theory

Question 1

mild anxiety level physiological

Answer 1

vital signs normal
fairly relaxed
pupils normal

Question 2

mild anxiety level cognitive

Answer 2

thoughts are controlled

broad perceptual field

Question 3

mild anxiety level emotional/behavioural

Answer 3

usual patern

Question 4

moderate anxiety level physiological

Answer 4

vital signs up

headache/muscle tension

Question 5

moderate anxiety level cognitive

Answer 5

alert, perception narrowed, focused , attentive, good concentration.

Question 6

moderate anxiety level behavioural

Answer 6

excited, energized, tense, voice and facial expressions how interest and concern

Question 7

severe anxiety level physiological

Answer 7

fight or flight, tense muscles, vital signs up, urge to void up, diarrhea, dilated pupils, diaphoresis, hearing down, pain sensation down,

Question 8

severe anxiety level cognitive

Answer 8

difficult to concentrate, low attention, on auto pilot

Question 9

severe anxiety level behavioural

Answer 9

threatened and overwhelmed, disassociate behaviours

Question 10

panic attack physiological

Answer 10

exhausted, blood pressure down, poor muscle coordination, minimal hearing and pain sensation

Question 11

panic attack cognitive

Answer 11

scattered, no logical thinking.

Question 12

panic attack behavioural

Answer 12

feel helpless, total loss of control. terrified, competitive, crying.

Question 13

Nursing interventions for someone with anxiety

Answer 13

o Person may use ETOH, sedatives to self-manage symptoms
o Assess sleep patterns and promote sleep hygiene
o Promote physical activity and breathing control
o Promote good nutrition e.g. reduce/ eliminate caffeine
o Promote physical relaxation and breathing control techniques
o SSRI therapy (i.e. paroxetine/paxil; sertraline/Zoloft)

Question 14

Psychological Domain

Answer 14

o Nurses may use tools such as self-reporting scales and the MMSE
o Most effective intervention is teaching a person how to prevent anxiety
o Psychotherapy helps clients discover the basis for their anxiety (i.e. cognitive-behavioural therapy, relaxation techniques, problem solving techniques)

Question 15

o Exposure therapy

Answer 15

tx of choice for agoraphobia, OCD and specific phobias.
o Person is repeatedly exposed to anxiety provoking situations until they become desensitized, thereby reducing/eliminating anxiety

Question 16

o Systemic desensitization

Answer 16

client learns to cope with one anxiety provoking stimulus at a time - focuses on managing the stimulus until it no longer causes anxiety

Question 17

Flooding

Answer 17

used to treat phobias, is performed by experts in this technique, and is the opposite of systematic desensitization. The client is rapidly and repeatedly exposed to the feared object or situation until anxiety levels diminish

Question 18

How to display cultural competency

Answer 18

anxiety is a sign of weakness in some cultures; e.g. ginseng and other Asian herbal remedies can induce panic via ↑HR, ↑ BMR, ↑ BP and diaphoresis.

Question 19

Nursing diagnosis for OCD

Answer 19

Anxiety
Powerlessness
Ineffective verbal communication
Self-esteem disturbance
Impaired social interaction
Risk for injury
Sleep pattern disturbances
Ineffective breathing pattern

Question 20

OCD is characterized by one or both of the following

Answer 20

1. Severe obsessions: repetitive, persistent, intrusive thoughts that are distressing and unwanted. The person cannot control obsessions. The obsessions cause anxiety.
2. Compulsions: repetitive, persistent, ritualistic behaviours. The person is distressed by the behaviours but feels driven to perform the behaviours in order to reduce anxiety.

Question 21

Assessment of someone with a fracture

Answer 21

General assessment
	History and physical assessment
•	Edema and swelling
•	Pain and tenderness
•	Muscle spasm
•	Deformity
•	Ecchymosis or contusion (discoloration of the skin)
•	Loss of function
•	Crepitation 
o	Neurovascular assessment also includes: Skin sensation, colour, and temperature, Pulses at the site and distal to the site

Question 22

• Traction purpose

Answer 22

o	Reduce and immobilize # or dislocation
o	Reduce or eliminate muscle spasm
o	Regain normal length and realignment of an extremity
o	Prevent joint deformity
o	Reduce pain
o	Expand joint space

Question 23

• Amputations and nursing interventions

Answer 23

routine nursing observation, pain control, positioning and exercise, stump conditioning, and patient education.

Question 24

• Amputations

Answer 24

o Pre op: pt and family need to be informed about type of amputation, proposed prosthesis, and post op exercises that will need to be performed and the need to lay prone for 30 min q4h when awake
o If a traumatic amputation, monitor pt for PTSD – have not had time to psychologically prepare for the amputation
o Be alert to possible hemorrhage in the early post op period
 Keep a tourniquet at the bedside

Question 25

Amputations

Answer 25

 Pt not to sit in a chair > 1 hour at a time
 Do not put pillows under the amputated limb
 Lie prone x30 min q4h while awake (unless contraindicated)
 Pt often comes back from OR with a compression bandage applied – must be worn at all times except during bathing and physio – will need to be removed and reapplied several times a day.

Question 26

Amputations

Answer 26

o Avoid dangling the amputated limb
o Teach pt to transfer from bed to chair and actively exercise upper body and limbs to improve strength for ambulation
o Pt will need to learn to balance newly altered body weight
o Prior to discharge, pt needs to learn crutch walking and demonstrate ability to go up and down stairs
o May be fitted for a prosthesis prior to discharge

Question 27

• Complications of fractures

Answer 27

o	Direct complications:
	Osteomyelitis
	Non union of bone fragments 
	Avascular necrosis 
o	Indirect complications:
	Blood vessel and nerve related damage

Question 28

 Compartment syndrome

Answer 28

• Occurs when the pressure within a confined myofascial compartment may become greater than that of the blood vessels in the same compartment. Blood vessels and nerves become compressed. Circulation and nerve transmission in the affected extremity is affected.
• 6 neurovascular “Ps” – pulselessness, pain, paresthesia (pins and needles), pallor, polar, paralysis
• As muscle is destroyed, it releases myoglobin which precipitates a gel like substance that can obstruct the renal tubules → acute kidney failure

Question 29

 Fat embolism; venous thrombosis

Answer 29

• Always aim to prevent it in the first place
• Careful immobilization of long bone #s is key
• Minimal repositioning prior to immobilization of the #
• Treat symptoms should fat embolism occur
• May require intubation if PaO2 cannot be improved
• Pt may develop pulmonary edema, ARDS or both – increased risk of death in this case
 Traumatic or hypovolemic shock

Question 30

• Hip replacement and nursing interventions, what a client can and can not do

Answer 30

o Have patient exercise the unaffected leg and both arms
o Teach pt and family out of bed and chair transfers
o If femoral head prosthesis surgery was performed, pt is at risk for hip displacement up to 6-8 weeks post op. Teach pt and family to avoid > 90 degrees of flexion, adduction or internal rotation during this time:
 Maintain good alignment – abductor splint when turning side to side
 Sandbags, pillows or trochanter rolls can help prevent external rotation
 Teach pt which common activities increase risk for dislocation, e.g. crossing legs or feet, putting on shoes.
 Do not allow hips to be lower than knees – raised toilet seat, no tub baths and no driving

Question 31

Osteoporosis and assessment of

Answer 31

o Characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility, which predisposes the individual to bone fractures at the hip, wrist, and spine.
o Diagnostic
o history and physical examination
o serum calcium, phosphorus, and alkaline phosphatase levels
o Bone mineral densitometry
 Dual-energy x-ray absorptiometry (DEXA)
 Quantitative ultrasonography (QUS)

Question 32

• Osteoporosis clients –diet

Answer 32

o Focus on adequate calcium intake (1000 mg/day in women 19-50 yrs. and men 19-70yrs. 1200mg/day women >50yrs and men >70yrs.)
o Vitamin D aids in calcium absorption
o Foods high in calcium content include whole and skim milk, yogourt, cottage cheese, ice cream, spinach, almonds, and sardines

Question 33

• Strain vs sprain

Answer 33

o Sprain injury:
 R/t stretching or tearing of ligament tissue surrounding a joint
 Classified according to degree of injury: 1st – 3rd degree
 Ankle and wrist are most common sites of injury
o Strain injury:
 R/t twisting or pulling a muscle or tendon
 Also classified according to degree of injury: 1st – 3rd degree strain
o Prevention, Rest, Ice, Compression, Elevation

Question 34

Repetitive strain injury nursing interventions

Answer 34

o Is a cumulative traumatic injury r/t prolonged, awkward, or forceful movements
o Help pt identify precipitating activity and modify the equipment and/or activity
o Provide education re good ergonomics – body mechanics, ergonomic principles for computer use
o Take regular breaks
o NSAIDs, resting the affected area
o Heat and cold applications prn, lifestyle changes
o Physio to strengthen and condition

Question 35

Carpal tunnel syndrome

Answer 35

o The carpal tunnel is formed by the ligaments and bones in the wrist
o CTS results when the median nerve is compressed beneath the transverse carpal ligament.
o CTS is the most common compression neuropathy in the upper extremities
o Ranks second after back injuries as the leading cause of time off work
o Women are more likely than men to develop CTS
o Educate about dangers of continuous repetitive wrist movements
o Teach about ergonomic aids – e.g. keyboards, ergonomic workstation
o May require vocational rehabilitation
o Splint may be ordered for HS or during the day
o Corticosteroid injection into the carpal tunnel may be ordered
o Teach pt to protect hand from injury r/t ↓ sensation
o May need surgical decompression if conservative tx ineffective

Question 36

Vitamin B12 absorption

Answer 36

o Intrinsic factor:
o Secreted by the gastric mucosa
o Needed for Vit B12 to be absorbed
o In pernicious anemia, IF not secreted (autoimmune) causing a Vit B12 deficiency
o VIT B12 plays an important role in the maturation of RBCs

Question 37

• GERD s/s

Answer 37

o S/S
o Heartburn – most common symptom
o Respiratory symptoms – e.g. coughing, sore throat, dyspnea
o Otolaryngeal symptoms – e.g. hoarseness, choking, sore throat, feeling of lump in the throat (globus sensation)
o Regurgitation of food into the esophagus or mouth
o Gastric symptoms – e.g. early satiety, bloating after eating, N&V

Question 38

• GERD diagnosis

Answer 38

o History and physical examination
o Barium swallow (determines if there is protrusion of stomach)
o Endoscopy – can take a biopsy for cytological analysis
o Motility studies
o pH level in the esophagus
o Esophageal pressure studies
o Radionuclide tests – determine rate of esophageal clearance and presence of reflux material in the esophagus

Question 39

Cirrhosis nursing interventions

Answer 39

o No specific therapy for advanced cirrhosis. Tx is aimed at preventing or treating complications
o Rest – helps with fatigue and may ↓ metabolic demands on the liver
o Management of ascites – Na+ restriction (2 grams per day), diuretics. Fluid restriction is not ordered unless ascites is severe
o Paracentesis (draining the fluid from the gut) – only indicated when diuretics are unsuccessful and to relieve SOB or abdominal pain – fluid will re-accumulate, so this tx may be ongoing
o Strict I&O and daily weight and abdominal girth and teach pt and family importance of monitoring same
o Monitor respiratory function for distress r/t acites/edema
o Monitor lab work
o Monitor for bleeding and teach pt importance of doing same
o Nutritional therapy:
o Malnutrition is a more serious complication than hepatic encephalopathy
o protein is not restricted in general (restriction may apply in certain circumstances)
o ↑carb ↓fat ↑calorie (3000kc/day)
o ↓ Na+ if pt has acites (fluid pooled in the gut) or edema
o Teach pt and family about diet and how to read food labels

Question 40

• Gerd nursing interventions

Answer 40

o Conservative tx – inform pt about the importance of lifestyle changes
o Avoid aggravating factors:
o Foods that aggravate symptoms – high fat foods and foods that ↓ lower esophageal sphincter pressure (chocolate, peppermint, coffee, tea)
o Acidic foods – e.g. tomato based foods, orange juice, vinegar
o Milk ↑ gastric acid secretion (milk may help initially but has rebound effect)
o Practice good oral hygiene
o ↑ HOB 30o for 2-3 hours post meals and sleep with HOB ↑
o Loosen belt, no tight clothing around tummy
o Eat smaller, more frequent meals
o Avoid late-evening meals, nocturnal snacking
o Stop smoking – ↓ acid clearance from the lower esophagus
o Adhere to national ETOH drinking guidelines
o Stress management
o Weight reduction if overweight/obese
o Antacids (Maalox, Mylanta)
o Antisecretory agents
 H2-receptor blockers
o Proton Pump Inhibitors (PPI)

Question 41

• Barrett’s esophagus

Answer 41

o Barrett’s esophagus is a condition in which the cells that make up your esophagus begin to look like the cells that make up your intestines
o Precancerous lesions

Question 42

• Peptic ulcer symptoms

Answer 42

o Usually asymptomatic - no pain or other symptoms due to a lack of sensory pain fibres – first symptom may be hemorrhage or perforation
o When pain r/t a duodenal ulcer does exist:
o Is described as burning or cramping
o Is usually felt just below the xypoid process or in the back
o Occurs up to 4 hours after a meal
o Can occur intermittently over time
o When pain r/t a gastric ulcer does exist:
o Is usually described as burning or gaseous
o Is usually felt high in the epigastric region
o Occurs up to 2 hours after a meal

Question 43

Peptic ulcer complications

Answer 43

o Three major complications and all are emergency situations - unstable patient:
o 1. Hemorrhage – duodenal ulcers cause more bleeds than gastric ulcers. Unstable pt – requires RN intervention
o 2. Perforation – more often due to a duodenal ulcer, but mortality is higher if due to a gastric ulcer. Unstable pt – requires RN intervention
o 3. Gastric outlet obstruction – occurs when the ulcer blocks any part of the pylorus due to scarring, inflammation, edema and/or pylorospasm

Question 44

Hemorrhage

Answer 44

o Same as for an upper GI bleed
o NPO; IV, blood transfusion; NG may be ordered; lavage may be ordered
o monitor VS q15-30min
o Monitor NG drainage/emesis and stool for blood
o Use sound clinical judgment before sedating pt if restless – sedatives will mask signs of shock secondary to an upper GI bleed

Question 45

Perforation

Answer 45

o Sudden onset of severe abdominal pain which can be referred to the shoulder (r/t phrenic nerve); boardlike rigid abdomen, no bowel sounds, shallow rapid respirations.
o Peritonitis will usually set in within 6-12 hours if not treated stat
o Collaborative care for perforation
o Immediate focus: stop spillage of gastric or duodenal contents into peritoneal cavity
o Stop all po intake, notify MD stat, monitor VS q15 min, prepare pt for immediate surgery

Question 46

Gastric outlet obstruction

Answer 46

o Generally, already is a long hx of ulcer pain – pain progresses to a more generalized upper abdominal pain, worse at the end of the day after the stomach is full
o Pain is relieved by belching or vomiting; vomiting is projectile and emesis contains undigested food pieces from a day or so before
o Loud peristalsis is audible and visible peristaltic waves can be seen across the abdomen
o Collaborative care for gastric outlet obstruction
o Aim is to decompress the stomach (NG tube), correct fluid and electrolyte imbalances, and improve health status
o Monitor VS, strict I&O
o Turning pt from side to side may help with NG drainage
o Nonsurgical option for pyloric obstruction is to undergo a series of balloon dilations (performed through an endoscope)
o Surgical treatment may be necessary

Question 47

o Postprandial hypoglycemia

Answer 47

r/t uncontrolled gastric emptying of a bolus high in carbohydrate into the small intestine
 Result is hyperglycemia and secretion of excess insulin
 Secondary hypoglycemia occurs and hypoglycemic symptoms are seen about 2 hours after eating

Question 48

o Bile reflux gastritis

Answer 48

r/t the stomach lining’s prolonged contact with bile
 May result in another peptic ulcer
 Symptoms are continuous epigastric discomfort or pain that increases after meals
 Questran (cholestyramine) or aluminum hydroxide may be prescribed

Question 49

• Gastritis and nursing interventions

Answer 49

o Bile reflux gastritis r/t the stomach lining’s prolonged contact with bile
o May result in another peptic ulcer
o Symptoms are continuous epigastric discomfort or pain that increases after meals
o Questran (cholestyramine) or aluminum hydroxide may be prescribed
o Pathophysiology
o Breakdown in the gastric mucosal barrier exposes stomach tissue to HCL and pepsin – result is tissue edema, auto digestion. If blood vessels are eroded, can get hemorrhage

Question 50

Gastritis Contributing factors

Answer 50

o Drugs – e.g. ASA, NSAIDs, digitalis, corticosteroids
o Diet – e.g. large quantities of spicy irritating foods, binge drinking (can result in acute and chronic gastritis)
o Environmental – e.g. smoking; radiation
o Microorganisms – H. pylori and chronic gastritis
o Autoimmune response – H. pylori is often present here
o Bacterial, viral and fungal infections – e.g. salmonella, staph

Question 51

o Clinical manifestations for acute gastritis

Answer 51

o	Anorexia, nausea and vomiting
o	Epigastric tenderness
o	Feeling of fullness
o	Hemorrhage
	Common with ETOH abuse
	May be the only symptom
o	Acute gastritis is self limiting:
	Course lasts hours to a few days
	Usually have complete mucosal healing 
o	Similar to those of acute gastritis
o	Some clients have no symptoms until…
o	Cobalamin is depleted and deficiency takes place
o	This causes anemia and neurological complications

Question 52

o Collaborative care for acute gastritis

Answer 52

o Supportive care similar to that for N&V
o If vomiting, NPO, fluids – dehydration can occur rapidly
o Rest and anti emetics
o NG tube if severe symptoms:
 May be used for lavage or suctioning
o Monitor vital signs closely if hemorrhage is suspected
o If hemorrhaging, provide similar collaborative management as that for an UGI bleed
o Drug therapy – focus is on ↓ gastric mucosal irritants
o Antacids
o Focuses on evaluating and eliminating cause
o Identify and eliminate the specific cause, e.g. if H. pylori, tx with antibiotics
o Determine whether cobalamin (VB12) deficiency anemia is present and tx same (IF may be lost causing a decrease in V B12 absorption)
o Help pt and family identify and eliminate the cause:
o Stop drinking if ETOH related
o Stop taking offending meds if drug related
o Quit smoking
o Non irritating diet and 6 smaller meals/day
o Note: risk for gastric Ca is higher in the person who has chronic gastritis – will need ongoing medical follow-up

Question 53

o Hepatitis A

Answer 53

 Transmission: fecal-oral (most common ingesting contaminated water/food)

Question 54

o Hepatitis B

Answer 54

 Transmission: blood- percutaneous, sexual, perinatal

 Non-infective: breastfeeding, sweat, urine, tears, feces, kissing, hugging, sharing food items

Question 55

o Hepatitis C

Answer 55

 Transmission: percutaneous, perinatal (uncommon)

Question 56

o Clinical Manifestations hepatitis

Answer 56

o Hepatitis is classified into acute and chronic phases:
o Acute phase: (1–4 months)
o Most common symptoms are GI related - anorexia, nausea, vomiting, URQ pain, constipation or diarrhea
o May find food, alcohol and/or cigarettes don’t taste good
o May have non-specific symptoms such as malaise, fatigue, headaches, low grade fever, arthralgia, skin rashes
o May have jaundice (icterus) but also may not – if present, will experience pruritis
o Physical exam may reveal hepatomegaly, lymphadenopathy, or splenomegaly
o Convalescent period of the acute phase lasts up to 4 months and begins when jaundice starts to subside – chief pt complaints during this time are malaise and fatigue

Question 57

Clinical Manifestations hepatitis

chronic

Answer 57

o Disappearance of jaundice does not mean the infection is no longer present
o Most cases of hepatitis B & C result in life long disease
o Many patients have no symptoms, while others may have non-specific symptoms
 Malaise
 Easy fatigability
 Myalgia and arthralgia
 Hepatomegaly
o Note: most cases of acute hepatitis A resolve with no progression to a chronic state

Question 58

o Collaborative care hepatitis

Answer 58

o Symptomatic tx of jaundice
o May require smaller, more frequent meals r/t distaste for food and reported fatigue and nausea
o Daily weight
o Comfort measures to treat pruritis (i.e. lotions, steroids, antipruritic, emollients)
o Provide very good mouth care to help stimulate appetite
o Rest is very important – space pt activities out and assess energy levels; modify activity plan as needed
o No specific treatment or therapy for acute viral hepatitis
o Most clients can be managed at home and emphasis is on resting the body and receiving adequate nutrients
o Drug therapy as ordered
o Teach pt importance of avoiding alcohol and other hepatoxins (e.g. drugs) that will worsen their condition
o Teach pt and family to implement universal precautions (i.e. hand hygiene, teach them about bodily fluids, separate towels, facecloths)
o Teach pt and family the adverse effects of their prescribed medications (Common: malaise, fatigue, irritability, anemia, nausea)
o Teach pt and family S&S of worsening liver function: bleeding tendencies r/t ↑ INR, ascites, and confusion r/t encephalopathy
o Fulminant hepatitis- not common - rapid and severe onset of hepatic failure causing liver necrosis – patient is unstable

Question 59

• Biliary tract obstruction

Answer 59

o Acute cholecystitis:
o Pain in the RUQ (stone is passing through or lodged in the bile duct):
 May be referred to the R shoulder and scapula
 May induce N&V, restlessness and diaphoresis
o Tenderness in the RUQ
o Abdominal rigidity
o Indigestion
o Fever
o If acute episode, focus on:
 Pain control – analgesics as prescribed
 Infection control – antibiotics may be prescribed
 Maintain fluid and electrolyte balance
 NG if N&V are severe
 Anticholinergics to ↓ secretion and counteract smooth muscle spasms
o Pt likely needs fat soluble vitamin supplements if gallbladder disease is chronic
o Bile salts may be prescribed to aid digestion and vitamin absorption
o Cholestyramine may be prescribed - binds with bile salts in the intestine, for excretion by the bowel
o Pts may have fewer symptoms when they eat smaller, more frequent meals
o Teach pt: diet should be low in saturated fats, and high in fibre and calcium

Question 60

o Chronic pancreatitis

Answer 60

o Bland, low-fat, high-carbohydrate diet
o Bile salts – to facilitate absorption of fat soluble vitamins
o Control diabetes if it develops
o Abstain from alcohol
o Pancreatic enzyme replacement (refer to p. 1253)
o Surgery to divert bile flow or relieve ductal obstruction

Question 61

• Role of lactulose in a client with cirrhosis/ encephalopathy

Answer 61

o Acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

Question 62

• Cirrhosis

Answer 62

o The final stage of liver disease
o Is chronic and progressive
o Extensive parenchymal cell degeneration and destruction
o Liver cells attempt to regenerate but process is disorganized, leading to fibrosis (scar tissue)
o Now known that cirrhosis can be reversible because of fibrosis regression (liver can regenerate itself if given a chance)
o 13th leading cause of death in Canada
o Highest incidence between 40–60 years of age
o Twice as common in men

Question 63

o Types of cirrhosis

Answer 63

o Alcoholic cirrhosis (most common) – ETOH is hepatotoxic
o Nutrition related cirrhosis r/t extreme dieting, malabsorption, obesity
o Primary biliary cirrhosis r/t inflammation and destruction of small bile ducts in the liver
o Primary sclerosing cholangitis - chronic inflammation of the liver and bile ducts, is associated with ulcerative colitis
o Cardiac cirrhosis r/t long standing severe R sided heart failure

Question 64

Collaborative Care cirrhosis

Answer 64

o No specific therapy for advanced cirrhosis. Tx is aimed at preventing or treating complications
o Rest – helps with fatigue and may ↓ metabolic demands on the liver
o Management of ascites – Na+ restriction (2 grams per day), diuretics. Fluid restriction is not ordered unless ascites is severe
o Paracentesis (draining the fluid from the gut) – only indicated when diuretics are unsuccessful and to relieve SOB or abdominal pain – fluid will re-accumulate, so this tx may be ongoing
o Liver transplant may be considered
o Prevent and manage gastric or esophageal variceal bleeding
o Pt with bleeding gastric or esophageal varices is unstable
o Balloon tamponade, e.g. Sengstaken-Blakemore Tube
o Vasopressors
o Endoscopic sclerotherapy
o Endoscopic ligation or banding of varices (like varicose veins)
o Shunts: (to keep the pneumonia down.)
o Non-surgical, e.g. insertion of a catheter between the systemic and portal circulation via radiological guidance
o Surgical, e.g. portacaval or distal splenorenal. Surgical shunts are not commonly used today

Question 65

o Management of hepatic encephalopathy

Answer 65

Goal is to ↓ amount of ammonia formed in the body
o Lactulose traps ammonia in the gut and its laxative effect helps expel ammonia from the colon
o Treat other precipitating causes – electrolyte imbalance, acid-base imbalance, hemorrhage, infections
o Strict I&O and daily weight and abdominal girth and teach pt and family importance of monitoring same
o Monitor respiratory function for distress r/t acites/edema
o Monitor lab work
o Monitor for bleeding and teach pt importance of doing same
o Nutritional therapy:
o Malnutrition is a more serious complication than hepatic encephalopathy
o protein is not restricted in general (restriction may apply in certain circumstances)
o ↑carb ↓fat ↑calorie (3000kc/day)
o ↓ Na+ if pt has acites or edema
o Teach pt and family about diet and how to read food labels

Question 66

• Dumping syndrome

Answer 66

o Dumping syndrome r/t ↓ gastric reservoir capacity, is experienced by up to half of all post op pts
o Stomach no longer can control amount of gastric chyme, which is hyperosmolar, from entering the small intestine
o Intestinal juice is slightly alkaline and isotonic with blood plasma
o Large bolus of hyperosmolar chyme entering the small intestine causes significant sudden osmolar fluid shift from plasma into the bowel:
o Following symptoms occur within 15-30 min post meal and last about an hour:
o Generalized weakness, sweating, palpitations, dizziness (r/t sudden ↓ plasma volume)
o Abdominal cramps, hyperactive intestinal peristalsis, urge to defecate

Question 67

Nursing interventions Dumping syndrome

Answer 67

o Diet instruction, rest, and reassurance.
o Recumbent position
Purpose
To slow the rapid passage of food into the intestine; to control symptoms of the dumping syndrome (dizziness, sense of fullness, diarrhea, tachycardia), which sometimes occur following a partial or total gastrectomy
1. Meals are divided into six small feedings to avoid overloading intestines at mealtimes.
2. Fluids should not be taken with meals but at least 30-45 min. before or after meals; this helps prevent distension or a feeling of fullness.
3. Concentrated sweets (e.g. honey, sugar, jelly, jam, candies, sweet pastries, sweetened fruit) are avoided because they sometimes cause dizziness, diarrhea, and a sense of fullness.
4. Protein and fats are increased to promote rebuilding of body tissues and to meet energy needs. Meat, cheese, eggs, and milk products are specific foods to increase in the diet.
5. The amount of time these restrictions should be followed varies. The health care provider decides the proper amount of time to remain on this prescribed diet according to the patient’s clinical condition and progress.

Question 68

• IBS

Answer 68

o Diet therapy – at least 20 grams of fibre daily, avoid gas producing foods, avoid lactose if a causative factor

Question 69

• Appendicitis diet

Answer 69

o If appendicitis is suspected, should become NPO in the event appendicitis is dx’d – surgery immediately follows dx

Question 70

• Peritonitis diet

Answer 70

o More severe cases require surgical intervention and may be placed on TPN due to ↑ nutritional needs

Question 71

• Gastroenteritis diet

Answer 71

o NPO until no longer vomiting

o May require IV fluid replacement

Question 72

• Ulcerative Colitis diet

Answer 72

o ↑ calorie, ↑ protein, ↓ residue diet (Table 45-21, p. 1185) with vitamin and iron supplements or iron injections
o TPN may be ordered during early post op period
o Low Residue (i.e. no porridge)
o Low fibre
o Low spice

Question 73

• Crohn’s Disease diet

Answer 73

o Elemental (liquid) diet
o Parenteral nutrition (may be given pre and post op)
o Diets should be low in residue, roughage, and fat (difficult to digest), high in calories and protein
o Milk free diet may be necessary if damaged intestinal mucosa is unable to digest lactose
o VB12 injections may be needed

Question 74

• Intestinal Obstruction diet

Answer 74

o normal fluid and electrolyte status, and adequate nutrition

Question 75

• Uncomplicated diverticular disease: diet

Answer 75

o High fibre diet, bulk laxatives, increased fluid intake

Question 76

• Acute diverticulitis diet

Answer 76

o IV fluids and antibiotics, NPO, possible colon resection (for abscess, perforation), bedrest
o Oral fluids once acute phase is over, progressing to a semisolid diet
o Ambulatory and home care:
 High-fibre diet, stool softeners, and oral antibiotics

Question 77

• Clients with ileostomy: teaching

Answer 77

o Routinely change appliances, cleanse skin, and inspect stoma and skin
o Empty pouch before it is one-third full
o Use deodorants as needed
o Explain how to contact the enterostomal therapy nurse
o Explain how to obtain additional supplies or accessories
o Ensure access to home health services
2. Teach the following dietary and fluid intake guidelines
o Identify a well-balanced diet and dietary supplements if necessary to prevent nutritional deficiencies
o Identify foods to reduce diarrhea, gas, or obstruction (with ileostomy)
o Identify foods to reduce constipation and gas (with colostomy)
o Drink at least 1500-2000 mL/day of fluid to prevent dehydration (unless contraindicated)
o Increase fluid intake during hot weather, excessive perspiration, or diarrhea to replace losses and prevent dehydration
o Get to know the signs and symptoms of dehydration and when to seek help from a health care provider
o Contact your registered dietitian with any questions
3. Describe potential resources to assist with emotional and psychological adjustment
4. Explain the importance of follow-up care. Report signs and symptoms of the following:
o Fluid and electrolyte deficits (dehydration)
o Fever
o Diarrhea
o Constipation
o Other stoma problems, including a change in appearance of the stoma or its function, a change in the peristomal skin, tenderness, erythema, or pain

Question 78

• Appendicitis

Symptoms

Answer 78

o Persistent, continuous periumbilical pain (pain comes first) followed by anorexia, N&V
o Pain eventually shifts to the RLQ and localized at McBurney point (halfway between the umbilicus and R ileac crest)
o Tenderness on palpation
o Rebound pain
o Guarding
o Patient prefers to lie still
o Low grade fever (not always present)

Question 79

Appendicitis Interventions

Answer 79

o Teach people to seek medical attention if they have abdominal pain. Self tx with laxatives, heating pads, can cause an inflamed appendix to rupture
o If appendicitis is suspected, should become NPO in the event appendicitis is dx’d – surgery immediately follows dx
o Same post op care as for laparotomy
o Usually discharged day 2 if no peritonitis
o Teach pt re symptoms of infection and not to lift > 10 pounds for 3 weeks post laparotomy

Question 80

• Stool characteristics of Crohn’s, ulcerative colitis, other GI diagnosis

Answer 80

o Diverticular disease - Alternating constipation and diarrhea
o Crohn’s disease - Diarrhea, non-bloody, elevated tumor necrosis factor alpha (TNF-α) level
o Ulcerative colitis - Bloody diarrhea
o Gastroenteritis – diarrhea
o Peritonitis - Altered bowel habits may be present
o Irritable bowel syndrome - Diarrhea or constipation

Question 81

• What is a low residue diet

Answer 81

o Purpose
 Low-residue that provides foods low in fibre, which will result in a reduced amount of fecal material in the lower intestinal tract
o General Principles
 This diet eliminates foods that are indigestible or stimulating to the intestinal tract to reduce the amount of residue in the colon. Foods should be included or excluded accordingly.
 Hot and cold foods should be eaten slowly
 Milk products are limited to 2 cups daily. For a more restricted residue diet, milk should be eliminated.

Question 82

Crohns treatment

Answer 82

o Drug therapy
 Is similar to that for ulcerative colitis
 Immunomodulators to inhibit TNF-α
o Nutritional Therapy
 Elemental (liquid) diet
 Parenteral nutrition (may be given pre and post op)
 Diets should be low in residue, roughage, and fat (difficult to digest), high in calories and protein
 Milk free diet may be necessary if damaged intestinal mucosa is unable to digest lactose
 VB12 injections may be needed
o Surgical therapy
 Needed when pts have severe symptoms that do not respond to conservative therapy.
 Surgery does not cure Crohn’s disease - recurrence rate is high

Question 83

Crohns prognosis

Answer 83

o Most pts will require surgery at least once.

Question 84

Colitis treatment

Answer 84

o Drug therapy
 Sulfasalazine
 Salicylate therapy
 Corticosteroids
 Hydrocortisone enemas
 Immunosuppressive (i.e. Imuran)
 Antimicrobial (i.e. flagyl)
o Surgical therapy (Note: 80-85% of pts do not require surgical intervention)
 Total proctocolectomy with permanent ileostomy
 Total colectomy and ileoanal reservoir
• More commonly performed of the two procedures
• Involves up to three operations performed 12 weeks apart and involves a temporary ileostomy (needed while the reservoir heals)
• Have 4-8 pasty stools/day and good daytime continence
• Takes 3-6 months to adjust to the reservoir

Question 85

Colitis prognosis

Answer 85

o the rate of colectomy is low, and most patients achieve remission.

Question 86

• s/s of bowel obstruction

Answer 86

o Vary depending upon the location of the obstruction
 Vomiting if in the small intestine, and may be absent if in the large intestine. May vomit fecal material if the ileocecal valve is incompetent.
 Pain - varies according to location of obstruction
 Abdominal distension if the obstruction is in the lower intestine and minimal to nil if in the upper intestine
 High pitched bowel sounds above the site of obstruction