Nursing diagnosis for a patient with oral cancer
Ineffective breathing pattern: Monitor respiratory status frequently & report any signs of inadequate oxygenation (dyspnea, restlessness, tachycardia) If edema is present, elevate the head of the bed & be prepared to administer O2
Patient teaching to prevent oral cancer
Tell the patient to report any dental problem or pain in the mouth to a dentist or a physician for early evaluation.
Disorders affecting digestion & absorption
Prolonged severe vomiting can lead to significant losses of fluids & electrolytes.
Patient teaching for the patient with a hiatal hernia.
Eat small frequent meals & avoid foods that aggravate the condition ( fatty foods, caffeine, or alcohol)
Dumping syndrome after gastric surgery (stages)
1st stage- 20 to 30 minutes after eating the patient experiences abdominal fullness & nausea.
Intermediate stage- 20-60 minutes after eating the patient experiences abdominal bloating, flatulence, cramps & diarrhea
Late stage- 1 to 3 hours after eating the patient may perspire, feel weak, anxious, shaky, or hungry
These symptoms are blamed on hypoglycemia caused by an exaggerated rise in insulin secretion in responce to the rapid delivery of carbohydrates into the intestine. Dumping syndrome usually disappears within a few months.
Sign & symptoms of malabsorption
A common nsign of malabsorption is steatorrhea, which is the presence of excessive fat in the stool, these stools are large, bluky, foamy, & foul smelling. Patients may also have weight loss, fatigue, dicreased libido, easily brusing, edema, anemia, & bone pain.
Complication of malabsoption
Chronic diarrhea interferes with absorption of nutrients & can lead to malnutrition and anemia
Nursing diagnosis for the patient with malabsorption
Deficient fluid volume & imbalanced nutrition: less than body requirements. This diagnosis focuses on the prevention of serious fluid & electrolyte imbalances. This patient should drink atleast 2000-3000 mL of fluids daily. Excessive or rapid fluid replacement can cause heart failure, especially in older adults!
Hernias are classified as reducible or irreducible. A reducible hernia slips back into the abdominal cavity with gentle pressure or when the patient lyes on their back. An irreducible hernia cannot be manipulated back into place, this type of hernia may impair blood flow to the trapped loop of intestine, causing it to become gangrenous.
Diseases associated with IBD
Inflammatory bowel disease (IBD) refers to both Ulcerative colitis & Crohn's disease
Recommended diet for the patient with IBD
A low roughage diet without milk products is prescribed for mild to moderate IBD. IV fluids or TPN may be needed to provide fluid, eletrolytes, & nutrients when symptoms are severe
Treatment of Diverticulosis
Diverticulosis is currently being treated with a high residue, which is high fiber diet without spicy foods, nuts or seeds such as peanuts & rasberries.
Signs & symptoms of right sided colorectal cancer
In the early stages the sympotms are usually mild, this patient may experience vague cramping until the disease has progressed, unexplained anemia, weakness & fatigue related to blood loss may be the only early symptoms of right sided colon cancer.
Signs & symptoms of left sided colorectal cancer
Cancers on the left side cause more obvious changes in bowel function, patients may develop diarrhea or constipation and may notice blood in the stool. These patients usually have no pain!
Nursing assessment of the liver, review of systems
Note the color of stools because clay-colored stools are characteristic of bile obstruction & black stools can indicate GI bleeding
Physicial examination of the liver patient
Examination of the abdomen is especially important in detecting liver disease. note the presence of prominent veins. If significant ascites (fluid accumulation in the abdomen) is present, the abdomen appears distended. Measure the abdomen at the largest circumference by marking the abdomen on the midline & both sides so that any other measurements taken are acurate, also daily weights are important to dectect fluid retension!
Crae for the patient after a liver biopsy
A pressure dressing is placed over the puncture. It should be checked for bleeding every 15 minutes for the first hour, then every 30 minutes for the next hour & then hourly thereafter or according to protocal of the facility. The primary complications of a liver biopsy are hemorrhage & a pneumothorax
preicteric phase of hepatitis
patient feels malase, severe headache, right upper quadrant abdominal pain, anorexia, nausea, vomiting, fever, arthralgia (joint pain), rash, enlarged lymph nodes, urticaria, & enlargement & tenderness of the liver. This stage lasts for 1 to 21 days.... This is the stage where the patient is the most infectious!
icteric phase of hepatitis
this stage is characterized by jaundice, light clay-colored stools, & dark urine, puritis may be present & the GI systems from the preicteric phase often persist. This stage lasts for 2 to 4 weeks
posticteric phase of hepatitis
During this stage the patient feels malase, fatigued, & liver enlargement. This stage lasts for several months
2 Nursing diagnosis for hepatitis
Deficient fluid volume related to inadequate intake & vomiting, the patient should maintain a fluid intake of 3000 mL/day unless contrindicated, kepp intake & output records & be alert for signs of fluid retension such as increasing abdonimal girth, rising blood pressure, & edema.
Risk for impaired skin integrity related to puritis & scratching, bathe the patients skin in cool water, & pat dry. Mild soap may be used as well as lubricating lotions or topical antiprurectics, trim the fingernails or mittens may be used for confused patients or consult the physician about ordering an antihystamine.
Staff protection against hepatitis
Standard precautions are utilized, OSHA requires vaccination for hepatitis B for nurses & other health care providers. The vaccine is given in a series of 3 injections, follow up titers will be taken to establish if there are antibodies present. The health care worker may also sign a waver to refuse the vaccinations.
Complications of cirrhosis
Portal hypertension- the portal vein is obstructed which restricts blood flow & causes blood flow to back up in the portal system, therefore causing high portal pressure (hypertension) & this causes collateral vessels, commonly found in the esophagus, anterior abdominal wall & rectum.
Espohageal varicies- distended engorged veins in the esophagus which are fragile & bleed easily. intra-abdominal pressure is increased by vomiting, coughing, heavy lifting, & straining at stool.
Ascities- Accumulation of fluid in the peritoneal cavity
Hepatic encephalopathy- The failing liver is unable to detoxify ammonia, a breakdown product of protein metabolism, this causes neurologic symptoms such as cognitave disturbances, decling levels of conciousness, & changes in neuromuscular function. This patient should be placed on seizure precautions
Medical treatment for the patient with cirrhosis
The goal is to limit deterioration of liver function & prevent complications, but there is no specific medical treatment. Bed rest is usually ordered if the patient is in liver failure & a diet high in carbohydrates & vitamins with a protein restriction until the ammonia levels fall
Nursing care for the patient with cirrhosis
Ongoing assessment should include daily weights, I & O, & measurement of abdominal girth. Patients should be monitored for signs & symptoms of complications- bleeding, ascities, encephalopathy, & renal failure.
Nursing diagnosis for the patient post cholelithiasis
Acute pain related to surgical incision, nasogastric tube, show the patient how to support incision using a pillow during coughing & deep breathing.
Ineffective breathing pattern related to splinting of surgical incision, explain the importance of deep breathing & coughing to avoid pneumonia
Impaired skin integrity related to wound drainage & surgical incision, it is espially important to monitor wound & frequently change dressing as drainage contains bile & digestive enzymes which can cause skin irritation
deficient fluid volume related to GI suctioning, measure I&O & check to be sure suction equipment is working properly, Nausea & vomiting can occur from suctioning so watch for dehydration!
Risk for infection related to surgical incision, invasive proceedure monitor drainage site for infection as draining wounds provide a warm moist enviornment for bacteria to grow
chronic inflammation of the pancreas can cause the patient to develop diabetes millitis.
Diagnostic test done to determine acute pancreatitis
The most important diagnostic test that indicates acute pancreatitis is an elevated serum amylase level.
Nursing diagnosis for the patient with acute pancreatitis
Acute pain related to bilary obstruction, inflammation, infection, & auto digestion. Provide ordered analgesics promptly, utilize other methods such as distraction, repositioning & imagery