Unit 3 Study Exam Guide PDF

1. Pancreatic Hospital Discharge Teaching: avoid high-fat foods, heavy meals, and alcohol. receive verbal and written instructions about signs and symptoms of acute pancreatitis and possible complications that should be reported promptly to the primary provider. 2. Pancreatitis- Inflammati...

1. Pancreatic Hospital Discharge Teaching: avoid high-fat foods, heavy meals, and alcohol. receive verbal and written instructions about signs and symptoms of acute pancreatitis and possible complications that should be reported promptly to the primary provider. 2. Pancreatitis- Inflammation of pancreas Clinical manifestations of acute pancreatitis: *sever epigastric abdominal pain that may radiate to the back *May occur after eating heavy or spicy meals * Alcohol ingestion may also stimulate an episode of pancreatitis. *tachycardia *fever, *extreme malaise, * molted and or cold skin, *restlessness, *ecchymosis (purple or blue patches of the skin) Signs of acute pancreatitis that suggest peritonitis *rigid board like abdomen *decreased or absent breath sounds *crackles at the bases *left plural effusion *abdominal guarding *resp. Distress Clinical manifestations of chronic pancreatitis *Dull nonspecific discomfort to sever upper abdominal and back pain often accompanied with vomiting *Diagnostic testing: *amylase levels elevated *lipase levels elevated *calcium level low *glucose level elevated *hematocrit elevated Diagnostics for pancreatitis: *abdominal xray *ultrasound *ct scan *ERCP *glucose tolerance test Medical Management:  IV fluid, pain management (morphine) DO NOT USE DEMEROL NPO may need TPN management DIET: HIGH CARBS and LOW PROTIEN AND FATS, avoid caffeine, NO SMOKING 3. Hepatic encephalopathy is a life-threatening complication of liver disease that occurs with profound liver failure. It affects the brain due to the seriousness of the liver disease. Hepatic encephalopathy is the neuropsychiatric manifestation of hepatic failure associated with portal hypertension and the shunting of blood from the portal venous system into the systemic circulation Ammonia is considered the major etiologic factor in the development of encephalopathy. Asterixis (“liver flap”) may occur in hepatic encephalopathy. The patient is asked to hold the arm out with the handheld upward (dorsiflexed). Within a few seconds, the hand falls forward involuntarily and then quickly returns to the dorsiflexed position. The earliest symptoms of hepatic encephalopathy include: mental status changes and motor disturbances. alterations in mood and sleep patterns. The patient tends to sleep during the day and has restlessness and insomnia at night. Diagnostics: ECG Medications: Lactulose is given to reduce serum ammonia levels- The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well. Can be put in fruit juice to mask the taste Sedatives, tranquilizers, and analgesic medications are discontinued. Nursing responsibilities Keep daily protein intake between 1.2 and 1.5 g/kg body weight per day. Provide small, frequent meals and 3 small snacks per day in addition to a late-night snack before bed. The nurse is responsible for maintaining a safe environment to prevent injury, bleeding, and infection. The potential for respiratory compromise is great given the patient’s depressed neurologic status 4. Hepatitis A –viral infection that causes inflammation symptoms: Fatigue Nausea Vomiting Abdominal pain Diarrhea Fever Jaundice (yellowing of the skin and eyes) Cause: Consumption of contaminated food or water or close contact of a contaminated person 5. Hepatitis B- viral virus transmitted primarily through blood (percutaneous and permucosal routes). Signs and symptoms: Fatigue Jaundice (yellowing of the skin and eyes) Dark urine Clay-colored stools Nausea and vomiting Abdominal pain Found in: blood saliva, semen, vaginal secretions can be transmitted through mucous membranes and breaks in the skin. HBV is also transferred from carrier mothers to their infants, especially in areas with a high incidence 6. Gastritis-swelling and inflammation of the stomach (erosive or non-erosive) Signs/Symptoms of ACUTE gastritis: epigastric pain/ discomfort dyspesia indegeston anorexia nausea and comiting Management: No spicy food bland meals plenty of fluids Medications: antacids PPI’s H2 blockers Antibiotics (for H. Pylori) *acute gastritis can develop when ptnt has a major trauma injury, burns, sever infection, lack of perfusion to the stomach lining or major surgery. Often referred as stress gastritis or ulcer Signs/Symptoms of CHRONIC gastritis: fatigue pyrosis after eating belching sour taste halitosis feeling fullness anorexia nausea/vomiting Management: modifying diet rest reduce stress No drinking, smoking, NSAIDS, or coffee Erosive gastritis may cause: bleeding and may manifest as blood in vomit or melena (black tarry stool) hematochezia (bright red stool)  Caused by: NSAIDS (aspirin, ibuprofen, naproxen) Corticosteroids: hydrocortisone, prednisone, etc Non-erosive gastritis: Characterized by disruption of the mucosal barrier that normally protects the stomach tissue from digestive jucies Caused by: H. Pylori autoimmune d/o alcohol smoking DEFENITIVE DX OF GASTRITIS: endoscopy and histologic exam of specimen obtained by bx 7. GERD (gastroesophageal reflux disease): fairly common disorder marked by backflow of gastric or duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus. Excessive reflux may occur because of an incompetent lower esophageal sphincter, pyloric stenosis, hiatal hernia, or a motility disorder. GERD increases with aging and is seen in patients with irritable bowel syndrome and obstructive airway disorder exacerbations associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori. Pyrosis (heartburn, specifically more commonly described as a burning sensation in the esophagus that is noncardiac in nature) and regurgitation are the hallmark symptoms, but patients may also experience dyspepsia (indigestion), dysphagia or odynophagia, hypersalivation, and esophagitis. GERD can result in dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications Diagnostic testing may include ambulatory pH monitoring, which is the gold standard for the diagnosis of GERD Lifestyle modifications include tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet Surgical management involves an open or laparoscopic Nissen fundoplication, which involves wrapping of a portion of the gastric fundus around the sphincter area of the esophagus 8. Colon cancer Cancer of the colon and rectum is predominantly (95%) adenocarcinoma The genetic  mutations are associated with the transformation of a benign polyp to invasive adenocarcinoma, which can invade and destroy normal tissues and extend into surrounding structures. Cancer cells may migrate away from the primary tumor and spread to other parts of the body, most often to the liver, peritoneum, and lungs. Risk factors: smoking, family hx, alcohol, high fat high proetien diet, type 2 diabetes, age, history of IBD, male gender, obesity, black or Jewish the most common presenting symptom is a change in bowel habits. The passage of blood in or on the stools is the second most common symptom. The symptoms most commonly associated with right-sided lesions (i.e., more proximal tumors) are dull abdominal pain and melena (i.e., black, tarry stools). Patients with right-sided tumors tend to have poorer outcomes than those with left-sided tumors. The symptoms most commonly associated with left-sided lesions are a change in bowel habits or those associated with obstruction (i.e., abdominal pain and cramping, narrowing stools, constipation, distention), as well as hematochezia (i.e., bright red blood in the stool). Symptoms associated with rectal lesions are tenesmus, rectal pain, the feeling of incomplete evacuation after a bowel movement, alternating constipation and diarrhea, and bloody stool Screening is an effective method to identify and prevent colorectal cancer. Screening colonoscopies can reduce mortality by decreasing the incidence of and increasing the survival rates for patients with colorectal cancer Surgery is the mainstay of initial treatment for colorectal cancer. The goal is removal of the primary tumor with clean margins, including lymph nodes Postoperative infection is a major cause of morbidity and mortality following colorectal surgery. The patient is observed for signs and symptoms of complications. The nurse monitors vital signs for increased temperature, pulse, and respirations and for decreased blood pressure that may indicate an intra-abdominal infectious process. It is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. Rectal bleeding must be reported immediately because it indicates hemorrhage. 9. Ascites - 3rd space fluid that is accumulated in the peritoneal cavity and pleural space, resulting from fluid volume disturbances such as hypervolemia. Usually from liver disease, heart failure, and kidney injury. Common reports of SHORTNESS OF BREATH AND SENSE OF PRESSURE. Is a consequence of portal hypertension and increase in capillary pressure and obstruction of venous blood flow through the damaged liver. Is an albumin rich fluid. Increased abdominal girth and rapid weight gain are common presenting signs, is assessed by percussion of abdomen. Must maintain LOW SODIUM DIET, diuretics are often prescribed Spironolactone, an aldosterone-blocking agent, is most often the first-line therapy in patients with ascites from cirrhosis. Bed rest in an upright position. Surgical; paracentesis. nursing measures include assessment and documentation of intake and output (I&O), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia,  creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of hepatic encephalopathy. 10. 11. Protonix (pantoprazole) Proton pump inhibitor that decreases the amount of acid produced in the stomach. Used to treat erosive esophagitis caused by GERD or gastroesophageal reflux NOT USED FOR IMMEDIATE RELIFE OF HEARTBURN SYMPTOMS Can cause kidney problems, call dr if you have blood in your diarrhea More likely to break a bone Do not take with medicine that contains dipivefrine 12. lactulose (Constulose) Laxative Should not take if on a low galactose (milk sugar) diet 13. Gastrectomy- removal of all or part of the stomach Type of bariatric surgical procedure and is the most commonly performed involving removal of part of the stomach Sugar-free fluids are preferred because they are not implicated in causing dumping syndrome After bowel sounds have returned and oral intake is resumed, six small feedings consisting of a total of 600 to 800 calories per day are provided, and consumption of fluids between meals is encouraged to prevent dehydration. Common dietary deficiencies in patients who have had bariatric surgery include malabsorption of organic iron and b12 Assume a low Fowler position during mealtime and then remain in that position for 20 to 30 minutes after mealtime Avoid drinking fluid with meals; instead, consume fluids up to 30 minutes before a meal and 60 minutes after mealtime. Gastrectomy for stomach cancer: The entire stomach is removed along with the duodenum, the lower portion of the esophagus, supporting mesentery, and lymph nodes. Reconstruction of the GI tract is performed by anastomosing the end of the jejunum to the end of the esophagus, a procedure called an esophagojejunostomy A radical partial (subtotal) gastrectomy is performed for a respectable tumor in the middle and distal portions of the stomach. The Billroth I involves a limited resection and offers a lower cure rate than the Billroth II. The Billroth II procedure is a wider resection that involves removing approximately 75% of the stomach and decreases the possibility of lymph node spread or metastatic recurrence.  A proximal partial (subtotal) gastrectomy may be performed for a resectable tumor located in the proximal portion of the stomach or cardia. A total gastrectomy or an esophagogastrectomy is usually performed in place of this procedure to achieve a more extensive resection. Complications: hemorrhage dumping syndrome bile reflux gastric outlet obstruction. Postoperative bleeding from the surgical site is a common complication of gastric surgery. 14. Esophagogastroduodenoscopy (EGD) Fibroscopy of the upper GI tract allows direct visualization of the esophageal, gastric, and duodenal mucosa through a lighted endoscope is valuable when esophageal, gastric, or duodenal disorders or inflammatory, neoplastic, or infectious processes are suspected. This procedure also can be used to evaluate esophageal and gastric motility and to collect secretions and tissue specimens for further analysis. Therapeutic endoscopy can be used to remove common bile duct stones, dilate strictures, and treat gastric bleeding and esophageal varices. The use of topical anesthetic agents and moderate sedation makes it important to monitor and maintain the patient’s oral airway during and after the procedure. Finger or ear oximeters are used to monitor oxygen The patient should be NPO for 8 hours prior to the examination. Midazolam, a sedative that provides moderate sedation with loss of the gag reflex and relieves anxiety during the procedure, is given. Atropine may be given to reduce secretions, and glucagon may be given to relax smooth muscle. The patient is positioned in the left lateral position to facilitate clearance of pulmonary secretions and provide smooth entry of the scope. 15. Ulcerative Colitis is a chronic ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum that is characterized by unpredictable periods of remission and exacerbation with bouts of abdominal cramps and bloody or purulent diarrhea. The inflammatory changes typically begin in the rectum and progress proximally through the colon The predominant symptoms of ulcerative colitis include diarrhea, with passage of mucus, pus, or blood; left lower quadrant abdominal pain; and intermittent tenesmus. The bleeding may be mild or severe, and pallor, anemia, and fatigue result. The patient may have anorexia, weight loss, fever, vomiting, and dehydration, as well as cramping, and the passage of six or more liquid stools each day. Abdominal x-ray studies are useful for determining the cause of symptoms. Sever cases get a colectomy Patients with ulcerative colitis also have a significantly increased risk of osteoporotic fractures due to decreased bone mineral density. Corticosteroid therapy may also contribute to the diminished bone density. Patients with ulcerative colitis are also at increased risk for colon cancer. Approximately 20 years post diagnosis  ulcerative colitis have long periods of well-being interspersed with short intervals of illness. Aminosalicylates such as sulfasalazine are typically the first pharmacologic agents selected to induce and maintain remission of mild to moderate IBD antibiotics include a combination therapy of both metronidazole and ciprofloxacin, These antibiotics are associated with adverse effects that include nausea and diarrhea, and increased risk of Clostridium difficile infection. Furthermore, metronidazole can cause peripheral neuropathy that, if present, can warrant its discontinuance. Cold foods and smoking are avoided because both increase intestinal motility. Some patients may experience an improvement in symptoms if they follow the FODMAP diet 16. Bowel Obstruction Intestinal obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract. Two types of processes can impede this flow (Norris, 2019; Ramnarine, 2017): Mechanical obstruction: Extrinsic lesions from outside the intestines or intrinsic lesions within the intestines can obstruct flow. Examples of extrinsic lesions include adhesions, hernias, and abscesses. Examples of intrinsic lesions include intestinal tumors (benign and cancerous), strictures (from prior surgery or radiation), or intraluminal lesions due to a defect in the bowel lumen (e.g., intussusception). Functional or paralytic obstruction: The intestinal musculature cannot propel the contents along the bowel either due to interruption of innervation or vascular supply to the bowel. Examples are amyloidosis, muscular dystrophy, endocrine disorders such as diabetes, or neurologic disorders such as Parkinson’s disease. The blockage also can be temporary and the result of the manipulation of the bowel during surgery (i.e., ileus). Obstruction can occur in the large or small intestine and can be partial or complete. Severity depends on the region of bowel affected, the degree to which the lumen is occluded, and especially the degree to which the vascular supply to the bowel wall is disturbed. Most obstructions occur in the small intestine. Adhesions, hernia, and tumor account for 90% of obstructions in the small intestines Other causes of small bowel obstruction include Crohn’s disease, intussusception, volvulus, and paralytic ileus. Most obstructions in the large intestines occur in the sigmoid colon. The most common causes of large bowel obstruction are cancer (60%), diverticular disease (20%), and volvulus (5%). Other causes of large bowel obstruction include benign tumors, strictures, and obstipation or fecal impaction Mechanical causes of obstruction include: adhesions, intussusception, volvulus, hernia, and tumor SBO: Intestinal contents, fluid, and gas accumulate proximal to the intestinal obstruction. With continued intestinal distention and edema, perfusion to the affected intestinal segment can be compromised, leading to ischemia, necrosis, and eventual rupture or perforation of the intestinal wall, with resultant peritonitis i nitial symptom is usually crampy pain that is wavelike and colicky due to persistent peristalsis both above and below the blockage. The  patient may pass blood and mucus but no fecal matter and no flatus. Vomiting occurs. If the obstruction is complete, the peristaltic waves initially become extremely vigorous and eventually assume a reverse direction, with the intestinal contents propelled toward the mouth instead of toward the rectum. Vomiting results in loss of hydrogen ions and potassium from the stomach, leading to reduction of chloride and potassium in the blood and to metabolic alkalosis. Decompression of the bowel through insertion of an NG tube is necessary for all patients with small bowel obstruction; Nursing management of the patient with a small bowel obstruction who does not require surgery includes maintaining the function of the NG tube, assessing and measuring the NG output, assessing for fluid and electrolyte imbalance, monitoring nutritional status, and assessing for manifestations consistent with resolution (e.g., return of normal bowel sounds, decreased abdominal distention, subjective improvement in abdominal pain and tenderness, passage of flatus or stool). Maintaining fluid and electrolyte balance is a priority to monitor in the patient with a small bowel obstruction. The presence of the NG tube in conjunction with the patient’s nothing-by-mouth (NPO) status places the patient at significant risk of fluid imbalance. Thus, measures to promote fluid balance are critically important. LBO: A large bowel obstruction results in an accumulation of intestinal contents, fluid, and gas proximal to the obstruction. It can lead to severe distention and perforation unless some gas and fluid can flow back through the ileocecal valve. Large bowel obstruction, even if complete, may be undramatic if the blood supply to the colon is not disturbed. However, if the blood supply is cut off, intestinal strangulation and necrosis occur; this condition is life threatening. In the large intestine, dehydration occurs more slowly than in the small intestine because the colon can absorb its fluid contents and can distend to a size considerably beyond its normal full capacity. Similar to small bowel obstruction, complications include perforation, peritonitis, and sepsis. Large bowel obstruction differs clinically from small bowel obstruction in that the symptoms develop and progress relatively slowly. In patients with obstruction in the sigmoid colon or the rectum, constipation may be the only symptom for weeks. The shape of the stool is altered as it passes the obstruction that is gradually increasing in size. Blood loss in the stool may result in iron deficiency anemia. The patient may experience weakness, weight loss, and anorexia. Eventually, the abdomen becomes markedly distended, loops of large bowel become visibly outlined through the abdominal wall, and the patient has crampy lower abdominal pain 17. Peptic Ulcer Disease peak onset between 30 and 60 A peptic ulcer may be referred to as a gastric, duodenal, or esophageal ulcer, depending on its location. A peptic ulcer is an excavation (hollowed-out area) that forms in the mucosa of the stomach, in the pylorus, (the opening between the stomach and duodenum), in the duodenum, (the first portion of the small intestine, between the stomach and the jejunum), or in the esophagus. Erosion of a circumscribed area of mucosa is the cause. Peptic ulcers are more likely to occur in the duodenum than in the stomach. Chronic gastric ulcers tend to occur in the lesser curvature of the stomach, near the pylorus. Esophageal ulcers occur as a result of the backward flow of HCl from the stomach into the esophagus (gastroesophageal reflux disease [GERD]). most peptic ulcers result from infection with H. pylori, The use of NSAIDs, such as ibuprofen and aspirin, represents a major risk factor for peptic ulcers. Peptic ulcer disease is also associated with Zollinger-Ellison syndrome (ZES). ZES is a rare condition in which benign or malignant tumors form in the pancreas and duodenum that secrete excessive amounts of the hormone gastrin Exposure of the mucosa to gastric acid (HCl), pepsin, and other irritating agents (e.g., NSAIDs or H. pylori) leads to inflammation, injury, and subsequent erosion of the mucosa. Patients with duodenal ulcers secrete more acid than normal, whereas patients with gastric ulcers tend to secrete normal or decreased levels of acid. The use of NSAIDs inhibits prostaglandin synthesis, which is associated with a disruption of the normally protective mucosal barrier. Damage to the mucosal barrier also results in decreased resistance to bacteria, and thus infection from H. pylori bacteria may occur Stress ulcer is the term given to the acute mucosal ulceration of the duodenal or gastric area that occurs after physiologically stressful events, such as burns, shock, sepsis, and multiple organ dysfunction syndrome most common in patients following significant burn injuries, traumatic brain injury, or who require mechanical ventilation. Stress ulcers are believed to be a result of ischemia to gastric mucosa and alterations in the mucosa barrier Curling ulcer is frequently observed after extensive burn injuries and often involves the antrum of the stomach or the duodenum Cushing ulcer is common in patients with a traumatic head injury, stroke, brain tumor, or following intracranial surgery. As a rule, the patient with an ulcer complains of dull, gnawing pain or a burning sensation in the mid epigastrium or the back. classically, the pain associated with gastric ulcers most commonly occurs immediately after eating, whereas the pain associated with duodenal ulcers most commonly occurs 2 to 3 hours after meals. Patients with duodenal ulcers are more likely to express relief of pain after eating or after taking an antacid than patients with gastric ulcers. Upper endoscopy is the preferred diagnostic procedure because it allows direct visualization of inflammatory changes, ulcers, and lesions. Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and sometimes bismuth salts that suppress or eradicate H. pylori. Recommended combination drug therapy is typically prescribed for 10 to 14 days and may include triple therapy with two antibiotics (e.g., metronidazole or amoxicillin and clarithromycin) plus a proton pump inhibitor (e.g., lansoprazole, omeprazole, or rabeprazole), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton pump inhibitor and bismuth salts. Currently, the most commonly used therapy for peptic ulcers is a combination of antibiotics, proton pump inhibitors, and sometimes bismuth salts that suppress or eradicate H. pylori. Recommended combination drug therapy is typically prescribed for 10 to 14 days and may include triple therapy with two antibiotics (e.g., metronidazole or amoxicillin and clarithromycin) plus a proton pump inhibitor (e.g., lansoprazole, omeprazole, or  rabeprazole), or quadruple therapy with two antibiotics (metronidazole and tetracycline) plus a proton pump inhibitor and bismuth salts Stop smoing a diatery modifications no caffeine 18. TPN is complete nutrition delivered intravenously to people who can’t use their digestive systems at all. TPN might be required when certain conditions impair your ability to process food and absorb nutrients through your digestive tract, or when you need to avoid using your digestive system for a while so it can heal. It may include different amounts of any of the six essential nutrients that your body requires: water, carbohydrates, proteins, fats, vitamins and minerals and talored to your lab results Parenteral nutrition is a method of providing nutrients to the body by an IV route. The nutrients are a complex admixture containing proteins, carbohydrates, fats, electrolytes, vitamins, trace minerals, and sterile water in a single container. The goals of parenteral nutrition are similar to the goals of enteral feedings (see Chapter 39); namely, to improve nutritional status, establish a positive nitrogen balance, maintain muscle mass, promote weight maintenance or gain, and enhance the healing process (Seres, 2020). Parenteral nutrition is indicated in adults who are malnourished or at risk for becoming malnourished and who cannot tolerate receiving nutrition orally or by the enteral route Typically, a large, high-flow vein such as the superior vena cava (at the right atriocaval junction) is the preferred site A total of 1 to 3 L of solution is given over a 24-hour period. The label of the solution is verified by at least two identifiers and compared with the prescription Ideally, cyclic parenteral nutrition is infused over a 10- to 14-hour period that continues through the nigh Potential Complications of Parental Nutrition: pneumothorax, air embolism, clotted catheter line, catheter displacement, sepsis, hyperglycemia, fluid overload, rebound hyperglycemia 19. Appendicitis is the most common reason for emergency abdominal surgery. The inflammatory process increases intraluminal pressure, causing edema and obstruction of the orifice. Once obstructed, the appendix becomes ischemic, bacterial overgrowth occurs, and eventually gangrene or perforation occurs Vague periumbilical pain (i.e., visceral pain that is dull and poorly localized) with anorexia progresses to right lower quadrant pain (i.e., parietal pain that is sharp, discrete, and well localized) and nausea in approximately 50% of patients with appendicitis (Craig, 2018). A low-grade fever may be present. Rebound tenderness may be present. WBC (>10,500i)s helpful in determining diagnosis The major complications of appendicitis are gangrene or perforation of the appendix, which can lead to peritonitis, abscess formation, or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic  intestines. Perforation generally occurs within 6 to 24 hours after the onset of pain and leads to peritonitis Antibiotic prophylaxis is recommended for less than 24 hours for nonperforated appendicitis and for