adult health2 exam 1
A patient has a bowel perforation from a recent surgery and has now been diagnosed with peritonitis. He has hypoactive bowel sounds, a temperature of 100.5 F, and an elevated WBC count. To which of the following should the nurse be alert as the most serious complication of peritonitis? A. Nausea B. Diarrhea C. Sepsis D. Abdominal tenderness
C. sepsis (peritonitis is a nasty infection, this area is supposed to be sterile)
diagnostics with peritonitis
CBC, CT scan abdomen (see if there is perforation/look for cause if it isn't obvious), peritoneal aspiration (culture and sensitivity to identify organism)
medical mgmt of esophageal cancer
EGD (most common technique), CT scan, PET scan Early vs late treatment early==cure later== relief of symptoms (opening up esophagus for ex) Surgery, chemotherapy, and radiation (all to shrink tumor, surgery to remove)
med/nursing mgmt for hiatal hernias
Frequent small feedings that can easily pass through esophagus--> 6-8 feedings a day Do not recline 1 hour after eating to reduce reflux Elevate HOB 4-8 inches decreases reflux Management of GERD symptoms (meds, antacids, etc) Surgical repair-- Nissen Fundoplication
risk factors for esophageal cancer
Males have higher risk more than females alc and tobacco (risk increases 44 times), Barrett's esophagus, GERD, obesity
mgmt of jaw trauma= nontraumatic
PT, NSAIDs, oral appliances (to help with pain, motion, eating)
hiatal hernia
Portion of the stomach protrudes upward through esophageal hiatus and into lower portion of the thorax (displaces LES= GERD symptoms) type 1 and type 2
Barrett's Esophagus
Uncontrolled GERD→ alerted esophageal mucosa; repeated insults of gastric acid n esophageal mucosa (overtime change morphology of cells to resemble precancerous cells) Precancerous cells→ precursor to developing esophageal cancer
nursing care post RND= coping/communication
coping--> impacts self image (scars neck, can leave pts with indentation in neck, alters appearance), allow space for expression/listening/expressing concern for needs, alc and tobacco cessation support if necessary communication→ assess prior to surgery (set up a plan pre-op), dry erase boards/communication board/hand signals, ensure call bell is in reach
risk factors for gastric cancer
diet→ smoked foods, pickled vegetables, salted fish and meat; low in fruits and vegetables; Alc, smoking, family history, H pylori (huge risk factor; almost 60%), chronic gastritis and ulcers
clin manifestations of gastric cancer
early→ pain relieved by antacids late→ indigestion, early satiety, weight loss, abdominal pain just above umbilicus, anorexia, bloating after meals, N/V, fatigue
A nurse cares for an obese client taking phentermine for weight loss. What client teaching will the nurse include when discussing precautions about the medication? "Take the medication at night before bedtime." "Do not drink alcohol while taking this medication." "Do not drive while taking this medication." "Take the medication with a full glass of water."
"Do not drink alcohol while taking this medication." Explanation: The nurse should tell the client to avoid drinking alcohol while taking this medication. The other answer choices are not as important as avoiding the drug/alcohol interaction associated with this medication.
A patient is complaining of LLQ pain, fever, and decreased appetite. The nurse knows that which of the following is the most likely cause? A. Diverticulitis B. Appendicitis C. Small bowel obstruction D. Sigmoid colon cancer
A. diverticulitis, most common site of pain is LLQ
A client comes to the clinic after developing a headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. The client tells the nurse that the last food was buffalo chicken wings and beer. Which medical condition does the nurse find to be most consistent with the client's presenting problems? Gastric ulcer Gastric cancer Acute gastritis Duodenal ulcer
Acute gastritis Explanation: A client with acute gastritis may have a rapid onset of symptoms, including abdominal discomfort, headache, lassitude, nausea, anorexia, vomiting, and hiccupping, which can last from a few hours to a few days. Acute gastritis is often caused by dietary indiscretion-a person eats food that is irritating, too highly seasoned, or contaminated with disease-causing microorganisms. A client with a duodenal ulcer will present with heartburn, nausea, excessive gas and vomiting. A client with gastric cancer will have persistent symptoms of nausea and vomiting, not sudden symptoms. A client with a gastric ulcer will have bloating, nausea, and vomiting, but not necessarily hiccups.
clin manifestations of duodenal PU
epigastric pain 2-3 hours after meals (food acts as a buffer), more likely to awaken at night, improves with food at night; gets better after eating and taking antacids
clin manifestations of gastric PU
epigastric pain that occurs immediately after eating, little or no relief from antacids
how often does an Upper GI need to be performed in adulthood?
every 5 years
what if a pt experiencing dry mouth is using a nasal cannula?
humidify oxygen can be coming through NC (normal saline connected to oxygen port); usually humidified if pt is on a high flow NC
Vagotomy
severs vagal nerve supply to the proximal two thirds of the stomach (where parietal cells are located); decreases acid production by 70%
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention? Foley catheter bag containing 500 ml of amber urine Serosanguineous drainage on the dressing The client lying in a lateral position, with the head of bed flat A piggyback infusion of levofloxacin
the client lying in a lateral position, with the head of bed flat Explanation: A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.
Pyloroplasty
to enlarge pyloric opening, allowing the stomach to empty more easily into duodenum (done after vagotomy in most cases)
mgmt of Barrett's Esophagus
very close monitoring depending on severity; EGD (upper GIs to examine tissue in order to detect esophageal cancer earlier, every 3-5 years); PPIs (protonix, Omeprazole)
nursing care post RND=wound care
wound drainage tubes (JP drain, helps to prevent subq buildup of fluid), record drainage (80-120 mL of serosanguineous drainage, not all pts will stay in this range; if increase in emptying/excess let PCP know), reinforce dressing PRN and monitor (usually changed 2-5 times per day, 1st changed by surgeon, make sure dressing is not too tight to ensure graft is not being impacted/cutting off circulation), changes are prescribed by PCP, prophylactic antibiotics to prevent infection
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Take antacids with meals." "Lie down after meals to promote digestion." "Avoid coffee and alcoholic beverages." "Limit fluid intake with meals."
"Avoid coffee and alcoholic beverages." Explanation: To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.
A nurse is providing discharge instruction for a client who is postoperative bariatric surgery. What statement will the nurse include when providing teaching aimed at decreasing the risk of gastric ulcers? "Keep the head of your bed propped on blocks at night." "Avoid taking non-steroidal anti-inflammatory drugs." "Avoid taking antacid drugs." "Sit in a semi-recumbent position while eating."
"Avoid taking non-steroidal anti-inflammatory drugs." Explanation: The only statement that aids in avoiding gastric ulcers is the statement instructing the client to avoid taking non-steroidal anti-inflammatory (NSAID) drugs. Sitting in a semi-recumbent of low Fowler's position aids in digestion but does not aid in the prevention of gastric ulcers. Propping the head of the bed would be beneficial for a client report GERD or acid reflux. antacid drugs do not increase the risk of gastric ulcers.
A nurse cares for a client who is obese. The health care provider prescribes orlistat in an effort to help client lose weight, along with diet and exercise. When teaching the client about this medication, what will the nurse include? "It decreases your appetite." "It binds with enzymes to decrease carbohydrate absorption." "It binds with enzymes to help prevent digestion of fat." "It works to make you feel full."
"It binds with enzymes to help prevent digestion of fat." Explanation: Orlistat (Xenical) works to bind to gastric and pancreatic lipase to prevent the digestion of 30% of ingested fat, thereby decreasing caloric intake.
A client with obesity is prescribed lorcaserin for weight loss. The client reports dry mouth. What is the nurse's best response? "Taking this medication with meals decreases this symptom." "Your dose may need to be adjusted." "This is an expected finding with this medication." "How much water are drinking?"
"This is an expected finding with this medication." Explanation: Lorcaserin (Belviq), a selective serotonergic 5-HT2C receptor agonist, causes dry mouth. This is an expected and normal finding. Increasing fluid intake does not make this symptom go away. The other answer choices are incorrect.
oral/pharynx cancer intro
"head and neck cancer" Rising rates; curable if discovered early but if later hard to cure Risk factors: smoking/tobacco, alc, poor oral hygiene, HPV, previous hx of head and neck cancer Squamous cell carcinomas (SCCAs)--> vast majority; epithelium lines oral cavity in pharynx Can be on lips, tongue, buccal mucosa, floor of mouth (very common place; everything drains through this part of the mouth), hard palate, upper and lower gingiva
Nissen fundoplication
(laparoscopy, minimally invasive, outpatient procedure, pts can go home same day most times) Upper section of stomach if wrapped around oesophageal to form a collar; this tightens LES to stop acid moving back out of the stomach
type 2 hiatal hernia
(paraesophageal hiatal hernia) less common "rolling" upper part of stomach also slips through esophageal hiatus and sits on side of esophagus clin manifestations: feeling full/breathless/suffocating after eating, chest pain that feels like angina, increase in symptoms when laying flat
type 1 hiatal hernia
(sliding hiatal hernia)= most common, goes up and down out of esophageal hiatus clin manifestations: pyrosis, regurg, dysphagia, some asymptomatic if minor
Esophagectomy
(surgery; hallmark treatment)→ high rate of mortality (d/t infection, pulmonary complications, anastomosis has potential for leaking) removal of tumor and wide margin of healthy esophageal tissue; esophagus is rejoined with stomach
clin manifestations of esophageal cancer
--Progressive dysphagia --Sensation of a mass in the throat/upper esophagus --Painful swallowing --Persistent cough and/or hoarseness of voice --Substernal pain and illness --Later= regurg, halitosis, hiccups, resp difficulty; weight loss and loss of strength; hemorrhage
Which instructions would the nurse include in a teaching plan for a patient with mild gastroesophageal reflux disease (GERD)? A.) "The best time to take an as-needed antacid is 1 to 3 hours after meals." B.) "A glass of warm milk at bedtime will decrease your discomfort at night." C.) "Consuming yogurt will help alleviate your symptoms" D.) "Limit your intake of food high in protein because they take longer to digest ."
A (antacid to take g1-3 hours as needed); dairy can make GERD worse especially at bedtime, food high in protein does not affect
A client is diagnosed with a hiatal hernia and is suffering from acid reflux. Which statement indicates effective client teaching about hiatal hernia and its treatment? A.) "I'll eat frequent, small, bland meals that are high in fiber." B.) "I'll lie down immediately after a meal." C.) "I'll eat three large meals every day without any food restrictions." D.) "I can continue drinking 6 cups of coffee per day"
A (small frequent meals)
A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, what would the nurse stress the importance of? A. Increasing fluid intake to prevent dehydration B. Consume a low protein, high fiber diet C. Only take enteric coated medications
A. Increasing fluid intake to prevent dehydration Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.
While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit? Approximately 80 to 120 mL Greater than 160 mL Between 40 and 80 mL Between 120 and 160 mL
Approximately 80 to 120 mL Explanation: Wound drainage tubes are usually inserted during surgery to prevent the collection of fluid subcutaneously. The drainage tubes are connected to a portable suction device (e.g., Jackson-Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.
post-op graft checks
Assess color-- look for cyanosis (cap refill) Doppler pulse check-- problems with tissue perfusion Frequency determined by PCP orders Can be difficult to assess grafts in the mouth-- can still assess color/appearance and compare to pre-op state
Esophageal cancer intro
Asymptomatic, present later in course of disease; no symptoms until 50% of esophageal lumen is occluded (usually at this point metastasize to other places) Squamous cell (upper esophagus) or adenocarcinoma (lower esophagus) 5 year survival 5-30% since often diagnosed later
A patient with canter of the stomach at the lesser curvature undergoes a total gastrectomy with esophagojejunostomy. Postoperatively, what should the nurse teach the patient to expect? A.) Rapid healing of the surgical wound B.) Lifelong administration of cobalamin (vit B12) C.) To be able to return to normal dietary habits D.) Close follow-up for development of peptic ulcers in the jejunum
B (lack of absorption of vitamin B12 since those who don't have stomach lack intrinsic factor which is needed to get vitamin B12 to body)
A 47 year-old man with epigastric pain is being admitted to the hospital. During the admission assessment and interview, what specific information should the nurse obtain from the patient, who is suspected of having peptic ulcer disease? A. Any allergies to food or medications B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) C. Family history of peptic ulcer disease D. History of side effects from medications
B use of NSAIDs (these meds can inhibit prostaglandin synthesis which is responsible for protecting the stomach lining and cause ulcers)
mgmt of gastric cancer
Diagnostic tests: EGD (of choice to examine tissues/get biopsy) , barium x-rays, CT scan (examine if there is lymph node involvement/how extensive it is in stomach), CBC (see if pt has anemia) Radiation and chemo surgical→ gastric resection- partial vs total (maybe lymph nodes removed as well); can be used as a cure or palliative (end of life, to help pt with symptoms of vomiting/discomfort)
dumping syndrome DATEDW
Dizziness/diarrhea, abdominal cramping, tachycardia, epigastric fullness, diaphoresis, weakness
clinical manifestations of jaw trauma
Dull ache-->throbbing debilitating pain Restricted jaw motion lock jaw Misalignment of upper and lower jaw chewing/swallowing difficult Popping, clicking, grating sounds Swelling if trauma
The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease? Dysphagia Regurgitation of food Pain Malnutrition
Dysphagia Explanation: Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).
stomach overview
First stages of protein and carbohydrate digestion occur Water and alcohol is absorbed here too Secretes intrinsic factor-- vitamin b12 Mixes, churns and transports to duodenum
management of peritonitis
Fluid and electrolyte replacement→ several liters of isotonic IV fluid since they will most likely be in shock (fluid leaves viscera) Analgesia and antiemetics NGT to assist in relieving abdominal distention and to promote intestinal function Supplemental oxygen→ fluid in abdomen can put pressure on lungs to cause respiratory distress IV antibiotics→ started right away, initiated early, large doses of broad spectrum given until organism is identified then can be more targeted Surgery (main goal is to look for source of infection and eradicating it)
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition? Diverticulitis with perforation Gastritis Peptic ulcer with melena Gastroesophageal reflux disease
Gastroesophageal reflux disease Explanation: Metoclopramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.
risk factors for PUD
H. Pylori NSAID, ASA, ETOH smoking (alters healing, leads to ulcer recurrence) acid hypersecretory disorders) (zollinger's syndrome, tumor, causes a lot of acid production that damages lining of stomach) physiological stress (trauma of some sort such as burns, shock, sepsis)
Which of the following is the most common complication associated with peptic ulcer? Vomiting Abdominal pain Fever Hemorrhage
Hemorrhage Explanation: Hemorrhage, the most common complication, occurs in 28% to 59% of patients with peptic ulcers. Vomiting, elevated temperature, and abdominal pain are not the most common complications of a peptic ulcer.
complications of hiatal hernias
Hemorrhage, strangulation (twisting), or obstruction; although rare these all can happen
Peptic Ulcer disease
Hollowed out area that forms in the mucosa (ulcer) patho--> Erosion from corrosive action of gastric juice on already damaged epithelium Can Penetrate mucosa and extend into smooth muscle layers Regeneration can happen but is imperfect Used as a broad term since ulcers can occur in the duodenum (most common=80%) , stomach, and the esophagus (could be in any one of these areas)
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess? Sensation of a mass in throat Foul breath Increasing difficulty in swallowing Hiccups
Increasing difficulty in swallowing Explanation: The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.
Peritonitis
Inflammation of peritoneum (serous cavity that lines abdominal cavity) Variety of causes→ bacterial (typical origin), fungal; comes from trauma, surgery
medical mgmt of GERD
Lifestyle modifications→ chronic illness, management important foods→ low fat (fried food exacerbate symptoms); avoid caffeine, tobacco, beer/any type of alcohol, milk, foods containing peppermint/spearmint and carbonated beverages, acidic food/drink(citrus fruits, tomato juice, pineapple juice, etc); avoid eating/drinking 2 hours before bed Maintain normal body weight→ helps decrease pressure on esophageal sphincter Avoid tight fitting clothing→ increases pressure in thoracic cavity and LES Elevate HOB→ helpful for pts waking up in middle of night with GERD; elevate hob with cinder blocks when at home (4 inches)
H. pylori
MC risk factor for stomach adenocarcinoma gram negative bacteria that's usually acquired through the ingestion of contaminated food/water orally from someone affected by bacteria. doesn't mean you develop ulcers but bacteria damages stomach lining leading you to higher chance of getting an ulcer. Often does not cause illness. Major risk factor for PUD Treatment→ antibiotics x2 and proton pump inhibitor; adherence is key
nursing care post radical neck dissection
Maintaining clear airway→ fowler's (take pressure off wound site, facilitate breathing), look for stridor, assess for s/s of resp distress (dyspnea, cog changes, oxygen changes, cyanosis), pulmonary hygiene (support neck, deep breathing), oral suctioning (use care because sutures/surgical site may be injured/disrupted), humidified oxygen via face tent Assess/control pain (opioids, PCA)
post-op esophagectomy
NGT (decompress pressure on suture lines, for healing, do not manipulate); NPO for a while (After surgery will have barium swallow study before PO intake to ensure there is no leaking/obstruction or evidence of pulmonary aspiration)
gastric cancer
Not as easily detected, symptoms vague until severe Patho: Arises from mucus producing cells of the stomach in the innermost lining; Occur anywhere in the stomach→ 40% lower part, 40% middle part, can involve more than one area; Starts on top→ infiltrates stomach wall; Lymph node involvement early since stomach is richly vascular
A client with obesity taking lorcaserin reports feeling agitated lately and has had diarrhea for several days. What is the nurse's priority response? Notify the health care provider. Obtain a stool sample. Assess the frequency of bowel movements. Prepare for intravenous fluid replacement.
Notify the health care provider. Explanation: The client may be developing serotonin syndrome, a potentially life-threatening condition which the health care provider needs to know about right away.
medical mgmt of oral cancer
Prognosis and treatment variable radiation→ shrink tumor/lesion, can be done before surgery to shrink or after if not all cancer was able to be removed chemotherapy→ if metastasized Surgical options (main treatment)--> can be simple excision (if contained to lips), partial or complete glossectomy, Radical neck dissection→ involves removal of cervical lymph nodes/muscle/blood vessels (may need grafting to close surgical wound)
A client with oral cancer reports dryness of the mouth. What is the nurse's best response? Provide a humidifier for the client to use while sleeping. Ensure that the client maintains a fluid intake of 2000 mL per day. State, "This is a normal consequence of oral cancer." Allow the client to continue with his or her usual diet.
Provide a humidifier for the client to use while sleeping. Explanation: Dryness of the mouth (xerostomia) is a frequent sequeala of oral cancer. While explaining this to the client provides information, it does nothing to help solve the problem. The nurse should encourage this client to increase intake of fluids to 2000 to 3000 mL per day. Providing a humidifier will assist in moisturizing the oral cavity. The client needs to be instructed to avoid dry, bulking, and irritating foods and fluids.
clin manifestations of GERD
Pyrosis (burning sensation, heartburn), dyspepsia (upset stomach), regurg, dysphagia/odynophagia (usually later stage, painful swallowing), hypersalivation, esophagitis, can lead to dental caries, barrett's esophagus, pulmonary complications (at risk for aspiration if severe/untreated)
nutrition considerations post esophagectomy
Required to have barium swallow before allowing to eat after esophagectomy (test can see level of dysphagia, ensures there's no leaking in passageway) Appetite is usually poor (stimulate appetite by supplying foods they like/family involvement) Sips water→ soft diet Monitor for dumping syndrome (DATEDW) Dizziness/diarrhea, abdominal cramping, tachycardia, epigastric fullness, diaphoresis, weakness Avoid boost/ensure: really thick and concentrated, increases likelihood for DS Other supplements may be used Upright for 2 hours after meals--. Helps allow food to move through GI tract pharm→ antacids (relieve reflux), prokinetics (promote peristalsis/gastric motility)
A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake? Three meals and three snacks and 120 mL fluid daily Six small meals and 120 mL fluid daily Three meals and 120 ml fluid daily Six small meals daily with 120 mL fluid between meals
Six small meals daily with 120 mL fluid between meals Explanation: After the return of bowel sounds and removal of the nasogastric tube, the nurse may give fluids, followed by food in small portions. Foods are gradually added until the client can eat six small meals a day and drink 120 mL of fluid between meals.
A client is preparing for discharge to home following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal? Allows for better absorption of vitamin B12 Slows gastric emptying Provides much needed rest Removes tension on internal suture line
Slows gastric emptying Explanation: Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.
surgical management of PUD
Surgical not always needed but if treatment program is serious/not healing it might be time to consider surgical options; also can be done if there are complications such as hemorrhage/perforation Depends on type, location or extent of ulcer Performed open or laparoscopically (minimally invasive)
A nurse is monitoring a client with peptic ulcer disease. Which assessment findings would most likely indicate perforation of the ulcer? Select all that apply. Tachycardia Mild epigastric pain A rigid, board-like abdomen Diarrhea Hypotension
Tachycardia Hypotension A rigid, board-like abdomen Explanation: Signs and symptoms of perforation include sudden, severe upper abdominal pain (persisting and increasing in intensity); pain, which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock. Perforation is a surgical emergency.
clin manifestations of diverticulitis
acute onset of mild-severe pain LLQ, constipation, nausea, fever, leukocytosis (increased WBCs from infection), complications (massive rectal bleeding; brighter red)
nursing mgmt for Nissen Fundooplication
advance diet slowly (educate pt), management of N/V (this can put a lot of pressure on sutures which can open things back up), monitoring nutritional intake/weight (ensure pt is tolerating intake, make sure they aren't losing too much weight/haven't lost appetite)
Diverticulum
an out-pouching outside of the GI tract (without inflammation); most often occurs in colon (sigmoid); many people develop these and have no problem (lots of outpouchings= diverticulosis); form from a lack of fiber in the diet years over time, can be related to obesity and a lack of physical activity, smoking, NSAIDs, and having a positive GI history
Select the assessment finding that the nurse should immediately report, post radical neck dissection. A. Temperature of 100.8 degrees B. Pain C. Stridor D. Localized wound tenderness at the incision site
answer: C (stridor= epiglottis is swollen, loud/musical sounding, at times may not need to auscultate to hear sound; sign of upper airway swelling which is bad because we can lose open airways) nursing interventions immediately upon finding stridor: 1) raise HOB to assist with breathing 2) ensure tools are ready to prepare for advanced airway/intubation 3) non rebreather mask 4) let surgeon/rapid response team know
A public health nurse is participating in a community health fair that is focused on health promotion and illness prevention. Which of the following older adults most likely faces the highest risk of developing oral cancer? A.) A person who describes themselves as always having been a "heavy smoker and a heavy drinker." B.) A person who is morbidly obese and has a longstanding diagnosis of systemic lupus erythematosus (SLE). C.) A person who describes themselves as a "proud breast cancer survivor for over 10 years." D.) A person who states that they enjoy good health, with the exception of "heartburn every once in a while."
answer= A (smoking and drinking increase risk for developing oral cancer; 30 fold increased risk)
pharm mgmt GERD= antacids
calcium carbonate (TUMs) action/class: neutralize acid nursing consideration= gastric acid suppression (loss of protective flora and increases risk of infection) usually first line
GERD intro
chronic; d/t diet, activity level, prevalence of obesity Acid reflux--> esophagus; backflow of gastric and duodenal contents into esophagus; causes symptoms and damages esophagus (strictures) Often d/t weak LES If poorly treated-- barrett's esophagus: morphology of esophagus changes (precancerous to esophageal cancer) Usually identified by symptoms, more tests can be done
Roux-en-Y gastric bypass
combined restrictive and malabsorption procedure; horizontal row of staples across the fundus of stomach that creates a ouch with a capacity of 20-30 ml; bypasses portion of small intestine
medical management of PUD
diagnosis→ upper GI (typical way to diagnose), CBC (if suspected bleeding to look at hemoglobin/hematocrit), Fecal Occult (to see if there is blood in stool), H pylori testing (blood, serology, antibodies) Acid control (adherence is key) --> PPI's, H2 antagonists (control of acid can allow tissues to heal) Possible antibiotics-- h pylori (two antibiotics) Discontinuation of NSAIDs Sucralfate (Carafate)--> viscous medication that enhances mucosal layer of stomach, binds to necrotic ulcer tissues, barrier to action of acid/bile diet→ avoid spices, alcohol, coffee and caffeine; avoid extremes in temp of food and beverages; 3 regular meals per day (if eating more meals per day increase in acid production overall) Stop smoking-- increases acidity of stomach, delays healing
S/S of peritonitis
diffuse pain→ more intense, localised, and constant; pain worse with movement (pt may be in fetal position in bed to reduce pressure); abdominal tenderness and distention; anorexia, N/V; fever and increased pulse→ hypotension→ septic shock
small and large intestine
digestion, absorption and elimination Small intestine: duodenum→ jejunum→ ileum (lots of absorption) Large intestine: cecum→ ascending colon→ transverse colon→ descending colon→ sigmoid colon (where a lot of water is absorbed, feces is formed)
diverticulitis
diverticulum that become inflamed/infected Bowel contents can get trapped in these out-pouchings and cause inflammation→ now have diverticulitis
Xerostomia
dry mouth Causes: oral cancer, meds, HIV, those who can't close mouth Interventions: avoid dry bulky or irritating foods, avoid alc (even alc based mouthwashes) and tobacco, encourage PO intake, humidified oxygen, chewing gum/lozenges (all stimulate saliva), synthetic saliva
worst case scenario post PUD surgery: perforation
erosion through stomach wall into peritoneal cavity (often times without warning) s/s→ sudden severe abdominal pain, vomiting, fainting, rigid/tender/"board like" abdomen, hypotensive, tachycardic, septic shock (peritonitis) assessment→ monitor/trend vital signs, pain assessments (look for s/s of pain such as curling up in fetal position), abdominal inspection/palpation (hot belly→ usually absent bowel sounds and warm to touch), assess for septic shock from peritonitis Interventions→ notify provider immediately, NGT lavage, monitor fluid and electrolyte balance, assess for peritonitis and infection, antibiotic therapy
risk factors for GERD
esophageal motility dysfunction, increased intraabdominal pressure (tight fitting clothing, belts), hiatal hernias, eating large meals, obesity, pregnancy, ascites, girdles, spanx, corsets, presence of NGT (holds LES sphincter open)
pharm mgmt of GERD: Histamine-2 receptor antagonists
famotidine (pepcid); Cimetidine (tagamet)= can get in drugstores; decreases acid production nursing considerations= gastric acid suppression (monitor QT interval prolongation in pts with kidney injury)
clin manifestations of oral cancer= early
few/no early symptoms Painless sore/lesion that bleeds easily and does not heal→ hardened with raised edges Red or white patch in mouth or throat
post-op nursing mgmt: esophagectomy
fowler's, pulmonary hygiene (IS, oob, mobilize, nebulizer possible), NPO w/ NGT to LCS (low continuous suction to decompress bowels/healing), parenteral or enteral, oral suctioning for secretions monitor→ WBC, temp, drainage from cervical neck wound; HR/regularity/rhythm
types of peptic ulcers and clin manifestations of both
gastric and duodenal pyrosis, vomiting (side effect of a complication called gastric outlet obstruction), constipation or diarrhea, sour eructation (sour taste in mouth from burping), and bleeding (complication, unlikely to happen)
nursing care post RND= mobility
get up and moving asap, spinal accessory nerve may be damaged-may have problems with shoulder, shoulder exercises to promote/prevent malfunction
nursing care post RND= monitoring complications
hemorrhage (assess/trend VS frequently), avoid valsalva maneuver (bearing down, can put stress on pt's graft which can interfere with perfusion), look out for nerve injury (shoulder, facial paralysis, neuro/stroke checks, report changes), graft checks
mgmt of jaw trauma= traumatic
maintain airway and control bleeding, surgery (screws, plates, putting things back together)→ monitor airway, wire cutters @ bedside (can be cut in case of emergency aka vomiting/aspiration), various diet restrictions
pharm mgmt of GERD: prokinetic agents
metoclopramide (reglan)= accelerate gastric emptying; nursing considerations= may cause tardive dyskinesia typically used short-term
worst case scenario post PUD surgery: gastric outlet obstruction
narrowing to the area distal to the pyloric sphincter due to scarring and stenosis, making stomach contents unable to pass through S/S→ vomiting, epigastric fullness, constipation, weight loss, anorexia, hard and distended abdomen Assessments→ diminished or absent bowel sounds, IOs, abdominal assessment Interventions→ NGT for stomach decompression, monitor fluid and electrolyte imbalance, prep for upper GI or enterectomy
post-op nursing care RND= nutrition
nutrition→ optimizing pre-op (maximize intake before surgery for post-op reserves), parenteral or enteral nutrition (oftentimes enteral, at time of surgery pt may have j tube placed), eventually advance to liquid or soft diet...
pre-op nursing mgmt: esophagectomy
optimization of pt nutritional status (may be on TPN/enteral before)
complications of diverticulitis
perforation, obstruction, abscess, fistula formation (abnormal passageway between two structures; etc bowel and bladder, btw colon/rectum and vagina; happens from chronic inflammation overtime), peritonitis, hemorrhage
Antrectomy
removal of portion of stomach which has cells that secrete gastrin and acid; lower stomach, duodenum and pylorus For more significant/severe ulcers
Sleeve Gastrectomy (SG)
restrictive procedure; stomach incised vertically (up to 85% stomach removed) which leaves a "sleeve" shaped tube that remains intact nervous innervation and does not obstruct or decrease the size of gastric outlet look out for unilateral swelling, redness and tenderness as this can be indicative of complication
worst case scenarios post PUD surgery: GI hemorrhage
s/s→ hypotension, tachycardia, bloody/black tarry stool, pale, dizzy, hematemesis (if severe can be bright red, may be coffee colored if digestion has begun to occur), lower MAP, decreased respirations, low urine output (anuria or oliguria), bloating, diarrhea, stomach upset Nursing assessment→ monitor/trend vital signs (BP, HR, RR), NSAID use, monitor IOs, look at neuro status, hemoglobin/hematocrit, assessing for fall risk, hourly urine output Interventions→ call doctor, administer blood products/IV fluids (isotonic), supplemental oxygen, NG tube if at risk for aspiration (remove blood and clots), hold blood thinners/NSAIDs May go to endoscopy to cauterize site, may go back into operating room to open up and close bleeding site, interventional radiology (arteriography)
clin manifestations of oral cancer=later
tenderness, difficulty chewing/swallowing/speech, coughing up bloods, enlarged cervical lymph nodes (many lymph nodes here, easy to spread) Usually when pts seek treatment it has affected lymph nodes, removal may be necessary
pharm mgmt of GERD: PPIs
third line; more powerful than Hist-2 Pantoprazole (protonix) and Omeprazole (Prilosec) decreases gastric acid production nursing considerations= gastric acid suppression (may increase risk of hip fractures; interferes with vitamin/mineral absorption of B12 and magnesium)
