Unit 10 - Final Chapters - Notes
Grey-Turner's Sign
-Abdominal trauma -Blusish discoloration of the flanks -Retroperitoneal hematoma or Hemorrhagic pancreatitis
Kehr's Sign
-Abdominal trauma -Referred pain to right shoulder, irritation of the diaphragm -Splenic injury, Free air, Intra-abdominal bleeding
Lactulose
-Treats portal hypertension -Flushes out ammonia build up -Side effects: belching, flatulence, n/v, diarrhea
A client is in the emergency department with an esophageal trauma. The nurse palpates subcutaneous emphysema in the mediastinal area and up into the lower part of the client's neck. What action by the nurse takes priority?
Assess the client's oxygenation.
A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)?
Assist the client to void before the procedure.
A nurse is teaching clients with gastroesophageal reflux disease (GERD) about FOODS TO AVOID. Which foods should the nurse include in the teaching? (Select all that apply.)
Chocolate Citrus fruits Peppermint Tomato sauce
A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see first?
Client who had an esophagectomy with a respiratory rate of 32/min
A nurse teaches a client with Cushing's disease. Which dietary requirements should the nurse include in this client's teaching? (Select all that apply.)
Low carbohydrate Low calories Low sodium
A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client's plan of care to reduce discomfort?
Maintain nothing by mouth (NPO) and administer intravenous fluids.
A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect?
Mid-sternal chest pain
A client is admitted to the ED in severe pain with a gunshot wound to the right upper abdomen. Admitting vital signs are BP 118/70, O2 Sat 94%. What is the nurse's priority when monitoring this client?
Monitor vital signs frequently.
A nurse assesses a client with Cushing's disease. Which assessment findings should the nurse correlate with this disorder? (Select all that apply.)
Moon face Petechiae Muscle atrophy Weight gain Hypertension
The nurse closely monitors the client with acute pancreatitis for which complication?
Pneumonia
S/S of DKA
Polyuria, Polydipsia, Dehydration, Tachycardia, N/V, Combative, Confused, Coma *Fruity breath (acetone), Kussmaul breathing (very deep and rapid causing respiratory alkalosis)
A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.)
Urine output is increased Specific gravity is decreased Urine osmolality is decreased *Diabetes insipidus causes urine output to be greatly increased, with a low urine osmolality, as evidenced by a low specific gravity. Effective treatment results in decreased urine output that is more concentrated, as evidenced by an increased specific gravity.
A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.)
Registered dietitian Clinical pharmacist Health care provider
A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L. Which action should the nurse take first?
Restrict the client's fluid intake to 600 mL/day.
A nurse plans care for a client with Cushing's disease. Which action should the nurse include in this client's plan of care to prevent injury?
Use a lift sheet to change the client's position.
A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge?
"Do you have a one- or two-story home?"
A nurse cares for a client with acute pancreatitis. The client states, "I am hungry." How should the nurse reply?
"Have you passed any flatus or moved your bowels?"
A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.)
"How frequently do you drink alcohol?" "Have you ever had sex with a man?" "Were you previously incarcerated?"
Somogyi Phenomenon
*Morning hyperglycemia from response to nighttime hypoglycemia -Ensure adequate dietary intake at bedtime -Evaluate insulin dose -Exercise programs that prevent conditions leading to hypoglycemia -Blood glucose monitoring at night -Patient education
A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client?
pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg
A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.)
"Apply lotion to the client's dry skin areas." "For the client's oral care, use a soft toothbrush." "Provide clippers so the client can trim the fingernails."
A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client's teaching? (Select all that apply.)
"Attend local Alcoholics Anonymous (AA) meetings weekly." "Use cooking spray when you cook rather than margarine or butter." "We can talk to your doctor about a prescription for nicotine patches."
A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, "I do not want to take this medication because it causes diarrhea." How should the nurse respond?
"Diarrhea is expected; that's how your body gets rid of ammonia."
The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What statements by the client indicate good understanding of the teaching? (Select all that apply.)
"I just joined a gym, so I hope that helps me lose weight." "I sure hate to give up my coffee, but I guess I have to." "I will eat three small meals and three small snacks a day." "Sitting upright and not lying down after meals will help."
After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
"I need to avoid protein in my diet."
A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, "All of my family hates me." How should the nurse respond?
"I will help you identify a support system."
A nurse teaches a client with a cortisol deficiency who is prescribed prednisone (Deltasone). Which statement should the nurse include in this client's instructions?
"If you work outside in the heat, you may need another drug."
After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why this medication is given since there is no history of ulcers. What response by the nurse is best?
"It prevents stress-related ulcers."
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.)
"Make sure the client receives a protein shake." "Do not allow caffeine-containing beverages." "Make sure the foods are bland with little spice."
A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The client's symptoms have now resolved and the client asks, "When can I stop taking these medications?" How should the nurse respond?
"Once you start corticosteroids, you have to be weaned off them."
A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client?
"Read the label before using salt substitutes."' *Spironolactone is a potassium-sparing diuretic used to control potassium levels. Its use can lead to hyperkalemia. Although the goal is to increase the client's potassium, unknowingly adding potassium can cause complications. Some salt substitutes are composed of potassium chloride and should be avoided by clients on spironolactone therapy.
A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by the nurse is best?
"Slippery elm is often used for this disorder."
After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
"The best time to take the enzymes is immediately after I have a meal or a snack." *The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.
A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." How should the nurse respond?
"You feel this way because of your hormone levels."
Abdominal Trauma
-Can be blunt (car accidents, sports) or penetrating (gunshot, stabbing) *ABCs - airway, breathing, circulation (hemorrhage, shock, peritonitis) -Ecchymosis may indicate internal bleeding or if bruising is seen under seatbelt to should be reported immediately because bowel or other organs may be damaged ER CARE: -2 large-bore IVs -Type and cross patient -Continuous hemodynamic monitoring -Foley -If there's an open wound cover it with sterile dry dressing until HCP says otherwise -NG tube if no head/skull trauma -Antibiotics S/S: ecchymosis, grey-turner's sign, kehr's sign
Esophageal Varices
-Caused by portal hypertension, chronic alcohol abuse, ingestion of caustic agents TX: -Volume resuscitation -IV octreotide -Antibiotics -Endoscopic therapy -Recurrent or uncontrolled bleeding, consider balloon tamponade (sengstaken-blakemore tube or TIPS shunt)
Barret's Metaplasia
-Complication of esophageal reflux -Cancer
Diabetes Insipidus
-Decreased ADH *POLYURIA, increased thrist, dilute low specific gravity -Fluid volume deficit, Dry/dehydrated, Sunken eyes *Low BP, HYPERNATREMIA TX: Desmopressin
Treatment of DKA
-Dehydration: Give 2L IVF (crystalloids) first 2 hrs -Potassium: if K <3.5 give K, hold insulin/ if K 3.5-5.3 give K, give insulin/ if K >5.4 start insulin -Anion Gap: Regular insulin until AG closed -Address Trigger: Infection, Not enough insulin, Forgot to take insulin, Ischemia, Pregnant, Intoxication
Gastrectomy
-Gastric cancer = total gastrectomy (most find the cancer too late and the surgery is done palliatively) -PREOP: NG tube, TPN, informed consent -OPERATIVE: remove part or all the stomach and resection is done -POSTOP: Prevent atelectasis, paralyitc ileus, wound infection, peritonitis Ascultate lungs and listen for bowel sounds Early ambulation Check operative site Q8H HOB elevated to prevent reflux NG tube (check patency to ensure draining)
Esophageal Diverticulum
-Herniation of esophageal mucosa into surrounding tissue -Older patients S/S: dysphagia, regurgitation, nocturnal cough, halitosis -Avoid laying down for at least 2hrs after eating -Semisoft foods and smaller meals -Sleep with HOB elevated -Avoid restrictive clothing and vigorous exercising after meals -Surigcal postop NPO for several days to promote healing
Concept Map Cirrhosis (page 1198)
-History: Chronic Alcoholism -S/S: hematemesis, melena, lightheaded, dizzy, BP 100/60, HR 116, T 100.8F, O2 92%, Ascites present -Patient Problems: Excess Fluid Volume, Potential for Hemorrhage - Pain, F/E Imbalance, Infection, Inflammation 1. Evaluate the effects of chronic inflammation and necrosis resulting from cirrhosis (assess for jaundice, edema, ecchymosis, rashes, listen to bowel sounds, look for abdominal distention) 2. Prevent hemorrhage and death (monitor for complications) 3. Proteins provide some protection against bacteria and antibiotics if ordered to prevent infection (low grade fever, loss of appetite, pain, mental change s/s infection) 4. Monitor BUN, serum protein, H&H, platelets, and electrolytes 5. Drug Therapy: Antibiotics, Propranolol, Vasoconstrictors-octreotide (prevents or controls bleeding or infection with esophageal varices) - Thiamine for alcohol withdrawal 6. Daily weights, I&Os (pt. may be dehydrated, hypokalemic, hypernatremic) 7. Sodium Restriction (controls fluid excess) 8. Decrease Activity (to decrease pressure put on varices or abdominal distention strain) 9. Priority: PREVENTING INFECTION, protect skin integrity 10. Monitor for decreased LOC if patient is bleeding or has hepatic encephalopathy because this indicates decreased oxygenation to the brain
SIADH
-Increased ADH *HYPONATREMIA, decreased urine output, High BP -Fluid volume excess, Edema TX: Fluid restriction, Conivaptan (IV) or Tolvaptan (PO) to promote water excretion w/o losing sodium (these two drugs only given in hospital, closely monitor sodium levels)
Hiatal Hernia
-Increases intra-abdominal pressure -Complications include: volvulus (twisting of a GI structure), obstruction, GERD S/S: heartburn, belching, chest pain, dysphagia, fullness or breathlessness after eating, worsening when in recumbent position (feel worse lying down, so elevate HOB) -Management is aimed towards controlling reflux and treating the symptoms.
Most Common Precipitating Factors to DKA
-Infection (pneumonia, UTIs, sepsis) -Inadequate insulin treatment (noncompliance, insulin pump failure) -Myocardial infarction -Acute pancreatitis -Alcohol abuse -Severe burns
Gastroesophageal Reflux Disease (GERD)
-Most common upper GI disorder -Most common cause is excessive relaxation of the lower esophageal sphincter -Risk factors: obese, smoking MANAGEMENT: food makes it worse (eat smaller meals more often), antacids, HOB >30 degrees, prevent strictures -more on page 1113 in textbook
Common Complications of Cirrhosis
-Portal Hypertension: Increased pressure within the portal vein greater than 5, Causes back flow into spleen leading to splenomegaly -Ascites and Esophageal Varices: Collection of fluid in peritoneal cavity from portal hypertension, Hypovolemia and edema, Sodium and water retention, Results in esophageal varices, Bleeding esophageal varices is life-threatening -Coagulation Defects: Prolonged prothrombin time -Jaundice: Yellowish coloration of the skin from obstruction, Elevated bilirubin levels, Pruritis -Portal-systemic Encephalopathy with Hepatic Coma: Mental status changes, May be reversible is caught early, Elevated serum ammonia and GABA -Hepatorenal Syndrome: Poor prognosis and often the cause of death in these patients, Sudden decrease in urinary flow, Elevated BUN and creatinin, Decreased sodium excretion, Increased urine osmolarity
Acute Pancreatitis
-Risk Factors: Gallstones, Alcohol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bite, Hyperlipidemia, Drugs S/S: Pain (continuous, burning), Tenderness, Ascites, Left UQ Mass, Diminished breath sounds, Dyspnea, Clay-solored stools, Weight loss, Jaundice, Dark urine, Diabetes (polyuria, polydipsia, polyphagia) *Lipase, Lipolytic Process - lipase elevated, leukocytosis, fever MANAGEMENT: -IV fluid resuscitation -Correct electrolytes -Foley -Analgesics -NPO/clear fluid diet -Antibiotics
Esophageal Rupture
-Risk Factors: age 50-70yrs, bulimia, hx of vomiting -Management: Chest xray to rule out mediastinitis (most common complication), Broad spectrum antibiotics, Surgical consultation MACKLER'S TRIAD: -Lower chest pain -Vomiting -Subcutaneous emphysema *Assess for airway patency, breathing, chest pain, dysphagia, vomiting, and bleeding as priorities -NPO, Suctioning, TPN nutrition therapy, Antibiotics prophylactically, High-dose corticosteroids to prevent strictures and decrease inflammation, Lidocaine -Surgical resection and G-tube may be needed
A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B?
A 20-year-old college student who has had several sexual partners
A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for adrenal insufficiency? (Select all that apply.)
A 22-year-old female with metastatic cancer A 43-year-old male with tuberculosis A 65-year-old male with gram-negative sepsis
The student nurse learns about risk factors for gastric cancer. Which factors does this include? (Select all that apply.)
Achlorhydria Chronic atrophic gastritis Helicobacter pylori infection Pernicious anemia
A client who had a partial gastrectomy has several expected nutritional problems. What actions by the nurse are best to promote better nutrition? (Select all that apply.)
Administer vitamin B12 injections. Ask the provider about folic acid replacement. Provide iron supplements for the client.
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take?
Administration of intravenous insulin
Risk Factors for Cirrhosis
Alcoholic Liver Disease Viral Hepatitis Autoimmune Hepatitis Steatohepatitis (fatty liver) Drugs and Chemical Toxins Gallbladder Disease Metabolic/genetic Causes Cardiovascular Disease Biliary Obstruction
A client has dumping syndrome after a partial gastrectomy. Which action by the nurse would be most helpful?
Arrange a dietary consult.
Serum Lipase and Amylase
As a pancreas, we release Lipase and Amylase into the blood when we get hurt or inflamed. Both levels rise within 2-12 hours. In 3 days Amylase levels return to normal, but Lipase stays elevated for up to 7 to 10 days, diagnosis of pancreatitis. -LABS- Lipase: 0-160 Amylase: 30-220
An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first?
Assess and maintain a patent airway.
An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first?
Assess for abdominal guarding or rigidity.
An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a "steering wheel mark" across the client's chest. Which action should the nurse take?
Assess the client by gently palpating the abdomen for tenderness.
A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?
Assess the client for airway patency.
A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?
Assess the client's bowel sounds.
A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take?
Consult the provider to test for ketoacidosis.
A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.)
Deep and fast respirations (Kussmaul) Tachycardia Orthostatic hypotension
The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.)
Delayed gastric emptying Eating large meals Hiatal hernia Obesity
The nurse is working with clients who have esophageal disorders. The nurse should assess the clients for which manifestations? (Select all that apply.)
Dysphagia Eructation (belching) Halitosis Weight loss
A client previously diagnosed with liver cirrhosis visits the medical clinic. What assessment findings does the nurse expect in this client?
Ecchymosis Jaundice Ankle Edema
Musty Odor of Breath and Urine
Elevated BUN (>20)
A client with an esophageal tumor is having extreme difficulty swallowing. For what procedure does the nurse prepare this client?
Esophageal dilation
Clinical Triad of DKA
Hyperglycemia - BS >200 Ketosis - ketones in blood or urine Acidosis - pH <7.35 and bicarb <15
An older female client has been prescribed esomeprazole (Nexium) for treatment of chronic gastric ulcers. What teaching is particularly important for this client?
Increase intake of calcium and vitamin D.
Encephalopathy
Increased ammonia levels > Increased urea > Toxic effects > Coma -Assess neuro -I&Os -Monitor for infection, bleeding -Watch ammonia levels MEDS: diuretics (furosemide, excretes K, spironolactone, keeps K), propanolol (decreases portal pressure) -PN therapy, Low sodium diet
An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition?
Increased rate and depth of respiration
A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate?
Inform the client a second scan may be needed.
A client is scheduled for a total gastrectomy for gastric cancer. What preoperative laboratory result should the nurse report to the surgeon immediately?
International normalized ratio (INR): 4.2 *An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in gastric cancer.
The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain. On palpation, the client's abdomen is tense and rigid. What action takes priority?
Notify the health care provider immediately. *This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client medical attention.
An emergency nurse cares for a client who is experiencing an acute adrenal crisis. Which action should the nurse take first?
Obtain intravenous access
A client has gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor. About what medication should the nurse anticipate teaching the client?
Omeprazole (Prilosec) *Omeprazole is a proton pump inhibitor used in the treatment of GERD. Famotidine and ranitidine are histamine blockers. Maalox is an antacid.
A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?
Provide a low-sodium diet.
Cushing's Syndrome - Adrenal Hyperfunction
S/S: Moon face, Buffalo hump, Truncal obesity, Weight gain, Petechiae, Osteoporosis, Thinning skin, Striae, Hiriturism *Hypertension, Decreased immune function **Hypernatremia, Hypokalemia, Hypocalcemia -Causes: overproduction by pituitary gland, tumors, prolonged steroid therapy -Prevent fluid overload -Maintain good skin integrity -Drug therapy (to decrease ACTH production: metyrapone, aminoglutethimide, ketoconazole) (to stop if pituitary secreting: cyproheptadine) (to decrease tumor: mitotane) -Restrict fluids and sodium -Monitor I&O, daily weight -Radiation therapy if pituitary adenoma
Addison's Disease - Adrenal Insufficiency
S/S: Muscle weakness, Fatigue, Anorexia, N/V, Abdominal pain, Weightloss, Vitiligo (skin spots) *Hypotension, Hyponatremia, Hyperkalemia ER CARE: -Hormone Replacement (IV NS, High loading dose dexamethasone, Hydrocortisone Q12hr IM, IV H2 blocker ranitidine to prevent ulcer) -Hyperkalemia Management (IV insulin in dextrose in NS, Kayexalate, Diuretics, Potassium restriction, I&Os, Monitor HR and rhythm) -Hypoglycemia Management (IV glucose, Glucagon as ordered, Maintain IV access, Monitor blood glucose level hourly)
GI Ulcers
S/S: emesis with blood, pain, tarry stool (upper), bloody stool (lower) -Common places for ulcers: Esophageal ulcer, Gastric ulcer (stomach), Duodenal ulcer (small intestine), Peptic ulcer (may lead to bleeding or perforation, emergency) -CAM: Herbs & Vitamins therapy: Cranberry, Ginger, Probiotics, Slippery elm, Vitamin C
A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.)
Serum potassium of 2.8 mEq/L Abdominal pain in upper quadrants Serum sodium of 121 mEq/L *Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.
A client has undergone a subtotal gastrectomy for gastric cancer and is scheduled to begin radiation therapy. What is the most important information for the nurse to include in the teaching plan for this client?
Skin Care
Addison's Disease LABS
Sodium decreased Potassium increased Glucose decreased or normal Calcium increased Bicarbonate increased BUN increased Cortisol decreased
Cushing's Syndrome LABS
Sodium increased Potassium decreased Glucose increased or normal Calcium decreased Bicarbonate decreased BUN normal Cortisol increased
A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The client's blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate?
Start a large-bore IV with normal saline.
An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.)
Tachycardia Confusion
A nurse cares for a client with chronic hypercortisolism. Which action should the nurse take?
Wash hands when entering the room.
