AH1 exam 4

Assessment of GI system

Family history, personal health history, nutritional history, physical assessment (inspection, auscultation, percussion, palpation)

Diagnostic assessment of GI system

Laboratory: CBC, prothrombin time, electrolytes, AST, alanine ALT, amylase and lipase, bilirubin, ammonia, CEA and CA 19-9, gastric analysis, stool tests

Imaging: CT scan, MRI, barium swallow, small bowel follow through, barium enema, ultrasound

Endoscopy, EGD, ERCP, colonoscopy, virtual colonoscopy (CT), small bowel capsule endoscopy, sigmoidoscopy

Colon cancer

Average risk: begin screening starting at 45 years

Colonoscopy: every 10 years, flexible sigmoidoscopy every 5 years, CT colonography every 5 years, cologaurd (test stool for DNA), Colosensen (test stool for RNA)

Stomatitis

Oral cavity infection

Primary: Aphthous stomatitis (noninfectious stomatitis), herpes simplex stomatitis, traumatic ulcers

Secondary: opportunistic viral, fungal, or bacterial infections; cancer patients prescribed chemotherapy, radiation, or steroids, candida albicans

Treatment: oral health (Nystatin, chlorhexidine rinse), manage pain (2% viscous lidocaine, diphenhydramine, cool liquids, protein)

Oral care: every 2 hours, soft toothbrush or gauze, toothpaste freeof sodium lauryl sulfate, avoid commercial mouthwash and lemon-glycerin swabs, frequent rinse mouth with warm saline or sodium bicarbonate solution or combination

Pre-cancerous lesions

Leukoplakia, erythroplakia

Oral cancer

Squamous cell carcinoma: red, raised, and eroded area

Basal cell carcinoma: raised scab, ulcer with raised, pearly border

Kaposi’s sarcoma: vascular tumor, raised, purple, reddish, brown, nodule or plaque

Assessment: bleeding, poor appetite, difficulty chewing, dysphagia, weight loss, painless oral lesion, lump in cheek

Management: nonsurgical or surgical, glossectomy, laryngectomy, mandibular resection, matxillectomy, mandibulectomy, neck dissection, pedicle or free flap reconstruction, tumor resection, tracheotomy

Esophageal disorders

Gastroesophageal reflux, gastroesophageal reflux disease

GERD

GERD: dyspepsia, eructation, flatulence, nausea, vomiting, dysphagia, odynophagia, cough, vocal hoarseness

Complications: Barrett’s epithelium, esophageal stricture

Diagnosis: 24hr esophageal pH monitoring, endoscopy

Management: nonsurgical (nutrition, lifestyle changes, weight reduction, stretta procedure), surgical (laparoscopic nissen fundoplication)

Medication: antacids, histamine 2 receptor antagonists, proton pump inhibitor

Hiatal hernia

Types: sliding (type 1), paraesophageal (rolling)

Treatment: nonsurgical, surgical (laparoscopic nissen fundoplication

Esophageal tumor

Upper 2/3 of esophagus: squamous cell carcinoma, Lower 1/3 of esophagus: adenocarcinoma (most common)

Risk factors: alcohol and tobacco use, Barrett’s esophagus

Nonsurgical treatment: nutrition, consult speech therapist, chemo/radiation, targeted therapies (PDT), esophageal dilatation

Surgical treatment: esophagectomy, esophagogastrostomy, colon interposition

Post operative care: nutritional management, wound management, cardiovascular management, respiratory management, NG tube care, positioning, oral care

Stomach disorders

Peptic, duodenal, stress

Manifestations: possible epigastric tenderness, rigid boardlike abdomen with rebound tenderness and pain (peritonitis), dyspepsia (most reported symptom), gastric ulcer pain, duodenal ulcer pain

Diagnosis: Serologic testing (H pylori) antibody

Treatment: medication, pain relief, treat H. pylori infection, PPIs, H2 antagonist, antacids, mucosal barrier, bland diet

GI bleed: PUD bleeding, prevent/treat hpovolemia, monitor H&H

Gastric ulcer

Gastric ulcer: upper abdominal pain, occurs 30-60 minutes after a meal, at night, rarely, worsened by ingestion of food

Duodenal ulcer

Upper abdominal pain, occurs 1 1/2- 3 hours after a meal, at night, often awakens patient between 1 and 2 am

Relieved by ingestion of food

Irritable bowel syndrome

Chronic/recurrent diarrhea, constipation, abdominal pain & bloating

Assess bowel patterns, food intolerance, usually appear well and normal weight

Diagnostics: CBC, electrolytes, stool for occult blood (usually normal)

Treatment: identify triggers, dietary fiber & bulk, medication

Intestinal obstruction

Partial vs complete, mechanical vs non-mechanical, accumulation of intestinal contents at/above obstruction

Manifestations: small intestine, colon, non-mechanical obstruction

Diagnosis: no single laboratory test to dx, abdominal xray, CT scan of abdomen, sigmoidoscopy/colonosopy

Interventions: non-surgical, surgical exploratory laparotomy

Ulcerative colitis

Cause? genetic immunologic

Lab values: increased WBC, C-reactive protein, or erythrocyte sedimentation rate, colonoscopy (definitive diagnosis)

Manifestations: stool contains mucus and blood tenesmus, lower abd pain, malaise, anorexia, anemia, dehydration, febrile, weight loss

Nonsurgical management (medication), surgical treatment (restorative proctocolectomy with ileo pouch-anal anastomosis, totalproctocolectomy with permanent ileostomy)

Chron’s disease

Causes: genetic, immunologic, environmental

Manifestations: diarrhea, pain and low grade fever, steatorrhea common, weight loss

Lab values: anemia, low folic acid and vitamin B12

X-rays: narrowing, ulcerations, strictures, and fistulas

Drug therapy, nutritional therapy, surgical management

Diverticular disease

Can occur in ant part of the small or large intestine, diverticula without inflammation usually cause few problems, abscess, peritonitis can develop

Small abnormal outpouchings or herniations that occur along the wall of the intestine

Diverticulitis is the inflammation of a diverticulum that occurs when undigested food or bacteria become trapped in the diverticulum

Assessment: may have no symptoms, may have abdominal pain, fever, tachycardia, nausea, vomiting, abdominal distention, tenderness

Interventions: nonsurgical and surgical management

Colorectal cancer

Most common in the rectum, refers to colon and rectum, which together make up the large intestine, most CRCs are adenocarcinomas

Risk factors: >50 years, genetic predisposition, personal/family history of cancer, diseases that predispose the patient to cancer, smoking, obesity, physical activity, heavy alcohol consumption, high-fat diet

Prevention: genetic testing for those family members with CRC, diagnostic screening, modify diet, stop smoking and drinking, exercise

Assessment/ signs and symptoms: vomiting, changes in bowel habits, rectal bleeding, anemia, pain or cramping, incomplete evacuation, FOBT, FIT, CEA, CT, sigmoidoscopy, colonoscopy

Management of colorectal cancer

Nonsurgical management: radiation therapy, adjuvant chemotherapy

Surgical management: colon resection, colectomy, colostomy

Colostomy types

Ascending colostomy: right-sided tumors

Transverse (double barreled) colostomy: used in emergencies and has two stomas

Descending colostomy: left-sided tumors

Sigmoid colostomy: rectal tumors

Care coordination for colostomy

Nursing priorities: home care management, self-management education, colostomy care, psychosocial concerns, health care resources

Gastritis

Inflammation of gastric mucosa, erosive versus nonerosive, acute vs chronic, often caused by long term NSAID use, can be caused by H. pylori

Acute: rapid onset of epigastric pain and dyspepsia, sometimes accompanied by gastric bleeding, hematemesis or melena

Chronic: may have few symptoms unless ulceration occurs, nausea, vomiting, upper abdominal discomfort

Diagnosis: EGD via endoscope is gold standard tool

Prevention of gastritis

Balanced diet, regular exercise, stress-reduction techniques, limit foods and spices that cause gastric distress, avoid alcohol and tobacco

Gastric cancer

Assessment: may be asymptomatic in early stage, duspepsia, abdominal discomfort are most common symptoms, in advanced disease anemia is present, EGD with biopsy is used to diagnose

Nonsurgical management: radiation, chemotherapy

Surgical management: gastrectomy or subtotal gastrectomy

Perioperative care: preoperative care, operative procedures, postoperative care

Nursing priorities: home care management, self-management education, health care resources

Breast cancer

Early detection is key, most common female cancer second to lung cancer, 5 year survival rate (localized 98.6%, spread to regional lymph nodes 83.8%, drops significantly when metasizes

Noninvasive (20%): ductal carcinoma in Situ, lobular carcinoma in Situ

Invasive (80%): Infiltrating ductal carcinoma, inflammatory breast cancer

Risk factors: BRCA 1 and or BRCA 2, breast density, family history

Paget’s disease

Rare type, occurs in or around the nipple ducts, women > men, affects the nipple area, alveoli, area becomes scaly red and irritated

Triple negative breast cancer

Estrogen receptor (ER) (negative), progesterone receptor (negative), human epidermal growth factor receptor 2 (negative), grows rapidly, requires progressive chemotherapy treatment, often found in women with BRCA gene mutation

Breast cancer in men

Rare, fewer than 1%, average age 68, relationship between family history and genetic factors

S/S: hard, painless, subareolar lump, gynecomastia, nipple discharge, retraction

Lower survival rate when compared to women, treatment is the same as for women

Screening for breast cancer

Mammography, breast examination, clinical breast examination, MRI, ultrasound

Diagnosis for breast cancer

Tissue biopsy, 3D mammogram, ultrasound, MRI, HER2

Breast cancer oncotype DX

Can help decide on the best course of treatment for invasive breast cancer, predicts chemotherapy benefit and the likelihood of distant and local breast cancer recurrence

Breast cancer treatment

Breast conserving surgery: lumpectomy, partial mastectomy

Total mastectomy, modified radial mastectomy, sentinel lymph node biopsy

Post operative care: do not use operative arm, monitor dressing and JP drains, elevate affective arm on a pillow, pain control, assess incision

Interventions to prevent DVT, PE, pneumonia, infection

Reconstruction: temporary prosthesis, breast expanders, autologous, review post op care in textbook

Chemotherapy

Targeted cancer therapy (Herceptin), hormonal therpy (Lupron, Zoladex), selective estrogen receptor modulators (Tamoxifen), aromatase inhibitors (Arimidex, femara)

Endometrial cancer

Arises from inner uterine lining

Stage 1: confined to the endometrium

Stage 2: involves the cervix

Stage 3: includes the vagina and lymph nodes

Stage 4: spread to the bowel/ bladder and beyond the pelvis

Risk factors for endometrial cancer

Estrogen replacement, middle aged or older, nulliparity, early menarche or late menopause, high fat diet, familial history of nonpolyposis colorectal cancer, use of tamoxifen, obesity or type 2 DM, polycystic ovarian syndrome, breast or ovarian cancer, endometrial hyperplasia, use of an intrauterine device, early menarche, treatment of the pelvis with radiation therapy

Clinical manifestations of endometrial cancer

Postmenopausal bleeding, watery-sero-sanquinious vaginal discharge, lower back, abd, and pelvic pain (late)

Diagnosis for endometrial cancer

Endometrial biopsy and transvaginal ultrasound, CEA 125 and AFP, hereditary nonpolyposis colorectal cancer (genetic testing), CXR, abd, CT of pelvis, MRI of abd/pelvis, PET scan, bone scan

Treatment for endometrial cancer

Surgical: total hysterectomy/ bilateral salpingo oophrectomy, radical hysterectomy

Non-surgical: brachytherapy, radiation therapy, chemotherapy

Brachytherapy

Short term effects: fatigue, urinary discomfort, urinary frequency (which may persist even beyond treatment), loss of pubic hair (temporary), loose stools

Report immediately: heavy vaginal bleeding, urethral burning for more than 24 hours, hematuria, extreme fatigue, severe diarrhea, fever over 100.4, abdominal pain

Types of hysterectomy

Total hysterectomy, bilateral salpingo-ophorectomy, radical hysterectomy

Preoperative nursing care for hysterectomies

Explain the procedure, including laboratory tests and what’s expected, depending on the type of surgical technique planned

Teach about the need for turning, coughing, and deep-breathing exercises, IS, early ambulation, and pain relief

Correct any misperceptions about the effects of hysterectomy

Post operative nursing care for hysterectomy

Incisional characteristics (presence of bleeding at site), heart, lung, bowel sounds, vital signs and pain level, temperature and color of skin, activity intolerance, perineal site care

Post hysterectomy nursing care

Assess cardiovascular, respiratory, renal, and GI status

Physical changes, activity, sexual activity, complications, symptoms to report

Cervical cancer

Most common, cervical intraepithelial neoplasia, noninvasive is more common than invasive

Etiology: HPV, early sexual encounter, multiple sexual partners, history of STDs, smoking

CIN 1: mild, CIN 2: moderate, CIN 3: severe to carcinoma in situ

Cells progress from normal to dysplasia, progression over years, strong correlation between sexual exposure to HPV and dysplasia, peak age for noninvasive is 30, average age for invasive is 50

Risk factors for cervical cancer

Infection with HPV, history of STIs, infection with chlamydia, multiparity (multiple births), long term use of oral contraceptives, being immunocompromised, smoking, familiar history, early age of first sexual experience

Clinical manifestations of cervical cancer

Asymptomatic, painless vag bleeding (spotting), post-coital bleed, watery bld tinged vaginal discharge becomes dark and foul smelling, dysuria, hematuria, rectal bleeding, chest pain, cough

Late S/S: leg pain, flank pain, unilateral leg edema, weight loss, anemia, cachexia

Diagnosis of cervical cancer

Pap smear 100% accurate, HPV-typing DNA test, colposcopy

Treatment of cervical cancer

Loop electrosurgical excision procedure, laser therapy, cryosurgery, cone biopsy, total hysterectomy, radiation, chemotherapy

Care after local cervical ablation therapies

Refrain from sexual intercourse, do not use tampons, do not douche, take showers rather than tub baths, avoid lifting heavy objects, report any heavy vaginal bleeding, foul-smelling drainage, or fever

Prevention of cervical cancer

Vaccine

Reduces the incidence of cervical related neoplasia and cervical cancer, infection from HPV types 16-18, approved for females aged 9-26

Approved for males to prevent genital herpes, 3 doses administered at 1 month, 2 months, 6 months

Ovarian cancer

Excessive estrogen, after menopause women >50 yrs old, mutations in genes BRCA-1, BRCA-2

These genes are tumor suppressors, familial history, personal history of breast or uterine cancer, hereditary nonpolyposis colorectal cancer

Risk and protective factors of ovarian cancer

Risk factors: BRCA gene mutation, nulliparity, early menarche, late menopause, obesity, endometriosis, and infertility drugs

Protective effects: BCP