Exam 4 Flashcards
Inflammation of the mouth
Stomatitis
Acyclovir is used for what?
Oral herpes if renal function is adequate
How to care for stomatitis
- Rinse every 2-3 hours with warm saline with or without baking soda (Na+HCO3)
- dont use lemon swabs
Statins are used for what?
Oral yeast infections
Develops from long term irritation of the mucous membranes
Non-removable, white rounded, elevated benign → malignant lesions
In patients with HIV, signals conversion to AIDS
Leukoplakia
Considered more likely to become cancerous
Red, velvety lesions on the mucous membranes
Erythroplakia
Lips, tongue, buccal mucosa & oropharnyx
Red, raised, eroded, & non healing for 2 weeks
-90% of oral cancer
Squamous Cell Carcinoma
Occurs on the lips Raised scab Pearly borders Do not metastasize Due to sun
Basal Cell Carcinoma
Malignant lesion of blood vessels Painless Purple nodule Raised Hard palate, gums, tongue, tonsils Mostly seen with AIDS
Kaposi’s Sarcoma
Oral Cancer biopsies
Biopsy
MRI for neural involvement and spread
CT for spread
1% toluidine dye
Oral Cancer Interventions
Oral hygiene every 2 hours when infection/lesions or fresh post-op/ saline or HCO3 rinse
Soft bristle brush - no toothettes
Apply lubricants to the lipsAssess gag reflex before feeding
Feed small bites
Thickened liquids
Semi Fowlers
Preoperative Care for oral cancer
Placement of a temporary tracheostomy, oxygen therapy, and suctioning
Temporary loss of speech because of the tracheostomy
Frequent monitoring of postoperative vital signs
NPO status until intraoral suture lines are healed
Need to have IV lines in place for drug delivery and hydration
Postoperative drug therapy and activity (out of bed on the first postoperative day)
Possibility of surgical drains
Postop Care for oral cancer
Use a non deodorant soap
Add seasonings to food
Rinse chemobrush with H2O2/water or bleach weekly
Inflammation of the salivary glands
Sialadenitis
Chronic autoimmune disease in which a person’s white blood cells attack their moisture-producing glands.
-Can cause Sialadenitis
Sjögrens syndrome
How do you assess for Sialadenitis?
Assess facial nerve (7)
-smile, raise brows, puff cheeks
Sialadenitis interventions
Frequent small sips of water Sialagogues (drugs that promote saliva) -Lemon slices -Fruit flavored candy Glycerin preparations Saline
Failure of muscle to relax
Achalasia
Pouches of pressure in colon
Diverticula
Painful swallowing
Odynophagia
Pyrosis
Heartburn
Eructation
Burp
Endoscopy
Views inside body
Laparoscopy
Incision in abdomen
Laparotomy
Large surgical incision into abdominal wall
Upper esophageal sphincter
Keeps food/secretions from going down windpipe. Conscious control
Lower esophageal sphincter (Cardiac)
Prevents acid from going back up esophagus from stomach. Unconscious control
Pyloric sphincter
Allows stomach contents to enter intestines
EGD
5-20 minute test to examine the lining of the esophagus, stomach, and first part of the small intestine.
Laparoscopic Nissen fundoplication (LNF)
Treats GERD
Tissue in the esophagus is replaced by tissue similar to the intestinal lining.
Barrett’s esophagus
Pt teaching for GERD
4-6 small meals daily Eat slowly Chew thoroughly NPO 2-3 hours before bedtime Avoid culprits No tight clothes Avoid heavy lifting Avoid working in a bent-over position Right side lying while sleeping
Nu interventions for GERD
Elevate HOB about 6 inches Help with smoking and alcohol cessation CPAP if the patient is also obese Elimination of drugs that lower LES pressure Oral contraceptives NSAIDs Anticholinergics Sedatives Nitrates Calcium channel blockers
Drugs that protect gastric mucosa for GERD
Maalox/Mylanta
Carafate/Gaviscon
Pepto-Bismol
Drugs that accelerate Gastric emptying for GERD
Reglan
Drugs that inhibit Gastric Acid Secretions for GERD
Histamine Receptor Antagonists
(Pepcid, Zantac, Tagamet, Axid)
Proton pump inhibitors for GERD
Prilosec, Prevacid, Aciphex, Protonix, Nexium
Why should a pt contact the health care provider after Nissen surgery?
Chest or abdominal pain Bleeding Dysphagia SOB NV
Postop care after Nissen surgery
Assess for return of gag reflex Clear liquids for 24 hours post procedure Soft diet following first 24 hours Avoid ASA/NSAIDS for 10 days Continue GERD meds when possible Use liquid meds when available No NG tubes for a month post procedure
Sliding Hiatal Hernias signs
- Heartburn
- Regurgitation
- Chest pain
- Dysphagia
- Belching
Paraesophageal Hernias signs (rolling)
- Feeling of fullness after eating
- Breathlessness after eating
- Feeling of suffocation
- Chest pain that mimics angina
- Worsening of manifestations in a recumbent position
Preoperative care for hiatal hernia
Prepare the patient for an anatomically high incision (trans-thoracic with chest tube insertion) vs laparoscopic approach
Crush or dissolve simethicone in water and take OTC for bloating
3-6 week activity restriction with open procedures
Use stool softeners/fiber to prevent constipation
Report reflux S&S to healthcare provider
A condition where part of the stomach pushes up through the diaphragm muscle
Hiatal Hernia
How to prevent gas bloat syndrome
No straws, chewing gum, carbonated beverages, gas forming, high fat foods
Postop complications after hiatal hernia
Prevent resp. complications (cough)
Dysphagia is common w/ first feeding
Aerophagia
Swallowing air
Pt teaching for Nissen surgery
Stay on a soft diet for about a week, including mashed potatoes, puddings, custard, and milkshakes; avoid carbonated beverages, tough foods, and raw vegetables that are difficult to swallow.
Remain on antireflux medications as prescribed for at least a month.
Do not drive for a week after surgery; do not drive if taking opioid pain medication.
Walk every day, but do not do any heavy lifting.
Remove small dressings 2 days after surgery, and shower; do not remove Steri-Strips until 10 days after surgery.
Wash incisions with soap and water, rinse well, and pat dry; report any redness or drainage from the incisions to your surgeon.
Report fever above 101° F (38.3° C), nausea, vomiting, or uncontrollable bloating or pain. For patients older than 65 years, report elevations above 100° F (37.8° C).
Schedule an appointment for follow-up with your surgeon in 3 to 4 weeks.
Esophageal tumors
Most are malignant
Metastasize quickly
Smoking and heavy alcohol intake are primary risk factors
Obesity & malnutrition are also risk factors
Low fresh fruit and high nitrosamines are risks
Long term GERD→Barrett’s Esophagus→ adenocarcinoma
Halitosis
Bad breath, present w/ esophageal tumors
Esophageal tumors
Loss of interest in eating and socialization
Fear of choking
Barium swallow for dx
Esophagogastroduodenoscopy (EGD)-visualize
Reports of food sticking in their throat
Esophageal tumor care
Keep the HOB elevated to at least 30o
Remain upright for a few hours after meals
Semi-soft foods and thickened liquids
Swallowing exercises:
Suck on lollipop
Reach for food on lip with tongue
Forward flexion of the head (chin tuck) aids swallowing
Place food in the back of mouth, close lips tight, and use tongue to aid swallowing
Chemotherapy, chemoradiation, radiation, & photodynamic therapy may be used to shrink tumors before excision
Esophageal dilation with stent placement may be used when surgery is not possible
Postop care for esophagectomy
Maintain patent airway
Be vigilant for hypotension
Monitor for fluid volume overload
Monitor for atrial fibrillation – irregular pulse
Monitor for infection
Mediastinitis
Anastomosis leak- NPO until healed
Splint incision during coughing & turning
NG tube – secure, DO NOT IRRIGATE OR REPOSITIONNG drainage should change from red to greenish-yellow by 24 hours
Meticulous oral and nasal care every 2-4 hours
Once oral feedings start ( may be as long as a month) prevent aspiration and reflux
Take liquids between meals rather than with meals due to vagotomy syndrome diarrhea
Teach the patient to continue good pulmonary care and prevent infection
Teach to report temp>101oF, swollen painful neck incision (anastomosis leak)
High calorie& protein soft foods
Provide hospice care information
Preop care for esophagectomy
Prompt smoking cessation 2-4 weeks pre-op
Enhanced nutrition pre-op
Dental visit pre-op to prevent infection followed by meticulous oral care 4x/day
Teaching related to tubes and drains (N/G, Jejunostomy, NG, Chest tube maybe)
Bowel prep
Teaching for respiratory post-op
Manage grief and anxiety
Esophageal Diverticula
Dysphagia Regurgitation (reflux) Nocturnal cough HalitosisMonitor for perforation Small frequent meals Semisoft food Similar to GERD management
Pyloroplasty
Surgery to widen the lower stomach so the contents can empty into the small intestine
Saline lavage
Help keep nasal passages clear by washing out mucous
Vagotomy
Removal of vagus nerve to reduce stomach acid secretion
Prostaglandins
Provide a protective mucosal barrier preventing autodigestion
Erosive gastritis
Acute gastritis short term in response to stimuli resolves over several months
Stress ulcers
-pathogenic break in the protective barrier (H.pylori most common)
Inflammatory process begins
Histamine is released
Vagus nerve is stimulated
Hydrochloric acid then is able to reach and damage the gastric mucosa which causes small vessel injury, edema and more damage.
Nonerosive gastritis
Chronic as a result of mucosal damage, doesn’t resolve easily
-Chronic insult leads to atrophy and thinning of the lining and mucosa
Atrophy leads to decreased acid secretion by the parietal cells causing a loss of intrinsic factor (necessary for B12 absorption)
Increased incidence of cancer
Autoimmune attack on the parietal cells and intrinsic factor
Chronic gastritis type A
Caused by Helicobacter pylori
Chronic gastritis type B
Seen in older adults and is associated with chronic irritation
Atrophic gastritis
Rapid onset of epigastric pain, N/V, hematemesis (vomitting blood), gastric hemorrhage, dyspepsia, anorexia
Pt has what?
Acute gastritis
Vague complaint of epigastric pain relieved by eating,
intolerance of fatty/spicy foods, pernicious anemia (body can’t absorb enough b-12, melena (blood in stool)
Pt has what?
Chronic gastritis
Signs of problems w/ patency/position of NG tube
Pain, fullness, hiccups, tachycardia, hypotension
Postop complications for gastritis
Dumping syndrome (30 min after ingestion)- rapid emptying of gastric contents into the small intestine
Late dumping syndrome (1.5 -3 hours after ingestion) – release of large amounts of insulin
Reflux gastropathy – regurgitation of bile into the stomach. S/S: include pain, vomiting, and early satiety
Delayed gastric emptying – due to mechanical or metabolic factors
Afferent loop syndrome – partial obstruction of the duodenal loop
Carafate for gastritis
Mucosal barrier fortifier (demulcent)
Ph Buffers for gastritis
Antacids
Maalox, Mylanta
Antisecretory drugs for gastritis
Proton pump inhibitors
Generic names end in -prazole
Prilosec, Pervacid, AcidHex
Why give antimicrobials for gastritis?
To eradicate the gram negative H. pylori
Why give postaglandin analogs for gastritis?
To protect the mucosal lining
Cytotec (misoprostol)
Types of peptic ulcer dz
- Gastric
- Antrum - Duodenal
- Upper portion - Stress
Stress ulcers
Acute gastric lesions Follow an acute medical crisis or trauma or NPO status Curling’s ulcer- burns Cushing’s ulcer – increased ICP Bleeding is the major concern
Complications of stress ulcers
Hemorrhage is the most lethal Hematemesis Melena Perforation- emergency Infection & peritonitis Pyloric obstruction Intractability
Signs for stomach ulcers
Tenderness at the midline between the umbilicus and the xiphoid
Right – gastric
Left- duodenal
PUD complications
Rigid, board like abdomen
Coffee ground emesis
Bright red blood hematemesis
Tarry stools
PUD diagnostic tests
Stool H. pylori
Esophagogastroduodenoscopy (EGD)
Nuclear medicine scan
DOC for PUD
PPIs
- Associated with osteoporotic fractures over time
- Reduce efficacy of clopidogrel (Plavix)
GI bleed interventions
Provide oxygen 2 large bore intravenous catheters 0.9% NS RBCs Fresh frozen plasma (FFP) Monitor vs for impending shock Track H&H and coags N/G tube with lavage Left side lying 200-300ml of room temp solution water or saline in and out until clear without clots EGD for embolization of the bleeder Pre: 1 or 2 large bore IVs NPO for 4-6 hours prior Insure consent has been signed Post: VS frequently Assess swallow and gag Clot the bleeder via the femoral approach
Perforation interventions
Fluid & electrolyte replacement
Antibiotics
N/G to suction
NPO
Obstruction interventions
Assess for symptoms of delayed emptying Fullness Distention Post prandial nausea Copious vomiting N/G tube to decompress Monitor for F & E and acid base imbalance Surgical procedures Vagotomy Sub total gastrectomy Pyloroplasty
PUD home care teaching
No NSAIDs following surgery – Teach the patient to read labels as many OTC therapies contain ASA
Gastric cancer
Atrophic gastritis, and intestinal metaplasia are precursors to the adenocarcinoma
Gastric polyps, pernicious anemia, achlorhydria, lead to atrophic gastritis
H. pylori greatest risk factor
Intake of pickled foods, nitrates from processed food, and salt lead to atrophic gastritis
Low fruit/vegetable diet risk
HX of gastric surgery is risk
Incidence is higher in Asians and Asian Americans
Older age is a risk
Spreads vastly and quickly
Lymphatics
Blood
Peritoneal seeding
Direct invasion
Gastric Ulcer Assessment
Adherence to lifestyle to prevent gastritis, eliminate high risk foods
Hx of risk factors
Family Hx of gastric cancer
Indigestion or abdominal, epigastric, or back discomfort
Nausea and vomiting due to obstruction
Weakness, fatigue, anemia
Palpable epigastric mass
Lymphandopathy
Hematochezia
Abnormal liver tests with advanced disease
Gastric cancer interventions
Chemotherapy – multi-agent
Radiation- limited use
Surgical resection is best option for cure but is usually palliative due to late diagnosis
Pre-op
NG tube placement
Nutrition - ? Enteral or parenteral
Review pre-op for patients having abdominal surgery and general anesthesia
Intra-op – gastrectomy, partial gastrectomy or gastroenterostomy
Post- op:
Review post op management of patients with abdominal surgery
Blocked NG tube – hiccups, fullness, tachycardia, hypotension- irrigate or replace per order
Gastric cancer complication-Dumping syndrome
Rapid dumping of food into the small intestines which pulls lots of fluid in as well causing distention. Symptoms occur within 30 minutes of eating Vertigo Tachycardia Syncope Sweating Pallor Palpitations Desire to lay down
Symptoms occurring within 90 min-3 hr are due to high levels of insulin released Diaphoresis Confusion Dizziness Lightheadedness Palpitations High protein/fat & low to moderate carbs in small amounts Octreotide (Sandostatin) 2-3/day
Gastric cancer teaching
Teach the patient to report abdominal bloating and pain, early satiety, vomiting Teach patient signs of pernicious anemia Administer and encourage B12 per orders Monitor for leukopenia and anemia Assess need for end of life care Teach wound management when indicated Teaching related to chemo and radiation therapy Eliminate liquids with meals
Hole or weakness in the abdominal wall through which intestine or other abdominal structure protrudes
Hernia
Strangulated hernia
Blood supply is stopped, EMERGENCY
-bowel sounds may be absent
Hernia assessment findings
Lump or protrusion with or without straining
Lump may disappear when lying down and be present when standing
Truss use teaching
Inspect skin daily, put on before getting out of bed
Herniorrhaphy post op care
No coughing otherwise standard post-operative care No straining/lifting for prescribed time Elevate scrotum Use antibacterial soap Urination may be difficult Males-Stand 1500-25oomL fluid/day Catheterization (In/Out)
Colorectal cancer
Arises from polyps, easily metastasizes to liver
FOBT
2-3 specimens on 3 consecutive days
-avoid red meant, aspirin, vitamin C
What should the stoma look like?
Pink-red, moist, protrude about ¾ inch from the abdominal wall, may be slightly swollen, may have a little bit of blood
Stoma care post op
Stoma should begin to function in 2-4 days.
Phantom rectal pain
Rectal itching
Avoid lifting/straining
Open procedure – no driving for 4-6 weeks
Stool softener
Avoid gas forming foods
Teach patient how to measure stoma and instruct patient to do so at last once a week for the first 6 weeks as the stoma shrinks or when weight changes
Stoma care
1/16-1/8 inch of skin around stoma Trace shape on the wafer and cut out Clip peristomal hair Do not apply lubricants to the area Teach bowel regulation will occur with diet vs irrigation
Paralytic ileus
Obstruction in the intestines due to intestinal muscle paralysis. Non-mechanical
Mechanical Obstruction
Physical blockage
Intestinal Obstruction findings
Plasma leakage due to inflammation→↓vascular volume
F & E imbalance and metabolic alkalosis/acidosis occurs depending on location of obstruction
Strangulation leads to necrosis and perforation
Shock and sepsis may occur
Volvulus
Intestinal Obstruction caused by twisting
Intussusception
A part of the intestine folds into another part
Intestinal Obstruction findings
Borborygmi→ absent distal bowel sounds Distention F&E imbalance with upper obstruction Vomiting bile Alkalosis with vomiting in upper May have acidosis with lower Labs consistent with dehydration ↓Na+, K+, & Cl- due to vomiting CT scan
Non-surgical interventions for intestinal obstructions
NG to LWS/NPO Listen for BS with LWS disconnected Meds to ↑ gastric motility Flatus assessment Assess patency of NG tube every 4 hours Irrigate NG every 4 hr with 30 mL NS or per order Disimpaction and enema F & E replacement based on labs Monitor fluid status every 2-4 hours Blood replacement as needed Manage TPN Oral care Notify MD of pain that changes from crampy/colicky to constant – perforation/peritonitis Opioids are held Semi fowlers
Postop intestinal obstruction surgery
Clamp NG and give clear liquids unless vomiting ensues
Residual checks
Teach S&S of obstruction so they can report recurrence
Teach incision care
Encourage expression of fears and concerns
Harmless unless they bleed or cause pain
Caused by increased abdominal pressure
Hemorrhoids
Hemorrhoid care
Cold packs for comfort Tepid sitz bath OTC topical anesthetics Steroids for itching Moist wipes Dab, don’t wipe High fiber, high fluid intake Stool softeners not laxatives Avoid spicy foods, nuts, alcohol, coffee
Hemorrhoidectomy postop care
Tell the patient who has had surgical intervention for hemorrhoids that the first postoperative bowel movement may be very painful. Be sure that someone is with or near the patient when this happens. Some patients become light-headed and diaphoretic and may have syncope (“blackout”).
monitor for bleeding
Moist heat – sitz baths 3-4 times a day for pain relief
Care for chronic diarrhea
Observe for fungal or yeast infections, which appear as dark red rashes with “satellite” lesions. Obtain prescription for medication if this problem occurs.
IBS assessment
Caffeinated and artificially sweetened drinks
Dairy products, raw fruits, grains cause bloating
Pain in left lower quadrant usual reason for seeking help
Bowel sounds – normal
Hydrogen breath test
IBS interventions
Symptom diary can help identify triggers
30-40g bulk a day to regulates bowels
Medication compliance
Daily probiotic
Appendicitis
Blockage of the lumen results is increased retained secretions, decrease blood flow, and infection
Perforation may occur esp after 48 hours
Peritonitis is life threatening and may occur
Appendicitis pain pattern
Pain may begin anywhere in the abdomen or flank and progress to the RLQ at McBurney’s point
followed by N/V
Appendicitis assessment
Perforation or Peritonitis
Pain that increases with cough or movement and is relieved by bending the right hip or knees
WBC.20,000/mm3
Appendicitis surgery
NPO for surgery and pain management
Open (laparotomy) or closed procedure (laparoscopy)
Closed procedure=less pain, shorter recovery, fewer complications
No laxatives, enemas or heat
Peritonitis
Inflammatory process → third spacing of fluids in the abdomen (7-8L/day) → hypovolemia/shock → organ failure → death
Peristalsis slows or stops
Distended abdomen → respiratory compromise
Peritonitis assessment
Leukocytosis Free air or fluid on X-ray Hiccups Rigid, board-like abdomen (classic) Abdominal pain (localized, poorly localized, or referred to the shoulder or chest) Distended abdomen
Peritonitis implementation
Hypertonic fluids Broad spectrum antibiotics NG & NPO Oxygen Analgesics Monitor for S&S of shock Sterile care for irrigating drains – I&O
Peritionitis surgery postop care
Monitor the patient’s level of consciousness, vital signs, respiratory status (respiratory rate and breath sounds), and intake and output at least hourly immediately after abdominal surgery. Maintain the patient in a semi-Fowler’s position to promote drainage of peritoneal contents into the lower region of the abdominal cavity. This position helps increase lung expansion.
Self-limiting viral or bacterial infection of the small bowel spread by the fecal oral route. Vomiting causes the pathogens to become airborne.
Gastroenteritis
Gastroenteritis causes
Norovirus is the most common and spreads among crowds in close proximity - HANDWASHING
Gastroenteritis implementation
Push fluids
Oral rehydration therapy – fluid and electrolyte replacement
Do not use peristalsis slowing drugs –diphenoxylate hydrochloride (Lomotil)
Administer/teach antibiotics when ordered
Ulcerative Colitis
Widespread inflammation of the rectum and/or colon
Ulcerations occur and abscesses and necrosis form at the ulceration sites
Scarring → narrowed colon and partial obstruction
Flare-ups & remissions
S/S of UC
Colicky pain relieved by defecation
Tenesmus: cramps like you need to defecate
Lab values of UC
↓ H&H
↓albumin
↑ESR
↑C-reactive protein
Meds for UC
Teach patients taking sulfasalazine to report nausea, vomiting, anorexia, rash, and headache to the health care provider. With higher doses, hemolytic anemia, hepatitis, male infertility, or agranulocytosis can occur. This drug is in the same family as sulfonamide antibiotics. Therefore assess the patient for an allergy to sulfonamide or other drugs that contain sulfur before the patient takes the drug. The use of a thiazide diuretic is also a contraindication for sulfasalazine.
UC care
Expect ileostomy drainage in about 24 hours
Drink an additional 500mL/day, increase salt intake and avoid sweating, etc
Monitor for toxic megacolon
Provide written information and healthcare contact numbers
Petroleum based ointments
Chron’s Dz
Inflammatory disease of the small intestine
Flare-ups & remissions
Thickened bowel wall
Develop fistulas
Malabsorption diarrhea → anemia
Obstructions from inflammation and scarring
Chron’s signs
Constant pain RLQ Pain around the umbilicus pre and post BM ↓albumin ↑ESR ↑C-Reactive protein Absent or decreased BS High pitched rushing BS
Chron’s care
3000 cal/day
High cal, high protein, high vitamin, low fiber
Enteral supplements
TPN
Hypokalemia
DehydrationDressing for low output and pouch for high output
Vac dressings to prepare for surgery
Diverticulosis
Pouch like intrusions
Diverticular Dz
Mostly commonly in the sigmoid colon
Food gets trapped, blood supply is decreased, bacteria invade, abscesses form
Bleeding, fistula formation, and obstruction can occur
High luminal pressure may be the cause of the pouching
Diverticular Dz assessment
Diverticulosis usually S&S free unless bleeding or pain develops
Constipation
LLQ pain=diverticulitis
Acute Mental Status change in elders sign of peritonitis
Watching for sepsis and bleeding
Leukocytosis
H&H changes with bleeding
Diverticular Dz dx
Barium contrast X-ray in non acute periods
CT scan
Ultrasound
Diverticular Dz implementation
Teach to seek help Temperature over 101oF Severe for persistent pain >3 days Lower GI bleeding High fiber diet when stable and low fiber with flare ups Rest during acute phases No laxatives or enemas Watch for dehydration Opioid analgesics Broad spectrum antibiotics Stool checks for blood Frequent abdominal assessments Avoid coughing, bending, straining Re-introduce fiber slowly once bowel function returns to normal
