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119 Cards in this Set
- Front
- Back
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What are the risk factors for oral cancer?
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Tobaccos (smoked & smokeless)
Alcohol Male 50 y.o. > A.A. |
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What are some S&S of squamous cell carcinoma?
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**Painless & won't heal
**Blister of surface of epithelium sloughs off Slow Growing Dysplagia Crusted or scaly w/ red, inflamed base Persistent, non-healing & ulcerated or thickened skin |
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What are some S&S of basal cell cancer?
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Primary on lips
Ulcer w/ raised, pearly border Can have ulceration Bleeds when disturbed Translucent Depression in center May ooze |
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What diagnostics are performed for oral or pharyngeal cancer?
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Oral exams (@ dentist)
Cervical lymph node assessment Biopsy suspicious lesions (esp. when won't heal in 2 weeks) CT scan of head/neck |
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What size tumors of the oral/pharyngeal area are likely to recur?
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Tumors > 4 cm often recur.
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What medical management is provided for cancers of the lip?
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Surgical revision w/ wide margins
Radiation therapy to shrink tumor allows smaller margins - less disfigurement Chemotherapy |
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What medical management is provided for cancers of the tongue?
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Radiation & Chemo - to shrink size
Surgery - hemiglossectomy or total glossectomy If metastasis - neck dissection & reconstruction |
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Explain radical neck dissection.
What complications may occur? |
Removal of all cervical lymph nodes
Removal of sternocleidomastoid muscle Removal of internal jug. vein & spinal access. muscle Complications: Shoulder drop & neck depression (aka cosmesis) |
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Explain modified radical neck dissection.
What complications may occur? |
Patient retains one or more non-lymph structures
Patient retains one or more lymph node groups Increase risk of recurrence |
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What are the potential complications for neck dissection?
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Hemorrhage
Nerve depression/Injury Chyle Fistula Impaired Airway Communication problems |
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Why is it difficult to assess for hemorrhage in the first 24 h post-op of neck dissection?
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We don't take dressings off in the first 24 h, we simply reinforce the dressing. Difficult to know what is going on under the dressing.
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S&S of Hemorrhage?
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Frank Blood
Hypotension Tachycardia Tachypnea Hypovolemic Cool, Clammy Skin Respiratory Distress - Pulse Ox, Lung Sounds, Respirations |
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What is a chyle fistula?
What is the hallmark sign? |
A leak of lymphatic fluid to the surface.
Milk white substance (fat, lymph, protein) in JP drain instead of blood. |
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How should we handle the risk of communication issues with a neck dissection?
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1 - Pre-op, discuss the possibility with the patient
2 - Ensure they know it is not permanent 3 - If trach is necessary, determine ways to communicate (wipe board, paper & pencil, iPad) |
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How is reconstruction handled for oral cancer?
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A graft of muscle, skin, subcutaneous tissue OR
microvascular free flap which includes muscle, skin, bone, artery & vein. Free flaps usually obtain from scapula, radial area, forearm or fibula. Fibula is often used to reconstruct the jaw. |
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What nursing care is provided for the surgical patient for neck dissections, reconstructive surgeries?
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Pre-Op teaching
**Maintain airway (**Fowlers) Assess for hemorrhage or chyle fistula Pain management Wound flap care & site care Assess for nerve injury Encourage nutrition Support coping measures Promote communication Maintain mobility Call Light within Reach Anxiety |
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What are the 3 top S&S of hypovolemic shock?
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Tachypnea
Tachycardia Hypotension |
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How much drainage is concerning post-surgery for neck dissection in the JP drain?
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> 120 ml in 24 hours is of concern.
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How do you assess a graft site?
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Color, temp & pulse
Should be warm & pale pink or appropriate for race Can use doppler if needed Look for S&S of infection - REEDA |
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If you have a patient with a mandibular fracture, what tool must you have easily accessible?
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Wire Cutters - this patients jaw is wired shut, if the patient aspirates, you must be able to access their airway
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What are the risk factors for Gastric Cancer?
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> 55 y.o.
Male Diet of smoked, pickled or salted foods Smoking Obesity Poor drinking water or lack of refrigeration |
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Where does stomach cancer usually metastasize too?
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This area is highly vascularized & there are a lot of nearby organs.
Liver, Pancreas, Esophagus & Duodenal Lymph Nodes |
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What are the early vs. late symptoms of gastric cancer?
What is the extremely late sign? |
Early: **Usually Asymptomatic
Pain relieved with antacids Late: Dyspepsia Early satiety Weight Loss Abdominal pain above umbilicus Extremely late: Anemia |
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What is the preferred test of gastric cancer?
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EGD w/ biopsy & cytology (this gets us cell scrapings to study)
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What are the assessments & diagnostics to be performed if gastric cancer is suspected?
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EGD w/ biopsy & cytology
Stools for occult blood CBC - checking anemia Palpation - if palpated, it is late Barium Swallow (upper GI) Endoscopic U/S CT-chest, abdomen, pelvis - metastasis? |
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When are most gastric cancers found (staging wise)
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Stage III or IV (IV is metastasis already)
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If a patient survives gastric cancer, what screenings will be performed regularly?
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CEA's for life.
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What common problems occur with advanced gastric cancer?
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Pyloric Obstruction - r/t scar tissue formation
Bleeding & ***ANEMIA*** - bleeding may occur at anastamosis site - anemia - indicative of advanced cancer Severe Pain - r/t laparotomy Gastric Perforation - causes peritonitis (severe pain) |
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What is the causative factor of gastric perforation?
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Ulcers cause scar tissue which are less elastic & more fragile which increases risk of eventual perforation. Perforation leads to peritonitis which will present as severe pain.
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What is the medical management of gastric cancer?
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Surgery - total gastrectomy or tumor resection
Diagnostic Laparoscopy - biopsy, evaluate, make plan Palliative |
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Explain a total gastrectomy.
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Removal of:
stomach duodenum (where calcium is absorbed) lymph nodes & mesentary lower portion of esophagus Esophagus is then reconnected to jejunum. |
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What is the problem/outcome of a total gastrectomy?
What is the medical management of this? |
Pernicious anemia - without the stomach there is no intrinsic factor, with no intrinsic factor there is no absorption of B12, without B12 - pernicious anemia.
Management - B12 injections for life (initially will be weekly & then monthly for management) |
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What is the difference between a Billroth 1 & a Billroth 2 surgery?
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Billroth 1 - lower stomach resection. Upper part of the stomach and is anastamosed to the (jejunum (Robin) or duodenum (textbook))
Billroth 2 - Total stomach removal (Robin) / 75% of lower stomach removed (Textbook) |
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Which procedure has a better outcome? Billroth 1 or Billroth 2?
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Billroth 2 in that you have a less likelihood of recurrence.
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What are the indications for Gastric Surgery?
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Life threatening hemorrhage
Obstruction - can't be fixed by other means Penetrations - stab wounds Gastric Cancer Trauma Ulceration (unresponsive to meds or EGD treatment) |
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What are the short term complications of gastric surgery?
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Anastomosis leaks
Blood clots Bowel obstruction Pneumonia Inflammation of Gallbladder or Pancreas |
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What are the long term complications of gastric surgery (total gastrectomy)?
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B12 deficiency
Esophagitis Osteoporosis r/t < Vit D & Calcium absorption (duodenum has been removed) Immune system suppression |
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What S&S might occur with a leaky anastomosis?
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Abdominal pain post-op
Peritonitis (intense pain, inflammation & infection) |
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What nutrition is recommended for the post gastric surgery patient?
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**High fat & protein
Small frequent meals Avoid fluid w/ meals, focus on calories Lower sugar intake |
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What obstacles may cause difficulty with good nutrition after gastric surgery?
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Reflux - feeling of N/V post meal
**Dumping Syndrome Dysphagia Gastric Retention |
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What is dumping syndrome?
What are the S&S? |
When food and fluids move too quickly through the stomach & into the small intestine.
Fluid shift into GI tract HA Dizziness Flushing Diaphoresis Weakness |
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What are the post-op interventions after gastric surgery?
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Nutrition - TPN, Lipids, Supplements, Fluids
Pain Control Glucose Monitoring q 6 h Sliding Scale Insulin (risk of hypoglycemia) |
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What are the outcomes or goals for the gastric surgery patient?
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**Maintain weight
Reduce Anxiety Relieve Pain Prevent Infection Accurate I&O |
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What palliative care is given for gastric cancer?
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Decrease pain (chemo & radiation to decrease size)
Surgery (bypass the tumor) |
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What are the risk factors for Colon Cancer?
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Age > 50
Family hx of colon cancer or polyps Previous colon cancer of suspicious polyps Alcohol & Smoking Obesity Hx of Gastrectomy Hx of IBD High Fat, High Protein, Low Fiber Diet Genital Cancer |
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What is the most common type of colon cancer?
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Adenocarcinoma
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What are the clinical manifestations of colon cancer?
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#1 Sign - change in bowel habits
#2 Sign - Blood in stool Unexplained anemia Anorexia Weight Loss Fatigue |
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What signs and symptoms occur r/t the location of the cancerous tumor of colon cancer?
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Right Sided - dull pain, melena (black/tarry stools)
Left Sided - abdominal pain & cramping, diarrhea, narrow stools, constipation, abd distention Rectal Lesions - *Tenesmus (ineffective/painful straining to have a BM), constipation alternative w/ diarrhea & bloody stool |
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What is the gold standard assessment for Colon Cancer? What other assessment/diagnostics might occur?
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**Colonoscopy - gold standard
Occult blood in stools (Guiac) Labs - CEA |
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What complications might occur with colon cancer?
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Bowel Obstruction (partial or complete)
Hemorrhage Perforation |
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What is a complication of a complete bowel obstruction r/t colon cancer?
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Intussusception - pain, N/V, diarrhea
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What is the medical management of colon cancer?
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#1 - Surgery/Resection w/ good margins
Radiation Chemo |
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What pre-op management occurs with colon cancer?
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**Antibiotics - to decrease bacterial load in colon
Bowel Prep Clear Liquids for a couple of days Dulcolax... |
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What post-op care occurs with colon cancer?
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**Monitor for anastamosis leak (pain, fever, rigidity)
Prolapse Stoma Perforation Stoma Retraction Fecal Impaction Skin Irritation |
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How is nutrition handled after a colostomy?
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NPO for awhile
TPN or IVF until bowel fx/peristalsis returns Slow advancement of diet w/ 1-2 meals at each diet Soft bland foods Avoid raw vegetables causing gas/diarrhea (cabbage, broccoli) |
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What is ok vs. not ok with a stoma?
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OK - deep pink/red color, small mucous discharge, minor bleeding when cleaning or changing appliance.
Not OK - purple color, swelling (can block passage) |
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Why is colostomy irrigation done?
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This is for more continent colostomies
To schedule daily BM's To avoid a stomal appliance & wear a cap instead |
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How is colostomy irrigation done?
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1000-1500 ml of warm tap water in elevated bag
colostomy bag is removed & drainage collection bag is applied Warm water is introduced gradually over 10 minutes Stop & wait 10 minutes or so Then drain through collection bag into toilet or graduate |
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How is the liver perfused?
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20% of blood flow is from hepatic artery w/ oxygen
80% of blood flow is from portal vein w/ nutrients & bacteria |
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What fights bacteria in the liver?
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Kupffer cells
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What are the primary causes of hepatic dysfunction?
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Primary liver disease (cirrhosis)
Obstruction of bile (gallstones) Derangements of circulation (portal hypertension) |
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What are the most common symptoms of liver disease?
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Jaundice
Portal Hypertension |
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What is bilirubin
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A yellow/orange byproduct of the liver breaking down old red blood cells that is then converted to bile.
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What is jaundice
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A buildup or accumulation of bilirubin in the blood
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What are some common causes of jaundice?
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Hemolytic - RBC destruction from childbirth or beating/bruised victims
Hepatocellular - Damaged liver cells can't convert bilirubin to bile. Obstructive - gallstones/tumors block bile Hereditary - no liver damage, just produce too much bilirubin |
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What is portal hypertension?
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An obstruction of blood flow through the liver due to damage that causes an increase in pressure throughout the portal venous system.
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What are the two major consequences of portal hypertension?
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Ascites - fluid shift to the abdomen
Varices - risk of hemorrhage |
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What is ascites?
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An obstruction causes increased capillary pressure and fluid shift into intraperitoneal space.
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What are the clinical manifestations of ascites?
What assessment/diagnostics are done for ascites? |
Increased abdominal girth & rapid weight gain.
Daily weights Percussion Flanks bulge in supine position Fluid wave Monitor bleeding times - may need vitamin K |
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What diet is recommended for ascites?
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Low sodium
No salt substitutes (contain ammonia) If renal impairment, watch Potassium Decreased protein intake (causes ammonia) Lactulose (decreases ammonia) |
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What is the medical management for ascites?
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Diet - low sodium, low protein
Diuretics - Spironolactone & Lasix Bedrest - < RAAS & > kidney perfusion Paracentesis - removes excess fluid from abdomen TIPS - diverts blood flow from liver to < portal hypertension |
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What is the TIPS procedure?
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Transjugular intrahepatic portosystemic shunt (TIPS)
Shunts blood from portal vein to an artery to decrease liver portal pressure. Should decrease ascites & esophageal varices. |
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What is the nursing management for ascites?
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I & O's
Abdominal girth measurement Daily weights Labs - E'Lytes, Total Protein, Albumin, Ammonia Frequent rest periods (fall risk) Small frequent meals |
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Explain the pathophysiology of esophageal varices.
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Portal system pressures are high causing venous blood from the intestinal tract and spleen to seek collateral circulation. These collateral vessels are not very elastic & bleed easily and can result in massive hemorrhage.
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What diagnostics are performed for esophageal varices?
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Endoscopy to look at lower esophagus
Portal System Pressures |
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What are the clinical manifestations of esophageal varices?
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Hematemesis
Melena Shock - cool, clammy, hypotensive, tachycardia, tachypnea Mental/physical deterioration |
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What medical management is provided for esophageal varices?
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Vasopressin
Beta Blockers Balloon Tamponade Endoscopy |
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How does vasopressin help with bleeding esophageal varices?
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**Constricts preportal splanchnic arterioles to decrease portal pressure
**Can cause angina so need NTG & cardiac monitoring |
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When are beta blockers given for esophageal varices?
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These decrease portal pressures and may be given prophylactically or permanently to prevent bleeding/rebleeding.
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How does endoscopy help with esophageal varices?
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Sclerotherapy - injecting sclerosing agent into varices causing thrombosis & eventual sclerosis, thereby obliterating the varices.
Variceal Banding - a ligating band is placed tightly around the varicose to prevent blood from escaping. |
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What is balloon tamponade?
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A Sengstken-Blakemore tube is inserted into the esophagus & it has four ports. After insertion the port connected to the balloon in the stomach is inflated w/ 100-200 ml of air & then gentle traction is applied. Irrigation is then done to determine if blood is still present. If not, pressure is maintained for up to 24 h. If so, the port connected to the esophageal balloon is inflated to put pressure on the esophagus.
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What is a risk of balloon tamponade?
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Esophageal rupture
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How long can balloon tamponade be performed
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No more than 24 hours.
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What surgical interventions can be used for esophageal varices?
Which procedure is more successful? |
TIPS
Shunts (portocaval, splenorenal, H-Graft Mesocaval) TIPS - hepatic encephalopathy rates remain high with shunts. |
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What nursing management is provided for esophageal varices?
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Frequent neuro assessment
Nutritional status V/S's I&O Monitor suctioning for blood Monitor for bleeding Teach meds & interventions r/t disease process Assess & help w/ anxiety |
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Who is at risk for cirrhosis liver disease?
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Men; however, women are more at risk of alcoholic liver disease
40-60 y.o. |
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What is cirrhosis?
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A chronic disease characterized by replacement of normal liver tissue w/ diffuse fibrosis that disrupts the structure & function of the liver causing SCARRING.
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What is Laennec's Cirrhosis?
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Alcoholic cirrhosis
Most common type of cirrhosis Scar tissue surrounds portal area so circulation is impaired |
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What are the four cirrhosis types?
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Laennec's
Post Necrotic Biliary Cryptogenic |
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What are the risk factors associated with post necrotic cirrhosis?
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Acute Viral Hepatitis
IV Drug Users |
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What is the Child Pugh Scale?
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A scale to determine the severity of cirrhosis. Scores from 1-15.
1-6 is Grade A 7-9 is Grade B 10-15 is Grade C |
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What are the parameters on the Child Pugh Scale?
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Ascites
Bilirubin Albumin PT Time Encephalopathy |
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What are the S&S of compensated cirrhosis?
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This is early in the disease process.
Liver enlargement Firm & palpable with possible pain Enlarged spleen r/t backup of blood flow Vascular spiders on the abdomen |
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What are the S&S of decompensated cirrhosis?
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This is late in the disease process.
Liver shrinks in & on itself Edges of liver are palpable & hobnail in feeling Portal obstruction & ascites GI Varices Hemorrhoids * Edema, Vit Deficiency/Anemia, Fatigue, Mental Deterioration |
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What is the order for assessment of the abdomen?
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Inspect, Auscultate, Palpate, Percuss
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What labs are performed for Cirrhosis?
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***Ammonia levels (elevated)
AST, ALT, GTT (elevated) Bilirubin (elevated) PT/INR (elevated) H&H (decreased) Electrolyte imbalances |
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What tests are performed for cirrhosis?
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U/S
CT & MRI (spiral CT preferred) Radio-isotope liver scan Liver biopsy - core needle |
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How should patient be positioned after a core needle liver biopsy?
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On their Right Side with a pillow under their thorax.
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What is the medical management for cirrhosis?
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Can't be fixed to treat symptoms
* Eliminate alcohol * Meds (PPI's, H2 Blockers, Antacids) * No Tylenol * Nutrition - Low Protein, High Calorie |
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What medications are given for cirrhosis?
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Potassium sparing diuretics for associated ascites
Anti-inflammatories (Colchicine) |
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What nursing management is provided for cirrhosis?
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Rest - easily fatigued & rest periods
Nutrition - Low/lean protein, F&V, small frequent meals Skin Care - Atarax (moisturizer) / Benadryl (itching) Decrease Injury Risk - prevent falling **bleed risk Monitor complications - frequent V/S's |
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What is hepatic encephalopathy or portal systemic encephalopathy?
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An accumulation of ammonia in the blood & brain causing somnolence, confusion, depression.
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What are the sources of ammonia?
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Protein in the diet
Liver unable to convert ammonia to urea for excretion Absorption from GI tract Kidney cells Muscle cells |
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What are the clinical manifestations of hepatic encephalopathy?
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**Asterixis
**Fetor Hepaticus Confusion Unkempt Mood Changes Impaired Sleep Pattern Somnolence |
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What is Asterixis?
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Flapping tremor of the hands
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What is the medical management of hepatic encephalopathy?
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Supportive
Lactulose - promotes excretion of ammonia Neomycin - suppress GI bacteria that produces ammonia Low Protein Diet Small frequent meals Serum ammonia Avoid sedatives, tranquilizers, analgesics (esp. tylenol) |
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What is done diagnostically for hepatic encephalopathy?
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Labs - ammonia levels
EEG - shows slowed electrical activity |
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What is the most common cause of anemia in adults?
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GI Bleed
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What would you be looking for on a CBC for a GI patient?
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Anemia
Infection Cancer Inflammatory Bowel |
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What does elevated Amylase/Lipase indicate?
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Pancreatitis
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What explains a pancreatitis patient with normal Amylase/Lipase?
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The pancreas has extensive necrosis & is no longer producing the enzymes
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What is being checked in urine for GI patients?
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Amylase
Urobilinogen |
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What cancer markers are being monitored for the GI patient?
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CEA
CA 19-9 |
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What are the methods for stool tests?
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Hemocult II (Guiac impregnated paper slide)
Fecal immunochemical test (FIT) |
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Do foods/drugs affect the Hemocult II or FIT tests?
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Yes - Hemocult II
Hold Coumadin/NSaids for 7 days Hold meat, raw fruits, vegetables & Vit C foods No - FIT - drugs/food do not affect this test |
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When endoscopic procedures may be performed for GI?
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Esophagogastroduodenoscopy (EGD)
Small Bowel Capsule Endoscopy |
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What must the patient know about EGD?
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They will be under conscious sedation
They will need someone to drive them home OR if moderate sedation may need to stay overnight |
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What is the difference between a regular sigmoidoscopy & a flexible fiberoptic sigmoidoscopy?
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The regular sig allows visualization 10 inches from the anus
A flex sig allows 16-20 inches from the anus. |
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What do decreased levels of gastric acid or increased levels of gastric acid indicate during the gastric acid stimulation test?
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Decreased - Gastric Cancer
Increased - Zollinger Ellison Ulcer or Duodenal Ulcer |
