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Nursing Assessment for GERD
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Nursing interventions for GERD/Hernias
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Hesi Final NR142
| Question | Answer |
|---|---|
| Nursing Assessment for GERD | Heartburn after eating that radiates to shoulders/arms, feeling of fullness/discomfort after eating, positive diagnosis (several episodes) determined by fluroscopy or barium swallow, gastroscopy |
| Nursing interventions for GERD/Hernias | small, frequent meals; eliminate irritating foods; sit up while eating & 1 hr after; stop eating 3 hrs before bed; elevate HOB on blocks; teach meds |
| What position should patient be in? | Fowlers/Semi fowlers reduces amt of regurgitation and preventing stomach tissue upward thru diaphragm opening |
| Teaching for GERD | difference btw hernia & MI Symptoms, be alert for aspiration possibility; teach meds |
| Peptic Ulcer | ulceration that pentetrates mucosal wall of GI tract |
| Causes of PUD | H pylori, stress, drugs (NSAIDS, corticosteroids), alcohol, smoking |
| Symptoms of PUD | Belching, bloating, epigastric pain radiating to back & relieved by antacids, melena |
| Potential Complications of PUD | Hemorrhage, obstruction, perforation |
| Interventions for PUD | symptom onset/relief; monitor COCA of stools, test for occult blood;small freq meals, no bedtime snacks, no caffeine, |
| When do you give sulcrafate, a mucosal healing agent? | 1-2 hrs after meals and one hour before bedtime |
| Dumping syndrome postop of stomach surgery | secondary to rapid entry of hypertonic food into jejunum pulls water out of bloodstream, occurs 5-30 mins post eating; symptom: vertigo, syncope, swewating, pallor, tachycardia; |
| interventions for dumping syndrome | minimized by small freq meals high protein/low fat/low carb diet; do not consume liquids with meals, do not lie down after eating |
| Avoid what medicines to prevent PUD? | salicylates, NSAIDS, corticosteroids in high doses, reserpine, anticoags |
| Teach symptoms of GI Bleed such as? | dark tarry stools, coffee ground emesis, bright red rectal bleeding, fatigue, pallor, severe abd pain (indicates perforation), Decreased BP, rapid pulse, cool extremities, abd mass/bruit, |
| Stress & PUD | Stress can cause or exacerbate ulcers. teach stress reduction & those with family hx must obtain medical follow up |
| Patho of Crohns disease | chronic inflammation thru entire intestinal mucosa w/periods of remission & exacerbation. occurs teenage/childhood. no cure just tx. with meds |
| Assessment of Crohns Disease | abdominal pain unrelieved by defecation, diarrhea, steatorrhea, weight loss, constant fluid loss, low grade fever, perforation of intestine d/t inflammation |
| interventions for Crohns | bowel elimination pattern, control diarrhea. low residue/low fat /high protein/high calorie diet. vitamin suppl. provide bowel rests, I/O, serum electrolytes, weight 2x week, |
| Teaching for clients w/crohns | avoid diarrhea causing foods ie dairy & spicy foods, avoid smoking, caffeine, pepper, alcohol, |
| patho Ulcerative colitis | superficial mucosa of colon causing bowel to narrow, shorten, and thicken. sigmoidoscopy/colonoscopy tests, |
| Water loss in GI tract | 100-200ml/day but filters 8L |
| Assessment for UC | diarrhea, abd pain, intermittent tenesmus/rectal bleeding, liquid stools w/blood, mucus & pus, anemia |
| NI for UC | bowel pattern/Control diarrhea, low residue/low fat/high protein/high cal diet, no dairy, avoid spicy or diarrhea causing foods, I&O, electrolytes, emotional support |
| Opiate drugs and GI motility | depresses so must be given with care & monitored |
| Diverticulitis | Inflammed pouches in intestinal wall. can lead to bowel perforation |
| Assessment for Diverticulitis | left lower quadrant pain, increased flatus, rectal bleeding, signs of intestinal obstruction, |
| Signs of intestinal obstruction | constipation altering with diarrhea, abd distention, anorexia, low grade fever |
| NI for Diverticulitis | well balanced high fiber diet unless inflammation is present, include bulk forming laxatives, increase fluid to 3L, monitor I/O, weight, bowel elimination, avoid constipation, observe for complications -obstruction, peritonitis, hemorrhage, infection |
| Intestinal Obstruction -causes | adhesions (most common), hernia, intusseception Neurogenic - paralytic ileus, spinal cord lesion; vascular causes |
| Nutritional needs of client w/Diverticulitis (hesi hint) | Acute phase-NPO graduating to liquids; recovery phase- no fiber or bowel irritating foods; maintenance-high fiber w/bulk laxatives to prevent pooling of foods & avoid small poorly digested foods such as popcorn, nuts, seeds |
| Bowel Obstruction mechanical vs non mechanical (hesi Hint) | mech- due to disorders outside bowel caused by disorder inside bowel or blockage; non mech- d/t paralytic ileus which isnt an actual physical blockage |
| NA for Bowel Obstruction | sudden onset of ab pain, tenderness or guarding, hx of abd surgeries, hx of obstruction, distention, increased peristalsis then becoming absent when paralytic ileus occurs, high pitched sounds diminishing to absent with late mech obstruction |
| Blood gas analysis with bowel obstruction (hesi hint) | alkalotic state if obstruction is high blocking gastric acid secretion; acidotic state if obstruction is low blocking base secretion |
| NI for bowel obstruction | maintain NPO w/iV fluids & electrolytes; monitor I/O, catheter, NG intubation, food./fluids restricted 8-10hrs if surgery, prophylactic antibiotics, NG intub done before surgery unless complete obstruction |
| Patho for Cirrhosis | degeneration of liver tissue causing enlargement d/t alcoholism, viral hepatitis, hepatoxins, infections, congenital abnormalities. Initially hepatomegaly then liver hardens and becomes nodular |
| NA for Cirrhosis | hx alcohol or drug use, work hx of exposure to chemicals medication hx of hepatoxic drugs, family hx. |
| NA for cirrhosis - physical | weakness, malaise, anorexia, weight loss, palpable liver. abd girth increases, jaundice, fetor hepaticus, asterixis, mental changes, spider angiomas, ascites, neuropathy, hematemesis, |
| Clinical manifestations of jaundice (hesi hint) | yellow skin, sclera or mucous membranes; dark color urine (bilirubin in urine); clay or chalky colored stools (absence of bilirubin) |
| Fetor Hepaticus | distinctive breath odor of chronic liver disease with a fruity or musty odor |
| treatment of ascites (hesi hint) | paracentesis or peritoneovenous shunts |
| Tx of esophageal varices caused by portal hypertension in liver (hesi hint) | may rupture and cause hemorrhage. insertion of balloon tamponade, vasopressors, vitamin K, coagulation factors and blood transfusions |
| Lab findings in Cirrhosis | elevated bilirubin, AST, ALT, alkaline phosphate; decreased Hct, Hgb, albumin |
| Encephalopathy (hesi hint) | ammonia is not broken down so serum level rises causing confusion/mental changes; also metabolism of drugs is slowed so they remain in system longer |
| Complications of Cirrhosis | ascites, portal hypertension, esophageal varices, encephalopathy, resp distress, coag defects |
| NI for Cirrhosis | adm vit supplements (ABCK) observe mental status, avoid initiating bleeding (no uncessary sticks, electric razor, soft tooth brush, maintain venipressure 5 mins, check stools for blood, prevent straining w/defecation. restrict protein, skin care |
| NI for cirrhosis (continued) | low sodium/low fat/high carb diet. restrict/monitor protein |
| What drug is used for encephalopathy | lactulose |
| Hepatitis patho | inflammation of liver cells |
| NA for hepatitis | known exp (sex, blood, parenteral, oral-fecal) recent transfusions, |
| Individuals at risk for hepatitis | homosexual males, iv drug users, piercings/tattoos, living in crowded conditions, health care workers |
| Physical assessment for hepatitis | fatigue, malaise, weakness, anorexia, n/v, jaundice, myalgia, dull headaches, irritability, abd tenderness RUQ, elevation of liver enzymes |
| NI for Hep A (hesi hint) | provide environment conducive to eating d/t n/v- remove odors, encourage pt to sit up while eating, small frequent meals, antiemetic b4 eating |
| Hepatitis NI (hesi hint) | rest & adequate nutrition, monitor drug therapy d/t drugs being metabolized in liver, do not resume drugs or use OTC during tx for hepatitis w/out dr approval |
| patho for pancreatitis | non bacterial inflammation of pancreas. acute- digestions of the pancreas by its own enzymes d/t alcohol ingestion & biliary tract disease. chronic-progressive destructive w/permanent dysfunction |
| NA acute pancreatitis | severe mid epigastric pain radiating to back w/alcohol consumption or fatty meal; abd guarding, rigid boardlike abd, n/v, temp, tachycardia, dcreased bp, bluish flank discoloration or periumbilical area, elevated amylase, lipase or glucose levels |
| NA chronic pancreatitis | continuous burning or gnawing abd pain, ascites, steatorrhea, diarrhea, weight loss, jaundice, dark urine, s/s of DM |
| NI acute pancreatitis | NPO, NG suction, TPN, pain med, antacids PPI, H2; side laying w/knees to chest, avoid alcohol, fatty & spicy foods, monitor blood sugar (insulin if needed),monitor for hypocalcemia |
| NI Chronic Pancreatitis | administer analgesics, pancreatic enzymes (mix w/fruit juice or applesauce, monitor coca of stool to determine enzyme tx effectiveness, low fat bland diet, monitor for s/s of DM |
| Acute pancreatic pain (hesi hint) | acute pain located retroperitoneally. any enlargement of pancreas causes the peritoneum to stretch tightly. sitting up or leaning forward reduces pain |
| Hyperthyroidism (graves disease) | excessive thyroid activity |
| Common tx for hyperthyroidism | thyroid ablation by medication, radiation, thyoidectomy, adenectomy (removing anterior portion of pituitary (tsh) |
| NA for hyperthyroidism | enlarged thyroid (goiter), weight loss, diarrhea, heat intolerance, tachycardia, Inc BP, diaphoresis, exopthalmos |
| Labs for Hyperthyroidism | T3 >220, T4 >12, low level TSH indicates primary disease, high level =pituitary prob, thyroid scan |
| NI for hyperthyroidism | calm restful atmosphere, observe for s/s thyroid storm, |
| Thyroid storm (hesi hint) | life threatening uncontrolled hyperthyroidism d/t graves. s/s fever, tachycardia, agitation, anxiety, htn. maintain adequate airway. PTU/tapazole antithyroid drugs to tx thyroid storm with propanolol |
| teach for hyperthyroidism | daily HRT, medic alert bracelet, s/s of hormone replacement overdose or underdose; diet- high cal high protein low caffeine low fiber (if diarrhea), eye care. |
| tx for hyperthyroidism | medications-take as prescribed; radiation -GI irritant, vomitus is radioactive; thyroidectomy |
| Post op thyroidectomy (hesi hint) | be prepared for laryngeal edema. trach kit with O2 and suction machine. calcium gluconate accessible; check for bleeding, support neck, |
| calcium implications w/thyroidectomy d/t removal of parathyroid glands (hesi hint) | normal serum calcium 9-10.5. best indicator of prob is decrease in calcium level post op |
| If parathyroid glands removed change of tetany increases so...(hesi hint) | monitor calcium level, check for tingling of toes, fingers and circumoral; check for chovsteks & trousseaus sign |
| Hypothyroid - myxedema coma (hesi hint) | can be precipitated by acute illness, withdrawal of meds, anesthesia, sedatives or hypoventilation. airway must be kept patent and ventilator support if needed |
| NA hypothyroidism | weight gain, constipation, bradycardia, fatigue, cold intolerance, thin brittle hair, think brittle nails, goiter, periorbital edema. |
| Teachings for hypothyroidism | medication regimen, effects, s/s of myxedema coma, 3L fluid intake, increase activity, high fiber diet. avoid sedation (leads to resp distress) |
| Addison's disease - andrenocortical deficiency | autoimmune disorder - lack of cortisol, aldosterone & androgens. diagnosis made by ACTH stimulation test. |
| Teaching in Addisons' disease (hesi hint) | that pts must follow prescribed regimen precisely. no stopping suddenly and must taper off dosage. |
| NA for Addisons | fatigue, weakness, weight loss, anorexia, postural hypotension, hypOglycemia, hypOnatremia, HypErkalemia, hyperpigmentation, alopecia (loss of body hair), hypovolemia |
| NI for Addisons disease | VS q15 mins if crisis, monitor I/O & weight, rise slowly d/t ortho hypotn, monitor electrolytes |
| Addison Crisis (Hesi hint) | sudden withdrawal of steroids or stress. vascular collapse - fast IV of fluids; IV glucose for hypOglycemia, essential to administer Hydrocortisone and aldosterone replacement |
| Cushing syndrome | excess adrenocorticoid caused by chronic corticosteroid administration, adrenal, pituitary or hypothalamus tumors |
| Physical assessment of Cushing's | moon face, buffalo hump, truncal obesity, abd stiae, muscle atrophy, hirsuitism, hyperpigmentation, amenorrhea, thinning of skin |
| Lab findings in Cushings | HypErglycemia, HypErnatremia, HypOkalemia, increased cortisol, |
| NI for Cushing's | protect from infection, monitor for s/s of infection, teach safety measures, low sodium diet, encourage vit D & calcium, wean from steroids. |
| Steroid Admininstration (hesi hint) | teach clients to take steroids with meals to prevent gastric irritation. dont skip doses, |
| Diabetic ketoacidosis | glucose >350, ketonuria, venous PH 6.8-7.2 |
| TX of DKA | isotonic IV fluids, slow infusion of regular insulin, potassium replacement, |
| non ketotic hyperosmolar hyperglycemia | no ketones hyperglycemia, dehydration, plasma hyperosmolity, changed mental status |
| tx non ketotic hyperosmolar hyperglycemia | isotonic IV fluids, IV insulin (if needed) |
| Why do diabetics have trouble with wound healing? (hesi hint) | high blood glucose adds to damage of capillaries causing permanent scarring. causes disruption of capillary elasticity, promoting probs such as diabetic retinopathy, poor healing, cardiovascular issues |
| What is glycosylated hgb (A1C)? Hesi hint | indicates glucose control over previous 120 days (life of red blood cells). valuable measure of diabetic |
| Insulin | lift skin/90degree angle; refrig or room temp (28 days); rotate injection sites, clear(reg) before cloudy) |
| DM Diet | carb counting/exchange lists; time meals to med peak times; 55-60% carbs/12-15% protein/ 30% or less fat. choose complex carbs, fiber low fat. Bedtime snack prevent insulin reaction to long acting insulin peaks. |
| Sick day rules for insulin | keep taking insulin; monitor glucose more frequently, watch for hypEr glycemia |
| Body response to illness & stress regarding Blood sugar (hesi hint) | bodies response is to produce glucose therefore any illness results in hypErglycemia |
| Exercise regimen r/t DM | regular non strenuous exercise; after mealtime & with someone; snack might be needed before or during exercise; |
| what to do if unable to determine if client is hypO or hypEr glycemic (hesi hint) | treat for hypOglycemia |
| Rapid acting insulin (humalog/novolog) | 5-15min onset, 2-3hr peak or less; give within 15 mins of a meal |
| Short Acting (regular) | 30-60min onset, 2-3hr peak, can be given IV |
| Intermediate acting (NPH) | 1-2hr onset, 6-12 hr peak; mix with rapid acting |
| Long acting (ultralente/lantus) | 4-8hr onset, 14-20 hr peak, once daily @bedtime, do not mix |
| S/S of hypErglycemia | 3 P's, blurred vision (type2), weaknness, weight loss, syncope |
| Tx of hypErglycemia | water, check BG, assess for ketoacidosis |
| S/S of hypOglycemia | HA, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth, anxiety, nightmares |
| tx of of hypOglycemia | occurs rapidly and can be life threatening. give complex carbs such as graham cracker & peanut butter and seek medical attention, check BG |
| SMBG (hesi hint) | provides tight glucose control to prevent long term complications; monitor before meals, bedtime and when symptoms occur; record results and report to provider |
| Foot care for DM | checked daily, washed with mild soap & warm water dried well esp between toes; moisturize but not between toes; clean socks, nails filed straight across. |
| Urinary tract obstruction-BPH | enlargement or hypertrophy of the prostate in men over 40years old. |
| Tx of BPH | TURP |
| NA of BPH | increaed freq of voiding; nocturia, dribbling, hesitancy, decrease size/force of stream, acute urinary retention, bladder distention |
| Bladder spasm with Turp (hesi hint) | ballon causes continuous feeling of needing to void, do not try and void around catheter or it will cause bladder spasms. medications to prevent spasms given. |
| Bladder irrigation with TURP (hesi hint) | use only sterile saline to prevent cellular fluid shifts |
| Drainage after TURP | reddish pink clearing to pink. some small clots. monitor for bright red bleeding w/large viscous clots. normal for some bleeding & small clots to be passed. If large amts sh/be reported |
| Prostate Cancer | rarely before age 40, 2nd leading cause of male death; high risk-multiple sex partners, STD's and some viral infections |
| NA for prostate cancer | Elevated PSA |
| Identify interventions related to Orchitis? | rest with scrotal elevation, application of ice, admin of analgesics and antibiotics. Treat partner if bacterial, mumps vaccine, nsaids or antiinflammatories |
| Identify nursing education related to orchiectomy? | decreased hormone levels after the removal. Avoid sexual activity for 2-4 weeks after surgery, avoid lifting heavy weights or strenuous activity, s/s of infection. Increase fluids & high fiber diet to avoid constipation. Will also need follow up appt |
| Identify nursing assessments related to toxic shock syndrome (TSS)? | Sudden onset, high temp (>102), HA, sore throat, vomiting, diarrhea, generalized rash, hypotension, Rash on palms and soles of hands/feet, confusion, muscle aches, redness of eyes/mouth/throat and headaches |
| Uterine Prolapse | downward displacement of uterus. Can impinge on other structures. bladder, rectum, small intestine can protrude thru vaginal wall |
| Cystocele | relaxation of anterior vaginal wall with prolapse of bladder |
| Rectocele | relaxation of posterior vaginal wall with prolapse of rectume |
| Benign Tumors - uterine | more common in black women, non parity women. most common symptom is abnormal uterine bleeding. TX D&C, ablation |
| Cervical cancer | 95% squamous cell cancer; HPV vaccine; |
| Hesi hints for Cervical cancer | pap smear annually to age 39, then 2-3 years; laswer/crysurgery for small lesions; invasive cancer radiation / hysterectomy/conization. chemo not effective |
| Care of pt with radiation implants | transmission precautions; isolation (provide support); leadlined container; client must remain in bed; limit time with client |
| ovarian cancer | germ cells |
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rivabard
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