and vomiting 3. Pain relieved by food intake 4. Pain radiating down the right arm

Answer: 1 1. Sweating and pallor Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. Test-Taking Strategy: Note the strategic word, early. Think about the pathophysiology associated with dumping syndrome and its etiology to answer correctly.

553. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? 1. Sweating and pallor 2. Bradycardia and indigestion 3. Double vision and chest pain 4. Abdominal cramping and pain

Answer: B Rationale: The hematocrit reflects acute magnitude of blood loss after a period of 2 to 24 hours depending on bleeding rate; serial hematocrit assessments can follow a patient's course. Other hemodynamic assessments, such as a complete blood count, coagulation tests, and electrolytes (i.e., BUN and creatinine) should also be included to assess fluid volume deficit.

A 67-year-old male is suspected of having a peptic ulcer. The nurse monitors for a decrease in which diagnostic value with GI hemorrhage in this patient? A. Reticulocyte count B. Hematocrit C. Prothrombin time D. IgG antibodies to H. pylori

Answer: C Rationale: Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a gastrectomy. Frequent small meals with solid foods or liquids, not both, are effective in controlling the hyperosmolar problem of dumping syndrome. The nurse should instruct the patient to decrease the amount of fluid taken at meals and to avoid highcarbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowler's position during meals; and to lie down for 30 minutes after eating to delay gastric emptying.

Following a partial gastrectomy for gastric cancer, a patient complains of nausea, abdominal pain and cramping, and diarrhea after eating. Recognizing manifestations of dumping syndrome, what should the nurse recommend? A. Fasting for a period of 6 to 12 hours before meals B. Decreasing the protein content of meals C. Decreasing the amount of fluid taken at meals and avoiding high-carbohydrate foods, including fluids such as fruit nectars D. A diet rich in carbohydrates to maintain blood glucose levels

Gastrointestinal Bleeding

Hypovolemia management • IV solution • Blood replacement • Fresh frozen plasma • Monitor for s/s of GI bleed • Vital signs, hemoglobin and hematocrit, coagulation studies, hidden (occult) blood

Answer: C Rationale: A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options A, B, and D are incorrect descriptions of a vagotomy

Mrs. Taylor is scheduled for a vagotomy and asks the nurse about the purpose of this procedure. Which response by the nurse is most accurate? A. Diminishes stress reactions B. Heals the gastric mucosa C. Reduces the stimulus to acid secretions D. Decreases food absorption in the stomach

Answer: C Rationale: Serious adverse GI effects (e.g., bleeding, ulceration, perforation) can occur at any time in patients receiving NSAID therapy, and such effects may not be preceded by warning signs or symptoms. Only one in five patients who develop a serious upper GI adverse event while receiving NSAID therapy is symptomatic. The enteric nervous system controls peristalsis

The nurse is caring for a 33-year-old woman who has been taking aspirin for back pain and has experienced a sudden episode of tachycardia and feeling faint. She also vomited coffee-ground emesis and passed a tarry stool but has no complaints of pain or heartburn. The patient wants to know why there was no sign of pain as a warning signal prior to the sudden bleeding. What is the nurse's best response? A. Pain is the most common sign of NSAID-induced gastric injury, so the patient must have a high pain tolerance. B. NSAIDs cause damage to epithelial cells, which inhibit the enteric nervous system response of the GI tract. C. NSAID-induced gastric injury often is without symptoms, and life-threatening complications such as GI bleeding can occur without warning. D. NSAIDs have anti-inflammatory and analgesic effects, preventing the patient from feeling any pain as a warning sign.

Answer: C Rationale: Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a patient with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Rabeprazole sodium is a proton pump inhibitor used in treating gastrointestinal disorders such as GERD and duodenal ulcers. Propranolol (Inderal) is a β-adrenergic blocker. Furosemide and propranolol are not contraindicated in patients with gastric disorders.

The nurse is reviewing the medication record regarding Mrs. Taylor's PUD. Which medication, if noted on the patient's record, will the nurse question? A. Rabeprazole sodium (AcipHex) B. Furosemide (Lasix) C. Indomethacin (Indocin) D. Propranolol hydrochloride (Inderal)

Answer: A, C, and D Rationale: In a patient with a duodenal ulcer, pain is usually relieved by eating because food neutralizes the gastric acid. Furthermore, after eating, pancreatic enzymes are secreted into the duodenum in an alkaline solution, which further buffers stomach acid. Pain is also relieved by taking alkali; however, once the stomach is emptied or the alkali's effect has decreased, pain returns. Heartburn, regurgitation, and vomiting are also signs of peptic ulcer disease.

The nurse monitors for which clinical manifestations in the patient diagnosed with a duodenal ulcer? (Select all that apply.) A. Intermittent abdominal pain, which is relieved after eating and taking antacids but becomes worse at night B. Nausea and vomiting C. Right upper quadrant tenderness and is positive for occult blood in stool D. Complaints of heartburn or regurgitation and vomiting E. Bloating and flatulence

Answer: A and C Rationale: There are various treatment regimens for H. pylori eradication and most include the combination of a proton pump inhibitor (PPI) with two antibiotics for 7 to 14 days. H. pylori release a toxin that promotes mucosal inflammation and ulceration, stimulating the release of cytokines and other mediators of inflammation that contribute to mucosal damage. Damage to gastroduodenal mucosa allows for decreased resistance to bacteria, and thus infection from H. pylori bacteria may occur.

The nurse recognizes that the treatment of H. pylori includes which medications? (Select all that apply.) A. PPIs B. Antiemetics C. Antibiotics D. NSAIDs E. Antacids

Answer: B B. Absorption

The process through which nutrients enter the bloodstream through the intestinal wall is called: A. Diffusion B. Absorption C. Mucositis D. Motility