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56 Cards in this Set

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Client with Oral Cancer
Background
Uncommon (5% of all cancers) but has high rate of morbidity, mortality
b. Highest among males over age 40
c. Risk factors include smoking and using oral tobacco, drinking alcohol, marijuana use, occupational exposure to chemicals, viruses (human papilloma virus)
Client with Oral Cancer
Collaborative Care
Elimination of causative agents
b. Determination of malignancy with biopsy
c. Determine staging with CT scans and MRI
d. Based on age, tumor stage, general health and client’s preference, treatment may include surgery, chemotherapy, and/or radiation therapy
e. Advanced carcinomas may necessitate radical neck dissection with temporary or permanent tracheostomy; Surgeries may be disfiguring
f. Plan early for home care post hospitalization, teaching family and client care involved post surgery, refer to American Cancer Society, support groups
Client with Oral Cancer
4. Nursing Care
a. Health promotion:
Teach risk of oral cancer associated with all tobacco use and excessive alcohol use
2. Need to seek medical attention for all non-healing oral lesions (may be discovered by dentists); early precancerous oral lesions are very treatable
Client with Oral Cancer
Nursing Diagnoses
1. Risk for ineffective airway clearance
2. Imbalanced Nutrition: Less than body requirements
3. Impaired Verbal Communication: establishment of specific communication plan and method should be done prior to any surgery
4. Disturbed Body Image
Gastroesophageal Reflux Disease (GERD)
1. Definition
b. GERD common, affecting 15 – 20% of adults
c. 10% persons experience daily heartburn and indigestion
d. Because of location near other organs symptoms may mimic other illnesses including heart problems
a. Gastroesophageal reflux is the backward flow of gastric content into the esophagus.
Gastroesophageal Reflux Disease (GERD)
2. Pathophysiology
a. Gastroesophageal reflux results from transient relaxation or incompetence of lower esophageal sphincter, sphincter, or increased pressure within stomach
b. Factors contributing to gastroesophageal reflux
1.Increased gastric volume (post meals)
2.Position pushing gastric contents close to gastroesophageal juncture (such as bending or lying down)
3.Increased gastric pressure (obesity or tight clothing)
4.Hiatal hernia
Gastroesophageal Reflux Disease (GERD)
c.Normally the peristalsis in esophagus and bicarbonate in salivary secretions neutralize any gastric juices (acidic) that contact the esophagus; during sleep and with gastroesophageal reflux esophageal mucosa is damaged and inflamed; prolonged exposure causes ulceration, friable mucosa, and bleeding; untreated there is scarring and stricture
Gastroesophageal Reflux Disease (GERD)
Manifestations
a. Heartburn after meals, while bending over, or recumbent
b. May have regurgitation of sour materials in mouth, pain with swallowing
c. Atypical chest pain
d. Sore throat with hoarseness
e. Bronchospasm and laryngospasm
Gastroesophageal Reflux Disease (GERD)
4. Complications
a. Esophageal strictures, which can progress to dysphagia
b. Barrett’s esophagus: changes in cells lining esophagus with increased risk for esophageal cancer
Gastroesophageal Reflux Disease (GERD)
Collaborative Care
a. Diagnosis may be made from history of symptoms and risks
b. Treatment includes
1.Life style changes
2.Diet modifications
3.Medications
Gastroesophageal Reflux Disease (GERD)
6. Diagnostic Tests
a. Barium swallow (evaluation of esophagus, stomach, small intestine)
b. Upper endoscopy: direct visualization; biopsies may be done
c. 24-hour ambulatory pH monitoring
d. Esophageal manometry, which measure pressures of esophageal sphincter and peristalsis
e. Esophageal motility studies
Gastroesophageal Reflux Disease (GERD)
7. Medications
a. Antacids for mild to moderate symptoms, e.g. Maalox, Mylanta, Gaviscon
b. H2-receptor blockers: decrease acid production; given BID or more often, e.g. cimetidine, ranitidine, famotidine, nizatidine
c. Proton-pump inhibitors: reduce gastric secretions, promote healing of esophageal erosion and relieve symptoms, e.g. omeprazole (prilosec); lansoprazole (Prevacid) initially for 8 weeks; or 3 to 6 months
d. Promotility agent: enhances esophageal clearance and gastric emptying, e.g. metoclopramide (reglan)
Gastroesophageal Reflux Disease
8. Dietary and Lifestyle Management
a. Elimination of acid foods (tomatoes, spicy, citrus foods, coffee)
b. Avoiding food which relax esophageal sphincter or delay gastric emptying (fatty foods, chocolate, peppermint, alcohol)
c. Maintain ideal body weight
d. Eat small meals and stay upright 2 hours post eating; no eating 3 hours prior to going to bed
e. Elevate head of bed on 6 – 8 blocks to decrease reflux
f. No smoking
g. Avoiding bending and wear loose fitting clothing
Esophageal Cancer
1. Definition:
Relatively uncommon malignancy with high mortality rate, usually diagnosed late
Esophageal Cancer
3. Manifestations
a. Progressive dysphagia with pain while swallowing
b. Choking, hoarseness, cough
c. Anorexia, weight loss
Esophageal Cancer
6. Treatments: dependent on stage of disease, client’s condition and preference
Early (curable) stage:
surgical resection of affected portion with anastomosis of stomach to remaining esophagus; may also include radiation therapy and chemotherapy
Esophageal Cancer
6. Treatments: dependent on stage of disease, client’s condition and preference
More advanced carcinoma:
treatment is palliative and may include surgery, radiation and chemotherapy to control dysphagia and pain
Esophageal Cancer
Nursing Diagnoses
a. Imbalanced Nutrition: Less than body requirements (may include enteral tube feeding or parenteral nutrition in hospital and home)
b. Anticipatory Grieving (dealing with cancer diagnosis)
c. Risk for Ineffective Airway Clearance (especially during postoperative period if surgery was done)
Cancer of Stomach
1. Incidence
a. Worldwide common cancer, but less common in US
b. Incidence highest among Hispanics, African Americans, Asian Americans, males twice as often as females
c. Older adults of lower socioeconomic groups higher risk
Cancer of Stomach
a. Worldwide common cancer, but less common in US
b. Incidence highest among Hispanics, African Americans, Asian Americans, males twice as often as females
c. Older adults of lower socioeconomic groups higher risk
Cancer of Stomach
3. Risk Factors
a. H. pylori infection
b. Genetic predisposition
c. Chronic gastritis, pernicious anemia, gastric polyps
d. Achlorhydria (lack of hydrochloric acid)
e. Diet high in smoked foods and nitrates
4. Manifestations
Cancer of Stomach
5. Collaborative Care
a. Support client through testing
b. Assist client to maintain adequate nutrition
Cancer of Stomach
7. Treatment
a.Surgery, if diagnosis made prior to metastasis
1.Partial gastrectomy with anastomosis to duodenum: Bilroth I or gastroduodenostomy
2.Partial gastrectomy with anastomosis to jejunum: Bilroth II or gastrojejunostomy
3.Total gastrectomy (if cancer diffuse but limited to stomach) with esophagojejunostomy
Cancer of Stomach
b. Complications associated with gastric surgery
1. Dumping Syndrome
a.Occurs with partial gastrectomy; hypertonic, undigested chyme bolus rapidly enters small intestine and pulls fluid into intestine causing decrease in circulating blood volume and increased intestinal peristalsis and motility
Dumping Syndrome
Manifestations
5 – 30 minutes after meal: nausea with possible vomiting, epigastric pain and cramping, borborygmi, and diarrhea; client becomes tachycardic, hypotensive, dizzy, flushed, diaphoretic
2 – 3 hours after meal: symptoms of hypoglycemia in response to excessive release of insulin that occurred from rise in blood glucose when chyme entered intestine
Cancer of the Stomach
Common post-op complications
Pneumonia
Anastomotic leak
Hemorrhage
Relux aspiration
Sepsis
Reflux gastritis
Paralytic ileus
Bowel obstruction
Wound infection
Dumping syndrome
Cancer of Stomach
Nutritional problems related to rapid entry of food into the bowel and the shortage of intrinsic factor
1 Anemia: iron deficiency and/or pernicious
2 Folic acid deficiency
3. Poor absorption of calcium, vitamin D
Intestinal Obstruction
Definition
a. May be partial or complete obstruction
b. Failure of intestinal contents to move through the bowel lumen; most common site is small intestine
c. With obstruction, gas and fluid accumulate proximal to and within obstructed segment causing bowel distention
d. Bowel distention, vomiting, third-spacing leads to hypovolemia, hypokalemia, renal insufficiency, shock
Intestinal Obstruction
Pathophysiology
a. Mechanical
1. Problems outside intestines: adhesions (bands of scar tissue), hernias
2. Problems within intestines: tumors, IBD
3. Obstruction of intestinal lumen (partial or complete)
a. Intussusception: telescoping bowel
b. Volvulus: twisted bowel
c. Foreign bodies
d. Strictures
Intestinal Obstruction
Functional
1. Failure of peristalsis to move intestinal contents: adynamic ileus (paralytic ileus, ileus) due to neurologic or muscular impairment
2. Accounts for most bowel obstructions
3. Causes include
a. Post gastrointestinal surgery
b. Tissue anoxia or peritoneal irritation from hemorrhage, peritonitis, or perforation
c. Hypokalemia
d. Medications: narcotics, anticholinergic drugs, antidiarrheal medications
e. Spinal cord injuries, uremia, alterations in electrolytes
Intestinal Obstruction
Manifestations Small Bowel Obstruction
a. Vary depend on level of obstruction and speed of development
b. Cramping or colicky abdominal pain, intermittent, intensifying
c. Vomiting
1. Proximal intestinal distention stimulates vomiting center
2. Distal obstruction vomiting may become feculent
d. Bowel sounds
1. Early in course of mechanical obstruction: borborygmi and high-pitched tinkling, may have visible peristaltic waves
2. Later silent; with paralytic ileus, diminished or absent bowel sounds throughout
e. Signs of dehydration
Intestinal Obstruction
Complications
a. Hypovolemia and hypovolemic shock can result in multiple organ dysfunction (acute renal failure, impaired ventilation, death)
b. Strangulated bowel can result in gangrene, perforation, peritonitis, possible septic shock
c. Delay in surgical intervention leads to higher mortality rate
Intestinal Obstruction
Large Bowel Obstruction
a. Only accounts for 15% of obstructions
b. Causes include cancer of bowel, volvulus, diverticular disease, inflammatory disorders, fecal impaction
c. Manifestations: deep, cramping pain; severe, continuous pain signals bowel ischemia and possible perforation; localized tenderness or palpable mass may be noted
Intestinal Obstruction
Collaborative Care
a. Relieving pressure and obstruction
b. Supportive care
Diagnostic Tests
a. Abdominal Xrays and CT scans with contrast media
1. Show distended loops of intestine with fluid and /or gas in small intestine, confirm mechanical obstruction; indicates free air under diaphragm
2. If CT with contrast media meglumine diatrizoate (Gastrografin), check for allergy to iodine, need BUN and Creatinine to determine renal function
b. Laboratory testing to evaluate for presence of infection and electrolyte imbalance: WBC, Serum amylase, osmolality, electrolytes, arterial blood gases
c. Barium enema or colonoscopy/sigmoidoscopy to identify large bowel obstruction
Gastrointestinal Decompression
a. Treatment with nasogastric or long intestinal tube provides bowel rest and removal of air and fluid
b. Successfully relieves many partial small bowel obstructions
Intestinal Obstruction
Surgery
a. Treatment for complete mechanical obstructions, strangulated or incarcerated obstructions of small bowel, persistent incomplete mechanical obstructions
b. Preoperative care
1. Insertion of nasogastric tube to relieve vomiting, abdominal distention, and to prevent aspiration of intestinal contents
2. Restore fluid and electrolyte balance; correct acid and alkaline imbalances
3. Laparotomy: inspection of intestine and removal of infarcted or gangrenous tissue
4. Removal of cause of obstruction: adhesions, tumors, foreign bodies, gangrenous portion of intestines and anastomosis or creation of colostomy depending on individual case
Intestinal Obstruction
Nursing Care
a. Prevention includes healthy diet, fluid intake
b. Exercise, especially in clients with recurrent small bowel obstructions
Intestinal Obstruction
Nursing Diagnoses
a. Deficient Fluid Volume
b. Ineffective Tissue Perfusion, gastrointestinal
c. Ineffective Breathing Pattern
Oral Cancer

3. Collaborative Care
a. Elimination of causative agents
b. Determination of malignancy with biopsy
c. Determine staging with CT scans and MRI
d. Based on age, tumor stage, general health and client’s preference, treatment may include surgery, chemotherapy, and/or radiation therapy
e. Advanced carcinomas may necessitate radical neck dissection with temporary or permanent tracheostomy; Surgeries may be disfiguring
Oral Cancer
Nursing Diagnoses
1. Risk for ineffective airway clearance
2. Imbalanced Nutrition: Less than body requirements
3. Impaired Verbal Communication: establishment of specific communication plan and method should be done prior to any surgery
4. Disturbed Body Image
Fetal Development
Fistula
Fistula is an abnormal connection
Tracheal esophageal fistula
Anal-rectal malformations with fistula
Atresia
Atresia or abnormal closing of structure:
Esophogeal atresia
Anal-rectal malformation
Biliary atresia
Pyloric Stenosis
Clinical Manifestations
Projectile vomiting
Visible peristaltic waves
Olive shape mass in the upper abdomen to right of the midline
Electrolyte imbalance
Pyloric Stenosis
Management Pre-surgery
NPO / document any emesis

IV therapy / Correct electrolyte imbalance

Comfort infant and caretakers
Pyloric Stenosis
Feeding Post-operatively
Give 10 ml oral electrolyte solution after recovered from anesthesia
Start pyloric re-feeding protocol.
Increase feeding volumes from clear fluids to dilute to full-strength formula.
Keep feeding record
Assess for vomiting
Discharged when taking full-strength formula
Hirschsprung Disease
Definition
Lack of ganglion cells in colon prevents bowel from transmitting peristaltic
waves needed to move fecal material.
Hirschsprung Disease
Clinical Manifestations
No meconium in the first 24 hours.
History of constipation or fecal mass.
Distended abdomen.
Obstructions
What is Pyloric stenosis?
Opening between stomach and small intestine too narrow
Obstructions
What is Intussusception?
Slipping of part of intestine into part below
Obstructions
Volvulus?
Intestinal twisting
Obstructions
Ileus?
Intestinal obstruction caused by lack of peristalsis
Obstructions
Hemorrhoids?
Varicose veins in rectum
Describing the Abdomen
RUQ
liver & gallbladder
pylorus & duodenum
head of pancreas
portion of right kidney
right adrenal gland
hepatic flexure of colon
portions of colon
Describing the Abdomen
RLQ
lower pole of right kidney
cecum and appendix
portion of ascending colon
ovary and salpinx
right ureter
right spermatic cord
Describing the Abdomen
LUQ
left lobe of liver
spleen and stomach
body of pancreas
portion of left kidney
left adrenal gland
splenic flexure of colon
portions of colon
Describing the Abdomen
LLQ
lower pole of left kidney
sigmoid colon
portion of descending colon
ovary and salpinx
left ureter