Adult 3 Exam 2!!!!!!

Risk factors for liver cancer ?

Hx of cirrhosis, Hep. B, exposure to toxic chem., metastases. asymptomatic until later stages. liver cancer usually rare.

s/s of cirrhosis

increased liver size, liver large and firm, GI complaints, anorexia, N/V R/T liver failure and increase size of liver, weight loss, HA, decrease resistance to infection, alopecia, anemia, leukopenia. low platlet count R/T hyperthyroidism, bone marrow suppression.

Dyspepsia

indigestion - upset stomach

Esophageal manometric (motility) study

measures pressure in esophagus and LES

S/S of hepatic encephalopathy

personality changes, restless, twitching of extremities "aster-ixis"/"liver flap", dizziness, lethargic, event. coma, increased body temp. damage done to brain=permanent. become worse if left untreated.

what's paracentisis?

procedure that removes fluids from the ABD and relieves pressure on diaphragm and lungs. small incision made and trochar is inserted into the ABD and drains fluids. Albumin may be infused at same time to pull excess fluids back into vascular system.

Hepatic coma (complication of cirrhosis)

relates to hepatic encephalopathy which is degeneration of brain tissue associated w. liver failure due to hypoxia, severe electrolyte, and increase serum ammonium levels.

malnutrition R/T cirrhosis

results from the liver inability to absorb fat and fat soluble vitamins and leads to muscle wasting, weight loss , and fatigue.

Portal hypertension R/T cirrhosis..

results from when blood flow through the cirrhotic liver resulting in blood back flowing in portal vein. leads to distention of the esophageal veins resulting in esophageal avarices. distention of rectal veins=hemorrhoids. distention of splenic vein = splenomegaly.

Which of the following dietary measures would be useful in preventing Esophageal reflux? 1. Eating small, frequent meals 2. increasing fluid intake 3. avoiding air swallowing with meals 4. Adding a bedtime snack to the dietary plan

1. Esophageal reflux worsens when the stomach is over-distended with food. Therefore, an important measure is to eat small,frequent meals.

The client attends two sessions with the dietitian to learn about diet modifications to minimize GERD. The teaching would be considered successful if the client decreases the intake of which of the following foods? 1. fats 2. high-sodium foods 3. Carbohydrates 4. high calcium foods

1. Fats are associated with decreased esophageal sphincter tone.

Surgical Complications Interventions

1. Goal: slow rapid passage of food into intestine --> slow S/S 2. Rest period after eating - semi fowlers at least 1 hr post-perandial 3. Small frequent meals 4. Eat food at room temp 5. Drink fluids between meals 6. Eat dry foods with Low carb

The client with GERD has a chronic cough. This symptom may be indicative of which of the following? 1. Development of laryngeal cancer 2. Irritation of the esophagus 3. Esophageal scar tissue formation 4. Aspiration of gastric contents

4. Clients with GERD can develop pulmonary symptoms such as coughing, wheezing, and dyspnea, that are caused by the aspiration of gastric contents.

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which of the following symptoms? 1. Heartburn 2. Jaundice 3. Anorexia 4. Stomatitis

1. Heartburn, the most common symptom of a sliding hiatal hernia , results from reflux of gastric secretions into the esophagus. Regurgitation of gastric contents and dysphagia are other common symptoms.

PUD Complications - Hemorrhage

*most common: Erosion of tissue through a blood vessel - Emesis: bright red or coffee ground - Stool: black, tarry Intervention 1. How to assess signs for hemorrhagic shock: urine output, vitals, O2, lab values (CBC-Hgb & Hematocrit) 2. Give IV fluids 3. Give NG tube: drainage - to remove blood, clots, vomiting 4. NG Lavage w/Saline - stop the bleeding 5. Foley Catheter - monitor urine output 6. Supplemental Oxygen 7. Draw frequent lab (CBC-Hgb, Hematocrit)

The client is scheduled to have an upper GI tract series of x-rays. Following the x-rays, the nurse should instruct the client to: 1. Take a laxative 2. follow a clear liquid diet 3. Administer an enema 4. Take an antiemetic

1. The client should take a laxative after an upper GI series to stimulate a bowel movement. This examination involves the administration of barium, which must be promptly eliminated from the body because it may harden and cause an obstruction.

The physician prescribes metoclopramide hyrochloide (Reglan) for the client with a hiatal hernia. This drug is used in hiatal hernia therapy to accomplish which of the following objectives? 1. Increase tone of the esophageal sphincter 2. Neutralize gastric secretions 3. delay gastric emptying 4. reduce secretion of digestive juices

1. This medicaiton increases esophageal sphincter tone and facilitates gastric emptying; both actions reduce the incidence of reflux.

what are the four complications patient may experience with cirrhosis?

1.Ascites, 2.esophageal avarices, 3.cancer of the liver, and 4.hepatic coma.

what are the 8 dysfunctions patient may have with cirrhosis?

1.malnutrition,2. hypoglycemia,3. clotting disorder, 4.jaundice,5. portal hypertension,6. ascites,7. hepatic encephalopathy,8. hepatorenal syndrome

Which of the following factors would most likely contribute to the development of a client's hiatal hernia? 1. having a sedentary desk job 2. being 5 feet, 3 inches tall and weighing 190 lbs 3. using laxatives frequently 4. being 40 years old

2. Any factor that increases intra-abdominal pressure, such as obesity, can contribute to the development of hiatal hernia. Other factors include abdominal straining, frequent heavy lifting, and pregnancy. Hiatal hernia is also associated with older age and occurs in women more frequently than in men.

hepatic encephalopathy in the body..

the pathway from protein and urea is ammonia that the liver is responsible to break down for waste. when the liver fails to do so and ammonia does not break down properly it accumulates and keeps increasing in the body which results in coma hepatic encephalopathy due to liver being damaged and not working properly.

foods that irritate the esophagus

tomato based products orange juice (citrus) colas red wine

The client has been taking magnesium hydroxide (milk of magnesia) to control hiatal hernia symptoms. The nurse should assess the client for which of the following conditions most commonly associated with the ongoing use of magnesium based antacids? 1. anorexia 2. weight gain 3. diarrhea 4. constipation

3. The magnesium salts in magnesium hydroxide are related to those found in laxatives and may cause diarrhea.

What's portal systemic shunt?

used for end stage liver disease, it redirects blood from portal vein to the inferior mesenteric. it releases pressure from the esophageal varices and decreases portal HTN. this procedure is done if the portal HTN is not controlled.

Upper GI endoscopy

useful in assessing LES competence, degree of inflammation, scarring, strictures also used to obtain biopsy and cytologic specimens

S/S to watch for with ascites?

watch for infection, hypervolemia; Abnormal decrease in the volume of blood plasma. Albumin levels. More albumin can be infused if levels drop at same time.

The nurse should instruct the client to avoid which of the following drugs while taking metoclopramide hydrochloride (Reglan)? 1. Antacids 2. Antihypertensives 3. Anticoagulants 4. Alcohol

4. This drug can cause sedation. Alcohol and other CNS depressants add to this sedation. A client taking this drug should be cautioned to avoid driving or performing other hazardous activities for a few hours after taking the drug.

Peptic Ulcer Disease: Incidence

40-60 Pain in mid epigastric area

Proton Pump Inhibitors (PPIs)

> Example: Omeprazole (prilosec) -prazole >promote esophageal healing in 80-90% of patients >available in prescription and OTC preps >most common SE: headache >long-term use or high doses of PPIs may increase the risk of fractures of hip, wrist and spine >long term use associated with chronic hypochlorhydria >associated with increased risk of C. difficile infection in hospitalized patients

Histamine -2 receptor blockers

>Examples: cimetidine, ranitidine or famotidine >decrease secretion of HCL acid >reduce symptoms and promote esophageal healing in 50% of patients >side effects are uncommon

PUD Surgical Intervention Complications: Postprandial Hypoglycemia

As a result of dumping syndrome 1. high carb food 2. enter stomach and intestine 3. pt gets hyperglycemia 4. excessive insulin release 5. subsequent secondary hypoglycemia 2 hours post perandial (after eating) s/s - sweating - weakness - confusion - palpitations - tachycardia - anxiety Treatment - Give a fast acting carb Prevention - dietary intervention to prevent dumping syndrome

PUD: Complications - Gastric Outlet Obstruction (Pyloric Obstruction)

Cause - Scarring at the pylorus - Fluid and food not being able to pass into duodenum S/S - NV - epigastric fullness - constipation - anorexia Dx 1. NG Tube Decompression 2. withdraw residual 3. if residual > 400: obstruction is suggested 4. Order Upper GI x-ray & Endoscopy 5. These confirm the Dx Treatment 1. Endoscopy: balloon dilation - widens pylorus to widen stomach & allow fluid to come through

regurgitation

Described as hot, bitter, or sour liquid coming into throat or mouth

S/S of hepatorenal syndrome ?

Diminished production of urine, excess nitrogen in blood, anorexia, fatigue, and weakness.

Predisposing factors of GERD

Incomplete lower esophageal sphincter (LES) Decreased LES pressure Increased intraabdominal pressure Hiatal Hernia

Nursing management (cirrhosis)

Low sodium, low protein diet. restrict fluid intake as ordered. Record I&O, weigh p.t daily, reposition q 2hrs, monitor redness and skin breakdown, provide frequent oral hygiene.

Heart burn (pyrosis) in GERD

Most Clinical Manifestation Felt intermittently Burning, tight sensation felt beneath lower sternum and spreading upward to throat or jaw

Peptic Ulcer DIsease

Occurence - Duodenum (most common) - Stomach (pyloric area) - Esophageal (as a result of GERD)

Sx procedures for (cirrhosis)

Paracentisis, portal systemic shunt, TIPS, and Denver peritoneal shunt.

PUD Surgical Interventions Complications: Pernicious Anemia

Pernicious Anemia - loss of intrinsic factor in stomach - can't absorb vitamin b12

Drug therapy for GERD includes

Pronton pump inhibitors Histamine-3 receptor (H2R) blockers. Acid protective Prokinetic drugs (metoclopramide (Reglan)) Antacids

Treatment for ascites (complication of Cirrhosis)

Rest, Sodium and water restriction, potassium sparing diuretics. Paracentisis usually done in peritoneal cavity to withdraw large amnts of fluid, then place dry sterile dressing.

Treatment (hepatic Encephalopathy)

Restrict protein (more intake of protein=more ammonia production). give Vit. replacement. decrease ammonia levels. monitor neuro status.

what's TIPS?

Trans jugular intrahepatic portal systemic shunt is done when portal HTN not controlled. also done for patients that are not stable enough. its done in radiology, it redirects blood flow, relieving portal HTN and decreases risk of rupturing distended veins in the esophagus.

Respiratory symptoms in GERD

Wheezing Coughing Dyspnea Nocturnal discomfort and coughing with loss of sleep

what accounts for most cases of cirrhosis?

alcohol accounts for most cases of cirrhosis.

Objective data (cirrhosis)

ascites, jaundice, enlarged liver and spleen, petechial, vomiting, weight loss, fever, epistaxis, decreased breath sounds, lethargy, confusion, and coma(late symptoms)

lifestyle modifications for GERD

avoiding triggers maintain appropriate weight smoking cessation stress management

Medical management (cirrhosis)

based on symptoms. Antacids, Vit., balanced diet, nutritional supp., potassium sparing diuretics, avoid alcohol. plan rest periods in between scheduled day activities

when the liver is not able to produce right amount of PT and fibrinogen what disorders arises?

clotting disorders.

PUD Surgical Interventions 4: Pyloroplasty

- often with vagotomy - take out pyloric sphincter --> easy passage from stomach to duodenum - increases gastric emptying

Bethanechol (Urecholine) has been prescribed for a client with GERD. The nurse should assess the client for which of the following adverse effects? 1. Constipation 2. Urinary urgency 3. Hypertension 4. Dry oral mucosa

2. This is a cholinergic drug that may be used in GERD to increase lower esophageal sphincter pressure and facilitate gastric emptying. Cholinergic adverse effects may include urinary urgency, diarrhea, abdominal cramping, hypotension, and increased salivation.

A client who has been diagnosed with GERD has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet? 1. Lean beef 2. Air-popped popcorn 3. Hot chocolate 4. Raw vegetables

3. With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol.

Complications of GERD

>related to direct local effects of gastric acid on esophageal muscle. -Esophagitis -Barrett's Esophagus -Respiratory

Hepatorenal syndrome R/T cirrhosis

A complication of cirrhosis which patient eventually go into liver failure.

Hepatic encephalopathy R/T cirrrhosis

A condition which ammonia accumulates in the brain. fluid pulled into extracellular compartment, acellerarting brain stem herrnation. Confusion, lethargy. and coma may occur, and flapping tremor of hands "Aster Ixis"

Peptic Ulcer Disease: Pathophysiology

Agents that destroy mucosal barrier (H. pylori, dietary, aspirin/ corticosteroids, CNS stimulation, anxiety) --> impairs mucosal barrier --> HCL acid enter mucosa and damages tissues --> cell destruction and inflammation (ulcer) --> more prone to bacteria --> crater like ulcer

Treatment for Esophageal avarices (complication of cirrhosis)

Gastric Isotonic saline lavage performed. Iced Normal saline down NG tube to promote vasoconstriction. replace blood w. transfusions (ideally fresh donated blood) because ammonia will be released w. blood sitting at the bl.bank. liver has hard time metabolizing sodium sitrate in blood clotting reaction begins to break down.

Peptic Ulcer Disease: Treatment: Medications

H. Pylori Related - PIP + Antibiotic Therapy Non-H.Pylori Related - H2 Receptor Antagonists (maintenance doses can be given up to a year) - PIP

Cancer of liver (complication of cirrhosis)

decrease liver function. increases risk of malignant develop. cirrhosis of liver increases risk for CANcer

subjective symptoms (cirrhosis)

fatigue, Nausea, anorexia, weakness and indigestion.

Ascites R/T cirrhosis

fluid accumulation in pleural cavity in form of pleural effusions, also forms in peritoneal cavity

Dental erosion in GERD

from acid reflux in the mouth especially seen on posterior teeth

PUD Surgical Interventions 3: Vagotomy

- disconnect vaus nerve to stomach --> interrupt stimulation of HCL acid - can be done with BI, BII, Pyloroplasty

PUD: Complications - Perforation

*most lethal: medical emergency & requires surgery bc it can lead to --> PUD: Complications peritonitis s/s - sudden onset of severe abdominal pain (can develop in a few hours) - may start vomiting - faint - may develop rigid board like abdomen - hypotension (shock) - tachycardia (shock) 1. Put them in emergency surgery 2. Postop: give an NG tube for decompression 3. Monitor (vitals, F/E) 4. Assess for infection/Peritonitis - temperature - abdominal pain - paralytic ileus - increased or absent bowel sounds - abdominal distention 5. If so, give antibiotics

PUD Surgical Interventions 1: Bilroth I

- Removes 2/3 of stomach (area that secreted HCL) - Gastroduodenostomy: attaches Stomach + Duodenum Postop s/s - Full (smaller stomach) - Dumping syndrome - diarrhea

Respiratory complication in GERD

From irritation of upper airway by secretions -cough -bronchospasm -laryngospasm -cricopharyngeal spasm (if the pt has asthma or bronchitis already this can be very serious) From aspiration -potential for asthma, bronchitis and pneumonia

Globus sensation

lump in throat

s/s of shock

increase pulse rate, decrease BP, cool, clamy, watch for albumin levels when removing fluids "ascites".

Antacids

>Maalox, Mylanta >taken 1-3 hours after meals/at bedtime >Neutralize HCL acid >quick but short lived relief

Surgerys for GERD

Nissen and Toupet fundoplications

BPH patho

Noncancerous enlargement/hypertrophy of prostate 50% of men by 60; 90% of men by 90 yrs old

GERD (gastroesophageal reflux)

backward flowing of gastric contents into the esophagus >> heartburn

foods that decrease LES

chocolate peppermint tomatoes coffee caffeinated tea

Nursing management for GERD pts

>elevate head of bead 30 degrees >do not lie down for 2-3 hours after eating >avoid factors that cause reflux -stop smoking & avoid alcohol -avoid acidic foods >stress reduction techniques >weight reduction, if appropriate >small , frequent meals

PUD - Tx

eradicating H. pylori infection and treating or preventing ulcers related to use of NSAIDs

(hepatitis)

inflammation of the liver

LES

lower esophageal sphincter

Diagnositic studies for GERD

History and physical exam Upper GI endoscopy Barium swallow Esophageal manometric (motility) studies

Cirrhosis of the Liver - vit K deficiency

Impairs absorption and storage of vit K = large component of platelets and ,', clotting (r/t *splenomegaly* >> excess bleeding/bruising <> interventions?

GERD - Tx

(1) antacids, PPIs, H2-receptor blockers <> reduce acid amt (2) promotility agent to enhance esophageal clearance and gastric emptying (3) dietary changes Avoid acidic foods (i.e. tomato products, citrus fruits, spicy foods, coffee); Avoid fatty foods, chocolate, peppermint, alcohol which all relax the lower esophageal sphincter OR delay gastric acid emptying (4) lifestyle changes Maintain good lb; Small, frequent meals, upright 2 hrs after meals; no eating 3 hrs before bed (laying down), elevate HOB No smoking, alcohol Avoid tight clothing, bending over for "relief"

Chronic Pyelonephritis

(UTI)-. Due to malformations (deformity), urinary obstruction, or vesicoureteral reflux. Risk for UTI: hx of spinal injury, bladder tumor, renal calculi, prostatic hypertrophy, catheterization, DM, overuse of NSAIDS.

TURP post op care

- 3-way foley catheter inserted during procedure - Traction & pulled down into prostatic fossa - Continuous bladder irrigation - Will have post-op bleeding and bladder spasms - Anticholinergics, antispasmodics to ↓ spasms

GI bleeding Pathophysiology

- Stomach irritation - Nausea and vomiting (with blood hematemesis) - Accumulation of blood stimulates peristalsis, leading to hyperactive bowel sounds and diarrhea - Stools: melena (black and tarry); Hematochezia (bloody) - Occult (hidden) bleeding detected chemically

BPH treatment

-Alpha blockers [relax bladder neck muscles in the prostate making urination easier]; alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), and silodosin (Rapaflo), -5-alpha reductase inhibitors [shrink your prostate by preventing hormonal changes that cause prostate growth]; finasteride (Proscar), dutasteride (Avodart)

•Zollinger-Ellison syndrome

-Caused by gastrinoma in the pancreas, stomach, intestines -Diarrhea, steatorrhea

urinary calculi (kidney stones)

-Defined as masses of crystals composed of minerals that are normally excreted in the urine (majority are calcium) -Stones may develop and cause obstruction at any point in the urinary system Risk factors: •Most affected -Male -White -Young adult or middle-aged •Personal or family history •Gout •Hyperparathyroidism •Urinary stasis •Repeated U T I •Dehydration •Immobility •Diet

•Sliding hiatal hernia

-Gastroesophageal junction, fundus of stomach slide upward

•Paraesophageal hiatal hernia

-Part of stomach herniates through esophageal hiatus

BPH manifestations

-urinary frequency -increased time to begin voiding -small urinary stream -dribbling of urine -increased time required to void -urgency -nocturia

Barrett's esophagus

<< GERD, changes in the cells lining the esophagus >> inc risk of developing esophageal cancer

Portal Systemic Encephalopathy (hepatic encephalopathy (brain disease))

<< alcohol induced *cirrhosis* <<<< accumulation of neurotoxins (i.e. ammonia, b/c liver not producing bile to breakdown stuff) in the blood and cerebral edema - clogging/backing things up...to the brain! precipitating factors (cloggers): High serum ammonia levels; Constipation; Blood transfusions; GI bleeding; (slow down responses): Rx (sedatives, tranquilizers, narcotics, analgesics, anesthetics); Hypoxia (divert attention): Infection; Surgery

Acid protective GERD drugs

>Sucralfate >used for cytoprotective properties

Barrett's esophagus

>esophageal metaplasia >replacement of flat epithelial cells with columnar epithelium >precancerous lesion >thought to be primarily due to GERD >diagnosed in 5-20% of pt with chronic reflux >signs and symptoms: none to perforation >must be monitored every 2-3 years by endoscopy

esophagitits

>inflammation of the esophagus >frequent complication >from repeated exposure to acid: -> scar formation, esophageal stricture, dysphagia

Prokinetic drugs

>metoclopramide (Reglan) >promotes gastric emptying >reduces risk of gastric acid reflux

Etiology and Pathophysiology of GERD

>no one single cause >defenses of lower esophagus are overwhelmed allowing reflux of acidic gastric contents into the lower esophagus

Splenomegaly

A complication / manifestation of cirrhosis Enlarged spleen << portal HTN >> blood to be shunted into the splenic vein >>>> increases the rate at which red and white blood cells and platelets are removed from circulation and destroyed >>>>>>>> anemia (low RBCs), leukopenia (low WBCs), and thrombocytopenia (low platelets)

Cirrhosis of the Liver

A severe medical condition where scar tissue in the liver replaces functional tissue << is caused by overworking the liver trying to assimilate (metabolize) large amounts of alcohol; Hepatitis >>>> portal HTN b/c blood flow gets backed up as it is not used in the liver >>>>>>>> *splenomegaly*

The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's best response is based on the knowledge that

Ascites is accumulation of serious fluid in peritoneal cavity. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space.

The nurse is reviewing the record of a client with a dx of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? Dorsiflex the foot Measure abdominal girth Ask pt to extend the arms Instruct pt to lean forward

Ask the pt to extend the armsAsterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. It is the most common and reliable sign that hepati encephalopathy is developing.

Urinary Tract Tumors

Can be in bladder or kidney. Usually in bladder transitional cell CA -renal calyces and down -painless hematuria w/o casts d/t smoking, anilidine dyes, phenacetin, cyclophosphamide

GERD - clinical manifestations

Heartburn (usually after meals as gastric juices are most active) <> bending/reclining), atypical chest pain (< exposure to unneutralized gastric acid); Regurgitation (sour taste); Painful swallowing / sore throat / hoarseness / cough (gastric contents where they don't belong <> aspiration, to include lungs, hence cough); >> esophageal *strictures* (<< irritation <> inflammation) >> dysphagia >> *Barrett's esophagus*

PUD - complications

Hemorrhage (most frequent) <> occult blood >> anemia, weak, dizzy, orthostatic hypotension >> hematemesis, melena (tarry stool), hematochezia, hypovolemic shock; Obstruction (gastric outlet obstruction) << edema surrounding ulcer <> feeling full, accentuated ulcer symptoms, nausea, vomit (w/ complete obstruction) ~>> electrolyte imbalance / metabolic alkalosis (lost of HCl, Na, K); Perforation >> gastric acids entering the (sterile) *peritoneum* >> inflammatory process and peritonitis s/s: immediate, severe upper abdominal pain, radiating throughout the abdomen and possibly to the shoulder; rigid ab; absent bowel sounds ~~>> shock (diaphoresis, tachycardia, rapid, shallow respirations (<~ alkalosis) (older adult) = mental confusion and other nonspecific symptoms ~>> more mortalities

Cirrhosis of the Liver - Nutrition and Fluid Mngmt

Limit Na intake (water/blood follows salt), <2 g/d Fluid restricted, 1500 mL/day - adjusted for act, Rx, etc Protein-calorie nutrition, w/ focus on veggie protein and minimal red meat protein, better than being malnourished in protein and calories; TPN to maintain nutritional status when food intake is limited; Vitamin supplements (B (B12, thiamine, folate), A, D, E) for electrolyte balances

The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be presribed for this pt?

Low-protein diet

(spleen)

Old red blood cells are recycled in the spleen, and platelets and white blood cells are stored there

PUD - clinical manifestations

Pain (gnawing, burning, aching, hunger-like in the epigastric region, sometimes radiating to the back), when stomach empty (2-3 hrs after meals / in the middle of the night); <> eating to relieve ~>> heartburn or regurgitation, vomitting; (older adults) less severe pain, but + chest pain or dysphagia, weight loss, anemia (<> hemorrhage)

GERD - pathophysiology

Reflux (backflow) of gastric contents into the esophagus is prevented by pressure differences between the stomach and the lower esophagus, keeping the esophageal sphincter closed except during swallowing << transient relaxation of the lower esophageal sphincter << incompetent lower esophageal sphincter << inc pressure w/in stomach <<<< increased gastric volume (i.e. after meals) <<<< positioning keeping gastric contents close to gastroesophageal junction (i.e. bending over, lying down) <<<< inc gastric pressure (i.e. obesity, tight clothing) (hiatal hernia) >> gastric juices in esophagus w/ impaired peristalsis or dec salivation means nothing to neutralize the acidic nature of gastric juices >> damaged/inflammed esophagus

PUD - r/f

Smoking (inhibits the section of bicarbonate by the pancreas possibly causing more rapid transit of gastric acid into the duodenum; no time to become "less acidic"); H. pylori infection (<> older, poorer, crowded, unsanitary); Overuse/abundant use of NSAIDs (NSAIDs reduce production of prostaglandins which inhibit gastric acid secretion)

H. pylori - Tx

Therapy for H. pylori infection consists of 10 days to 2 weeks of one or two effective antibiotics, such as amoxicillin, tetracycline (not to be used for children <12 yrs.), metronidazole, or clarithromycin, plus either ranitidine bismuth citrate, bismuth subsalicylate, or a proton pump inhibitor. Acid suppression by the H2 blocker or proton pump inhibitor in conjunction with the antibiotics helps alleviate ulcer-related symptoms (i.e., abdominal pain, nausea), helps heal gastric mucosal inflammation, and may enhance efficacy of the antibiotics against H. pylori at the gastric mucosal surface

urinary retention treatment

Treatment for urinary retention includes catheterization, treating prostate enlargement, and surgery.

Paracentesis preparation

Tx for *Cirhosis of the liver* (1) Verify/confirm informed consent; (2) Reduce anxiety by explaining the how and why of procedure, monitor BP; (3) Weigh and measure ab girth beforehand <> effectiveness; (4) Vital signs before and after <> effectiveness; (5) Void beforehand - decrease the risk of bladder punctures and minimize discomfort (6) Sit for ease of fluid flow/removal from lower ab

Proton Pump Inhibitors (PPIs)

Tx for *GERD* <> reduce gastric secretion; 8 wk to 3-6 mos tx, Relapse is common after PPI therapy is discontinued; Minimal s/e BUT may interfere with absorption of calcium and vitamin B12 ~>> hip fractures

Peptic Ulcer Disease

a break in the mucous lining of the gastrointestinal tract (esophagus, stomach, duodenum (most common)) where it comes in contact with gastric juice

(hiatal hernia)

a condition in which a portion of the stomach protrudes upward into the chest, through an opening in the diaphragm <> possible cause of GERD

(peritoneum)

a multilayered membrane that protects and holds the organs in place within the abdominal cavity

(stricture)

a narrowing of a passage in the body

neurogenic bladder

a urinary problem caused by interference with the normal nerve pathways associated with urination

urinary retention

abnormal accumulation of urine in the bladder because of an inability to urinate

H. pylori

bacteria that causes *PUD*

urinary retention causes

bladder outlet obstruction (BPH, cystocele) or deficient detrusor contraction strength (nerve dysfunction, spinal cord injury, constipation, immobility, side effects of meds)

Barium swallow

can detect protrusion of gastric fundus

During assessment of a pt with obstructive jaundice, the nurse would expect to find:

clay-colored stools

surgical therapy reserved for those with complications

failure of conservative therapy medication intolerance Barrett's metaplasia Esophageal stricture and stenosis Chronic esophagitis

Hypoglycemia R/T cirrhosis..

occurs when the liver is unable to perform gycogenolyse efficiently.

(liver)

produces bile - a digestive juice secreted by the liver and stored in the gallbladder

A pt has been told she has NAFLD. The nursing teaching plan should include

recommend a heart healthy diet

TURP and pre op care

removes small amount of tissue; Scrape out tissue like an apple core and do that over and over, destroys urethra but tissue heals around catheter and creates healed urethra complications: -hematuria -urethral stricture -incontinence or dribbling of urine up to 1 year (taking away tissue that held urine back so you did not have a prior need to control bc it was controlled for you; takes time to restrengthen muscles) -retrograde ejaculation (makes them sterile-80% of men) will the patient be impotent? -depends on the status prior to a TURP, if present, will possibly continue - new problems with erectile dysfunction can occur after TURP (5-8% occurrence; long term is less than 1%) Reasoning: you need good blood flow to have good erectile function; ED issues are based on overall health, not procedure Teaching indicated: -procedure -expected post-op care: catheter drainage, irrigation, monitoring of hematuria -risk for impotence -bowel prep/ fasting -prophylactic antibiotics -no heavy lifting > 10 lb 6 weeks -no straining during defecation -no prolonged sitting, driving -no sexual intercourse 6-8 weeks; Remind that sexual dysfunction may not return for as long as 6 months -Kegel exercises 10-20X/hr. to improve sphincter control -Drink 1-2 liters fluid daily

Why would medications need to be monitored in patients with liver disorders

responsible for the metabolism of steroid hormones and most drugs

Cirrhosis of the Liver - skin breakdown

results of cirrhosis such as jaundice, rash, itching >> disturbed body image use warm, not hot water when bathing - hot stimulate blood flow to skin breaks; use mild or no soap - not to further irritate; limit duration of baths and showers; pat dry, do not rub, apply an alcohol-free lotion soon after bathing to retain skin moisture - not slough off "dead" skin; wear loose cotton garments that allow moisture to evaporate from skin - no sweating; reduce room temperature, especially at night, to prevent overheating - no sweating; keep fingernails short - minimize intensity of scratching and skin breaks, wear cotton mittens or gloves as needed to prevent scratching during sleep

Paracentesis

surgical puncture of a body cavity for fluid removal; aspiration of fluid from the peritoneal cavity; >> relieve respiratory distress caused by excess fluid in the abdomen >> balance electrolyte imbalance

TURP

transurethral resection of the prostate gland

Acute pyelonephritis patho and manifestations

•Bacterial infection of the kidney •Infection usually ascends to kidneys from lower urinary tract •E. coli responsible for 85% of cases •Infection spreads from renal pelvis to renal cortex. -Primarily affects pelvis, calyces, and medulla of kidney -White blood cell infiltration and inflammation -Kidney becomes grossly edematous; abscesses can develop on cortical surface.

Hiatal hernia Dx and Tx

•Diagnosis -Barium swallow or upper endoscopy •Usually require no treatment -If symptoms present, treatment is similar to that of G ER D. •Severe cases involving incarcerated herniation can require surgery.

UTI pathophysiology and manifestations

•Lower urinary tract infections -Urethritis -Prostatitis •Cystitis -Manifestations of dysuria, urinary frequency and urgency, nocturia, pyuria, hematuria -Usually responds to treatment •Catheter-associated U T I -The longer left in place, the greater the risk of infection -Biofilm resistant to antibiotics -Often asymptomatic

GI bleeding manifestations

•Pallor: conjunctival, mucous membranes, nail beds •Dark, tarry stools •Bright red or coffee-ground emesis •Abdominal mass or bruit •Decreased BP, rapid pulse, cool extremities (shock), increased respirations

Acute pyelonephritis risk factors

•Pregnancy •Urinary tract obstruction •Congenital malformation •Urinary tract trauma or scarring •Calculi or kidney disorders •Chronic diseases

Urinary calculi manifestations

•Renal colic -Acute, severe flank pain caused by ureteral spasm -Nausea; vomiting; pallor; and cool, clammy skin -Signs of U T I -Hematuria

Urinary calculi patho

•Types of kidney stones -Calcium -Uric acid -Struvite (staghorn stones) ▪Magnesium-ammonium phosphate -Cystine

Peptic Ulcer Disease: Diagnostic Tests

- Barium Contrast X-Ray - Endoscopy (preferred, can directly visualize ulcer & take biopsy) - Stool for Occult Blood (if GI bleeding is a complication) - Urea Breath Test (aren't done as often, NPO overnight, take this urea, and measured by the radioactive CO2 you breath out)

PUD Surgical Intervention Complications: Dumping Syndrome

- Complications of BI & BII 1. hyperosmolar food enter stomach and intestine 2. bowel release hypertonic fluid into intestine 3. fluid shift - decrease in plasma 4. volume 5. bowel lumen because distended pt has urge to defecate - diarrhea s/s - weakness, sweating - palpitation - abdominal cramping - nausea - epigastric fullness - dizziness - can occur 15-30 min of eating and last 1 hour after eating

PUD Surgical Interventions 2: Bilroth II

- Removes 2/3 of stomach - Gastrojejunostomy: attaches Stomach + Jejunum Postop s/s - dumping syndrome - pernicious anemia - malabsorption - weight loss

hypochlorhydria

hydrochloric acid is low or almost gone -> causing failure to sterilize stomach contents

Peptic Ulcer Disease: Clinical Manifestations

- Dull, gnawing pain or burning sensation in mid-epigastric area - Pain relieved by eating (food in stomach neutralizes food) - Pyrosis (burp - reflux of acid into mouth when on an empty stomach) - Constipation/Diarrhea - Vomiting (obstruction of pyloric orifice --> muscle spasm, scarring, inflammation)

Description of GERD

>common problem >chronic symptom of mucosal damage that occurs form stomach acid >not a disease, but a syndrome

GERD related chest pain

>described as burning, squeezing >radiating to back, neck, jaw or arms >can mimic angina or MI >More common in older adults with GERD >Relieved with antacids

Peptic Ulcer Disease: Treatment: Diet

- avoid coffee, alcohol, milk/cream - 3 regular meals a day - if you are on an H2 medication: small frequent meals are not needed

The nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. Which of the following statements would indicate that the client has understood the instructions? 1. "I'll avoid lying down after a meal." 2. "I can still enjoy my potato chips and cola at bedtime." 3. "I wish I didn't have to give up swimming." 4. "If I wear a girdle, I'll have more support for my stomach."

1. A client with a hiatal hernia should avoid the recumbent position immediately after meals to minimize gastric reflux. Bedtime snacks, as well as high fat foods and carbonated beverages should be avoided.

Peptic Ulcer Disease: Cause

1. H. Pylori: - makes ammonia --> chronic inflammation to mucosa - secrete urease --> protects itself - spread by close contact & ingestion 2. Dietary - increase gastric acid/HCL secretion (caffeine, milk, alcohol) 3. Increased vagal stimulation - increases secretion of HCL --> altered mucosal barrier 4. ASA - inhibit synthesis of mucous & causes abnormal permeability 5. Corticosteroids - decreases rate of mucosal cell renewal 6. Cigarette Smoking - delays mucosal healing - decreased pancreatic secretion of bicarbonate --> decrease pH in duodenum - increase HCL secretion

In developing a teaching plan for the client with a hiatal hernia, the nurses assessment of which work-related factors would be most useful? 1. number and length of breaks 2. body mechanics used in lifting 3. temperature in the work area 4. Cleansing solvents used

2. Bending, especially after eating, can cause GERD. Lifting heavy objects increases intra-abdominal pressure. Assessing the client's lifting techniques enables the nurse to evaluate the client's knowledge of factors contributing to hiatal hernia and how to prevent complications.

The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse would be the MOST accurate? 1. "Surgery is usually required, although medical treatment is attempted first." 2. "Hiatal hernia symptoms can usually be successfully managed with diet modification, medications, and lifestyle changes." 3. "Surgery is not performed for this type of hernia." 4. "A minor surgical procedure to reduce the size of the diaphragmatic opening will probably be planned."

2. Most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modifications. Surgery is performed only when these attempts fail.

Which of the following lifestyle modifications should the nurse encourage the client with hiatal hernia to include in ADLs? 1. Daily aerobic exercise 2. eliminating smoking and alcohol use 3. balancing activity and rest 4. avoiding high-stress situation

2. Smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux. They therefore should be avoided by clients with hiatal hernia.

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? 1. Limit caffeine intake to two cups of coffee per day 2. Do not lie down for 2 hours after eating 3. Follow a low-protein diet 4. Take medications with milk to decrease irritation

2. The nurse should instruct the client to not lie down for about 2 hours after eating to prevent reflux.

Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia? 1. Introduce the client to other people who are successfully managing their care. 2. Include the client's daughter in the teaching so that she can help implement the plan 3. Ask the client to identify other situation in which the client changed health care habits 4. Provide reassurance that the client will be able to implement all aspects of the plan successfully.

3. self-responsibility is the key to individual health maintenance. Using examples of situation in which the client has demonstrated self-responsibility can be reinforcing and supporting. The client has ultimate responsibility for personal health habits.

nutritional therapy for GERD

>avoid foods that decrease LES pressure or irritate the esophagus >small, frequent meals >avoid late night evening meals >drink fluids between meals >chewing gum and oral lozenges

A client is taking cemetidine (Tagament) to treat a hiatal herna. The nurse should evaluate the client to determine that the drug has been effective in preventing which of the following? 1. esophageal reflux 2. dysphagia 3. esophagitis 4. ulcer formation

A histamine receptor blocker that decreases the quantity of gastric secretions. It may be used in hiatal hernia therapy to prevent or treat the esophagitis and heartburn associated with reflux.

Diet (cirrhosis)

low protein(40g/day). if ascites presents sodium and fluids restricted. fluids restricted to 1000-2,00 ml/day depends of severity on fluid accumulation.

Clinical manifestations of GERD

Heart burn Dyspepsia Regurgitation Chest pain Respiratory problems Hoarseness Sore throat Globus sensation Hypersalivation Choking

when does jaundice occur?

caused by excess bilirubin in the blood. Bilirubin is produced by the normal breakdown of red blood cells. Normally, bilirubin passes through the liver and is excreted as bile through the intestines. Jaundice occurs when bilirubin builds up faster than a liver can break it down and pass it from the body. it then collects in areas that contain elastin such as sclera of eyes, nail beds, and skin.

Cirrohsis

chronic degenerative changes in liver cells and thickening of surrounding tissues that result from the liver repairing itself after chronic inflammation. damage cant be reversed but can be slowed down by removing the cause such as alcohol.

what are the causes for cirrhosis?

chronic hepatitis, repeated exposure to toxic substances, disease process, cancer, and chronic alcohol abuse.

what is Denver peritoneal shunt?

it is done on pt having continuous fluid build up "ascites". it transfer fluid from the peritoneal space to the circulatory system.