Chapter 54: Care of Patients with Esophageal Problems, pp. 1087-1092 Gastroesophageal Reflux Disease (GERD)
• Risk factors include consumption of foods
... [Show More] such as caffeine, alcohol, spicy or fried foods,
chocolate, and tomatoes. Lifestyle factors play a big part especially alcohol and smoking.
• The nursing assessment should include asking about a history of heartburn or atypical chest pain associated with the reflux of GI contents. GERD manifest differently depending on the patient and the severity of the disorder.
• Heartburn, dyspepsia, is the most common symptom and may be described as substernal
burning moving up and down the chest. Pain usually develops within 30-60 minutes after meals. Severe heartburn pain can radiate to the neck, jaw, or back and patients may think they are having an MI.
• GERD symptoms are exacerbated when lying down flat or bending over. Regurgitation
may lead to aspiration or bronchitis. These patients are at risk of aspirating when lying flat. Symptoms of GERD include coughing or wheezing at night, dysphagia, belching and nausea, hoarseness, and insomnia. Assess lungs for the presence of crackles.
Chapter 52: Assessment of the Gastrointestinal System, pp. 1092-1095 Hiatal Hernias (diaphragmatic hernias)
• A condition where a part of the stomach that normally is in the abdominal cavity
protrudes through the esophageal hiatus to rest within the chest cavity.
• Symptoms usually are worse after meals. These symptoms may be made worse when lying flat and may resolve with sitting up or walking. Patient should immediately report abdominal pain with nausea, vomiting, and fever.
• Lifestyle changes may include elevating the head of the bed when sleeping to allow
gravity to prevent acid from refluxing into the esophagus and remaining upright after meals.
• Small frequent meals may help instead of eating two or three larger meals a day. Avoid
vigorous movement after meals.
• Some foods that should be avoided include spicy, greasy foods, onions, tomatoes and citrus fruits, however, most individuals are generally aware of the foods that trigger heartburn symptoms and avoid them.
Chapter 54, Care of Patients with Esophageal Problems, pp. 1089 Esophagogastroduodenoscopy (EGD)
• An esophagogastroduodenoscopy (EGD), which is also known as an upper endoscopy or
upper gastrointestinal endoscopy, is a diagnostic procedure that is performed to view the esophagus, stomach, and duodenum (part of the small intestine). In an EGD, the doctor uses an endoscope, a flexible, tube-like, telescopic instrument with a tiny camera mounted at its tip, to examine images of the upper digestive tract displayed on a monitor in the examination room.
• Small instruments may also be passed through the tube to treat certain disorders or to
perform biopsies (remove small samples of tissue).
• Certain medications (such as aspirin, anticoagulants and the anti-inflammatory drugs called NSAIDs) should be discontinued at least five to seven days before an EGD to reduce the risk of bleeding.
• NPO - Patients will be asked not to eat or drink anything for at least 8 hours before the
procedure to ensure that the upper intestinal tract will be empty.
• Before the procedure, patients may be given a moderate sedative and/or pain medication, usually by intravenous injection.
• Monitor gag reflex, the sedation will block the gag reflex to prevent aspiration.
• Keep NPO until they get their gag reflex back. (1 to 2 hours before the anesthetic is out the system).
• Patient must have someone accompany them home after recovery.
Chapter 55: Care of Patients with Stomach Disorders, pp. 1103-1107 Gastritis
• Gastritis occurs when the lining of the stomach known as the mucosa becomes inflamed
or swollen. When the stomach mucosa becomes inflamed edema, hemorrhage and erosion of the mucosa occur.
• Medical treatment for gastritis depends on the specific cause. Patients will be instructed
to stop taking irritating medications such as ASA and NSAIDS. Medications to decrease the amount of hydrochloric acid in the stomach are usually prescribed. These would include Antacids, H2 antagonists, and Proton pump inhibitors.
• The patient with gastritis is at risk for deficient fluid volume. A nursing priority is to
access for the patient’s hydration status. This would include I&O, daily weights, & VS.
Chapter 55: Care of Patients with Stomach Disorders, pp. 1107-1115 Peptic Ulcer Disease (PUD)
• Peptic ulcers are a break in the mucous lining of gastrointestinal tract from continued
contact with gastric juice. This results in inflammation. Pain that is worsened by the ingestion of food.
• Ulcers in the mucosa of GI tract occur from several different causes. Duodenal ulcers are
associated with a H. pylori infection.
• Gastric ulcers may cause a dull, aching pain, often right after a meal; eating does not relieve the pain and may even worsen it. Pain may also occur at late at night.
• Other symptoms associated with PUD are nausea with or without vomiting, weight loss,
anorexia, belching and dyspepsia or indigestion. Patient may report a distended abdomen that is painful.
• Smoking contributes to the pathogenesis of peptic ulcer disease. Smoking causes an
acceleration of gastric emptying of liquids, promotes of duodenogastric reflux and causes a reduction in mucosal blood flow. Patient should attend a smoking cessation course.
Chapter 55, Care of Patients with Stomach Disorders, pp. 1116-1119 Gastric Cancer
• Stomach cancers tend to develop slowly over many years. Before a true cancer develops, pre-cancerous changes often occur in the inner lining (mucosa) of the stomach. These early changes rarely cause symptoms and therefore often go undetected.
• The decline of stomach cancer has been linked to the frequent use of antibiotics to treat
infections. Antibiotics can kill the bacteria called Helicobacter pylori (H. pylori), which is thought to be a major cause of stomach cancer.
• Administer protein and vitamin supplements to foster wound repair and tissue building.
Eat small, frequent meals rather than three large meals. Reduce fluids with meals but take them between meals. Stress the importance of long-term vitamin B12 injections after gastrectomy to prevent surgically induced pernicious anemia.
Chapter 56, Care of Patients with Noninflammatory, pp. 1135-1137 Irritable Bowel Syndrome (IBS)
• Irritable bowel syndrome (IBS) refers to a disorder that involves abdominal pain and
cramping, as well as changes in bowel movements
• Risk factors include consuming a diet high in fats and gas producing foods. Consuming carbonated beverages, caffeine and alcohol contribute to the development of IBS.
• Smoking and stress are other related factors. Emotional experiences such as anxiety and
depression are also a factor as this affects the autonomic nervous system and its innervation to the bowel.
• Nursing care for the patient with IBS focuses on education and emotional support. Help
the patient implement lifestyle changes that reduce stress. Remind the patient about regular exercise, discourage smoking while encouraging the need for regular physical examinations.
Chapter 56, Care of Patients with Noninflammatory, pp. 1137-1139 Herniation
• A weakness in the abdominal muscle wall through which a segment of the bowel or other
abdominal structure protrudes. Hernias can also penetrate through any other defect in the abdominal wall, through the diaphragm, or through other structures in the abdominal cavity.
• The most significant factors contributing to increased intra-abdominal pressure are
obesity, pregnancy, and lifting heavy objects.
➢ Indirect Inguinal Hernia is a sac formed from the peritoneum that contains a portion of the intestine or omentum. The hernia pushes downward at an angle into the inguinal canal. In males, indirect inguinal hernias can become large and often descend into the scrotum.
➢ Direct Inguinal Hernias, in contrast, pass through a weak point in the abdominal
wall.
➢ Femoral Hernias protrudes through the femoral ring. A plug of fat in the femoral canal enlarges and eventually pulls the peritoneum and often of the urinary bladder into the sac.
➢ Umbilical Hernias are congenital or acquired. Congenital umbilical hernias appear in infancy. Acquired umbilical hernias directly result from increased intra- abdominal pressure. They are most commonly seen in people who are obese.
➢ Incisional, or Ventral Hernias occur at the site of a previous surgical incision.
These hernias result from inadequate healing of the incision, which is usually caused by post-operative wound infections, inadequate NUTRITION, and obesity.
Chapter 56: Care of Patients with Noninflammatory Intestinal Disorders, pp. 1121-1126 Intestinal Obstruction
• Intestinal obstruction is a partial or complete blockage of the bowel that results in the
failure of the intestinal contents to pass through. With obstruction, gas and fluid accumulate proximal to and within obstructed segment causing bowel distention. A bowel obstruction is divided into two basic categories: mechanical and non-mechanical.
• Treatment of intestinal obstruction is directed toward relieving symptoms, managing fluid
and electrolyte imbalances, preventing complications, and treating the cause of the obstruction.
• Surgery may be needed to relieve the obstruction if gastric decompression does not
relieve the symptoms, or if there are signs of bowel necrosis. The type of surgery will depend on the type and area of obstruction and may include intestinal resection with an anastomosis or creation of an ileostomy or colostomy.
SMALL BOWEL:
• If the small bowel obstruction is complete, the peristaltic waves become quite vigorous, assuming reverse direction, propelling intestinal contents toward the mouth rather than the rectum.
• The patient vomits stomach contents first, then the bilious contents of the duodenum, and
finally the fecal contents of the ileum.
• A distended abdomen, a bloated sensation, and altered bowel sounds may indicate a small bowel obstruction. Patients with Ileostomy who develops distention and cramping should apply warm, moist towels to abdomen or lightly massage abdomen.
LARGE BOWEL:
• Constipation may be the only symptom for several days. Barium enema may be ordered to reveal a distended, air-filled colon. Monitor the patient for bowel movement after a barium enema.
• Patients with large bowel obstructions may experience intermittent persistent lower
abdominal cramping. Severe pain may result from strangulation or bowel perforation.
Chapter 57, Care of Patients with Inflammatory Intestinal Disorders, pp. 1117-1119 Dumping Syndrome (postop) (No treatment, patient waits it out).
• Rapid emptying of gastric contents into the small intestines. This results in a fluid shift
into the gut causing abdominal distention.
• Observe for early manifestation of this syndrome, which typically occur within 30 minutes of eating.
• Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitation, and the desire to lie down
• Monitor patient for late dumping syndrome, which occurs 90 minutes to 3 hours after
eating, is caused by a released of an excessive amount of insulin. The insulin release follows a rapid rise in the blood glucose level that results from the rapid entry of high carbohydrate food into the jejunum.
• Observe for manifestations including dizziness, lightheadedness, palpitations,
diaphoresis, and confusion.
• Dumping syndrome is managed by nutrition changes that include decreasing the amount of food taken at one time and eliminating liquids ingested with meals.
• Teach small frequent feedings, no liquids before or with meals.
• Teach to eat high protein, fat foods, low to moderate carbohydrate diet.
• Avoid smoking and NSAIDS.
• All we can do is to teach, there is nothing we a do for the patient.
• Patient will need to lie down and wait it out.
Chapter 56: Care of Patients with Noninflammatory Intestinal Disorders: pp. 1130-1135 Colostomy
When are colostomies performed?
• Colostomies are performed because of problems with the lower bowel. Some problems can be corrected by temporarily diverting stool away from the bowel. This is when temporary colostomies are used to keep stool out of the colon. If the colon becomes diseased, as in the case of colon cancer, permanent colostomies are performed, and the colon may be removed completely.
How does it initially look like?
• Must be patent, must be functional, healthy and do not injury it (need to protect the stoma).
• It will be quite swollen from surgery at first but will shrink to its final size about 6 to 8
weeks after surgery.
• What you are seeing is the inner lining of the intestinal wall folded under to form a stoma.
• It should nice beefy red, and moist. (if not red, pink and must be moist)
• Should not be dry, pale, yellow, dusky, ash and the surrounding skin should not be dry and shiny around the stoma (all indication something wrong with the circulation).
• There should be no drainage except for the normal, if an ileostomy the drainage will be
dark green liquid drainage, and a colostomy once patient starts having bowel movement there will be fecal material coming out into the pouch.
• If the drainage is greenish, with pus, and a foul odor, should not happen, contact doctor.
What does a healthy stoma look like?
• When you look at a stoma, you are looking at the lining (the mucosa) of the intestine wall, which looks a lot like the inside lining of your cheek. The stoma will look pink to red. It’s warm and moist and secretes small amounts of mucus.
What teaching would you do regarding diet and pouching/application of appliance?
• The patient will receive only IV fluids for two to three days after a colectomy or colostomy, to give the colon time to heal. After that, you can try clear liquids, such as soup broth and juice, followed by easy-to-digest foods, such as toast and oatmeal.
• You will be able to go back to your normal diet after this, but if you have a colostomy,
you may want to avoid certain foods that cause odors or gas, which can over-inflate the colostomy bag and make it more difficult to manage.
• There should be an ostomy nurse come in initially and do a plan of care, teaching and we
will do a lot of reinforcing.
• Teach them what the stoma looks like and how to monitor for infection (increase of drainage, the increase of redness around the stoma, warm to the touch and pain are signs of infection and need to report it).
• Need to monitor the drainage and that it is the correct drainage in the pouch, in the
ileostomy there will always be drainage from the small intestine like enzymes, fluids, and partially digested food.
• No thickening agents with an ileostomy, can cause an obstruction.
• If there is no drainage does not take laxatives with an ileostomy or an enema.
• You can have an enema with a colostomy.
• Teach to place moist towel on abdominal to stimulate the peristalsis or lying down on the side in a fetal position, and if cramping drink hot tea.
• Do not do anything else to start peristalsis.
• Teaching to avoid offending foods like cabbage, broccoli, beans or and foods that can cause gas.
• Application of their appliance or the wafer, every time they change the wafer, the stoma
needs to be remeasured until the stoma remains to their normal size and make sure it is seal good, no moisture or skin exposure. (paste to seal, 1/8 -1/16 may want to draw a stencil once normal size)
• Do not allowed the bag to get more than 1/3 full or ½ full at the max, will need to be
empty.
Chapter 57: Care of Patients with Inflammatory Intestinal Disorders, pp. 1147-1148; Appendicitis
• When the appendix becomes inflamed and fills with pus it is called appendicitis.
Obstruction of the appendiceal lumen causes appendicitis.
• If 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 peritoneum that can be fatal unless it is treated quickly with strong antibiotics.
• The classic symptom of appendicitis is abdominal pain. Pain becomes sharper over
several hours and worsens with coughing, walking or other jarring movements.
• May start with pain around the belly area and move and localize in the RLQ.
• A sharp pain is felt in the lower right abdomen when the area is pressed on and then the pressure is quickly released. This is known as rebound tenderness. Pain is relieved by bending the knees.
Chapter 57, Care of Patients with Inflammatory Intestinal Disorders, pp. 1144-1147 Peritonitis
• Peritonitis results from contamination of a normal sterile peritoneal cavity with bacteria
or chemical irritant.
• Classically the patient will have an acute abdomen with abrupt onset of diffuse, severe abdominal pain.
• Depending on signs and symptoms, treatment includes nasogastric decompression,
hyperalimentation, and colloids such as plasma and blood cells.
• The plan of care will have been effective if the patient’s peritonitis has been eliminated and the source removed without complications and the patient fluid balance and pain are effectively treated.
Chapter 57, Care of Patients with Inflammatory Intestinal Disorders, pp. 1148-1150 Gastroenteritis
• Gastroenteritis is an inflammation of the stomach and intestinal tract that primarily
affects the small bowel. The major clinical manifestations are diarrhea resulting in hypokalemia and abdominal pain and cramping.
• Associated clinical manifestations are nausea, vomiting, fever anorexia, distention,
tenesmus, and borborygmic.
• Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit and electrolyte imbalance. Treatment should focus on intravenous fluids and monitoring for cardiac dysrhythmias.
Chapter 57, Care of Patients with Inflammatory Intestinal Disorders, pp. 1150-1157 Inflammatory Bowel Disease
Ulcerative Colitis
• Inflammatory bowel disease refers to two chronic diseases that cause inflammation of the intestines: Ulcerative colitis and Crohn's disease. Both have similar symptoms but are different in the way they affect the digestive tract.
• When providing patient education for the patient who has had an ostomy the nurse needs
to include many things. The nurse should discuss dietary modifications related to nutritional status and provide referral to dietitian for diet planning (lean meats, legumes, water). Teach the importance of maintaining a high fluid intake and manifestations to recognize dehydration.
• The treatment is considered to have been effective if the patient has a decrease in
diarrhea, increases their nutritional intake and gains weight, pain is reduced or eliminated, complications do not occur, and they effectively manage stress.
Chapter 57, Care of Patients with Inflammatory Intestinal Disorders, pp. 1157-1162 Inflammatory Disease of Small Intestines
Crohn’s Disease
• Crohn’s disease involves all the intestines. Ulcers and fissures develop in Crohn’s disease. In Crohn’s disease the pain is in the lower right quadrant of the abdomen.
• New therapies are beginning to be utilized for patients with Crohn’s disease including
immune response modifiers such as therapeutic monoclonal antibody certolizumab pegol (Cimzia) and adalimumab (Humira). Patients should report cold-like symptoms or sore throat, avoid public places while taking this medication, understand abdominal pain, nausea, and vomiting are common side effects of this medication, and learn to give self- injection.
• The patient who is acutely ill may need to have total bowel rest and receive parenteral
nutrition. This usually is through hyperalimentation. Anxiety is common for newly diagnosed patients and therapeutic communication about the disease is critical to treatment.
• When medical management for ulcerative colitis is not successful surgical intervention
will result in the patient having an ostomy. A stoma is created on the abdomen where an appliance is applied to retain stool. It is emptied at intervals and always before it is half full. Apply a skin barrier directly to the stoma prior to application of the pouch system.
Chapter 57, Care of Patients with Inflammatory Intestinal Disorders, pp. 1162-1164 Diverticulosis (pouches or sacks) / Diverticulitis
• Diverticulitis occurs when one or more diverticula become inflamed or infected.
Diverticula are small, bulging pouches that can form anywhere in the digestive system, including the esophagus, stomach, small intestine, and most commonly in the large intestine.
• The medical treatment includes a liquid or low-fiber diet and antibiotics. Rest is also
needed. Over-the-counter pain reliever, such as acetaminophen (Tylenol) may be taken.
• Opioids are avoided if possible as they tend to be constipating and may aggravate the problem. Patients should void the use of over-the-counter (OTC) laxatives to prevent constipation, monitor for signs of bleeding, and limit intake of dietary fat
Chapter 58: Care of Patients with Liver Problems, pp. 1180-1186 Hepatitis
• Hepatitis is a widespread inflammation of the liver that results in degeneration and
necrosis of liver cells.
• Hepatitis A has an incubation period of 15 to 50 days. It is spread via the fecal-oral route by fecal contamination either from person-to-person contact or by consuming contaminated food or water. More common in countries with poor sanitation (handwashing) are most at risk.
• The hepatitis B virus is spread through unprotected sexual intercourse with an infected
partner, sharing needles, accidental needle sticks, and hemodialysis. Use standard precautions when caring for a client who has hepatitis HBV.
• Hepatitis C is caused by a single-stranded RNA virus, has an incubation period of 7
weeks, and is transmitted via blood to blood. It is usually spread by sharing drug needles,
needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia.
Chapter 59, Care of Patients with problems of the Biliary System and Pancreas, pp. 1071 Endoscopic Retrograde Cholangiopancreatography (ERCP)
What is it?
• A visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas to identify the cause and location of obstruction. It is commonly used today for therapeutic purposes rather than for diagnosis.
• The test looks "upstream" where digestive fluid comes from the liver, gallbladder, and
pancreas to where it enters the intestines.
• After a cannula is inserted into the common bile duct, a radiopaque dye is instilled, and several x-ray images are obtained.
• The physician may perform a papillotomy (a small incision in the sphincter around the
ampulla of Vater) to remove gallstones. If a biliary duct stricture is found, plastic or metal stents may be inserted to keep the ducts open.
• Biopsies of tissue are also frequently taken during this test.
What is the prep required?
• This test requires the use of moderate sedation during the procedure.
• NPO the night before or at least 8 hours.
• Five to seven days off the anticoagulants or NSAIDS before the procedure.
• Monitor for implants like pacemaker or defibrillators etc.
What does after care consist of?
• Monitor for bleeding (high risk), perforation, fever, and pain.
• Monitor gag reflex, the sedation will block the gag reflex to prevent to prevent aspiration.
• Keep NPO until they get their gag reflex back. (1 to 2 hours before the anesthetic is out the system). Patient must have someone accompany them home after recovery.
Chapter 59, Care of Patients with problems of the Biliary System and Pancreas, pp. 1072 Colonoscopy
What is it?
• Is an endoscopic examination of the entire bowel.
• The American Cancer Society recommends that, beginning at age 50 years, all healthy men and woman should have a colonoscopy every 10 years or sooner if at high risk for polyps or family history of colon cancer.
• Use for GI bleeding, precancerous polyps, and this is usually when Diverticulitis is
found.
What is the prep required?
• The bowels will need to be cleansed (doctor will prescribe a laxative like GoLYTELY (laughing, that’s what you think) prep the day before the procedure to help with the cleanse. (“prepare to stay home”) Bisacodyl (Dulcolax), or Fleet.
• Teach patient to stay on a clear liquid diet the day before the scheduled colonoscopy.
• 3Teach to avoid consuming anything red, orange, or purple (grape) beverages or gelatin and to drink an abundant amount of Gatorade or other sports drink to replace electrolytes that are lost during bowel preparation.
• The patient needs to be NPO (except water) 4 to 6 hours before the procedure.
• Remind patients to avoid aspirin anticoagulant, and antiplatelet drugs for several days before the procedure.
• Patients with diabetes should check with their primary health care provider about drug
therapy requirements on the day of the test because they are NPO.
• GoLYTELY should not be used for older adults to prevent excessive fluid and electrolyte loss.
• IV access is necessary for the administration of moderate sedation. (IV Midazolam
hydrochloride (Versed), Propofol (Diprivan), and or an opiate such as fentanyl.
What does after care consist of?
• Maintain NPO status until patient has passed flatus to indicate that peristalsis has returned.
• Have patient to lie on their left side to promote comfort and encourage passing flatus.
• Patient must have someone accompany them home after recovery.
Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas, pp. 1191- 1197
Gallbladder Disorders
• Cholelithiasis, or gallstones, develop due to the inflammation of the gallbladder, the inflammation is called cholecystitis.
• The nursing assessment will include dietary preferences focusing on consumption of fatty
food in relation to pain developing. Patients with acute cholecystitis present with abdominal pain, although clinical manifestations vary in intensity and frequency.
• Cholecystectomy is removal of the gallbladder. The laparoscopic cholecystectomy is the
gold standard and is performed far more often than the traditional open approach.
• Patient education for patients with biliary disorders includes dietary teaching. Tell the patient not to skip meals and to exercise regularly. Foods not well tolerated include eggs, pork, onions, poultry, milk, coffee, oranges, corn, beans, and nuts.
Chapter 59: Care of Patients with Problems of the Biliary System and Pancreas: pp. 1192- 1195
Cholelithiasis What is it?
• Cholecystitis is an inflammation of the gallbladder
• If left untreated, cholecystitis can lead to serious complications, such as tissue damage, tears in the gallbladder and infection that spreads to other parts of the body
• Cholecystitis may occur suddenly (acute cholecystitis), or it may develop slowly over
time (chronic cholecystitis)
Causes:
• Gallstones - resulting in gallbladder inflammation
• Injury - trauma to your abdomen or surgery — may cause cholecystitis
• Infection - An infection within the bile can lead to gallbladder inflammation
• Tumor may prevent bile from draining out of the gallbladder properly
What does it look like?
• Pain (unbearable pain)
• Upper abdominal pain (RUQ) (some people feel pain in difference places like mid-gastric in the chest, right shoulders or back)
• Nausea
• Vomiting
• Fever
• Bloating, distending abdominal
• A gallbladder attack occurs after digesting a large meal with high fat content.
How is it managed?
• In the hospital the patient will be put NPO
• IV narcotics for pain
• IV hydration
Blood tests
• white blood cell count is higher
• bilirubin (elevated)
• alkaline phosphatase (elevated)
• serum aminotransferase (liver enzymes)
Scans
• Abdominal ultrasound or a computerized tomography (CT) scan
• Hepatobiliary iminodiacetic acid (HIDA) scan - track the production and flow of bile from the liver to the small intestine and show if bile is blocked at any point along the way (cholescintigraphy, hepatobiliary scintigraphy or hepatobiliary scan)
Surgery (laparoscopic or cholecystectomy)
• Open cholecystectomy
• Insert a T tube or Penrose into the common bile duct.
What are the nursing measures?
• Administer pain medications & assess results
• IV fluids if acute attack
• Cholesterol dissolving agents
• Ursodeoxycholic acid (Urdox tablets) Primary and secondary bile acids to help the body digest fat)
• Low-fat diet, don't skip meals (small frequent meals)
• Provide and teach post-operative care
• Assess incision
• Monitor drainage from T tube
• Prevent pneumonia
• Comfort measures
• Exercise most days of the week (early ambulation)
• Lose weight slowly (maintain a healthy weight)
• Avoid offending foods are eggs, pork, onions, poultry, milk, coffee, oranges, corn, beans, and nuts.
What are the complications and how do we prevent them?
• Peritonitis’s (ruptured or hemorrhage)
Chapter 60: Care of Patients with Undernutrition and Obesity, pp. 1211-1232 Malnutrition
• Complications associated with malnutrition in adults include muscle wasting, lethargy,
intolerance to cold, edema, dry skin or dermatitis, poor wound healing, infection, and possible death.
• Socioeconomic factors can have a negative effect on nutritional status. The assessment
should include details on social isolation, access to food, depression, substance abuse, and poverty.
• Nutritional status is influenced by the ability to swallow and the body’s ability to absorb
nutrients.
• Nursing interventions to promote intake include providing mouth care before meals, getting the patient up to a chair for meals if possible, and trying to increase social interaction during meals. Six small meals a day consisting of high-calorie and nutrient- rich foods, such as milkshakes and cheese, are recommended.
• If the patient is unable to consume adequate nutrition by mouth, either total enteral
nutrition (TEN) or total parenteral nutrition (TPN) is needed. Total enteral nutrition (TEN) or tube-feeding refers to a method of infusing nutrient solutions or formulas directly into the GI tract through tubes that enter through the nose, mouth, or abdominal wall.
Chapter 60: Care of Patients with Malnutrition Undernutrition and Obesity, pp. 1225-1232 Obesity
• Bariatric surgery is treatment for patients who have a BMI > 40. The laparoscopic
adjustable-banded gastroplasty (lab band) is a procedure where an adjustable band is used to create a small pouch.
• Postoperative care depends on the type of surgery. Special bariatric equipment such as
extra-wide bed and additional personnel for moving the patient may be required. If there is an NG tube, do not reposition, as it can disrupt the suture line.
• Clear liquids are introduced slowly at first. Pureed foods, juice, and soups thinned with
broth, water, or milk are added to the diet 24 to 48 hours after clear liquids are tolerated. During the first six weeks, intake is limited to liquids or pureed foods before regular food is introduced slowly.
• Leaks are the most common serious complication and cause of death. Manifestations
include pain in the back, shoulder, or abdominal area, restlessness, tachycardia, and oliguria.
• Use an abdominal binder to prevent wound dehiscence postop and place the patient in
semi-fowler’s position. Early ambulation is key to preventing complications; ambulation is expected on the day of surgery.
• Observe for signs and symptoms of dumping syndrome after gastric bypass, such as tachycardia, nausea, diarrhea, and abdominal cramping. Consuming several small meals daily will help dumping syndrome.
Chapter 60: Care of Patients with Malnutrition Undernutrition and Obesity, pp. 1220-1221 NG Tube Insertion
• Patient in high fowlers
• Towel on patient’s chest and emesis basin within reach
• Wipe nasal bridge with alcohol swab
• Stand on pts right side if right handed
• Select nostril with greatest air flow
• Measure tube distance – tip of nose to earlobe, then to xiphoid process
• Mark length on tube with tape prior to insertion to prevent inserting greater length than needed
• Lubricate 7.5-10cm of tube
• Instruct patient to initially extend neck back against pillow
• Insert tube gently and slowly through nares
• Aim down to patient’s ear
• If resistance is felt, do not force tube
• If resistance is felt, try to rotate tube to advance
• If resistance still met, withdraw tube, allow patient to rest, then lubricate again and attempt in other nare
• When tube reaches just above oropharynx, instruct patient to flex head forward, take a
small sip of water and swallow
• Advance tube 2.5-5cm with each swallow
• If patient begins to cough, gag or choke withdraw tube slightly and stop advancement, instruct patient to breath and take sips of water
Check placement
• Instruct patient to talk
• Inspect posterior pharynx for coiled tube
• Attach catheter tip syringe to end of tube and aspirate contents – check color and pH
• Order X ray to check tube placement
Med Surg Exam 3 Streb PP Chapter 8
Chapter 27, Assessment of the Respiratory System, pp. 520
Breath Sounds
Bronchial breath sounds https://www.easyauscultation.com/cases? coursecaseorder=6&courseid=201
• Bronchial breath sounds are hollow, tubular sounds that are higher pitched compared to
vesicular sounds. They can be auscultated over the trachea where they are considered normal.
Bronchovesicular breath sounds https://www.easyauscultation.com/cases? coursecaseorder=8&courseid=201
• Inspiration to expiration periods are equal. These are normal sounds in the mid-chest area
or in the posterior chest between the scapula. They reflect a mixture of the pitch of the bronchial breath sounds heard near the trachea and the alveoli with the vesicular sound.
Vesicular breath sounds https://www.easyauscultation.com/cases? coursecaseorder=1&courseid=201
• Vesicular breath sounds are soft and low pitched with a rustling quality during inspiration
and are even softer during expiration. These are the most commonly auscultated breath sounds, normally heard over most of the lung surface. They have an inspiration/expiratory ratio of 3 to 1
Wheezes breath sounds https://www.easyauscultation.com/cases? coursecaseorder=4&courseid=201
• Wheezes are adventitious lung sounds that are continuous with a musical quality.
Wheezes can be high or low pitched. High pitched wheezes may have an auscultation sound like squeaking. Lower pitched wheezes have a snoring or moaning quality.
Rales breath sounds https://www.easyauscultation.com/cases? coursecaseorder=3&courseid=201
• Fine crackles are brief, discontinuous, popping lung sounds that are high-pitched. Fine
crackles are also like the sound of wood burning in a fireplace, or hook and loop fasteners being pulled apart or cellophane being crumpled
• Coarse crackles are discontinuous, brief, popping lung sounds. Compared to fine crackles
they are louder, lower in pitch and last longer. They have also been described as a bubbling sound. You can simulate this sound by rolling strands of hair between your fingers near your ear.
• After reviewing the sound, use the waveform and anatomy tabs for more information
about this sound.
Rhonchi breath sounds https://www.easyauscultation.com/cases? coursecaseorder=5&courseid=201
• Low pitched wheezes (rhonchi) are continuous, both inspiratory and expiratory, low
pitched adventitious lung sounds that are like wheezes. They often have a snoring, gurgling or rattle-like quality.
Chapter 28, Care of Patients requiring Oxygen Therapy or Tracheostomy, pp. 533 Oxygen Therapy (see flyer)
• Assess patient’s general appearance (facial expression, posture, alertness, speech pattern
or signs of distress), vital signs (tachycardia, tachypnea), assess trachea, chest movement, respiratory effort, and use of accessory muscles.
• Pursed Lip Breathing inhibits airway collapse and decreases dyspnea. Encourage patients [Show Less]