Chapter 57 Flashcards
Occurs as a result of reflux (backward flow) of GI contents into the esophagus
GERD
The most common upper Gi disorder in the US. Occurs most often in middle-aged and older adults.
GERD (gastroesophageal reflux disease)
Reflux into the esophagus is usually prevented by….
the Lower esophageal sphincter (LES) (where the esophagus meets the stomach)
Which position worsens symptoms of GERD?
Supine
When the body substitutes columnar epithelium for normal squamous cell epithelium in the lower esophagus, this is known as…
Barrett’s epithelium- Considered pre-malignant
What are some complications that can arise from prolonged GERD?
Risk of cancer
Difficulty swallowing from esophageal stricture
Hemorrhage
Aspiration pneumonia
Adult-onset asthma, laryngitis, or tooth decay
Cardiac disease
Causes of GERD are… (5)
Smoking and alcohol use (weaken LES tone)
Gastric distention from eating large meals
NG tubes
Delayed gastric emptying
Certain foods that decrease LES pressure
Which of these foods is NOT appropriate from a patient with GERD?
- Caffeine
- Chocolate
- Tea
- Bananas
- Milk products
- Peppermints
- Bacon
- Oranges
All but bananas and milk products
Which of these is NOT appropriate for patients with GERD?
- Use of NSAIDS
- Use of calcium channel blockers
- Antacids
- Anticholinergic drugs
- PPIs
- Eating tomatoes
all but 3, 5
The patient has coughing, hoarseness, odynophagia, and pyrosis. The nurse suspects…
GERD
which of these patients is at the greatest risk for GERD?
- Overweight patient with OSA who loves bacon and eats large meals
- A pregnant patient
- A patient who bends over quite frequently at her job
- A personal trainer who wear tight athletic clothes and uses caffeine pills as a health supplement
All are at risk, but 1 is at highest risk
The main symptoms of GERD are…
dyspepsia and regurgitation
True or False: Pain from heartburn in a patient with GERD radiates to the neck,jaw, or back and feels similar to a heart attack.
True. (Usually occurs after eat meal and lasts 20min- 2hrs.)
The nurse notes crackles in the lungs in a patient with GERD, this is an indication of…
Aspiration.
Which of these are symptoms of GERD?
- Vomiting
- Atypical chest pain
- Confusion
- Coughing at night time
- Morning hoarseness
- Water brash (salivary hypersecretion)
All but 1, 3
In an older adult, what are the symptoms of GERD?
Atypical chest pain
Ear, nose, throat infections
Pulmonary problems (aspiration pneumonia, sleep apnea, asthma)
Barrett’s esophagus and esophageal erosion
The most accurate method for diagnosing GERD is…
24-hour ambulatory esophageal pH monitoring
Test that involves placing a small catheter through the nose into the distal esophagus that continuously monitors and records pH.
24-hour ambulatory esophageal pH monitoring
______ is useful in diagnosing or evaluating reflux esophagitis or monitoring complications of Barrett’s esophagus.
EGD (esophagogastrodudoenoscopy)
The most important role for the nurse concerning the patient with GERD is….
Teaching (it is a chronic disorder that requires ongoing management)
Patient teaching regarding nutrition therapy for GERD should include…
- eat 4-6 small meals each day
- avoid foods that irritate and cause heartburn
- avoid NSAID use
- Elevate head of bead 6-12 inches at night
- Do not eat for at least 3 hours before bed- DO NOT eat nighttime snacks
Main drug treatments for GERD includes use of…
PPIs, Histamine blockers, and Antacids
Drug therapy for GERD is aimed at… (3)
- Inhibiting gastric acid secretion
- Accelerating gastric emptying
- Protecting the gastric mucosa
________ is a combination of alginic acid and sodium bicarbonate that forms a thick foam that floats on top of gastric contents and decreases incidence of reflux. It is a very effective drug for GERD.
Gaviscon
________ are available for long-term use.
Histamine blockers
_____ are the main treatment for severe GERD.
PPIs
________________ are used for short-term prevention of stress ulcers from surgery.
IV PPIs (Nexium, Protonix)
Endoscopic therapies are contraindicated for patients who….
Are very obese or have severe symptoms
___________ is indicated for otherwise healthy patients who have failed to respond to medical treatment or have developed complications related to GERD. ____________ is the gold standard.
Anti-reflux surgery, Laparoscopic Nissen fundoplication (LNF)
_______ involves the protrusion of the stomach through the esophageal hiatus of the diaphragm into the chest. The two major types are _______ and ______.
Hiatal hernias, sliding hernia, rolling hernia
The most common type of hernia in which the esophagogastric junction and a portion of the fundus slide upward through the esophageal hiatus into the chest, usually as a result of a weakened diaphragm
Sliding hernia
The major concern for a sliding hernia is… .
Development of esophageal reflux and its complications
Gastroesophageal junction remains in its normal intraabdominal location while the fundus (and possible portions of the stomachs greater curvature) roll through the esophageal hiatus and into the chest beside the esophagus.
Rolling hernia (paraesophageal hernia)
Reflux tends to be present in _____ hernias but not _______ hernias.
Sliding, rolling
Risk for volvulus (twisting), obstruction/blockage, and strangulation/stricture are greater in _______ hernias.
Rolling
The development of iron deficiency anemia is higher in ________ hernias.
Rolling
Which of these are signs of sliding hernias and which are signs of esophageal hernias?
- Heartburn
- Belching
- Feeling of suffocation
- Breathlessness after eating
- Chest pain
- Angina chest pain
- Heartburn- Sliding
- Belching- Sliding
- Feeling of suffocation- rolling
- Breathlessness- rolling
- Chest pain- sliding
- Angina chest pain- rolling
Which of these are symptoms of sliding hernias and which are symptoms of rolling hernias? 1. Worse symptoms when lying down 2 Regurgitation 3. Dysphagia 4. Feeling of fullness after eating
- Worse symptoms when lying down- rolling
- Regurgitation- Sliding
- Dysphagia- sliding
- Feelings of fullness after eating- Rolling
The most specific diagnostic test for identifying hiatal hernias is….
Barium swallow study with fluoroscopy
Sliding hernias are more easily visualized during a barium swallow study when….
The patient moves through a series of positions (taht increase intra-abdominal pressure)
To visualize sliding hernias, a _____ may be performed.
EGD (esophagogastroduodenoscopy)
The most important role for the patient with the hiatal hernia is…
Teaching
What is included in the teaching plan for a patient with a hiatal hernia?
- Sleep with head of bed elevated 6inches
- Remain upright for several hours after eating
- Avoid straining or excessive vigorous exercise
- Refrain from wearing tight, constrictive clothing around the abdomen
The drugs used to treat hernias are….
antacids, histamine receptor antagonists
If the patient needs surgery for the hiatal hernia, what are the important pre-operative measures?
- weight loss
- smoking cessation
- teaching about post-op (NG tube, pain management, oral intake after peristalsis, deep breathing and incentive spirometry)
________ is commonly used for surgical hiatal hernia repair and the surgeon wraps a portion of the stomach fundus around the distal esophagus to anchor and reinforce the LES.
LNF (laparoscopic nissen fundoplication)
Patients postoperative of an LNF procedure for hiatal hernia repair are at risk for ______ and _______
Bleeding, infection
The priority after a conventional surgery for a hiatal hernia repair is….
PREVENTION OF RESPIRATORY COMPLICATIONS
- Elevate head of bed to 30 degrees
- Ambulate as soon as possible
- Support incision during coughing
- Reduce pain
The patient has difficulty belching after a fundoplication procedure. This is known as…
Gas bloat syndrome
The patient has fever, chest pain, and dyspnea after a fundoplication procedure. The nurse should…
Take immediate action as these are indicative of atelectasis or pneumonia
An obstructed NG tube presents with…
nausea, vomiting, abdominal distention, and cease of tube drainage
The use of a ____________ is used to prevent the fundoplication wrap from becoming too tight around the esophagus
Large bore NG tube
The patient with GERD should be on which type of diet?
Bland (with flare-ups), low fat, high protein
Initial drainage from the NG tube after fundoplication surgery will be ________ but should turn ________ within __________.
dark brown (w/ old blood)
yellowish-green
the first 8 hours
After a LNF, the patient should be on which type of diet?
Soft diet for about a week
Which foods are appropriate for the patient 2 days post-op of an LNF?
- Raw vegetables
- Milkshakes
- Custard/pudding
- Meat
- Mashed potatoes
- Carbonated beverages
2, 3, 5
True or False: The patient who has had an LNF should be advised to not drive for a week after the surgery.
True. Also instruct patients not to drive if taking opioid pain medications.
The patient post-op of an LNF should remove their dressing _____ days after surgery and ________.
2, shower
*Do not remove steri-strips until 10 days after surgery
True or False: The patient post-op LNF should walk every day.
True- instruct patient to avoid heavy lifting
NG tube placement should be checked every __________ hours for proper placement for a post-op LNF patient. The tube should be irrigated frequently to keep it patent and prevent strain or rupture of suture.
4-8
True or False: reposition NG tubes that are out of place for patients post-op LNF
FALSE- RE-INSERTION COULD PERFORATE THE FUNDOPLICATION
The patient may begin ________ when peristalsis is re-established and gradually progresses to a near-normal diet during the first ______ weeks.
clear fluids, 4-6
Why should the nurse supervise initial oral feedings of the LNF post-op patient?
Dysphagia is common.
If dysphagia continues in the LNF post-op patient, the nurse may suspect…
The fundoplication is too tight (dilation is required)
Patients with aerophagia should be taught to….
consciously relax before and after meals, eat and drink slowly, and chew all food thoroughly to prevent the air swallowing.
The doctor will usually prescribe ________ for the first few LNF post-operative weeks until healing is complete.
Stool softeners/bulk laxatives
True or False: The LNF post-op patient should know that gas bloat syndrome and dysphagia are temporary and reflux will now be controlled.
FALSE- gas bloat syndrome and dysphagia may be permanent and reflux may occur again.
Most esophageal tumors are ____________
Malignant (cancerous)
The two primary risk factors associated with the development of squamous cell carcinoma of the esophagus are…
Tobacco use and Alcohol intake
Other risk factors of esophageal cancer are…
- Obesity
- Malnutrition
- GERD (long-term untreated)
- Barrett’s esophagus
- Low consumption of fruits/veggies
- Eating many processed foods
- Genetics
A patient with GERD is most likely to develop which type of esophageal cancer?
Adenocarcinoma
What age and racial/ethnic factors play into esophageal cancer?
Middle-age/Older adults (squamous cells) Black males (squamous cell) White males (adenocarcinoma)
_______ is the most common symptom of esophageal cancer, but may not be present in early stages.
Dysphagia
Other signs and symptoms of esophageal cancer include….
- Sensation of food sticking in throat
- Weight loss of more than 20 pounds in a few months
- Odynophagia
- Halitosis
- Vomiting
- Regurgitation
- Chronic hiccups
- Chronic cough
- Hoarseness
Patients usually have a fear of _______ when they have esophageal cancer.
choking
The first diagnostic test requested to evaluate dysphagia is usually ______________ while the definitive diagnosis of esophageal cancer is made by __________. A ____ may be performed to inspect the esophagus and obtain tissue specimens for disease staging. _______ may be able to identify metastasis and evaluate response to chemotherapy.
Barium swallow study with fluoroscopy
Esophageal ultrasound (EUS)
EGD (esophagogastroduodenoscopy)
PET (positron emission tomography)
The biggest concern for the patient with esophageal cancer is….
Weight loss/inadequate nutrition
Which of these are essential interventions for the patient with esophageal cancer?
- Testing
- Nutrition therapy
- Head of bead elevated to 30 degrees
- Small meals
- Speech and swallowing therapy
- Daily weights
- Semisoft foods and thickened liquids
- Supplements
All but 1, 4
The patient with esophageal cancer begins to cough while eating. This is a concern to the nurse because…
It is a sign of aspiration and can cause airway obstruction or pneumonia
To prepare for swallowing, the patient with esophageal cancer should ______ and place food ________. The nurse should monitor for ________ and ________ and check for _________ after swallowing.
- Chin tuck (put the head forward)
- In the back of the mouth
- Sealing of the lips
- Tongue movements
- Pocketing of food in cheeks
Chemotherapy and radiation are given in the patient with esophageal cancer because….
They shrink tumors and provide the best chance for a cure after surgical resection
This therapy is performed under moderates sedation. Therapy in which the patient is injected with porfimer sodium (Photofrin) which collects in cancer cells. Two days later, a fiberoptic probe with a light tip is threaded into the esophagus through an endoscope and the light activates the Photofrin destroying cancerous cells.
PDT (photodynamic therapy)
Side effects of Photofrin
fever
nausea
constipation
Teaching for patients receiving PDT (photodynamic therapy)
- Avoid sun exposure for 1-3 months
- Sunglasses and protective clothing are necessary at all times
- Chest pain may require pain relief with opioid analgesics
- Tissue particles may be present in sputum
This procedure may be performed as necessary for the patient with esophageal cancer to temporarily, immediately relieve dysphagia
Esophageal Dilation
**PERFORATION IS A RISK
Preoperative care for the patient having an esophagectomy or an esophagogastrostomy include which of these?
- Weight loss
- Increased nutritional support
- Smoking cessation
- NPO status for 2 days
- Meticulous oral care 4x per day
- Complete bowel preparation
2, 3, 5, 6
Pre-op patient teaching for esophageal surgery should include post-op measure including…
- Teach patient about TURNING, COUGHING, DEEP BREATHING, and CHEST PHYSIOTHERAPY
- NG tube purpose
- Need for IV infusion
- Need for J tubes or chest tubes
The highest priority for the patient post-op for esophageal resection surgery is…..
Respiratory care!
The patient is 10 hours post op for esophageal resection. What should the nurse expect?
- Mechanical ventilation for up to 16-24 hours
- Ambulation
- Risk of atelectasis and pneumonia
- Regular diet
1, 3
What are priority interventions for the patient post-op esophageal resection? (5)
- Turning, coughing, and deep breathing every 1-2 hours after extubation
- Assess breath sounds every 1-2 hours
- Provide incisional support and adequate analgesics for effective coughing
- Patient remains in semi/high-Fowler’s
- Ensure chest tube patency and monitor for drainage
If cardiovascular complications due to hypertension occur post-op of an esophageal resection, the nurse should expect to…. and be aware while doing so to look for….
- Replace fluids via IV, assess cardiac system every 2 hours, and be alert for A-Fib
- Monitor for fluid overload (edema, crackles, increased jugular venous pressure)
An anastomotic leak could lead to _______ which leads to _________. This can occur ____ days after surgery. __________ is discontinued until the site of the leak has healed.
- Mediastinitis (inflammation of the mediastinum)
- fatal sepsis
- 2-10
- ALL oral intake
Wound infection usually occurs ____ days after surgery
4-5
The patient is post-op for esophageal resection and the nurse assesses tachycardia and tachypnea. Priority intervention is to…
Report findings immediately (sign of shock).
*** Also report fever, fluid accumulation, and inflammation immediately.
True or False: The nurse should irrigate and reposition the NG tube after esophageal surgery.
FALSE- do not do so unless requested by the surgeon
Initial NG tube drainage is ______ but should change to ______ by _______________.
Bloody, yellowish-green, first post-op day
The nurse is assessing the 2 day post-op esophageal surgery patient. She notes bloody discharge from the NG tube. The nurse should…
Report this finding immediately as it may indicate internal bleeding at the suture line
Oral hygiene should be provided every _____ hours while the NG tube is in place for the patient post-op for esophageal surgery.
2-4
The patient may require initial feedings through ________ for post-op esophageal cancer
J-tube
Before the patient begins oral feedings, a ___________ study is performed to detect…
Cine- esophagram
anastomical leaks, strictures, or signs of aspiration
Post-operative diet teaching for the patient with esophageal cancer includes…
Eat 6-8 smaller meals per day
Fluids taken in between not with meals (to prevent diarrhea)
Patient should remain in upright position
Diarrhea after eating for the patient who has had esophageal cancer is thought to a result of…
Vagotomy syndrome (can occur 20 min- 2hrs after eating and managed with Imodium)
When the patient is discharged to home ______ is the priority and _______ and _________ are used to promote this.
Respiratory care, ambulation, incentive spirometer
_______ are sacs resulting from the herniation of esophageal mucosa and submucosa into surrounding tissue .They may devlop anywhere along the length of the esophagus.
Diverticula
The incomplete or late opening of swallowing muscles can cause high pressure in the hypopharynx leading to _______________
Zenker’s diverticula (most common form)
Signs and symptoms of Zenker’s diverticula
- most common in older adults
- Dysphagia
- Regurgitation
- Bad breath
- Risk for perforation
