Adult 2 Medical Surgical Nursing Department 2024 PDF

ADULT 2 Medical Surgical Nursing Department 2024 1  ‫‪ADULT 2 Medical Surgical Nursing Department 2024‬‬ ‫رؤية البرنامج‬ ‫تحمٍك انتًٍس فى انتعهٍى انتًرٌضً نكى ٌىاكب انت...

ADULT 2 Medical Surgical Nursing Department 2024 1  ‫‪ADULT 2 Medical Surgical Nursing Department 2024‬‬ ‫رؤية البرنامج‬ ‫تحمٍك انتًٍس فى انتعهٍى انتًرٌضً نكى ٌىاكب انتمذو فى انعهىو انحذٌثت وتحمٍك احتٍاجاث انًجتًع ويتطهباث سىق انعًم‬ ‫انًحهٍت وااللهًٍٍت وانذونٍت‬ ‫رسالة البرنامج‬ ‫ٌهذف انبرَايج انى تخرٌج أخصائً تًرٌض يؤهم بانكفاٌاث انتًرٌضٍت انتى تساعذِ عهى تمذٌى رعاٌت تًرٌضٍت شايهت‬ ‫تهبً احتٍاجاث انًجتًع يٍ خالل انبحج انعهًى وانًًارست انمائًت عهى دالئم األبحاث‬ ‫رؤية القسم‪:‬‬ ‫ٌتطهع لسى انتًرٌض انباطًُ انجراحً كهٍت انتًرٌض‪ ،‬جايعت انسلازٌك‪ ،‬إنً انصذارة بٍٍ كافت االلساو انعهًٍت انًختهفت فً‬ ‫انكهٍت وانكهٍاث انًُاظرة‪ ،‬وٌكىٌ لادرا عهً يُافست كم يؤسساث انتعهٍى انعانً‪ ،‬وانبحج انعهًً نهتًرٌض عهً انًستىي‬ ‫االلهًًٍ وانذونً‪.‬‬ ‫رسالة القسم‪:‬‬ ‫تكًٍ رسانت لسى انتًرٌض انباطًُ انجراحً كهٍت انتًرٌض‪ ،‬جايعت انسلازٌك‪ ،‬فً إعذاد طانب‪ -‬يؤهم يعرفٍا‪ ،‬ويهارٌا‪،‬‬ ‫وسهىكٍا‪ ،‬نتمذٌى رعاٌت تًرٌضٍت شايهت راث جىدة عانٍت نهًرضً‬ ‫واالصحاء بانًستشفٍاث وانًراكس انصحٍت انًختهفت وانمٍاو بئجراء األبحاث انعهًٍت انًتطىرة‬ ‫نتهبٍت احتٍاجاث سىق انعًم يحهٍا‪.‬‬ ‫‪Chapter‬‬ ‫‪Page‬‬ ‫‪1.‬‬ ‫)‪Care of Surgical Patients (Perioperative Nursing‬‬ ‫‪3-19‬‬ ‫‪2. Nurses management for patient with cancer‬‬ ‫‪20-32‬‬ ‫& ‪3. Nurses management for patient with gastrointestinal‬‬ ‫‪33-64‬‬ ‫‪accessory disorders‬‬ ‫‪4. Nurses management for patient with fluid and electrolyte‬‬ ‫‪65-77‬‬ ‫‪imbalance‬‬ ‫‪5. Nurses management for patient with urological disorders‬‬ ‫‪77 -89‬‬ ‫‪6. Nurses management for patient with endocrine disorders‬‬ ‫‪90-113‬‬ ‫‪7. Nurses management for patient with musculoskeletal‬‬ ‫‪113-131‬‬ ‫‪disorders‬‬ ‫‪2‬‬  ADULT 2 Medical Surgical Nursing Department 2024 Care of Surgical Patients (Perioperative Nursing) Learning objectives 1. Explain the preparation of patients physically, emotionally, and psychosocially for surgical procedures. 2. Identify the types of patients most at risk for surgical complications, and state why each patient is at risk. 3. Plan and implement patient and family teaching to prevent postoperative complications. 4. Compare the roles of the scrub nurse and the circulating nurse. 5. Analyze the differences in the various types of anesthesia 6. Perform a thorough nursing assessment for a preoperative patient. 7. Teach patient postoperative exercises during the preoperative period. 8. Prepare a patient for surgery using a preoperative checklist. 9. Document preoperative care and assessment data. 10. Demonstrate an understanding of the care delivered to patients in the perioperative environment 11. Understand the role of risk management within perioperative care An introduction Surgery is the use of instruments during an operation to treat injuries, diseases, and deformities. Perioperative nursing refers to care of the patient before, during, and after surgery. Surgical procedures are named according to o The involved body organ, part, or location o The suffix that describes what is done during the procedure: -ectomy- Removal by cutting Surgery is done for several reasons  Preventive surgery removes tissue before it causes a problem as in mole to prevent cancer development.  Diagnostic, or exploratory, surgery takes tissue samples for study to make a diagnosis  Curative surgery involves the removal of diseased or abnormal tissue as in an inflamed appendix  Palliative surgery is done when an underlying condition cannot be corrected but symptoms need to be alleviated.  Cosmetic, or reconstructive: surgery is done to improve appearance Surgery according Urgency Level  Emergent: Immediate surgery needed to save life  Urgent: Surgery needed within 24–30 hours  Elective: Planned/scheduled, with no time requirements 3  ADULT 2 Medical Surgical Nursing Department 2024 Surgery according Degree of Risk of Surgery o Minor Procedure without significant risk; often done with local anesthesia o Major Procedure : greater risk, usually longer and more extensive than a minor procedure Bloodless surgery;  Uses a combination of techniques to minimize blood loss and maximize blood volume and function.  Epoetin alfa (Epogen) may be given before surgery to stimulate red blood cell production  During surgery, the surgeon may request induced hypotension or hypothermia to decrease oxygen demand.  Ambulatory surgery includes outpatient, same-day, or short-stay surgery that does not require an overnight hospital stay but may entail an admission to an inpatient hospital setting for less than 24 hours  Quickly and comprehensively assess and anticipate the patient‘s needs and at the same time begin planning for discharge and follow-up home care Ambulatory surgery, sometimes referred to as same day or outpatient surgery, is defined as surgery that requires fewer than 24 hours of hospitalization A client admitted for ambulatory surgery must meet the following criteria: The client is not critically ill. The surgical procedure is not extensive and does not require many hours of general anesthesia. The client has few, if any, coexisting and disabling illnesses. Recovery is expected to be quick, with minimal specialized care after surgery. The client or family can provide adequate postoperative care.  Emergency Surgery  Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team  It is important for the nurse to communicate with the patient and team members as calmly and effectively as possible in these situations, A quick visual survey & suitable  Preparation of the patient is essential , condensed time frame  Informed consent and essential information, such as pertinent past medical history and allergies, need to be obtained from a family member  Extra support and explanation of the surgery 4  ADULT 2 Medical Surgical Nursing Department 2024 Perioperative Surgical Phases: Perioperative: All three phases surrounding and during surgery 1. Preoperative : Begins with decision for surgery and ends with transfer to the operating room 2. Intraoperative : Begins with transfer to operating room and ends with admission to post-anesthesia care unit (PACU) 3. Postoperative : Begins with admission to PACU and continues until recovery is complete 1. Preoperative Phase The primary roles in preoperative phase are to: Assist in data collection for developing the patient‘s plan of care. Reinforce explanations and instructions given to the patient and family Provide emotional and psychological support Factors Influencing Surgical Outcomes Diabetes mellitus Stress of surgery may cause swings in blood glucose levels that are and other chronic difficult to control. diseases Patients may receive intravenous insulin during and after surgery. Wound healing tends to be delayed in patients with diabetes, making the risk of dehiscence (wound separation) greater. The incidence of infection in surgical wounds is higher. Liver and kidney disease makes it more difficult to metabolize and eliminate anesthesia and waste products. Advanced age  Healing is slower in older adults. with inactivity  The risk of hypostatic pneumonia, (inflammation and consolidation in the lungs), and thrombus formation is higher in inactive older adults. Very young  Infants have difficulty with temperature control and in maintaining person normal circulatory blood volume; they are at risk of dehydration Dehydration  Reduced circulating volume reduces kidney perfusion and urine output and thrombus formation. Alters electrolyte values.  A more at risk for problems with pressure areas during surgery. Malnutrition  Inadequate nutritional stores lead to poor wound healing and skin breakdown. Obesity  An extremely heavy patient does not breathe as deeply and is at risk of hypostatic pneumonia.  Excessive fatty tissue also is a factor in poor wound healing. Regular use of  Aspirin, non-steroidal anti-inflammatory drugs, and anticoagulants certain drugs make the patient more prone to excessive bleeding.  Corticosteroids reduce the body's response to infection and delay the healing process. Excessive fear  Stimulates the sympathetic nervous system, swings in the body's chemistry and vital signs.  Increased muscle tension makes surgery more difficult. 5  ADULT 2 Medical Surgical Nursing Department 2024 Preoperative teaching: All surgical patients should receive information related to: o Preoperative procedures: Enemas, skin preparation, restriction of food and liquid intake, and administration of bedtime sedatives and preoperative medication; time to come to the hospital o Technical information: Anticipated surgical procedure; location of incisions; dressings, tubes, drains, catheters, or other equipment that is expected o Day of surgery: Time surgery is scheduled; time to arrive at the hospital or leave room, probable length of procedure, effects of preoperative medications, where family will wait, when and where family can see the patient after surgery, pain control, and postoperative routine o Post-anesthesia care unit (PACU): General environment (noise, lights, equipment), frequent taking of vital signs, pulse oximetry, and administration of oxygen o Surgical intensive care unit (SICU) (if patient go to PACU): Location of the unit, expected length of stay, and visiting privileges Preoperative Instructions:  To reduce the risk of aspiration when anesthesia is started, as well as postoperative nausea and vomiting, fluid and food restrictions.  The patient is told when to stop fluid and food intake (NPO), usually after midnight the night before surgery.  If surgery is scheduled for the afternoon, clear liquids in the early morning  Brush teeth  Cancellation of surgery may result if the patient has not been NPO as ordered.  Special preparations, such as an enema, to empty the bowel to reduce fecal contamination preoperatively and straining or distention postoperatively.  Instructions for postoperative care: how to report their pain level using a pain rating scale, before surgery so the patient is alert when being taught and has time to learn.  Postoperative exercises are taught to decrease complications, include : o Deep breathing helps prevent the development of atelectasis o Leg exercises improve circulation & help prevent complications related to stasis of blood, such as emboli formation. o Coughing moves secretions to prevent pneumonia Preoperative Data Collection\ Nursing Assessment  Health History and Psychosocial Assessment  Physical Assessment  Laboratory and Diagnostic Test Data 6  ADULT 2 Medical Surgical Nursing Department 2024 Subjective Data:  Demographic information: Name, age, marital status, occupation, roles?  History of condition for which surgery is scheduled: Why are you having surgery?  Medical history: Any allergies, acute or chronic conditions, current medications, pain, or prior hospitalizations?  Surgical history: Any reactions or problems with anesthesia? Previous surgeries?  Tobacco use: How much do you smoke? Pack-year history (number of packs per day _ number of years)?  Alcohol use: How often do you drink alcohol? How much?  Coping techniques: How do you usually cope with stressful situations? Support systems?  Family history: Hereditary conditions, diabetes, cardiovascular, anesthesia problems?  Female patients: Date of last menses and obstetrical information? Objective Data: Body System Review Vital signs, oxygen saturation Height and weight Emotional status: calm, anxious, tearful, affect Neurological: ability to follow instructions Skin: color, warmth, bruises, lesions, turgor, dryness, mucous membranes Respiratory: infection: cough; breath sounds; chronic obstructive pulmonary disease; respiratory rate, pattern, and effort; barrel chest Cardiovascular: angina, MI, heart failure, hypertension Gastrointestinal: bowel sounds, date of last bowel movement, abdominal distention….. Musculoskeletal: deformities, weakness, ROM Immediate Preoperative Care:  Make sure that the client is wearing his or her ID band. Surgery will be cancelled if the client is not properly identified.  Record the client‘s VS,. Report immediately any deviation from normal to the surgeon.  Determine and document the client‘s fall risk status  Check that the client is wearing two special blood identification when possibility of receiving blood.  Help the client with bathing and other hygiene measures. Be sure the client removes all clothes and wears clean gown  Remove any prostheses, braces, splints, wigs, hair pins, contact lenses, hearing aids, false eyelashes, and glasses.  Remove the client‘s jewelry and valuables, itemize them, and put them in the vault or give them to the client‘s family.  Help the client to void immediately before going to the OR. 7  ADULT 2 Medical Surgical Nursing Department 2024  Pull the hair back and cover it with a surgical cap  Remove partial dentures and place them in a denture cup with clear water.  Remove makeup, and nail polish & artificial nails  Make sure the preoperative checklist in the client‘s health record is complete and signed Preoperative medications may be given to: o Reduce anxiety and promote a restful state o Decrease secretion of mucus and other body fluids o Counteract nausea and reduce emesis o Enhance the effects of the anesthetic Informed Consent Informed consent is the patient‘s autonomous decision about whether to undergo a surgical procedure. Before surgery, the client must sign a surgical consent form or operative permit. Clients must sign a consent form for any procedure that requires anesthesia and has risks of complications. If an adult client is confused, unconscious, a family member or guardian must sign the consent form. If the client is younger than 18 years of age, a parent or legal guardian must sign the consent form. Voluntary and written informed consent from the patient is necessary before non-emergent surgery protect the patient from unsanctioned surgery and protect the surgeon from claims of an unauthorized operation. it is the surgeon‘s responsibility to provide a clear and simple explanation of what the surgery benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. What is a criterion for Valid Informed Consent? The nurse clarifies the information provided; the consent form has been signed before administering psychoactive premedication. Signed consent form is placed in a prominent place on the patient‘s chart and accompanies the patient to the OR. Preoperative Preparation —1. Physical Preparation. o Skin preparation, following hospital policy, to prevent post-operative wound infection. shaving hair and clean with antiseptic solution 10cm round surgical site then covered by sterile dressing o Elimination, indwelling catheter and enema as physician orders 8  ADULT 2 Medical Surgical Nursing Department 2024 o Food and fluids, fasting based on type of anesthesia o Care of valuables , Clothing/ grooming , Prostheses —2. Psychosocial Preparation. —Careful preoperative teaching can reduce fear and anxiety of the clients. —Common preoperative problem statements include:  Anxiety due to the surgical experience and outcome o Fear due to the potential for death, effects of impending surgery, or loss of control due to anesthesia o Potential for grief due to impending loss of a body function or body part o Insufficient knowledge of preoperative and postoperative routines o Insomnia due to stress or unfamiliar environment o Limited coping ability due to lack of problem-solving skills or adequate support o Altered role performance due to inability to perform job duties — General nursing goals for all preoperative patients  Prepared for surgery physically and emotionally  Able to demonstrate deep breathing, coughing, and leg exercises  Able to verbalize understanding of the procedure and the expectations for the postoperative period  Able to maintain fluid and electrolyte balance throughout the perioperative period 9  ADULT 2 Medical Surgical Nursing Department 2024 2. Intraoperative The Surgical Team: The surgeon is the head of the surgical team, determining the preoperative diagnosis, perform of the surgical procedure, the explanation of the risks and benefits, obtaining inform consent and the postoperative management Surgeon assistant assists surgeon in performing homeostasis, tissue retraction, and wound closure). Anesthesiologist: Anesthesia provider. Scrub nurses : Role and responsibilities  Checks prior to beginning of the operating list (in collaboration with circulating nurses): Cleanliness of the theatre environment Temperature and humidity levels, and efficient air-conditioning, taking the appropriate action if necessary to adjust the levels  Preparation of instrument sets and accessories: Swabs Needles Extra instruments Accessories (e.g. sutures and dressings)  Scrubbing-up procedure: wash hands and arms, don sterile gown and gloves 11  ADULT 2 Medical Surgical Nursing Department 2024  Preparation of instrument trolley and Mayo stand  Passing instruments to the surgeon  Anticipation of the surgeon‘s needs  Maintenance of the sterile field  Swab, needle and instrument checks  Handling and passing of instruments Specimens  Documentation (electronic and hard copy)  Cleaning between surgical procedures and at the end of the operating list Circulating nurses: Role and responsibilities  Assisting the scrub practitioner in the preparation of the instrument sets, accessories, swabs, needles and instruments  Preparation of sterile surgical gowns and gloves  Tying donned sterile gowns  Opening instrument sets  Passing accessories to the scrub practitioner  Maintenance of the sterile field  Swab, needle and instrument checks with the scrub practitioner  Anticipation of the scrub practitioner‘s needs  Safe practice in placing specimens into appropriately sized specimen containers  Documentation (electronic and hard copy)  Cleaning between surgical procedures and at the end of the operating list  Sterile technique is maintained at all times. Intra operative team must be  Applying surgical hand scrub  Gloves are worn  Enhance aseptic technique.  Wears shoe covers, caps, masks, and goggles  Surgical case cart preparation  Count needles and sponges & others surgical instruments  Ensure safety, electrical equipment is checked Scrub nurse setting up the instrument table in the operating room 11  ADULT 2 Medical Surgical Nursing Department 2024 Anesthesia Agent used to alter sensation so that surgery can be done painlessly & safely Type of anesthesia Description General Blocks awareness centers in the brain Produces unconsciousness, body relaxation, and loss of sensation Is administered by inhalation or I.V. infusion Regional Inhibits excitatory processes in nerve endings or fibers Provides analgesia over a specific body area Doesn‘t produce unconsciousness Is administered by nerve block, I.V. regional block with tourniquet, spinal (intrathecal) block, or epidural block Local Blocks nerve impulse transmission at the site of action Provides analgesia over a limited area Doesn‘t produce unconsciousness Is administered topically or by infiltration There are three stages of general anesthesia: 1. Induction: Unconsciousness is induced. 2. Maintenance: Period during which the surgical procedure is performed. 3. Emergence: Surgery is completed and the patient is prepared to return to consciousness; neuromuscular blocking agents are reversed. The Operating Room Environment  The OR environment is physically isolated from other areas of the hospital, air is filtered and positive pressure is maintained to reduce the number of possible microbes that can cause infection.  OR are designed to be efficient, in that the needed equipment and supplies are immediately available for use  Usually the furniture is made of stainless steel for easy cleaning and disinfecting.  The temperature in the OR is kept below 70 F to provide a cooler environment that does not promote bacterial growth, more comfort for OR personnel working in bright lights and wearing and enhances client comfort and safety. Prevention of Intraoperative Complications 1. Infection:  Strict aseptic technique is absolutely necessary before and during surgery.  If a nurse notes a break in technique, immediately notifies the surgeon 12  ADULT 2 Medical Surgical Nursing Department 2024 2. Fluid volume excess or deficit: The circulating nurse is responsible for recording and keeping a running total of IV fluids administered 3. Injury related to positioning:  The OR staff positions the client on the OR table according to the type of surgery.  Careful positioning and monitoring help to prevent interruption of blood supply secondary to prolonged pressure, nerve injury related to prolonged pressure, postoperative hypotension, dependent edema, and joint injury related to poor body alignment 4. Hypothermia: o The client may be at risk for hypothermia related to the low temperature in the o The OR, administration of cold IV fluids, inhalation of cool gases, and exposure of body surfaces for the surgical procedure, opened incisions/wounds, and prolonged inactivity. o For some surgeries, the body temperature is purposely lowered to make the procedure safer 5. Malignant hyperthermia (MH)  Occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents.  There are two tests that indicate if a client is susceptible to MH: skeletal muscle biopsy, which determines muscle contractile qualities, and a blood test for a genetic mutation linked to MH.  Certain anesthetic agents trigger uncontrolled calcium release within skeletal muscle cells, which leads to muscle rigidity and a hyper- metabolic state Signs and symptoms  jaw muscle rigidity, rapidly rising temperature, elevated Paco2 and serum potassium levels, metabolic acidosis, tachycardia, tachypnea, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output and , cardiac arrest. Prevention is essential because the mortality rate is high. Clients at risk include ‗‗those with bulky, strong muscles, a history of muscle cramps or muscle weakness and unexpected temperature elevation and an 13  ADULT 2 Medical Surgical Nursing Department 2024 unexplained death of a family member during surgery that was accompanied by a febrile response‘‘ The circulating nurse  Closely monitors the client for signs of hyperthermia.  If the client‘s temperature begins to rise rapidly, anesthesia is discontinued and the OR team implements measures to correct physiologic problems, such dysrhythmias. Potential Adverse Effects of Anesthesia Cardiac dysrhythmia from electrolyte imbalance or adverse effect of anesthetic agents Myocardial depression, bradycardia, and circulatory collapse Central nervous system agitation, seizures, and respiratory arrest Over sedation or under sedation Agitation or disorientation, especially in elderly patients Hypoxemia or hypercarbia from hypoventilation and inadequate respiratory support during anesthesia Laryngeal trauma, oral trauma, and broken teeth from difficult intubation 3. Postoperative Transport of the Client  Immediately after the surgical procedure is complete, the client is transported to the post-anesthesia care unit (PACU), known as the post- anesthesia recovery room.  The nursing staff there is specifically knowledgeable in the care of clients recovering from anesthesia.  Specialized equipment is available to monitor and treat the client.  Patients may remain in a PACU unit for as long as 4 to 6 hours, depending on the type of surgery and any preexisting conditions  The nurse receiving the client from the OR needs the following information Medical diagnosis and surgical procedure done Past medical history and allergies Age, general condition, airway status, and current vital signs Anesthetic agents and medications given during surgery Complications during surgery Any pathology found and if so whether family members are informed Amounts of fluids & blood administered or lost Any tubes connected 14  ADULT 2 Medical Surgical Nursing Department 2024 Immediate Postoperative Initial Assessment: Initial Assessment  Airway patency  Effectiveness of respiration  Presence of artificial airways  Mechanical ventilation, or supplemental oxygen  Circulatory status, vital signs  Wound condition, including dressings and drains  Fluid balance, including IV fluids, output from catheters and drains and ability to void  Level of consciousness and pain  The nurse‘s major responsibilities during the client‘s PACU are to  ensure a patent airway  help maintain adequate circulation  prevent or assist with the treatment of shock  maintain proper position and function of drains, tubes, and IV infusions; monitor for potential complications.  An important assessment is determining how the client is recovering from anesthesia.  A useful assessment tool is the Aldrete scale, used to determine readiness for transfer patient from PACU to department which rates the client‘s mobility, respiratory status, circulation, consciousness, and pulse oximetry  A score of 9 or greater indicates that the client has recovered from anesthesia. Modified Aldrete Scale for Assessing Recovery from Anesthesia Score 0 1 2 Activity Unable to move Able to move two Able to move all extremities extremities extremities voluntarily or voluntarily or on voluntarily or on on command command command Respiration Apneic Dyspnea or limited Able to breathe deeply breathing and cough freely Circulation BP+/- 50mmHg of BP+/ - 20-49mmHg of BP+ /- 20mmHg of Pre-anesthesia level Pre-anesthesia level Pre-anesthesia level Consciousness Unresponsive Arousable with verbal Fully awake stimuli SpO2 < 90% with Needs supplemental > 92% on room air supplemental oxygen oxygen to maintain > 90% Surgical recovery can take from 2 to 6 hours Assessments are performed at least every 15 minutes for the first hour 15  ADULT 2 Medical Surgical Nursing Department 2024 Immediate nursing interventions o Assess breathing and administer supplemental oxygen, if prescribed. o Monitor vital signs and note skin warmth, moisture, and color. o Assess the surgical site and wound drainage systems. o Assess level of consciousness, orientation, and ability to move extremities. o Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems. o Assess pain level, pain characteristics (location, quality) and timing, type, and route of administration of last pain medication. o Administer analgesics as prescribed and assess their effectiveness in relieving pain. o Position patient to enhance comfort, safety, and lung expansion. o Assess IV sites for patency and infusions for correct rate and solution. o Assess urine output in closed drainage system or the patient‘s urge to void and bladder distention. o Place call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach. o Provide information to patient and family Measures are used to determine the patient’s readiness for discharge from the PACU  Stable vital signs  Orientation to person, place, events, and time  Uncompromised pulmonary function  Pulse oximetry readings indicating adequate blood Oxygen saturation  Urine output at least 30 mL/h  Nausea and vomiting absent or under control  Minimal pain Early warning score (EWS), a tool that is used throughout ward areas as an alert system for deteriorating patients 16 ADULT 2 Medical Surgical Nursing Department 2024 Ongoing Assessment 17 ADULT 2 Medical Surgical Nursing Department 2024 Post-operative discomfort 18  ADULT 2 Medical Surgical Nursing Department 2024 Prevent Postoperative Complications Problem Signs & Symptoms Preventive Interventions Atelectasis Decreased breath sounds over Deep breathing and coughing; use of areas not aerating; dyspnea incentive spirometer; early ambulation; teach to cough properly. Pneumonia: Fever, malaise, increased Deep breathing, coughing, and frequent hypostatic, sputum, purulent sputum, cough, turning; early ambulation; incentive aspiration, or flushed skin, spirometer use; range-of-motion exercises if bacterial dyspnea, pain on inspiration; unable to ambulate; medication if bacterial. abnormal breath sounds, crackles, rhonchi Paralytic No bowel sounds 24-36 hr after Monitor bowel sounds; encourage early ileus surgery or fewer than 5 ambulation; nothing by mouth as ordered. sounds/min Do not feed until bowel sounds return. Urinary Distended bladder; inability to Palpate bladder; encourage voiding, if retention void spontaneously unable to void within 8 hr per order obtain a bladder scan and if needed an order for catheterization; medicate to increase urinary sphincter tone as ordered. Pulmonary Shortness of breath, anxiety, Anti-embolism stockings, adequate fluid embolus chest pain, rapid pulse and intake, frequent turning or ambulation, respirations, preventive anticoagulant if ordered; leg cyanosis, cough, bloody sputum exercises Wound Redness, swelling, pain, warmth, Assess wound characteristics and drainage. infection drainage, fever, increased Monitor white blood cell count and leukocytes, temperature. rapid pulse and respirations Use aseptic technique for wound care; (fever 72 hr after surgery encourage adequate nutrition and fluids; indicates infection in some encourage activity. system or in the wound) Wound Discharge of serious drainage Teach to splint properly for coughing. dehiscence or from wound and sensation that Place patient supine with knees flexed; evisceration separation of wound edges with cover wound with sterile saline-soaked intestines visible through gauze or towels; return to operating room abdominal incision for repair; monitor for shock Fluid Signs of over hydration: crackles Control intravenous flow rate. Monitor imbalance in lungs, edema, weight gain intake and output; correct imbalances. Signs of dehydration: weight Output will be less than intake for first 72 hr loss, diminished pulse, dry after surgery with general anesthesia. mucous membranes, decreased Auscultate lungs each shift. Monitor weight; tissue turgor check for edema. Hemorrhage Evidence of copious bleeding; Give blood or volume expander; stop and decreased blood pressure, bleeding. Place in shock position with feet shock elevated pulse, and legs elevated and head flat; administer cold clammy skin, decreased ordered medications to raise blood pressure; urinary output administer oxygen; measure vital signs frequently. 19  ADULT 2 Medical Surgical Nursing Department 2024 Oncology Management Objectives: Analyze organization of neoplastic (abnormal tissue) growth. Identify at least five factors that may contribute to the development of a malignancy. List at least four practices that can contribute to prevention and early detection of cancers. Include the recommendations of routine checkups and detection of cancers into patient education. Explain the advantages and disadvantages of the various treatments available for cancer. List the major side effects of radiation or chemotherapy for cancer, and state the appropriate nursing interventions. Create an individualized plan of care for a patient receiving chemotherapy. Formulate a teaching plan for a patient who has bone marrow suppression from cancer treatment. Institute nursing interventions to help a patient cope with the common problems of cancer and its treatment. Use appropriate nursing interventions to help patients and families deal with the psychosocial effects of cancer and its treatment. Defintin Growth and spread of the abnormal cells which, continue to reproduce until they form a mass of tissue known as cancer neoplastic growth patterns: The four common neoplastic growth patterns are:  Hypertrophy: Is increase in cell size due to increased hormonal stimulation.  Hyperplasia: Increase in the number of cell of a certain types as pregnancy and adolescence it is abnormal when the volume of cell produced exceeds than normal physiologic demand.  Metaplasia: One adult cell type is substituted by anther type. The process is reversible if the stimulus as chemical agent, in inflammation, vitamin deficiencies and irritation Dysplasia: Alteration in normal adult cells in which cell varies from its normal size, shape or organization or one mature cell type is replaced with less mature cell type. 21  ADULT 2 Medical Surgical Nursing Department 2024 Classification of tumor: Tumor can by classified according to behavior into: benign, malignant. Benign tumors: They are usually encapsulated and don't disseminate or recur after removal. They are much type of benign tumors. Type of benign tumors: Papilloma: This arises from epithelial surfaces as skin, tongue, lips and vocal cords. Adenoma: This arises from the glandular tissues in the intestinal tract, glands (endocrine and exerine) and bronchi. Lipoma: arise from fat cells in the body and may be single or multiple. Neuron fibroma: from sheaths. Dangerous of benign tumor: Benign tumor may cause dangerous effect due to their size, position and structures Etiology: Certain categories of agents or factors implicated in carcinogenesis include viruses and bacteria, physical agents, chemical agents, genetic or familial factors, dietary factors, and hormonal agents. - Viruses and Bacteria: Viruses are thought to incorporate themselves in the genetic structure of cells, thus altering future generations of that cell population, perhaps leading to a cancer. For example, - The Epstein-Barr virus is highly suspect as a cause in Burkitt‘s lymphoma, nasopharyngeal cancers - The hepatitis B virus is implicated in cancer of the liver; - the human T-cell lymphotropic virus may be a cause of some lymphocytic leukemias and lymphomas - Physical Agents: Physical factors associated with carcinogenesis include - Exposure to sunlight or radiation, chronic irritation or inflammation, and tobacco use. - Excessive exposure to the ultraviolet rays of the sun, especially in fair skinned, blue or green eyed people, increases the risk for skin cancers. - Factors such as clothing styles, use of sunscreens, occupation, recreational habits, and environmental variables, including humidity and altitude, all play a role in the amount of exposure to ultraviolet light. - Exposure to ionizing radiation can occur with repeated diagnostic x- ray procedures or with radiation therapy used to treat disease. 21  ADULT 2 Medical Surgical Nursing Department 2024 - Chemical Agents: - About 75% of all cancers are thought to be related to the environment. - Tobacco smoke, thought to be the single most lethal chemical carcinogen, accounts for at least 30% of cancer deaths. - Tobacco may also act synergistically with other substances, such as alcohol, asbestos, uranium, and viruses, to promote cancer development. - Many chemical substances found in the workplace have proved to be carcinogens or co-carcinogens. The extensive list of suspected chemical substances continues to grow and includes aromatic amines and aniline dyes; pesticides and formaldehydes - Genetic and Familial Factors: - Almost every cancer type has been shown to run in families. This may be due to genetics, shared environments, cultural or lifestyle factors, or chance alone. - Genetic factors play a role in cancer cell development. Abnormal chromosomal patterns and cancer have been associated with extra chromosomes, too few chromosomes, or translocated chromosomes. Approximately 5% to 10% of cancers of adulthood and childhood display a familial predisposition - Dietary Factors: - Dietary factors are thought to be related to 35% of all environmental cancers. - Dietary substances can be proactive (protective), carcinogenic, or cocarcinogenic. - The risk for cancer increases with long term ingestion of carcinogens or cocarcinogens or chronic absence of proactive substances in the diet. - Dietary substances associated with an increased cancer risk include: Fats, alcohol, salt cured or smoked meats, foods containing nitrates and nitrites, and a high caloric dietary intake. - Obesity is associated with endometrial cancer and possibly postmenopausal breast cancers. Obesity may also increase the risk for cancers of the colon, kidney, and gallbladder. - Hormonal Agents: - Tumor growth may be promoted by disturbances in hormonal balance either by the body‘s own (endogenous) hormone production or by administration of exogenous hormones. Cancers of the breast, prostate, and uterus are thought to depend on endogenous hormonal levels for growth. - Oral contraceptives and prolonged estrogen replacement therapy are associated with increased incidence of hepatocellular, endometrial, and breast cancers 22  ADULT 2 Medical Surgical Nursing Department 2024 - Hormonal changes with reproduction are also associated with cancer incidence. Increased numbers of pregnancies are associated with a decreased incidence of breast, endometrial, and ovarian cancers. - Defects of immune system. Diagnosis of Cancer: 1- Radiological studies; images of areas inside the body help the physician tell whether a tumor is present. The most common imaging procedures used are X-rays, a CT scan, radionuclide scanning, ultrasonography, and MRI 2- Endoscopy; endoscopy allows the physician to look into the body through a thin, lighted tube called an endoscope. The exam is named for the organ involved (for example, colonoscopy to look inside the colon). During the exam, the physician may collect tissue or cells for closer examination. 3- Laboratory tests; although no single test can be used to diagnose cancer, laboratory tests such as blood and urine tests give the physician important information related to cancer and its impact on the patient's health. 4- Biopsy; a biopsy is the only sure way to know whether the problem is cancer. In a biopsy, the physician removes a sample of tissue from the abnormal area or may remove the whole tumor. A pathologist examines the tissue under a microscope.  Staging Determines the size of the tumor and the existence of metastasis ♦ Tumor stage describes the extent of the disease and generally considers three important factors:  Local size of primary tumor  Presence or absence of lymph node involvement and its extent  Presence or absence of distant metastases  Grading Refers to the classification of the tumor cells Based on degree of cellular differentiation. Cancers are classified into 4 grades  G1 Well differentiated, most or all. Tumor cell have a similar arrangement to that of normal tissue.  G2 moderately differentiated, some but not all cells resemble their normal counterparts.  G3 poorly differentiated, only a few cells resemble their normal counterparts.  G4 no resemble at all to original tissue.  Classification of tumor A- according to their characters 1) Benign 2) Malignant 23  ADULT 2 Medical Surgical Nursing Department 2024 B- according to cell of origin 1) Epithelial tumor 2) Mesenchymal 3) other tissues Malignant A tumor which always invades the surrounding tissues and give metastasis  Following table show the deference between benign and malignant tumor: Characteristi Benign Malignant c Cell Well-differentiated cells that Cells are undifferentiated and often characteristics resemble normal cells of the bear little resemblance to the normal tissue from which the tumor cells of the tissue from which they originated arose Mode of growth Tumor grows by expansion Grows at the periphery and sends out and does not infiltrate the processes that infiltrate and destroy the surrounding tissues; usually surrounding tissues encapsulated Rate of growth Rate of growth is usually Rate of growth is variable and depends slow on level of differentiation; the more anaplastic the tumor, the faster its growth Metastasis Does not spread by Gains access to the blood and metastasis lymphatic channels and metastasizes to other areas of the body General effects Is usually a localized Often causes generalized effects, such phenomenon that does not as anemia, weakness, and weight loss cause generalized effects unless its location interferes with vital functions Tissue Does not usually cause Often causes extensive tissue damage destruction tissue damage unless its as the tumor outgrows its blood supply location interferes with or encroaches on blood flow to the blood flow area; may also produce substances that cause cell damage Ability to cause Does not usually cause Usually causes death unless growth death death unless its location can be controlled interferes with vital functions  Clinical manifestation of cancer The clinic manifestations of cancer are numerous. Each variant of the disease has its unique manifestations that may be ranged from vague complaints of unexplained 24  ADULT 2 Medical Surgical Nursing Department 2024 fatigue, weight loss, and fever to severe symptoms of pain, inability to function, and life threatening medical emergencies The following sings may be associated with cancer and it called  Warning signs: CAUTION 1) Changes in bowel or bladder habits, 2) A sore that does not heal, 3) Unusual bleeding or discharge, 4) Thickening or lump in breast or any other part of the body 5) Indigestion or difficulty swallowing, 6) Obvious changes in a wart or mole, 7) Or nagging cough or hoarseness. Ten step to reduce the risk of cancer; 1. Increase consumption of fresh fruits and vegetables especially those of cabbage family. 2. Increase intake of vitamin A, C which act as protective against many cancers. 3. Increase fiber intake and choose whole grains instead of refined (processed) grains and sugars. 4. Maintain ideal body weight. 5. Limit consumption of red meat, especially processed meats. 6. Reduce intake of dietary fat especially taken from animal source. 7. Limit salt intake, salt-cured food, smoked, and nitrate-cured foods. 8. Stop smoking. 9. Reduce alcohol intake. 10. Avoid exposure to direct sun light especially at the duration from 10am to 3pm. test Indication  Breast checkup:  Routine monthly breast self examination starting at age 20  Clinical breast examination every 3 years from age 20-40 and yearly thereafter.  Screening mammography every 2 years from age 40 to 50 and yearly thereafter.  Colon and - Digital rectal exam yearly starting at age 40 rectum - Stool occult blood test yearly after age 50 - Flexible sigmoidoscopy every 3 to 5 years after age 50  Uterus  Yearly pelvic examination and papanicolau's (pap) test for sexually active girl and any women over 18  An endometrial tissue sample at menopause for high risk women  Prostate  Digital rectal exam yearly after age 50  Prostate specific antigen test yearly after age 50 25  ADULT 2 Medical Surgical Nursing Department 2024 Management of Cancer Goal of treatment: 1. Complete eradication of malignant disease (cure). 2. Prolonged survival and containment of cancer cell growth (control). 3. Relief of symptoms associated with the disease (palliation). Considerations in choosing therapy  Disease and results obtained from each type of therapy.  Patient‘s general conditions and coexisting disease. Multiple modalities are commonly used in cancer treatment including: 1) Surgery 2) Radiation therapy 3) Chemotherapy 4) Hyperthermia 5) Acupuncture 6) Hormone therapy 7) Gene therapy 8) Bone marrow transplantation and steam cell/ 9) Photodynamic therapy or phototherapy 10) Biological therapy; interferon 1-SURGERY Surgical removal of the entire cancer remains the ideal and most frequently used treatment method. Types of cancer surgeries 1) Diagnostic Surgery 2) Primary Treatment 3) Prophylactic Surgery 4) Palliative Surgery Diagnostic Surgery Diagnostic surgery, such as a biopsy, is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. Surgery as Primary Treatment Remove the entire tumor or as much as is feasible and any involved surrounding tissue, including regional lymph nodes. Prophylactic Surgery Prophylactic surgery involves removing vital tissues or organs that are likely to develop cancer. Factors are considered when electing prophylactic surgery:  Family history and genetic predisposition  Presence or absence of symptoms  Potential risks and benefits  Ability to detect cancer at an early stage 26  ADULT 2 Medical Surgical Nursing Department 2024 Palliative Surgery Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulcerations, hemorrhage, pain, and malignant effusions. Examples; relief of intestinal obstruction removal of mass causing pain The goals of treatment are to:  Relief of symptoms and Improve the quality of life Complication of surgery Lymph edema - Hematoma formation - Infection 2-Radiation therapy Irradiation means application or exposure of body tissues to radiation energy which may occur either accidentally or for therapeutic purposes. Indications of radiation therapy 1. Radiation may be used to cure the cancer, as in, thyroid carcinomas, localized cancers of the head and neck, and cancers of the uterine cervix. 2. When a tumor cannot be removed surgically or when local nodal metastasis is present. 3. It can be used prophylactically to prevent leukemic infiltration to the brain or spinal cord. 4. Palliative radiation therapy is used to relieve the symptoms of metastatic disease, especially when the cancer has spread to brain, bone, or soft tissue. Methods of delivering radiation 1-External method Radiation is administered by a large machine that points the energy waves directly at the tumor. Since radiation is used to kill cancer cells, special shields may be made to protect the tissue surrounding the treatment area. Radiation treatments are painless and usually last a few minutes. 2-Internal radiation  High dose of radiation is given inside the body as close to the cancer as possible in a shorter time span when compared with external radiation.  The radiation treatment may be swallowed, injected, or implanted directly into the tumor.  Some of the radioactive implants are called ―seeds‖ or ―capsules‖.  Some internal radiation treatments stay in the body temporarily; other stay in the body permanently.  In some cases, both internal and external radiation therapies are used. Effect of radiation A- Systemic effect  Radiation sickness causing nausea, vomiting, and depression  Radiation cachexia caused by poor appetite, weight loss, and anemia  Anemia, leucopenia, and thrombocytopenia 27  ADULT 2 Medical Surgical Nursing Department 2024 B- Local effect  Skin: Erythema – Edema-Chronic ulcer-Dermal fibrosis-Loss of hair  Bone and cartilage: ostitis- Bone necrosis and pathological fracture  GIT: Increase mucus secretion-Ulceration and hemorrhage-Atrophy of lymphoid tissue-Necrosis and perforation  Kidney: Radiation nephritis-Chronic renal failure-  Testes and ovaries: Atrophy of germ cells leading to sterility  Bone marrow and blood: Anemia-Leucopenia-Thrombocytopenia- Leukemia Nursing Management in Radiation Therapy 1-Nursing protection from radiation 1. to avoid exposure to radiation while the patient is receiving therapy, consider the following: a. Time: exposure to radiation is directly proportional to the time spent b. Distance: amount of radiation reaching a given area decreases as resistance increases c. Shield: sheet of absorbing material placed between the radiation source and the nurse decreases the amount of radiation exposure. 2. If exposed to penetrating radiation (x-ray or gamma rays), wear film badges on the front of the body. 3. Take appropriate measures associated with sealed sources of radiation implanted:  Follow directives on precaution sheet that is placed on the charts of all patients receiving radiotherapy.  Do not remain within 1meter (3feet) of the patient any longer than required to give essential care. 4. be alert for implants that may have become loosened (those inserted in cavities that have access to the exterior); 5. Notify the radiation therapist of any implant that has moved out of position 6. Use long-handled forceps and hold at arm's length when picking up any dislodged radium needle, seeds, or tubes. 7. Do not discard any dressings or linens unless you are sure that no radioactive source is present. 8. After the patient is discharged from the hospital, the radiologist check the room with a radiograph or survey meter to be certain that all radioactive materials have been removed 9. Continue radiation precautions when a patient has a permanent implant, until the radiologist declares precautions unnecessary 2- Instruct the patient on external radiation therapy to: 1. Avoid washing the marked skin with soap just applying water only. 2. Avoid using deodorant, lotion, medication, perfumes, or talcum powder to the site during the treatment period. 28  ADULT 2 Medical Surgical Nursing Department 2024 3. Avoid rubbing, scratching, or scrub treated area. 4. Applying neither heat not cold to the treated area 5. Inspect the skin for damage or serious changes and report these to radiologist or physician. 6. Wear loose, soft, and cotton clothing over the treated area. 7. Protect skin from sun exposure during treatment period and one year after radiation therapy stopped. 8. External radiation poses no risk to other people for radiation exposure. 9. be sure to get plenty of rest and well balanced diet. 3-In relation to patient under going internal radiation the nurse should: 1. Place the patient in private room and limit visits to 10 to 30 minutes, and have visitors sit at least 6 feet from the patient. 2. Assess for necrosis of adjacent tissue. 3. Instruct the patient to stay in bed and rest quietly while a temporary implant in place to avoid dislodging the implant. 4. Instruct the patient to dispose excretory materials in a special container or in toilet not used by others, if the radiologist indicates that. 3. Chemotherapy  Chemotherapy is the use of anticancer drugs to treat cancerous cells.  Chemotherapy works by interfering with the cancer cell's ability to grow or reproduce.  Chemotherapeutic drugs are effective in destroying or preventing the multiplication of cancer cell, normal tissue is also affected.  It may be used alone for some types of cancer or in combination with other treatments such as radiation or surgery.  Chemotherapy can be administered by many routs, topical, oral, intravenous, intramuscular, subcutaneous…etc. The goals of chemotherapy 1. To reduce tumor size preoperatively. 2. To destroy any remaining tumor cells postoperatively. 3. To treat some forms of leukemia. 4. Cure, control, palliation (20% to 99%, depending on dosage) of tumor cells is destroyed. Side effects of chemotherapy  Bone marrow suppression: - ↓Red blood cells carry oxygen, Risk for anemia- - ↓white blood cells that fight infection, Risk for fatigue, and infection -- ↓platelets that help the blood to clot, Risk for bleeding  mouth sores, nausea, vomiting, and diarrhea  Hair loss, also called "alopecia": Chemotherapy affects the cells of the hair and nails. 29  ADULT 2 Medical Surgical Nursing Department 2024 Nursing Safety measures in handling chemotherapy 1. Wear powder-free latex gloves when preparing or working with chemotherapeutic agents. 2. Wash hands before putting on and after removing gloves. 3. Change latex gloves after each use, tear, puncture, or medication spill 4. Wear a long-sleeve, nonabsorbent gown with elastic at the wrists and back closure. 5. Eye and face shields should be worn 6. Wrap gauze or alcohol pads around the neck of ampules when opening 7. Wrap gauze or alcohol pads around injection sites when removing syringes or needles from IV injection ports. 8. Label all syringes and IV tubing containing chemotherapeutic agents as hazardous material. 9. Place an absorbent pad directly under the injection site to absorb any accidental spillage. 10. If any contact with the skin occurs, immediately wash the area thoroughly soap and water. 11. If contact is made with eye, immediately flush the eye with water and seek medical attention. 12. Do not eat, drink while preparing or handling chemotherapy. 13. Wash hands before and after handling chemotherapy. 14. Discard all contaminated linens, gown, gloves, and excreta from patient in specially marked hazardous waste bags. Nursing measures and Management of an extravasations 1. If extravasations are suspected, stop the infusion of the chemotherapy. 2. Disconnect the IV tubing and attempt to aspirate all residual chemotherapy in the IV catheter using a syringe. 3. If an antidote is available, instill the appropriate amount through the existing IV. 4. Inject 5-6 ml of the antidote SQ in divided doses into the extravasated site with multiple injections. 5. Apply warm or cold compress as indicated, depending on the chemotherapeutic agent that has extravasated. 4-Hyperthermia (thermal therapy or thermotherapy) Definition: Hyperthermia is a type of cancer treatment in which body tissue is exposed to high temperatures (up to 113°F). How is hyperthermia used to treat cancer? 1. High temperatures can damage and kill cancer cells, usually with minimal injury to normal tissues by: A. Killing cancer cells and damaging proteins and structures within cells. B. Hyperthermia may shrink tumors. 2. Hyperthermia is always used with other forms of cancer therapy, such as radiation therapy and chemotherapy. 31  ADULT 2 Medical Surgical Nursing Department 2024 3. Hyperthermia may make some cancer cells more sensitive to radiation or harm other cancer cells that radiation cannot damage. 4. Hyperthermia can also enhance the effects of certain anticancer drugs. Methods of hyperthermia 1. Local hyperthermia Heat is applied to a small area, May using microwave and ultrasound depending on the tumor location. 2. External hyperthermia Used to treat tumors that are in or just below the skin, External applicators are positioned around or near the appropriate region, and energy is focused on the tumor to raise its temperature. 3. Intraluminal Used to treat tumors within or near body cavities, such as the esophagus or rectum; Probes are placed inside the cavity and inserted into the tumor to deliver energy and heat the area directly. 4. Interstitial Used to treat tumors deep within the body, such as brain tumors; Under anesthesia, probes or needles are inserted into the tumor. Imaging techniques, such as ultrasound, may be used to make sure the probe is properly positioned within the tumor. The heat source is then inserted into the probe. 5. Deep tissue Used to treat cancers within the body, such as cervical or bladder cancer 7. Whole-body hyperthermia Is used to treat metastatic cancer that has spread throughout the body; This can be accomplished by several techniques, including the use of thermal chambers (similar to large incubators) or hot water blankets. Complications  Burns, blisters, discomfort, or pain  Tissue swelling, blood clots, bleeding, and other damage to the normal tissues in the perfused area  Whole-body hyperthermia can cause more serious side effects, including Cardiac and vascular disorders, but these effects are uncommon, Diarrhea, nausea, and vomiting 5-Acupuncture  Acupuncture causes physical reactions in nerve cells of the pituitary gland, parts of the brain. So that it stimulates the body protein, releasing hormones and chemicals in the brain that controls various body functions.  Acupuncture stimulates the activity of the immune system and causes the body's natural painkillers.  Improve immune response, including the growing number of white blood cells. 31  ADULT 2 Medical Surgical Nursing Department 2024  Acupuncture controls symptoms caused by cancer treatment, such as weight loss, cough, chest pain, fever, anxiety, depression, night sweats, hot flashes, and dry mouth. 6- Photodynamic therapy or phototherapy: An investigational cancer treatment that uses photosensitizing agents, such as porfimer (Photofrin). When administered intravenously, these agents are retained in higher concentrations in malignant tissue than in normal tissue. They are then activated by a light source, usually laser light, which penetrates body tissue. The light activated agent then creates activated singlet oxygen molecules that are cytotoxic or harmful to body tissue cells. Because most of the photosensitizing agent has been retained in malignant tissue, a selective cytotoxicity can be achieved with minimal destruction to normal tissues.  Cancers treated with phototherapy include esophageal cancers, endobronchial tumors, skin cancers, breast cancers, intraperitoneal tumors, and malignant central nervous system disease. The major side effect of therapy:  Photosensitivity for 4 to 6 weeks after treatment.  Patients must protect themselves from direct and indirect sunlight to prevent skin burns.  In addition, local reactions are observed in the area treated.  Liver and renal function should also be monitored for transient abnormalities.  As with any investigational treatment, emotional support and education are vital to assist the patient and family. 7- Gene therapy: Gene therapy includes approaches that correct genetic defects or manipulate genes to induce tumor cell destruction in the hope of preventing or combating disease. Normally this gene is responsible for repairing damaged cells or causing cell death when the cell cannot be repaired. 8- Biological therapy; interferon Biological therapy (also called immunotherapy) is a form of treatment that uses the body's natural ability (immune system) to fight infection and disease or to protect the body from some of the side effects of treatment. 9- Hormone therapy Some types of cancer, including most breast and prostate cancers, depend on hormones to grow. For this reason, physician may recommend therapy that prevents cancer cells from getting or using the hormones they need. Sometimes, the patient has surgery to remove organs (such as the ovaries or testicles) that make the hormones. 32  ADULT 2 Medical Surgical Nursing Department 2024 10- Bone marrow or hematopoietic stem cell transplantation (HSCT): Bone marrow transplantation (BMT) is a special therapy for patients with cancer or other diseases which affect the bone marrow. A bone marrow transplant involves taking cells that are normally found in the bone marrow (stem cells); filtering those cells and giving them back either to the patient they were taken from or to another person. The goal of BMT is to transfuse healthy bone marrow cells into a person after their own unhealthy bone marrow has been eliminated and to cure many diseases and types of cancer. The basis for stem cell transplantation is that blood cells (red cells, white cells and platelets) and immune cells (lymphocytes) arise from the stem cells, which are present in marrow, peripheral blood and cord blood. Although this procedure is still referred to as "bone marrow transplantation" (BMT) at times, the term "stem cell transplantation" (SCT) is now often used. Nurses management for patient with gastrointestinal & Accessory disorders Outlines 1. Anatomy and physiology of gastro intestinal system. 2. Common laboratory procedures. 3. Common disorders: Gastrointestinal signs & symptoms Chronic Inflammatory Bowel Disorders (Ulcerative Colitis Esophageal disorders Crohn‘s disease (Regional Enteritis) Gastro esophageal reflux disease Hemorrhoids [GERD] Hiatal hernia Intestinal obstruction and paralytic ileus Gastritis Hepatobiliary dysfunction Peptic Ulcer Disease (PUD) Hepatic Cirrhosis Appendicitis HEPATITIS Irritable bowel syndrome (IBS) Disorder of the Gallbladder Cholecystitis Cholelithiasis Learning objectives: By the end of this chapter the student will be able to: 1. Review the anatomy and physiology of gastro intestinal system. 2. Recognize the Common laboratory procedures to GIT disorders 3. Summarize measures to prevent disorders of the gastrointestinal system. 4. Explain GIT disorders. 5. Develop & apply a nursing care plan for a patient with to GIT disorders. 33  ADULT 2 Medical Surgical Nursing Department 2024 An overview of Anatomy and physiology of gastro intestinal tract  The gastrointestinal system includes the alimentary canal (mouth, esophagus, stomach, small intestine, large intestine, and rectum) and accessory organs (salivary glands, liver, pancreas, and gallbladder) and ducts.  The gastrointestinal tract functions to digest food, absorb nutrients, propel the contents through the lumen, and eliminate the waste products. Functions of the Gastrointestinal System 34  ADULT 2 Medical Surgical Nursing Department 2024 The teeth and tongue are instrumental in the chewing (mastication) process, and they help break down food into smaller pieces that can be swallowing & acted on by various enzymes. Food moves from the mouth through the pharynx down the esophagus to the stomach, where mixing movements occur. Mucus, hydrochloric acid (HCl), intrinsic factor, pepsinogen, and gastrin are secreted into the stomach from cells within its walls and are mixed into the food to break down further the particles for absorption. This mixture of partially digested semi-liquid food is called chyme. The small intestine receives the chyme from the stomach, adds more digestive enzymes and fluids, receives bile and pancreatic enzymes from the common duct, and further digests the chime into a more liquid state. Substances are moved along the intestinal tract by the peristaltic action of the intestinal smooth muscle. Digested food particles are absorbed into the bloodstream from the villi on the walls of the small intestine. The large intestine reabsorbs water and electrolytes, formulates some vitamin K, and eliminates waste products The large intestine is populated with bacteria that aid in the breakdown of waste products. The rectum stores fecal material until it is eliminated through the anus. The internal anal sphincter at the top of the anal canal is under involuntary control; the external anal sphincter at the end of the anal canal is under voluntary control. The gastrocolic reflex initiates elimination; it is stimulated by the ingestion of food. By tightening the voluntary anal sphincter, the reflex emptying of the rectum can be stopped. Prevention of Gastrointestinal System Disorders  Eating a normal, well-balanced diet aids digestion.  Maintaining good oral health is important to the health of the rest of the body.  Consuming sufficient bulk in the diet helps maintain a healthy colon by enhancing passage of waste.  A diet lacking in fiber is one factor in the development of diverticulosis, in which pockets form along the colon where waste material can lodge.  Drinking at least eight glasses of fluid a day prevents constipation by helping to keep the stool moist. Prevention of gallbladder disorders.  Maintaining a normal body weight  Eating a low-fat, low-cholesterol, high-fiber, and high-calcium diet  Avoiding rapid weight loss diets  Consuming alcohol moderately  Maintaining an active lifestyle Common Laboratory Procedures 1. Stool Analysis ▪ Examination of stool consistency, color and the presence of occult blood. ▪ Special tests for fat, nitrogen, parasites, ova, pathogens and others. Stool specimens are collected to identify:  White blood cells (indicating inflammation)  Red blood cells (indicating GI blood loss 35  ADULT 2 Medical Surgical Nursing Department 2024  Fat (indicating mal-absorption)  Identify infection (bacterial, ova or parasite ) specimens should be fresh and warm , collect in covered container  Presence of occult blood in the stool is the Hem occult test: positive result indicates that the client is bleeding or has recently bled, consider food &drugs altered color Foods and Medications That Alter Stool Color Altering Substance Color Meat protein Dark brown Spinach Green Carrots and beets Red Cocoa Dark red or brown Barium Milky white Iron, licorice, and charcoal Black Nursing intervention for Occult Blood Testing: ▪ Instruct the patient to adhere to a 3-day meatless diet. ▪ No intake of NSAIDS, aspirin and anti-coagulant. 2. Upper GIT study: barium swallows ▪ examines the upper GI tract. ▪ Barium sulfate is usually used as contrast. Nursing interventions Upper GIT study: barium swallow ▪ Pre-test: NPO post-midnight. ▪ Post-test: Note stool color and consistency to ensure that the barium has been passed, Laxative is ordered, increase fluid intake, inform the patient that the barium may make his stools appear a light color for several days after the test 3. Lower GIT study: barium enema ▪ examines the lower GI tract Nursing intervention for Lower GIT study: barium enema ▪ Pre-test: To remove any residual stool, the client follows prescribed restrictions for 24 to 48 hours before test: Low-residue diet 1 to 2 days before the test, clear liquid diet the evening before the test, a laxative the evening before the test, NPO after midnight, Cleansing enemas the morning of the test. Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn white. 4. Gastric analysis ▪ Aspiration of gastric juice to measure pH, appearance, volume and contents. ▪ Pre-test: NPO 8 hours, avoidance of stimulants, drugs and smoking. ▪ Post-test: resume normal activities. 5. EGD (esophagogastroduodenoscopy) Visualization of the upper GIT by endoscope 36  ADULT 2 Medical Surgical Nursing Department 2024 ▪ Pre-test: ensure consent, NPO 8 hours, pre-medications like ▪ Intra-test: position: LEFT lateral to facilitate salivary drainage and easy access. ▪ Post-test: NPO until gag reflex returns, place patient in SIMS position until he awakens, monitor for complications, saline gargles for mild oral discomfort. 6. Lower GI- scopy ▪ Use of endoscope to visualize the anus, rectum, sigmoid and colon. ▪ Pre-test: consent, NPO 8 hours, cleansing enema until return is clear. ▪ Intra-test: position is LEFT lateral, right leg is bent and placed anteriorly. ▪ Post-test: bed rest, monitor for complications like bleeding and perforation. 7. Liver biopsy ▪ Pretest: Consent, NPO, and Check for the bleeding parameters. ▪ Intra test: Position: Semi fowler‘s LEFT lateral to expose right side ▪ Post-test: monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week. Diagnostic tests for disorders of the intestinal tract and accessory organs consist of x-rays, computed tomography (CT) scans, nuclear medicine scans, magnetic resonance imaging, ultrasound studies, endoscopy, biopsy, laboratory tests, tests of gastric secretions, and stool and urine studies Gastrointestinal Symptomatology Anorexia is the lack or absence of appetite. The appetite center, which stimulates or suppresses the appetite, is located in the hypothalamus.  Pleasant or noxious food odors, effects of drugs, emotional stress, fear, psychological problems, or illnesses may affect appetite. Signs and Symptoms Hunger usually is absent, and clients describe having no desire for food Wight loss vary Vitamin deficiency (B & C vitamins) Diagnostic tests: CBCS ECG Serum albumin, electrolyte, and protein levels Medical and Nursing Management: Based on risk Factors  Persistent anorexia may require various approaches, such as: A high-calorie diet high-calorie supplemental feedings Tube feedings total parenteral nutrition (TPN) psychological support, psychiatric treatment, or both Managing Clients with Anorexia Provide foods that the client likes during meals. Offer nourishing beverages ( milk shakes ) as between-meal snacks. If the client is hospitalized encourage family members to bring favorite foods. In sever prolonged total parenteral nutrition prescribed. 37  ADULT 2 Medical Surgical Nursing Department 2024 Conduct a daily caloric count if necessary to determine total proteins and carbohydrates in the client‘s diet. Serve and keep hot foods hot and cold foods cold. Encourage eating in the company of others. Formulate a nutritional plan with the client and dietitian Obtains a complete medical and allergy (drugs and food) history If necessary, arrange for supplementation based on deficiencies Consult the physician and dietitian in cases of prolonged anorexia, diarrhea or constipation Nausea and Vomiting Nausea and vomiting are common, if prolonged, weakness, weight loss, nutritional deficiency, dehydration, and electrolyte and acid-base imbalances may result. Nausea is the subjective feeling of the urge to vomit. Vomiting is the act of expelling stomach contents from the body through the esophagus and mouth. (forceful ejection of partially digested food and secretions (emesis)  Vomiting is a protective function to rid the body of harmful substances  Valsalva maneuver, which accompanies the forceful expulsion of stomach contents, causes dizziness, hypotension, and bradycardia Causes & Risk Factors: GIT. Infection, food poisoning motion sickness - stress pregnancy - Medications (narcotics) myocardial infarction - uremia Medical and nursing management: o Elimination of the cause e.g. food poising o Providing IV fluid and electrolyte replacement o Restricting food intake until the cause of vomiting is eliminated o Protection of the airway during vomiting is a priority to prevent aspiration o Place Pt. on their side when they begin to vomit o Assess amount, odor , content & color of emesis o After the vomiting is resolved, clear liquids are started 38  ADULT 2 Medical Surgical Nursing Department 2024 o Keep HOB elevated & emesis basin handy o Protect airway with suction & positioning o Provide frequent mouth care o Control sights & odors o Reduce anxiety o Provide quiet, odor-free, visually clean environment o Give antiemetic's as ordered o Modify environmental stimuli (cool cloth & dim lights ) o Provide ongoing patient support o Maintain NPO if severe o Obtain daily weight on same scale, at same time o Monitor intake and output and vital signs o Provide fluids as ordered o Administer antiemetic's as order Nutrition Notes of Client with Nausea\ vomiting  The client should eat small meals and eat and drink slowly.  Dry, salty foods, such as crackers and pretzels, may relieve nausea.  Fried food, spicy food, and foods with strong odors should be avoided.  Cold foods may be preferable to hot foods.  Liquid diet for 12 to 24 hours. Frequent, small amounts of clear liquids are best.  Avoid milk, ice cream, pudding, cheese, yogurt, citrus juice, and cream soups Constipation It is a term used to describe o an abnormal infrequency or irregularity of defecation o abnormal hardening of stools that makes their passage difficult & painful o a decrease in stool volume o retention of stool in the rectum for a prolonged period. Etiology  Medications such as narcotics, tranquilizers, iron and antacids  Rectal conditions such as hemorrhoids or fissures  Metabolic or neurological conditions, diabetes mellitus, multiple sclerosis  Colon cancer  Low intake of dietary fiber and fluids  Decreased mobility, weakness, and fatigue 39  ADULT 2 Medical Surgical Nursing Department 2024  Chronic laxative use The urge to defecate is stimulated normally by rectal distention, which initiates a series of four actions:  stimulation of the inhibitory recto-anal reflex  relaxation of the internal sphincter muscle  relaxation of the external sphincter muscle and muscles in the pelvic region  increased intra-abdominal pressure Signs and Symptoms  indigestion  Abdominal distention  rectal pressure  feeling of incomplete emptying  straining at stool  elimination of hard, dry stool  intestinal rumbling  headache, fatigue  decreased appetite Complications of Constipation  Fecal impaction  Pressure on the colon mucosa from stool ,cause ulcers, hemorrhoids and fissures  Straining can result in cardiac , neurological ,respiratory complications  Pt. has a history of heart failure, hypertension, or recent myocardial infarction, straining can lead to cardiac rupture and death  Megacolon, dilated loops of the colon  Perforation of the colon leads to peritonitis Diagnostic Tests self-diagnosed history and physical examination If complications are suspected, a radiographic examination, Sigmoidoscopy, and stool testing for occult blood Medical –Surgical and Nursing Management  Treatment of constipation depends on the cause.  Fiber should be added to the diet  Behavior changes, such as regular timing, proper positioning to defecate  Drinking warm water every morning, 2 to 3 L of water every day, if it is not contraindicated  Chronic laxative use should be discontinued  Stool softeners such as docusate sodium (Colace) should be used 41  ADULT 2 Medical Surgical Nursing Department 2024  Enemas and rectal suppositories  Surgical management to complication  Assess normal pattern of defecation, diet and fluid intake  Instruct pt. to setting a specific time for defecation  Place feet on a footstool to promote flexion of the hips to aid defecation  a high-fiber, high residue diet including fresh fruits, vegetables  Increase activity through a daily walking program  Increase fluid if not contraindicated to 2 to 3 L per day, and fiber in the diet  Teach factors leading to constipation and preventive interventions Diarrhea It is :  increased frequency of bowel movements (more than three per day)  increased amount of stool (more than 200 g per day  altered consistency (looseness) of stool. It is usually associated with urgency, perianal discomfort, incontinence, or combination  Classification and severity of diarrhea are based on the number of unformed stools in 24 hours (sever, mild). Or based on times to Acute & chronic (Diarrhea present for longer than 4 weeks)  Classify according to infection (Acute noninflammatory Watery, nonbloody. Usually mild, self-l limited) & Acute inflammatory : Blood or pus, fever, caused by an invasive or toxin-producing bacterium  Three major problems associated with severe or prolonged diarrhea include dehydration, electrolyte imbalances, and vitamin deficiencies Etiology  Common cause of acute diarrhea is a bacterial or viral infection  Poor tolerance or allergies to certain foods: additives, caffeine, milk products, meats  Inflammatory diseases such as Crohn‘s disease or ulcerative colitis  Mal-absorption , Viruses infectious  Radiation therapy for cancer  Enteral tube feedings  Certain medications (thyroid hormone replacement, laxatives, antibiotics) Clinical Manifestations: Abdominal cramps& distention Low-grade fever Weight loss Dehydration, electrolyte disturbances (e.g., hypokalemia) 41  ADULT 2 Medical Surgical Nursing Department 2024 Acid-base imbalances (metabolic acidosis) Urge to defecate Diagnostic Tests The diagnosis of diarrhea is determined by : o The onset and progression of the disease o Absence or presence of fever o Laboratory examinations, and visual inspection of the stool o Evidence of bacteria, pus, and blood in stool is checked o CBCS, serum electrolytes Medical and Nursing Interventions  Replacing fluids and electrolytes is the first priority  Treating the underlying disease & risk factors prevention  Increasing oral fluid intake, using solutions with glucose and electrolytes  Intravenous fluid replacement for rapid hydration ( very young or very old).  An elimination diet that contribute to diarrhea.  Encouraged to increase fiber and bulk in the diet to avoid post diarrhea.  Motility of the intestines can be decreased with the use of drugs as order  Dietary supplement used to restore the normal flora.  Antimicrobial agents are prescribed  Ask the patient to describe any symptoms, when they started, and how long they have been present (abdominal pain, stool consistency, color, odor, and frequency).  Abdomen is inspected for distention  Dietary habits and any changes is assessed  Find out if any contributed to diarrhea ( medications, exposure to an infected person, geographical location  Assess for symptoms of dehydration :wt., I &O, skin turgor  Monitor and record stool characteristics, amount, and frequency  During acute diarrhea nothing is taken by mouth  Give anti-diarrheal medications as ordered  Provide clear liquids, such as water, juices  Limit caffeine, very hot and very cold foods, ( stimulate intestinal motility)  Restrict milk products, fat, whole-grain products, fresh fruits, and vegetables for several days.  Keep skin clean, dry, and protected with a moisture barrier  Strict infection control precautions that prevent transmission of infection Encourages bed rest and dizziness precautions Esophageal disorders 42  ADULT 2 Medical Surgical Nursing Department 2024 Esophagitis: inflammation of the esophagus. Gastro esophageal reflux disease [GERD] It is a reflux of stomach contents into the esophagus. This typically causes symptoms because the lining of the esophagus is not protected against the acid that is normally found only in the stomach. Risk factors  Increased gastric volume & pressure (Excessive ingestion of foods)  Position pushing gastric contents (such as bending or lying down)  Increased gastric pressure (obesity, tight clothing, pregnancy)  Hiatal hernia  Medications that relax the LES (nitrates, calcium channel blockers, & diazepam) Clinical manifestations: Symptoms are aggravated by lying down Epigastric burning, worse after eating Heartburn (dyspepsia) and reflux Burping (eructation Sour taste in mouth, often worse in the morning Nausea Bloating Cough due to reflux high in the esophagus Hoarseness or change in voice Investigation 24-hour pH monitoring of lower esophageal area will show elevations. Barium swallows or upper GI study may show reflux. Endoscopy or esophagogastroduodenoscopy shows irritation from cellular changes of chronic reflux. Treatment Administer antacids to neutralize acid. Administer H2 (histamine type 2) blockers to decrease the production of acid. Administer proton pump inhibitors to reduce the production of acid. Have patient eat six small meals rather than three large ones to reduce intraabdominal pressure. Surgery or endoscopic procedures may be performed to prevent the reflux from occurring. Nursing intervention Monitor vital signs. Assess abdomen for distention, bowel sounds. Teach about medication management. Teach patient about lifestyle modifications:  Wait 2 to 3 hours after eating before lying down.  Sleep with the head of the bed elevated 6 to 8 inches  Avoid wearing clothing that is tight at waist. 43  ADULT 2 Medical Surgical Nursing Department 2024  Avoid acidic foods (citrus, vinegar, and tomato), peppermint, caffeine, alcohol.  Stop smoking.  Lose weight if overweight  Avoid high-fat oils and spicy foods.  Eat four to six small meals a day.  Eat slowly and chew food thoroughly  Participate in regular stress-reducing activities Hiatal hernia Hiatal hernia is the result of a defect in the wall of the diaphragm where the esophagus passes through; this creates protrusion of part of the stomach or the lower part of the esophagus up into the thoracic cavity Causes 1. Muscle weakening 2. Esophageal trauma 3. Surgical procedures Clinical manifestations Reflux of stomach acid : sub sternal or epigastric pain or feelings of pressure after eating Difficulty swallowing (dysphagia) Nighttime coughing may awaken the patient Regurgitation of a hot, sour liquid coming into the throat Shortness of breath Diagnostic tests Barium swallow or upper GI study shows hiatal hernia Complications 1. Hemorrhage 2. Strangulation 3. Obstruction Treatment Administer antacids for patients with reflux symptoms. Administer histamine type 2 (H2) blockers to reduce stomach acid. Administer proton pump inhibitors to reduce the production of acid. 44  ADULT 2 Medical Surgical Nursing Department 2024 Avoid lying down after eating. Modify eating schedule; small, frequent meals. Surgery to repair a hiatal hernia may involve pulling the stomach down into the abdomen and making the opening in the diaphragm smaller. Nursing intervention Monitor vital signs. Assess abdomen for distention, bowel sounds. Teach patient about lifestyle modifications: Medication management. Not to lie down after eating. Elevate head of bed. Avoid wearing clothing that is tight at waist. Avoid acidic foods (citrus, vinegar, tomato), peppermint, caffeine, alcohol. Stop smoking. Lose weight if overweight. GASTRITIS Definition Gastritis is an inflammation of the stomach lining due to either erosion or atrophy. Causes & Risk Factors:  Diet : Alcohol Spicy , fatty foods  Microorganisms: Helicobacter pylori  Medications : Aspirin NSAIDs Corticosteroids Digitalis Chemotherapeutic drugs  Stress : Physiological Psychological  Trauma  Other Factors Smoking Radiation Naso-gastric suctioning Endoscopic procedures Types : Acute gastritis has sudden onset, is of short duration, and may result in gastric bleeding if severe. Chronic gastritis has a slow onset and, if profuse, may damage parietal cells resulting in pernicious anemia. Atrophic gastritis involves all layers of the stomach, association with gastric ulcer and malignancies of the stomach Gastritis associated with uremia is common in patients with kidney failure: excessive urea causes gastric irritation Autoimmune atrophic gastritis : is an inherited condition in which there is an immune response directed against parietal cells Clinical manifestation Nausea and vomiting Anorexia Epigastric area discomfort 45  ADULT 2 Medical Surgical Nursing Department 2024 Epigastric tenderness on palpation due to gastric irritation Bleeding from irritation of the gastric mucosa Hematemesis—possible coffee ground emesis due to partial digestion of blood Melena—black, tarry stool Diagnostic findings Hemoglobin and hematocrit decrease. Anemia (iron deficiency) due to chronic, slow blood loss. Fecal occult blood positive. Helicobacter pylori may be positive. Upper endoscopy shows inflammation, allows biopsy. Treatment Administer antacids. Administer sucralfate to protect gastric lining. Administer histamine 2 blockers. Administer proton pump inhibitors. Eradicate Helicobacter pylori infection if present. Diet modification. Monitor hemoglobin and hematocrit. Nursing intervention Monitor vital signs. Monitor intake and output. Monitor stool for occult blood. Assess abdomen for bowel sounds, tenderness. Teach patient about: Diet restrictions: avoid alcohol, caffeine, acidic foods. The need to avoid smoking. The need to avoid NSAIDs. Peptic Ulcer Disease (PUD) A peptic ulcer is ulceration with loss of tissue of the upper GI tract. The term includes both duodenal and gastric ulcers Types 1. Gastric Ulcer 46  ADULT 2 Medical Surgical Nursing Department 2024 Ulcer in the stomach caused action of acid, pepsin on the stomach lining (mucosa). 2. Duodenal Ulcer Ulcer in the duodenum caused by the action of acid and pepsin on the duodenal lining. Duodenal ulcers tend to be deeper, penetrating through the mucosa to the muscular layer. Predisposing factors  Stress  Smoking  Alcohol intake  Caffeine  Drugs [NSAIDS, and Steroids].  Gastritis  Infection [H. pylori] is responsible for 80% of gastric ulcers and more than 90% of duodenal ulcers  Irregular, hurried meals  Spicy, highly acidic foods  Type a personality ―stress personality‖  Genetics Clinical manifestation Epigastric pain: - Pain 1-2 hr. after meals with gastric ulcer. Aggravation of discomfort with food - Pain 2-4 hr. after meals with duodenal ulcer, Pain relief with food With a gastric ulcer the pain is diminished in the morning when secretion is low and after meals when food is in the stomach, and pain is most severe before meals and at bedtime. Weight changes - Loss with gastric ulcer - Gain with duodenal ulcer Bleeding from ulcer causes: - Hematemesis (vomiting bloody fluid); more likely with gastric ulcer - Melena (tarry stool) more likely with duodenal ulcer Perforation of ulcer causes: Tender, rigid, board-like abdomen Knee-chest position reduces pain Hypovolemic shock Perforation is characterized by a sudden and severe pain in the upper abdomen that persists and in