exam 2 chapter 22 Flashcards
The ability of the esophagus to transport food and fluids is facilitated by which two sphincters?
- upper esopharyngeal (hypopharyngeal)
- lower esopharyngeal (gastroesophageal or cardiac)
prevents reflux (backward flow) of gastric contents
difficult swallowing
dysphagia
odynophagia
acute pain on swallowing
Achalasia
absent or ineffective peristalsis of the distal esophagus, accompanied by failure of the sphincter to relax in response to swallowing.
what is the common symptom of achalasia
difficult swallowing fluids and solids.
Pyrosis
chest pain and heartburn.
How is achalasia treated
by pneumatic dilation
RN should instruct patient to eat slowly and drink fluids with meals.
what is a potential complication when pneumatic dilation is performed to treat achalasia?
perforation
what are some reasons GI intubation
decompress stomach fluid or air lavage the stomach and remove toxins administer medicaitons and nutrition treat an obstruction bypass sections of the GI tract to allow them to rest.
what should the suction be when a levine tube is used?
intermittent low wall suction (30 to 40 mm Hg)
To prevent gastric erosion or tearing of the stomach lining.
what are NG tubes such as the Levin used for?
decompression of distended stomach due to air or fluid.
tube feeding is also known as
enteral nutrition
administration of nutritionally balanced liquefied food or formule through tube inserted into stomach, deodenum or jejunum
tube feeding or enteral nutrition
contraindications for gastric feedings
patients at risk of aspiration
patients undergoing gastric surgery
A patient having a pancreatic surgery may have what type of tube?
jejunal tube to rest the pancreas by bypassing the hepatopancreatic ampulla, thereby avoiding the release of digestive enzymes into the duodenum.
when should feeding be started after inserting tube feeding
bowel sounds
x-ray
tube lenght from insertion site to distal end should be measured and recorded.
Tube should be marked at skin insertion site.
insertion lenght should be checked regularly.
tube feeding administration
HOB >30
HOB remains elevated for 30 to 60 minutes for intermittent delivery.
HOB remains semi Fowlers (45) with continuous feeding.
after feeding the HOB remains high fowlers (90) for 30-60 min.
Bolus feeding
resembles normal feedings pattern
300-400 formula over 30 -60 min
given every 3-6 hrs.
continous feeding
for 24 hours period pt remains in semi fowlers position
type of feeing, given over a 8-16 hr period, usually given at night to allow freedom during the day.
cyclic feeding
reasons for cyclic feeding
pt weaned from tube feeding to oral diet
supplements for pt who cannot eat enough.
position of the tube
placement checked before each feeds and medication.
every 8 hours with continuous feeds.
must be checked before administration of any contents.
Tube patency
continuous feedings adminstered on feeding pump with occlusion alarm.
some machines have a water bag that infuses Qhour.
bolus/cyclic irrigated with water before/after each feeding and meication administration.
what do you do with residual and why?
put back
to prevent F&E imbalance
Before feeings
aspirate gastric contents and measure amount of residual
general nursing consideration for tube feeding
daily weights assess for bowel sounds before feedings accurate I&O initial glucose checks Q6 label with date and time started feedings have life of 8-24 hours pump tubing changed Q24 formula room/body temperature.
Tube feeding complications
vomiting diarrhea constipation dehydration aspiration clogged tube
if there is asiration compications
check tube placement
check residual
elevate HOB
when tube is clogged
use liquid medications if possible
flush with 30-50 ml of H2O
flush with H2O Q4h for continuous feeding
Do not crush externed relase!!
two potential problems for tube
skin irritation
pulling out of tube
gerontologic considerations
more vulnerable to complications F&E imbalances glucose intolerance decrease ability to handle large volumes increased risk of aspiration
what is the primary factor in GERD
incompetent LES
what is the results of incompetent LES
results in decrease pressure in distal portion of esophagus.
what happens when there is a decrease pressue in the distal portion of the esophagus
gastric contents move from stomach to esophagus.
it can be due to certain foods (caffeine, chocolate) and drugs (anticholinergics.
meal size and number for a patient with GERD
6-8 small males a day
symptoms of GERD
heartburn(pyrosis)
most common clinical manifestation of GERD
buring
tight sensation felt beneath the lower sternum and spreads upward to throat or jaw
felt intermittenly
relieved by milk, alkaline substances, or water
what are some complications with GERD
- Barrett’s esophagus; replacement of normal squamous epithelium with columner epithelium.
s&s none, to bleeding, to perforation
monitor every2 to 3 years by endoscopy. - Respiratory
due to irritation of upper airway by secretions - Dental erosion
Drug there for GERD
- step up
start with antacids and OTC H2R blockers and progress to prescription H2R blockers and finally PPIs - Step down
start with PPIs and titrate down to prescription H2R blockers and finally OTC H2R blockers and antacids
Histamine (H2) receptor blockers for GERD
remember (tidines) Famotidine (Pepcid) Ranitidine (Zantac) Cimetidine (Tagamet) Nizatidine (Axid)
Suppress secretion of gastric acid (HCl)
when is the best time for the patient to take H2 for GERD
HS (hours of sleep)
to decrease vagally induced histamine release in the stomach
caution with cimetidine
increases bioavailability of many drugs ( beta blockers, morphine, theophyllin, warfarin, dilantin.
passes the blood brain barrier (causes CNS effects)
reacts with antacids
Proton pump inhibitors (PPI) for GERD
REMEMBER (THE PRAZOLES) omeprazole (Prilosec) Esomeprazole (Nexium) Rabeprazole (Aciphex) Pantoprazole (Protonix) Lansoprazole (Prevacid)
PPIs
suppress gastric acid secretion
promotes esophageal healing
may be beneficial in decreasing esophageal strictures
Tx of active ulcer
take 30 minutes before 1st meals of the day
Side Effects: headache, diarrhea, abd pain, nausea
Drug therapy for GERD; Antacids
quick but short lived relief
Neutralize HCl acid
take 1 to 3 hours after meal before bedtime
Allow 1-2 hour between administration of other medications
Aluminum hydroxide preparations (Maalox, alu-cap)
slow-acting
contain lots of NA (caution: renal, CHF, hypertentsion)
may cause constipation
Antacids Calcium carbonate (Mylanta, Tums)
Rapid acting
may cause constipation
SE: belching and flatulence (the release of carbon dioxide in the stomach)
Magnesium hydroxide (Milk of magnesia)
rapid acting
may cause diarrhea
caution in renal (toxicity)
often given in combo with aluminum prep
what is vitamin B12 important for
health of peripheral and central nervous system brain health nerve health RBC production happines
True or false
evidence that C.difficile is higher risk if patient is on PPIs
True
acid zaps food born pathogens
what happens when acid production is blocked
decreases intrinsic factor
Treatment of B12 deficiency
diet ( citrus fruits, dried beans, green leafy veggies, liver, buts, organ meats.
B12 injection weekly at first and monthly for lifelong.
which surgical intervention may be necessary if medical management of GERD is unsuccessful
Nissen fundoplication : wrapping of a portion the gastric fundus around the sphincter area of the esophagus.
herniation of portion of the stomach into esophagus through an opening or hiatus in diaphragm
Hiatal Hernia
AKA: diaphragmatic and esophageal hernia
most common type of hiatal hernia
stomach slides into thoracic cavity when supine, goes back into abdominal cavity when standing upright
Sliding or type 1 hiatal hernia
Paraesophageal Hiatal hernia
Esophageal junction remains in place, but fundus and greater curvature of stomach roll up through diaphragm.
no reflux
pt usually feels a sense of fullness after eating or chest pain
causes of hiatal hernia
structural changes: weakening of muscles in diaphragm. Increased intraabdominal pressure obesity pregnancy heavy lifting tumors ascites
what are some risk factors for esophageal cancer
smoking excessive alcohol intake Barrett's esophagus GERD diets low in fruits and veggies central obesity
what is noted in the latter stages of esophagus cancer
obstruction of the esophagus
possible perforation into the mediastinum and erosion into the great vessels.
what will be the Dx for an EGD that reveals an esophageal lining that is red rather than pink?
Barrett’s Esophagus
saclike outpouching of one or more layers of esophagus
Esophageal diverticula
what is the most common type of esophageal diverticula found most frequently in men than in women?
Zenker’s diverticulum
clinical manifestations by patients with phargngoesophageal pulsion diverticulum
difficulty swallowing fullness in the neck belching regurgitation of undigested food gurgling noise after eating halitosis and sour test in the mouth
True or false? Esophagoscopy contraindicated in patient with esophageal diverticula.
True
because of the danger of perforation of the diverticulum
Blind insertion of NG tube should be avoided.
after a removal of esophageal diverticula (diverticulectomy) what should the nurse monitor for
observed for evidence of leakage from the esophagus
developing fistual.
withhold food and fluids until radiographic studies indicate there is no leakage at the surgical site.
diet begins with liquids and progressed as tolerated.
post op care for esophagectomy
Place patient in a low fowlers position and later in fowlers. monitor for regurgitation and dyspnea. monitor for aspiration and pneumonia Use of IS, sitting in a chair nebulizer treatment monitor temp drainage from cervical neck wound (saliva) evidence of leak DO NOT MANIPULATE NG TUBE!!
what is an excellent marker for malnutrition
prealbumin it has a shorter half life (2 days) does not influence fluid balance normal level 19 to 38 mg/dL should be checked before tube placement
what should be done before placement of NG when patient has head trauma
Evaluated for basilar skull fracture
a pulse pressure of less than 30 mm Hg is indicative of what
fluid volume deficit (FVD)
True or False? Hemoccult test for stool can be used for evaluation of gastric drainage
false
what is the optimal position of central venous access devices (CVADs)
midproximal third of the superior vena cave at the junction of the right atrium.
