Exam 3 Flashcards
Risk Factors for Heme Cancers
Genetic Damage (Ionizing Radiation)
Drug and Chemical Exposures (Benzenes and alkylating agents)
Genetics?
Viruses
Leukemia
Malignant disease of blood forming organs
WBC precursors proliferate in the bone arrow and lymphatic tissue
Leukemia Cell Types
Acute lymphocytic Leukemia
Acute Myeloid Leukemia
Chronic Lymphocytic Leukemia
Chronic Myeloid Leukemia
Acute Leukemia
Rapid Onset and Progression
100% Mortality within days/months if left untreated
Acute lymphocytic leukemia- most common in children, second most common in adults
Acute myeloid leukemia- most common in adults, second most common in children
Chronic Leukemia
Slower onset and progression
Survival weeks/years
-can sometimes change to acute
Leukemia S/Sx
Fatigue, Weakness
Enlarged lymph nodes
Bleeding, bruising, petechiae (Low platelets)
Infection that doesn’t heal, fever
Flu like symptoms that just won’t go away
Upper abdominal pain or feeling of fullness
Sometimes asymptomatic
(Bone marrow is busy making all the leukemia cells, no room to make the normal RBC and platelets. Thromobocytopenia and anemia are often common)
Leukemia Diagonsis
CBC= first thing they look at, blast cells in the WBC differential are NEVER normal, it means the patient has leukemia
Bone marrow aspiration and biopsy
LP for acute lymphocytic leukemia’s (have an affinity for the cerebrospinal fluid)
Leukemia Treatment
Chemo (Induction, consolidation, maintenance)
Radiation
Nursing Diagnoses
Risk for infection Risk for injury Activity intolerance Fatigue Impaired oral mucous membranes Impaired nutrition: less than body requirements Anxiety Risk for disturbed body image Risk for social isolation
Lymphoma Cell Types
Hodgkins (Reed-Sternberg Cell)
Non-Hodgkins (Small cell or large cell)
Hodgkins Lymphoma Signs and symptoms
- Painless enlargement of one or more lymph nodes on one side of the neck (Cervival, Supraclavicular, mediastinal)
- Medastinal Mass
- Pruritis (Severe Itching)
- Pain after drinking alcohol
- “B” symptoms (leads to more aggressive treatment) = Fever, Night sweats, Unintentional weight loss of > 10%
Lymphoma Diagnosis
Rule out of infection first, excisional biopsy of affected lymph node (Reed sternberg cell if present it is always diagnostic of lymphoma), Staging (CXR, CT of chest, abdomen, and pelvis, CBC, Platelets, ESR, bone marrow asipiration and bx)
Lymphoma Treatment
Goal: hodgkins- cure, NHL- control
Radiation therapy - used for early stage hodgkins
Chemotherapy - used for late stage hodgkins and NHL
Bone marrow trasnplant
Multiple Myeloma Histology
Malignancy of plasma cells (most mature forms of B-lymphocytes)
chronic disease with long term survivors but use to be fatal
Multiple Myeloma Epidemiology
Elderly (Mean age of dx is 68yo)
Occupation exposures (Farmers, petroleum workers, woodworkers, leather workers, nuclear industry workers.
Most common hematologic cancer in AA
Multiple Myeloma S/Sx
Bone pain (back or ribs, lytic lesions/osteoporosis on xray, fractures, hypercalcemia)
Renal failure
Fatigue (Anemia)
Headache, Blurred Vision
Multiple Myeloma Treatment
Considered incurable (Sx can be controlled sometimes allowing patients to live for several years, bone marrow transplants have increased the possibilities)
Chemo and RT
Bisphosphonates (Decrease pathological fractures) - aredia, zometa
Plasmapheresis (Remove blood from large chain immune complexes that are produced in cancer cells)
Thalidomide (Anti-myeloma properties)
Nursing Diagnoses for MM
Risk for infection
Risk for injury
Acute/Chronic Pain
Bone Marrow Transplant
Diseases (Leukemias, myeloma, myelodysplastic syndromes)
Eligibility
Types (Autologous (own cells), allogeneic (others cells), stem cell)
Bone Marrow Transplant Process
Bone marrow conditioning -Total body irradiation -Chemotherapy -Monoclonal Antibodies -The goal of the conditioning pase is to completely knock out the patients own bone marrow to allow the body to accept the donor bone marrow Bone marrow harvesting from donor Bone marrow infusion to recipient
Bone Marrow Transplant Supportive Care
- Transfusions (PRBC and platelets)
- Antibiotics (to prevent infection)
- Nutrition (Tube feeding, TPN)
- Strict protective isolation (neutropenic procautions)
Engraftment
When the donor marrow has engrafted into the patient;’s bone and begins producing cells
Uncontrollable Breast Cancer Risk Factors
Female gender Increasing Age Family hx Personal hx hx of bx: atypical hyperplasia Manarche before 12, menopause after 50 Bearing few or no children Having first child after 30 Not breast feeding
Breast Cancer Risk Factors
Increasing age and female sex
High hormone levels for a long period
(Estrogen promotes the growth of about two-thirds of breast cancers)
Family history is less significant, only 5-10% inherited mutations of the brca1and2 gene
Oral contraceptive use, prolonged post-menopausal hormone replacement therapy, and benign proliferative breast disease all increase the risk (Dutal hyperplasia, lobular hyperplasia, and papillomas)
Modifiable Breast Cancer Risk Factors
Sedentary Lifestyle Lack of physical activity Excess weight High Fat Diet - independent of obesity Alcohol consumption
Controllable Breast Cancer Risk Factors
Birth control pills? still in debate Estrogen replacement therapy Not breast feeding Alcohol consumption High Fat Diet Lack of exercise
Breast Cancer Screening
Ages 20-39: prompt reporting of breast changes, physical exam of breasts by physician/NP/PA every three years
Ages 40 and older: prompt reporting of breast changes, PE of breasts every year, screening mammogram every year
Breast Cancer Cell Types
Ductal-Most common
Lobular - Second most common
can either be in situ (still within the area) or infiltrating (worked out into surrounding tissue)
Typical S/Sx of Breast Cancer
Mass (Palpable or Non-Palpable) Nipple Retraction/Inversion Thickening of skin or any change in texture (any unilateral change, new pronounced change) Peau d'orange Dimpling Increased venous prominence Nipple leakage Change in size/shape of breast Pain
Diagnosis of Breast Cancer
SBE
Mammogram (Screening or diagnostic)
Ultrasound (solid from fluid filled or hollow things)
Clinical breast exam
Biopsy of Breast Exam
FNA- Fine needle aspiration
Core needles/stereotactic
Incisional - take out a piece (not very often)
Excisional - take out whole lump
Prognostic Factors
Cell type Hormone receptor status Her-2-neu S-phase Size of tumor Node status Metastatic Work up
Hormone receptor status (Prognostic factors)
Looks at estrogen and progesterone receptors on breast cancer cells (when there is a lot of estrogen and progesterone it helps the cancer grow)
Positive estrogen and progesterone receptor status is a positive prognostic indicator
Treatment of Breast Cancer
Surgery - pretty much always the first treatment Lumpectomy Mastectomy Axillary node dissection Breast reconstruction
Radical Mastectomy
No longer performed
Removed: All breast tissue, underlying muscle, supportive cartilage, lymph node chains
Sentinal Lymph Node Biopsy
Radio-opaque dye is injected at site of tumor
Theorectically, the first nodes for the dye to appear in are the ones deemed most likely to show metastatic disease if present.
Can remove the need for axillary lymph node dissection where a number of nodes are removed
Assessment for Breast Cancer
Physical, Emotional, Psycosocial
Nursing Diagnoses
Anxiety Anticipatory grieving Acute Pain Disturbed body image Sexual dysfunction Fatigue
Care of Drainage tube after BC Surgery
Milk tubing: apply a drop of hand lotion to tubing and slide, pinching tubing between fingers from insertion site to drainage device
Measure drainage
Patient teaching: teach patient family how to change dressings, milk tubing, empty drainage device, and measure drainage
Comfort Measures for after Breast Surgery
HOB Elevated
Arm Elevated
Pain Management
Mobility after breast surgery
ROM exercises- when surgeons okay’s, full ROM essential before beginning radiation therapy
posture and arm support- encourage good posture
Strengthening exercises per surgeons instruction
Lymphedema Prevention after breast cancer surgery
No needle sticks, BP’s, etc in effected arm
Protect arm from injury, burns, stings, sun exposure
No hot tubs/hot baths
Pressure sleeve for air travel
Carry bags/purse on opposite arm
External Beam Radiation Therapy
given over 6-8 weeks, 5days/week. Main side effect is skin burning over the treatment area. fair skinned patients more susceptible, but can happen with any patient. Burn can be anything from a very superficial pinkening of the skin to blistering and desquamation. The burn is usually most severe in the skin fold under the breast and tends to be worse in women with larger breasts
Bachytherapy of Breast Cancer Therapy
Delivered into a balloon that is inserted into the pocket left when the tumor is removed, a catheter extends out of the breast from the balloon and the catheter is attached to a machine which delivers the radiation when attached.
Hormonal Manipulation
Ablation (Bilateral oophorectomy)
Suppression (Androgen therapy)
Selective estrogen receptor modulators (SERM, Tamoxifen, nolvadex)
Aromatase Inhibitors (anastrazole, letrozole)
Hormonal Manipulation Cont.
In tumors which are estrogen and progesterone receptor positive, either stopping the patient’s endogenous production of these hormones or blocking the receptor sites on the breast tissue can reduce the incidence of recurrence after the initial treatment. . This can be achieved by performing a bilateral oophorectomy or suppressing the production of these hormones by administering an androgen such as Lupron. More frequently, however, patients are prescribed either a selective estrogen receptor modulator which fills the hormone receptor sites on the breast cells and prevents the estrogen and progesterone from attaching; or an aromatase inhibitor such as anastrazole or letrozole which inhibit the enzyme aromatase which is partially responsible for the conversion of precursors to estrogen.
Anemia
Decreased RBC and/or decreased hemoglobin
Important to figure out the cause of the anemia
Causes of Anemia
Loss of RBC (Slow GI bleed?)
Decreased production of RBCs (Cancer, toxic substances, etc)
Increased destruction of RBCs
signs and symptoms of anemia
CNS: Fatigue, Dizziness, Vertigo, Depression, Impaired cognitive function
Immune: Impaired T cell and macrophage function
GI: Anorexia, Nausa
Cardio: Exertional dyspnea, tachycardia, palpitations, cardiac enlargement, hypertrophy, increased pulse pressure, systolic ejection murmur, risk of life-threatening cardiac failure
Vascular System: Low skin temp, Pallor of skin mucous membranes, and conjunctival
Gential: Manstrual problems, loss of libido
Signs of Mild Anemia (8-12 g/dl)
Often symptom free, but can have fatigue, tachycardia; palpitations on exertion and dyspnea on exertion
Signs of Severe Anemia (>7.5 g/dl)
Fatigue, decreased ADL’s and role performance, exercise intolerance, dizziness, H/A, mood changes, insomnia, difficulty concentrating, tachycardia, palpitations at rest, systolic ejection murmur, S3 sound, dyspnea at rest, SOB, anorexia, indigestion, menstrual irregularities, loss of sexual desire, male impotence, pallor, hypersensitivity to cold.
Fatigue Related Symptoms
Fatigue, weakness, tiredness, listlessness, low energy, trouble starting tasks, requires assistance, too tired to eat, social limitation, frustration with fatigue, need help with usual activities, need to sleep during the day
Non-Fatigue Related Symptoms
Trouble walking, dizziness, headaches, dyspnea, chest pain, libido, motivation
History assessment for patients with anemia
- Energy, fatigue (0-10 scale)
- Quality of Life
- Weakness
- General malaise
- Medications
- Alcohol intake
- Family history
- athletic activities (injuries?)
- nutritional history
Skin assessment for patients with anemia
Jaundice, pallor, oral mucous membranes (changes in tongue), Angular cheilosis (sores at corner of mouth), Brittle, ridged, concave nails
Cardiac Assessment for patients with anemia
Vital signs (Orthostatic blood pressures)
Murmurs (common with low hemoglobin)
Edema (cardiac failure?)
Lung sounds
GI Assessment for patients with anemia
N/V, anorexia, appetite
Stool for occult blood
Neuro assessment for patients with anemia
Peripheral numbness and paresthesias, ataxia (Uncoordinated movement), coordination, LOC, orientation (as hemoglobin level decreases, mentation will change)
Diagnosis of Anemia
Initial CBC with all RBC indices Iron Study Creatinine Level (Kidney function is important) B 12 Level Folate Level Reticulocyte Count
Understand Reticulocyte count in Anemia
If the number is higher than normal it means the bone marrow is compensating for the anemia, if the number is lower than normal it means the bone marrow is not compensating for the anemia
WBC
Normal: 4500-11,000
Measures: total number of WBCs in peripheral circulation
Causes of high count: Infection, inflammation, autoimmune disorders, leukemia
Causes of low count: prolonged infection, bone marrow suppression
RBC
Hemoglobin
Hematocrit
RBC Normal: 3.0-5.8
Hgb Normal: 11.7-17.4
Hct Normal: 34%- 51%
Causes of high values: chronic anorexia, polycythemia vera
Causes of low values: Decreased production, increased destruction, bleeding
Platelets
Normal: 150-400,000
Measures: number of circulating thrombocytes
Causes of high values: Polycythemia vera, malignancy
Causes of Low values: Bone marrow suppression, autoimmune disease, hypersplenism
Medical Management of Anemia
Therapy depends on: underlying cause, severity, symptoms Transfusion: dont transfuse until hgb <10 on RT) and/or symptomatic Use PRBC (red blood cells that have plasma, WBC and platelets spun out)
Epoietin
Antianemic
RBC Growth Factor
Stimulates erythropoiesis
-the same compound produced by healthy kidneys
50-100 units/kg, IV, or sub-q, three times per week
may decrease bleeding times and require additional heparin
Side Effects: seizures, HTN, H/A, thrombotic events, transient rashes, restored fertility, resumption of menses
Nursing Diagnosis
Fatigue
Activity Intolerance
Nursing Interventions
Adequate diet should be maintained
Nutritional education should be provided to patient and family
Exercise schedule should be followed to maintain condition and increase functional capacity
Conduct lifestyle modifications - rest, help with meals, children, or household chores
Practice restoration activities such as a walk on the beach or sitting in nature
Attend a support group with an education competent to help mange fatigue
Transfusions - Type of Blood Products
Whole Blood (Very rarely given) PRBCs Leukocyte-reduced RBC Washed RBCs Fresh Frozen Plasma Platelets Cryoprecipitate Clotting factors albumin IgG
Transfusion Guidelines
HGB < 8.0 (except for Rt patients <20
OR symptomatic
Transfusion Procedure
Assess labs, confirm transfusion order, make sure permit is signed to give the transfusion, explain the procedure, get some baseline VS, wash hands, standard precautions, prime blood tubing with 0.9 % NS, Start IV with at LEAST 20 gauge needle, obtain blood product from blood bank, start transfusion within 15 minutes of arrival on unit, check blood labels, (ABO/Rh, ID numbers, Patient ID, Expiration date), Check blood for unusual coloration/bubbles, run very slowly the first 15 minutes, observe closely VS every 15-30 minutes, D/C transfusion if not infused within 4 hours, change tubing every 2 units or per policy
Acute Hemolytic Reaction
Cause: administration of incompatible blood, preexisting antibodies against transfused RBCs, resulting in massive hemolysis, improper administration
S/Sx: Fever, chills, nausea, cardivascular collapse, dyspnea, low back pain, chest pain, hemoglobinuria, hypotension, renal failure, DIC, Pain at infusion site
Prevention: strict adherence to policies/procedures, run blood slowly for first 15, administer with ONLY NS
Immediate Onset
Allergic Reaction
cause: mild to severe response to foreign substance
S/sx: flushing, hives, itching, dyspnea, cramps, stridor, LOC, chest pain, HTN, Nausea, Abdominal
Prevention: transfuse plasma-free products, premedicate with antipyretics and/or antihistamine
Onset: First 15 minutes
Febrile Reactions
Cause: Recipient antibodies to donor leukocytes, bacterial contamination, inflammatory cytokine release
S/Sx: Rise in temp 1 degree or greater within two hours, Chills
Prevention: Premedicate with antipyretics, very carefully exam unit of blood for funny looking, get blood in within 4 hours
Onset: first two hours
Bacterial Contamination
Cause: Contamination of blood products during procurment, storage, preparation, or administration
S/Sx: Fever, chills, sepsis
Prevention: Use aspetic technique with collecting, priming, starting IV, Properly store product, change tubing every 4 hours, or after every unit of blood, ensure transfusion takes no longer than 4 hours
Onset: Within first two hours
Circulatory Overload
Too rapid infusion of too much volume
S/Sx: cough, dyspnea, pulmonary congestion, H/A, HTN, Tachycardia, Distended neck veins
Prevention: Adjust transfusion volume and flow rate to patient size and clinical status, cardiac status
Onset: Variable
Transfusion associated graft versus host disease
Allogenic lymphocytes in transfused blood engraft in profoundly immunocompromised patient
S/Sx: Fever, rash, hepatitis, diarrhea, bone marrow suppression, infection
Prevention: Irradiate all blood products
Onset: Variable
Neutropenia
An absolute neutrophil count less than 1,500
-Agranulocytosis = ANC <200
Calculating the ANC
Neutrophils(Segs) + Bands X WBC X 10
60+ 0 X10X10
Risk factors for Neutropenia
Leukemia, Lymphoma, Myelodysplastic Syndrome, Solid tumor with bone marrow metastasis, preexisting neutropenia, prior chemotherapy or RT with inherent bone marrow damage, history of febrile neutropenia, open wounds, active tissue infections, older persons with comorbid conditions who have reduced bone marrow reserve, decreased immune function
Assessment of the neutropenic/ immune compromised patients
VS q4h, skin and mucous membranes, lung sounds, bowel movements, appetite, n/v, LOC, orientation, subtle mental status changes
Symptoms associated with neutropenia-induced infection
organ dysfunction, hypotension, oliguria, pain or irritation at the site of infection, increased exudate from infection site, fever, chills, myalgias or arthralgias, dyspnea, cough, fatigue, anorexia, n/v, constipation, diarrhea, cognitive and mental changes
Usually wont show common signs of inflammation or infection, going to depend on fine tune observations and assessment skills. These are some of the things you might notice, it is different for every person.
Neutropenic Complications
Sepsis: need to catch this quickly, after this they can go into organ failure
Organ failure: Respiratory, renal, multiple organ dysfunction
Fligrastim (Neupogen)
Pegfilgrastim (Neulasta) -Newer longer lasting
Colony stimulating factor
5mcg/kg/day IV or subQ for up to 2 weeks
Binds to and stimulates immature neutrophils t divide and differentiate (Also activates mature neutrophils)
Use cautiously in cancer with myeloid characteristics (these tend to be the people that need it the most, can be used with caution, might stimulate the leukemic cells to start to multiply again) - it allows for higher doses of chemo it brings cell counts up
SE= excessive leukocytosis, pain, redness at SC site, medullary bone pain
Number one Nursing Diagnosis for Neutropenia
Risk for Infection
Nursing Interventions for the Neutropenic Patient
Good handwashing (for everyone), No fresh flowers, fruit, veges, or living plants, no contact with soil, Dont drink water left standing for >15 minutes. No contact with pet litter boxes, avoid crowds and people who are ill, good personal hygiene, wash dishes in dishwasher or VERY hot water, run toothbrush through dishwasher every day or rinse in diluted bleach, use soft bristle tooth brushes, limit number of caregivers, monitor VS and overall condition carefully
Assessment for the thrombocytopenic patient
Skin and mucus membranes, bleeding, bruising, petechiae, fecal occult blood test, ulders, menses, hematuria, change in LOC and orientation, very low platelet count
Risk factors for thrombocytopenia
Hematologic malignancies, myelosuppressive chemotherapy, autoimmune diseases (idiopathic thrombocytopenia prethera), reactions to drugs and chemicals (antibiotics, heparin, pesticides)
S/Sx/Complications of Thrombocytopenia
Bleeding from skin, mucous membranes, and body orifices, easy bruising, petechiae, neurologic changes
Medical management of Thrombocytopenia
Therapy depends on underlying cause, severity, and symptoms.
Platelet transfusion: <20 K or symptomatic, typically put multiple units in one bag, run in as fast as you can, can have reaction to platelets monitor closely, remedicate with acetaminophen and benadryl
Primary nursing diagnosis for thrombocytopenia
Risk for injury
Self care teaching for thrombocytopenia
use electronic razor, use soft-bristled toothbrush, no flossing, no dental work without consulting physician, no ASA, no contact sports, apply ice to injuries for at least 1 hour, notify doc of persistent bleeding, avoid anal intervourse, take stool softener, no enemas or suppositories, no bending at waist, no tight clothing/shoes, do not blow your nose
Nursing interventions for thrombocytopenia
Avoid invasive procedures, unless absolute necessary, no IM, manual BP only, instruct patient to call for help when getting out of bed, aggressively prevent constipation, careful assessment
Hiatal Hernia
is a herniation of stomach through diaphragmatic hiatus causing decompensation of cardiac sphincter
Diverticulum
is an outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature
Perforation
May result from trauma, caustic injury, or puncture during surgical procedure
S/Sx of Hiatal Hernia
Same as esophagitis
PAIN
Pyrosis (heartburn) 30-40 minutes after eating, lying down, no functioning sphincter, can be confused with cardiac chest pain
Risk factors for Hiatal Hernia
Weakness of diaphragm
- genetic predisposition
- congenital
- previous surgeries
Diagnosis of Hiatal Hernia
Barium Contrast Swallow
- Watch Barium pass through the GI tract
- Make sure barium passes (need bowel regimen after, white stool, high risk for severe constipation if doesn’t pass)
Nursing Management of Hiatal Hernia
Teaching, correct taking of medications, diet (avoid what bothers you, most commonly spicy foods and late night meals), frequent small meals, avoid ETOH, Lifestyle same as GERD
Surgical Management of Hiatal Hernia
Nissen fundoplication can be open or laparoscopic usually laparoscopic complications (more with open) -Pneumonia, risk for wound infection
Post Op care of Hiatal Hernia
Respiratory management Chest Tube -NPO -Careful management of NG tube -Assess placement of NG q4h Gradual resumption of diet -stomach will be smaller -specific guidelines what to eat -WNL within 4-6 weeks
Esophageal Injury
Foreign bodies may injure esophagus, chemical burns ma be caused by undissolved medications, strictures caused by medication causes scars
Common Foreign Bodies of Esophageal Injury
Fish bones, popcorn, chicken bones, drinking something corrosive like hydrogen peroxide, undissolved medication
GERD
Gastroesophageal Reflux Disease is caused by back-flow of gastric or duodenal contents into the esophagus, barretts esophagus is believed to occur after untreated GERD. It is precancerous, Benign tumors of the esophagus can arise most common lesion is leiomyoma
GERD Cont.
Pathologic changes in the esophagus associated with long term inflammtion
- Associated with reflux of acid from stomach
- About 30% of population affected in US
- Most common in people >45 years
Predisposing Factors of GERD
Reduced LES pressure Hiatal Hernia H/O of HG intubation >4 days Pyloric Surgery Increased intra-abdominal pressure (pregnancy, big dinners)
Characteristics of GERD
Incompetent LES Irritation from reflux Chronic Inflammation Formation of new tissue (new tissue is abnormal) Fibrosis and scarring Delayed gastric emptying Can cause asthma, and dental decay
Esophagitis
Inflammation of the esophagus caused by backflow of stomach contents through the LES into esophagus
Gastric pH is much lower than esophageal pH
Inflamed esphagus cannot return reflux effectively
Can be first step of GERD
What causes an incompetent LES?
Obestiy
Ingestion of fatty foods, caffeinated beverages
Prolonged NG intubation
S/Sx of GERD, Esphagitis, Hiatal Hernia
Dyspepsia (indigestion) Coughing Dysphagia Chest Pain Belching/flatulence Regurgitation Pyrosis
Diagnosis of GERD
H&P
Barium Swallow
EGD (scope of the track)
24 hour acid monitoring (common in peds)
Risks of Inaction in GERD
Chronic Pain Syndrome
Erosive esphagitis
Esophageal cancer
Control of GERD symptoms and prevention of complications
Medications
Lifestyle changes
Diet therapy
GERD Medication
Antacids
Histamine Receptor Antagonists
Proton Pump Inhibitors
Agents to promote gastric emptying
Nursing Responsibilities GERD: Antacids
Take antacids 2-3 hours after meals
Concern with altering acid-base balance if used excessively (neutralize gastric acid)
Concern with getting to much magnesium, sodium, or calcium
Examples: Maalox, MOM, Sodium Bicarb, Tums
Nursing Responsibilities GERD: Histamine receptor antagonists
Given every 12-24 hours, can be given prescription strength
Tagament interferes with many other drugs and is short acting
Often using OTC
Examples: Pepcid, Axid, Tagamet, Zantac
Nursing Responsibilities GERD: Proton pump inhibitors
Reduce gastric acid production for up to 24 hours
Used with more severe GERD
Take before meals or at bedtime
DO NOT CRUSH (Time released)
Examples: Protonix, nexium, prevacid, prilosec
Nursing Responsibilities GERD: Gastric Emptying Agents
Extrapyramidal s/sx
Not for long term use
Example: Reglan
Diet Modifications for GERD
Small frequent meals and snacks
Do not eat for at least 2 hours prior to bedtime
No carbonated beverages (Causes gas, distended stomach, increase reflux)
Avoid foods that aggravate
GERD Lifestyle Modifications
Sleep with HOB elevated Eat slowly and chew well Avoid heavy lifting avoid tight clothes Gentle exercise Lose weight if obese
Peptic Ulcer Disease
Umbrella Disorder- erosion of the mucosal lining of the stomach and duodenum
Peptic Ulcer Disease (PUD) Pathophys
Break in mucosal barrier
Helicobacter pylori
Ingested Items: NSAIDS, ASA, Steriods, ETOH, Tobacco, caffeine, spicy food?, Familial tendency, chronic pulmonary, chronic renal failure
GUD (Gastric Ulcer Disease)
Larger and deeper Most on lesser curvature Tends to occur after 50yo Main s/sx: pain 30-60 minutes after meals 15% of peptic ulcers Male:Female= 1:1
DUD (Duodenum Ulcer Disease)
Vagal Over-activity and stress can cause Increased amounts of HCl in duodenum Smaller and more shallow Past the pyloric sphincter 80% of peptic ulcers Tends to occur in 30-60 age range Pain 2-3 hours after meals Male: Female = 2-3:1
H. Pylori
Discovered in 1982 Bacteria Common, may be acquired in childhood Easily transmitted Seems to turn on ulcer disease in hostile environment in some people
PUD: Major Complications
May be asymptomatic
Dropping Hgb, extremely tired
Gnawing pain in upper abdomen (usually relieved with food)
Pyrosis
Bleeding
Epigastric tenderness with palpitation
adult patient was a new onset of anemia first place to look is a GI bleed
PUD: Diagnosis
EGD (Scope)
Abdominal Films (Looking for free air, should be no free air outside GI tract)
Barium Swallow (UGI)
H. Pylori (Breath Test or serum antibodies)
PUD: Medical Treatment
Goals: Pain relief (Change diet, and meds) Decrease/remove H.Pylori (antibiotics) Heal ulcerations Reduce chance of reoccurance (Holistic Care)
PUD: Diet
No coffee, tea, dark colas, tobacco, chocolate, alcohol, tomatoes
Milk and other calcium containing fluids actually INCREASE gastrin production which increases HCl secretion
Avoid foods that aggravate
PUD: Drugs
Antacids?
H2 Receptor Antagonists
Acid Pump inhibitors
Antibiotics/anti-infectives
PUD: Complication- Hemorrhage
Erosion through blood vessels
Manifestations: bleeding (hematemesis, melena, coffee ground), Hypovolemia and shock (lab values, first sign is sudden tachycardia)
PUD: Complication- Hemorrhage
Nursing Responsibilites
Insert large bore IV Catheter (18 or greater)
Quickly determine amount of blood lost
Monitor H and H
Insert NG tube
Lavage as ordered: washing out stomach
Prepare for endoscopy
Foley Catheter (measure output precisely)
Monitor VS and Administer O2
Position patient to prevent hypotension and aspiration
PUD: Complications - Perforation
Erosion through the ulcer directly into peritoneum Paritonitis -Bacterial -Chemical Require immediate surgery
PUD: Complications - Penetration
Erosion through the gastric serosa into adjacent structures -Pancreas -Biliary tract -Gastrohepatic omentum Require immediate surgery
Perforation and Penetration Manifestations
Sudden, severe upper abdominal pain, vomiting collapse, tender, boardlike abdomen, hypotension, tachycardia, shock
If someone comes in with these symptoms, first thing you do is take away all food and drink items
Treatment: Surgery
PUD: Complication - Peritonitis
Manifestations : Fever, abdominal pain, paralytic ileus, increased or absents bowel sounds, abdominal distention
Treatment: Antibiotics
Constipation
Abnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem
Increased risk in older age
Perceived Constipation
A subjective problem in which the person’s elimination pattern is not consistent with what he or she believes is normal
-Stools are well within normal limits but the person doesn’t think it is right
Common Causes of Constipation
Diet: Low residue type diet, no fiber/nutritional value
Fluid: Stay well hydrated to keep stool soft
Activity: Decreased
Medications: pain meds, anti-depressants, vitamins/minerals, blood pressure meds, antihistamines
Stressful lifestyle
Medical Conditions that Cause Constipation
Hypothyroidism Depression IBS Pregnancy and Childbirth Weakness Fatigue
Manifestation of Constipation
Fewer than 3 BM per week Abdominal distention Decreased appetite H/A Fatigue Indigestion A sensation of incomplete evacuation -Rectal Pressure Straining at stool Elimination of small volume, hard, dry stools
Complications of Constipation
Hypertension Fecal Impaction Hemorrhoids Fissues -Can become an abscess and in immunocompromised patients it can be very serious Megacolon (bowl loses tone and it is a surgical emergency) Increased intracranial pressure Increased risk for intracranial bleed
Patient learning needs about Constipation
Normal Variations of Bowel Patterns Establishment of normal pattern -responding to the urge to defecate -Establish a regular time to defecate, establish a habit Dietary fiber and fluid intake -eat high residue/high fiber foods (35g/day) -Add bran to diet gradually -Increase fluid intake (2-3 L a day)
High Fiber Foods
Wheat, barley, quinoa, oats, brown rice, flaxseeds, almonds, sunflower seeds, peanuts, walnuts, dried beans, avocados, broccoli, spinach, sweet potatoes, carrots, raspberries, blackberries, pears, apples, oranges, bananas
Learning Needs about Constipation
Exercise and activity -Increase ambulation -Abdominal muscle toning -Semi squatting position to maximize use of abdominal muslces Laxative -Cautious use of stimulant laxatives -Can be habit forming
Bulk Forming Laxative
Good for diarrhea too
Not for people who have trouble swallowing
“swells up”, by using fluid in the GI tract
Metamucil
FiberCon
Lubricant Laxative
Work really well for the elderly, without strength to push the stool out
Mineral Oil
Glycerin Suppositories
Stimulant Laxative
Bisacodyl (Dulcolax)
Senna (Senokot)
Stimulate the peristalsis
Osmotic Agent Laxative
Pull fluid into the GI tract
Miralax
MOM, Magnesium Cirate
Fecal Softener Laxative
Does not stimulate peristlsis
Docusate
often used in conjunction of a stimulate
Diarrhea
Increased frequency of bowel movements (more than 3 per day), increase amount of stool (more than 200g per day), and altered consistency of stool (looseness)
May be acute or chronic Causes include: -Infections -Medications -Tube feedings formulas -Metabolic and endocrine disorders -Various disease processes
Common Causes of Diarrhea
Viral Infections
- Rotavirus
- Norovirus (Cruise Ships)
- Cytomegalovirus
Bacterial Infections
-Food Poisoning
Camptobacter, E.Coli, staph aureus, shigella, salmonella
More causes of diarrhea
Parasitic Infections -Giardia -Cryptosporidium Functional bowel disorders -IBS, Constipation and diarrhea Intestinal Diseases -Chron's disease -Ulcerative colitis -Celiac disease
More causes of diarrhea cont.
Food intolerances -lactose, sorbitol, gluten Medications -Antibiotics, anti-cancer drugs, antacids Tube feeding formula -Too concentrated, too fast Metabolic/endocrine disorders -Hyperthyroidism Neuroendocrine Tumors
Manifestations of Diarrhea
Increased frequency and fluid content of stools Abdominal Cramps Distention Borborygmus Tenesmus (Spasms of the anus) Urgency Incontinence
Complications of Diarrhea
Fluid and electrolyte imbalances Dehydration Cardiac Dysrhythmias Skin Breakdown -Greater incontinence, but still happens if not
Patient learning needs for Diarrhea
Recognition of need for medical treatment
Rest
Diet and Fluid intake (clear liquids, low fiber, low residue, NPO is good for a few hours)
Avoid irritating foods
Perianal skin care
Medications
May need to avoid milk, fat, whole grains, fresh fruit, and veges for a while depending on the cause
Recognition of need for medical treatment of diarrhea
>2 days duration s/sx of dehydration Blood and pus in stools severe pain in abdomen or rectum Fever of >/= 102 Black tarry stools
BRATT Diet
Bananas, Rice, Applesauce, Tea, and Toast (White)
Managing Lactose Intolerance
Eliminate milk and milk products
pretreatment of food with lactase preparations
active culture yogurts help digestion of lactose
supplement vitamin d and calcium
Loperimide (Diarrhea therapy)
inhibits peristalsis/prolongs transit time
direct effect on nerves in intestinal wall
Diminishes loss of F and E
Diphenoxylate/Atropine - Lomotil (Diarrhea Therapy)
Inhibits excess GI motility
Related to opioid analgesics but no analgesic properties, but some sedating properties
Polycarbophil/Fibercon/Metamucil (Diarrhea Therapy)
Takes on water within the bowel lumen to create formed stool, soaks up the extra fluid
Bismuth Subsalicylate / Kaopectate, pepto-bismol (Diarrhea therapy)
Promotes intestinal absorption of F and E
Decreases synthesis of intestinal prostaglandins
Antibiotics and anti-inflammatory agents
Particularly in people with either IBS or other bowel problems and infections
Diverticulum
Sac-like herniations of the lining of the bowel that extend through a defect in the muscle layer
-may occur anywhere in the intestine but are most common in the sigmoid colon
Diverticulosis
Multiple diverticula without inflammation
Diverticulitis
Infection and inflammation of diverticula
Diverticular disease increases with age and is associated with low-fiber diet
-diagnosis is usually by colonoscopy
Maintaining Normal Elimination Pattern
If not inflamed and they just have them
encourage fluid intake of at least 2L/d
Soft foods with increased fiber, such as cooked vegetables
-avoid foods with seeds
Individualized exercise program
-gentle progressing to more strenuous as tolerated
Bulk laxative and stool softeners
Inflammatory Bowel Disease (IBD)
Crohn’s Disease
UIcerative colitis
Assessment of Patient with Inflammatory bowel disease
HH to identify onset, duration, characteristics of pain, diarrhea, urgency, tenesmus, nausea, weight loss, bleeding, and fam hx
Discuss dietary patterns, etoh, caffeine and nicotine
assess bowl elimination patterns of stool
Abdominal assessment
Nursing Diagnoses for Inflammatory Bowel Disease
Diarrhea, acute pain, deficient fluid, imbalanced nutrition, activity intolerance, anxiety, ineffective coping, risk for impaired skin integrity, risk for ineffective therapeutic regimen management
Collaborative problems/Potential Complications of Inflammatory Bowel Disease
Electrolyte Imbalance
Cardiac Dysrhythmias
GI Bleeding with fluid loss
Perforation of the bowel
