NUR 170 Exam 4 Study Guide- Galen College of Nursing

Gastroesophageal Reflux Disease (GERD) ○ Patho: backflow of gastric contents into the esophagus. ○ Causes: imcompenent weaken lower esophageal sphincter, increased intraabdominal pressure - (pregnancy, overeating, obesity, HH), pyloric stenosis, certain medications (antihistamines, CCBs sedatives), or mobility disorder. ○ Risk factors: diets that are chronically low in fresh produce. affects all ages- but elderly are more prone to complications , food irritants - Caffeine, chocolate, citrus, tamoties, smoking/tobacco, CCBs, nitrates, mint, alcohol. Medications: anticholinergics (delay gastric emptying), high estrogen/ progesterone, NG tube placement. ○ s/s: Pyrosis (heartburn), epigastric pain, dyspepsia (indigestion), pain and difficulty swallowing (dysphagia), hypersalivation, bitter taste in mouth, regurgitation (aspiration risk), Dry coughing/wheezing (worst at night), belching, nausea, pharyngitis, dental caries (serve). ○ eledery s/s: atypical chest pain, ear, nose throat infections, pulmonary problems (aspiration pneumonia, sleep apnea, asthma) more at risk for developing severe complications- HH and med s/e, barrett's esophagus or erosion ○ Labs: ○ Diagnostics: esophagogastroduodenoscopy (EGD)endoscopy - assess esophagus for s/s of narrowing and ulcers. Esophageal manometry - assesses function and ability of esophagus to squeeze food down and how LES closes. . pH monitoring - measures acid amount in esophagus for 24 hours (small tube stays in esophagus during. ○ Interventions: nutrient therapy is usually enough. ■ Eat 4-6 small meals a day. Low fat - high fiber ■ Limit or eliminate fatty foods, coffee, tea, cola, carbonated drinks , mint, chocolate ■ Reduce or eliminate from your diet any food that increases gastric ■ acid and causes pain ■ Limit or eliminate alcohol and tobacco, and reduce exposure to ■ secondhand smoke**Smoking and alcohol decrease LES pressure and irritate tissues.** ■ Do not eat 2-3 hours before bed ■ Eat slowly and chew your food thoroughly to reduce belching ■ Remain upright 1-2 hours after meals, if possible ■ Elevate HOB 6-12 inches using wooden blocks, or elevate your ■ head using foam wedges. Never sleep flat in bed. ■ If you are overweight, lose weight. ■ Do not wear constrictive clothing. ■ Avoid heavy lifting, straining, and working in a bent-over position. ■ Chew “chewable” antacids thoroughly, and follow with a glass of water ■ Do not take anticholinergics (dalay stomach emptying), NSAIDs (contains acetylsalicylic acid). ■ Surgery: laparoscopic nissen fundoplication (LNF), ○ Medications: Take antacids (calcium carbonate) (when taking wait 1-2 hours before taking H2 blocker, antibiotics, or caratate) , H2 receptor antagonist (IV Famotidine)(reduces gastric acid) , PPIs (IV protonix) (reduces acid, helps esophagus heal, can be given long term, long term use complication = bone fractures; most common in elderly). Prokinetics ( oral metoclopramide) ○ Surgical: extreme cases only - fundoplication, wrapping gastric fundus around sphincter area of esophagus. ○ Complications: Esphogitis - where the esophagus cells start to erode and become inflamed due to acid. Barrett's esophagus - results from exposure to acid and pepsin (sometimes nitrosamines) which changes the cells DNA making them precancerous. Strictures- build up scar tissue in the esophagus causing narrowing. Laryngopharyneal reflux - acid going into the pharynx going into respiratory system causing lung infections, ear infections, coughing. complications are most common in eledery. ● Hiatal Hernia NUR 170 Exam 4 Study Guide- Galen College of Nursing ● Increases risk of GERD because of increase of intra abdominal pressure. It's a hernia that is formed at the top of the stomach near the LES putting pressure on it causing it to not operate properly. ● Types s/s: ○ Sliding: heartburn, regurgitation, chest pain, dysphagia, belching. ○ Paraesophageal: feeling of fullness or breathlessness after eating, feeling of suffocation. Chest pain that mimics angina, s/s worse in recumbent position. ● Patho: (esophageal/ diaphragmatic hernia) portion of stomach herniates through diaphragm into thorax. ● Risk factors: Herniation results from weakening of muscles of diaphragm aggravated by that increase abdominal pressure (pregnancy, ascites, obesity, tumors, heavy lifting) ● Complications: ulceration, hemorrhage, regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with necrosis, peritonitis, mediastinitis. ● Interventions: The most important role of a nurse is health teaching for HH. small frequent meals, avoid eating at night, avoid food irritants. Sleep with the head of the bed elevated 6 inches, remain upright for several hours, avoid straining or excessive exercise, and avoid restrictive clothing. Teach patients and families that they need to follow a strict diet and exercise and should reduce body weight to reduce intra abdominal pressure. ● Medications: avoid anticholinergics (delay stomach emptying) ● Herniation ● Patho: weakness in abdominal muscle wall through which a segment of bowel protrudes ● Causes: congenital or acquired muscle weakness and increased intra abdominal pressure contribute to hernia formation. ● Types: ● Assessment: patient should be lying down and then assess when patient is standing. If hernia is reducible it may disappear when the patient is lying flat. Listen for bowel sounds (absence = GI obstruction) ● Interventions: truss- pad with firm support for people who can’t have surgery. Herniorrhapy - replaces contents of the hernia sac into the abdominal cavity and closing the opening. Hernioplasty - reinforces the weakened muscular wall with a mesh patch. ○ Pre/post care: avoid coughing - but deep breath. Inguinal repair - wear scrotal support and elevate scrotum with pillow in bed. Avoid bowel or bowel distension by - stimulating voiding techniques (standing them up), avoid constipation ( avoid straining during healing) ● Intestinal obstruction = compromises elimination ● Patho: an obstruction can be partial or complete and can occur in either the small or large intestine. ● Types and s/s: ○ Small: abdominal discomfort or pain by visible waves in middle abdomen, upper or epigastric abdominal distention, nausea, profuse vomiting, obstipation, sever F&E imbalances, metabolic alkalosis. ○ Large: intermittent lower abdominal cramping, lower abdominal distention, no vomiting, constipation or ribbon like stools, sometimes metabolic acidosis. ○ Diagnostics: no definitive test to confirm. CT scan , abdominal ultrasound ● Interventions: decompress GI tract by inserting a gastric tube (oral or nasal) ** must check placement, patency, output every 4 hours. Assess for peristalsis by auscultating for bowel sounds with suction off** monitor nasal skin around the tube. ● It is a surgical emergency when this is an obstruction with compromised blood flow. ● Perforation: Sudden change in abdominal pain from dull to sharp or local to generalized may indicate a perforation. Inform MD ASAP of pain, VS & o2 sat. perforation is an emergency. Peptic Ulcer Disease ● Patho: Ulcer formation in the upper GI that affects lining of the stomach . The ulcers form due to gastric acid and pepsin and breakdown of defenses (prostaglandins - release bicarbonate, control acid amount secreted; bicarbonate of the mucosa = protect lining of the stomach) that protect the stomach lining which signals to the parietal cells to release more HCL acid which erodes the stomach lining further. . ● Causes: ○ H. Pylori (spiral shaped bacteria that releases urease that breaks down urea into ammonia which neutralizes acid = breaks down mucosa) spread from food or drink - fecal to oral, ○ NSAID usage (aspirin, Ibuprofen, etc) reduces production of prostaglandins which black prostaglandins which protect stomach mucosa lining which causes break down. ○ Zollinger- ellison syndrome - tumor formation that over secretes acid. ● Risk factors: smoking, alcohol, genetics. Food and stress do not play a role. ● Types of ulcers ○ Gastric: found inside the stomach ■ s/s: food makes pain worse. indigestion, epigastric pain, aching or dull pain occurs 30- 60 mins after meals. Weight loss. Hematemesis (vomiting blood- coffee grounds or bright red) ○ Duodenal: found inside the duodenum (1st part of small intestine) ■ s/s: food makes pain better. indigestion, epigastric pain, growling pain 1.5-3 hours after a meal and during the night - usually wakes them up. Melena (tarry dark stools) ● Assess: VS bowel sounds, tenderness, stool, vomit, history of H pylori ● Diagnostics: EGD, CT scan with contrast , upper GI series (barium). Tests to test for H pylori. ○ After EGD monitor VS, heart rhythm, and O2 sat frequently until they return to baseline. Frequently assess patient’s ability to swallow saliva. The gag reflex might be absent after EGD because of the numbing spray. After the procedure do not give the patient any food or liquids until gag reflex is back. ● Interventions: avoid alcohol, caffeine, spicy, acidic, fried foods, chocolate, smoking. Get rest and reduce stress. ● Medications: antacids, H2 receptor antagonists (IV famotidine) , PPIs (IV protonix) to decrease gastric secretions. Administer anticholinergics - reduce gastric mobility. Administer mucosal barrier protectant (oral sucralfate) 1 hr before each meal. Administer Flagyl (no alcohol before 2 days or 2 days after taking) Avoid aspirin and NSAIDs (block prostaglandins). If meds dont work gastric bypass is necessary ● Complications: ○ Active GI Bleeding:increased HR, decreased BP, weak, plale, low hematocrit and hemoglobin. Dark tar stools or bright red vomit. NPO and administer IV fluids. Monitor i&o. Monitor labs: hemoglobin and hematocrit. Administer blood transfusions. ○ Recongize that priority care with GI bleed is to maintain ABCs. respond to these needs by providing oxygen and ventilation as needed, starting 2 large bore IV lines for replacing fluids and blood, and monitoring VS, hematocrit, and O2 sat. ○ Perforation (leads to peritonitis) = erodes hole in the lining letting juices leak into the abdominal cavity. Increased RR, increased HR fever. ○ Bowel blockage ○ Call MD ASAP: sharp, sudden, persistent epiggastric/abdominal pain. Bloody/black stools. Vomit blood that looks like coffee grounds. ● Surgical interventions: gastrectomy- removal of stomach with attachment of esophagus to the jejunum or duodenum. ○ Post-op interventions: monitor VS, high fowler’s position for comfort and promote drainage. Administer fluids and electrolyte replacements IV, I&O output. Assess bowel sounds. Monitor NG suction, NPO. 6 small bland meals a day when bowel sounds return. Monitor for dumping syndrome. ○ After surgery avoid any OTCs containing aspirin or other NSAIDs. Emphasize the importance of following treatment for H.pylori, the ulcer, and keeping follow up ap