Chamberlain College of Nursing
NR142 Exam 1 Study Guide
Chamberlain College of Nursing
NR142 Exam 1 Study Guide
Instructions: The contents on this
... [Show More] guide are intended to help you organize your preparation for the Subject for the NR142 exam 1. This is NOT intended to serve as a direct reflection of the exact questions which will be presented in the exam. As you review the topics listed below, be sure that you can
1. Understand the Pathophysiology
2. Identify the appropriate assessment skills
3. Interpret the appropriate lab or other diagnostic findings
4. Develop a safe and competent plan of care with rationale
5. Associate the nursing implications with the appropriate medications or other treatments
6. Teach the RATIONALE for all the above.
7. Prioritize especially r/t interventions and use of the nursing process keeping in mind scope of practice and responsibilities related to practicing as a R.N.
Medication calculations
Review: All oral and injectable; IV fluids, IV medications (continuous/intermittent; with meds; not weight based); Reconstitution
Gastrointestinal Alterations
Esophagus (Meg)
Esophageal Cancer – Occurs 3x more often in men than in women. Seen more frequently in African Americans than in Caucasians. Occurs most often in 5th or 6th decade of life. Is seen more in China and Northern Iran than in other parts of the world.
Pathophysiology – Consists of 2 cell types – Adenocarcinoma and Squamous cell carcinoma. Normally not found till disease is advanced and then there is a very poor prognosis
1. Adenocarcinoma is primarily found in the distal esophagus and gastroesophageal junction.
• Risk factors – chronic esophageal irritation as with tobacco and alcohol use, people with GERD and Barrett’s esophagus (chronic irritation of the mucous membranes due to reflux)
2. Squamous Cell Carcinoma
• Risk factors – chronic ingestion of hot liquids or foods, nutritional deficiencies, poor oral hygiene, exposure to nitrosamines in the environment or food, cigarette smoking or chronic alcohol use and some esophageal medical conditions such as caustic injury
Tumor cells of both types may spread beneath the esophageal mucosa or directly into, through and beyond the muscle layer into the lymph nodes. In later stages patients can have obstruction of the esophagus and possible perforation into the mediastinum and erosion into the vessels.
Assessment – Diagnosis confirmed by biopsy
S/S – lesions in the throat, dysphasia, with solid foods first and then liquids, sensation of a mass in the throat, painful swallowing, substernal pain or fullness, regurgitation of undigested foods with bad breathe and hiccups.
Rationale – Pain and trouble swallowing can indicate a blockage or mass in the throat. A mass in the throat can cause gastroesophageal reflux, and damage or irritation to the nerves. Both of these things can cause consistent hiccupping. Reflux or respiratory issues denying oxygen into the blood, to the heart and other muscles, can cause substernal pain
Treatment:
• Surgery to remove tumor or surgical resection of the esophagus
• Esophagectomy – partial or full removal of the esophagus
• Radiation
• Chemo
• Combination
• Palliative treatments – dilation of the esophagus, laser therapy, placement of a stint
• Radical neck dissection is how they perform surgery on the esophagus
Tumors in the cervical or upper thoracic area of the esophagus may be maintained by a free jejunal graft in which the tumor is removed and the area is replaced with a portion of the jejunum. (Esojejunostomy)
Complications:
• Surgery or surgical resection – high mortality rate due to infection, pulmonary complications, leakage through the anastomosis
• Radiation & Chemo – Infection, hair loss, N/V, fatigue
Education for surgical patients:
• To talking or eating
• Keep pt in semi-fowlers position
• Support head
• Ask about preferred form of communication since will not be able to talk (ie…communication board, writing)
• Nutrition
• Parental feeding for 24-48 hours after, enteral feeding after until cleared by speech therapist evaluation and ability to swallow returns
Esophageal Varices – extremely dilated (tortured) sub-mucosal veins in the lower third of the esophagus – Usually develop in patients with cirrhosis. Caused by portal hypertension, cirrhosis and alcoholism
Pathophysiology – almost always develops from portal hypertension, which results from obstruction of the portal venous circulation within the damaged liver. Due to obstruction, blood from the intestinal tract and spleen increases pressure in the vessels of the lower esophagus and upper part of the stomach. Life threatening and can result in hemorrhagic shock. Chart on page 1129
Bulimia is second greatest cause after portal hypertension due to constant vomiting
Assessment: S/S hematemesis, melena, general deterioration in mental and physical status, alcohol abuse, vomiting, blood in stool, black tarry stool, anemia, thrombocytopenia, ascites (fluid collection in peritoneum), low WBC, hypovolemia
Rationale: melena is black tarry stool and is a symptom of upper gastrointestinal bleeding, Hematemesis or vomiting blood can indicate esophageal bleeding, ascites from decrease in protein due to liver disease, confusion from build up of waste products because the liver cannot filter, anemia and thrombocytopenia due to backed up blood flow from failing liver, low WBC from infection due to all of above morbidities, hypovolemia due to hemorrhage (AIRWAY IS A PRIORITY FOR PERFORATION/RUPTURE OF VARICIES)
Treatments: Non-Surgical preferred due to high mortality rate associated with surgery to control bleeding and current patient status
• EDG with Cauderization
• Medications first administered – Vasopressin to decrease portal pressure – Somatostatin and octreotide to decrease bleeding from esophageal varices, propranolol (Inderal) and Nadolol (Corgard) beta blockers to decrease pressure
• O2 administration
• IV fluids with electrolytes ad volume expanders
• Blood transfusions
• Balloon Tamponade – puts pressure on the bleeding varices and is placed on the upper orifice of the stomach
• Sclerotherapy – injection through fiber optic endoscope into the bleeding varices to promote thrombosis and eventual sclerosis
• Variceal Banding – endoscope with an elastic rubber band is passed through an overtube directly onto the varices and banded causing necrosis, ulceration and sloughing of the varix. (Picture on 1132)
• Portal Vein Bypass Procedures – Splenorenal, End-to-Side, H-Graft mesocaval shunt
• NO NG USED WITH ESOPHAGEAL VARICIES
Complication of treatments:
• Balloon Tamponade – displacement of the tube and balloon and airway obstruction – effects circulation so nurse deflates for a few minutes every 8 hours – balloon in place for roughly 24 hours
• Sclerotherapy – acid reflux
• Variceal Banding – superficial ulceration, dysphasia, chest pain, esophageal strictures
• Portal Vein Bypass – encephalopathy, accelerated liver failure
MAIN PROCEDURE DONE FOR GI PATIENTS – ESOPHAGOGASTRODUODENOSCOPY (EGD)
• Education – Pt NPO for 6-8 hours including chewing gum
• Conscious sedaton – will need to be driven home
• Use cough drops, cough spray and warm liquids for soar throat after procedure
• NO eating or drinking until gag reflex returns
Esophageal Achalasia – absent or ineffective peristalsis of the distal esophagus and failure of the esophageal sphincter to relax after swallowing
Pathophysiology – results from the degeneration of nerves in the esophageal wall. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest.
Diagnosed by x-ray, barium swallow, chest CT, endoscopy and esophageal manometry
Assessment – S/S – difficulty swallowing both solids and liquids, sensation of food sticking to lower part of esophagus, vomiting either spontaneous or intentional, chest pain (heartburn), pulmonary complications from aspiration, low or absent peristalsis @distal end of esophagus, lower esophageal sphincter does not relax – watch airway, for bleeding and v/s
Rationale – all assessment items are directly related to food residue in the esophagus, either from the feeling or from the related complication
Treatments: pts instructed to eat slowly and drink fluids with meals
• Calcium channel blockers and nitrates administered to decrease esophageal pressure and improve swallowing
• Injection of Botox into the esophagus via endoscopy is used to inhibit the contraction of smooth muscle
• Pneumatic dilation stretches the narrowed area of the esophagus (high success rate)
• Esophagomyotomy –esophageal muscle fibers are separated to relieve the lower esophageal stricture
Complications of treatments:
• Pneumatic dilation – painful (patient must be sedated), perforation is possible so watch for abdominal tenderness and fever
Upper GI alterations
Types
GERD
Hiatal Hernia
Barrett’s Esophagus
PUD
Gastritis
Gastric cancer
Morbid Obesity
Pathophysiology
Assessment with rationale
Diagnostics
Treatment with rationale with consideration to long-term use of GI suction and complications from long-term use of NG tubes
Consider the role of intrinsic factor on Vitamin B12 deficiency
Complications
Inflammatory
Types
Crohn’s Disease
Ulcerative Colitis
Diverticullitis
Pathophysiology
Assessment with rationale
Diagnostics
Treatment with rationale including use of TPN and special diets
Appendicitis (Matt)
Appendicitis is a condition in which your appendix becomes inflamed and fills with pus. Your appendix is a finger-shaped pouch that projects out from your colon on the lower right side of your abdomen. Appendicitis is a medical emergency that requires prompt surgery to remove the appendix. Left untreated, an inflamed appendix will eventually burst, or perforate, spilling infectious materials into the abdominal cavity. This can lead to peritonitis, a serious inflammation of the abdominal cavity's lining (the peritoneum) that can be fatal unless it is treated quickly with strong antibiotics.
S/S
• Dull pain near the navel or the upper abdomen that becomes sharp as it moves to the lower right abdomen. This is usually the first sign.
• Loss of appetite
• Nausea and/or vomiting soon after abdominal pain begins
• Abdominal swelling
• Fever of 99-102 degrees Fahrenheit
• Inability to pass gas
Diagnosis
• Abdominal exam to detect inflammation
• Urine test to rule out a urinary tract infection
• Rectal exam
• Blood test to see if your body is fighting infection
• CT scans and/or ultrasound
Treatment
Surgery to remove the appendix, which is called an appendectomy
Peritonitis
Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. Peritonitis is usually caused by infection from bacteria or fungi. Left untreated, peritonitis can rapidly spread into the blood (sepsis) and to other organs, resulting in multiple organ failure and death. (Appendix bursting can cause peritonitis)
The two main types of peritonitis are primary spontaneous peritonitis, an infection that develops in the peritoneum; and secondary peritonitis, which usually develops when an injury or infection in the abdominal cavity allows infectious organisms into the peritoneum.
The most common risk factors for primary spontaneous peritonitis include: Liver disease with cirrhosis. Such disease often causes a buildup of abdominal fluid (ascites) that can become infected. Kidney failure getting peritoneal dialysis. This technique, which involves the implantation of a catheter into the peritoneum, is used to remove waste products in the blood of people with kidney failure. It's linked to a higher risk of peritonitis due to accidental contamination of the peritoneum by way of the catheter.
S/S
• poor appetite and nausea
• a dull abdominal ache that quickly turns into persistent, severe abdominal pain, which is worsened by any movement
• Abdominal tenderness or distention
• Chills
• Fever
• Fluid in the abdomen
• Extreme thirst
• Not passing any urine, or passing significantly less urine than usual
• Difficulty passing gas or having a bowel movement
• Vomiting
Diagnosis
• Blood and urine tests
• Imaging studies such as X-rays and computerized tomography (CT) scans
• Exploratory surgery
• doctor also may perform a paracentesis, a procedure in which fluid from the abdominal cavity is withdrawn through a thin needle and checked for infection. Paracentesis is useful for identifying primary spontaneous peritonitis and secondary peritonitis caused by pancreatitis.
Treatment
Antibiotics or antifungal medications to treat the infection. Additional supportive treatments will be necessary if organ failure from sepsis develops as a complication of the infection. Such treatments may include intravenous fluids, drugs to maintain blood pressure, and nutritional support.
If caused by say the appendix the goal is to then remove the appendix immediately!!
Intestinal Obstruction
Intestinal obstruction is a blockage that keeps food or liquid from passing through your small intestine or large intestine (colon). Tumors, scar tissue (adhesions), or twisting or narrowing of the intestines can cause a bowel obstruction. These are called mechanical obstructions camera. In the small intestine, scar tissue is most often the cause. Other causes include hernias and Crohn's disease, which can twist or narrow the intestine, and tumors, which can block the intestine. A blockage also can happen if one part of the intestine folds like a telescope camera into another part, which is called intussusception. In the large intestine, cancer is most often the cause. Other causes are severe constipation from a hard mass of stool, and narrowing of the intestine caused by diverticulitis or inflammatory bowel disease
S/S
• Cramping and belly pain that comes and goes. The pain can occur around or below the belly button.
• Vomiting.
• Bloating.
• Constipation and a lack of gas, if the intestine is completely blocked.
• Diarrhea, if the intestine is partly blocked. (the liquid seeps around the obstruction)
Diagnosis
• An abdominal X-ray, which can find blockages in the small and large intestines
• A CT scan of the belly, which helps your doctor see whether the blockage is partial or complete
Treatment
• May place a tiny tube called a nasogastric (NG) tube through your nose and down into your stomach. The tube removes fluids and gas and helps relieve pain and pressure
• Most bowel obstructions are partial blockages that get better on their own. Some people may need more treatment. These treatments include using liquids or air (enemas) or small mesh tubes (stents) to open up the blockage
• Surgery is almost always needed when the intestine is completely blocked or when the blood supply is cut off. You may need a colostomy or an ileostomy after surgery. The diseased part of the intestine is removed, and the remaining part is sewn to an opening in the skin. Stool passes out of the body through the opening and collects in a disposable colostomy bag.
Hernias
A hernia occurs when an organ or fatty tissue squeezes through a weak spot in a surrounding muscle or connective tissue called fascia. The most common types of hernia are inguinal (inner groin), incisional (resulting from an incision), femoral (outer groin), umbilical (belly button), and hiatal (upper stomach).
In an inguinal hernia, the intestine or the bladder protrudes through the abdominal wall or into the inguinal canal in the groin. About 80% of all hernias are inguinal, and most occur in men because of a natural weakness in this area.
In an incisional hernia, the intestine pushes through the abdominal wall at the site of previous abdominal surgery. This type is most common in elderly or overweight people who are inactive after abdominal surgery.
A femoral hernia occurs when the intestine enters the canal carrying the femoral artery into the upper thigh. Femoral hernias are most common in women, especially those who are pregnant or obese.
In an umbilical hernia, part of the small intestine passes through the abdominal wall near the navel. Common in newborns, it also commonly afflicts obese women or those who have had many children.
A hiatal hernia happens when the upper stomach squeezes through the hiatus, an opening in the diaphragm through which the esophagus passes.
S/S
Many hernias are picked up by routine physicals
Hernias can cause discomfort or pain during your daily activities, especially when you exert yourself.
Hernias can cause discomfort or pain during urination or bowel movements.
Hernias can cause a feeling of weakness or pressure in the groin area.
Hernia pain may be sharp and sudden or dull and achy. It can also be a combination of both.
Signs and symptoms of strangulated hernia include:
Nausea, vomiting or both
Fever
Rapid heart rate
Sudden pain that quickly intensifies
A hernia bulge that turns red, purple or dark
Diagnosis
Most often physical examination
Treatment
Hernia treatment consists of surgery unless you have medical conditions that preclude surgery. In some cases, belts or trusses can be used to temporarily hold the hernia in place
Colorectal Cancer
• Colorectal cancer is a malignant tumor arising from the inner wall of the large intestine.
• Colorectal cancer is the third leading cause of cancer in males and fourth in females in the U.S.
• Risk factors for colorectal cancer include heredity, colon polyps, and long-standing ulcerative colitis.
• Most colorectal cancers develop from polyps. Removal of colon polyps can prevent colorectal cancer.
• Colon polyps and early cancer can have no symptoms. Therefore regular screening is important.
• Genetics and/or a high fat diet are believed to increase risk of getting this type of cancer
S/S
• fatigue, weakness, shortness of breath, change in bowel habits, narrow stools, diarrhea or constipation, red or dark blood in stool, weight loss, abdominal pain, cramps, or bloating.
• Other diseases can mimic these symptoms and it is possible for you to have colon cancer for several years without a symptom. SCREENING IS IMPORTANT!!!
Diagnosis
• Colon cancer is suspected, either a lower GI series (barium enema X-ray) or colonoscopy is performed to confirm the diagnosis and locate the tumor. A barium enema involves taking X-rays of the colon and the rectum after the patient is given an enema with a white, chalky liquid containing barium. The barium outlines the large intestines on the X-rays. Tumors and other abnormalities appear as dark shadows on the X-rays
• Colonoscopy is the best procedure to use when cancer of the colon is suspected. While the majority of the polyps removed through colonoscopes are benign, many are precancerous. Removal of precancerous polyps prevents the future development of colon cancer from these polyps.
Treatment
• Surgery- the tumor, a small margin of the surrounding healthy intestine, and adjacent lymph nodes are removed. The surgeon then reconnects the healthy sections of the bowel. In patients with rectal cancer, the rectum sometimes is permanently removed. The surgeon then creates an opening (colostomy) on the abdominal wall through which solid waste from the colon is excreted.
• Chemotherapy is used for advanced stages of colon cancer- (5-fluorouracil, or 5-FU) is a pill form drug for chemotherapy often used.
Ostomies
Types
o Ascending
o Descending
o Transverse
o Double barrel (Loop)
o Ileostomy
o Sigmoid colostomy
Pathophysiology
Assessment with rationale
Diagnostics
Treatment with rationale
Hepatic, Biliary, and Pancreatic Alterations (Maira)
Cirrhosis (pgs. 1116,1125f, 1146-1158)
• Ac chronic liver disease characterized by fibrotic changes and the formation of dense connective tissue within the liver, subsequent degenerative changes and loss of functioning cells
• Extensive scarring of the liver; r/t chronic reaction to hepatic inflammation and necrosis.
• Compensated cirrhosis
There are three types of cirrhosis or scarring of the liver:
1. Alcoholic cirrhosis – the scar tissue surrounds the portal areas. Most frequently caused by chronic alcoholism & is the most common type.
2. Post-necrotic cirrhosis – there are broad bands of scar tissue which is a late result of a previous bout of acute viral hepatitis.
3. Biliary cirrhosis – scarring occurs in the liver around the bile ducts. Usually the result of chronic biliary obstructions & infection (cholangitis). This is the least common type of the three.
Pathophysiology
• Alcohol consumption is the major causative factor but has occurred in those who do not consume alcohol
• Nutritional deficiency – reduced protein intake and malnourishment are also contribute to liver destruction
• Exposure to chemicals – carbon tetrachloride, chlorinated naphthalene, arsenic, phosphorus or infectious schistosomiasis
• Affects men twice as much as women
• Most patients are between 40-60
• Etiology: alcohol, viral hepatitis, autoimmune hepatitis, steatohepatitis, drugs and toxins, biliary disease, metabolic/genetic causes, cardiovascular disease
• S/S increase in severity as the disease progresses and is used to categorize as Compensated (less severe) or Decompensated (more severe)
• S/S Compensated:
Intermittent mild fever
Vascular spiders
Palmar erythema (reddened palms)
Unexplained epistaxis
Ankle edema
Vague morning indigestion
Flatulent dyspepsia
Abdominal pain
Firm, enlarged liver
Splenomegaly
• S/S Decompensated:
Ascites
Jaundice
Weakness
Muscle wasting
Weight loss
Continuous mild fever
Clubbing of fingers
Purpura (due to decreased platelet count)
Spontaneous bruising
Epistaxis
Hypotension
Sparse body hair
White nails
Gonadal atrophy
Assessment with rationale
The extent of liver disease & type of treatment are determined by lab findings (see list of labs under Diagnostics below)
Onset of symptoms
Alcohol use/abuse
Dietary intake & nutritional status
Exposure to toxic agents & drugs
Assess mental status
ADL/IADL
Monitor for s/s: bleeding, fluid volume changes and lab data
Abdominal Assessment:
• Massive ascites
• Umbilicus protrusion
• Caput medusa (dilated abdominal veins)
• Hepatomegaly (liver enlargement)
Physical Assessments’:
• Blood in NG drainage
• Vomitus
• Stool
• Fetor hepaticus*
• Amenorrhea
• Gynecomastia, testicular atrophy, impotence
• Bruising, petechiae, enlarged spleen
• Neurologic changes
• Asterixis*
Dyspnea – elevate the hob at least 30 degrees or as high as pt. wishes/can tolerate, encourage pt. to sit in a chair and weigh pt. in standing position
Diagnostics
• Liver biopsy confirms diagnosis
Labs: LFT’s, Serum alkaline phosphatase, AST, ALT & GGT, Serum cholinesterase, Bilirubin and Prothrombin time (See Table 39-1 pg. 1121)
Ultrasound is used to measure the density of parenchymal cells & scar tissue
CT, MRI & radioisotope liver scans used to get liver size & hepatic blood flow & obstruction.
ABG analysis may reveal a ventilation-perfusion imbalance & hypoxia
Treatment with rationale
Treatments & management is based on presenting symptoms
• Antacids or histamine-2 (H2) antagonists are used to decrease gastric distress & minimize GI bleeding
• Vitamin & nutritional supplements promote healing of damaged liver cells
• Nutritional therapy – low sodium diet, limited fluid intake, vitamin supplements, protein
• Drug therapy – diuretic, electrolyte replacement, Lactulose, Neomycin sulfate, Metronidazole
• Paracentesis
• Observe for impending shock
Complications
Bleeding & Hemorrhage – at risk because of decreased production of prothrombin & decreased ability of deceased liver to synthesize the necessary substances for blood coagulation
Portal-systemic Hepatic Encephalopathy & Coma – manifest as deteriorating mental status & dementia &/or physical signs like abnormal voluntary/involuntary movements.
Fluid Volume Excess – develop cardiovascular abnormalities due to an ↑cardiac output, ↓peripheral vascular resistance
Portal hypertension –increased pressure throughout the portal venous system d/t obstructed blood flow through the liver. Results in ascites & esophageal varices
Ascites – Fluid in peritoneal cavity due to portal hypertension, vasodilation of splanchnic circulation, changes in ability to metabolize aldosterone, decreased synthesis of albumin and movement of albumin into the peritoneal cavity
Bleeding esophageal varices
Coagulation defects
Jaundice – due to increased serum bilirubin levels. Four kinds:
1. Hepatocellular – lack of appetite, nausea, weight loss, malaise, fatigue, weakness, HA, chills & fever if infectious in origin
2. Obstructive – pruritus, dark orange-brown urine, light clay-colored stools, dyspepsia, fat intolerance fat/impaired digestion
3. Hemolytic
4. Hereditary hyperbilirubinemia
Hepatorenal syndrome
Spontaneous bacterial peritonitis
Hepatitis all types
Pathophysiology
Assessment with rationale
Diagnostics
Treatment with rationale
Cancer (liver & pancreatic)
Pathophysiology
Assessment with rationale
Diagnostics
Treatment with rationale
Pancreatitis
Pathophysiology
Assessment with rationale
Diagnostics
Treatment with rationale [Show Less]