EVERYTHING CHAPTER 41 LEWIS- STUDY AND KNOW
-Caused by herpes simplex -Lip/mouth lesions, painful ulcers -Treatment w/ antivirals, lidocaine, creams, mouthwashes
Herpes Simplex
-Heartburn - Factors contributing include obesity, pregnancy, tumors, ascites, and increased physical exertion -Stomach herniation into esophagus through the diaphragm -Barium swallow and endoscopy
Hiatal hernia
A patient who has been vomiting for several days from an unknown cause is admitted to the hospital. WHAT should the nurse anticipate will FIRST be included in inter professional care?
IV Replacement of fluid and electrolytes
What physiologically occurs with vomiting?
Immediately before the act of vomiting, activation of the parasympathetic nervous system causes increased salivation, increased gastric motility, and relaxation of the lower esophageal sphincter.
Which laboratory findings should the nurse expect in the patient with persistent vomiting?
Increased PH Decreased Potassium Increased hematocrit
EAQ Which patient statement indicates a need for further teaching regarding appropriate dietary choices for illness with vomiting?
"I should drink carbonated beverages on ice."
Postprandial hypoglycemia
-Caused by bolus of fluid high in carbs into the small intestine -High carbs cause hyperglycemia -Hyperglycemia causes reflex hypoglycemia -Sweating, weakness, confusion, palpitations, anxiety, tachycardia
Bile Reflux Gastritis
-Reflux of bile into stomach -Damage to gastric mucosa, chronic gastritis, recurrent PUD -Continuous epigastric distress increased after meals -Cholestyramine is the treatment
Dumping syndrome
-Result of surgical removal of a large part of the stomach and pyloric sphincter -Bolus of hypertonic fluid entering intestine - Weakness, sweating, palpitations, dizziness -Abdominal cramps, borborygmi, defecation urge -Avoid sugary foods, no fluids w/ meal, divide meal into six feedings
gastritis
-inflammation of gastric mucosa -May or may not be present when suggested by clinical or radiologic signs
-Prokinetic -Inhibits dopamine -High doses can cause tardive dyskinesia -N/V drug
Metoclopramide (Reglan)
EAQ Following administration of a dose of metoclopramide to the patient, the nurse determines that the medication has been effective when what is noted?
Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient's nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.
EAQ The patient history indicates the patient was taking ondansetron at home before admission. The nurse inquires as to the effectiveness of this medication in treating which symptom?
Nausea - Ondansetron is an antiemetic. The nurse would inquire as to its effectiveness in reducing the patient's nausea. Ondansetron will not treat headaches, pain, or leg cramps.
GERD (gastroesophageal reflux disease)
Not a disease, but a syndrome. REFLUX of STOMACH ACID into the lower esophagus. Most common upper GI problem.
EAQ The patient receiving chemotherapy rings the call light and reports the onset of nausea. The nurse should prepare an as needed dose of which medication?
Ondansetron is a 5-HT3-receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting.
- Lesions usually on the lip - Tobacco/alcohol, sunlight exposure, HPV -Leukoplakia, erythroplakia, painless ulcer, dysphagia -Screening w/ toluidine blue test -Surgery is best option but may entail radical resection
Oral cancer
-From candida albicans or prolonged abx - "Milk curd" lesions on mucosa of mouth/larynx -Bad breath "yeasty" -abx and good oral hygiene are treatments
Oral candidiasis
Drugs for upper GI bleed
PPI, epinephrine during endoscopy, octreotide (Sandostatin), vasopressin
-GERD drug -Use associated w/ increased risk of C-diff infection in hospitalized patients -Take in the morning before the first meal of the day
PPIs (-zine)
Drugs used w/ GERD
PPIs (-zole), Histamine Receptor Blockers (-dine), Prokinetics, Antiulcer Protectants, Antacids, Prostaglandin
Normal GRV
Under 250 mL
-Bleeding in upper GI tract -Bloody vomit, coffee-ground emesis -Melena (black, tarry stools, foul-smelling) -PUD, aspirin, NSAIDs, chronic esophagitis, esophageal varices are all possible causes -First-line management is endoscopy to coagulate or thrombose the bleeding vessel
Upper GI bleed
-Painful bleeding gingivae -Necrotic lesions, bleeding ulcers, metallic taste -"trench mouth" -Bacterial - Treat w/ abx, rest, cessation of smoking/alcohol, irrigation w/ chlorhexidine and saline
Vincent's infection
-Major concern is electrolyte imbalance and dehydration -Another major concern is aspiration -Can be regurgitation or projectile or emesis -Spicy/acidic foods, caffeine, and food w/ strong odor can make it worse
Vomiting
A patient treated for vomiting is to begin oral intake when the symptoms have subsided. To promote REHYDRATION, the nurse plans to admirer which fluid first?
Water
Treatments for stomach cancer
1.) Surgery to remove as much of stomach as necessary and a margin of normal tissue 2.) Radiation and chemotherapy 3.) Targeted therapy
Nursing interventions for hiatal hernia
1.) Teach pt to dispose of constricting garments and to avoid heavy lifting or straining 2.) Decrease contributing factors 3.) take antacids
Surgery for hiatal hernia
1.) herniotomy (excision of hernial sac) 2.) herniorrhaphy (closing the hiatal defect) 3.) Gastropexy (attaching stomach below the diaphragm)
Nursing interventions for achalasia
1.) semisoft diet 2.) Eat slowly 3.) Drink fluid w/ meals 4.) Sleep w/ HOB elevated
Pre-op nursing for stomach cancer
1.) support 2.) Several small meals, caregiver assistance 3.) Supplements or EN/PN feedings 4.) Positive nutritional state enhances wound healing
Normal range for potassium?
3.5-5
What are good things to eat during N/V?
Bland foods, dry toast, crackers, warm tea, clear liquids
Post-op nursing for stomach cancer
1.) Check drainage 2.) When pt tolerates fluid w/o distress fluids are increased w/ some solid food added 3.) Dumping syndrome 4.) Impaired wound healing
gastric outlet obstruction from ulcers
1.) Discomfort/pain worse towards end of day 2.) Constipation from dehydration/ deceased intake 3.) NG tube w/ suction, electrolyte/fluid replacement, PPI or H2 receptor blocker if cause is ulcer 4.) If GRV is under 200 mL pt can start oral intake of clear liquids
What are the most common long-term post-op complications of PUD surgery?
1.) Dumping syndrome 2.) Postpranidal hypoglycemia 3.) Bile reflux gastritis
Nursing interventions for GERD
1.) Elevate HOB 30 degrees 2.) Have pt cough and deep breathe 3.) PPI given before first meal of the day 4.) Give prn meds for N/V and pain
Nursing for chronic gastritis
1.) Eliminate cause 2.) Abx for H. pylori 3.) Lifelong B12 therapy for anemia 4.) Stop smoking 5.) Nonirritating diet of six small meals/day
Nursing interventions for esophageal cancer
1.) Elimination of smoking/alcohol 2.) Emotional/physical support 3.) High calorie, high protein diet 4.) Turn, C&DB, incentive spirometry post-op 5.) Semi-Fowler's or Fowler's post-op 6.) Good oral hygiene
Other treatments for esophageal cancer
1.) Endoscopy 2.) Radiation/ chemo 3.) Targeted therapy (-mab)
Surgery for esophageal cancer
1.) Esophagectomy w/ use of Dacron graft 2.) Esophagogastrostomy 3. Esophagoenterostomy
Major complications of PUD
1.) Hemorrhage 2.) Perforation 3.) Gastric outlet obstruction
Nursing interventions for oral cancer?
1.) Identify those at risk 2.) Teach pt to report pain of mouth, unusual bleeding, dysphagia, sore throat, lumps/swelling, and voice changes 3.) Teach pt how to communicate after surgery
health promotion for stomach cancer
1.) Identify those at risk (H.pylori, pernicious anemia) 2.) Poor appetite, weight loss, fatigue, persistent stomach distress are signs 3.) Family history of stomach cancer
Nursing for PUD
1.) Identify those at risk and teach to report sx like epigastric pain, N/V, bloody emesis, black, tarry stools 2.) NPO, NG, IV fluids for acute care 3.) VS to detect shock 4.) Physical/emotional rest 5.) avoid cigarettes and alcohol intake and OTC drugs 6.) Stress management
Hemorrhage
1.) Increase in amount/redness of aspirate 2.) Maintain patency of NG tube
Surgeries for GERD
1.) LINX Reflux Management System (magnetic ring around lower esophagus) 2.) Nissen fundoplication (stomach wrapped around lower esophagus)
Treatments for esophageal varices
1.) Ligation 2.) Injection 3.) Sclerotherapy 4.) Balloon tamponade
Nursing for PUD surgery
1.) Make sure suction is working 2.) Observe aspirate (usually bright red first 24 hr) 3.) observe for decreased peristalsis 4.) Analgesics, deep breathing, splinting 5.) IV therapy 6.) Lifelong B12 needed for gastrectomy
Gerontologic considerations for hiatal hernia
1.) May take meds that decrease LES pressure 2.) Some are asymptomatic or sx are less severe 3.) Taking NSAIDs that irritate the esophagus
Nursing for acute gastritis
1.) NPO + IV fluids if vomiting occurs 2.) Monitor for dehydration 3.) Check vomit for blood 4.) Give meds
Ambulatory care for stomach cancer
1.) Pain relief 2.) wound care 3.) Community agencies 4.) Referral to home health 5.) Notify HCP of any changes
Risks for upper GI bleed?
1.) Previous episode 2.) Regular use of aspirin or NSAIDs 3.) Smoking 4.) Severe coughing or sneezing (ruptures varices) 5.) Those w/ anemia, liver dysfunction, or taking chemo drugs (decreased clotting factors and platelets)
Emergency management of upper GI bleed
1.) Recognize tachycardia, weak pulse, hypotension, cool extremities 2.) Urine output is best measure of perfusion 3.) Administer supplemental O2 4.) assess for perforation and peritonitis 5.) Administer fluids and blood
Some nursing interventions for N/V?
1.) Semi-Fowler's or side-lying position 2.) Record I/O 3.) Monitor VS and electrolytes 4.) Keep environment free of noxious odors 5.) Make sure suction is on if ordered for NG tube
Perforation from ulcers
1.) Sudden severe upper abdominal pain 2.) Shallow, rapid respirations, weak pulse, absent bowel sounds 3.) Bacterial peritonitis within 6-12 hours 4.) Fluid and blood replacement and abx plus suctioning
EAQ The patient has a prescription for amoxicillin 750 mg by mouth. Available is 125 mg/5 mL. How many milliliters should the nurse administer?
30mL Using ratio and proportion, multiply 125 by x and multiply 750 × 1 to yield 125x = 3750. Divide 3750 by 125 to yield 30 mL.
What is most important to assess in a pt with upper GI bleed?
ABCs, vitals, mental state
-Absent peristalsis in lower esophagus -Food and fluid accumulate -Dysphagia, halitosis, nocturnal regurgitation, chest pain -Dx through barium swallow or manometric studies -Dilation, Heller myotomy, botulinum toxin, smooth muscle relaxants are all treatments
Achalasia
What does bright red blood in emesis mean?
Active bleeding from Mallory-Weiss tear, esophageal varices, ulcers, or cancer
Things to avoid w/ gastritis
Alcohol (excessive), spicy foods, NSAIDs, smoking
Causes of gastritis pg 909
Alcohol, ingestion of chemical or drug, aspirin, caffeine, chemo/radiation, food allergens, smoking, bacteria
-Quick, short relief of heartburn -Take 1-3 hours after meals -Aluminum hydroxide, calcium carbonate (Tums, Titralac), magnesium oxide, sodium bicarb (Alka-Seltzer)
Antacids
Drugs for PUD
Antibiotics, PPI (-zole), Histamine receptor blockers, antacids, sucralfate, misoprostol (prostaglandin), TCAs, anticholinergics
Habits to avoid w/ GERD
Avoid smoking, late evening meals, night snacking, and milk
-Chronic, recurrent infection -Secondary to another cause - Mouth/lip painful ulcers w/ red base -Treatment w/ corticosteroids and tetracycline
Canker sore
Foods to avoid w/ GERD
Chocolate, peppermint, fatty foods, coffee, tea
Peptic Ulcer Disease (PUD)
Chronic irritation, burning pain, and erosion of the mucosa to form an ulcer
esophageal varices
Dilated and tortuous veins in the submucosa of the esophagus - Caused by portal hypertension, often associated with liver cirrhosis; are at high risk for rupture if portal circulation pressure rises
EAQ Which is the oral active cannabinoid used in the prevention of chemotherapy-induced emesis?
Dronabinol -is an oral active cannabinoid, which helps prevent chemotherapy-induced emesis.
-'burning" or "cramplike" pain -Pain/sx 2-5 hours after meal -Antacids and food provide relief
Duodenal ulcer
-Swelling due to eosinophils - Food triggers of milk, egg, wheat, rye, beef -Pollens, molds, allergens -Allergy skin testing used to dx -treatment includes PPIs and corticosteroids
Eosinophilic esophagitis
-Not common - Risk factors are Barrett's esophagus, smoking, excessive alcohol intake, obesity -Majority have advanced disease upon dx -Progressive dysphagia is most common symptom -Late pain development and weight loss
Esophageal cancer
-Dysphagia, regurgitation, chronic cough, aspiration, weight loss -Outpouchings of esophagus -Food gets trapped in pouches -Endoscopy and barium studies to dx -Treated w/ stapling diverticulotomy or divertisulostomy
Esophageal diverticula
-Most common cause is chronic GERD -Narrowing of esophagus -Dysphagia, regurgitation, weight loss -Treatment is dilation or excision
Esophageal stricture
-Dilated, tortuous veins in lower esophagus -Due to portal hypertension -Major cause is liver cirrhosis -Major complication is perforation and hemorrhage
Esophageal varices
What do you take NSAIDs or gastric-irritating drugs with to reduce irritation?
Food, milk, or antacids
SG What are characteristics of gingivitis?
Formation of abcesses with loosening teeth
- Heartburn, regurgitation, globus sensation, sore throat - Caused by incompetent LES or hiatal hernia -Risk factors are smoking and obesity - Endoscopic and manometric studies can diagnose -Can cause esophagitic, Barrett's esophagus (precancerous), breathing problems
GERD
What does "coffee-ground" emesis mean?
Gastric bleeding due to blood interaction w/ HCl
-High in epigastrum - Discomfort 1-2 hours after meals -Food aggravates pain
Gastric ulcer
-Inflammation of gastric mucosa - Some risk factors are NSAIDs, alcohol abuse, H.pylori, infection, and autoimmune related -Can be acute or chronic -Anorexia, N/V, tenderness, feeling full -Loss of intrinsic factor can lead to pernicious anemia
Gastritis
- Inflamed gingivae w/ possible bleeding and abscesses -Etiology form oral hygiene neglect, missing teeth, eating soft foods -Treat w/ good hygiene dental care, and fibrous foods
Gingivitis
When is surgery indicated for upper GI bleed?
Pt continues to bleed after rapid transfusion of 2000 mL of whole blood or remains in shock after 24 hours
-Usually from staphylococcus or prolonged NPO status -Pain in glandular area, no salivation, purulent exudate from glands -treatment w/ abx, fluid intake, mouthwashes, preventive measures to increase salivation (gum, hard candy)
Parotitis
When caring for a patient following a glossectomy with dissection of the floor of the most and a radical neck dissection for cancer of the tongue, wha is the nurse's PRIMARY CONCERN
Patent Airway
-Erosion of GI mucosa -Acute (superficial) or chronic (deep) -Only develop in acid environment -H.pylori, NSAIDs, aspirin, alcohol, coffee, smoking -80% are duodenal
Peptic ulcer disease (PUD)
-Used to prevent or treat N/V -Has CNS effects -Can have dangerous sedative effects
Promethazine
EAQ Deep muscle injection is the preferred route of administration of this drug used to treat nausea and vomiting because of its necrotizing effect on tissue when infiltration occurs.
Promethazine -When promethazine is administered intravenously (IV), it can leak out from the vein and cause serious damage to surrounding tissue. Deep muscle injection is the preferred route of injection administration.
What are some drugs used for N/V?
Serotonin Antagonists (-tron), Phenothiazines (-zine), Antihistamines, Prokinetics, Anticholinergics, corticosteroids, cannabinoids
How should the nurse teach the patient with a hiatal hernia or GERD to control symptoms
Sleep with the head of the bed elevated on 4-6inch blocks.
Not good to eat/drink w/ N/V?
Spicy foods, coffee, highly acidic foods, foods w/ strong odors, extremely hot or cold liquids
Esophageal cancer
Squamous cell carcinoma (worldwide); adenocarcinoma (U.S.)
-Higher rate in Asian Americans, Pacific Islanders, Hispanics, and African Americans - Predisposing factors are H.pylori, smoking, obesity, certain foods (smoked, salted, pickled) -Unexplained weight loss, abdominal discomfort, early satiety, anemia -Ascites is a poor prognostic sign
Stomach cancer
-From trauma, pathogens, irritants (tobacco/alcohol) -Can be side effect of chemo/radiation -Halitosis, sore mouth, excessive salivation -Treatment w/ removing cause, oral hygiene, soft bland diet
Stomatitis
SG Which infection or inflammation is found related to systemic disease and cancer chemotherapy
Stomatitis
EAQ Which disorder does the nurse suspect to be present in an alcoholic patient who complains of excessive salivation?
Stomatitis -Excessive salivation in a patient abusing alcohol indicates stomatitis, which is inflammation of the mouth
Chemoreceptor trigger zone (CTZ)
The area of the brain that is involved in the sensation of nausea and the action of vomiting
EAQ The nurse is teaching care guidelines to the caregiver of a patient with upper gastrointestinal (GI) bleeding. In the follow-up visit, the patient complains of traces of blood in the vomit. Which action of the patient's caregiver is responsible for the patient's condition?
The caregiver gave aspirin to the patient on an empty stomach.
regurgitation
backward flowing, as in the return of solids or fluids to the mouth from the stomach
Mallory-Weiss tear
tear in the gastric mucosa near the gastroesopahgeal junction that typically occurs due to forceful vomitting, which can also cause metabolic alkalosis
Cyclic vomiting syndrome (CVS)
chronic condition involving severe nausea and vomiting that can last for hours or days
Stress-related mucosal damage SRMD aka physiologic stress ulcer
continuum of conditions ranging from stress-related injury to stress ulcers. Seen in critically ill patients who have had severe burns, trauma or major surgery.
pyrosis (heartburn)
the burning sensation caused by the return of acidic stomach contents into the esophagus
Barret's Metaplasia
reversible change from one type of cell to another type because of an abnormal stimulus. - COMPLICATION OF CHRONIC GERD
dysphagia
difficulty swallowing or eating
-Cannabinoid -Potential for abuse and sedation -only for N/V when other meds aren't effective
dronabinol (Marinol)
halitosis
foul-smelling breath
esophagitis
inflammation of the lining of the esophagus
Stomach cancer
metastasizes to left supraclavicular nodes (Virchow node)
Achalasia
peristalsis of the lower two thirds (smooth muscle) of the esophagus is absent. Is a RARE CHRONIC DISORDER. UNKNOWN CAUSE.
histal hernia
protrusion of a part of the stomach through the esophageal opening in the diaphragm
Esophageal Diverticula
saclike outpouchings of one or more layers of the esophagus
