73 terms

NCLEX: Alteration in body system

Giardia lamblia: source
contaminated water
Shigella: source
fecal contamination: affects pediatric population
Hiatal Hernia:
opening in diaphragm through which the esophagus passes becomes enlarged, part of the upper stomach comes up into the lower portion of the thorax
Hiatal Hernia: tx
cytoprotective agents: protect the lining of the GI tract (carafate). Surgery to tighten cardac sphincter (fundoplication)
inflammation of stomach that may be actue or chronic.
Gastritis: implementation
-NPO slowly progressing to bland diet
-Antacids often relieve pain
Duodenal ulcer & Gastric Ulcer Risk factors:
alcohol, smoking, stress, NSAIDS (gastric)
Duodenal ulcer Pain
2-3 hrs pc; food intake relieves pain
Gastric ulcer Pain:
1/2-1 hrs pc meal; relieved by vomiting, food does not help
Ulcer: plan/implementation
eat 3 meals/day; avoid extreme temp; avoid coffee, alcohol caffeinated beverages, milk, cream, STOP smoking
removal of stomach and attachment to upper portion of deodenum
cutting the vagus nerve ( decrease the HCl secretion)
Billroth I
partial removal of stomach
Billroth II
removal of distal segment of stomach and antrum
pyloric stenosis
in adults, narrowing or obstruction of the pyloric sphincter caused by scarring from healing ulcers (peptic ulcers). in infants, obstruction caused by hypertrophy and hyperplasia of pylorus
pyloric stenosis: assessment
projectile in infants, palpable olive-shaped tumor in epigastrium
pyloric stenosis: postoperative
small frequent feeding of glucose water or electrolyte solution 4-6 hrs Post Op, if clear fluids rained start formula 24 hrs postop. Fold diapers so it doesnt touch incision site.
excavation formed in the mucosal wall, caused by erosion that my extend to muscel layers or through the muscle to the peritoneum (h. pylori)
ulcers: plan
avoid oversecretion and hypermotility in the GI tract. eat 3 small frequent meals, stop smoking (inhibits ulcer repair)
ulcers: Postoperative
vitamin b12 required for life.
dumping syndrome:
rapid passage of food from stomach causing diaphoresis, diarrhea, hypotension
dumping syndrome: teaching
restrict fluids with meals, drink 1 hr ac or 1 hr pc
Crohn's disease: diagnosis
inflammatory condition of any area of large or small intestine, usually ileum and ascending colon
Crohn's disease & ulcerative colitis: diet
high: protein & calories
Low: fiber & fat
TPN to rest bowel
Crohn's disease: assessment
steatorrhea, abdominal pain pc meals, ileum and right colon affected.
ulcerative colitis: diagnosis
inflammatory condition of the colon characterized by eroded areas of the mucous membrane and tissues beneath it. Ulcerative colitis is a type of inflammatory bowel disease (IBD) that affects the large intestine (colon) and rectum
ulcerative colitis: assessment
BLOOD, pus, mucus in stool, abdominal pain predefecation, involves the rectum and left colon
Appendicitis: Assessment
periumbilical abdominal pain shifts to RLQ at McBurney's point (located between umbilicus and the right iliac crest), localized tenderness, muscles gaurding, low-grade fever
Appendicitis: plan
no heatin pads, enemas or laxative pre-op, Maintain NPO, Ice bag to abdomen to alleviate pain, sudden cessation of pain indicates rupture of appendix
Appendicitis: surgery
appendectomy ( places in fowlers position Post-op)
Diverticular disease: assessment
cramping pain in left lower quadrant of abdomen relieved by passage of stool or flatus; constipating alternating with diarrhea
Diverticular disease: diagnosis
infection, inflammation or obstruction of diverticula (sacs or pouches in the intestinal wall) cause the pt to be symptomatic
Diverticular disease: plan
bulk laxative (metamucil), high fiber diet, avoid food with seed, increase fluid, anticholinergic (bentyl)
Anticholinergics are a class of medications that inhibit parasympathetic
Hirschsprung's Disease: Dx
Hirschsprung's disease is a blockage of the large intestine due to improper muscle movement in the bowel. It is a congenital condition, which means it is present from birth.
Hirschsprung's Disease: Plan
High calories, protein diet. Low-fiber diet. Measure abdominal at umbilicus. Let partent know colostomy is usually temporary, closed when child is 17-22lbs.
Abdominal hernias: Dx
protrusion of an organ through the wall of the cavity in which it is normally contained.
Strangulated hernia:
severe abdominal pain, n/v distention intestinal obstruction. blood supply to the intestine is obstructed.
Meckel's Diverticulum: assessment
painless rectal bleeding, abdominal pain, Hematochezia(jelly-like stool)
Intestinal obstruction:assessment
high-pitched sounds above area of obstruction, decreased or absent below area of obstruction. Abdominal pain and distention; obstipation (no gas or stool)
Mechanical obstruction:
physical blockage of lumen of intestine usually seen in the small intestine. hernia, tumors, adhesions, strictures d/t radiation, intussusception, volvus ( twisting of bowel)
Nonmechanical obstruction:
paralytic ileus, no mechanical blockage absence of peristalsis
Intestinal obstruction: plan
intestinal decompression: insert of plastic or rubber tube into the stomach or intestine via nose or mouth. remove fluid or air mb removed.
types of tube used for intestinal obstruction:
salem sump or levin tubes (NG tube)
miller-abbot (intestinal)
Cantor (intestinal)
Bowel surgery purpose for intestinal obstruction:
removal of disease portion of bowel; creation of an outlet for passage of stool when there is an obstruction or need for bowel rest.
Intestinal ostomies for fecal diversion: plan
enemas evening before and morning of surgery; antibiotic day before surgery (erthromyocin);
Intestinal ostomies for fecal diversion: observation and condition of stoma
first few days appears beefy-red and swollen; gradually swelling receds and color is pink or red; notify physician if stoma is dark blue "blackish or purple" my indicate insufficient blood supply.
Intestinal ostomies for fecal diversion: drainage and description
first 1-2 days: mucus and serousanguineous begins to work 3-6 days post op
end of ileum (small intestine) rest of large intestine removed. ostomy return is liquid, soft and semisolid. open end pouch worn at all times. low residue diet no meats, corn or nuts. remove q 4-6 h
transverse colostomy
transverse colon (usually temporary). ostomy return is firm, very foul odor, pouch is worn continuously
descending or sigmoid colostomy:
descending or sigmoid colon (usually permanent. descending produce firm stool. sigmoid product solid stool.
Principles of skin protection:
pouch opening 1/8 in larger than stoma, use skin barrier under all tapes, use skin barrier to protect skin immediately surrounding the stoma, cleanse skin gently and pat dry (do not rub) pouch applied by pressing adhesive area to sin for 30 seconds, change appliance when seal breaks or when 1/3 or 1/4 full
Colostomy irrigations for sigmoid colostomy: purpose
to stimulate emptying of colon of gas, mucus, feces at scheduled times to avoid need for appliance. usually begin 5-7 post op. performed after meal same time each day.
Colostomy irrigations for sigmoid colostomy: procedure
500-1500 ml luke warm water, insert catheter 8 cm (3 inch), hang irrigating container at shoulder height (18-20 inch above stoma); water flow in 5-10 min, wait 10-15 min to allow return. leave sleeve on for 30-45 min. clean with soap and water
Cirrhosis complications
portal hypertension; edema and ascites, hepatic encephalopathy,
cirrhosis: plan
shunts to relieve portal hypertension, high protein, carbs, diet. sodium fat restrictions
Reyes Syndrome:
acute metabolic encephalopathy of childhood that causes hepatic dysfunction with links of aspirin with viral illness.
Reye's syndrome: assessment
Fever, increase ICP, decreased LOC, coma, decreased hepatic fxn
Reye's syndrome: mediation and tx
mannitol to decrease ICP, Diuretics (lasix) to decrease CSF production, Dilantin for anticonvulsants, FFP Vitamin K platelet transfusion for overt or covert bleeding
inflammation of the gallbladder
presence of stones in the gall bladder
Risk factors for Cholelithiasis/cholecystitis
Obesity, sedentary lifestyle, women, 50 yo, increased level of cholesterol
Cholelithiasis/cholecystitis: diet plan
avoid fried food, pork, cheese, alcohol
low fat
high protein, carbs skim milk
laparoscopic laser cholecystectomy:
removal of gallbladder by a laser through laparoscope; laparoscope is attached to video camera and procedure is viewed through monitor; four small puncture holes made in abdomen
Traditional cholecystectomy-
removal of gall bladder through a high abdominal incision
Endoscopic retrade cholangipancreatogrpahy (ERCP)
removes stones from bile duct no incision, done under sedation no anesthesia.
Murphy's Sign:
positive a sign of gallbladder disease consisting of pain on taking a deep breath when pressure is placed over the location of the gallbladder
inflammatory disease of the pancreas that may result in autodigestion of the pancreas by its own enzymes
Pancreatitis: assessment
abdominal pain, n/v vomiting 24/48 hrs after heavy meal or alcohol ingestion; pain relief with position change. RUQ/ LUQ pain radiates to back.
Pancreatitis: diet:
no etoh and caffeine, low fat bland diet, small frequent meals.
Systemic Lupus Erythematosus (SLE)
chronic systemic inflammatory disease of connective tissue that involves skin, joints, serous membranes, kidneys, hematologic system.
Systemic Lupus Erythematosus (SLE): assessment
polyarthralgia, arthritis, joint swelling, butterfly rach across bridge of nose ad cheeks,
Systemic Lupus Erythematosus (SLE): plan
protect skin from Ultraviolet rays and sunlight because of photosensitivity scaly and itchy rash.