Med surge Exam 4

Hiatal Hernias

-Also called diaphragmatic hernias -Protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest -May be asymptomatic or have symptoms similar to those with GERD -Sliding versus paraesophageal -Sliding hiatal hernias, where the gastroesophageal junction (GEJ) and the gastric cardia migrate into the thorax, account for 95% of hiatal hernia -In paraesophageal hernias (PEH), only the gastric fundus herniates into the thorax, whereas in mixed hiatal hernias, the GEJ as well as the gastric fundus herniate.

Health Promotion and Maintenance

-American Cancer Society (ACS) and Canadian Cancer Society (CCS) establish evidence-based guidelines -Teach to use multiple methods for early detection -Mammography -Breast self-awareness/self-examination -Clinical breast examination -Options for high-risk women

Inflammatory Disorders

-Appendicitis -Peritonitis -Gastroenteritis -Ulcerative colitis -Crohn's Disease: Crohn's disease (CD) is a chronic inflammatory disease of the small intestine (most often), the colon, or both. It can affect the GI tract from the mouth to the anus but most commonly affects the terminal ileum. CD is a slowly progressive and unpredictable disease with involvement of multiple regions of the intestine with normal sections in between (called skip lesions on x-rays). Like ulcerative colitis (UC), this disease is recurrent, with remissions and exacerbations. -Diverticulosis versus diverticulitis: Diverticula are pouchlike herniations of the mucosa through the muscular wall of any part of the gut, but most commonly the colon. Diverticulosis is the presence of many abnormal pouchlike herniations (diverticula) in the wall of the intestine. Acute diverticulitis is the inflammation or infection of diverticula

Problems of the Biliary System and Pancreas

-Cholecystitis -Cholecystectomy -Pancreatitis -Pancreatic Abscess -Pancreatic Pseudocyst -Pancreatic Cancer

Pancreatic Cancer

-Difficult to diagnose -Treatment has limited results -Low survival rates -Nonsurgical management -Drug therapy -Radiation therapy -Biliary stent insertion Surgical Management uPreoperative care uNG tube may be inserted uTPN typically begun uOperative procedure may include Whipple procedure uPostoperative care uObserve for complications uGI drainage monitoring -Positioning -Fluid and electrolyte assessment -Glucose monitoring

Noninvasive Breast Cancers

-Ductal carcinoma in situ (DCIS) -Lobular carcinoma in situ (LCIS)

Evaluation: Reflecting

-Exhibit adherence to choosing appropriate dietary selections, taking drugs as prescribed, and making appropriate lifestyle modifications. -Report decrease of reflux signs and symptoms associated with GERD. -Avoid complications resulting from GERD. -Acid-suppressive agents have become the drugs of choice for GERD. -Both proton pump inhibitors (PPIs) and histamine H2-receptor antagonists (H2-RA) are effective and can be safely used to treat GERD.

Psychosocial Assessment

-Fear, shock, disbelief -Previous history of mental illness, age, and life circumstances can increase distress -Encourage expression -Refer to support group -Assess for concerns related to sexuality

Fibrocystic Breast Condition (FBC)

-Fibrocystic changes of breast (may involve lobules, ducts, stromal tissues) -Common in premenopausal women between 20 and 50 years of age -Thought to be caused by imbalance in normal estrogen-to-progesterone ratio -Symptoms: Breast pain, tender lumps, swelling (often before menstrual period) -Two main features are fibrosis and cysts -Interprofessional collaborative care -Analgesics -Limit salt intake before menses -Wear supportive bra at all times -Ice or heat may help -Reduce or eliminate caffeine, dairy product -Needle aspiration may be necessary -Oral contraceptives or selective estrogen receptor modulators may be prescribed

Types of Ulcers

-Gastric -Duodenal -stress Complications of Ulcers -Hemorrhage -Perforation -Pyloric obstruction -Intractable disease Etiology and Genetic Risk -H. pylori -NSAIDs -Other substances that alter gastric secretion Assessment: Noticing -Assess risk factors, including alcohol and tobacco intake; increased stress; dietary habits. -History of H. pylori, GI surgeris -Prescription and OTC drugs -Physical Assessment -Epigatric tenderness, dyspepsia -Rigid, boardlike abdomen w/rebound tenderness and pain = perforation into peritoneal cavity -Gastric versus duodenal ulcer pain -Assess for fluid volume deficit Psychosocial Assessment -Assess impact of ulcer disease on lifestyle, occupation, family, social, leisure activities. -Evaluate impact of necessary lifestyle changes. Diagnostic Assessment -Testing for H. pylori -Chest, abdomen x-ray series (if perforation is suspected) -EGD -Nuclear medicine test (if GI bleeding is suspected) Analysis: Interpreting -Acute pain or chronic noncancer pain due to gastric and/or duodenal ulceration -Potential for upper GI bleeding due to ulceration Planning and Implementation:Responding -Managing acute pain or chronic non-cancer pain -Drug therapy - -Proton Pump Inhibitors -block acid production and promote healing -H2 Blockers ureduce acid the stomach produces -Antibiotics for H pylori-related gastritis -Clarithomycin, metronidazole, amoxicillin -Nutrition therapy- -Foods rich in antioxidants (berries, bell peppers) -Complementary and integrative therapies -Managing Upper GI bleeding-slow bleed versus acute -Nonsurgical management-triple therapy -as above -Surgical management-Endoscopic therapy first -(cauterize or clip) Evaluation: Reflecting -Does not have active PUD or complications -Verbalizes pain control or relief -Adheres to drug regimen, lifestyle changes -Does not experience upper GI bleed

Breast Cancer in Young Women

-Genetic predisposition is a strong risk factor -Often younger women have more aggressive forms of the disease -Screening can be less effective

Cellular Regulation Concept Exemplar: Breast Cancer

-Heterogeneous disease with different presentations and therapy responses -Invasive versus noninvasive -Most common sites of metastasis are bones, liver, lung, and brain

Psychosocial Assessment

-High anxiety due to terminal nature of this cancer -Fear of choking -Social impact -Coping strengths, support systems, and resources

Complications of Acute Pancreatitis

-Hypovolemia -Hemorrhage -Acute kidney failure -Paralytic ileus -Hypovolemic or septic shock -Pleural effusion, respiratory distress syndrome, pneumonia -Multisystem organ failure -Disseminated intravascular coagulation -Diabetes mellitus

Etiology and Genetic Risk

-Increased age -Family history -Early menarche, nulliparity, late menopause -Lack of breastfeeding -Postmenopausal obesity -Use of postmenopausal HRT -Alcohol consumption Mutations in BRCA1 and BRCA2

Invasive Breast Cancers

-Infiltrating ductal carcinoma -Fibrosis develops around the cancer -Peau d'orange -Inflammatory breast cancer (IBC) -Diffuse erythema -Peau d'orange -Often harder to successfully treat

Crohn's Disease

-Inflammation of the digestive tract -Causes -Immune System-bacteria or virus -Heredity -Risk factors-age, ethnicity(Caucasian), family history, smoking, NSAIDS -Signs and symptoms -Abdominal pain, severe diarrhea, fatigue, weight loss fever, blood in stool, pain and/or drainage around the anus, malnutrition -Diagnostic tests -Colonoscopy, CT, MRI -Treatments -No cure -Reduce the symptoms -Antiinflmmatory Drugs -Corticosteroids Immune System Supressors

Diagnostic Assessment

-Laboratory studies -Serum tests-hpylori (gastric cancer) -Urine tests -Stool tests -gFOBT-Fecal Occult Blood test (blood in stool) -FIT-Fecal Immunochemical Test) is a stool test used to look for possible signs of colorectal cancer. -CT, Computed tomography; Endoscopy, esophagogastroduodenoscopy.

Cholecystectomy

-Laparoscopic versus traditional -Minimally invasive -Performed far more than the traditional open approach -Complications are not common. -Patient recovery is quicker. -Postoperative pain is less severe. -Preoperative -Fasting -IVF -Post Operative -Antibiotics -Pain Medications

Liver Trauma

-Most common organ injured during abdominal trauma -Observe for early signs of hypovolemic shock. -Signs and Symptoms -Anxiety or agitation, Cool, clammy skin. Confusion. Decreased or no urine output. Generalized weakness. -Pale skin color (pallor), Rapid breathing, Sweating, moist skin. -May require enhanced critical care monitoring, surgery, blood replacement, volume infusion

GERD

-Most common upper GI disorder in the U.S. -Occurs as a result of backward flow of stomach contents into esophagus -Hiatal hernias increase risk for GERD -During healing, Barrett's epithelium and esophageal stricture are concerns.

Gastric Cancer

-Most stomach cancers are adenocarcinomas. -May be asymptomatic until detected in advanced stage Etiology and Genetic Risk -Infection with H. pylori -History of pernicious anemia, gastric polyps, chronic atrophic gastritis, achlorhydria -Eating pickled foods, nitrates from processed foods, and salt added to foods -Prior gastric surgery Incidence and Prevalence -More common in males than females, and those over 50 -In U.S., Hispanic Americans, African Americans, and Asian/Pacific Islanders have higher incidence. Health Promotion and Maintenance -Follow treatment regimen closely. -Eat well-balanced diet; limit pickled, processed, and salted foods. Assessment: Noticing -Ask about dietary history; previous H. pylori infection; gastric surgery or polyps. -Indigestion and abdominal discomfort are most common early symptoms. -Anemia, progressive weight loss, nausea and vomiting may be present in advanced cancer. EGD, EUS, CT, PET, and MRI are used for diagnosis Interventions: Responding -Nonsurgical management -Radiation, chemotherapy -Surgical management -Gastrectomy or subtotal (partial) gastrectomy -Preoperative care -Operative procedures -Postoperative care

Immunity Concept Exemplar: Peptic Ulcer Disease

-Mucosal lesion of stomach or duodenum -Occurs when mucosal defenses become impaired; epithelium not protected from effects of acid and pepsin

Fatty Liver (Steatosis)

-NAFLD versus NASH -Nonalcoholic fatty liver disease (NAFLD) is a condition in which fat builds up in your liver. Nonalcoholic steatohepatitis (NASH) is a type of NAFLD. If you have NASH, you have inflammation and liver cell damage, along with fat in your liver. -ALT/AST, MRI, US, nuclear medicine are used to diagnose -Interventions include weight loss, glucose control, lipid-lowering agents.

Colostomy Care

-Normal appearance of stoma -Signs and symptoms of complications -Measurement of stoma -Choice, use, care, application of appropriate appliance to cover stoma -Measures to protect skin -Dietary measures to control gas and odor -Resumption of normal activities

Incidence and Prevalence

-One of every eight women in the U.S. will develop breast cancer by age 70 (similar in Canada) -Second leading cause of cancer death in women

Psychosocial Assessment of GI

-Patients may be embarrassed to discuss elimination problems. -Ask how GI health problem affects life, lifestyle, activities, employment. -Ask about stressful events that preceded or exacerbate GI problems. -Patients with cancer may experience the grieving process.

Health Promotion and Maintenance

-Patients may be initially asymptomatic. -Healthy eating habits -Limitation of fried, fatty, spicy foods, and caffeine -Sit upright for one hour after eating.

Cancer of the Liver

-Primary versus metastatic tumors -One of the most fatal types of cancer -Cirrhosis increases risk -Most people don't have signs and symptoms in the early stages of primary liver cancer. - When signs and symptoms do appear, they may include: -Losing weight without trying -Loss of appetite -Upper abdominal pain -Nausea and vomiting -General weakness and fatigue -Abdominal swelling -Yellow discoloration of your skin and the whites of your eyes (jaundice) -White, chalky stools Diagnostics Elevated AFP and alkaline phosphatase are common. US and contrast-enhanced CT are used. Risks Chronic infection with HBV or HCV. Cirrhosis. Hemochromatosis and Wilson's disease. Diabetes. Nonalcoholic fatty liver disease. Exposure to aflatoxins. Aflatoxins are poisons produced by molds that grow on crops that are stored poorly. Excessive alcohol consumption.

Care Coordination and Transition Management

-Self-management education -Maintain a healthy weight. ... -Stop smoking. ... -Elevate the head of your bed. ... -Don't lie down after a meal. ... -Eat food slowly and chew thoroughly. ... -Avoid foods and drinks that trigger reflux. ... -Avoid tight-fitting clothing.

Nutrition Concept Exemplar: Esophageal Tumors

-Some can be benign; most are malignant -More than half metastasize -Primary risk factors are smoking and obesity. Barrett's esophagus results from acid and pepsin exposure Assessment: Noticing -Assess for risk factors. uAsk about consumption of smoked/pickled foods, appetite and/or taste changes, weight loss. -May report dysphagia, odynophagia (painful swallowing) -"Silent tumor" in early stages

Esophageal trauma

-The main causes for esophageal perforation in adults are iatrogenic, traumatic, spontaneous and foreign bodies. -High rate of morbidity and mortality

Acute versus Chronic Cholecystitis

-Underlying cause -Gallstones or biliary sludge -Signs/symptoms -Severe pain in upper right or center abdomen that spreads to your right shoulder, nausea, vomiting, fever -Risk factors -gallstones -Role of diet -High Fat and Low Fiber increase the risk uUltrasonography (Abdomen) uHIDA Scan uA hepatobiliary iminodiacetic acid (HIDA) scan uimaging procedure used to diagnose problems of the liver, gallbladder and bile ducts. ubile-excreting function of your liver and to track the flow of bile from your liver into your small intestine. uradioactive tracer is injected into a vein in your arm (allergies) uERCP (Endoscopic retrograde cholangio-pancreatography} uused to examine and treat diseases of the liver, bile ducts, and pancreas uInvasive uUses contrast dye uMajor Risk of procedure-pancreatitis uMRCP (Magnetic Resonance Cholangio-Pancreatography) uNon-invasive uNo dye uNo major risks of procedure Analysis: Interpreting -The priority collaborative problems for patients with cholecystitis include -Weight loss due to pain, nausea, and inflammation -Acute pain due to cholecystitis Planning and Implementation Promoting Nutrition uHigh fiber, low fat diet uSmall, frequent meals Manage Pain uNonsurgical Management uDrug Therapy-Antibiotics: To treat gallbladder infections. uMetronidazole . PiperacillinAnalgesics: To manage the pain caused due to gallstones. uOxycodone . AcetaminophenGallstone dissolvers: To dissolve gallstones. uUrsodiol . Chenodiol uLithotripsy uuses shock waves or a laser to break down stones in the kidney, gallbladder, or ureter. uSurgical Management uCholecystectomy

Pelvic Organ Prolapse (POP)

-Uterine, cystocele, rectocele -patients often report feeling of "something falling out" Assessment: Noticing Uterine prolapse—may report painful intercourse, backache, pelvic pressure Rectocele—constipation, hemorrhoids, fecal impaction, rectal fullness Elimination problems may accompany prolapse Diagnostic testing Cystography Bladder ultrasound Urine culture and sensitivity Radiographic imaging of urinary anatomy, voiding

Appendicitis

-a serious medical condition -appendix becomes inflamed and painful. -McBurney's point is located midway between the anterior iliac crest and the umbilicus in the right lower quadrant. -Classic area for localized tenderness during the later stages of appendicitis

Nursing Safety Priority

Action Alert A stool softener may be prescribed to keep stools soft in consistency for ease of passage. Teach patients to note the frequency, amount, and character of the stools. In addition to this information, teach those with colon resections to watch for and report signs and symptoms of intestinal obstruction and perforation (e.g., cramping, abdominal pain, nausea, vomiting). Advise the patient to avoid gas-producing foods and carbonated beverages. The patient may require 4 to 6 weeks to establish the effects of certain foods on bowel patterns

Nursing Safety Priority

Action Alert After esophagogastroduodenoscopy (EGD), monitor vital signs, heart rhythm, and oxygen saturation frequently per agency protocol until they return to baseline. In addition, frequently assess the patient's ability to swallow saliva. The patient's gag reflex may initially be absent after EGD because of anesthetizing (numbing) of the throat with a spray before the procedure. After the procedure, do not allow the patient to have food or liquids until the gag reflex has returned!

Nursing Safety Priority

Action Alert For the patient with suspected appendicitis, administer IV fluids as prescribed to maintain fluid and electrolyte balance and replace fluid volume. If tolerated, advise the patient to maintain a semi-Fowler position so that abdominal drainage can be contained in the lower abdomen. Once the diagnosis of appendicitis is confirmed and surgery is scheduled, administer opioid analgesics and antibiotics as prescribed. The patient with suspected or confirmed appendicitis should not receive laxatives or enemas, which can cause perforation of the appendix. Do not apply heat to the abdomen because this may increase circulation to the appendix and result in increased inflammation and perforation!

Nursing Safety Priority

Action Alert Monitor the patient's level of consciousness, vital signs, respiratory status (respiratory rate and breath sounds), and intake and output at least hourly immediately after abdominal surgery. Maintain the patient in a semi-Fowler position to promote drainage of peritoneal contents into the lower region of the abdominal cavity. This position also helps increase lung expansion.

Nursing Safety Priority

Action Alert Peristaltic movements are rarely seen unless the patient is thin and has increased peristalsis. If these movements are observed, note the quadrant of origin and the direction of peristaltic flow. Report this finding to the health care provider because it may indicate an intestinal obstruction. If a bulging, pulsating mass is present during assessment of the abdomen, do not touch the area because the patient may have an abdominal aortic aneurysm, a life-threatening problem. Notify the health care provider of this finding immediately!

Nursing Safety Priority

Action Alert Report any of these early postoperative stoma problems to the surgeon: • Stoma ischemia and necrosis (dark red, purplish, or black color; dry) • Continuous heavy bleeding • Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal wall)

Nursing Safety Priority

Action Alert Teach the patient who has had surgery for PUD to avoid any OTC product containing aspirin or other NSAIDs. Emphasize the importance of following the treatment regimen for H. pylori infection and healing the ulcer and of keeping all follow-up appointments. Help the patient identify situations that cause stress, describe feelings during stressful situations, and develop a plan for coping with stressors.

Nursing Safety Priority

Action Alert Teach the patient who has peptic ulcer disease to seek immediate medical attention if experiencing any of these symptoms: • Sharp, sudden, persistent, and severe epigastric or abdominal pain • Bloody or black stools • Bloody vomit or vomit that looks like coffee grounds

Nursing Safety Priority

Action Alert Teach the patient with peptic ulcer disease to follow healthy nutrition habits and avoid substances that increase gastric acid secretion. This includes caffeine-containing beverages (coffee, tea, cola). Both caffeinated and decaffeinated coffees should be avoided because coffee contains peptides that stimulate gastrin release Critical Rescue Recognize that your priority for care of the patient with upper GI bleeding is to maintain a irway, b reathing, and c irculation (ABCs). Respond to these needs by providing oxygen and other ventilatory support as needed, starting two large-bore IV lines for replacing fluids and blood, and monitoring vital signs, hematocrit, and oxygen saturation.

Nursing Safety Priority

Action Alert Tell the patient who has had surgical intervention for hemorrhoids that the first postoperative bowel movement may be very painful. Be sure that someone is with or near the patient when this happens. Some patients become light-headed and diaphoretic and may have syncope (temporary loss of consciousness) related to a vasovagal response.

Nursing Safety Priority

Action Alert The priority for care to promote patient safety after esophagogastroduodenoscopy is to prevent aspiration. Do not offer fluids or food by mouth until you are sure that the gag reflex is intact! Monitor for signs of perforation, such as pain, bleeding, or fever Action Alert Teach the patient and family to monitor for severe postprocedure complications at home, including cholecystitis or cholangitis (gallbladder inflammation or infection), bleeding, perforation, sepsis, and pancreatitis (Lee et al., 2018). The patient has severe pain if any of these complications occur. Fever is present in sepsis. These problems do not occur immediately after the procedure; they may take several hours to 2 days to develop

Acute pancreatitis

Acute pancreatitis is a serious and at times life-threatening inflammation of the pancreas. This inflammatory process is caused by a premature activation of excessive pancreatic enzymes that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas. The pathologic changes occur in different degrees. The severity of pancreatitis depends on the extent of inflammation and tissue damage. Pancreatitis can range from mild involvement evidenced by edema and inflammation to necrotizing hemorrhagic pancreatitis (NHP). NHP is diffuse bleeding pancreatic tissue with fibrosis and tissue death.

Nursing Safety Priority

After a laparoscopic cholecystectomy, assess the patient's oxygen saturation level using pulse oximetry frequently until the effects of the anesthesia have passed. Remind the patient to perform deep-breathing exercises every hour

Erectile Dysfunction (ED)

Also called "impotence" Inability to achieve or maintain erection for sexual intercourse Organic versus functional ED Assessment History Serum hormone levels Doppler ultrasonography test Interprofessional Collaborative Care Medication—teach about vasodilation effects Vacuum constriction device Injections with vasodilating drugs Penile implants (prostheses)

Inflammatory Disorders Plan of Care

Assessment: Noticing Cardinal Signs abdominal pain, tenderness, and distension Laboratory Assessment: WBC counts are often elevated to 20,000/mm^3 Analysis: Interpreting/Planning: Responding Potential for Infection Potential for fluid volume shift due to fluid moving into interstitial or peritoneal space. Restore Fluid Volume Balance Diarrhea Risk for Deficient Fluid Volume Anxiety Ineffective Coping Acute Pain and Manage pain Imbalanced Nutrition: Less Than Body Requirements Deficient Knowledge

Nursing Safety Priority

Because paralytic (adynamic) ileus is a common complication of acute pancreatitis, prolonged nasogastric intubation may be necessary. Assess frequently for the return of peristalsis by asking the patient if he or she has passed flatus or had a stool. The return of bowel sounds is not reliable as an indicator of peristalsis return; passage of flatus or a bowel movement is the most reliable indicator. For the patient with acute pancreatitis, monitor his or her respiratory status every 4 to 8 hours or more often as needed and provide oxygen to promote comfort in breathing. Respiratory complications such as pleural effusions increase patient discomfort. Fluid overload can be detected by assessing for weight gain, listening for crackles, and observing for dyspnea. Carefully monitor for signs of respiratory failure

Interprofessional Collaboration

Care of Patients with Cirrhosis For patients with moderate-to-late-stage liver disease, collaborate with the case manager (CM) or other discharge planner to coordinate interprofessional continuing care. According to the Interprofessional Education Collaborative (IPEC) Expert Panel's Competency of Roles and Responsibilities, using the unique and complementary abilities of other team members optimizes health and patient care (IPEC Expert Panel, 2016; Slusser et al., 2019). Collaborate with health care team members to help the client be as ADL independent as possible, including physical and occupational therapists. Patients with end-stage disease may benefit from hospice care

Condylomata Acuminata (Genital Warts)

Caused by certain types of HPV HPV is primary risk factor for development of cervical cancer Incubation—2 to 3 months Assessment: Noticing Single, small white or flesh-colored papillary growths that may grow into large, cauliflower-like masses Warts may disappear and resolve, or recur Pap and HPV DNA testing; other STI tests may be done as well Wart biopsy Interventions: Responding Drug therapy Cryotherapy, TCA or BCA, podophyllin Self-management education Teach about transmission, incubation, treatment, complications, partner education Gardasil

Chlamydia Infection

Chlamydia trachomatis is an intracellular bacterium and the causative agent of cervicitis (in women), urethritis, and proctitis. It invades the epithelial tissues in the reproductive tract. The incubation period ranges from 1 to 3 weeks, but the pathogen may be present in the genital tract for months without producing symptoms. C. trachomatis is reportable to local health departments in all states. In the United States, it is the most frequently reported bacterial sexually transmitted infection Chlamydia trachomatis—intracellular bacterium, causative agent of genital chlamydial infections Reportable to local health departments in all states Often asymptomatic African-American women between 15 and 24 a highest risk Assessment: Noticing Complete history GU review Psychosocial history Sexual history Interventions: Responding Treatment of choice is azithromycin or doxycycline EPT Education Mode of transmission Incubation period Possibility of asymptomatic infection Need for abstinence until treatment is completed

Colorectal Cancer

Colorectal—refers to colon and rectum, which together make up large intestine Most CRCs are adenocarcinomas umalignant tumor formed from glandular structures in epithelial tissue. Etiology -Age > 50 years -Genetic predisposition -Personal/family history of cancer -Familial adenomatous polyposis Interprofessional Collaborative Care Assessment Physical Assessment -Bleeding and change in stool (most common signs) Psychosocial Assessment Laboratory Assessment -Fecal occult blood test (FOBT) -Carcinoembryonic antigen (CEA) Imaging Assessment -Sigmoidoscopy -Colonoscopy Analysis: Interpreting -Potential for metastasis due to colorectal cancer -Potential for grieving due to cancer diagnosis Planning and Implementation: Responding -Prevent/Control Metastasis -Radiation Therapy -Chemotherapy -Surgical Management -Assist with Grieving Process -Care Coordination and Transition Management

Nursing Safety Priority

Critical Rescue Recognize that it is important to monitor stools for blood loss for the patient with ulcerative colitis. The blood may be bright red (frank bleeding) or black and tarry (melena). Monitor hematocrit, hemoglobin, and electrolyte values and assess vital signs. Prolonged slow bleeding can lead to anemia. Observe for fever, tachycardia, and signs of fluid volume depletion. Changes in mental status may occur, especially among older adults, and may be the first indication of dehydration or anemia. If symptoms of GI bleeding begin, respond by notifying the Rapid Response Team or primary health care provider immediately. Blood products are often prescribed for patients with severe anemia. Prepare for the blood transfusion by inserting a large-bore IV catheter if it is not already in place. Chapter 37 outlines nursing actions during blood transfusion.

Patient-Centered Care: Cultural/Spiritual Considerations

Cultural and spiritual patterns are important in obtaining a complete nutrition history. Ask if certain foods pose a problem for the patient. For example, spices or hot pepper used in cooking can aggravate or precipitate GI tract symptoms such as indigestion. Note spiritual observations such as fasting or abstinence. Many non-white Americans and those of Asian and South American heritage are lactose intolerant as a result of having insufficient amounts of the enzyme lactase or producing a less active form of the enzyme (Bass, 2017). A much smaller percentage of Caucasian people also have this problem. Lactase is needed to convert lactose in milk and other dairy products to glucose and galactose. Lactose intolerance causes bloating, cramping, and diarrhea as a result of lack of lactase

Diverticula, Diverticulitis, Diverticulosis

Diverticular Group Diverticulosis, diverticular bleeding, and diverticulitis Affecting the colon or large intestine. Causes herniation or out-pouching of the walls of colon, creating small pouches Caused by trapped food or bacteria Pain, which may be constant and persist for several days. LLQ of the abdomen is the usual site of the pain. RLQ side of the abdomen is more painful, especially in people of Asian descent. Nausea and vomiting. Fever. Abdominal tenderness. Constipation or, less commonly, diarrhea. Several abnormal outpouchings, or herniations, in the wall of the intestine, which are diverticula. These can occur anywhere in the small or large intestine but are found most often in the sigmoid, as shown in this figure. Diverticulitis is the inflammation of a diverticulum that occurs when undigested food or bacteria become trapped in the diverticulum.

Nursing Safety Priority

Drug Alert Teach patients taking sulfasalazine to report nausea, vomiting, anorexia, rash, and headache to the health care provider. With higher doses, hemolytic anemia, hepatitis, male infertility, or agranulocytosis can occur. This drug is in the same family as sulfonamide antibiotics. Therefore, assess the patient for an allergy to sulfonamide or other drugs that contain sulfa before the patient takes the drug. The use of a thiazide diuretic may be a contraindication for sulfasalazine

Early Versus Advanced Gastric Cancer

Early Gastric Cancer • Dyspepsia • Abdominal discomfort initially relieved with antacids • Feeling of fullness • Epigastric, back, or retrosternal pain Advanced Gastric Cancer • Nausea and vomiting • Iron deficiency anemia • Palpable epigastric mass • Enlarged lymph nodes • Weakness and fatigue • Progressive weight loss

Cholecystitis

Gallstones within the gallbladder and obstructing the common bile and cystic ducts. Cholecystitis is an inflammation of the gallbladder that affects many adults, very commonly in affluent countries. It may be either acute or chronic, although most patients have the acute type. The inflammatory process often affects the client's nutrition status.

Patient and Family Education: Preparing for Self-Management

Gastritis Prevention • Eat a well-balanced diet and exercise regularly. • Avoid drinking excessive amounts of alcoholic beverages. • Do not take large doses of aspirin, other NSAIDs (e.g., ibuprofen), or corticosteroids. • Avoid excessive intake of coffee (even decaffeinated). • Be sure that foods and water are safe to avoid contamination. • Manage stress levels using complementary and integrative therapies such as relaxation and meditation techniques. • Stop smoking and/or using other forms of tobacco. • Protect yourself against exposure to toxic substances in the workplace such as lead and nickel. • Seek medical treatment if you are experiencing symptoms of gastroesophageal reflux (see Chapter 49).

Gastritis

Gastritis is the inflammation of gastric mucosa (stomach lining) It can be classified according to cause, cellular changes, or distribution of the lesions, and can be erosive (causing ulcers) or nonerosive. Although the mucosal changes that result from acute gastritis typically heal after several months, this is not true for chronic gastritis-Inflammation of gastric mucosa -Erosive versus nonerosive -Acute versus chronic -Chronic: Type A versus Type B versus atrophic -Acid autodigestion Etiology and Genetic Risk -H. pylori -Long-term NSAID use -Local irritation from radiation therapy -Accidental or intentional ingestion of corrosive materials -Autoimmune causes Health Promotion and Maintenance -Balanced diet -Regular exercise -Stress-reduction techniques -Limit foods and spices that cause gastric distress. -Avoid tobacco, alcohol. -Avoid excessive use of aspirin, NSAIDs. Assessment: Noticing -Epigastric alterations in comfort -Nausea, vomiting, upper abdominal or epigastric pain -Diagnostic assessment -EGD -Cytologic examination -Rapid urease testing Interventions: Responding -Acute gastritis treated with supportive care -Chronic gastritis treated based on causative agent

Patient-Centered Care: Gender Health Considerations

Genetic predisposition is a stronger risk factor for younger women than older women. Younger women frequently present with more aggressive forms of the disease; they are usually diagnosed at a later stage, have triple-negative breast cancer, and must receive more aggressive treatment. Screening tools can be less effective for this group because the breasts tend to be denser and mammographic recognition of breast cancer may be impaired in areas of dense tissue. Nurses should encourage women who have symptoms to seek evaluation and not watch and wait.

Genital Herpes

Genital herpes (GH) is an acute, recurring, common viral disease. Although preventative and therapeutic vaccines are still under investigation, at this time, GH is still considered incurable (American Sexual Health Association, 2020). Two serotypes of herpes simplex virus (HSV) affect the genitalia: type 1 (HSV-1) and type 2 (HSV-2) (McCance et al., 2019). Most nongenital lesions such as cold sores are caused by HSV-1, transmitted via oral-oral contact. Historically, HSV-2 caused most of the genital lesions. However, either type can produce oral or genital lesions through oral-genital or genital-genital contact with an infected person. HSV-2 recurs and sheds asymptomatically more often than HSV-1. Many people with GH have not been diagnosed because they have mild symptoms and shed the virus intermittently. The incubation period of genital herpes is 2 to 20 days (average is 1 week). Many people do not have symptoms during the primary outbreak. The virus remains dormant and recurs periodically, even if the patient is asymptomatic. Recurrences are not caused by reinfection; they are related to viral shedding, and the patient is infectious. Long-term complications of GH include the risk for neonatal transmission and an increased risk for acquiring HIV infection Acute, recurring, incurable viral disease HSV-1, HSV-2 Incubation—2 to 20 days Primary outbreak may be asymptomatic but patient is still infectious Assessment: Noticing -History, physical examination, serology testing, viral culture or polymerase chain reaction assays of lesions Interventions: Responding Drug therapy Antivirals Self-management education Education about infection, transmission, recurrence, antivirals, sexual activity

Gonorrhea

Gonorrhea is a sexually transmitted bacterial infection caused by Neisseria gonorrhoeae, a gram-negative intracellular diplococcus. It is transmitted by direct sexual contact with mucosal surfaces Sexually transmitted bacterial infection Can be asymptomatic First symptoms occur 3 to 10 days after sexual contact with infected person Can cause PID, endometriosis, and salpingitis in females Assessment: Noticing Complete history GU history Sexual history Allergies to antibiotics May be asymptomatic or symptomatic Diagnostic swabbing may be done Other STI testing should be done Interventions: Responding Treatment of choice is ceftriaxone plus azithromycin, or doxycycline EPT Self-management education Transmission Medication education needed, especially if co-treating other infection Possibility of re-infection Risk for PID in women Stop sexual activity until antibiotic therapy is done Reportable

Assessments: Noticing GYN issues

Health habits—e.g., nutrition history Alcohol, tobacco, drug use Family history, genetic risk Childhood or chronic illnesses; surgeries History of radiation or chemotherapy, corticosteroids, hormone therapy Current health problems Females: last Pap, self-exams Males: last prostate exam and PSA test

Assessment: Noticing

History -Risk factors -Breast mass -Health maintenance practices -OBGYN history -Alcohol use Physical assessment -Location, shape, size, consistency, mobility of mass -Skin changes -Lymph nodes

Cystocele and Rectocele

In cystocele, the urinary bladder is displaced downward, causing bulging of the anterior vaginal wall. In rectocele, the rectum is displaced, causing bulging of the posterior vaginal wall. Interventions: Responding Conservative treatment preferred over surgical, when possible Nonsurgical management Kegel exercises Surgical management

Issues of Breast Size in Women

Large-breasted women Clothing difficulty Backaches Fungal infections under the breast Small-breasted women Breast augmentation may be elected to increase or improve size, shape, or symmetry Implantation of saline-filled or silicon prostheses

Patient-Centered Care: Gender Health Considerations

Male breast cancer is rare and accounts for less than 1% of all breast cancer cases (Attebery et al., 2020). Risk factors for male breast cancer include previous radiation, a family history of breast cancer (male or female), BRCA1 and/or BRCA2 mutation, diabetes, alcohol use and liver disease, testicular disorders, and obesity (ACS, 2020c). Men usually present with a hard, painless, subareolar mass; gynecomastia may be present. Other symptoms include nipple discharge (often bloodstained), rash around the nipple, inverted nipple, ulceration or swelling of the chest, and possibly swollen lymph nodes. Because men usually do not suspect breast cancer, they often ignore the symptoms and postpone seeing their primary health care provider. As a result, many men are diagnosed at later stages than women. Treatment of breast cancer in men is the same as in women at a similar stage of disease

Patient-Centered Care: Older Adult Considerations

Many older adults have H. pylori infection that is undiagnosed because of vague symptoms associated with physiologic changes of aging and comorbidities that mask dyspepsia. Because the average age of gastric cancer diagnosis is 70 years, it is important to teach older adults about the symptoms of PUD and to consider H. pylori screening. Early detection and aggressive treatment can prevent PUD and gastric cancer.

Cirrhosis

Most common causes are hepatits B and D. Cirrhosis is extensive, irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis. This scarring process directly impairs cellular regulation . The disease typically develops slowly and has a progressive, prolonged, destructive course resulting in end-stage liver disease -Characterized by widespread fibrotic (scarred) bands of connective tissue •This changed the liver's normal makeup and its associated cellular regulation •Inflammation destroys hepatocytes •Liver become nodular; blood and lymph flow are impaired Cellular Regulation Concept Exemplar: Cirrhosis uCompensated versus decompensated uCompensated: When you don't have any symptoms of the disease, you're considered to have compensated cirrhosis. uDecompensated: When your cirrhosis has progressed to the point that the liver is having trouble functioning and you start having symptoms of the disease, you're considered to have decompensated cirrhosis. -Complications -Portal hypertension -Ascites and esophageal varices -Coagulation defects -Jaundice -PSE with hepatic coma -Hepatorenal syndrome -Spontaneous bacterial peritonitis Treatment uMedications to reverse poisoning. -Acute liver failure caused by acetaminophen overdose is treated with a medication called acetylcysteine. -This medication may also help treat other causes of acute liver failure. Mushroom and other poisonings also may be treated with drugs that can reverse the effects of the toxin and may reduce liver damage. Relieving pressure caused by excess fluid in the brain. -Cerebral edema caused by acute liver failure can increase pressure on your brain. Medications can help reduce the fluid buildup in your brain. Liver transplant. When acute liver failure can't be reversed, the only treatment may be a liver transplant. During a liver transplant, a surgeon removes your damaged liver and replaces it with a healthy liver from a donor. Screening for infections. Your medical team will take samples of your blood and urine every now and then to be tested for infection. If your doctor suspects that you have an infection, you'll receive medications to treat the infection. Preventing severe bleeding. Your doctor can give you medications to reduce the risk of bleeding. If you lose a lot of blood, your doctor may perform tests to find the source of the blood loss. You may require blood transfusions. Providing nutritional support Future Treatments uArtificial hepatic assist devices. A machine would do the job of the liver, much like dialysis helps when the kidneys stop working. uThere are many different types of devices being studied. Research suggests that some, but not all, devices may improve survival uHepatocyte transplantation. Transplanting only the cells of the liver — not the entire organ — may temporarily delay the need for a liver transplant. uIn some cases, it could lead to a complete recovery. A shortage of good-quality donor livers has limited the use of this treatment. uAuxiliary liver transplantation. This procedure involves removing a small piece of your liver and replacing it with a similarly sized graft. This allows your own liver to regenerate without the need for immunosuppressant drugs. -At this time, auxiliary liver transplantation is a difficult procedure that needs more time to be evaluated. Xenotransplantation. This type of transplant replaces the human liver with one from an animal or other nonhuman source. Doctors performed experimental liver transplants using pig livers several decades ago, but results were disappointing. uHowever, advancements in immune and transplant medicine have prompted researchers to consider this treatment again. It may help provide support for those waiting for a human liver transplant

Endometrial (Uterine) cancer

Most common gynecologic malignancy Adenocarcinoma is most common type Stages I to IV Assessment: Noticing Postmenopausal bleeding is main symptom May also report low back, pelvic, or abdominal pain Pelvic examination may reveal palpable uterine mass Diagnostic assessment CA-125 tumor marker; alpha-fetoprotein (AFP); hCG to rule out pregnancy before treatment Transvaginal ultrasound Endometrial biopsy Chest x-ray IVP Abdominal US CT of pelvis; MRI of abdomen and pelvis Liver, bone scans Interventions: Responding Surgical management Total hysterectomy Bilateral salpingo-oophorectomy (BSO) Nonsurgical management Radiation Drug therapy Chemotherapy

Interventions of HerniA

Nonsurgical management: -Interventions for GERD -Elevate head of the bed while sleeping, eating small meals, losing excess weight, stopping smoking, not lying down or exercising after meals, and not wearing tight-fitting clothes. Eliminating or limiting intake of beverages that contain acid (such as orange juice and colas), alcohol, coffee, and certain foods (such as onions, and spicy, acidic, and fatty foods) is recommended. Surgical management: -Symptomatic paraesophageal hiatal hernia -Corrected surgically to prevent strangulation. - Surgery may be done through a tiny incision in the chest or abdomen through which thin instruments and a small video camera are inserted (thoracoscopic or laparoscopic surgery) or may require a full open operation. Care Coordination and Transition Management uTeach about activity restrictions. uShower starting around 36 hours after surgery uNo baths, pools or hot tubs for two weeks. uYou will usually be able drive when you have not needed the narcotic (prescription) pain medications for two days -Nutrition modifications (coordinate with dietician) -You will need to stay on a liquid/soft diet for approximately 3 weeks after surgery. -Remind to contact health care provider if signs of infection are present after surgery. -Fever to 100.4 or greater -Shaking chills -Pain that increases over time -Redness, warmth, or pus draining from incision sites -Persistent nausea or inability to take in liquids

Patient-Centered Care: Gender Health Considerations

Obesity is a major risk factor for gallstone formation, especially in women. Pregnancy and drugs such as hormone replacements and birth control pills alter hormone levels and delay muscular contraction of the gallbladder, decreasing the rate of bile emptying. The incidence is higher in women who have had multiple pregnancies. Therefore some clinicians continue to refer to the patient most at risk for acute cholecystitis and gallstones by the four Fs: Female, Forty, Fat, and Fertile. However, cholecystitis often occurs in younger and older women and in those who are thin

Patient-Centered Care: Older Adult Considerations

Older adults and patients with diabetes mellitus may have atypical symptoms of cholecystitis, including the absence of pain and fever. Localized tenderness may be the only presenting sign. The older patient may become acutely confused (delirium) as the first symptom of gallbladder disease.

Nursing Safety Priority

One of the most important aspects of ongoing care for the patient with cirrhosis is health teaching about the need for the client to avoid acetaminophen, alcohol, smoking, and illicit drugs. By avoiding these substances, the patient may: • Prevent further fibrosis of the liver from scarring • Allow the liver to heal and regenerate • Prevent gastric and esophageal irritation • Reduce the incidence of bleeding • Prevent other life-threatening complications

Ovarian Cancer

Ovarian cancer is the leading cause of gynecologic cancer death, and the second most common type of gynecologic cancer (Chen & Berek, 2019). Most ovarian cancers are epithelial tumors that grow on the surface of the ovaries. These tumors grow rapidly, spread quickly, and are often bilateral. Tumor cells spread by direct extension into nearby organs and through blood and lymph circulation to distant sites (McCance et al., 2019). Free-floating cancer cells also spread through the abdomen to seed new sites, usually accompanied by ascites (abdominal fluid). Ovarian cancer seems to be disordered growth in response to excessive exposure to estrogen. This would explain the protective effects of pregnancies and oral contraceptive use, both of which interrupt the monthly estrogen exposure. Leading cause of death from female reproductive cancers (but not most common) Survival rates are low due to not being detected until late stages Vague abdominal and GI symptoms; abdominal swelling Interventions: Responding Surgery Chemotherapy Radiation may be used for more widespread cancer Care Coordination and Transition Management Avoid tampons, douches, and intercourse for 6 weeks or as directed Keep follow-up surgical appointment Community health resources; support groups Possible hospice referral

Pancreatic Abscess and Pancreatic Pseudocyst

Pancreatic Abscess Area filled with pus within the pancreas -Most serious complication of pancreatitis -Always fatal if untreated -Symptoms High fever -Diagnostics & Treatments -Blood cultures -Percutaneous drainage -Laparoscopy -Antibiotic treatment alone does not resolve abscess. Pancreatic Pseudocyst Pseudocyst created by additional pancreatitis complications - Hemorrhage - Infection - Bowel obstruction - Abscess - Fistula formation - Pancreatic ascites May spontaneously resolve Surgical intervention after 6 weeks

Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease (PID) is an acute syndrome resulting in tenderness in the tubes and ovaries (adnexa) and, typically, dull pelvic pain. Some women experience only mild discomfort or menstrual irregularity, whereas others have acute pain, which can affect their gait, Others experience no symptoms at all (i.e., so-called "silent" or "subclinical" PID. This infectious process involves movement of organisms from the endocervix upward through the uterine cavity into the fallopian tubes. Usually multiple pathogens are involved in the development of PID. Sexually transmitted organisms are most often responsible, especially C. trachomatis, N. gonorrhoeae, and Mycoplasma genitalium Complex infectious process Organisms from lower genital tract migrate from endocervix upward through uterine cavity into fallopian tubes Resultant infections Endometritis Salpingitis Oophoritis Parametritis Peritonitis Tubal or tubo-ovarian abscess Sepsis and death can occur if treatment is delayed or inadequate Leading cause of infertility Related to increasing number of ectopic pregnancies in United States Assessment: Noticing Complete history Menstrual, obstetric, sexual, and family histories History of previous PID and/or STI diagnosis Contraceptive use Reproductive surgery Other risk factors Sexual abuse Lower abdominal or pelvin pain is most frequent symptom May have vaginal bleeding, dysuria vaginal discharge, malaise, fever, chills Pelvic examination may show discharge, "friable" cervix Patient may be anxious and fearful Analysis: Interpreting Problem: Infection due to invasion of pelvic organs by sexually transmitted pathogens Planning and Implementation: Responding Interventions Antibiotic therapy Possible hospitalization depending on severity Care coordination and transition management Home care management Self-management education Health care resources Evaluation: Reflecting 1. Evidence that infection has resolved 2. Report or demonstrate relieved or reduced pain 3. Plan for partner treatment and follow-up care

Patient-Centered Care: Genetic/Genomic Considerations

People with a first-degree relative (parent, sibling, or child) diagnosed with colorectal cancer (CRC) have three to four times the risk for developing the disease. Many genes are associated with CRC. An autosomal dominant inherited genetic disorder known as familial adenomatous polyposis (FAP) accounts for 1% of CRCs. FAP is the result of one or more mutations in the adenomatous polyposis coli (APC) gene. In very young patients, thousands of adenomatous polyps develop over the course of 10 to 15 years and have nearly a 100% chance of becoming malignant (McCance, et al., 2019). By 20 years of age, most patients require surgical intervention, usually a colectomy with ileostomy or ileoanal pull-through, to prevent cancer. Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer (HNPCC), is another autosomal dominant disorder and accounts for approximately 3% of all CRCs. Lynch syndrome is also caused by gene mutations, including mutations in MLH1 and MLH2. People with these mutations have an 80% chance of developing CRC at an average of 45 years of age. They also tend to have a higher incidence of endometrial, ovarian, stomach, small bowel, brain, and ureteral cancers (McCance et al., 2019). Genetic testing is available for both of these familial CRC syndromes. Refer patients for genetic counseling and testing if the patient prefers.

Key features

Peritonitis • Rigid, board-like abdomen (classic) • Abdominal pain (localized, poorly localized, or referred to the shoulder or chest) • Distended abdomen • Nausea, anorexia, vomiting • Diminishing bowel sounds • Inability to pass flatus or feces • Rebound tenderness in the abdomen • High fever • Tachycardia • Dehydration from high fever (poor skin turgor) • Decreased urine output • Hiccups • Possible compromise in respiratory status

Pancreatitis

RISK FactorsSIGNS and SYMPTOMS -Excessive Alcohol consumption -Cigarette Smoking -Obesity -Family History -Upper abdominal pain -Abdominal pain that radiates to your back -Abdominal pain that feels worse after eating -Fever -Rapid pulse -Nausea -Vomiting -Tenderness when touching the abdomen

Nursing Safety Priority

Remind patients to abstain from sexual activity while GH lesions are present. Sexual activity can cause pain, and likelihood of viral transmission is higher. Urge condom use during all sexual encounters because of the increased risk for HSV transmission from viral shedding, which can occur even when lesions are not present. Teach the patient how to properly use condoms

Patient-Centered Care: Veterans Health Considerations

Research shows that female veterans have a higher incidence of breast cancer than the general population, possibly due to increased exposure to risk factors or to earlier detection (McDaniel et al., 2018). Encourage women veterans to have screening done per recommended guidelines due to this increased risk.

Breast Cancer in Men

Risk factors -Family history (M or F) of breast cancer BRCA 1/2 mutation -Diabetes -Gynecomastia -Testicular disorders -Obesity Usually presents as hard, painless, subareolar mass -Treatment is the same as that for women at similar stage of disease

Sexually Transmitted Infections (STI's)

STIs that recur and become chronic = sexually transmitted disease (STD) Worldwide health concern Older adults may lack awareness of their risk for STIs Some STIs are reportable CDC provides regularly updated guidelines for treatment

Esophageal Varices Treatment

Sengstaken-Blakemore tube in place for the emergency treatment of hemorrhage from esophageal varices. The tube has three openings for (1) gastric aspiration, (2) inflating the esophageal balloon, and (3) inflating the gastric balloon. The esophageal balloon is inflated to a pressure of 20 to 40 mm Hg (monitored by attachment to a gauge or a sphygmomanometer) that compresses the esophageal veins. The gastric balloon, inflated with 250 cc of air, applies pressure to the fundal veins when slight traction is applied.

Ulcerative Colitis

Severe mucosal edema and inflammation with ulcerations and bleedingin digestive tract Etiology and Risk Factors -Immune System Malfunction -Example -Fighting off virus or bacteria and causes the immune system to attack the cell in the digestive tract. -Age, ethnicity, and family history Analysis: Interpreting -The priority collaborative problems for patients with ulcerative colitis include -diarrhea due to inflammation of the bowel mucosa. -acute pain or chronic noncancer pain due to inflammation and ulceration of the bowel mucosa and skin irritation. -potential for lower GI bleeding and resulting anemia due to UC Planning and Implementation: Responding -Decrease diarrhea -Drug Therapy -Anti inflammatory Drugs (5-Aminosalicylates) -Corticosteroids -Immune system suppressant agents -Antidiarrheals -Nutrition Therapy -Surgical Management- colostomy -Minimize Pain -antidepressants, antispasmodics -Monitor for Lower GI Bleeding -Complications -Severe Bleeding -Severe Dehydration -Bone loss (osteoporosis) -Increased risk of colon cancer Ulcerative colitis (UC) is a disease that creates widespread chronic inflammation of the rectum and rectosigmoid colon but can extend to the entire colon when the disease is extensive. Distribution of the disease can remain constant for years. UC is a disease that is associated with periodic remissions and exacerbations (flare-ups) and is often confused with Crohn's disease. Comparisons and differences are listed in Table 52.2. Many factors can cause exacerbations, including intestinal infection . Most patients who are affected have mild-to-moderate disease, but a small percentage of patients present with severe symptoms. Older adults with UC are at high risk for impaired fluid and electrolyte balance as a result of diarrhea, including dehydration and hypokalemia (McCance et al., 2019).

Cellular Regulation Exemplar:Prostate Cancer

Slow growing cancer with predictable metastasis Advanced age is leading risk factor Second most common cancer in men Has nearly 100% cure rate if found early The prostate gland with cancer and BHP. Note that cancer normally arises in the periphery of the gland, whereas BPH occurs in the center of the gland. Health Promotion and Maintenance Teach ACS guidelines for screening and early detection Nutrition habits Assessment: Noticing History Age, race/ethnicity, family history Nutrition habits Elimination issues Drug history Pain, weight loss, change in sexuality Physical assessment Weight DRE performed by health care provider Psychosocial Assessment Fear, anxiety Shock Grieving process Concern regarding sexual function Diagnostic Assessment PSA TRUS Analysis: Interpreting Potential for metastasis due to invasion of cancer cells in other parts of the body Planning and Implementation: Responding Preventing metastasis Active surveillance (AS) Surgical management Preoperative care Operative procedures Postoperative care Radiation therapy Drug therapy Care Coordination and Transition Management Home care management Self-management education Health care resources Evaluation: Reflecting No cancer metastasis

Syphilis

Syphilis is a complex sexually transmitted infection (STI) that can become systemic and cause serious complications, including death. The causative organism is a spirochete called Treponema pallidum. The infection is usually transmitted by sexual contact and blood exposure, but transmission can occur through close body contact such as touching or kissing where there are open lesions. Untreated syphilis is divided into two categories—early and late—and progresses through four stages: primary (localized chancre), secondary (systemic illness), early latent (seropositive yet without symptoms), and tertiary (symptomatic infection). Neurosyphilis can occur at any time in any stage; patients with this form of the disease may experience meningitis, vision or hearing loss, and brain and spinal cord dysfunction. Can become systemic and cause serious complications, including death Chancre is first sign of primary syphilis Primary, secondary, tertiary stages Assessment: Noticing History of ulcers or rash Sexual history Risk assessment Physical examination Chancre specimen VDRL and RPR tests Interventions: Responding Drug therapy Benzathine penicillin G (monitor for allergic reaction) Health teaching Follow-up evaluation at 6, 12, 24 months Partner notification and treatment Reporting to local health authority May need psychosocial support

Testicular Cancer

Testicular cancer, which can occur in one or both testicles, is a rare cancer that most often affects men between 20 and 35 years of age but can affect men of any age. It usually strikes men at a productive time of life and thus has significant economic, social, and psychological impact on the patient and his family and/or partner. With early detection by testicular self-examination (TSE) (see the Patient and Family Education: Preparing for Self-Management: Testicular Self-Examination box and Fig. 67.6) and treatment, testicular cancer has a greater than 95% cure rate Rare cancer affecting men, usually between 20 and 35 years of age Usually curable with early detection by testicular self-examination Germ cell versus non-germ cell tumors Assessment: Noticing Physical assessment/signs and symptoms Consider risk factors Often presents as painless, hard swelling or enlargement of testicle Assess family situation, sexuality, desire for children Inspect for swelling or lump (health care provider will palpate) Psychosocial Assessment Concerns regarding sexuality Fear Assess support systems Diagnostic Assessment Laboratory assessment AFP, hCG LDH, serum testosterone levels Other diagnostic assessment Ultrasound CT of abdomen Lymphangiography MRI Interventions Sperm bank storage if patient desires Surgical management Orchiectomy Preoperative care Operative procedures Postoperative care Nonsurgical management Chemotherapy Care Coordination and Transition Management Usually discharged after 1 to 2 days Scrotal support Sutures to be removed in 7 to 10 days by provider Teach about lifting, stair-climbing, driving restrictions as needed Emotional support

Patient-Centered Care: Gender Health Considerations

The amount of alcohol necessary to cause cirrhosis varies widely from individual to individual, and there are gender differences. In women, it may take as few as two or three drinks per day over a minimum of 10 years. In men, perhaps six drinks per day over the same time period may be needed to cause disease. However, a smaller amount of alcohol over a long period of time can increase memory loss from alcohol toxicity of the cerebral cortex. Binge drinking can increase risk for hepatitis and fatty liver

GI tract

The gastrointestinal system (GI tract) can be thought of as a tube (with necessary structures) extending from the mouth to the anus for a 25-foot length. The structure of this tube (shown enlarged) is basically the same throughout its length.

Cervical Cancer

The uterine cervix is covered with squamous cells on the outer cervix and columnar (glandular) cells that line the endocervical canal. Papanicolaou (Pap) tests sample cells from both areas as a screening test for cervical cancer. The squamocolumnar junction is the transformation zone where most cell abnormalities occur. The adolescent has more columnar cells exposed on the outer cervix, which may be one reason that she is more vulnerable to sexually transmitted infections (STIs) and human immune deficiency virus (HIV). In contrast, in the menopausal woman the squamocolumnar junction may be higher up in the endocervical canal, making it difficult to sample for a Pap test. Premalignant changes are classified on a continuum from cervical intraepithelial neoplasia (dysplasia) to cervical carcinoma in situ (where the full epithelial thickness of the cervix is involved) to invasive carcinoma Progressive development Most cases caused by certain types of HPV HPV vaccine available Health Promotion and Maintenance HPV vaccine—must get entire series Pelvic examinations and Pap tests Assessment: Noticing May be asymptomatic Classic symptom is painless vaginal bleeding (especially between periods, or after intercourse or douching) Unexplained weight loss, dysuria, pelvic pain, hematuria, rectal bleeding, chest pain may be reported Diagnostic assessment Pap HPV-typing DNA test of cervical sample Coloposcopy Endometrial curettage Interventions: Responding Surgery Cervical ablation LEEP Laser therapy Cryotherapy Conization Total hysterectomy Radiation and chemotherapy may be used for late-stage disease

Nursing Safety Priority

To detect early signs of hypovolemia and prevent shock, closely monitor vital signs for decreased blood pressure and increased heart rate, decreased vascular pressures with a pulmonary artery catheter (Swan-Ganz catheter) (in ICU setting), and decreased urine output. Be alert for pitting edema of the extremities, dependent edema in the sacrum and back, and an intake that far exceeds output. Maintain sequential compression devices to prevent deep vein thrombosis.

Toxic Shock Syndrome (TSS)

Toxic shock syndrome (TSS) can result from leaving a tampon, contraceptive sponge, or diaphragm in the vagina. Other conditions associated with TSS include surgical wound infection, minor trauma, viral infection (e.g., varicella), and use of nonsteroidal anti-inflammatory medications (NSAIDs) (Bush & Vazquez-Pertejo, 2019). TSS can be fatal. TSS usually develops within 5 days after the onset of menstruation. Most common symptoms include fever (which remains elevated despite treatment), diffuse macular rash, myalgias, and hypotension. The rash associated with TSS often looks like a sunburn, and patients often develop broken capillaries in the eyes and skin. TSS due to Staphylococcus aureus also causes vomiting, diarrhea, thrombocytopenia, and confusion; TSS due to streptococcal infection can cause acute respiratory distress syndrome (ARDS), coagulopathy, and hepatic damage Usually results from menstruation and tampon use, gynecologic surgical wound infection, use of internal contraceptives Can be fatal Staphylococcus aureus Develops within 5 days after onset of menstruation Fever, rash, myalgias, sore throat, edema, hypotension Treatment focuses on removal of infection source, restoring fluid and electrolyte balance; medication therapy

Intestinal Obstruction

Types -Nonmechanical -'ileus' or 'paralytic ileus -the natural movement of the bowel peristalsis fails to happen -Caused by bacteria or viruses -Mechanical -Partial or complete blockage of the intestine -Can happen along any point of the intestinal tract -Adhesions or scar tissue that form after surgery -Impacted stool -Hernias -Introspection (one segment of bowel into another) -Volvulus (twisted intestine) -Tumors Physical Assessment uObstipation-severe form of constipation uAbdominal distension uPeristaltic waves uBobborygmi-rumbling or gurgling noise made by movement of fluid and gas in the intestines Diagnostic Assessment abdominal x-ray,CT, US, Barium Enema (enhancing imaging of colon) Priority Collaborative management problems for patients with intestinal obstruction include Potential for injury (e.g., peritonitis, acute kidney injury, etc.) due to obstruction Acute pain due to obstruction Potential Infection related to complications Interventions -Nonsurgical Management -Nasogastric tubes (decompresses bowel) -IV Fluid replacement -Surgical Management -Exploratory laparotomy -Partial (see if goes away on own-low fiber diet) versus Complete Obstruction (surgery to the obstruction)

Vulvovaginitis

Vaginal discharge and itching are two common problems experienced by most women at some time in their lives. Vaginal infections may be transmitted sexually and nonsexually. Gonorrhea, syphilis, chlamydia, and herpes simplex virus infections are sexually transmitted infections (STIs) discussed in Chapter 69. Vulvovaginitis is inflammation of the lower genital tract resulting from a disturbance of the balance of hormones and flora in the vagina and vulva. It may be characterized by itching, change in vaginal discharge, odor, or lesions. Pediculosis pubis, known as crab lice or "crabs," and scabies are parasitic infections of the vulvar skin that are sexually transmitted. Inflammation of lower genital tract resulting from disturbance of the balance of hormones and flora in vagina and vulva Characterized by itching, change in vaginal discharge, odor, or lesions Treatment focuses on the causative agent for infection

Differences between Ulcerative Colitis and Chron's

Where -UC-limited to colon -Chron's occurs anywhere between the mouth and anus PAIN -UC-confined to left side of abdomen with rectal bleeding -Chron's -pain anywhere in the abdomen

Benign Prostatic Hyperplasia (BPH)

With aging and increased dihydrotestosterone (DHT) levels, the glandular units in the prostate undergo nodular tissue hyperplasia (an increase in the number of cells; an abnormal overgrowth of tissue). This altered tissue promotes local inflammation by attracting cytokines and other substances. As the prostate gland enlarges, it extends upward into the bladder and inward, causing bladder outlet obstruction (BOO) (Fig. 67.1). In response, urinary elimination is affected in several ways, causing lower urinary tract symptoms (LUTS)—an umbrella term that includes problems such as urinary retention, urinary leaking, or incontinence. First, the detrusor (bladder) muscle thickens to help urine push past the enlarged prostate gland Glandular units in the prostate that undergo nodular tissue hyperplasia, resulting in enlargement of prostate gland Causes bladder outlet obstruction (BOO) Common; exact cause unknown Risk factors include obesity, DM, hormone supplementation, lack of physical activity Assessment: Noticing History International Prostate Symptom Score (I-PSS) Elimination patterns Ask whether hematuria is present Physical assessment Health care provider provides examination Psychosocial Examination Irritability, depression Libido may be affected Social isolation Anxiety Diagnostic Assessment •Urinalysis and culture •CBC •BUN •PSA •Transabdominal ultrasound and/or TRUS •MRI Analysis: Interpreting Urinary retention due to bladder outlet obstruction Decreased self-esteem due to overflow incontinence and possible sexual dysfunction with or without surgery Planning and Implementation: Responding 1. Improving urinary elimination •Nonsurgical management •Surgical management 2. •Improving self-esteem Care Coordination and Transition Management Home care preparation Self-education management Health care resources

Gender Health Considerations

Women are more easily infected, and have more asymptomatic infections Young women sexually active with men have greatest risk for STI Younger adults may have more unprotected sex Postmenopausal women may not use barrier protection Health Promotion and Maintenance Healthy People 2020 objective—completely eliminate syphilis in U.S. Safer sex practices

Esophageal diverticula

a protruding pouch in the lining of the esophagus. It forms in a weak area of the esophagus. The pouch can be anywhere from 1 to 4 inches in length.

Peritonitis

inflammation of the peritoneum, typically caused by bacterial infection either via the blood or after rupture of an abdominal organ

Upper GI Bleeding

• Bright red or coffee-ground vomitus ( hematemesis ) • Melena (tarry or dark sticky stools) • Decreased hemoglobin and hematocrit • Decreased blood pressure • Increased heart rate • Weak peripheral pulses • Acute confusion (in older adults) • Vertigo • Dizziness or light-headedness • Syncope (loss of consciousness)

Key features of late stage cirrhosis

• Jaundice and icterus (yellow coloration of the eye sclerae) • Dry skin • Pruritus (itchy skin) • Rashes • Purpuric lesions, such as petechiae (round, pinpoint, red-purple hemorrhagic lesions) or ecchymoses (large purple, blue, or yellow bruises) • Warm and bright red palms of the hands (palmar erythema) • Vascular lesions with a red center and radiating branches, known as spider angiomas (also called telangiectases, spider nevi, or vascular spiders), on the nose, cheeks, upper thorax, and shoulders • Ascites • Peripheral dependent edema of the extremities and sacrum • Vitamin deficiency (especially fat-soluble vitamins A, D, E, and K

Analysis: Interpreting

•Potential for compromised nutrition status due to dietary selection •Acute pain due to reflux of gastric contents