Med-Surg Exam 4 Learning Objectives

a nurse is providing teaching for a patient and family about psoriasis, which of the following should be included in the teaching?

in some cases, psoriasis may run in families, psoriasis is a lifelong disorder and has no cure, psoriasis is characterized by periods of exacerbation and remission, psoriasis is sometimes associated with arthritis, and ultraviolet light is helpful in treating psoriatic lesions

the patient is diagnosed with H. pylori infection, which drugs does the nurse anticipate administering?

proton pump inhibitor (PPI) and two antibiotics

ch. 59 examine the pathophysiology of selected problems affecting the biliary system and pancreas (cholecystitis, pancreatitis, and pancreas cancer)

- acute cholecystitis: acute cholecystitis is the inflammation of the gallbladder, calculus cholecystitis is chemical irritation and inflammation resulting from gallstones that obstruct the cystic duct (commonly) gallbladder neck or common bile duct, because of trapped bile the gallbladder becomes inflamed and irritated, possibly to the point of necrosis and gangrene, rupture and peritonitis are also possible, cholelithiasis (gallstones) usually accompanies cholecystitis, and acalculous cholecystitis inflammation can occur in the absence of gallstones - chronic cholecystitis: repeated episodes of cystic duct obstruction result in chronic inflammation and obstructed bile flow, pancreatitis, cholangitis, jaundice, icterus, obstructive jaundice, and pruritus, bile blocked from the small intestine where it is converted to urobilinogen (responsible for normal brown color of stools, results in clay colored stools), dark foamy urine from increased bilirubin, increased WBCs and inflammation, increased alkaline phosphatase, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) show abnormalities in liver function, elevated serum bilirubin, serum amylase and lipase elevated if the pancreas is involved, abdominal x-ray for calcified gallstones, hepatobiliary scan (HIDA) and nuclear medicine scan, endoscopic retrograde cholangiopancreatography (ERCP), and MRI - acute pancreatitis: serious and possibly life-threatening inflammation of the pancreas, varies in severity from mild involvement to necrotizing hemorrhagic pancreatitis, activation in the pancreas of pancreatic enzymes that destroy ductal tissue and pancreatic cells (autodigestion), necrotizing hemorrhagic pancreatitis, 4 physiological processes of lipolysis, proteolysis, necrosis of blood vessels, and inflammation, laboratory assessment of amylase, lipase, alkaline phosphatase, alanine aminotransferase, WBC, erythrocyte sedimentation rate, glucose, and calcium, and contrast-enhanced computed tomography (CT) - chronic pancreatitis: progressive destructive disease of the pancreas, characterized by remissions and exacerbations leading to insufficiency and diminished organ function, chronic calcifying pancreatitis due to alcoholism (common), chronic obstructive pancreatitis due to inflammation and obstruction of the sphincter of Oddi, autoimmune pancreatitis, and idiopathic or hereditary pancreatitis due to gene mutations - pancreatic abscess: most serious complication of pancreatitis, always fatal if untreated, high fever, blood cultures, drainage via percutaneous method or laparoscopy, and antibiotic treatment alone does not resolve abscess - pancreatic pseudocyst: risk factors are acute or chronic pancreatitis and abdominal trauma, complications of hemorrhage, infection, bowel obstruction, abscess, fistula formation, and pancreatic ascites, may spontaneously resolve, and surgical intervention after 6 weeks - pancreatic carcinoma: a leading cause of cancer deaths in the US, treatment has limited results, and low survival rates

dosage calc

- 1 kg = 1,000 g = 2.2 lb - 1 g = 1,000 mg - 1 mg = 1,000 mcg - 1 L = 1,000 mL - 30 mL = 1 oz = 6 tsp = 2 tbsp - 1 cup = 8 oz - 1 lb = 16 oz - 5 mL = 1 tsp - 3 tsp = 1 tbsp = 15 mL - 1 in = 2.5 cm - 1 cm = 10 mm - 1 ft = 12 in - 1 unit = 1,000 milliunits - drop factor = 10, 15, or 60 gtts/mL

the nurse is caring for a patient with a bowel obstruction, which of the following interventions would be included in the care of this patient?

an NG tube will be inserted and connected to intermittent suction, suction on the NG tube should be shut off when auscultating bowel sounds, place the patient in semi-Fowler's position, and the patient may be scheduled for exploratory laparotomy

when admitting the patient with cirrhosis, the nurse assesses for which conditions as possible complications of the disease?

ascites, bleeding esophageal varices, coagulation defects, bacterial peritonitis, hemorrhoids, and anemia

which statements about the care of a patient with a T-tube after cholecystectomy are true?

avoid raising the drainage system above the level of the gallbladder and drainage will initially be bloody, but will change to greenish-brown bile

a patient comes to the clinic with a lesion that appears to be cutaneous anthrax, what question might the nurse ask this patient?

have you had any contact with infected animals?

the patient with a colostomy could safely include which of the following in their diet?

chicken noodle soup

a nurse is providing teaching for a patient about preventing colon cancer, which of the following foods should the nurse encourage the patient to avoid?

chocolate cake, bacon cheeseburger, white bread, cabbage slaw, fried chicken, and pumpkin pie

the nurse is caring for a patient after an umbilical hernia repair, which of the following should the nurse teach the patient to avoid?

coughing

a patient is admitted with epigastric pain, which diagnostic results support the diagnosis of PUD?

low hemoglobin (Hgb), low hematocrit (Hct), and positive for H. pylori bacteria

when teaching a group of adults about measures for preventing hepatitis A, which information does the nurse include?

perform proper handwashing, especially after handling shellfish, receive immune globulin within 14 days if exposed to the virus, and receive the HAV vaccine before traveling to Mexico or the Caribbean

in preparing to care for the patient, which conditions does the nurse recognize as potential complications of acute pancreatitis?

pleural effusion, diabetes mellitus, and acute kidney failure

the nurse identifies which laboratory value as the usual indication of hepatic encephalopathy?

elevated ammonia level

a patient is admitted to your unit with jaundice caused by obstruction from gallstones, which assessment findings fit with this diagnosis?

pruritus

which laboratory finding corroborates the diagnosis of acute pancreatitis?

serum amylase 200 U/L (normal is 23-85 U/L)

the patient has been NPO, but is now tolerating food, what education will the nurse provide regarding nutrition?

small and frequent meals are best

which of the following is true with regard to an irreducible hernia?

the hernia cannot be pushed back into the abdomen

a client shows the nurse two pictures of the same skin lesion taken one month apart, which assessment finding requires nursing intervention?

the lesion borders have expanded and are shaped differently in the second picture

a care provider charts that borborygmi is noted on abdominal assessment, what does this mean?

there are high pitched bowel sounds proximal to the obstruction

which of the following statements is true about mechanical intestinal obstruction?

this can be caused by fecal impaction, obstruction can be partial or complete, the bowel above the obstruction may increase peristalsis in an effort to move contents forward, this can lead to acid-base and electrolyte imbalances, and this can lead to fluid overload

the nurse is teaching the patient with cirrhosis about lactulose therapy, which statement by the patient indicates that the teaching has been effective?

this therapy will promote the removal of ammonia in my stool

a patient with chronic cholecystitis is complaining of pruritus, clay-colored stools, and voiding dark frothy urine, which laboratory analysis is a priority in the nurse's assessment of the patient?

total bilirubin

which medication does the nurse recognize that will provide the most comprehensive pain relief at this time?

PCA morphine sulfate

ch. 55 employ appropriate health teaching for the patient and their families regarding common stomach problems

- the stomach: prostaglandins provide a protective mucosal barrier that prevents the stomach from digesting itself (autodigestion), if there is a break in the barrier, hydrochloric acid can diffuse back into the mucosa, causing injury and erosion of the stomach lining, and the injury is worsened by histamine release and vagus nerve stimulation - health promotion and maintenance: balanced diet, regular exercise, stress-reduction techniques, limit food and spices that cause gastric distress (caffeine, chocolate, mustard, pepper, and strong or hot spices), avoid tobacco, alcohol, and excessive use of aspirin or NSAIDs, follow the treatment regimen closely, ensure that gastritis heals and H. pylori is eliminated, and eat a well-balanced diet and limit pickled, processed, and salted foods - helicobacter pylori: transmission is uncertain, might be from contaminated food or water, and H. pylori causes cytokines, neutrophils, and other substances to become activated to damage the stomach mucosa

ch. 25 examine the pathophysiology and risk factors associated with skin problems

- pressure injury: skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period, identify high risk patients early of immobility, incontinence, inadequate nutrition or hydration, aging skin, cognitive decline or impairment, decreased sensory perception, diabetes mellitus, and peripheral vascular disease, mechanical forces that create pressure injuries include pressure, friction, and shear, compromised tissue integrity due to vascular insufficiency and trauma, potential for infection due to insufficient wound management, preventing wound infection and early identification of infection, and maintain a safe environment to prevent wound infection - stage 1 pressure injury: skin intact, area is red, usually over bony prominence, does not blanch with external pressure, for patients with darker skin that does not blanch, compare with adjacent or opposite areas, and may be preceded by changes in sensation, temperature, or firmness - stage 2 pressure injury: partial-thickness loss with exposed dermis, wound bed is viable, pink or red, and moist, and may look intact or like a ruptured serum-filled blister - stage 3 pressure injury: full-thickness skin loss, adipose tissue (fat) may be visible in the ulcer, granulation tissue and rolled wound edges often present, slough and/or eschar may be present, undermining and tunneling may be present, and subcutaneous tissues may be damaged or necrotic - stage 4 pressure injury: full-thickness skin loss with exposed or palpable muscle, tendon, or bone, rolled edges, undermining, or tunneling may be present, and slough and eschar often present - unstageable pressure injury: skin loss is full thickness and the base is completely covered with slough or eschar, obscuring the true depth of the wound, suspected deep tissue injury, and mucosal membrane pressure injury - pruritus (itching): caused by stimulation of itch-specific nerve fibers at the dermal-epidermal junction, itching is a subjective symptom similar to pain, itch-scratch-itch cycle, cool sleeping environment is helpful, fingernails should be trimmed short, antihistamines, and topical steroids - urticaria (hives): presence of white or red edematous papules or plaques of varying sizes, caused by histamine release into the skin, removal of triggering substances, antihistamines are helpful, and avoidance of overexertion, alcohol consumption, and warm environments, which can worsen symptoms - inflammatory skin disorders: eczema, contact dermatitis, atopic dermatitis, and psoriasis - eczema: nonspecific dermatitis - contact dermatitis: an acute or chronic rash caused by direct contact with an irritant or allergen - atopic dermatitis: an acute or chronic rash that occurs with allergies and atopic skin disease - psoriasis: chronic autoimmune disorder with exacerbations and remissions, genetic predisposition, scaling with underlying dermal inflammation, no cure, plaque psoriasis is the most common type, and psoriatic arthritis - bacterial skin infections: folliculitis, furuncles (boils), cellulitis, methicillin-resistant Staphylococcus aureus, and cutaneous anthrax - folliculitis: superficial infection involving only the upper portion of the follicle - furuncles (boils): much deeper infection in the follicle - cellulitis: generalized infection with either Staphylococcus or Streptococcus involving deeper connective tissue, and methicillin-resistant Staphylococcus aureus - cutaneous anthrax: infection caused by the spores of the bacterium Bacillus anthracis, diagnosis based on appearance of the lesions and culture or anthrax antibodies in the blood, and oral antibiotics for 60 days (ciprofloxacin or doxycycline) - viral skin infections: herpes simplex virus, type 1 herpes simplex virus (HSV-1) is a classic recurring cold sore, type 2 herpes virus (HSV-2) is genital herpes, herpes zoster (shingles), and antiviral medications are needed - type 1 herpes simplex virus (HSV-1): classic recurring cold sores - type 2 herpes virus (HSV-2): genital herpes - herpes zoster (shingles): caused by reactivation of the dormant varicella-zoster virus in patients who have previously had chickenpox, multiple lesions occur in a segmental distribution on the skin area innervated by the infected nerve, eruption lasts several weeks, postherpetic neuralgia (pain) may occur after lesions have resolved, and shingles vaccine - fungal skin infections: dermatophyte infections, tinea (and location), candida albicans, and antifungal medications (ketoconazole, Nizoral) are needed - tinea (and location): tinea pedis (foot), tinea manus (hand), tinea cruris (groin and inner thighs, jock itch), tinea capitis (scalp, skin, and hair), and tinea corporis (arms and legs, ringworm) - parasitic disorders of the skin: pediculosis, scabies, and bedbugs - pediculosis: infestation by lice, pediculosis capitis (head lice, head louse with a number of egg capsules), pediculosis corporis (body lice), pediculosis pubis (pubic or crab lice), pruritus is the most common symptom, drugs, and laundering of clothing and bed linen - scabies: contagious skin disease caused by mite infestations, transmitted by close and prolonged contact or infested bedding, manifested by curved or linear ridges in the skin and intense itching, especially at night, and infestation is confirmed by an examination of a scraping of a lesion under a microscope - bedbugs: do not live on humans, but feed on human blood, the bedbug is approximately the size, shape, and color of an apple seed, bites resemble a flea or mosquito bite, and itching is usually treated with topical antihistamines - skin trauma: can vary from an antiseptic surgical incision to a grossly infected pressure ulcer with deep tissue destruction, phases of wound healing are the inflammatory phase, proliferative (connective tissue repair) phase, and maturation (remodeling) phase - partial-thickness wounds: involve damage to the epidermis and upper layers of the dermis, heal by re-epithelialization within 5-7 days, and skin injury is immediately followed by local inflammation - full-thickness wounds: damage extends into the lower layers of the dermis and underlying subcutaneous tissue, removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal, contraction is when wound edges are pulled together, and granulation tissue - skin cancer: actinic keratoses, squamous cell carcinomas, basal cell carcinomas, melanomas are highly metastatic, survival depends on early diagnosis and treatment, and assess family history of skin cancer, past surgery for removal of skin growths, recent changes in moles, birthmark, wart, and scars, and occupational and recreational activities (sun exposure) - toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS): life threatening skin reactions to medications, thought to be variations in severity of the same immune process, common causative drugs are allopurinol, carbamazepine, lamotrigine, phenobarbital, phenytoin, and sulfasalazine, and discontinuation of the drug is followed by gradual healing

ch. 60 apply nursing diagnoses commonly associated with malnutrition or obesity

- weight loss due to inability to ingest or digest food or absorb nutrients: older adults in any setting are most at risk for poor nutrition - weight gain due to excessive intake of calories

ch. 60 examine interventions for malnutrition and obesity

- interventions for eating disorders: meal management, high calorie and nutrient rich foods, assess food likes and dislikes, small frequent feedings, nutrition supplements if the patient cannot take in enough nutrients in food (ensure, sustacal, carnation instant breakfast), and drug therapy (multivitamins, zinc, and iron supplements) - total enteral nutrition (TEN): patients likely to receive TEN are those who can eat, but cannot maintain adequate nutrition by oral intake of food alone, those who have permanent neuromuscular impairment and cannot swallow, and those who do not have permanent neuromuscular impairment, but are critically ill and cannot eat because of their condition, TEN is inserted nasally into the GI tract, used to deliver short-term enteral feedings, safer for the patient at risk of aspiration if the tip of the tube is below the pyloric sphincter of the stomach, and nasoenteric tube (NET), nasogastric tube (NG), and nasoduodenal tube (NDT) - enterostomal feeding tubes: GI tract is directly accessed, used for long-term enteral feeding, gastrostomy is when a short feeding tube is inserted through the abdominal wall into the stomach, percutaneous endoscopic gastrostomy (PEG) and low-profile gastrostomy device (LPGD), and jejunostomy is when a tube is inserted through the abdominal wall into the jejunum used to bypass the stomach - administration of tube feedings: bolus feeding is intermittent feeding of a specific amount of enteral product at set intervals, continuous feeding is small amounts of feeding that are continuously infused over a specified time, and cyclic feeding is the same as continuous feeding, except that the feeding is stopped for a specified time in each 24 hour period - maintaining a patent feeding tube: flush the tube with 20-30 mL of water, or the prescribed amount at least every 4 hours during continuous feeding, before and after each intermittent feeding, before and after each drug administration, and after checking residual volume, if the tube is clogged, use 30 mL of water to flush gently in the 50 mL syringe, avoid using carbonated beverages, except when water is not effective, do not use cranberry juice, use liquid medication instead of crushed tablets unless liquid forms cause diarrhea, make sure that the drug is compatible with the feeding solution, do not mix drugs with the feeding product before giving, and crush tablets as finely as possible and dissolve in warm water (check which tablets are safe to crush) - parenteral nutrition: nutrition is given through an IV using an infusion pump, partial parenteral nutrition is when the patient can eat, but cannot take in enough nutrition to meet their needs, and total parenteral nutrition (TPN) is when the patient requires intensive nutrition support for an extended period of time through a central line - interventions for obesity: diet programs, nutrition therapy, exercise program, drug therapy to suppress appetite, behavioral management to change daily eating habits, complementary and alternative therapies (acupuncture, acupressure, ayurvedic therapy, and hypnosis), liposuction (cosmetic reduction of tissue), bariatrics (branch of medicine that manages obesity and its related diseases), gastric restriction decreases the volume capacity of the stomach and allows for normal digestion without the risk of nutritional deficiencies, malabsorption surgery interferes with the absorption of food and nutrients from the GI tract, gastric bypass roux-en-Y, preoperative care reinforces health teaching in preparation for surgery, and postoperative care includes airway management, pain management, patient and staff safety, extra wide bed, lifting and moving devices, care of NG tube if present, assess for anastomotic leaks, increasing back, shoulder, or abdominal pain, restlessness, and unexplained tachycardia and oliguria, pressure between skin folds, and reintroduction of nutrition

when preparing to discharge a client who has a history of pediculosis, what teaching should the nurse provide?

nits can be removed with a fine toothed comb, wash bed linens in hot water and detergent to remove lice and eggs, lice can live on clothing items and any surface that is covered with fabric, family members and other close contacts should also be treated for lice, and lice can infest any place on the body that has hair

a patient undergoing diagnostic work-up for possible intestinal obstruction is experiencing colicky and crampy abdominal pain that he ranks as 6-7/10 on the pain scale, he asks the nurse why the doctor won't give him some morphine, what is the nurse's best response?

opioid analgesics might mask the symptoms of peritonitis

which statement is true about Barrett's epithelium in the patient with GERD?

this new tissue is more resistant to acid and supports esophageal healing

exam blueprint

- Chapter 54: Esophageal Problems - 6 questions - Chapter 55: Stomach Problems - 6 questions - Chapter 56: Non-inflammatory Intestinal Problems - 7 questions - Chapter 60: Malnutrition and Obesity - 6 questions - Chapter 25: Skin Problems - 7 questions - Chapter 58: Liver Problems - 9 questions - Chapter 59: Biliary System and Pancreas - 7 questions - Dosage Calculation Problems - 2 questions

ch. 54 explain clinical findings of common esophageal problems

- GERD clinical findings: dyspepsia (indigestion), regurgitation (can lead to aspiration), coughing, hoarseness, and wheezing, water brash (hypersalivation), dysphagia and odynophagia, epigastric or abdominal pain, heartburn, belching and flatulence, globus (feeling of something in the back of the throat), pharyngitis, and dental caries - sliding hiatal hernia clinical findings: heartburn, regurgitation, pain, dysphagia, belching, asthma-like symptoms related to aspiration, particularly at night, and worsening symptoms after eating or when in recumbent position - rolling paraesophageal hernia clinical findings: feeling of fullness after eating, breathlessness after eating, feeling of suffocation, chest pain, and worse in a recumbent position - esophageal cancer clinical findings: persistent progressive dysphagia, feeling of food sticking in the throat, odynophagia (painful swallowing), severe persistent chest or abdominal pain, regurgitation, halitosis (bad breath), chronic cough with increasing secretions, hoarseness, anorexia, nausea and vomiting, weight loss, and changes in bowel habits

ch. 55 explain clinical findings of common stomach problems

- acute gastritis clinical findings: can be mild to severe, epigastric pain and discomfort, nausea and vomiting, hematemesis, gastric hemorrhage, dyspepsia (heartburn), anorexia, and abrupt onset with food poisoning (staphylococcal endotoxin) - chronic gastritis clinical finding: few symptoms unless ulceration occurs, epigastric pain that is relieved by food, anorexia possible, and nausea and vomiting - PUD clinical findings: hemorrhage, hematemesis, melena, tarry stools, and bright red blood in stools, perforation is a surgical emergency, peritonitis is a board-like abdomen with bacterial septicemia and hypovolemic shock to follow, epigastric tenderness and dyspepsia, and rigid board-like abdomen with rebound tenderness and pain (perforation into peritoneal cavity) - gastric ulcer clinical findings: pain in the upper gastrium left of the midline and aggravated by food - duodenal ulcer clinical findings: pain located to the right of or below the epigastrium, occurs 1.5-3 hours after eating and may awaken the patient at night, and assess for fluid volume deficit - dumping syndrome clinical findings: vertigo, tachycardia, syncope, sweating, pallor, desire to lie down, dizziness, light-headedness, palpitations, diaphoresis, and confusion

ch. 59 explain common clinical findings and risk factors of selected problems affecting the biliary system and pancreas

- cholecystitis clinical findings: upper abdominal pain radiates to the right shoulder, usually episodic, pain is triggered by high fat or a large meal, flatulence, dyspepsia, eructation, anorexia, N/V, and feeling of abdominal fullness, Blumberg's sign of rebound tenderness, fever, jaundice, clay-colored stools, dark urine, and steatorrhea (most common with chronic cholecystitis), and biliary colic with severe pain and stone lodged or moving - acute pancreatitis clinical findings: severe, boring, constant abdominal pain (side lying fetal position), generalized jaundice, Cullen's sign (gray-blue discoloration of abdomen and periumbilical area), Turner's sign (gray-blue discoloration of the flanks), bowel sounds are absent or decreased, abdominal tenderness, rigidity, and guarding, pancreatic ascites, and significant changes in VS - chronic pancreatitis clinical findings: abdominal pain, pancreatic mass may be palpated, ascites, steatorrhea (foul smelling fatty stools), weight loss and muscle wasting, jaundice, dark urine, and diabetes mellitus

ch. 59 apply nursing diagnoses commonly associated with selected problems affecting the biliary system and pancreas

- cholecystitis nursing diagnoses: the priority collaborative problems for patients with cholecystitis include weight loss due to pain, nausea, and inflammation and acute pain due to cholecystitis - acute pancreatitis nursing diagnoses: acute pain due to acute pancreatitis and imbalanced nutrition: less than body requirements

ch. 58 explain common clinical findings of selected liver problems

- cirrhosis clinical findings: in early stages, signs of liver disease include fatigue, significant change in weight, GI symptoms (anorexia, vomiting), abdominal pain, liver tenderness, pruritus, and abnormal lab tests (may be present before symptoms, liver function tests, thrombocytopenia), and in late stages, the signs vary and consist of jaundice and icterus, dry skin, rashes, petechiae, ecchymoses (lesions), warm bright red palms of the hands, spider angiomas, and peripheral edema of the extremities and sacrum - hepatitis clinical findings: abdominal pain, changes in skin or eye color (jaundice), arthralgia (joint pain), myalgia (muscle pain), diarrhea/constipation, fever, lethargy, malaise, N/V, and pruritus

ch. 58 apply nursing diagnoses commonly associated with liver problems

- cirrhosis nursing diagnoses: fluid overload due to third spacing of abdominal and peripheral fluid, potential for hemorrhage due to portal hypertension, and potential for hepatic encephalopathy due to shunting of portal venous blood and/or increased serum ammonia levels - hepatitis nursing diagnoses: weight loss due to complications associated with inflammation of the liver, fatigue due to decreased metabolic energy production, and potential for infection related to state of immunocompromise

ch. 58 examine the pathophysiology of selected problems affecting the liver (cirrhosis and hepatitis)

- cirrhosis: extensive irreversible scarring (fibrotic bands) of the liver, usually caused by a chronic hepatic inflammation and destruction of liver cells (hepatocytes), complications depend on the amount of damage sustained by the liver, liver becomes nodular, blood and lymph flow are impaired, complications consist of portal hypertension, ascites, bleeding esophageal varices, coagulation defects, jaundice, portal-systemic encephalopathy with hepatic coma, hepatorenal syndrome, and spontaneous bacterial peritonitis, common causes of cirrhosis include excessive and prolonged alcohol use (alcohol has a direct toxic effect on liver cells and causes liver inflammation, Lannec's cirrhosis), chronic viral hepatitis, nonalcoholic fatty liver disease (associated with obesity, diabetes type 2, and metabolic syndrome), bile duct disease, and genetic diseases, assess for exposure to alcohol, drugs, herbs, and chemicals, determine if there has ever been a needlestick injury, tattoo placement, imprisonment, or employment as a healthcare worker, firefighter, or police officer, assess sexual history and orientation, inquire about family history, collect previous medical history, assess the abdomen for massive ascites, umbilicus protrusion, caput medusae (dilated abdominal veins), and hepatomegaly (liver enlargement), assess NG drainage, vomitus, and stool for the presence of blood, fetor hepaticus (breath odor), amenorrhea, gynecomastia, testicular atrophy, impotence, bruising, petechiae, enlarged spleen, neurologic changes, asterixis, elevated aminotransferase serum levels indicate hepatic cell destruction or hepatitis (AST is aspartate aminotransferase and ALT is alanine aminotransferase, which is more specific), elevated lactate dehydrogenase (LDH) levels indicate hepatic cell destruction, increased alkaline phosphatase levels show obstructive jaundice or metastasis, increased total serum bilirubin and urobilinogen levels may rise with hepatic cell disease, decreased total serum protein and albumin levels, prolonged prothrombin time, low platelet count, decreased hemoglobin and hematocrit values and WBC count, elevated ammonia levels in advanced liver disease, the sick liver cannot convert ammonia and other products of protein metabolism to a less toxic form, ammonia is formed in the GI tract by the action of bacteria on protein, ammonia and other toxins are carried to the brain by the bloodstream where they affect cerebral function, the goal is to reduce ammonia levels, and evaluate for decreased or no ascites, electrolytes WNL, no hemorrhage or immediately managed, no encephalopathy or immediately managed, highest quality of life possible, successfully abstain from alcohol or drugs (if disease was caused by these substances) - hepatitis: widespread inflammation of liver cells, viral hepatitis can be hepatitis A, hepatitis B, hepatitis C, hepatitis D (delta hepatitis), or hepatitis E, hepatitis cases must be reported to the local health department, which then notifies the Center for Disease Control and Prevention, ask about exposure to someone with hepatitis and chemical exposure, inquire about alcohol, drug, and herbal use, travel, sexual activities, needlestick exposure, drug (IV) use, and military service, assess for family history of liver disease, laboratory assessment of liver enzymes ALT and AST, alkaline phosphatase (normal or elevated), total serum bilirubin, and blood tests specific to hepatitis type, and liver biopsy can confirm the diagnosis and degree of liver damage - hepatitis A: similar to that of a typical viral syndrome, but often goes unrecognized, spread via the fecal-oral route by oral ingestion of fecal contaminants (contaminated water, shellfish from contaminated water, food contaminated by handlers infected with hepatitis A), it is a hardy virus and survives on human hands, also spread by oral-anal sexual activity, incubation period for hepatitis A is 15-50 days, disease is usually not life threatening, disease may be more severe in individuals older than 40 years, and many people who have hepatitis A do not know it, symptoms are similar to a GI illness - hepatitis B: spread is via unprotected sexual intercourse with an infected partner, sharing razors or toothbrushes with infected individuals, sharing needles, accidental needle sticks, blood transfusions, hemodialysis, birth, contact with open cuts/sores, and immunosuppression, symptoms occur in 25-180 days after exposure, symptoms include anorexia, N/V, fever, fatigue, RUQ pain, dark urine, light stool, joint pain, and jaundice, blood tests confirm the disease, most adults with hepatitis B recover and clear the virus from their body and develop immunity, a small percentage do not develop immunity and become carriers, and hepatitis carriers can infect others, even if they are without symptoms, they are at risk for cirrhosis and liver cancer - hepatitis C: no vaccine available, transmission is blood to blood, spread by sharing needles, blood, blood products, or organ transplants (before 1992), needle stick injuries, tattoos, and intranasal cocaine use, average incubation period is 7 weeks, most individuals are asymptomatic, damage occurs over decades, are unaware of infection until they have an abnormal lab test or symptoms of liver problems, and hepatitis C is the leading indication for liver transplantation in the US - hepatitis D: transmitted primarily by parenteral routes, occurs only with hepatitis B virus, incubation period is 14-56 days, and usually develops into chronic hepatitis D - hepatitis E: present in endemic areas where waterborne epidemics occur and in travelers to those areas (Asia, Africa, Central and South America), transmitted via fecal-oral route, resembles hepatitis A, incubation period is 15-64 days, and disease is self-limiting and usually resolves on its own - fatty liver (steatohepatitis): caused by the accumulation of fats in and around the hepatic cells, causes include DM, obesity, elevated lipid profile, and alcohol abuse, many patients are asymptomatic, but may have elevated liver function tests, interventions include weight loss, glucose control, and lipid-lowering agents

ch. 25 use best practices for preventing pressure ulcers

- determine the risk level: assess risk using a reliable scale, assess the entire skin daily, use a proven skin care bundle, nutrition consult, fluid intake of 2,000-3,000 mL/day, help the patient eat the needed amount of protein and calories per day, monitor changes in weight, skin turgor, urine output, renal function, serum sodium, and osmolality, and document, communicate, and promote continuity of care - reduce pressure: do not keep the HOB elevated 30°, position the patient on their side at a 30° tilt, examine the source of the pressure and reduce it, stand and march in place for 5 steps per hour, use pressure off-loading devices and foam for bony prominences, use pressure reducing mattresses, avoid donut shaped pillows, reposition immobile patient, and turn and reposition every 2 hours or as needs are assessed - improve pressure tolerance: place pillows or foam between two bony surfaces, preserve skin integrity, clean skin quickly after soiling and routinely, moisturize the skin, change incontinence pads regularly, inspect the skin under the incontinence products every 2 hours, gently wash the skin with clean warm water and mild soap, do not massage reddened areas, perform perineal care every 2 hours using disposable cleaning cloths with skin barrier agents, refrain from putting skin on any type of plastic device, and keep skin to skin areas dry - according to the Joint Commission's National Patient Safety Goals, all patients admitted to a health care facility or home health care agency are to be assessed for pressure injury risk, particularly in skin areas where medical devices are used: the use of a risk assessment tool, such as the Braden Scale, increases the chances of identifying a patient at risk for skin breakdown - the RN should do the skin assessment on the patient and identify risk factors that could put the patient at risk for pressure injuries: patient assessment is not in the scope-of-practice for a CNA or other assistive personnel

ch. 60 explain common clinical manifestations of malnutrition and obesity

- eating disorder clinical findings: hair, eyes, oral cavity, nails, skin, MS, and neurologic systems, anthropometric measurements, food and fluid intake, decreased appetite, weight loss, poor fitting or no dentures, poor dental health, poor eyesight, dry mouth, limited income, lack of transportation, inability to prepare meals, loneliness or depression, chronic constipation, decreased meal enjoyment, chronic physical illness, failure to thrive (a combination of 3-5 symptoms: weakness, slow walking speed, low physical activity, unintentional weight loss, and exhaustion), prescription and OTC drugs, and acute or chronic pain - obesity clinical findings: height, weight, and BMI, waist, arm, and calf circumferences, waist-to-hip ratio, and skin

ch. 60 examine the pathophysiology and risk factors associated with malnutrition and obesity

- eating disorders: anorexia nervosa, bulimia nervosa, assessment of full medical history, independent ADLs, usual food intake, eating behaviors, change in appetite and weight, and food preferences (meals, culture, and snacks), BMI assessment, economic status, occupation, education level, gender orientation, ethnicity, living and cooking arrangements, and mental status, focus on the total patient, not just an isolated value, hemoglobin and hematocrit, serum albumin reflects the nutritional status of the patients a few weeks before testing, not a sensitive test, thyroxine-binding prealbumin is a sensitive indicator of nutrition deficiency because of a half-life of 2 days, transferring is an iron transport protein is a more sensitive indicator or protein status than albumin, cholesterol levels (normal is 160-200 mg/dL) below 160 may indicate malnutrition, and total lymphocyte count and immune function assessment, malnutrition suppresses the immune system - obesity: not just one disease, but many conditions with varying causes, overweight is an increase in body weight for height compared with standard or up to 10% greater than ideal body weight (BMI of 25-29), obesity is an excess amount of body fat when compared with lean body mass at least 20% above the upper limit of normal range for ideal body weight (BMI of > 30), morbid obesity is a severe negative effect on health, usually more than 100% above ideal body weight (BMI of > 40), more than one third of Americans have obesity, very complex pathophysiology, adipokines affect appetite and fat metabolism, risk factors are diet, physical inactivity, drug treatment, and familial and genetic factors, assess patient history, economic status, usual food intake, appetite, eating behaviors, attitude towards food, culture, chronic diseases, drugs (herbs, OTC), activity, family history, and developmental level, and emotional factors and perception of weight, weight reduction, health benefits, and lifestyle changes

ch. 54 employ appropriate health teaching for patients and their families related to common esophageal problems

- factors contributing to decreased lower esophageal sphincter pressure: caffeinated beverages, chocolate, citrus fruits, tomatoes and tomato products, smoking and use of tobacco products, calcium channel blockers, nitrates, peppermint and spearmint, alcohol, anticholinergic drugs, high levels of estrogen and progesterone, and nasogastric tube placement - postoperative care for hiatal hernias: may not be able to vomit, treat N/V aggressively, soft foods for about a week, avoid carbonated beverages, drinking with a straw, chewing gum, and gas producing foods (may be unable to belch to relieve distention), avoid tough and raw foods, remain on anti-reflux medications for at least a month, do not drive for a week after surgery or if taking opioid pain medications, walk daily, no heavy lifting, shower and remove bandages and steri-strips per physician's instructions, usually able to wash incisions with soap and water, no bathing, swimming, or hot tubs until incisions are healed, report redness, drainage from incisions or elevated temperature, uncontrollable bloating or pain, and N/V to physician, and follow-up appointments with the surgeon - postoperative care for esophageal cancer: highest postoperative priority is respiratory care, cardiovascular care, wound management, nasogastric tube management, and nutritional management - care coordination and transition management: home care management with ongoing respiratory care, self-management education with infection control and nutrition support, and health care resources of referrals to community or home care organizations and hospice services

ch. 55 examine the pathophysiology of common problems affecting the stomach (gastritis, ulcers, and gastric cancer)

- gastritis: defined as inflammation of the gastric mucosa of either acute or chronic gastritis, diagnosed with esophagogastroduodenoscopy (EGD) with biopsy (gold standard), cytologic examination for gastric cancer, and rapid urease testing for H. pylori - acute gastritis: infection with Helicobacter pylori (other forms of bacterial gastritis are possible), could also be related to long term NSAID use, risk factors of alcohol, coffee, caffeine, and corticosteroid use, and irritation from radiation therapy or exposure to corrosive substances (acids and alkalis) - chronic gastritis: patchy inflammation, as disease progresses, the stomach walls thin and atrophy, the function of the parietal (acid secreting) cells decrease and the source of intrinsic factor (necessary for absorbing vitamin B12) is lost, resulting in pernicious anemia, associated with increased risk for gastric cancer, type A is non-erosive, probably form an autoimmune cause, may be genetic, and is associated with pernicious anemia and loss of intrinsic factor, type B is caused by Helicobacter pylori, alcohol, tobacco, radiation, and other conditions, and atrophic is when cellular changes can lead to gastric cancer, seen most often in older adults, and can occur after exposure to toxic substances, H. pylori infection, or autoimmune factors - peptic ulcer disease (PUD): PUD is a mucosal lesion of the stomach or duodenum caused when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin, acid, pepsin, and Helicobacter pylori infection play an important role in the development of gastric ulcers, gastric, duodenal, and stress ulcers, pyloric obstruction is manifested by vomiting caused by stasis and gastric dilation, intractable disease is when the patient no longer responds to conservative management or recurrences of symptoms interfere with ADLs, risk factors of alcohol, tobacco, stress, diet, history of H. pylori, GI surgeries (partial gastrectomy), and prescription and OTC drugs, diagnosed by testing for H. pylori in the blood, breath, and stool, chest and abdomen x-ray series (if perforation is suspected), EGD (gold standard) gives direct visualization, and nuclear medicine test (if GI bleeding is suspected), acute pain or chronic noncancer pain due to gastric and/or duodenal ulceration, potential for upper GI bleeding due to ulceration, and evaluation of not having active PUD or complications, verbalizing pain control or relief, adhering to drug regimen and lifestyle changes, and no experiencing an upper GI bleed - gastric ulcers: conditions favoring the development of gastric ulcers are normal gastric acid secretion and delayed stomach emptying with increased diffusion of gastric acid back into the stomach tissues - duodenal ulcers: donditions favoring the development of duodenal ulcers are normal diffusion of acid back into stomach tissues with increased secretion of gastric acid and increased stomach emptying, and most duodenal ulcers occur in the first portion of the duodenum - stress ulcers: acute gastric mucosa lesions occurring after an acute medical crisis or trauma, associated with head injury, major surgery, burns, respiratory failure, shock, and sepsis, Curling's ulcer is associated with extensive burns, Cushing's ulcer is associated with increased intracranial pressure or sepsis, principal manifestation of bleeding caused by gastric erosion, and prevention with drug therapy (PPIs) - gastrointestinal bleeding: GI bleeding is a life threatening emergency, and priority is maintaining airway, breathing, and circulation (ABC) - gastric carcinoma: most cancers of the stomach are adenocarcinomas (cancer arising from a glandular organ), may be asymptomatic until detected in an advanced stage, infection with Helicobacter pylori is the largest risk factor for gastric cancer, history of pernicious anemia, gastric polyps, chronic atrophic gastritis, and achlorhydria, eating pickled foods, nitrates from processed foods, and salt added to foods, prior gastric surgery, often there are no symptoms in the early stages, the disease is advanced when diagnosed, ask about dietary history, previous H. pylori infection, gastric surgery, or polyps, indigestion and abdominal discomfort are the most common early symptoms, anemia, progressive weight loss, and nausea and vomiting may be present in advanced cancer, and EGD, EUS, CT, PET, and MRI are used for diagnosis - dumping syndrome: a group of vasomotor symptoms that occur after eating, occur as a result of rapid emptying of food contents into the small intestine, which shifts fluid into the gut causing abdominal distention, early symptoms show within 30 minutes of eating, late symptoms show 90 minutes to 3 hours after eating, caused by excessive release of insulin following rapid entry of high carbohydrate food into the jejunum, and general principles are to have several small meals daily, relatively high fat and protein content, low roughage, relatively low carbohydrate content, liquids between meals only, and no milk, sweets, or sugars

ch. 54 examine the pathophysiology of common problems affecting the esophagus (GERD, hiatal hernia, tumors, cancer, and diverticula)

- gastroesophageal reflux disease (GERD): occurs as a result of the backward flow (reflux) of GI contents into the esophagus, characterized by acute symptoms of inflammation, caused by excessive relaxation of the lower esophageal sphincter (LES, most common), increased intra-abdominal pressure, lying supine, hiatal hernias, and Helicobacter pylori, gastric acid and pepsin injure esophageal tissue (gastric pH of 1.5-2 and esophageal pH of 6-7), during healing, the body may substitute Barrett's epithelium (columnar) for the normal (squamous) epithelium, it is more resistant to acid, but is considered premalignant, fibrosis and scarring that can accompany healing may lead to esophageal stricture, Barrett's esophagus is acid backing up from the stomach that changes the esophagus lining, a biopsy is needed to diagnose, no definitive diagnostic test for GERD, barium swallow, esophagogastroduodenoscopy (EGD), pH monitoring exam is the most accurate, analyze for potential for compromised nutrition status due to dietary selection and acute pain due to reflux of gastric contents, evaluate for exhibiting adherence to choosing appropriate dietary selections, taking drugs as prescribed, and making appropriate lifestyle modifications, reporting decrease of reflux signs and symptoms associated with GERD, and avoiding complications resulting from GERD - hiatal hernia: stomach bulging above the diaphragm, protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest, sliding hernia is the most common, occurring when esophagogastric junction and a portion of the fundus of the stomach slide upward through the esophageal hiatus into the thorax, paraesophageal or rolling hernia is when the fundus rolls into the thorax beside the esophagus, reflux usually not present as LES below the esophagus - esophageal tumors: esophageal tumors can be benign or malignant, more than half metastasize, primary risk factors are smoking and obesity, Barrett's esophagus results from acid and pepsin exposure and is ultimately malignant - esophageal cancer: results from GERD and Barrett's esophagus, a silent tumor in the early stages, by the time it causes symptoms, it may have spread extensively, genetic considerations of mutations in tumor suppressor genes, risk factors are tobacco use, heavy alcohol intake, pickled and fermented foods, foods high in nitrate, obesity, malnutrition, and diets low in fresh fruits and vegetables, high anxiety due to the terminal nature of this cancer, fear of choking, social impact of the loss of pleasure and social aspects of eating affecting relationships with family and friends, coping, strengths, support systems, and resources, diagnosed with barium swallow with fluoroscopy, esophageal ultrasound (EUS), esophagogastroduodenoscopy (EGD), and positron emission tomography (PET) that identifies metastatic disease more accurately than CT scan, potential for compromised nutrition due to impaired swallowing and possible metastasis, goal of being able to consume adequate nutrition and maintain a stable weight - esophageal diverticula: sacs resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue, dysphagia, regurgitation, nocturnal cough, and halitosis

ch. 54 examine interventions (medical and surgical) for common esophageal problems

- interventions for GERD: patient education, GERD is a chronic disorder that requires ongoing management, important nursing role of patient and family education, lifestyle changes, nutrition therapy, drug therapy, endoscopic therapies, elevate the HOB 6+ inches for sleep, sleep in the right side-lying position, stop smoking and alcohol consumption, reduce weight, wear nonbinding clothing, refrain from lifting heavy objects, straining, or working in a bent-over posture, eliminate drugs that could cause GERD (oral contraceptives, NSAIDs, CCBs, etc.), eat 4-6 small meals per day, limit or eliminate caffeine, chocolate, and fatty foods, do not snack in the evening (no food for 2-3 hours before going to bed), eat slowly and chew food thoroughly, remain upright for 1-2 hours after meals, antacids elevate the pH level of the gastric contents, meant for short term use, Maalox, Mylanta, and Gaviscon are OTC antacids, give 1 hour before and 2-3 hours after each meal, histamine receptor antagonists decrease acid production, are long acting, have few side effects, famotidine (Pepcid), ranitidine (Zantac), and nizatidine (Axid) are available OTC or Rx, proton pump inhibitors provide effective long acting inhibition of gastric acid secretion, omeprazole (Prilosec), lansoprazole (Prevacid), and esomeprazole (Nexium) are the main treatment, given 1-2 times daily, endoscopic therapies, Stretta radiofrequency energy applied through needles near the gastroesophageal junction decreases vagus nerve activity to decrease discomfort, surgical therapies, and Laparoscopic Nissen fundoplication - interventions for hiatal hernia: patient teaching is an important nursing role, drug therapy with antacids and proton pump inhibitors, nutrition therapy has the same guidelines as GERD, lifestyle changes, elevate HOB 6+ inches for sleep, remain upright for several hours after eating, avoid straining and vigorous exercise, avoid clothing that is tight around the waist, weight reduction, preoperative care to lose weight and stop smoking, operative procedure of Laparoscopic Nissen Fundoplication, and open procedures are rarely done - interventions for esophageal cancer: nutrition therapy, swallow therapy, chemotherapy, radiation therapy, chemoradiation, photodynamic therapy, esophageal dilation, esophagectomy is the removal of all or part of the esophagus, esophagogastrostomy is the removal of part of the esophagus and proximal stomach, and minimally invasive esophagectomy is for early stage cancer

ch. 56 employ appropriate health teaching for patients and their families related to selected non-inflammatory intestinal disorders

- lifestyle modifications: decrease fat, refined carbohydrates, low-fiber foods, and animal fats, eat brassica vegetables (broccoli, cabbage, cauliflower, and sprouts), stop smoking, heavy alcohol consumption, and physical inactivity - colostomy care: normal appearance of the stoma, reddish pink, protrude about ¾ inch from the abdominal wall, initially may be edematous with a small amount of bleeding, S&S of complications are signs of ischemia and necrosis, dark red/purplish/black color, dry, firm, flaccid, unusual bleeding, breakdown of suture line securing the stoma to the abdominal wall, measurement of the stoma to determine the correct size of stomatal opening for appliance, choice, use, care, and application of appropriate appliances to cover the stoma, measures to protect the skin, dietary measures to control gas and odors, avoid gas forming foods, avoid foods that increase odor (broccoli, beans, spicy foods, cabbage, cauliflower, chewing gum, smoking, beer, eggs, fish, garlic, and turnips), crackers, toast, and yogurt help prevent gas, buttermilk, cranberry juice, parsley, yogurt, charcoal filters, pouch deodorizers, or a breath mint help eliminate odors, and resumption of normal activities (work, travel, sexual intercourse)

ch. 59 examine interventions for selected problems affecting the biliary system and pancreas

- interventions for cholecystitis: nutrition therapy of high fiber and low fat with small frequent meals, drug therapy of opioid analgesics (opioids cause sphincter of Oddi spasm) such as morphine or hydromorphone and antiemetics, extracorporeal transhepatic biliary catheter insertion (opens blocked ducts so bile can flow), cholecystectomy is the removal of the gallbladder (laparoscopic or traditional open), laparoscopic cholecystectomy with standard preoperative care, operative procedure, and postoperative care of free air pain as a result of carbon dioxide retention in the abdomen, ambulation, and return to activities in 1-3 weeks, and traditional cholecystectomy with standard preoperative care, operative procedure, and postoperative care of opioids via patient-controlled analgesia pump (PCA), T-tube (keep bag below level of the gallbladder, semi-Fowler's position, and do not irrigate, aspirate, or clamp), antiemetics, wound care, NPO to clear liquids and as tolerated, and nutrition therapy - interventions for acute pancreatitis: decrease GI activity by withholding food and fluids to decrease pancreatic stimulation (NPO, IV fluids), side-lying position with knees drawn up to the chest to decrease abdominal pain, drug therapy with opioids, histamine receptor antagonists, PPIs, and antibiotics if needed, endoscopic retrograde cholangiopancreatography (open the sphincter of Oddi and remove gallstones), NPO in early stages, antiemetics for nausea and vomiting, enteral feedings, daily weights, small, frequent, moderate to high carbohydrate, high protein, and low fat meals, and avoidance of foods that cause GI stimulation (caffeine, alcohol) - interventions for chronic pancreatitis: manage pain, maintaining nutrition, pancreatic enzyme replacement, preventing recurrence, insulin therapy, take pancreatic enzymes with meals and snacks and follow with a glass of water, administer enzymes after antacids or H2 blockers (decreased pH inactivates the drug), swallow pills whole to minimize oral irritation and allow the drug to release slowly, put pull contents into applesauce if unable to swallow, do not mix enzyme preparations in protein-containing foods, wipe lips after taking enzyme preparations to prevent skin irritation, do not crush enteric-coated preparations, and follow up with lab testing, pancrelipase can increase uric acid levels - interventions for pancreatic carcinoma: drug therapy with opioids and chemotherapy (limited success), radiation therapy to shrink tumors, biliary stent insertion for biliary obstruction, preoperative care where an NG tube may be inserted and TPN typically begun, and operative procedure may include the Whipple procedure

ch. 58 examine interventions for selected liver problems

- interventions for cirrhosis: nutrition therapy consists of a low sodium diet, limited fluid intake, and vitamin supplements, drug therapy includes a diuretic and electrolyte replacement, paracentesis is the insertion of a trocar catheter into the abdomen to remove and drain ascitic fluid from the peritoneal cavity, for dyspnea, elevate the HOB at least 30° or as high as the patient wishes to help minimize SOB, measure abdominal girth, daily weights, and I&Os, screen for esophageal varices (before they bleed), prevent bleeding, beta blockers decrease HR and hepatic-venous pressure gradient, and antibiotics for infections (of any kind) that put the patient at risk for bleeding, nutrition therapy as patients with cirrhosis have increased nutritional requirements, use simple and brief guidelines of moderate protein, fats, and carbs, drugs are used sparingly because the failing liver cannot metabolize them, and drugs used to reduce ammonia levels in the body are lactulose that excretes ammonia in the stool and draws fluid into the colon by osmotic pressure (laxative effect, rids colon of toxins) and neomycin sulfate and metronidazole (Flagyl) which are intestinal antiseptics (destroy normal bowel flora, diminishing protein breakdown and production of ammonia) - interventions for hepatitis: rest to reduce the liver's metabolic demands and increase its blood supply, diet therapy is high in carbohydrates and calories with moderate amounts of fat and protein and small frequent meals, drugs are used sparingly, drug therapy may include antiemetics and antiviral medications, and promoting nutrition, addressing fatigue, and reducing the potential for infection

ch. 55 examine interventions (medical and surgical) for common stomach problems

- interventions for gastritis: acute gastritis is treated with supportive care, to relieve symptoms, and to remove or reduce cause of discomfort, chronic gastritis is treated based on a causative agent and may require vitamin B12 for pernicious anemia, H2 receptor antagonists (ranitidine, famotidine) block gastric secretions, mucosal barrier fortifiers (sucralfate, carafate), antacids (maalox, tums), antisecretory agents (proton pump inhibitors), vitamin B12 (for chronic gastritis), treatment for H. pylori infection includes PPIs and two antibiotics, diet therapy, limit intake of foods and spices that cause distress (caffeine, high acid content, strong spices, peppers, and onions) as well as tobacco and alcohol, and stress reduction - interventions for PUD: managing acute pain or chronic non-cancer pain, primary purposes of drug therapy are to provide pain relief (PPIs are drugs of choice), eradicate H. pylori infection, heal ulcerations, and prevent recurrence, nutrition therapy excludes foods that cause discomfort, avoid alcohol and tobacco, complementary and integrative therapies, no single agent has been successfully able to eliminate H. pylori, and PPIs, metronidazole (Flagyl) and tetracycline, and clarithromycin (Biaxin) and amoxicillin - interventions for gastrointestinal bleeding: providing oxygen and ventilatory support, replacing fluids and blood by inserting two large-bore peripheral IVs, monitoring VS, H&H, oxygen saturation, and serum electrolytes, insert a large-bore nasogastric tube, determine if blood is present, assess rate of bleeding, prevent gastric dilation, and administer lavage, lavage (not common), insert 200-300 mL of room temperature solution with the patient lying on the left side, and withdraw and reinsert fluid until the returns are clear or light pink and without clots, esophagogastroduodenoscopy (EGD) can stop gastric bleeding by injecting chemicals into the bleeding site, stopping bleeding with heat, electric current, or laser, and placing a band or clip on bleeding vessels, interventional radiology and catheter-directed embolization, aggressive acid suppression to prevent re-bleeding, perforation is managed by immediately replacing fluid, blood, and electrolytes, administering antibiotics, and keeping the patient NPO, pyloric obstruction related to edema and spasm generally responds to medical therapy, NG suction and correcting metabolic acidosis and dehydration, preoperative care of the insertion of an NG tube, laparoscopy to remove chronic gastric ulcers or treat hemorrhage, may do partial stomach removal, vagotomy eliminates the acid-secreting stimulus to gastric cells and decreases the response of parietal cells, and pyloroplasty facilitates emptying of stomach contents - interventions for gastric carcinoma: drug therapy with combination chemotherapy, radiation therapy is limited because the disease is often widely disseminated upon diagnosis, surgical management of a gastrectomy or subtotal (partial) gastrectomy, preoperative care of an NG tube and nutrition, operative procedures, postoperative care, and postoperative complications of hemorrhage, reflux aspiration, wound infection, sepsis, reflux gastritis, paralytic ileus, bowel obstruction, and dumping syndrome

ch. 56 examine interventions (medical and surgical) for patients with selected non-inflammatory intestinal disorders

- interventions for intestinal obstruction: nothing by mouth (NPO), NG tube placement, nasointestinal tubes, IV fluid replacement and maintenance (mouth care), pain management (opioids are withheld), non-pharmacological pain control, exploratory laparotomy (open or MIS), postoperative care with a possible NG tube, and care coordination and transition management - interventions for CRC: prevent and control metastasis, radiation therapy, chemotherapy, surgical management, colon resection, colectomy, abdominoperineal (AP) resection, colostomy, minimally invasive surgery, colostomy preoperative care, consultation with an enterostomal therapist, discussions with a surgeon of risk for sexual and urinary dysfunctions, bowel prep, NG tube and IV line placed for use after surgery, assignment of case manager for long-term consequences, postoperative care, NG tube, PCA, catheter, and colostomy care - interventions for IBS: chronic disorder, health teaching the patient to avoid problem stimulants (caffeine, carbonated beverages, and dairy products), diet therapy of 30-40 grams of fiber, eating regular meals, drinking 8-10 cups of liquid, and chewing food slowly, stress reduction with relaxation, meditation, and yoga, drug therapy to treat the main symptoms, IBS-C has bulk-forming laxatives (psyllium, Metamucil) and linaclotide (Linzess) to increase fluid in the intestines, IBS-D has loperamide (Imodium) and psyllium (bulk-forming), bloating and abdominal pain without diarrhea has rifaximin (Xifaxan) that is an antibiotic working locally and darifenacin (Enablex) muscarinic receptor antagonists that inhibit intestinal motility, pain has tricyclic antidepressants amitriptyline (Elavil), and CAM probiotics - interventions for hernias: truss is a pad made of firm material held in place over the hernia with a belt to keep the hernia reduced, operative procedures, minimally invasive inguinal hernia repair (MIIHR, herniorrhaphy), hernioplasty (abdominal wall is reinforced with mesh), open or conventional herniorrhaphy, after an open surgical approach, have the patient avoid coughing, after indirect inguinal hernia repair, a scrotal support and use of ice bags to the scrotum may be used to prevent swelling, elevation of the scrotum on a soft pillow helps prevent and control swelling, and difficulty voiding - interventions for malabsorption syndrome: dietary management, surgical or nonsurgical management, and drug therapy

ch. 56 explain clinical findings of selected non-inflammatory intestinal disorders

- intestinal obstruction clinical findings: mid-abdominal pain or cramping, vomiting, obstipation, diarrhea, alteration in bowel pattern and stool, abdominal distention, peristaltic waves, borborygmi (high pitched bowel sounds proximal to the obstruction), abdominal tenderness (diffuse discomfort), fluid and electrolyte disturbances, and acid-base disturbances - CRC clinical findings: most common signs are rectal bleeding, anemia, changes in stool (ribbon-like stools), and blood in the stool, and clinical manifestations depend on the location of the tumor - malabsorption syndrome clinical findings: diarrhea and steatorrhea

ch. 56 examine the pathophysiology of selected non-inflammatory intestinal disorders (irritable bowel syndrome, hernias, colorectal cancer, intestinal obstruction, and hemorrhoids)

- intestinal obstruction: obstruction can be partial or complete, mechanical obstruction or physical block, nonmechanical obstruction (paralytic ileus or adynamic ileus), complications, etiology, no definitive laboratory test to determine obstruction, laboratory assessment, imaging assessment, other diagnostic tests, and the priority collaborative problems for patients with intestinal obstruction include potential for injury (peritonitis, acute kidney injury) due to obstruction and acute pain due to obstruction - colorectal cancer (CRC): colorectal refers to the colon and the rectum, which together make up the large intestine, most CRCs are adenocarcinomas (tumors that arise from the granular epithelium in the colon), etiology of age older than 50 years, genetic predisposition, personal or family history of cancer and/or diseases that predispose the patient to cancer, and familial adenomatous polyposis, colon cancer screening of genetic testing, fecal occult blood test (FOBT) annually, colonoscopy every 10 years, and double-contrast barium enema every 5 years, hemoglobin and hematocrit values usually decreased, fecal occult blood test, possible elevation of carcinoembryonic antigen (CEA), and imaging assessment of barium enema, CT, and MRI, colonoscopy is the definitive test for the diagnosis of colorectal cancer, and the priority collaborative problems for patients with colorectal cancer include the potential for metastasis due to CRC and potential for grieving due to cancer diagnosis - irritable bowel syndrome (IBS): IBS is a functional GI disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating, spastic contractions of the colon as they may occur with IBS shown in insert, most common digestive disorder, one in five people in the US have IBS, classifications as IBS-D (diarrhea), IBS-C (constipation), IBS-A (alternating diarrhea and constipation), and IBS-M (mix of diarrhea and constipation), etiology is unclear, but may be a combination of environmental, immunologic, genetic, hormonal factors, and stress, and a flare-up of symptoms usually brings the patient to the healthcare provider - herniation: weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes, causes are congenital or acquired muscle weakness and increased intra-abdominal pressure, types of hernias include indirect inguinal, direct inguinal, femoral, umbilical, incisional, and ventral, hernia repair using mesh to reinforce the abdominal wall, reducible hernias are when contents of hernia can be pushed back in the abdomen by gentle pressure, irreducible (incarcerated) hernias cannot be pushed back into the abdomen and require immediate surgical intervention, and strangulated hernias are when the blood supply is cut off, resulting in bowel necrosis, ischemia, and obstruction, and requires immediate intervention - hemorrhoids: unnaturally swollen or distended veins in the anorectal region, internal hemorrhoids, external hemorrhoids, nonsurgical management, surgical management, and hemorrhoidectomy - malabsorption syndrome: syndrome associated with a variety of disorders and intestinal surgical procedures, and the nutrient involved in the malabsorption depends on the type and location of the abnormality in the intestinal tract

ch. 58 employ appropriate health teaching for patients and their families related to selected liver problems

- liver functions: converts bilirubin to bile, detoxifies substances, carbohydrate metabolism, converts glucose to glycogen, stores it, and converts glycogen to glucose when needed, deactivates amino acids, removes ammonia, makes plasma proteins (albumen) and antibodies, which regulate osmotic pressure and fluid balance, makes prothrombin (clotting factor), produces cholesterol, and stores vitamin K, D, B12, and iron - liver failure: jaundice and icterus, changes in drug metabolism (toxicities), fatigue, elevated serum ammonia levels could be toxic to the brain (hepatic coma), ascites (also caused by portal hypertension), infection, bleeding, cholesterol needed for sex hormones, bile needed to store fat soluble vitamins, and without vitamin K, clotting factors II, VII, IX, and X are not produced in sufficient quantities and cause bleeding - active hemorrhage management: identify the source of bleeding and initiate measures to halt it, vasoactive drugs cause vasoconstriction, endoscopic therapies of ligation of bleeding veins and sclerotherapy (inject sclerosing agent into bleeding veins), esophagogastric balloon tamponade with a Sengstaken-Blakemore tube, and transjugular intrahepatic portal-systemic shunt (TIPS) - transitional care for cirrhosis: discharge to home or LTC facility, care and teaching individualized to the patient's situation, nutrition of low sodium, nutritional supplements, and small frequent meals, drug therapy with diuretics, beta blockers, lactulose, antibiotics, and drugs to decrease acid reflux, avoid acetaminophen, alcohol, illicit drugs, and OTC drugs (NSAIDs, hepatic toxic herbs, vitamins, and minerals), and keep appointments for follow-up medical care - health promotion and maintenance for hepatitis: vaccines for hepatitis A and B, use standard precautions, use needleless systems in hospitals, wash hands before eating and after using the toilet, drink water treated by a purification system, when traveling in developing countries, drink only bottled water and avoid ice, avoid food washed or prepared with tap water such as raw vegetables, fruit, and soups, do not share bed linens, towels, eating utensils, or drinking glasses, do not share needles or syringes for injection, body piercings, or tattoos, do not share razors, nail clippers, toothbrushes, or water piks, use a condom during sexual intercourse or abstain, cover cuts or sores with bandages, and if ever infected with hepatitis, never donate blood, body organs, or other tissues

ch. 60 employ appropriate health teaching for patients and their families with malnutrition or obesity

- malnutrition problem examples: protein catabolism exceeds protein intake and synthesis, weight loss, decreased muscle mass and cardiac output, weakness, cachexia, lethargy, dry flaking skin, dermatitis, and poor wound healing - situations linked to malnutrition: poverty, lack of education, substance abuse, decline in functional ability, infectious disease, and medical treatments (chemotherapy) - body mass index (BMI): (weight in pounds / height in inches squared) x 703, normal is 18.5-25, overweight is 27-30, obesity is 30-40, and morbidly obese is 40+ - complications of TEN: safety is the priority in managing feedings, clogged tubes are the most common issue, refeeding syndrome, tube misplacement and dislodgement, abdominal distention and N/V, check gastric residual volumes every 4-6 hours, hold feedings if gastric residual volumes on two consecutive assessments are > 200 mL (or amount specified), fluid and electrolyte imbalances with diarrhea, plasma hyperosmolarity leads to dehydration and diarrhea, hyperkalemia, and hyponatremia - complications of TPN: fluid imbalances, hyperosmolar solution, can cause dehydration or fluid overload, daily weights, I&O, monitor BG for hyperglycemia, electrolyte imbalances, check electrolytes frequently, and sodium, potassium, and calcium imbalances are the most common - common complications of obesity: type 2 diabetes mellitus, HTN, hyperlipidemia, CAD, CVA, PAD, metabolic syndrome, OSA, obesity hypoventilation syndrome, depression and other mental health problems, urinary incontinence, cholelithiasis (gallstones), gout, chronic back pain, early OA, and decreased wound healing - special considerations after bariatric surgery: abdominal binder, position in semi-Fowler's, monitor SaO2, sequential compression hose and/or heparin, assess skin, absorbent padding, remove urinary catheter within 24 hours, equipment appropriate to the patient, may need extra nursing staff assistance, assist the patient out of bed, ambulation as soon as possible, monitor abdominal girth, 6 small feedings and prevent dehydration, and observe for signs of dumping syndrome

ch. 59 employ appropriate health teaching for patients and their families for selected problems

- pancreas functions: endocrine gland secretes insulin, exocrine gland secretes enzymes that are responsible for assisting in the breakdown of proteins, fats, and starches (trypsin, lipase, and elastase), enzymes secreted are usually not activated until in the intestine, and early activation of these enzymes while still in the pancreas results in inflammation and tissue damage - complications of acute pancreatitis: pancreatic infection and septic shock (most common cause of death), hypovolemia, hemorrhage, acute renal failure, paralytic ileus, hypovolemic or septic shock, pleural effusion, respiratory distress syndrome, pneumonia, multisystem organ failure, coagulation defects and disseminated intravascular coagulation, and diabetes mellitus - prevention of chronic pancreatitis: avoid things that make symptoms worse, avoid alcohol ingestion and nicotine use, refer to self help, eat bland, low fat, high protein, and moderate carbohydrate meals, avoid gastric stimulants such as spices, eat small meals and snacks high in calories, take pancreatic enzymes with all meals and snacks, and frequent rest

ch. 25 employ appropriate teaching for patients and their families experiencing various skin problems

- treatment of psoriasis: topical therapy with topical steroids and emollients, anthralin, topical tar preparations, and others, light therapy, systemic therapy, and emotional support - process of wound healing is first intention: edges are brought together with the skin lined up in approximated position (surgical incision), second intention: granulation and contraction, deeper tissue injury or wound (pressure ulcer), and third intention: delayed closure, high risk for infection with resulting scar (contaminated traumatic wound) - mechanisms of wound healing are re-epithelialization: the production of new skin cells, granulation: the formation of scar tissue for wound healing, and wound contraction: fibroblasts pull the wound edges inward along the path of least resistance

ch. 25 examine interventions for various skin problems

- wound assessment: when assessing a pressure injury, document location, size, color, extent of tissue involvement, cell types in the wound base and margins, exudate, condition of surrounding tissue, and presence of foreign bodies in the wound, measure the length, width, and depth of the wound using a cotton tipped applicator, check for tunneling-hidden wounds that extend from the primary wound into surrounding tissues, use the face of a clock to document tunneling with the patient's head being 12 o'clock, a reddened area of intact skin that does not blanch indicates impaired capillary blood flow and early tissue damage, check for wound characteristics, cellulitis is inflammation of the skin and subcutaneous tissue extending beyond the area of injury, eschar is necrotic tissue that appears like a layer of black, gray, or brown collagen, may be dry and leathery or full of exudate and yellow or tan in appearance, granulation tissue may be pale pink or beefy red, healthy tissue is moist and slightly spongy, the formation of scar tissue for wound healing to occur, undermining is the separation of the skin layers at the wound margins from the underlying granulation tissue, and serial photographs if permitted by facility policy and informed consent - pressure injuries and their features are classified into four stages related to the depth of the injury: stage I, stage II, stage III, stage IV, unstageable, suspected deep tissue injury, and mucosal membrane pressure injury - pressure injury assessment: identify the cause of tissue integrity loss and factors that may impair healing, at each dressing change, compare the existing wound features with those previously documented to determine the current state of healing or deterioration, laboratory testing, and other diagnostic assessments - wound management: dressings help healing by removing surface debris, protecting exposed healthy tissues, and creating a barrier until the wound is closed, mechanical debridement, topical chemical debridement, natural chemical debridement, sharp (or surgical) debridement, specific dressing individualized to patients as recommended by wound care nurses, physical therapy, drug therapy, nutrition therapy, electrical stimulation, negative pressure wound therapy, hyperbaric oxygen therapy, topical growth factors, skin substitutes, ultrasound-assisted wound therapy, and surgical management - care coordination and transition management: home care management, self-management education, and health care resources - interventions for skin cancer: cryosurgery, curettage and electrodesiccation, excision, Mohs' surgery, wide excision, chemotherapy, immunotherapy, and radiation therapy

a nursing student is caring for a patient with chronic pancreatitis who is receiving pancreatic enzyme replacement, which statement by the student indicates a need for more instruction?

I can mix the enzymes into foods containing proteins

which of the following factors could contribute to decreased lower esophageal sphincter pressure?

chocolate halloween candy, orange juice, Dutch Bros coffee drinks, smoking cigars, chewing peppermint gum, diet pepsi, gin and tonic, and catsup with french fries

which of the following represent best practices for preventing pressure injuries?

do not keep the HOB elevated above 30° to prevent shearing, float the patient's heels off the bed surface using rolled towels under the ankles, when positioning a patient on their side, position at a 30° tilt, and place pillows or foam wedges between two bony surfaces

which statements will the nurse include when providing health teaching for the patient with hiatal hernia?

elevate the HOB at least 6 inches for sleeping at night, remain in the upright position for several hours after eating, avoid straining or excessive vigorous exercise, avoid wearing clothing that is tight around the abdomen, and avoid eating in the late evening

which of the following is not true about IBS?

in IBS, the patient may note the presence of mucus with stool passage

a nurse is providing diet teaching for a patient with IBS, which of the following should be included in teaching?

increase your intake of fiber from fruits and vegetables, chew your food more thoroughly and drink more water, and keep a food diary to keep track of foods that cause IBS for you