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NUR 360 > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

Risk Factors for Heme Cancers

A

Genetic Damage (Ionizing Radiation)
Drug and Chemical Exposures (Benzenes and alkylating agents)
Genetics?
Viruses

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2
Q

Leukemia

A

Malignant disease of blood forming organs

WBC precursors proliferate in the bone arrow and lymphatic tissue

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3
Q

Leukemia Cell Types

A

Acute lymphocytic Leukemia
Acute Myeloid Leukemia
Chronic Lymphocytic Leukemia
Chronic Myeloid Leukemia

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4
Q

Acute Leukemia

A

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

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5
Q

Chronic Leukemia

A

Slower onset and progression
Survival weeks/years
-can sometimes change to acute

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6
Q

Leukemia S/Sx

A

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)

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7
Q

Leukemia Diagonsis

A

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)

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8
Q

Leukemia Treatment

A

Chemo (Induction, consolidation, maintenance)

Radiation

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9
Q

Nursing Diagnoses

A 
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
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10
Q

Lymphoma Cell Types

A

Hodgkins (Reed-Sternberg Cell)

Non-Hodgkins (Small cell or large cell)

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11
Q

Hodgkins Lymphoma Signs and symptoms

A
  • 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%
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12
Q

Lymphoma Diagnosis

A

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)

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13
Q

Lymphoma Treatment

A

Goal: hodgkins- cure, NHL- control
Radiation therapy - used for early stage hodgkins
Chemotherapy - used for late stage hodgkins and NHL
Bone marrow trasnplant

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14
Q

Multiple Myeloma Histology

A

Malignancy of plasma cells (most mature forms of B-lymphocytes)
chronic disease with long term survivors but use to be fatal

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15
Q

Multiple Myeloma Epidemiology

A

Elderly (Mean age of dx is 68yo)
Occupation exposures (Farmers, petroleum workers, woodworkers, leather workers, nuclear industry workers.
Most common hematologic cancer in AA

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16
Q

Multiple Myeloma S/Sx

A

Bone pain (back or ribs, lytic lesions/osteoporosis on xray, fractures, hypercalcemia)
Renal failure
Fatigue (Anemia)
Headache, Blurred Vision

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17
Q

Multiple Myeloma Treatment

A

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)

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18
Q

Nursing Diagnoses for MM

A

Risk for infection
Risk for injury
Acute/Chronic Pain

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19
Q

Bone Marrow Transplant

A

Diseases (Leukemias, myeloma, myelodysplastic syndromes)
Eligibility
Types (Autologous (own cells), allogeneic (others cells), stem cell)

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20
Q

Bone Marrow Transplant Process

A 
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
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21
Q

Bone Marrow Transplant Supportive Care

A
  • Transfusions (PRBC and platelets)
  • Antibiotics (to prevent infection)
  • Nutrition (Tube feeding, TPN)
  • Strict protective isolation (neutropenic procautions)
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22
Q

Engraftment

A

When the donor marrow has engrafted into the patient;’s bone and begins producing cells

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23
Q

Uncontrollable Breast Cancer Risk Factors

A 
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
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24
Q

Breast Cancer Risk Factors

A

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)

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25
Q

Modifiable Breast Cancer Risk Factors

A 
Sedentary Lifestyle
Lack of physical activity
Excess weight
High Fat Diet - independent of obesity
Alcohol consumption
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26
Q

Controllable Breast Cancer Risk Factors

A 
Birth control pills? still in debate
Estrogen replacement therapy 
Not breast feeding
Alcohol consumption
High Fat Diet 
Lack of exercise
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27
Q

Breast Cancer Screening

A

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

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28
Q

Breast Cancer Cell Types

A

Ductal-Most common
Lobular - Second most common
can either be in situ (still within the area) or infiltrating (worked out into surrounding tissue)

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29
Q

Typical S/Sx of Breast Cancer

A 
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
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30
Q

Diagnosis of Breast Cancer

A

SBE
Mammogram (Screening or diagnostic)
Ultrasound (solid from fluid filled or hollow things)
Clinical breast exam

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31
Q

Biopsy of Breast Exam

A

FNA- Fine needle aspiration
Core needles/stereotactic
Incisional - take out a piece (not very often)
Excisional - take out whole lump

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32
Q

Prognostic Factors

A 
Cell type
Hormone receptor status
Her-2-neu
S-phase
Size of tumor
Node status
Metastatic Work up
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33
Q

Hormone receptor status (Prognostic factors)

A

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

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34
Q

Treatment of Breast Cancer

A 
Surgery - pretty much always the first treatment
Lumpectomy
Mastectomy
Axillary node dissection
Breast reconstruction
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35
Q

Radical Mastectomy

A

No longer performed

Removed: All breast tissue, underlying muscle, supportive cartilage, lymph node chains

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36
Q

Sentinal Lymph Node Biopsy

A

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

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37
Q

Assessment for Breast Cancer

A

Physical, Emotional, Psycosocial

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38
Q

Nursing Diagnoses

A 
Anxiety
Anticipatory grieving
Acute Pain
Disturbed body image
Sexual dysfunction
Fatigue
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39
Q

Care of Drainage tube after BC Surgery

A

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

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40
Q

Comfort Measures for after Breast Surgery

A

HOB Elevated
Arm Elevated
Pain Management

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41
Q

Mobility after breast surgery

A

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

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42
Q

Lymphedema Prevention after breast cancer surgery

A

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

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43
Q

External Beam Radiation Therapy

A

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

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44
Q

Bachytherapy of Breast Cancer Therapy

A

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.

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45
Q

Hormonal Manipulation

A

Ablation (Bilateral oophorectomy)
Suppression (Androgen therapy)
Selective estrogen receptor modulators (SERM, Tamoxifen, nolvadex)
Aromatase Inhibitors (anastrazole, letrozole)

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46
Q

Hormonal Manipulation Cont.

A

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.

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47
Q

Anemia

A

Decreased RBC and/or decreased hemoglobin

Important to figure out the cause of the anemia

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48
Q

Causes of Anemia

A

Loss of RBC (Slow GI bleed?)
Decreased production of RBCs (Cancer, toxic substances, etc)
Increased destruction of RBCs

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49
Q

signs and symptoms of anemia

A

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

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50
Q

Signs of Mild Anemia (8-12 g/dl)

A

Often symptom free, but can have fatigue, tachycardia; palpitations on exertion and dyspnea on exertion

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51
Q

Signs of Severe Anemia (>7.5 g/dl)

A

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.

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52
Q

Fatigue Related Symptoms

A

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

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53
Q

Non-Fatigue Related Symptoms

A

Trouble walking, dizziness, headaches, dyspnea, chest pain, libido, motivation

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54
Q

History assessment for patients with anemia

A
  • Energy, fatigue (0-10 scale)
  • Quality of Life
  • Weakness
  • General malaise
  • Medications
  • Alcohol intake
  • Family history
  • athletic activities (injuries?)
  • nutritional history
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55
Q

Skin assessment for patients with anemia

A

Jaundice, pallor, oral mucous membranes (changes in tongue), Angular cheilosis (sores at corner of mouth), Brittle, ridged, concave nails

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56
Q

Cardiac Assessment for patients with anemia

A

Vital signs (Orthostatic blood pressures)
Murmurs (common with low hemoglobin)
Edema (cardiac failure?)
Lung sounds

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57
Q

GI Assessment for patients with anemia

A

N/V, anorexia, appetite

Stool for occult blood

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58
Q

Neuro assessment for patients with anemia

A

Peripheral numbness and paresthesias, ataxia (Uncoordinated movement), coordination, LOC, orientation (as hemoglobin level decreases, mentation will change)

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59
Q

Diagnosis of Anemia

A 
Initial CBC with all RBC indices
Iron Study
Creatinine Level (Kidney function is important)
B 12 Level
Folate Level
Reticulocyte Count
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60
Q

Understand Reticulocyte count in Anemia

A

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

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61
Q

WBC

A

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

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62
Q

RBC
Hemoglobin
Hematocrit

A

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

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63
Q

Platelets

A

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

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64
Q

Medical Management of Anemia

A 
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)
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65
Q

Epoietin

A

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

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66
Q

Nursing Diagnosis

A

Fatigue

Activity Intolerance

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67
Q

Nursing Interventions

A

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

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68
Q

Transfusions - Type of Blood Products

A 
Whole Blood (Very rarely given)
PRBCs
Leukocyte-reduced RBC
Washed RBCs
Fresh Frozen Plasma 
Platelets 
Cryoprecipitate
Clotting factors
albumin
IgG
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69
Q

Transfusion Guidelines

A

HGB < 8.0 (except for Rt patients <20

OR symptomatic

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70
Q

Transfusion Procedure

A

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

71
Q

Acute Hemolytic Reaction

A

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

72
Q

Allergic Reaction

A

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

73
Q

Febrile Reactions

A

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

74
Q

Bacterial Contamination

A

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

75
Q

Circulatory Overload

A

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

76
Q

Transfusion associated graft versus host disease

A

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

77
Q

Neutropenia

A

An absolute neutrophil count less than 1,500

-Agranulocytosis = ANC <200

78
Q

Calculating the ANC

A

Neutrophils(Segs) + Bands X WBC X 10

60+ 0 X10X10

79
Q

Risk factors for Neutropenia

A

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

80
Q

Assessment of the neutropenic/ immune compromised patients

A

VS q4h, skin and mucous membranes, lung sounds, bowel movements, appetite, n/v, LOC, orientation, subtle mental status changes

81
Q

Symptoms associated with neutropenia-induced infection

A

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.

82
Q

Neutropenic Complications

A

Sepsis: need to catch this quickly, after this they can go into organ failure
Organ failure: Respiratory, renal, multiple organ dysfunction

83
Q

Fligrastim (Neupogen)

Pegfilgrastim (Neulasta) -Newer longer lasting

A

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

84
Q

Number one Nursing Diagnosis for Neutropenia

A

Risk for Infection

85
Q

Nursing Interventions for the Neutropenic Patient

A

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

86
Q

Assessment for the thrombocytopenic patient

A

Skin and mucus membranes, bleeding, bruising, petechiae, fecal occult blood test, ulders, menses, hematuria, change in LOC and orientation, very low platelet count

87
Q

Risk factors for thrombocytopenia

A

Hematologic malignancies, myelosuppressive chemotherapy, autoimmune diseases (idiopathic thrombocytopenia prethera), reactions to drugs and chemicals (antibiotics, heparin, pesticides)

88
Q

S/Sx/Complications of Thrombocytopenia

A

Bleeding from skin, mucous membranes, and body orifices, easy bruising, petechiae, neurologic changes

89
Q

Medical management of Thrombocytopenia

A

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

90
Q

Primary nursing diagnosis for thrombocytopenia

A

Risk for injury

91
Q

Self care teaching for thrombocytopenia

A

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

92
Q

Nursing interventions for thrombocytopenia

A

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

93
Q

Hiatal Hernia

A

is a herniation of stomach through diaphragmatic hiatus causing decompensation of cardiac sphincter

94
Q

Diverticulum

A

is an outpouching of mucosa and submucosa that protrudes through a weak portion of the musculature

95
Q

Perforation

A

May result from trauma, caustic injury, or puncture during surgical procedure

96
Q

S/Sx of Hiatal Hernia

A

Same as esophagitis
PAIN
Pyrosis (heartburn) 30-40 minutes after eating, lying down, no functioning sphincter, can be confused with cardiac chest pain

97
Q

Risk factors for Hiatal Hernia

A

Weakness of diaphragm

  • genetic predisposition
  • congenital
  • previous surgeries
98
Q

Diagnosis of Hiatal Hernia

A

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)
99
Q

Nursing Management of Hiatal Hernia

A

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

100
Q

Surgical Management of Hiatal Hernia

A 
Nissen fundoplication
can be open or laparoscopic 
usually laparoscopic
complications (more with open)
-Pneumonia, risk for wound infection
101
Q

Post Op care of Hiatal Hernia

A 
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
102
Q

Esophageal Injury

A

Foreign bodies may injure esophagus, chemical burns ma be caused by undissolved medications, strictures caused by medication causes scars

103
Q

Common Foreign Bodies of Esophageal Injury

A

Fish bones, popcorn, chicken bones, drinking something corrosive like hydrogen peroxide, undissolved medication

104
Q

GERD

A

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

105
Q

GERD Cont.

A

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
106
Q

Predisposing Factors of GERD

A 
Reduced LES pressure
Hiatal Hernia
H/O of HG intubation >4 days
Pyloric Surgery 
Increased intra-abdominal pressure (pregnancy, big dinners)
107
Q

Characteristics of GERD

A 
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
108
Q

Esophagitis

A

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

109
Q

What causes an incompetent LES?

A

Obestiy
Ingestion of fatty foods, caffeinated beverages
Prolonged NG intubation

110
Q

S/Sx of GERD, Esphagitis, Hiatal Hernia

A 
Dyspepsia (indigestion)
Coughing
Dysphagia
Chest Pain
Belching/flatulence
Regurgitation
Pyrosis
111
Q

Diagnosis of GERD

A

H&P
Barium Swallow
EGD (scope of the track)
24 hour acid monitoring (common in peds)

112
Q

Risks of Inaction in GERD

A

Chronic Pain Syndrome
Erosive esphagitis
Esophageal cancer

113
Q

Control of GERD symptoms and prevention of complications

A

Medications
Lifestyle changes
Diet therapy

114
Q

GERD Medication

A

Antacids
Histamine Receptor Antagonists
Proton Pump Inhibitors
Agents to promote gastric emptying

115
Q

Nursing Responsibilities GERD: Antacids

A

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

116
Q

Nursing Responsibilities GERD: Histamine receptor antagonists

A

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

117
Q

Nursing Responsibilities GERD: Proton pump inhibitors

A

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

118
Q

Nursing Responsibilities GERD: Gastric Emptying Agents

A

Extrapyramidal s/sx
Not for long term use
Example: Reglan

119
Q

Diet Modifications for GERD

A

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

120
Q

GERD Lifestyle Modifications

A 
Sleep with HOB elevated
Eat slowly and chew well
Avoid heavy lifting
avoid tight clothes
Gentle exercise
Lose weight if obese
121
Q

Peptic Ulcer Disease

A

Umbrella Disorder- erosion of the mucosal lining of the stomach and duodenum

122
Q

Peptic Ulcer Disease (PUD) Pathophys

A

Break in mucosal barrier
Helicobacter pylori
Ingested Items: NSAIDS, ASA, Steriods, ETOH, Tobacco, caffeine, spicy food?, Familial tendency, chronic pulmonary, chronic renal failure

123
Q

GUD (Gastric Ulcer Disease)

A 
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
124
Q

DUD (Duodenum Ulcer Disease)

A 
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
125
Q

H. Pylori

A 
Discovered in 1982 
Bacteria
Common, may be acquired in childhood
Easily transmitted
Seems to turn on ulcer disease in hostile environment in some people
126
Q

PUD: Major Complications

A

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

127
Q

PUD: Diagnosis

A

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)

128
Q

PUD: Medical Treatment

A 
Goals:
Pain relief (Change diet, and meds)
Decrease/remove H.Pylori (antibiotics)
Heal ulcerations
Reduce chance of reoccurance (Holistic Care)
129
Q

PUD: Diet

A

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

130
Q

PUD: Drugs

A

Antacids?
H2 Receptor Antagonists
Acid Pump inhibitors
Antibiotics/anti-infectives

131
Q

PUD: Complication- Hemorrhage

A

Erosion through blood vessels
Manifestations: bleeding (hematemesis, melena, coffee ground), Hypovolemia and shock (lab values, first sign is sudden tachycardia)

132
Q

PUD: Complication- Hemorrhage

Nursing Responsibilites

A

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

133
Q

PUD: Complications - Perforation

A 
Erosion through the ulcer directly into peritoneum 
Paritonitis 
-Bacterial
-Chemical
Require immediate surgery
134
Q

PUD: Complications - Penetration

A 
Erosion through the gastric serosa into adjacent structures
-Pancreas
-Biliary tract
-Gastrohepatic omentum 
Require immediate surgery
135
Q

Perforation and Penetration Manifestations

A

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

136
Q

PUD: Complication - Peritonitis

A

Manifestations : Fever, abdominal pain, paralytic ileus, increased or absents bowel sounds, abdominal distention

Treatment: Antibiotics

137
Q

Constipation

A

Abnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem
Increased risk in older age

138
Q

Perceived Constipation

A

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

139
Q

Common Causes of Constipation

A

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

140
Q

Medical Conditions that Cause Constipation

A 
Hypothyroidism
Depression
IBS
Pregnancy and Childbirth
Weakness
Fatigue
141
Q

Manifestation of Constipation

A 
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
142
Q

Complications of Constipation

A 
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
143
Q

Patient learning needs about Constipation

A 
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)
144
Q

High Fiber Foods

A

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

145
Q

Learning Needs about Constipation

A 
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
146
Q

Bulk Forming Laxative

A

Good for diarrhea too
Not for people who have trouble swallowing
“swells up”, by using fluid in the GI tract

Metamucil
FiberCon

147
Q

Lubricant Laxative

A

Work really well for the elderly, without strength to push the stool out
Mineral Oil
Glycerin Suppositories

148
Q

Stimulant Laxative

A

Bisacodyl (Dulcolax)
Senna (Senokot)
Stimulate the peristalsis

149
Q

Osmotic Agent Laxative

A

Pull fluid into the GI tract

Miralax
MOM, Magnesium Cirate

150
Q

Fecal Softener Laxative

A

Does not stimulate peristlsis

Docusate
often used in conjunction of a stimulate

151
Q

Diarrhea

A

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
152
Q

Common Causes of Diarrhea

A

Viral Infections

  • Rotavirus
  • Norovirus (Cruise Ships)
  • Cytomegalovirus

Bacterial Infections
-Food Poisoning
Camptobacter, E.Coli, staph aureus, shigella, salmonella

153
Q

More causes of diarrhea

A 
Parasitic Infections
-Giardia 
-Cryptosporidium
Functional bowel disorders
-IBS, Constipation and diarrhea
Intestinal Diseases
-Chron's disease
-Ulcerative colitis
-Celiac disease
154
Q

More causes of diarrhea cont.

A 
Food intolerances
-lactose, sorbitol, gluten
Medications
-Antibiotics, anti-cancer drugs, antacids
Tube feeding formula 
-Too concentrated, too fast
Metabolic/endocrine disorders
-Hyperthyroidism
Neuroendocrine Tumors
155
Q

Manifestations of Diarrhea

A 
Increased frequency and fluid content of stools
Abdominal Cramps
Distention
Borborygmus
Tenesmus (Spasms of the anus)
Urgency
Incontinence
156
Q

Complications of Diarrhea

A 
Fluid and electrolyte imbalances
Dehydration
Cardiac Dysrhythmias
Skin Breakdown
-Greater incontinence, but still happens if not
157
Q

Patient learning needs for Diarrhea

A

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

158
Q

Recognition of need for medical treatment of diarrhea

A 
>2 days duration
s/sx of dehydration
Blood and pus in stools
severe pain in abdomen or rectum
Fever of >/= 102
Black tarry stools
159
Q

BRATT Diet

A

Bananas, Rice, Applesauce, Tea, and Toast (White)

160
Q

Managing Lactose Intolerance

A

Eliminate milk and milk products
pretreatment of food with lactase preparations
active culture yogurts help digestion of lactose
supplement vitamin d and calcium

161
Q

Loperimide (Diarrhea therapy)

A

inhibits peristalsis/prolongs transit time
direct effect on nerves in intestinal wall
Diminishes loss of F and E

162
Q

Diphenoxylate/Atropine - Lomotil (Diarrhea Therapy)

A

Inhibits excess GI motility

Related to opioid analgesics but no analgesic properties, but some sedating properties

163
Q

Polycarbophil/Fibercon/Metamucil (Diarrhea Therapy)

A

Takes on water within the bowel lumen to create formed stool, soaks up the extra fluid

164
Q

Bismuth Subsalicylate / Kaopectate, pepto-bismol (Diarrhea therapy)

A

Promotes intestinal absorption of F and E

Decreases synthesis of intestinal prostaglandins

165
Q

Antibiotics and anti-inflammatory agents

A

Particularly in people with either IBS or other bowel problems and infections

166
Q

Diverticulum

A

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

167
Q

Diverticulosis

A

Multiple diverticula without inflammation

168
Q

Diverticulitis

A

Infection and inflammation of diverticula

Diverticular disease increases with age and is associated with low-fiber diet
-diagnosis is usually by colonoscopy

169
Q

Maintaining Normal Elimination Pattern

A

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

170
Q

Inflammatory Bowel Disease (IBD)

A

Crohn’s Disease

UIcerative colitis

171
Q

Assessment of Patient with Inflammatory bowel disease

A

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

172
Q

Nursing Diagnoses for Inflammatory Bowel Disease

A

Diarrhea, acute pain, deficient fluid, imbalanced nutrition, activity intolerance, anxiety, ineffective coping, risk for impaired skin integrity, risk for ineffective therapeutic regimen management

173
Q

Collaborative problems/Potential Complications of Inflammatory Bowel Disease

A

Electrolyte Imbalance
Cardiac Dysrhythmias
GI Bleeding with fluid loss
Perforation of the bowel

NUR 360 (2 decks)

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