adult 1 exam 4 obesity

inc health risk in waist circumference

>40 men

>35 women

OR

>0.8 waist/hip measurement

underweight BMI

normal weight BMI

18\.5-24.9

overweight BMI

25\.0-29.9

obese BMI

>29.9

extreme obesity BMI

> >40

apple shaped body

risk of

heart disease

DM

hypertension

pear shaped body

risk of

osteoporosis

varicose veins

treatment plan of obesity

meal planning

exercise

behavior modification

support groups

bariatric surgery

used to treat extreme obesity

only treatment found to have a successful lasting impact for sustained weight loss

criteria guidlines of bariatric surgery

BMI >40 OR >35 with 1 or more significant co-morbidities

not always covered by insurance

screened for psych issues (depression, binge eating disorder, drug/alc abuse)

restrictive bariatric surgery

stomach size reduced

reduce amount allowed to enter stomach

normal stomach digestion and intestinal absorption

laparoscopic approach available

use of gastric banding

malabsorptive bariatric surgeru

small intestine shortened

combination bariatric surgery

combo of restrictive and malabsorptive

gastric banding

limit size of stomach with inflatable band that is adjustable

creates sense of fullness

delays stomach emptying

can be modified or reversed later

restrictive sleeve gastrectomy

75% of stomach removed leaving a sleeve shaped stomach

stomach function preserved

eliminates hormones made in stomach that stimulates hunger

can be laparoscopic

leakage possible

NOT reversible

plication surgery

sleeve created by suturing rather than removing stomach

minimally invasive (laparoscopic)

folding stomach nward reducing stomach volume

reversible

requires hospital stay

nausea after common

blockage can occur from swelling or folding too tight

intragastric balloon

balloon occupies space in stomach

natural anatomy of stomach not altered

patient feels more full and appetite is dec

less invasive (can be endoscope)

balloon filled with saline, or nitrogen gas)

left in for 6 months

roux-en-y gastric bypass

stomach pouch created

connected to jejunum

rest of stomach and first part of small intestine bypassed

RYGB

most common bariatric surgery

low complications

excellent patient tolerance

food bypasses 90% of stomach

complication og dumping syndrome, leak, anemia

dumping syndrome

rapid gastric emptying

gastric cramps

n,d

insulin surge

symptoms of hypoglycemia

avoid sugary food

small frequent meals

dietician help

pre op care bypass surgery

have other comorbidities

team approach

prep room (room ready, large bp cuff, larger gown, patient transfer equipment, wheelchair with removable arms)

wound infection (skin prep)

breathing (coughing, deep breathing, turning) to avoid pulmonary complications

venous access

mechanical ventilation

post op care bypass surgery

close observation for complications

transfer with trained personnel

stabilize airway

anesthetic agents stored in adipose tissue (slower to wake)

manage pain

HOB 35-40 deg

diligent turning and ambulating

excess adipose tissue compresses chest and abdomen

causes CO2 retention

hypoxemia, pulmonary hypertension, polycythemia

risk for DVT

infection, dehiscence, delayed healing

keep skin folds clean and dry to prevent infection

attentive placement of NG tube

careful transition to a new diet

diet in bypass surgery

high protein

low carbs

low fats

low roughage

6 small feedings

fluid restriction

later complications from bariatric surgery

anemia

vitamin deficiencies

diarrhea

psychological problems

peptic ulcer formation

dumping syndrome

small bowel obstruction

NEED long term follow up care

right upper quadrant

liver

gallbladder

pylorus

duodenum

head of pancreas

right adrenal gland

portion of right kidney

hepatic flexure of colon

ascending and transverse colon

left lower quadrant

lower pole left kidney

sigmoid flexure

descending colon

bladder

left ovary and fallopian tube

left spermatic cord

left ureter

left upper quadrant

left lobe of liver

spleen

stomach

body of pancreas

left adrenal gland

portion of left kidney

splenic flexure of colon

transverse and descending colon

right lower quadrant

lower pole right kidney

cecum and appendix

portion ascending colon

bladder

right ovary and fallopian tube

uterus if enlarged

right spermatic cord

right ureter

upper GI/small bowel series

barium swallow

to detect structural changes in esophagus, stomach, duodenum/small intestine

NPO prep

post fluids or laxatives and monitor

watch stool for passage of barium

lower GI series

barium enema

to detect anatomic changes in lower GI tract

clear liquids, NPO, bowel prep

post of fluids/laxatives, monitor for passage of contrast

abdominal ultrasound

to detect solid masses, cysts, abdominal ascites

prep NPO 8-12h

post none

gallbladder ultrasound

to detect masses, cysts, tumors or cirrhosis of liver or biliary tract

prop NPO 8-12H

post none

esophagogastroduodenoscopy (EGD)

to direct visualization of mucosa of esophagus, duodenum, can can preform biopsy or sclerotherapy

prep NPO 6-12h, consent, preop meds, sedation

post of NPO until gag returns, assess for bleeding if biopsy

sigmoidoscopy

direct visualization of mucosa of colon to ileocecal valve vs rectum/sigmoid colon only

prep with clear liquid 1-2 days, bowel prep, NPO 8-12 hours, consent, preop meds, sedation

post of assessing rectal bleeding, signs of perforation, need to pass gas

capsule endoscopy

images of stomach and small intestine

prep NPO 8-12 until 4H after swallow

post of patient passes capsule in bowel movement, images downloaded

percutaneous cholangiography

local anesthesia, liver is entered with needle and using fluoroscopy inject contrast to assess hepatic and biliary duct filling

prep NPO

post to assess for bleeding or bile leakage (if you see green patient may be bleeding green)

computerized tomography (CT)

may require contrast dye

assess renal function and allergy to dye

magnetic resonance imaging (MRI)

IV contrast may be used

use caution with metal implants (pacemakers, joint replacements)

other GI lab studies

stool cultures

fecal analysis (occult blood)

liver function studies

serum amylase, lipase, ammonia, protein levels

factors affecting occult blood testing

red meat

poultry

fish

raw veggies

vitamin C

aspirin

ibuprofen

anticoagulants

nausea and vomiting

most common manifestations of GI disease

nausea

subjective complaint

usually accompanied by anorexia

vomiting

forceful ejection of partially digested food and secretion from GI tract

can lead to dehydration

water and essential electrolytes lost

metabolic alkalosis (loss of HCl from stomach)

metabolic acidosis (when contents of small intestine lost) less common

determining underlying cause of n/v

can’t treat it without knowing cause

look at history of timing, precipitating factors, contents of emesis

presentation of n/v

lethargy

sunken eyeballs

pallor

dry mucous membranes

poor skin turgor

amount/freq/color of emesis

dec urinary output

s/s of electrolyte imbalance (hypokalemia, metabolic alkalosis)

emesis

contains partially digested food several hours after meal

color can determine presence and source of bleeding (if present)

blood in emesis

possible mallory-weiss tear

mallory weiss tear

tear of tissue in lower esophagus

caused by violent coughing or vomiting

untreated can lead to anemia, fatigue, SOB, and shock

what else can cause blood in emesis

esophageal varices, gastric/duodenal ulcer or cancer

coffee ground emesis

gastric bleeding

blood turns dark brown when interacting with HCl acid

regurgitation

effortless process where partially digested food comes up from stomach slowly

projectile vomiting

forceful expulsion of stomach contents without nausea (neuro issue usually)

cyclic vomiting syndrome

recurrent episodes of nausea, vomiting, and lethargy

last 1h-10 days

4-12 cycles per year untreated

between attacks n/v absent

common triggers of emotional excitement and infection

can be variant of migraines

interprofessional care (hospital) of n/v

NPO and IV fluids

clear liquids when PO started

progress slowly

may need NG tube (persistent v, bowel obstruction)

address dehydration and acid base and electrolyte imbalances

I and O and VS

quiet and odor free environment

monitor mental status and aspiration risk

older/unconscious, altered gag reflex (semi fowlers or side lying)

nutrition in n/v

advance slowly

clear liquids to dry toast and crackers

advance to high carb/low fat

eat slow and small amounts

fluids between meals (not with)

CAT

acupressure/acupuncture

herbs (ginger or peppermint oil)

relaxation and breathing

n/v elderly consideration

more likely to have pre existing cardiac or renal imbalances

inc susceptibility to CNS side effects

alterations in LOC

inc risk of aspiration (semi fowlers or side lying)

oral cancer

oral cavity (starts in mouth)

oropharyngeal (develops in throat)

HNSCC

broad term for oral, pharynx, larynx

leukoplakia

smokers patch

white patch on mouth mucosa or tongue

precancerous legion

eryhtroplasia

or plakia

red velvety patch on mouth or tongue

precancerous legion

clinical manifestations of oral cancer

leukoplakia

erythroplasia

ulcer of lip or tongue

soreness of tongue

chronic sore throat

later:

dysphasia, inc salivation, jaw movement, slurred speech, tooth/earache

treatment of oral cancer

surgery:

extensive and deforming

mandibulectomy

radical neck dissection with tracheostomy

glossectomy

radiation therapy:

used alone if Ca small can’t be removed

used after surgery (6 weeks)

chemo:

before surgery to shrink

after surgery for metastisis

surgery treatment considerations in oral cancer

airways maintenance

communication

may require PEG tube

pain relief

body image

gastroesophageal reflux disease (GERD)

chronic symptoms or mucosal damage caused by reflux of stomach acid into lower esophagus

most common UGI problem in adults

diagnose with symptoms 2x/wk or mod-severe symptoms 1x week

GERD manifestations

heartburn (pyrosis)

dyspepsia (pain)

regurgitations (baby barf)

hypersalivation

non cardiac chest pain

wheezing, coughing, dyspnea, hoarseness, sore throat, lump in throat, choking, regurgitation

GERD complication

result from local effects of gastric acid on esophageal mucosa

esophagitis (inflammation)

esophageal ulcer or stricture

Barrett’s esophagus (precancerous lesion, MONITOR, endoscopy every 2-3y)

respiratory (cough, bronchospasm, laryngospasm)

aspiration leading to pneumonia

dental erosion

GERD diagnostic studies

endoscopy

biopsy

esophageal motility studies

GERD care

lifestyle modification

drug therapy

if ineffective surgery

GERD nursing management

avoid factors to cause reflux (smoking, food/drink that lower LES pressure like chocolate, peppermint, fatty food, coffee, tea) or irritate the esophagus (tomato based, oj, cola, red wine), stress

weight reduction (if applied)

small, frequent meals and avoid late evening meals and snacking at bedtime, avoid milk

fluid between meals (prevents overdistention of stomach)

drug therapy GERD

antacids (neutralize HCl acid)

histamine (H2) receptor blocker (dec HCl secretion)

proton pump inhibitor (PPI) (dec HCl secretions)

cholinergic (inc LES pressure)

prokinetics (inc gastric motility and emptying)

antiulcer (forms a protective layer)

management of GERD

low fat diet

small frequent meals

avoid alcohol, smoking, caffeine

don’t wear tight clothes around waste

no bending over esp after eating

sleep HOB on 4-6 in blocks

avoid eating within 3h of eating

weight reduction

surgical therapy in GERD

needed if

medication intolerance

esophageal stricture

esophagitis

persistent severe symptoms

goal to reduce refulx of gastric contents by enhancing integrity of LES

laproscopically

nissen fundoiplication

wrap the stomach around the esophagus

LINX reflux management

titanium beads with magnetic core connected to form a rung

implanted at LES

provides additional strength to keep weak LES closed

when swallowing magnetic force accommodates swallow and once passes it return to normal state

inserted laparoscopically

cannot go into MRI

post op GERD care

prevent respiratory complication

maintain fluid/electrolyte balance

prevent infection

resp rate, rhythm, pulse rate and rhythm, signs of pneumothorax (chest pain, dyspnea, cyanosis)

deep breathing, incentive spirometer

accurate I&O

pain med, and prevent n/v

peristalsis returns fluids only and gradually add solids then normal diet gradually

avoid gas forming foods, chew food

hiatal hernia

stomach slides up through diaphragm and into lower chest

caused by structural changes (weakening of muscle in diaphragm)

factors that inc intra abdominal pressure

obesity

pregnancy

ascites

tumors

kinds of hiatal hernia

can be sliding which is when pt is supine and fixed when upright

paraesophageal or rolling is when piece slides up but sphincter is in normal position

clinical manifestations of hiatal hernia

asymptomatic

heartburn

dyspepsia

regurgitation

dysphagia

complication of hiatal hernia

GERD

esophagitis

hemorrhage from erosion

stenosis of esophagus

ulcerations

strangulation

regurgitation with tracheal aspiration

diagnosis of hiatal hernia

barium swallow

endoscopy

hiatal hernia conservative management

eliminate restrictive or tight garments

avoid lifting or straining

eliminate smoking/alcohol

antacids/antisecretory meds

elevate HOB

weight loss

hiatal hernia surgery

can be laparoscopic

herniotomy (cut sack off)

herniorrhaphy (close defect)

gastropexy (attach stomach under diaphragm to prevent reherniation)

esophageal cancer

uncommon

diagnosed in later stages

risk factors of esophageal cancer

barrett’s esophagus

smoking

exposure to asbestos and cement dust

achalasia (delayed emptying of LES)

symptoms of esophageal cancer

progressive dysphagia

weight loss

pain (late)

regurgitation

hemorrhage

perforation

fistula with trachea or lung

if tumor sore throat, choking, hoarseness

diagnosis of esophageal cancer

endoscopy with biopsy

endoscopic ultrasonography

barium swallow

care/treating esophageal cancer

surgery

endoscopic

radiation and chemo

targeted therapy

nutrition

surgeries in esophageal cancer

esophagectomy

esophagogastrostomy

esophagoenterostomy

can be laparoscopic

endoscopic therapy with stent, radiofrequency and dilation

esophagectomy

with a dacron graft to replace resected part

esophagogastrostomy

resection of a portion of esophagus and anastomosis to stomach

esophagoenterostomy

resection of portion of esophagus and anastomosis of segment of colon to remaining portion

post op esophageal cancer surgery

ICU 1-2 days

can have complication of anastomotic leaks, fistula formation, interstitial pulmonary edema, respiratory distress

priorities of post op esophageal cancer surgery

NG tube (drainage blood 8-12J, NEVER REPOSITION or irrigate without surgeon consult)

respiratory care

VTE prophylaxis and pain management

nutrition (j or G tube, monitor for leak into mediastinum with pain, fever, dyspnea upon feeding)

fowler’s or semi fowler’s (prevent reflux)

after drinking or eating maintain upright 2-3H

gastritis

inflammation of gastric mucosa

one of most common stomach problems

may be acute or chronic

can be diffuse or localized

how does gastritis occur

breakdown of mucosal barrier

HCL and pepsin into mucosa

tissue edema

disruption of capillary walls

gastritis risk factors

drugs (ASA, steroids, iron supplements, NSAIDs)

diet (alc, spicy)

microorganisms (H.pylori)

environmental (smoking radiation)

pathophysiological (burns, hernia, stress, sepsis)

other (endoscopic, NH tube)

clinical manifestations of gastritis

anorexia

nausea

vomiting

epigastric tenderness

feeling of fullness

hemorrhage (with alcohol)

chronic only:

atrophy -→ loss of intrinsic factor -→ anemia