170 -exam #4 study guide outline and notes PDF

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Gastroesophageal Reflux Disease (GERD) ○ Patho: backflow of gastric contents into the esophagus. ○ Causes: imcompenent weaken lower esophageal sphincter, increased intraabdominal pressure (pregnancy, overeating, obesity, HH), pyloric stenosis, certain medications (antihistamines, CCBs sedatives), or mobility disorder. ○ Risk factors: diets that are chronically low in fresh produce. affects all ages- but elderly are more prone to complications , food irritants - Caffeine, chocolate, citrus, tamoties, smoking/tobacco, CCBs, nitrates, mint, alcohol. Medications: anticholinergics (delay gastric emptying), high estrogen/ progesterone, NG tube placement. ○ s/s: Pyrosis (heartburn), epigastric pain, dyspepsia (indigestion), pain and difficulty swallowing (dysphagia), hypersalivation, bitter taste in mouth, regurgitation (aspiration risk), Dry coughing/wheezing (worst at night), belching, nausea, pharyngitis, dental caries (serve). ○ eledery s/s: atypical chest pain, ear, nose throat infections, pulmonary problems (aspiration pneumonia, sleep apnea, asthma) more at risk for developing severe complications- HH and med s/e, barrett's esophagus or erosion ○ Labs: ○ Diagnostics: esophagogastroduodenoscopy (EGD)endoscopy - assess esophagus for s/s of narrowing and ulcers. Esophageal manometry - assesses function and ability of esophagus to squeeze food down and how LES closes. . pH monitoring - measures acid amount in esophagus for 24 hours (small tube stays in esophagus during. ○ Interventions: nutrient therapy is usually enough. ■ Eat 4-6 small meals a day. Low fat - high fiber ■ Limit or eliminate fatty foods, coffee, tea, cola, carbonated drinks , mint, chocolate ■ Reduce or eliminate from your diet any food that increases gastric ■ acid and causes pain ■ Limit or eliminate alcohol and tobacco, and reduce exposure to ■ secondhand smoke**Smoking and alcohol decrease LES pressure and irritate tissues.** ■ Do not eat 2-3 hours before bed ■ Eat slowly and chew your food thoroughly to reduce belching ■ Remain upright 1-2 hours after meals, if possible ■ Elevate HOB 6-12 inches using wooden blocks, or elevate your ■ head using foam wedges. Never sleep flat in bed. ■ If you are overweight, lose weight. ■ Do not wear constrictive clothing. ■ Avoid heavy lifting, straining, and working in a bent-over position. ■ Chew “chewable” antacids thoroughly, and follow with a glass of water ■ Do not take anticholinergics (dalay stomach emptying), NSAIDs (contains acetylsalicylic acid). ■ Surgery: laparoscopic nissen fundoplication (LNF), ○ Medications: Take antacids (calcium carbonate) (when taking wait 1-2 hours before taking H2 blocker, antibiotics, or caratate) , H2 receptor antagonist (IV Famotidine)(reduces gastric acid) , PPIs (IV protonix) (reduces acid, helps esophagus heal, can be given long term, long term use complication = bone fractures; most common in elderly). Prokinetics ( oral metoclopramide) ○ Surgical: extreme cases only - fundoplication, wrapping gastric fundus around sphincter area of esophagus. ○ Complications: Esphogitis - where the esophagus cells start to erode and become inflamed due to acid. Barrett's esophagus - results from exposure to acid and pepsin (sometimes nitrosamines) which changes the cells DNA making them precancerous. Strictures- build up scar tissue in the esophagus causing narrowing. Laryngopharyneal reflux - acid going into the pharynx going into respiratory system causing lung infections, ear infections, coughing. complications are most common in eledery.

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Hiatal Hernia Increases risk of GERD because of increase of intra abdominal pressure. It's a hernia that is formed at the top of the stomach near the LES putting pressure on it causing it to not operate properly. Types s/s: ○ Sliding: heartburn, regurgitation, chest pain, dysphagia, belching. ○ Paraesophageal: feeling of fullness or breathlessness after eating, feeling of suffocation. Chest pain that mimics angina, s/s worse in recumbent position. Patho: (esophageal/ diaphragmatic hernia) portion of stomach herniates through diaphragm into thorax. Risk factors: Herniation results from weakening of muscles of diaphragm aggravated by that increase abdominal pressure (pregnancy, ascites, obesity, tumors, heavy lifting)

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Complications: ulceration, hemorrhage, regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with necrosis, peritonitis, mediastinitis. Interventions: The most important role of a nurse is health teaching for HH. small frequent meals, avoid eating at night, avoid food irritants. Sleep with the head of the bed elevated 6 inches, remain upright for several hours, avoid straining or excessive exercise, and avoid restrictive clothing. Teach patients and families that they need to follow a strict diet and exercise and should reduce body weight to reduce intra abdominal pressure. Medications: avoid anticholinergics (delay stomach emptying)

Herniation Patho: weakness in abdominal muscle wall through which a segment of bowel protrudes Causes: congenital or acquired muscle weakness and increased intra abdominal pressure contribute to hernia formation. Types: Assessment: patient should be lying down and then assess when patient is standing. If hernia is reducible it may disappear when the patient is lying flat. Listen for bowel sounds (absence = GI obstruction) Interventions: truss- pad with firm support for people who can’t have surgery. Herniorrhapy - replaces contents of the hernia sac into the abdominal cavity and closing the opening. Hernioplasty - reinforces the weakened muscular wall with a mesh patch. ○ Pre/post care: avoid coughing - but deep breath. Inguinal repair - wear scrotal support and elevate scrotum with pillow in bed. Avoid bowel or bowel distension by - stimulating voiding techniques (standing them up), avoid constipation ( avoid straining during healing)

Intestinal obstruction = compromises elimination Patho: an obstruction can be partial or complete and can occur in either the small or large intestine. Types and s/s: ○ Small: abdominal discomfort or pain by visible waves in middle abdomen, upper or epigastric abdominal distention, nausea, profuse vomiting, obstipation, sever F&E imbalances, metabolic alkalosis. ○ Large: intermittent lower abdominal cramping, lower abdominal distention, no vomiting, constipation or ribbon like stools, sometimes metabolic acidosis. ○ Diagnostics: no definitive test to confirm. CT scan , abdominal ultrasound Interventions: decompress GI tract by inserting a gastric tube (oral or nasal) ** must check placement, patency, output every 4 hours. Assess for peristalsis by auscultating for bowel sounds with suction off** monitor nasal skin around the tube. It is a surgical emergency when this is an obstruction with compromised blood flow. Perforation: Sudden change in abdominal pain from dull to sharp or local to generalized may indicate a perforation. Inform MD ASAP of pain, VS & o2 sat. perforation is an emergency.

Peptic Ulcer Disease ●

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Patho: Ulcer formation in the upper GI that affects lining of the stomach . The ulcers form due to gastric acid and pepsin and breakdown of defenses (prostaglandins - release bicarbonate, control acid amount secreted; bicarbonate of the mucosa = protect lining of the stomach) that protect the stomach lining which signals to the parietal cells to release more HCL acid which erodes the stomach lining further. . Causes: ○ H. Pylori (spiral shaped bacteria that releases urease that breaks down urea into ammonia which neutralizes acid = breaks down mucosa) spread from food or drink - fecal to oral, ○ NSAID usage (aspirin, Ibuprofen, etc) reduces production of prostaglandins which black prostaglandins which protect stomach mucosa lining which causes break down. ○ Zollinger- ellison syndrome - tumor formation that over secretes acid. Risk factors: smoking, alcohol, genetics. Food and stress do not play a role. Types of ulcers ○ Gastric: found inside the stomach ■ s/s: food makes pain worse. indigestion, epigastric pain, aching or dull pain occurs 3060 mins after meals. Weight loss. Hematemesis (vomiting blood- coffee grounds or bright red) ○ Duodenal: found inside the duodenum (1st part of small intestine) ■ s/s: food makes pain better. indigestion, epigastric pain, growling pain 1.5-3 hours after a meal and during the night - usually wakes them up. Melena (tarry dark stools) Assess: VS bowel sounds, tenderness, stool, vomit, history of H pylori Diagnostics: EGD, CT scan with contrast , upper GI series (barium). Tests to test for H pylori.

After EGD monitor VS, heart rhythm, and O2 sat frequently until they return to baseline. Frequently assess patient’s ability to swallow saliva. The gag reflex might be absent after EGD because of the numbing spray. After the procedure do not give the patient any food or liquids until gag reflex is back. Interventions: avoid alcohol, caffeine, spicy, acidic, fried foods, chocolate, smoking. Get rest and reduce stress. Medications: antacids, H2 receptor antagonists (IV famotidine) , PPIs (IV protonix) to decrease gastric secretions. Administer anticholinergics - reduce gastric mobility. Administer mucosal barrier protectant (oral sucralfate) 1 hr before each meal. Administer Flagyl (no alcohol before 2 days or 2 days after taking) Avoid aspirin and NSAIDs (block prostaglandins). If meds dont work gastric bypass is necessary Complications: ○ Active GI Bleeding:increased HR, decreased BP, weak, plale, low hematocrit and hemoglobin. Dark tar stools or bright red vomit. NPO and administer IV fluids. Monitor i&o. Monitor labs: hemoglobin and hematocrit. Administer blood transfusions. ○ Recongize that priority care with GI bleed is to maintain ABCs. respond to these needs by providing oxygen and ventilation as needed, starting 2 large bore IV lines for replacing fluids and blood, and monitoring VS, hematocrit, and O2 sat. ○ Perforation (leads to peritonitis) = erodes hole in the lining letting juices leak into the abdominal cavity. Increased RR, increased HR fever. ○ Bowel blockage ○ Call MD ASAP: sharp, sudden, persistent epiggastric/abdominal pain. Bloody/black stools. Vomit blood that looks like coffee grounds. ○

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Surgical interventions: gastrectomy- removal of stomach with attachment of esophagus to the jejunum or duodenum. ○ Post-op interventions: monitor VS, high fowler’s position for comfort and promote drainage. Administer fluids and electrolyte replacements IV, I&O output. Assess bowel sounds. Monitor NG suction, NPO. 6 small bland meals a day when bowel sounds return. Monitor for dumping syndrome. ○ After surgery avoid any OTCs containing aspirin or other NSAIDs. Emphasize the importance of following treatment for H.pylori, the ulcer, and keeping follow up appointments. Help patient identify situations that cause stress, describe feeling during stressful situations and develop a plan to cope with stressors. ■ Dumping syndrome: rapid emptying of gastric contents into the small intestine that occurs following gastric resection. ● s/s: nausea, bloating, hypotension, syncope, and diarrhea. occurs 15-30 mins after eating, N&V, feeling of abdominal fullness, abdominal cramping, diarrhea, palpitations, tachycardia, perspiration, weakness, and dizziness, borborygmi ( loud gurgling sounds from bowel hypermotility. ) late dumping watch for s/s of hypoglycemia due to the release of insulin, sweating, weak, dizzy. Happens 3 hours after eating. ● Interventions: avoid salt, sugar, milk, or very hot or very cold foods. Eat a high protein, high fat ,low fiber, low carb diet. Eat small frequent meals, don't drink fluids with meals or after. Lay down for 30 mins after a meal. Take antispasmodic medications to delay gastric emptying.

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Irritable bowel syndrome (not inflammatory, no permanent damage) Patho: chronic or recurrent diarrhea, constipation, abdominal pain , and bloating. Cause: unclear, genetic, environmental, hormonal, stress s/s: abdominal pain, cramps, pain in the lower left quadrant. Changes in bowel patterns (diarrhea, constipation, or alternating pattern of both). Or consistency of stool or passing of mucous. Food intolerance. Risk factors: Labs: serum albumin, CBC, erythrocyte sedimentation rate, and H. pylori testing (to detect infection and nutritional deficits) Diagnostics: Interventions: increase fiber 30-49 g daily.. Drink 8-10 cups of liquid per day. Food diary - help identify triggers and bowel habits. Help patient ID and eliminate foods associated with exacerbations. Medications: antidiarrheals, bulk forming laxatives. Constipation: lubiprostone, linaclotide. Diarrhea: alosetron. Probiotics, peppermint oil capsules, stress management (medication, imagery, yoga)

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Appendicitis Patho: inflammation of appendix. When inflamed or infected it can rupture in hours. Causes: obstruction - hard stool that blocks off the appendix. (fecalith) (causes pressure by stopping mucus secretion by the appendix) , parasites, foreign object, enlargement of lymph nodes (crohn's gastroenteritis) Pressure causes: venous obstruction - stops blood flow and the blood that's in there is stagnant = risk for blood clots. If the appendix ruptures all the juices will go all over the abdominal cavity = peritonitis. s/s: ○ pain in periumbilical area to RLQ ○ pain most intense at mcburney’s point -. Rebound pain/tenderness, (pain after you stop touching it) ○ abdominal rigidity. ○ Cant fart ○ Side lying position with bent knees ○ Low grade fever. Anorexia, N&V. constipation/ diarrhea. Complications:ruptured appendix = life-threatening - peritonitis - inflammation of the peritoneum. ○ s/s: guardian of abdomen, increased temp and chill. Pallor. Abdominal pain and distention. Restlessness. Tachycardia and tachypnea. Risk factors: Labs: elevated WBC Diagnostics: Interventions: surgery- appendectomy , removal of appendix. ○ Interventions ■ Pre op: NPO, IV fluids, monitor for changes in pain, monitor for s.s of perforation (rupture of appendix) (relief of pain followed by increase of pain) and peritonitis ( increased HR, increased RR, increased temperature, abdominal distention or bloating) ● Position patient in ride side lying or low to semi fowlers position to promote comfort. Monitor bowel sounds. Apply ice packs to the abdomen for 20-30 mins every hour. Administer antibiotics. Avoid heat, laxatives, or enemas. ■ Post op: monitor VS especially temperature. Monitor for s.s of infection (drainage from surgical site) . NPO until bowel function returns. Advance diet gradually - high fiber diet. If the appendix ruptured there will be a drain. Expect profuse drainage for the first 12 hours. Position patient in right side lying or low to semi fowler's position with legs flexed to facilitate drainage. change dress, wound irrigation as ordered. Administer antibiotics and angelstics. Ambulate ( DVT prevention.) Avoid putting heat on the abdomen. Heat can rupture appendix leading to peritonitis. Medications: IV antibiotics post op

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Gastroenteritis: stomach virus ; inflammation of the stomach and bowel, caused by an infection. Patho: inflammation of the lining of the intestines caused by a virus, bacteria, or parasites. Viral gastroenteritis is the second most common illness in the U.S. The cause is often a norovirus infection. Campylobacter, e coli, and shigellosis. Causes: travel, contaminated food or water or by contact with an infected person. s/s: bloody watery mucous Diarrhea with cramps/pain, nausea, vomiting, fever, dehydration, hypotension Risk factors: Diagnostics: stool gram staining or culture to see if it is bacterial or viral Interventions: replace fluids (6 tsp sugar and 2 salt for every 1 L) or administer IV fluids. Check VS & orthostatic BP, monitor I&Os Medications: antibacterials( if appropriate if it will go away within 72 hours - no) avoid drugs that reduce GI motility. prevention: ○ Wash hands for 30 seconds with antibacterial soap ○ Use disposable silverware cups and own tube of toothpaste ○ Keep bathrooms clean to avoid exposure to stool. ○ Inform MD if symptoms last longer than 3 days ○ Do not prepare or handle food that will be eaten by others.

Gastritis inflammation of the stomach lining specifically, and not always caused by infection. Patho: inflammation of stomach or gastric mucosa. Causes: ○ acute - ingestion of disease contaminated food, or food that is irritating/ over seasoned. Overuse of aspirin or NSAIDs. Excessive alcohol. Bile reflux. Radiation therapy. ○ Chronic: benign/ malignant ulcers. Bacteria H pylori. Autoimmune disease. Dietary factors, medications, alcohol smoking, or reflux. s/s: ○ Acute: rapid epigastric discomfort, hematemesis, dyspepia, N&V, gastric hemorrhage, anorexia. ○ Chronic: vague epigastric pain that is relieved by food. Anorexia, N&V. intolerance of spicy and fatty foods, pericious anemia. Prevention: ○ ○ ○ ○ ○ ○ ○

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eat a well balanced diet. Avoid excess alcohol and coffee. Use caution in taking large doses of aspirin or ibuprofen (NSAIDs), and corticosteroids. Avoid food poisoning. manage stress. Stop smoking. Protect yourself against the workplace (lead, nickel) . Call MD if you have s/s of esophageal reflux.

Interventions: ○ Acute: food and fluids withheld until symptoms subside, give ice chips - clear liquids- then solid foods. ○ Chronic: monitor for s/s of hemorrhagic gastritis - hematemesis, tachycardia, hypotension, contact MD. avoid irritating foods and fluids - caffeine, spicy, high seasoned food, alcohol, nicotine. ○ Medications: antibiotics to treat H Pylori. Antacids. B12 injections if needed. Medications: sucralfate (carafate), B12 ○ Teach patients to monitor for symptom relief and side effects of drugs. Call MD if adverse effects appear or worsening of gastric distress. Remind patients not to take other OTCs if they are taking a similar prescribed drug.

Inflammatory bowel disease: comes in 2 forms UC and crohn's ○ Ulcerative colitis ■ Patho: inflammatory bowel disease that causes inflammation and ulcers in the inner lining of the colon and rectum. that results in poor absorption of nutrients. Starts in rectum. When the bowel gets inflamed it causes ulcers which release pus and mucous

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Crohn’s Disease ■ Patho: inflammatory bowel disease that can occur anywhere in the GI tract causing inflammation and ulcers .but usually affects the terminal end of the ileum. Effects all layers of the bowel. Can be scattered in the GI tract. No cure like UC (can't just get rid of disease part of colon due to it being spread through out) ■ Cause: unknown; potential autoimmune. ■ Risk factors: same as UC ■ s/s: abdominal pain (RLQ), ulcers in mouth, diarrhea, weight loss, malnourishment, fissures, bloating, ■ Complications: high alert for peritonitis (first sign of peritonitis in elderly is confusion) .abscesses= infection pocket = sepsis= death (abscesses can turn into fistulas), fistulas = ulcer in intestinal wall connecting to another intestine or organ = sepsis. Adequate nutrtion and F&E are priorities in care of fistula. Dehydration should be treated immediately. Be sure that wound drainage is not in direct contact with the skin because the fluids are caustic(skin integrity) Malnutrition. fissure= anal tears. Stricture = narrowing of intestinal wall= obstruction of food. Arthritis, gallbladder stones, rashes, eyes problems. ■ Interventions: no smoking makes it worse, bowel rest with TPN in severe cases. Monitor daily weights. Monitor I&O, full GI assessment (freq, description of BM, sounds of Bowels) ■ Diet: high fiber foods - nuts, raw fruits, vegetables, spicy, fatty. Eat a low fiber diet - white rice, cook vegetables, high protein. ■ Medications: salicylates, c...