CA 2 Exam 1

Normal Lipase Findings in Adult

0-160 unitls/L

Normal Total Bilirubin

0.3-1 mg/dL

Normal Amonia Levels

10-80 mcg/dL

Normal Amylase Findings in Adult

30-220 units/L

S/Sx peritonitis-

ABD. Pain, muscular rigidity, distention, spasms, fever, tachycardia, fetal position

Ways to Treat Acute Pancreatitis

NG Tube, Cannulation, Antiemetic Agents, Morphine, Catheter is important to monitor daily output

Hemorrhage

Presence of Cullen's sign & Grey-Turner's sign Indicate retroperitoneal hemorrhage Assess for hemorrhage, shock and peritonitis

Which ways do we check for Acute Pancreaitis?

Serum Amylase and Lipase which increase in the blood. Serum Lipase is more for Pancrease, ultrasound and ABG

Clostridium difficile (pg. 963)

Sources: Bacterial infection associated with antibiotic use Onset of symptoms: 4-9 days after starting antibiotics Clinical Manifestations: Range from mild watery diarrhea to severe abd. Pain, fever, leukocytes in stool. Diagnostic Studies: Stool culture Treatment: Fecal microbiota transplant: (proved 91% rate of success) Discontinue antibiotics, Flagyl is most common, Vanco is used if Flagyl ineffective

During the initial postoperative period following bariatric surgery, the nurse recognizes the importance of monitoring obese patients for respiratory insufficiency based on what knowledge?

A. The body stores anesthetics in adipose tissue.

Cullen's sign & Grey-Turner's

Cullens- Ecchymosis around umbilicus Grey-Turners- retroperitoneal hemm

Acute Cholecystitis

Inflammation of the Gallbladder by obstruction of the cystic duct caused by gallstones.

Complications of enteral feedings

Overfeeding, Diarrhea, Aspiration pneumonia, Refeeding Syndrome,

Paralytic ileus-

constant more generalized pain

Large bowel obstructions-

more distention, less vomiting, then if vomiting, might smell like feces

Salivary glands—parotid

parotid, submaxillary, and sublingual—produce saliva.

Diarrhea

passage of at least three loose or liquid stools per day. +

The more distal the ostomy

the more the intestinal contents resemble feces that is eliminated from an intact colon and rectum...also the more odor it produces.

After acute attack

Bulk forming laxatives High fiber diet-diet instruction

A nurse is providing teaching to a parent f a child who has Hirschsprung Disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching?

I'm glad that my child's ostomy is only temporary

Collaborative Care - Nutritional therapy

IV fluids to replace fluids and electrolytes NG tube suction to decompress stomach If hospitalized- may be NPO until diagnosis confirmed Adults-Clear liquids started first 5 to 15 mL fluid every 15 to 20 minutes No extremely hot/cold liquids Warm tea May advance to dry toast, crackers Infants & children- Adequate ORT, SEE WONG'S

Your client is prescribed total parenteral nutrition. Which will you place in the central line?

C. Pharmacy prepared TPN

The nurse is caring for a client following a Billroth II procedure. Which post-op order should the nurse question?

C. Repositioning the NGT

A client is started on continuous tube feedings at 80 mL/hr. The client had 5 diarrhea stools the 1st day of the feeding. Which action should the nurse take?

C. Slow the present tube feeding.

The severely obese patient has elected to have the Roux-en-Y gastric bypass (RYGB) procedure. The nurse will know the patient understands the preoperative teaching when the patient makes which statement?

D. This surgery decreases how much I can eat and how many calories I can absorb.

The nurse is teaching a group of high school students about the prevention of food poisoning. Which comment by the student shows understanding of foodborne illness protection?

D."When they gave me a pink hamburger I sent it back and asked for a new bun and clean plate."

The nurse is preparing to insert a nasogastric (NG) tube into a 68-year-old female patient who is nauseated and vomiting. She has an abdominal mass and suspected small intestinal obstruction. The patient asks the nurse why this procedure is necessary. What response by the nurse is most appropriate?

A."The tube will help to drain the stomach contents and prevent further vomiting."

Collaborative Care- Vomiting

Contents of emesis: Emesis containing partially digested food several hours after a meal is indicative of gastric outlet obstruction or delayed gastric emptying. Color of emesis: Vomitus with a "coffee ground" appearance is related to gastric bleeding, where blood changes to dark brown as a result of its interaction with HCl acid. Bright red blood indicates active bleeding. Time of day: Early-morning vomiting is a frequent occurrence in pregnancy. Emotional stressors with no evident pathologic disorder may elicit vomiting during or immediately after eating.

PeritonitisMedical-Surgical Management

IV Antibiotics NGT, NPO O2 Surgery

A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid?

Oral Rehydration Solution

Appendicitis Clinical Manifestations

Pain- Where? Anorexia & nausea Could have a low grade fever Localized tenderness-rebound tenderness Rovsing's sign S/S peritonitis: Assess for it!

A patient with a history of peptic ulcer disease has presented to the emergency department reporting severe abdominal pain and has a rigid, board-like abdomen that prompts the health care team to suspect a perforated ulcer. What intervention should the nurse anticipate?

Providing IV fluids and inserting a nasogastric (NG) tube

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manisfestations should indicate to the nurse that the child's appendix is perforated?

Sudden decrease in abdominal pain

Gallbladder stores

bile

Mechanical obstructions-

pain comes & goes- peristalsis still intact

The ileocecal valve

prevents reflux of contents from the large intestine.

The nurse is caring for a patient who is 5'6" tall and weighs 186 lb. The nurse has discussed reasonable weight loss goals and a low-calorie diet with the patient. Which statement made by the patient indicates a need for further teaching?

A. I will limit intake to 500 calories a day.

The nurse is conducting discharge teaching for a patient with metastatic lung cancer who was admitted with a bowel impaction. Which instructions would be most helpful to prevent further episodes of constipation?

A. Maintain a high intake of fluid and fiber in the diet.

A client with appendicitis begins to complain of increased pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. What is the appropriate nursing intervention?

A. Notify the health care provider.

Gastric secretions

Chief cells secrete pepsinogen Parietal cells secrete hydrochloric acid (HCl), water, and intrinsic factor Hydrochloric acid makes the gastric juice acidic, which aids in protection against ingested organisms.

Possible Complications of pancreas

Chronic Pancreatitis, Ascites, Inflammation to the lungs, fistula can form bw pancreas and plural of the lungs, Acute renal failure, pancreatic necrosis, fatty necrosis

The client has a body mass index (BMI) of 33. How does the nurse interpret this finding?

D. The client is obese

Nursing Interventions for Acute Pancreatits

Hourly BP, HR and UO is advised

Explain the indications of enteral feedings

Inability to eat due to medical condition (comatose, intubated) Pathologies that cause difficulty swallowing or increase in risks of aspiration (stroke, advanced Parkinsons disease, MS) Inability to maintain adequate oral nutritional intake and need for supplementation due to increased metabolic demands (cancer therapy, burns, sepsis)

Irritable Bowel Syndrome p. 972

Intermittent abdominal pain or discomfort and stool pattern irregularities Psychologic stressors associated with development and exacerbation of IBS Food Intolerances, More Common in Women, GI symptoms Abdominal pain, Diarrhea or constipation, Abdominal distention, Excessive flatulence, Bloating, Urgency Sensation of incomplete evacuation Non-GI symptoms Fatigue Sleep disturbances

A nurse is caring for a 6-month old infant who has a prescription for clear liquids by mouth after a repair of an intussesception. Which of the following fluids should the nurse select for the infant?

Oral Electrolyte Solution

C Diff- precautions

Place Patient on Contact Use soap and Water to wash hands Use gown and gloves in patient room Use special wipes to clean off surfaces in room

What is bilirubin test for

Suspected liver or biliary tract disorder

Differences in IBS, Crohns, Ulcerative Colitis

Symptoms are often the same in both Crohn's disease and ulcerative colitis. Bloody stools are more common with ulcerative colitis. (Think about near rectum) Weight loss is more common in Crohn's disease because inflammation of the small intestine impairs nutrient absorption. (think about small intestine- mouth to anus)

S/Sx of Acute Pancreatitis

Vomiting, Gradual Epigastric Central Pain, Pain radiate to back, Tripod relieve pain, Tachycardia, Jaundice, Fever

Cholelytheasis

formation of gallstones in the cystic duct

Small bowel obstructions-

less distention, more vomiting, bile colored

Minerals-

necessary for building tissues and regulation of body fluids. Electrolytes

Tenesmus

painful and ineffective straining at stool. Sense of incomplete evacuation r/t IBS, inflammatory bowel syndrome, food poisoinin

Too much Amonia can lead to

A coma

When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching?

A. "I will be able to regulate when I have stools."

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding would alert the nurse to notify the HCP immediately?

A. 3 cm increase in abdominal circumference

When preparing a patient for a capsule endoscopy study, what should the nurse do?

A. Ensure the patient understands the required bowel preparation.

Which assessment would be the priority for an infant who had surgery to correct an intussusception and is now at risk for developing a paralytic ileus postoperatively?

B. Auscultation of bowel sounds.

The nurse listens to bowel sounds for 60 seconds and does not hear gurgling. Which action should the nurse take next?

B. Continue to auscultate for bowel sounds.

The care of a newborn with a cleft lip and palate before surgical repair includes

C. providing nonnutritive and nutritive sucking.

Esophageal Achalasia

Dysphagia- difficult swallowing Regurgitation (esp. nocturnal) Substernal chest pain (during/after a meal) Halitosis Inability to belch Weight loss

Psoriasis of the liver can result in

Esophageal varicies

What position is most beneficial for a patient with Ascities?

High Fowlers Position

Which assessment finding indicates objective data obtained during patient admission?

Hypoactive bowel sounds

The client has a prescription for enteral feeding at 20 mL/hour for 8 hours. The formula is available in 8 ounce cans. How many cans of formula will the nurse need to get from supply?

One

During an abdominal assessment, the nurse understands that which assessment technique will be used last?

Palpation

Serum Amylase and Lipase should be monitored to confirm

Pancreatitis

Achalasia - Treatment: Esophageal dilatation

Smooth muscle relaxants before meals Semisoft bland diet and eating slow Drinking with meals Sleeping with head of bed elevated

Increase of Amonia is related to

build up of stool in the body

Xerostomia

decreased saliva (dry mouth) can lead to dysphagia

the parasympathetic (cholinergic) system is mainly

excitatory

Valsalva maneuver

facilitating defecation (heart conditions, brain issues, fresh post-op pt.'s)

Pyrosis

heartburn, burning in epigastric or substernal area

Pyorrhea

recessed gingivae, purulent pockets r/t periodontitis

Hematemesis

vomiting of blood

Vitamins

water soluble: B, C and fat soluble: K, A, D, E

Borborygmi-

waves of loud, gurgling sounds r/t eating (bowel movement)

After discharge instructions for a patient who has had bariatric surgery for treatment of obesity, the nurse determines that additional teaching is needed when the patient says:

"I should drink several glasses of fluids with my meals."

Nursing Management - Acute intervention

NG tube may be used for possible obstruction Zofran 8 mg IVP every 6 hrs PRN N/V Use relaxation techniques Cleanse face/hands with a cool washcloth Provide mouth care between episodes IVF and record I & O Monitor VS

Types of UGI bleeding

Obvious bleeding Hematemesis-Bloody vomitus Appears fresh, bright red blood or "coffee grounds" Melena-Black, tarry stools Caused by digestion of blood in GI tract Black appearance—due to iron Occult bleeding- small amounts of blood in gastric secretions, vomitus, or stools Undetectable by appearance ( only guaiac) Types of upper GI bleeding are presented in Table 42- 20.

When obtaining the nursing history from the mother of an infant with suspected intussusception, which question would be most helpful?

A. What do the stools look like?

At the first visit to the clinic, the female patient with a BMI of 29 kg/m2 tells the nurse that she does not want to become obese. Which question used for assessing weight issues is the most important question for the nurse to ask first?

D. In what ways are you interested in managing your weight differently?

The nurse is planning to teach the client with GERD about substances that will increase the lower esophageal sphincter pressure. Which item should the nurse include?

D. Non fat milk

After undergoing surgical correction of pyloric stenosis, an infant is returned to the room in stable condition. While standing by the crib, the mother says "perhaps if I had brought my baby to the hospital sooner, the surgery could have been avoided". Which would be the nurse's best response?

Do you think that earlier hospitalization could have avoided surgery?

A nurse is caring for an infant who has inadequate motility of part of an intestine resulting in a mechanical obstruction. The nurse should identify this finding as a manisfestation of which of the following disorders?

Hirschsprung's Disease

GASTRITIS

Inflammation of gastric mucosa due to a local irritant with breakdown in gastric mucosal barrier Stomach tissue unprotected from auto digestion by HCl acid and pepsin Many causes Table 42-12 The mucosal barrier normally protects the stomach tissue from the corrosive action of HCl acid and pepsin. When the barrier is broken, HCl acid and pepsin can diffuse back into the mucosa.

Nursing Management - For any post-op GI patient

Prevention of respiratory complications Assessment for bleeding, complications, worsening S/S, change in condition, vital signs, LOC, IV fluids, maintenance of fluid/electrolyte balance Prevention of infection Deep breathing techniques Accurate I/O Pain medication Medications to prevent nausea/vomiting Assessment for return of peristalsis, gradually resume normal diet once peristalsis returns For some patients, the laparoscopic fundoplication is performed as an outpatient procedure. However, patients at risk for complications, including those with prior upper abdominal surgeries and those with co-morbidities (e.g., cardiac disease, obesity), are hospitalized after the procedure.

Escherichia coli 0157:H7 PoisoningFoodborne Illness

Produces a toxin which causes illness Hemorrhage Colitis kidney failure Can be life threatening- esp in infants, children, elderly Bloody diarrhea Cramping, pain 2-8 days Systemic complications, kidney failure, may be fatal (3-5%), other have chronic abnormal kidney function, dialysis, seizures, blindness, paralysis

Which finding is considered normal in the GI system assessment?

Stool soft and brown

malabsorption syndrome,

impaired absorption of nutrients from the GI tract.

sympathetic (adrenergic) system is mainly

inhibitory

Proteins

build muscle, repair tissues (animal, plant sources)

Diverticular Disease - Nursing Management ACUTE ATTACK

Hospitalized if symptoms severe: fever, pain, unable to tolerate fluids, or advanced age NPO- rest bowel, Gastric tube to rest bowel, IV fluid replacement, Antibiotics, Bedrest,Opiods Surgery for ruptured diverticula Observe for S/S worsening pain, distention, infection, peritonitis Therapeutic Interventions: Prevent constipation, high fiber diet, adequate fluids, weight reduction, physical exercise, avoid straining

Possible Causes of Peritonitis to be Fatal

Hypovolemic shock Fluid is shifted from the extracellular fluid compartment into the peritoneal cavity (third spacing) Sepsis Bacteria enter blood stream Paralytic ileus Peristalsis slows or stops Respiratory distress syndrome Pressure against diaphragm

A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings?

Intussusception

Steps to check for Appendicitis

May start with umblical pain then pain to the right lower quadrant McBurneys point (halfway between umbilicus and iliac crest) Pt. prefers to lie still - may flex right leg Rovsing's sign pressure on LLQ pain radiates to RLQ May have temp relief if ruptures Then,

What should we do for Abdominal Trauma?

Monitor VS every 5-15 minutes- ongoing assessment Anticipate complications- Type and cross, etc. Impaled objects- do not remove External bleeding- direct pressure Protruding organs- sterile pressure dressing

Things to look for post-op after a stoma

Normal is rose to brick red- mild edema- small amount of blood oozing because it is so vascular! Pale or dark purple not normal The volume, color, and consistency of the drainage are recorded. Each time the pouch is changed, the condition of the skin is observed for irritation. A pouch should never be placed directly on irritated skin without the use of a skin barrier.

ORAL DISORDERS p 928

Stomatitis- inflammation of the mouth- many causes (trauma, pathogens, irritants like tobacco and alcohol, side effect of cancer treatment, renal disease, etc.). Topical meds and treat the cause. Herpes Cold Sores- caused by virus and will lay dormant until times or stress, sunlight, menstruation. Painful vesicles that need antiviral med. Oral candidiasis- Thrush- can be cause by antibiotic therapy- white lesions on nucosa of mouth. Take anti-fungal. Oral cancer could be found by dentist, scraping of suspicious lesion and view under microscope. Also can perform dye tests that only cancer cells will absorb blue dye. Will then do MRI to stage the oral cancer. Treatment is radiation, chemo, and surgery- usually a combo.

IBS is NOT

inflammation (no bloody explosive diarrhea) but more of an intestinal motility problem!

Fats

major source of energy

Barrets Esophagus

normal tissue lining the esophagus -- the tube that carries food from the mouth to the stomach -- changes to tissue that resembles the lining of the intestine.

tube feeding

-enteral nutrition, nutritionally balanced liquefied food or formula.

Steatorrhea

-fatty, frothy, foul-smelling stool r/t chronic pancreatitis, malabsorption (cystic fibrosis)

Hepatocytes

-hepatic cells r/t liver

Carbohydrates

-primary source of energy (simple: soda, sugar, white bread, complex: sweet potatoes, oatmeal)

parenteral nutrition

-refers to the administration of nutrients by a route other than the GI tract

Cheilosis

-softening, fissuring, and cracking of lips at angles of mouth r/t decreased B2 (riboflavin)

enteral nutrition

-through the mouth, tube feeding to the stomach, provided by tube, catheter, or stoma

A nurse is caring or a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?

Administer sodium biphosphate/sodium phosphate

Perforation

When ulcer penetrates mucosa with spillage of contents into peritoneal cavity Large perforations: Immediate surgical closure Clinical manifestations Sudden, dramatic onset Severe upper abdominal pain spreads throughout abdomen. Tachycardia, weak pulse Rigid, board-like abdominal muscles

After the nurse teaches a patient with gastroesophageal reflux disease (GERD) about recommended dietary modifications, which statement by the patient indicates that the teaching has been effective?

"I will have to use herbal teas instead of caffeinated drinks."

Deglutition

-(swallowing) mechanical component of ingestion

malnutrition

-a deficit, excess, or imbalance of essential nutrients

Endoscopy

-direct visualization of a body structure through a lighted fiberoptic instrument.

Diagnostic testing is planned for a patient with a suspected peptic ulcer. The nurse explains to the patient that the most reliable test for determining the presence and location of an ulcer is a(n):

1. Endoscopy

A patient is scheduled to receive "Colace 100 mg PO." The patient asks to take the medication in liquid form, and the nurse obtains an order for the interchange. Available is a syrup that contains 150 mg/15 mL. Calculate how many milliliters the nurse should administer. _______________ mL

10

The malnourished client's serum albumin level is 4.0 g/dL, and prealbumin is 10 mg/dL. What should this indicate to the nurse?

Although the serum albumin level is normal, the prealbumin level more accurately reflects the patient's nutritional status.

Lifestyle modifications & Nutritional therapy

Avoid triggers Stop smoking HOB elevated- at least 30 degrees Decrease high-fat foods Take fluids between rather than with meals Small frequent meals Avoid late-night snacking Weight reduction Most patients with GERD can successfully manage this condition through lifestyle modifications and drug therapy. These long-term approaches require patient teaching and compliance with therapies. With regard to triggers, give particular attention to diet and drugs that may affect the LES, acid secretion, or gastric emptying. Avoid chocolate, peppermint, caffeine, tomato products, orange juice

The nurse is caring for a patient treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice does the nurse understand would be most appropriate?

B. Dry toast

When assessing a 4 month old diagnosed with possible intussusception, the nurse would expect the mother to relate which statement about the infant's crying and episodes of pain?

B. Intermittent with knees drawn to the chest.

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment?

C. Absent bowel sounds

Which clinical manifestations of inflammatory bowel disease are common to both patients with ulcerative colitis (UC) and Crohn's disease (select all that apply)?

C. Bloody, diarrhea stools D. Cramping abdominal pain

A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solution (ORS). The child's mother calls the clinic nurse because the child is also occasionally vomiting. What should the nurse recommend?

C. Continue to give ORS frequently in small amounts.

The nurse is providing discharge instructions to a client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome?

C. Limit the fluids taken with meals

Enteral feeding via NGT for the first time: Which is priority intervention before administering?

C. Obtain an x-ray of the chest and abdomen

Which assessment should the nurse prioritize in the care of a patient who has recently begun receiving parenteral nutrition?

Electrolyte levels and daily weights

PEPTIC ULCER DISEASE

Erosion of mucous membrane lining esophagus, stomach, duodenum (Table 42-18) May erode underlying muscle tissue May be acute or chronic Develops only in acid environment Excess of gastric acid not necessary H. pylori is the cause of 80% of gastric ulcers and 90% duodenal ulcers Medication induced- ASA, NSAIDS Stress, trauma Any portion of the GI tract that comes into contact with gastric secretions is susceptible to ulcer development. Acute versus chronic Depends on degree/duration of mucosal involvement

Collaborative Care - Drug Therapy

Examples Serotonin Antagonists Ondansetron (Zofran) Antihistamines Dimenhydrinate (Dramamine) Meclizine (Antivert) Hydroxyzine (Vistaril) Phenothiazines Prochlorperazine (Compazine) Chlorpromazine (Thorazine) Promethazine (Phenergan)

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should recognize that which of the following finding's are associated with this condition?

Vomiting, Weight Loss, Wheezing

During physical assessment of a 4 year old with Hirschsprung's disease, the nurse would most likely note which finding?

Weight less than expected for height and age

When developing the plan of care for an infant with pyloric stenosis, the nurse identifies a nursing diagnosis of Deficient Fluid Volume r/t prolonged vomiting. Which parameter would the nurse expect to use when evaluating the client outcome?

Weight loss

Postoperative Care of Ostomies

Assessment of the stoma (Table 43-27) Color Edema Bleeding What does a healthy appearing stoma look like? Provision of an appropriate pouching system Skin barrier Drainage collection-one piece or two piece Size of stoma-use a measuring card Fit snugly

S/Sx of Acute Cholecystitis

Fever, N/V, RUQ Pain, pain radiating to rt side, positive Murphy sign (to check for pancreatic tenderness)

Inflammatory Bowel Disease S/Sx

Age of onset Abdominal Cramping Diarrhea Perforation

Clinical Manifestations of bowel obstructions

S/S dependent upon where obstruction is located, and to what degree the bowel is obstructed N/V Abdominal pain and distention Alteration in passage of feces, intestinal fluids Proximal obstructions usually exhibit with bile colored emesis Distal obstructions usually exhibit less vomiting, but may progress to fecal smelling

The most important function of the large intestine is

absorption of water and electrolytes. also forms feces and serves as a reservoir for the fecal mass until defecation occurs.

What does "GET SMASHED" Stand for?

Gallstones, Ethanol, Trauma, Steroids, Mumps Virus, Autoimmune, Scorpian Venom, Hyperkalemia, Hyperlipademia, ERCP (Investigation Method), Drugs