Medical Surgical Nursing 2 Prelims PDF

PRELIMS FRIDAY THIRD YEAR - 2ND SEMESTER/A.Y. 2024-2025 7:00AM–12:00 PM WEEK 2 LECTURER: PR...

PRELIMS FRIDAY THIRD YEAR - 2ND SEMESTER/A.Y. 2024-2025 7:00AM–12:00 PM WEEK 2 LECTURER: PROF. EARL JOHN S. AMADO, RN, MSN TRANSCRIBED BY: JUSTINE DIANE P. DULDULAO BSN 3-YB-1B DISEASES OF THE UPPER GASTROINTESTINAL TRACT to maintain GASTROESOPHAGEAL REFLUX DISEASE (GERD) ü normal body weight Some degree of gastroesophageal reflux (backflow of The patient is instructed to elevate the head of the bed on gastric or duodenal contents into the esophagus) is normal 6- to 8-inch (15 to 20cm) blocks; and to elevate the upper in both adults and children. body on pillows. Excessive reflux may occur because of an If reflux persists, antacids or H2 receptor antagonists, such ü lower esophageal sphincter, as ü pyloric stenosis, or ü famotidine (Pepcid), ü motility disorder. ü nizatidine (Axid), or ü ranitidine (Zantac), may be prescribed. The incidence of GERD seems to increase with aging. Proton pump inhibitors (medications that decrease the release of gastric acid), such as GERD ü lansoprazole [Prevacid], CLINICAL MANIFESTATIONS ü rabeprazole [AcipHex], Symptoms may include: ü esomeprazole [Nexium], pyrosis (burning sensation in the esophagus) ü omeprazole [Prilosec], and dyspepsia (indigestion) ü pantoprazole [Protonix]) regurgitation, dysphagia or odynophagia (pain on Ä may be used; however, these products may swallowing), increase intragastric bacterial growth and the risk hypersalivation, and of infection. esophagitis. In addition, the patient may receive prokinetic agents, which accelerate gastric emptying. These agents include: ü bethanechol (Urecholine), GERD ü domperidone (Motilium), and ASSESSMENT AND DIAGNOSTIC FINDINGS ü metoclopramide (Reglan). Ambulatory 12 to 36-hour esophageal pH monitoring (used Ä Because metoclopramide can have to evaluate the degree of acid reflux) extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson’s disease, it should be used only if no other option exists, and the patient should be monitored closely. If medical management is unsuccessful, surgical intervention may be necessary. ü Surgical management involves a ü Nissen fundoplication (wrapping of a portion of the gastric fundus around the sphincter area of the esophagus). ü A Nissen fundoplication can be performed by the open method or by laparoscopy. GASTRITIS Bilirubin monitoring (Bilitec) (used to measure bile reflux Gastritis is inflammation of the stomach mucosa. patterns) a) Acute gastritis Ä Exposure to bile can cause mucosal damage b) Chronic gastritis Diagnostic testing may include an GASTRITIS ACUTE GASTRITIS Ä endoscopy or Ä barium swallow lasts several hours to a few days and is often caused by to evaluate damage to the esophageal mucosa. dietary indiscretion (eating irritating food that is highly seasoned or food that is infected). Other causes include excessive use of GERD MANAGEMENT ü aspirin and other ü nonsteroidal anti-inflammatory drugs (NSAIDs), Management begins with teaching the patient to avoid ü excessive alcohol intake, situations that decrease ü bile reflux, and ü lower esophageal sphincter pressure or ü radiation therapy. ü cause esophageal irritation. A more severe form of acute gastritis is caused by strong The patient is instructed to eat acids or alkali, which may cause the mucosa to become ü low-fat diet; gangrenous or to perforate. to avoid Gastritis may also be the first sign of acute systemic ü caffeine, infection. ü tobacco, The patient is instructed to avoid GASTRITIS CHRONIC GASTRITIS ü milk, ü foods containing peppermint or is a prolonged inflammation of the stomach that may be ü spearmint, and carbonated beverages caused either by The patient is instructed to avoid ü benign or malignant ulcers of the stomach or ü eating or drinking 2 hours before bedtime; ü by bacteria such as Helicobacter pylori. ü tight-fitting clothes; Chronic gastritis may be associated with ü autoimmune diseases such as pernicious anemia Page 1  ü dietary factors such as caffeine ü gastric resection (gastrojejunostomy) may be ü the use of medications such as NSAIDs or necessary to treat pyloric obstruction. bisphosphonates (eg, alendronate [Fosamax], Chronic Gastritis Diet modification risedronate [Actonel], ibandronate [Boniva]) rest ü alcohol, stress reduction ü smoking, or avoidance of alcohol and NSAIDs ü chronic reflux of pancreatic secretions and bile into pharmacotherapy are key treatment measures. the stomach. Superficial ulceration may occur and can lead to GASTRITIS NURSING MANAGEMENT hemorrhage. a) Reducing Anxiety GASTRITIS CLINICAL MANIFESTATIONS ü Carry out emergency measures for ingestion of acids Acute Gastritis or alkalies. May have rapid onset of symptoms: ü Offer supportive therapy to patient and family during ü abdominal discomfort, treatment and after the ingested acid or alkali has ü headache been neutralized or diluted. ü lassitude ü Prepare patient for additional diagnostic studies ü nausea (endoscopy) or surgery. ü anorexia ü Calmly listen to and answer questions as completely ü vomiting, and as possible; explain all procedures and treatments. ü hiccupping b) Promoting Optimal Nutrition ü Provide physical and emotional support for patients Chronic Gastritis with acute gastritis. May be asymptomatic. ü Help patient manage symptoms (eg, nausea, vomiting, v Complaints of heartburn, and fatigue). ü anorexia ü Avoid foods and fluids by mouth for hours or days until ü heartburn after eating acute symptoms subside. ü Belching/burping ü Discourage caffeinated beverages (caffeine increases ü a sour taste in the mouth, or gastric activity and pepsin secretion), alcohol, and ü nausea and vomiting. cigarette smoking (nicotine inhibits neutralization of ü Patients with chronic gastritis from vitamin deficiency gastric acid in the duodenum). usually have evidence of malabsorption of vitamin ü Refer patient for alcohol counseling and smoking B12. cessation when appropriate. c) Promoting Fluid Balance ü Monitor daily intake and output for dehydration GASTRITIS ASSESSMENT AND DIAGNOSTIC FINDINGS (minimal intake of 1.5 L/day and urine output of 30 Gastritis is sometimes associated with achlorhydria or mL/h). hypochlorhydria (absence or low levels of hydrochloric acid) ü Infuse intravenous fluids if prescribed. or with high acid levels. ü Assess electrolyte values every 24 hours for fluid Upper gastrointestinal (GI) x-ray series, imbalance. endoscopy. ü Be alert for indicators of hemorrhagic gastritis Ø Hematemesis Ø Tachycardia GASTRITIS MEDICAL MANAGEMENT Ø Hypotension Acute Gastritis Ø NOTIFY PHYSICIAN!!! The gastric mucosa is capable of repairing itself after an d) Relieving Pain episode of gastritis. As a rule, the patient recovers in about ü Instruct patient to avoid foods and beverages that may 1 day, although the appetite may be diminished for an be irritating to the gastric mucosa. additional 2 or 3 days. ü Instruct patient in the correct use of medications to The patient should refrain from alcohol and eating until relieve chronic gastritis. symptoms subside. Then the patient can progress to a ü Assess pain and attainment of comfort through use of nonirritating diet. medications and avoidance of irritating substances If symptoms persist, intravenous fluids may be necessary. If bleeding is present, management is similar to that of PEPTIC ULCER upper GI tract hemorrhage. A peptic ulcer is an excavation formed in the mucosal wall If gastritis is due to ingestion of strong acids or alkali, of the ü dilute and neutralize the acid with common antacids ü esophagus (eg, aluminum hydroxide); ü stomach, ü neutralize alkali with diluted lemon juice or diluted ü pylorus, or vinegar. ü Duodenum. If corrosion is extensive or severe, It is frequently referred to as a ü avoid emetics and lavage because of danger of ü Esophageal ulcer perforation. ü Gastric ulcer ü Supportive therapy may include nasogastric ü Duodenal ulcer intubation, depending on its location ü analgesic agents and sedatives, ü antacids, and IV fluids. Fiberoptic endoscopy may be necessary; ü emergency surgery may be required to remove gangrenous or perforated tissue; Page 2  ü months and may subside only to reappear without cause. Many patients have asymptomatic ulcers. Dull, gnawing pain and a burning sensation in the mid epigastrium or in the back are characteristic. Pain is relieved by eating or taking alkali; once the stomach has emptied or the alkali wears off, the pain returns. It is caused by the erosion of a circumscribed area of mucous membrane. Peptic ulcers are more likely to be in the duodenum than in the stomach. They tend to occur singly, but there may be several present at one time. Chronic ulcers usually occur in the lesser curvature of the stomach, near the pylorus. Peptic ulcer has been associated with bacterial infection, such as Helicobacter pylori. Sharply localized tenderness is elicited by gentle pressure The greatest frequency is noted in people between the on the epigastrium or slightly right of the midline. ages of 40 and 60 years. Other symptoms include After menopause, the incidence among women is almost ü pyrosis (heartburn) and a burning sensation in the equal to that in men. esophagus and stomach, which moves up to the Predisposing factors include mouth, occasionally with sour eructation (burping). ü family history of peptic ulcer, Vomiting is rare in uncomplicated duodenal ulcer; it may or ü blood type O, may not be preceded by nausea and usually follows a bout ü chronic use of nonsteroidal anti-inflammatory drugs of severe pain and bloating; it is relieved by ejection of the (NSAIDs), acid gastric contents. ü alcohol ingestion, Constipation or diarrhea may result from diet and ü excessive smoking, and, medications. ü Possibly high stress. Bleeding (15% of patients with gastric ulcers) and tarry Esophageal ulcers result from the backward flow of stools may occur; a small portion of patients who bleed hydrochloric acid from the stomach into the esophagus. from an acute ulcer have only very mild symptoms or none Zollinger–Ellison syndrome (gastrinoma) is suspected when at all. a patient has several peptic ulcers or an ulcer that is resistant to standard medical therapy. PEPTIC ULCER ASSESSMENT AND DIAGNOSTIC METHODS This syndrome involves Physical examination (epigastric tenderness, abdominal ü extreme gastric hyperacidity (hypersecretion of gastric distention). juice), ü duodenal ulcer, and ü gastrinomas (islet cell tumors). About 90% of tumors are found in the gastric triangle. ü About one third of gastrinomas are malignant. ü Diarrhea and steatorrhea (unabsorbed fat in the stool) may be evident. ü These patients may have coexistent parathyroid adenomas or hyperplasia and exhibit signs of hypercalcemia. ü The most frequent complaint is epigastric pain. ü The presence of H. pylori is not a risk factor. Stress ulcer (not to be confused with Cushing’s or Curling’s ulcers) is a term given to acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events, such as ü burns, ü Shock, ü severe sepsis, and Endoscopy (preferred, but upper gastrointestinal [GI] ü multiple organ trauma. barium study may be done). ü Fiberoptic endoscopy within 24 hours of trauma or injury Diagnostic tests include shows shallow erosions of the stomach wall; ü analysis of stool specimens for occult blood, ü by 72 hours, multiple gastric erosions are observed, and as ü gastric secretory studies, the stressful condition continues, the ulcers spread. ü biopsy and histology with culture to detect H. pylori ü When the patient recovers, the lesions are reversed; this (serologic testing, stool antigen tests, or a breath test pattern is typical of stress ulceration. may also detect H. pylori) PEPTIC ULCER CLINICAL MANIFESTATIONS PEPTIC ULCER MEDICAL MANAGEMENT Symptoms of an ulcer may The goals of treatment are to eradicate H. pylori and ü last days, manage gastric acidity. ü weeks, or Page 3  PEPTIC ULCER PHARMACOLOGIC THERAPY Antibiotics combined with ü proton pump inhibitors and ü bismuth salts to suppress H. pylori. H2-receptor antagonists (in high doses in patients with Zollinger–Ellison syndrome) to decrease stomach acid secretion; maintenance doses of H2-receptor antagonists are usually recommended for 1 year. Proton pump inhibitors may also be prescribed. Cytoprotective agents (protect mucosal cells from acid or ü vagotomy with pyloroplasty, or NSAIDs). Antacids in combination with ü cimetidine (Tagamet) or ü ranitidine (Zantac) for treatment of stress ulcer and for prophylactic use. PEPTIC ULCER LIFESTYLE CHANGES Stress reduction and rest are priority interventions. The patient needs to identify situations that are stressful or exhausting (eg, rushed lifestyle and irregular schedules) and implement changes, such as ü establishing regular rest periods during the day in the acute phase of the disease. ü Biofeedback, ü Billroth I or II. ü hypnosis, ü behavior modification, ü massage, or ü acupuncture may also be useful. Smoking cessation is strongly encouraged because smoking raises duodenal acidity and significantly inhibits ulcer repair. ü Support groups may be helpful. Dietary modification may be helpful. ü Patients should eat whatever agrees with them; small, frequent meals are not necessary if antacids or histamine blockers are part of therapy. Over secretion and hypermotility of the GI tract can be minimized by avoiding extremes of temperature and PEPTIC ULCER ASSESSMENT overstimulation by meat extracts. Alcohol and caffeinated beverages such as coffee Assess pain and methods used to relieve it; take a (including decaffeinated coffee, which stimulates acid thorough history, including a 72-hour food intake history. secretion) should be avoided. If patient has vomited, determine whether emesis is bright Diets rich in milk and cream should be avoided also red or coffee ground in appearance. because they are potent acid stimulators. This helps identify source of the blood. The patient is encouraged to eat three regular meals a day. Ask patient about usual food habits, alcohol, smoking, medication use (NSAIDs), and level of tension or PEPTIC ULCER SURGICAL MANAGEMENT nervousness. Ask how patient expresses anger (especially at work and With the advent of H2-receptor antagonists, surgical with family), and determine whether patient is experiencing intervention is less common. occupational stress or family problems. If recommended, surgery is usually for Obtain a family history of ulcer disease. ü intractable ulcers (particularly with Zollinger–Ellison Assess vital signs for indicators of anemia (tachycardia, syndrome), hypotension). ü life threatening hemorrhage, Assess for blood in the stools with an occult blood test. ü perforation, or ü obstruction. Palpate abdomen for localized tenderness. Surgical procedures include ü vagotomy, PEPTIC ULCER COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Hemorrhage: upper GI Perforation Penetration Pyloric obstruction (gastric outlet obstruction) Page 4 PEPTIC ULCER PLANNING GOALS The major goals of the patient may include ü relief of pain, ü reduced anxiety, ü maintenance of nutritional requirements, ü knowledge about the management and ü prevention of ulcer recurrence, and ü absence of complications. PEPTIC ULCER NURSING INTERVENTIONS a) Relieving Pain and Improving Nutrition ü Administer prescribed medications. ü Avoid aspirin, which is an anticoagulant, and foods and beverages that contain acid-enhancing caffeine (colas, tea, coffee, chocolate), along with decaffeinated coffee. ü Encourage patient to eat regularly spaced meals in a relaxed atmosphere; obtain regular weights and encourage dietary modifications. ü Encourage relaxation techniques. b) Reducing Anxiety ü Assess what patient wants to know about the disease, and evaluate level of anxiety; encourage patient to express fears openly and without criticism. ü Explain diagnostic tests and administering medications on schedule. ü Interact in a relaxing manner, help in identifying stressors, and explain effective coping techniques and relaxation methods. ü Encourage family to participate in care, and give emotional support. PEPTIC ULCER MONITORING COMPLICATIONS a) If hemorrhage is a concern Ø Assess for ü faintness or dizziness and nausea, before or with bleeding; ü test stool for occult or gross blood; ü monitor vital signs frequently (tachycardia, hypotension, and tachypnea). Ø Insert an indwelling urinary catheter ü monitor intake and output; ü insert and maintain an IV line for infusing fluid and blood. ü Monitor laboratory values (hemoglobin and hematocrit). Ø Insert and maintain a nasogastric tube and monitor drainage; provide lavage as ordered. Ø Monitor oxygen saturation and administering oxygen therapy. Ø Place the patient in the recumbent position with the legs elevated to prevent hypotension, or place the patient on the left side to prevent aspiration from vomiting. Ø Treat hypovolemic shock as indicated. b) If perforation and penetration are concerns Ø Note and report symptoms of penetration (back and epigastric pain not relieved by medications that were effective in the past). Ø Note and report symptoms of perforation ü sudden abdominal pain, ü referred pain to shoulders, ü vomiting and collapse, ü extremely tender and rigid abdomen, ü hypotension and tachycardia, or ü other signs of shock Page 5