HESI: Mr. Lewin

You discuss the upper GI endoscopy procedure with Mr. Lewin. Which description is the most accurate? - "Secretions will be removed from your NG tube at various times and then analyzed for the amount of acid." - "A tube will be passed through your mouth and advanced into your stomach and upper intestines." - "You will drink a white liquid, after which x-rays will be taken." - "You will be given a dye by vein, after which x-rays will be taken."

- "A tube will be passed through your mouth and advanced into your stomach and upper intestines." This description of an upper GI endoscopy is correct. An upper GI endoscopy (esophagogastroduodenoscopy) permits direct visualization of the esophagus, stomach, and duodenum, using a flexible fiberoptic scope, advanced from the mouth to the intestines. Mr. Lewin's endoscopy procedure may also involve treatment of any ulcer(s) identified.

Which nursing actions are appropriate for Mr. Lewin after his return from the endoscopy? Select all that apply (there are 2 correct answers). - Assessing vital signs - Offering fluids by mouth - Assessing for abdominal pain

- Assessing vital signs Assessing vital signs is important. Vital signs assessment is indicated after any invasive procedure to evaluate client tolerance of the procedure and also to detect signs of complications. GI tract perforation with significant bleeding would result in clinical signs of tachycardia, tachypnea, and hypotension. Mr. Lewin may have lingering sedative effects that might be reflected in decreased pulse and respiratory rates. - Assessing for abdominal pain After upper GI endoscopy, assessing for abdominal or chest pain is important. Abdominal/chest pain may occur with perforation of the GI tract. GI tract perforation can occur as a complication of endoscopy. This complication would also cause onset of significant bloody drainage from Mr. Lewin's NG tube.

Mr. Lewin is advised to watch for GI bleeding. Which sign could indicate a bleeding ulcer, and should be reported? Select all that apply (there are 2 correct answers). - Black bowel movement - Vomiting dark brown or bloody fluid - Blood in the urine - Blood in sputum

- Black bowel movement Melena, black tarry stools, is a result of digested blood from upper GI bleeding. Melena should be reported. Bright red blood is present in stools when there is lower GI tract bleeding. - Vomiting dark brown or bloody fluid Hematemesis, bloody vomit, may occur with bleeding ulcers. It is more common with gastric ulcers than with duodenal ulcers. Bloody vomit should be reported.

Mr. Lewin tells you that he has had stomach discomfort on and off for years. Recently, he has become more aware of the discomfort. You ask Mr. Lewin to describe his pain in more detail. Which symptom is consistent with peptic ulcer disease? - Burning epigastric pain - Heavy substernal pain - Dull suprapubic pain - Sharp pain in the lower right quadrant of the abdomen

- Burning epigastric pain Burning pain over the stomach region is common with peptic ulcer disease. Pain may also be described as gnawing, aching, or fullness. The pain associated with duodenal ulcers generally occurs 2-4 hours after meals, and is usually relieved with food or antacids. The pain of gastric ulcers is unpredictable, may be associated with intake of food, and relief with antacids is less likely. Mr. Lewin says his discomfort usually occurs after meals. Occasionally, he takes an antacid at night for nighttime "indigestion."

Mr. Lewin is predisposed to dumping syndrome as a result of his surgery. Which of the following characterizes dumping syndrome? - Dizziness after eating - Bradycardia after eating - Constipation - Flushing after eating

- Dizziness after eating Dumping syndrome occurs after gastrectomy secondary to rapid "dumping" of hypertonic foods and fluids into the jejunum. Fluid subsequently shifts from the intravascular compartment into the lumen of the intestines. This causes release of hormones and vasoactive intestinal polypeptides. As a result, the client experiences vasomotor signs and symptoms such as palpitations, tachycardia, pallor, lightheadedness, and diaphoresis within 30 minutes of eating (early dumping syndrome). Additionally, there is a sudden increase in blood glucose which precipitates a sudden insulin release. This can result in an acute hypoglycemic reaction 2-3 hours later (late dumping syndrome). Hypoglycemia associated with dumping syndrome can cause dizziness, weakness, diaphoresis, pallor, confusion, and fainting.

You prepare Mr. Lewin for the upper GI endoscopy procedure. Pre-procedure preparation involves which actions by the nurse? Select all that apply (there are 5 correct answers). - Insuring that NPO status is maintained - Advising Mr. Lewin that a sedative will be administered - Removing hair from Mr. Lewin's abdomen - Obtaining written consent - Removing any dentures - Advising Mr. Lewin that a local anesthetic will be sprayed into his throat

- Insuring that NPO status is maintained During upper GI endoscopy, a lighted tube is passed through the oropharynx to view the esophagus, stomach, and duodenum. A client must be NPO for upper GI endoscopy. An empty stomach allows for clear visualization of the GI mucosa. Because of Mr. Lewin's recent GI bleed, gastric lavage will likely be done immediately before the procedure to facilitate visualization. - Advising Mr. Lewin that a sedative will be administered Sedation with lorazepam or midazolam is common with upper GI endoscopy. Although not usually painful, the procedure is uncomfortable and anxiety-producing. - Obtaining written consent Upper GI endoscopy is an invasive procedure requiring written informed consent. Mr. Lewin must be informed of risks associated with the procedure. Risks include the possibility of GI tract (esophagus, stomach, intestine) perforation, which would require surgical correction. - Removing any dentures If the client wears dentures, they must be removed to prevent damage to them during the procedure, and also to prevent airway obstruction which could occur if they became loose. - Advising Mr. Lewin that a local anesthetic will be sprayed into his throat A local anesthetic is usually sprayed into the client's oropharynx when upper GI endoscopy is performed. This eliminates the gag and swallowing reflexes, making passage of the endoscope easier.

Which intervention regarding Mr. Lewin's NG tube should be included in his care plan? - Keep vent (pigtail) lumen of NG tube positioned above the client's waist - Irrigate NG tube as often as necessary to keep it patent - Report bloody drainage from NG tube - If drainage is noted from vent (pigtail) lumen of NG tube, clamp it

- Keep vent (pigtail) lumen of NG tube positioned above the client's waist Keeping the pigtail port of Mr. Lewin's NG tube positioned above his waist will prevent gravity drainage of gastric contents through the port.

Your discharge plan for Mr. Lewin includes suggestions for preventing symptoms associated with dumping syndrome. What suggestion helps prevent symptoms of dumping syndrome? - Drink large amounts of fluids with meals - Lie down for 20-30 minutes after meals - Eat three large meals each day

- Lie down for 20-30 minutes after meals Lying down after meals often helps to prevent rapid stomach emptying, which causes the symptoms associated with dumping syndrome. In addition, limiting fluid intake with meals and eating small frequent low-carbohydrate meals are recommended. Complex carbohydrates are recommended over simple carbohydrates, which are quickly metabolized.

Mr. Lewin's lab results have become available. Red blood count (RBC), hematocrit (Hct) and hemoglobin (Hgb) are low, but within acceptable ranges, and a transfusion of PRNCs is not indicated at this time. Initially, after an episode of significant bleeding, hematocrit (Hct) results may be misleading. This is because significant bleeding causes hypovolemia and hemoconcentration. Hct, which is the percentage of blood comprised of red cells, may subsequently be high. With crystalloid fluid replacement, and physiological compensatory mechanisms that draw water into the vascular compartment, Hct will be decreased later, although the amount of red blood cells may be the same. Therefore, when bleeding has occurred, hematocrit (Hct) levels should be evaluated carefully, with consideration given to fluid replacement received by the client, and clinical evidence of the amount of blood loss. Clinical symptoms exhibited by the client are very important. If Mr. Lewin has GI bleeding prior to endoscopy, gastric lavage may be needed. Which of the following should be available for gastric lavage? - Iced saline - Room-temperature saline

- Room-temperature saline Room-temperature saline is recommended for gastric lavage when GI bleeding is present. When upper GI bleeding is present, gastric lavage is done to clear the stomach of excess blood and clots. Iced saline is not recommended for gastric lavage when GI bleeding is present. It can lower core body temperature and lead to hypothermia. It can also stimulate production of hydrochloric acid and prolong bleeding time.

Which suggestions do you include in your discharge plan for Mr. Lewin to prevent exacerbation of ulcer symptoms? Select all that apply (there are 3 correct answers). - Eat a diet rich in milk and cream - Start a smoking cessation program - Switch from caffeinated to decaffeinated coffee - Avoid aspirin - Avoid nonsteroidal antiinflammatory drugs (NSAIDs)

- Start a smoking cessation program Smoking increases risk for peptic ulcers and delays ulcer healing. Smoking cessation is encouraged. - Avoid aspirin Salicylates such as aspirin are irritating to GI tract mucosa and are a known cause of peptic ulcer formation. They should be avoided. - Avoid nonsteroidal antiinflammatory drugs (NSAIDs) Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen, are irritating to GI tract mucosa, are a known cause of peptic ulcer formation, and should be avoided. Acetaminophen is an alternative over-the-counter pain reliever.

Mr. Lewin has a Billroth II procedure, with general anesthesia. Which assessment should you perform first, after transferring Mr. Lewin from the OR stretcher to his bed? - Bowel sounds - Vital signs - PERRLA - Calf tenderness

- Vital signs Life-threatening complications such as hemorrhage, perforation, and peritonitis can occur suddenly. These can be detected early with ongoing vital signs assessments.

Mr. Lewin also recognizes the need to use acetaminophen for minor pain relief, rather than aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen. Despite treatment and attention to his diet, Mr. Lewin could still experience complications of peptic ulcer disease. What are the complications of peptic ulcer disease? Select all that apply (there are 3 correct answers). - bleeding from the ulcers - ulcer perforation through the GI tract wall - gastric outlet obstruction - small bowel cancer

- bleeding from the ulcers Despite treatment, Mr. Lewin's ulcers may not heal and may still bleed. - ulcer perforation through the GI tract wall Despite treatment, Mr. Lewin's ulcers may not heal. Deep ulcers can perforate through the wall of the GI tract, releasing stomach/intestinal contents into the peritoneal cavity. Perforation is accompanied by severe chest or abdominal pain and shock. - gastric outlet obstruction Peptic ulcers can cause edema and/or scarring near the pyloric sphincter. Passage of gastric contents can be obstructed. Vomiting may occur as a symptom.

What are major causes of peptic ulcer disease that are recognized in the current literature? Select all that apply (there are 3 correct answers). - chronic H. pylori infection - Use of nonsteroidal antiinflammatory drugs (NSAIDs) - dietary factors - emotional stress - smoking

- chronic H. pylori infection Helicobacter pylori (H. pylori) is a bacterium. It is a cause for the majority of peptic ulcers that are not associated with use of nonsteroidal antiinflammatory drugs (NSAIDs). - Use of nonsteroidal antiinflammatory drugs (NSAIDs) Long-term use of nonsteroidal antiinflammatory drugs (NSAIDs) is associated with an increased risk for developing peptic ulcer disease. - smoking Smoking increases risk for peptic ulcer disease.

You read the healthcare provider's (HCP) admission note, which describes Mr. Lewin as complaining of "pyrosis." The layman's term for this symptom is: - belching - heartburn - vomiting - hiccoughs

- heartburn Pyrosis, commonly referred to as heartburn or indigestion, generally occurs with peptic ulcer disease. It is characterized as a burning sensation in the epigastric or substernal region, secondary to the presence of acid in the esophagus, stomach, or duodenum.

Clarithromycin and amoxicillin are antibiotics, prescribed to eliminate H. pylori. Omeprazole is prescribed to: - neutralize gastric acid - inhibit gastric acid secretion - increase the production of gastric mucous - decrease the production of nasal mucous - coat the stomach mucosa

- inhibit gastric acid secretion Omeprazole is a proton pump inhibitor. Proton pump inhibitors block the final step in gastric acid production. They are more effective than H2-receptor antagonists in suppressing gastric acid secretion. Other proton pump inhibitors include lansoprazole and pantoprazole. These drugs should be taken on an empty stomach. Headache, abdominal pain, and diarrhea may occur as side effects.

Mr. Lewin's nasogastric (NG) tube is a vented (double lumen) type, attached to suction. The tube does not have an anti-reflux valve. You notice that gastric contents are leaking from the air vent (pigtail) port. What should you do initially? - notify the HCP - instill air into the air vent - tie off the air vent outlet

- instill air into the air vent With vented NG tubes, the air vent allows entry of air to decrease the effect of suction pressure on the stomach lining. The air vent needs to remain free of fluid. It is appropriate to instill air or saline (generally a volume of about 10 mL) into the air vent lumen, to clear it of fluid. Positioning the air vent above the level of the client's stomach may be helpful in preventing future occurrences of leaking. Tying off the air vent outlet is not indicated. This would defeat the purpose of the air vent.

How will the patient-controlled analgesia (PCA) contribute to Mr. Lewin's comfort? Select all that apply (there are 2 correct answers). - keep him sedated so that he will experience less pain - provide a consistent level of pain relief - allow him to administer his own pain medication - provide pain relief without the use of narcotics

- provide a consistent level of pain relief Patient-controlled analgesia (PCA) is designed to provide a consistent level of pain control by maintaining a constant blood level of the administered analgesic. With PCA, the peaks (high drug levels) and troughs (low drug levels) that occur when high dosages of the drug are administered every few hours are avoided. The use of PCA may prevent some postoperative complications because earlier and easier ambulation occurs as a result of effective pain relief. - allow him to administer his own pain medication With patient-controlled analgesia (PCA), Mr. Lewin will be able to self-administer doses of pain medication.

An IV infusion of pantoprazole IV is prescribed for Mr. Lewin. He asks you why he has to take this medication. What is the correct response to give the client for the use of pantoprozole IV? - neutralize stomach acid - suppress gastric acid secretion - create a protective barrier over any ulcerations - destroy bacteria in the stomach

- suppress gastric acid secretion Pantoprazole IV is a proton pump inhibitor. Proton pump inhibitors block gastric acid secretion. When an ulcer is present and a bleeding episode has occurred, IV administration of proton pump inhibitors can help to prevent additional bleeding.

You validate Mr. Lewin's understanding of his upcoming surgical procedure (selective vagotomy and antrectomy with Billroth II anastamosis) when he tells you that the procedure involves: Select all that apply (there are 2 correct answers). - surgical cutting of the vagus nerve - surgical enlargement of the pyloric sphincter - removal of the entire stomach - removal of part of the stomach

- surgical cutting of the vagus nerve A selective vagotomy involves interruption of some of the fibers of the vagus nerve. This disrupts nerve transmission to the anthrum, which results in decreased gastric acid production. Innervation to the pylorus is maintained, which preserves its motility. - removal of part of the stomach Antrectomy (also called a partial gastrectomy) involves removal of the distal segment of the stomach and antrum, which are responsible for the gastric phase of secretion; this procedure also promotes gastric emptying. The Billroth II procedure reanastamoses the remaining portion of the stomach to the jejunum, and the duodenal stump is closed.

You correctly advise Mr. Lewin that he can self-administer pain medication every___________ minutes.

10