MED SURG EXAM 3-2 PDF

Preview

Summary

Study guide...

Description

Med Surg Exam 3 Study Guide Topic

Number of Questions

Gerd

5-8

Peptic Ulcer Disease

5-8

Gastrointestinal Tubes

5-8

Malnutrition

5-8

Fluid & Electrolyte Balance

5-8

Diabetes Mellitus Type I and II

5-8

Hypothyroidism Hyperthyroidism

5-8

Gastroesophageal Reflux Disease (GERD) Overview of Gerd: ● GERD is a chronic symptom of mucosal damage caused by reflux of the stomach acid into the lower esophagus ○ Not a disease, but a symptom Etiology and Pathophysiology: ● No one single cause ○ Results when defenses are overwhelmed by reflux of acidic gastric contents into lower esophagus ■ The esophagus is not meant to withstand acid ● HCl acid and pepsin secretions in refluxate cause irritation and inflammation (esophagitis) ● Intestinal proteolytic enzymes and bile salts add to irritation ○ Cause inflammation of the esophagus ○ The degree of inflammation depends on the amount and composition of the gastric reflux and on the esophagus’ mucosal defense mechanisms. Predisposing factors: ● Incompetent lower esophageal sphincter (LES), decreased LES pressure, increased intra-abdominal pressure(coughing, valsalva maneuver, obesity), hiatal hernia(causes GERD)

○

Increased abdominal pressure→ pregnancy, coughing, valsalva maneuver, and obesity are factors of ↑ intra-abdominal pressure Incompetent LES: ● Primary factor in GERD→ the muscle isn’t tightening up as it should ● Results in ↓ pressure in distal portion of esophagus ○ Gastric contents move from stomach to esophagus ○ Can be due to certain foods (caffeine, chocolate) and drugs (anticholinergics) ○ LES acts as an antireflux barrier under normal conditions

Symptoms of GERD: ● Symptoms of GERD may vary from person to person ● Heartburn (pyrosis) ○ The most common clinical manifestation ○ Burning, tight sensation felt beneath lower sternum and spreading upward to throat or jaw ○ Felt intermittently: not there all the time ■ Symptoms felt more than twice a week is considered GERD -Other symptoms of GERD: ● Dyspepsia ● Regurgitation: stomach contents ○ Described as hot, bitter, or sour liquid coming into throat or mouth -GERD-related chest pain: can be mistaken as ♥ attack ● Described as burning, squeezing ● Radiating to back, neck, jaw, or arms ● Can mimic angina ● More common in older adults with GERD ● Relieved with antacids -May report respiratory symptoms: ● Wheezing, coughing, dyspnea, nocturnal discomfort and coughing with loss of sleep ○ Irritating the upper airway can sometimes be enough to induce an asthma attack: 80%-90% of adult-onset asthma cases are caused by GERD -Otolaryngologic symptoms include: ● Hoarseness, sore throat, globus sensation(lump in throat), hypersalivation, choking ●

Health care provider should evaluate:

○ ○

heartburn♥ occurring more than once a week, rated as severe, is associated with dysphagia, or occurring at night and waking the patient Older adults with recent onset of heartburn ■ Should be investigated a little more deeply

Complications: ↪ Related to direct local effects of gastric acid on esophageal mucosa ● Esophagitis: ○ Inflammation of esophagus ○ A frequent complication ○ Repeated exposure: scar formation, esophageal stricture, dysphagia

●

Barrett’s esophagus (esophageal metaplasia) ○ Replacement of flat epithelial cells with columnar epithelium ○ Precancerous lesion ○ Thought to be primarily due to GERD ■ **NEED to get biopsy** ○ Diagnosed in 5%-20% of the patients with chronic reflux ○ S/S: none to perforation ■ Nothing abnormal, they may just ℅ ‘heartburn’ ○ Must be monitored every 2-3 years by endoscopy

●

Respiratory→ from irritation of upper airway be secretions ○ Cough ○ Bronchospasm ○ Laryngospasm ○ Cricopharyngeal spasm ■ Hypercontraction of the cricopharyngeus muscle causing a constricted or lump in throat sensation Respiratory→ from aspiration: ○ Potential for asthma, bronchitis, and pneumonia ■ Aspiration is a risk.. It is a bigger risk for people with a ↓ LOC

●

●

Dental erosion: ○ From acid reflux into mouth

○

Especially posterior teeth ■ Back as opposed to front teeth Diagnostic Studies: ● History and physical examination ○ Want to do a good one ● Upper GI endoscopy ○ Useful in assessing LES competence, degree of inflammation, scarring, strictures ○ Obtain biopsy and cytologic specimens ■ Diagnostic studies are expensive and invasive ● Barium swallow ○ Can detect protrusion of gastric fundus ■ Barium swallow doesn’t really give a lot of information for GERD Interprofessional Care: ● Lifestyle modifications: ○ Avoiding triggers ○ Maintain appropriate weight ○ Smoking cessation ○ Stress management ■ Always advise these things ● Nutritional therapy: ○ Avoid food that ↓ LES pressure or irritate the esophagus ■ Caffeine, peppermint, tomatoes, chocolate, orange juice, red wine, and cola ○ Small, frequent meals ○ Avoid late evening meals + snacking ☾ ■ Have last meal 2-3 hours before laying down ○ Drink fluids between meals ■ Helps prevent overdistention of the stomach ○ Chewing gum and oral lozenges ■ ↑ Saliva production may help with mild symptoms ● Drug Therapy: ○ Proton pump inhibitors (PPIs): ■ Promote esophageal healing in 80%-90% of patients ■ Available in prescription and OTC preps ■ Example: omeprazole (Prilosec) ● Headache: most common side effect ■ Long-term use or high doses of PPIs may ↑ the risk of fractures of hip, wrist and spine ■ Associated with ↑ risk of C. difficile infection in hospitalized patients ● Given 30 minutes before first meal of the day ○ Histamine-2 receptor (H2R) blockers: ■ ↓ Secretion of HCl acid ■ Reduce symptoms and promote esophageal healing in 50% of patients ■ Example: cimetidine

● Side effects uncommon ● Allow acid to be produced, but not secreted ■ Fairly safe drug, doesn’t have to be taken @ certain time of the day ○ Acid protective: ■ Used for cytoprotective properties ■ Examples: sucralfate ● 20 mins ○ Cholinergic: ■ ↑ LES pressure ■ Improve esophageal emptying ■ ↑ gastric emptying ■ Example: bethanechol (Urecholine) ● Helps improve esophageal emptying and increases gastric emptying ○ Prokinetic drugs: ■ Promote gastric emptying ■ Reduce risk of gastric acid reflux ■ Example: metoclopramide (Reglan) ● Less chance of reflux; not used for GERD very often ○ Antacids: ■ Quick but short-lived relief ■ Neutralize HCl acid ■ Taken 1-3 hours after meals/at bedtime ■ Example: Maalox, Mylanta ● Available OTC; quick acting ● Less irritating pH range ● Patient may mask the signs of something else going on ● Surgical therapy reserved for those with complications: ○ Failure of conservative therapy ○ Medication intolerance ○ Barrett’s metaplasia ○ Esophageal stricture and stenosis ○ Chronic esophagitis ■ If they have Barrett’s, and severe, this may be an option ■ Surgery is available, but usually the LAST effort ever Nissen fundoplication:

Nursing Management: ● Elevate HOB 30 degrees ● Do NOT lie down for 2-3 hours after eating ● Avoid factors that cause reflux ○ Stop smoking ○ Avoid alcohol & caffeine ○ Avoid acidic foods ● Stress reduction techniques ● Weight reduction ○ If appropriate ● Small, frequent meals ● Evaluate the effectiveness of medications ● Observe for S/E of medications ○ How are they feeling? Less symptoms? Tolerating food better? ● Postoperative care goals: ○ Prevent respiratory complications ○ Maintain fluid/electrolyte balance ○ Prevent infection ■ Stomach is in the LUQ, patient in lots of pain, won’t want to cough. Risk of pneumothorax. Not eating a whole lot in the beginning ○ Postoperative care: Respiratory assessment ■ RR/rhythm ■ Pulse rate/rhythm ■ Signs of pneumothorax ● Dyspnea, chest pain, cyanosis ● May see unequal chest expansion ○ Postoperative care: ■ Deep breathing techniques ● Incentive spirometer ■ Accurate I/O ■ Observing for fluid/electrolyte imbalance ■ Pain medication ■ Ambulation ● Pain meds make easier to get up and moving ■ Medications to prevent nausea/vomiting ■ When peristalsis returns, only fluids given initially. Solids added gradually ● How do you know peristalsis returns? ○ Flatus, hungry, bm ■ Normal diet is gradually resumed ■ Patient must avoid gas-forming foods and MUST chew foods thoroughly

○ ○

First month after surgery; patient may report mild dysphagia; should resolve after edema subsides Patient should report persistent symptoms such as heartburn and regurgitation Peptic Ulcer Disease (PUD)

Overview of PUD: ● PUD is a condition characterized by erosion of the GI mucosa from the digestive action of HCl acid and pepsin ○ Any portion of the GI tract that is in contact with gastric secretions is susceptible to ulcer development ● Each year, 350,000 new cases of ulcers diagnosed Types of Peptic Ulcer Disease: ● Acute: ○ Superficial erosion ○ Minimal inflammation ○ Short duration: resolves quickly when cause identified and removed ■ Tends to heal completely. When it’s gone, it’s gone ● Chronic: ○ Muscular wall erosion with formation of fibrous tissue ○ Long duration: present continuously for many months or intermittently throughout a person’s lifetime ■ More common than acute erosions

Etiology and Pathophysiology: ●

Destroyers or mucosal barrier: ○ Helicobacter pylori ■ Produces enzyme urease ● Mediates inflammation, making mucosa more vulnerable ○ Aspirin and NSAIDs ■ Inhibit synthesis of prostaglandins ● Cause abnormal permeability ○ Corticosteroids ■ ↓ Rate of mucosal cell renewal ● ↓ Protective effects ○ Lifestyle factors ■ Alcohol, coffee, smoking, stress Gastric Ulcers: ● Can occur in any portion of the stomach ● Less common than duodenal ulcers ● Prevalent in women, older adults ● Peak incidence > 50 years of age Risk factors: ● H. pylori ● Medications ● Smoking ● Bile reflux ○ Bile salts should stay where they are released Clinical Manifestations: ● Pain high in epigastrium ○ 1-2 hours after meals ○ “Burning” or “gaseous” ○ Food aggravates pain as ulcer has eroded through gastric mucosa ■ Eating makes the pain worse

Duodenal Ulcers: ● Occur at any age and in anyone ○ ↑ Between ages of 35 and 45 years ● Account for ~80% of all peptic ulcers ● Familial tendency ● Associated with increased HCl acid secretion ○ Alcohol ○ Cigarette smoking ● H. pylori i s found in 90% to 95% of patients Clinical Manifestations: ● Midepigastric region beneath xiphoid process ● Back pain-- if ulcer is located in posterior aspect ● Symptoms occur usually 2-5 hours after meals ● “Burning” or “cramplike” pain description ● Tendency to occur, then disappear, then occur again Stress-Related Mucosal Disease ● Also called physiologic stress ulcer ● Acute ulcers that develop after major physiologic insult ○ Trauma or surgery ○ They are usually on PPIs→ C. diff risk Diagnostic Studies: ● Tests for H. pylori: ● Serum or whole blood antibody tests: ○ Immunoglobin G (IgG) ■ Will not distinguish between active and recently treated disease ○ Urea breath test ■ Can determine active infection ○ Stool antigen test ■ Not as accurate as breath test ● Endoscopy with biopsy: ○ Determines degree of ulcer healing after treatment ○ During procedure, tissue specimens can be obtained to identify H. pylori and rule out gastric cancer ■ Look for aspiration; make sure cough and gag reflex return before feeding them ● Barium contrast studies: ○ Reserved for patient who cannot undergo endoscopy ○ Not accurate for shallow, superficial ulcers ●

Gastric analysis: ○ Analysis of gastric contents for acidity and volume ○ NG tube is inserted, and gastric contents are aspirated

○ Contents analyzed for HCl acid Laboratory analysis: ○ CBC ■ Will show RBC, WBC, HCT, HGB ○ Urinalysis ○ Liver enzyme studies ■ Show baseline, rule out cirrhosis ○ Serum amylase determination ■ Pancreatic function ○ Stool examination ■ Look for blood in the stool Collaborative Care ● Medical regimen consists of ○ Adequate rest ○ Drug therapy ○ Elimination of smoking and alcohol ○ Dietary modification→ monitor diet ○ Long-term follow-up care ● Stress management ● Aims of treatment program ○ Reduce degree of gastric acidity ○ Enhance mucosal defense mechanism ● Generally treated in ambulatory care setting ○ Ulcer healing requires many weeks of therapy ○ Pain disappears after 3-6 days ● Complete healing may take 3-9 weeks ○ Should be assessed by means of x-rays or endoscopic examination ● Aspirin and nonselective NSAIDs may be stopped for 4-6 weeks ● Smoking cessation ○ Patients will go home, no need to stay in the hospital because of ulcer Drug Therapy ● Use of ○ H2R blockers ○ PPIs ○ Antibiotics ○ Antacids ○ Anticholinergics ○ Cytoprotective therapy Nutritional Therapy ● Dietary modifications ○ Food and beverages irritating to patient are avoided or eliminated ● Bland diet may be recommended ● Six small meals a day during symptomatic phase ●

○ NO drinking during meals Nursing Assessment ● Past health history ○ Ulcers before? GERD? What medications are they on? S/s of ♥ burn and how often experiencing it ● Medication usage ● ♥ burn ● Weight loss ○ Ask what weight normally is ● Black, tarry stools ● Epigastric tenderness ● Nausea and vomiting ● Abnormal lab values Nursing Diagnoses ● Acute pain ● Ineffective self-health management ● Nausea ○ All of this may be new to patient Nursing Management ● Overall goals ○ Comply with prescribed therapeutic regimen ○ Experience a reduction in or absence of discomfort ○ Exhibit no signs of GI complications ○ Have complete healing ○ Make lifestyle changes to prevent recurrence Nursing Implementation ● Health promotion ○ Identify patients at risk ■ Patients who smoke/drink (excessively) ○ Provide early detection and treatment ○ Encourage patients to take ulcerogenic drugs with food or milk ○ Teach patient to report to health care provider symptoms related to gastric irritation ● Acute intervention ○ NPO, possibility NG tube ■ Eating stimulates HCl production ○ IV hydration ○ Explain treatment measures to patient/family ○ Provide regular mouth care ○ Cleanse and lubricate nares if NG tube is in place ○ Vital signs hourly ■ More frequently, no need for hourly unless complication ○ Monitor I&O ○ Physical and emotional rest

■ Not stress ○ Sedatives can mask symptoms of shock Complications ● Hemorrhage ● Perforation ○ Big two complications ● Hemorrhage ○ Most common complication of peptic ulcer disease ○ Develops from erosion of: ■ Granulation tissue found at base of ulcer during healing ■ Ulcer through a major blood vessel ●

Perforation ○ Most lethal complication of peptic ulcer ○ Common in large penetrating duodenal ulcers that have not healed and are located on posterior mucosal wall ■ More often happens with duodenal ulcers (ulcer makes a hole) ○ Perforated gastric ulcers are often located on lesser curvature of stomach ○ Mortality rates are higher with perforation of gastric ulcers ○ When ulcer penetrates serosal surface with spillage of contents into peritoneal cavity ○ Size proportionate to length of time ulcer existed ■ Longer the ulcers been there, bigger the tear and vice versa ○ Large perforations: immediate surgical closer ● Clinical Manifestations of Perforation: ○ Sudden, dramatic onset ○ Initial phase (0-2 hours after perforation_ ■ Severe upper abdominal pain spread ■ Tachycardia, weak pulse ■ Rigid, boardlike abdominal muscles ○ No bowel sounds ○ Shallow, rapid respirations ○ Nausea/vomiting ○ History of reporting symptoms of indigestion or previous ulcer ○ Diminished LOC ○ Bacterial peritonitis may occur with 6-12 hours ○ Difficult to determine from symptoms alone if gastric or duodenal ulcer has perforated ■ Clinical characteristics are the same ■ Get it to stop and treat the patient ○ Sudden, severe abdominal pain unrelated in intensity and location to pain that brought patient to hospital ■ Possibility of perforation ○ Indicated by a rigid, boardlike abdomen ● Therapy Related to Complications: Perforation

○

○ ○ ○ ○

○

○ ○ ○

○ ○

○ ○

○

Immediate focus→ is the perforation ■ Stop spillage of gastric or duodenal contents into peritoneal cavity ■ Restore blood volume Check vital signs VERY frequently (15-30 minutes) Stop ALL oral, NG feeds/drugs until health care provider is notified ■ Do not put anything in their mouth IV fluids may be ↑ to replace volume lost Ensure any known allergies are reported on chart ■ Antibiotic therapy is usually started ■ Surgical or laparoscopic closure may be necessary if perforation does not heal spontaneously NG tube is placed into stomach ■ Continuous aspiration ■ Placement of tube near to perforation site facilitates decompression Circulation blood volume: replaced with lactated Ringer’s and albumin solutions Blood replacement in form of packed RBCs may be necessary CVP line inserted and monitored hourly ■ ICU monitoring ■ Pressure in R atrium Indwelling urinary catheter inserted and monitored hourly ECG if patient has history or cardiac disease ■ Drug therapy for perforation ● Broad-spectrum antibiotics ● Pain medication Open or laparoscopic repair ■ Excess gastric contents are suctioned from peritoneal cavity Nutritional Therapy Postoperatively ■ Start as soon as immediate postoperative period has successfully passed ■ Patient should be advised to reduce drinking fluid (4 oz) with meals ■ Diet should consist of ● Small, dry feedings ○ No fluids along with food ● Low carbohydrates ● Restricted sugar with meals ● Moderate amounts of protein and fat ■ Rest for 30 minutes after each meal Postoperative Complications: ■ Dumping syndrome ● 15-30 minutes after eating→ abdominal cramping, stomach grumbling, diarrhea (not long) ■ Post Gastrectomy surgery ■ Malnutrition and fluid electrolyte imbalances

●

● Very small meals very frequently ● NO FLUIDS WITH FOOD Ambulatory and Home Care ○ Patient teaching: ■ Lifestyle changes ● Appropriate changes in diet ● Smoking cessation ● Negative effects of alcohol ○ When we send them home, make dietary changes so this doesn’t happen again. ○ Frequent follow ups ○ When to call dr→ anything related to PUD ○ Regular follow-up care: ■ Discuss medications ■ Encourage compliance with plan of care ■ Importance of immediate reporting of N/V, epigastric pain, bloody emesis, or tarry stools ○ PATIENT TEACHING: ■ Disease; ● Teach basic etiology/pathophysiology ■ Drugs: ● Actions, S/E, danger of taking any medication without health care provider approval ● With medications they’re taking, nothing new unless discussed with DR Gastrointestinal Tubes

●

●

Enteral Feeding Tubes ○ Delivery of nutritionally complete feeding directly into the stomach, duodenum, or jejunum ○ Auscultatory method of checking placement is NOT considered reliable ■ Initial placement should be checked by x-ray ■ Subsequent placement should be checked by aspirating stomach contents and measuring pH ■ Gastric pH should be between 1.5 and 4 Nursing Interventions ○ Obtain x-ray to determine placement PRIOR to beginning any administrations of fluids/meds, etc ○ Assess gastric pH before each feeding; q 4 hours for continuous feedings ○ Maintain semi-fowlers position while feeding is infusing ○ Assess residual in stomach and re-feed the residual unless it exceeds the maximum ○ Provide nose/mouth care ○ Replace tube q 4 week

●

●

●

●

●

●

●

●

If residual exceeds 100mL for intermittent feedings, or 2hr worth of a continuous feeding, hold or stop the feeding; do NOT refeed aspirate, notify the provider

Complications ○ Infection ○ Bleeding ○ Tube misplacement/dislodgement, aspiration: immediately removed any tube suspected of being dislodged or misplaced ○ Abdominal distention, nausea, vomiting, diarrhea, constipation ○ Fluid imbalance ○ Electrolyte imbalance ○ If patient is on tube feed, and needs to lie flat for any reason, STOP the feed Percutaneous End...