nurs 360 exam 3 Flashcards
What are the complications for someone following a radical neck dissection with flap reconstruction?
➱ Drop/dysfunction and poor cosmesis (visible neck depression), high mortality
complications with flap –
➡Hemorrhage, hematoma formation, and rupture of the intrajugular vein or carotid artery
➡Chyle Leak (lymphatic leak in the thoracic duct)
➡Neurologic complications: stroke or nerve injury
➡Nutritional status (they can’t eat- must get their nutrition other ways such as NG tube)
What are the assessment findings for someone following a radical neck dissection with flap reconstruction?
➡ Postoperatively: patient is monitored for hemorrhage (raised site), wound infection (leakage [lymphatic fluid, saliva, gastric contents]), and altered respiratory status (airway, breathing, circulation)
★Swelling
★Low O2 sats
★ABC’s; watch for cold and blue flap
➡As they heal: Assess range of motion and determine if there has been a decrease due to nerve or muscle damage. Assess nutritional support.
What are the nursing interventions and nursing considerations for providing nasogastric nutrition?
➡ Management of tube feeding
Insert tube through the nose to the stomach and verify using x-ray and pH testing
✷pH 0-4 gastric
✷pH greater than 4 = in the intestine
✷pH greater than or equal to 5.5 =lungs
➡ Observe the color-gastric aspirate usually cloudy and green but may also be off white, tan, bloody, or brown
➡Flush tube with water or normal saline after feeding and before and after medication are administered through the tube
What would you educate on the client prior to insertion of a nasogastric tube?
Education of tube feeding
➡Signs and symptoms of dumping syndrome: fullness, nausea, osmotic diarrhea, tachycardia,
➡Prevention: give slow the feeding and room temperature feeding, decrease the amount of water you are distilling
➡NG education: patient will gag until the tube is passed the gag reflex
➡Every 4 hours on your tube feeds, 30 mL flush
what assessment findings should you be alert for in patients receiving tube feedings?
➡ tube placement, pt’s position (head elevated 30 degrees
➡ signs of dehydration (dry mucous membranes, thirst, decreases urine output)
➡ signs of infection (to avoid infection, replace any formula given by an open system every 4 to 8 hours with fresh formula; change tube feeding container every 24 hrs)
➡signs of complications ( if suspected, check gastric residual vL before each feeding or in the case of cont. feedings every 4 hours)
➡intake and output
➡weekly weights
what is continuous feeding
slow infusion over long periods, slow feeds usually better tolerated for critically ill, patients who are aspiration risks, patients at risk for for intolerance and small bowel feedings.
When small-bore feeding tubes for continuous infusion are irrigated after administration of medications, a 20-mL or larger syringe is used because the pressure generated by smaller syringes could rupture the tube.
what is intermittent infusion?
➡ Intermittent - Drip
✷Bolus
✷Gravity
Give by bolus; use 20 ml or larger syringe to flush small bore tubes (less pressure, less likely to rupture tubing; The feeding is paused, and the tube is flushed with at least 15 mL of water before and at least 15 mL of water after medication administration (30 mL total). Each medication should be prepared and administered separately, with a 15-mL flush provided between medications.
difference between open and closed feeding system
☆Open ➱needs mixing ➱Change tubing Q24h ➱Can be used for bolus, intermittent or continuous ➱feedings, push, gravity or pump ➱Hang time is usually 4-8 hours
☆Closed ➱pre-filled, premixed ➱needs a pump ➱can hang for 24 hours ➱less risk of infection
What is dumping syndrome? this is a complication of…
this is a complication of enteral nutrition
Formula infused into the small intestine too quickly or formula bypasses the stomach too readily into the small intestine; expansion of the intestinal wall; this leads to bloating, cramping, diarrhea, dizziness, diaphoresis, and weakness
Dumping syndrome- feelings of fullness, nausea, cramping, Disease, diaphoresis, diarrhea
Leads to dehydration, hypotension and tachycardia
Small intestine may adapt better is osmolality is increased slowly.
G tube vs. J tube
➱J tubes good for those who can’t have anything in the stomach but still get food into the gut
✰Typically does not last as long
✰Endoscopically placed gastrojejunal tube in the jejunum for the purpose of administration of nutrition, fluids and medications.
➱G tubes someone can have a G tube for the rest of their life
✰Opening created in stomach, preferred over nasogastric for long term maintenance, (use greater than 4-6 weeks)
✰Preferred in comatose patients because the gastroesophageal sphincter remains closed
Percutaneous endoscopic gastrostomy (PEG) tube
What are the potential problems associated with g tubes and j tubes?
Potential problems
➱Wound infection, cellulitis, and leakage
➱GI bleeding
➱Premature dislodgment of the tube
➱Tube obstruction/clogging
☆Monitoring and managing potential complications by checking for drainage, comitus, and stool Aspiration is a potential risk with tube dislodgement, especially with nasally inserted tubes.
☆Skin care. It is normal to see scant serous drainage a few days post insertion. After approx 1 wk, the site can be cleaned 2x a week with soap and water and left open to air. Candida may appear in warm moist areas of the body.
Complications of enteral feedings
✰ Mechanical tube displacement➱ replace rube
✰ Aspiration➱elevate head of bead, check residual before feeding for intermittent check residual every 4 hour for continuous.
✰ GI (v/d/n)➱ decrease feeding rate, change formula, administer at room temperature
✰ Metabolic hyperglycemia ➱ monitor glucose, osmolality , reduce infusion rate, give insulin if needed
✰ dehydration➱ flush with water or normal saline
✰ formula drug interactions➱ check compatibility, flush tubing prior to and after medication
Nasogastric tube management?
every four hours on your tube feeds, 30mL flush
What is gastritis? What are the symptoms?
➱inflammation of the gastric or stomach mucosa
➱Symptoms: ✰Acute--> possible signs of shock -anorexia -epigastric (rapid onset of symptoms) -hematemesis -hiccups -melena or hematochezia -N/V
✰Chronic–> anemia & fatigue
- belching
- early satiety
- intolerance of spicy or fatty foods
- N/V
- pyrosis
- sour taste in mouth
- vague epigastric
What are the nursing interventions of gastritis?
➱ANITBITOICS, H2, PROTON PUMP ,
Acute gastritis is usually self-limiting, client may have decreased appetite, instruct to avoid EtOH, and food, may need IV fluids, NG tube, intubation, antacids, H2 blockers, PPI’s,
➱Surgery may be needed in necrosis or gastric outlet obstruction
➱Chronic gastritis is managed by diet modification (decrease caffeine), rest, reduce stress, avoid EtOH, NSAIDS, antibiotic for H. Pylori, quit smoking
Nursing interventions:
★No food or fluids by mouth. With IV therapy, monitor I&Os and serum electrolyte values. Introduce solid food as soon as possible, but report any symptoms that indicate repeat episodes of gastritis. Discourage intake of caffeinated beverages, alcohol, and smoking. Administer any pharmacotherapy prescribed.
★Promote fluid balance- monitor daily I&Os, assess electrolyte values every 24 hours. Watch for signs of hemorrhagic gastritis (especially vomiting/defecation of blood)
★Relieve pain- avoid foods or beverages that irritate gastric mucosa. Regularly assess levels of pain/discomfort.
H2 blocker medications examples, MOA, and AE
reduce the amount of acid produced by the cells in the lining of the stomach
cimetidine, famotidine, nizatidine and ranitidine
side effects are cholinergic effects: constipation, dry mouth, dry skin, ringing int he ears, runny nose
How would you manage a GI bleed associated with gastritis and assess if it is getting better or worse?
Erosive gastritis my cause bleeding which may manifest as blood in vomit or as melena (black, tarry stools) or hematochezia (bright red, bloody stools
The nurse must always be alert to any indicators of hemorrhagic gastritis, which include hematemesis (vomiting of blood), tachycardia, and hypotension. All stools should be examined for the presence of frank or occult bleeding. If these occur, the primary provider should be notified, and the patient’s vital signs are monitored as the patient’s condition warrants. Guidelines for managing upper GI tract bleeding are discussed later in this chapter.
Why do we worry about pernicious anemia in clients with gastrointestinal disorders? What are the signs and symptoms of pernicious anemia? How is it treated?
Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. Vitamin B12 deficiency can occur in patients with disorders such as inflammatory bowel disease, or in patients who have had GI surgery such as ileal resection, bariatric surgery, or gastrectomy
signs and symptoms: smooth, sore, red tongue and mild diarrhea, extremely pale, particularly in the mucous membranes, confused; more often, paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception)
treatment: b12 shots once a month
What are the symptoms of peptic ulcer disease? What are the complications? What is perforation and what are the signs and symptoms?
Peptic ulcer disease: excavation formed in the mucosal wall, caused by erosion
Symptoms: dull, gnawing pain or burning sensation in the mid epigastrium or back Pain after eating Pyrosis Vomiting Constipation or diarrhea Bleeding Symptoms often accompanied by sour eructation (burping)
Complications: Hemorrhage Perforation Penetration Gastric outlet obstruction
What are the symptoms of peptic ulcer disease? What are the complications?
Peptic ulcer disease: excavation formed in the mucosal wall, caused by erosion
Symptoms: dull, gnawing pain or burning sensation in the mid epigastrium or back Pain after eating Pyrosis Vomiting Constipation or diarrhea Bleeding Symptoms often accompanied by sour eructation (burping)
Complications: Hemorrhage Perforation Penetration Gastric outlet obstruction
What is perforation and what are the signs and symptoms?
–Perforation
➱Signs and symptoms include:
-Sudden, severe upper abdominal pain (persistent and increasing in intensity); pain may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm
-Vomiting
-Collapse (fainting)
-Extremely tender and rigid (boardlike) abdomen
-Hypotension and tachycardia, indicating shock
How is peptic ulcer disease with h. pylori treated?
Management goal - eradicate H pylori, manage gastric acidity - antibiotics , proton pump inhibitor (“zoles”), and H2 blockers, completing treatment is crucial.
used for 10-14 days.
Maintenance H2 Blockers usually for 1 year post healing.
Combination of antibiotics, proton pump inhibitors, and sometimes bismuth salts that suppress or eradicate H. pylori
Recommended combination drug therapy is typically prescribed for 10-14 days and may include triple therapy with two antibiotics, plus a proton pump inhibitor or quadruple therapy with two antibiotics plus a proton pump inhibitor and bismuth salts
Research currently being conducted for vaccine against H. pylori
Avoid use of NSAIDS
Maintenance dosages of H2 blockers are usually recommended for 1 year
Look at most common antibiotics; know side effects of flagyl
What are preventative measures for “dumping syndrome”?
Dumping syndrome is the rapid passage of food to stomach, causing diaphoresis, diarrhea, hypotension; usually occurs 10-15 minutes after eating ➱ restrict fluids w/ meals ➱ avoid stress after eating ➱eat smaller, frequent meals ➱lie down after eating
Metronidazole aka flagyl
Dizziness, headache, stomach upset, nausea, vomiting, loss of appetite, diarrhea, constipation, or metallic taste in your mouth may occur
education: do not drink alcoholl
