Nurs 220 Exam #2

Priority problem of acute pancreatitis to report (MC) Page 1248 of Med surg textbook

Priority Problems in Acute Pancreatitis (Most to Least Urgent)

1. Respiratory Complications 🚨 HIGHEST PRIORITY

• Acute Respiratory Distress Syndrome (ARDS) - severe pulmonary edema from alveolar-capillary membrane disruption

• Pulmonary failure accounts for MORE THAN HALF of all deaths in the first week

• Pleural effusions, atelectasis, and pneumonia (especially in older adults)

2. Hemorrhage

• Caused by elastase enzyme → necrosis of blood vessels and ductal fibers

• Part of necrotizing hemorrhagic pancreatitis (NHP), which accounts for up to 10% of cases

• Can lead to multisystem organ failure

3. Shock

• Caused by kallikrein enzyme → edema, vascular permeability, smooth muscle contraction, and vasodilation

• Results from systemic inflammatory response

4. Disseminated Intravascular Coagulation (DIC)

• Hypercoagulation with consumption of clotting factors and microthrombi development

• Results from necrotic tissue and enzymes released into bloodstream

• Coagulation defects may result in death

5. Acute Kidney Injury

• Occurs due to systemic inflammatory response

• Serious complication requiring immediate intervention

6. Hypocalcemia

• Calcium levels fall and remain decreased for 7-10 days

• Observe for: muscle twitching, numbness, and irritability

• Occurs with fat necrosis

7. Hyperglycemia/Diabetes Mellitus

• From glucagon release and decreased insulin from islet cell damage

• Total pancreatic destruction may lead to diabetes mellitus

• Intermittent initially, may become permanent

8. Jaundice

• From pancreatic head swelling slowing bile flow

• Bile duct compression by calculi or pseudocyst

• Less immediately life-threatening but requires monitoring

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Key Principle: Prioritize ABCs (Airway, Breathing, Circulation) first. Respiratory complications are the leading cause of death in the first week, making them the absolute priority to report and manage.

Abnormal Serum Lab for pancreatitis (SATA)

-Amylase (If high, then it means there is pancreatic cell injury)

-Lipase (If high, then it means there is pancreatic cell injury)

-Serum bilirubin and alkaline phosphatase (If high, then it indicates they are biliary pancreatitis)

-ALT (Would be elevated)

-WBC (Would be elevated, increased means there is an inflammatory process happening in the body)

-ESR

-C-reactive protein (Would be elevated, increased means there is an inflammatory process happening in the body

-An increased direct bilirubin and/or alkaline phosphatase level or a transabdominal ultrasound examination may indicate the presence of an obstructing gallstone

Expected assessment findings for chronic pancreatitis (SATA)

Pain Characteristics

Abdominal Pain - Major symptom

• Continuous burning or gnawing dullness (differs from acute pancreatitis)

• Periods of acute exacerbation (flare-ups)

• Very intense and relentless

• Frequency of exacerbations increases as pancreatic fibrosis develops

• Less intense tenderness on palpation compared to acute pancreatitis

Gastrointestinal Findings

Steatorrhea - Hallmark sign

• Pale, bulky, frothy stools

• Offensive/extremely foul odor (from colonic bacteria acting on unabsorbed lipids and proteins)

• Visible fat content on inspection

• Results from severe fat malabsorption (requires greatly reduced pancreatic enzyme secretion)

Abdominal Assessment:

• Massive pancreatic ascites may be present

• Dullness on abdominal percussion (from ascites)

Nutritional/Metabolic Changes

Weight Loss and Wasting:

• Unintentional weight loss

• Muscle wasting (decreased muscle mass)

• General debilitation

• "Starvation" edema of feet, legs, and hands (from protein malabsorption causing decreased albumin)

Diabetes Mellitus Symptoms (from loss of endocrine function):

• Polyuria (increased urinary output)

• Polydipsia (excessive thirst)

• Polyphagia (increased appetite)

• Intermittent serum glucose elevations

Biliary Obstruction Signs:

• Jaundice

• Dark urine

Respiratory Complications

• Pleuritic pain (pain when pt takes deep breaths, can cause infection)

• Pleural effusions

• Pulmonary infiltrates

• Adventitious lung sounds or decreased aeration

• Dyspnea or orthopnea

• Impaired ventilation (from pancreatic ascites decreasing diaphragmatic excursion)

• Risk for ARDS in severely ill patients

Laboratory Findings

• Normal or moderately elevated serum amylase and lipase (differs from acute pancreatitis)

• Elevated serum bilirubin and alkaline phosphatase (if intrahepatic bile duct obstruction)

• Intermittent elevations in serum glucose

Mouth care patient teaching (MC)

-Proper oral hygiene can decrease the frequency and severity of stomatitis

Patient Teaching for Mouth Care

What to AVOID

Products that dry the mouth or alter pH:

• ❌ Commercial mouthwashes containing alcohol

• ❌ Lemon-glycerin swabs (too acidic)

• ❌ Glycerin swabs (dry the mouth and promote bacterial growth)

• ❌ Oral foam swabs/disposable foam brushes (don't adequately control plaque)

These cause burning sensations, dry oral mucosa, change mouth pH, and promote bacterial overgrowth

What to USE

Cleaning tools:

• ✅ Soft-bristle toothbrush or ultrasoft "chemobrush"

• ✅ Brush gently every 2 hours (or as recommended)

• ✅ Sponge tooth cleaner moistened in water

Rinsing solutions:

• ✅ Sodium bicarbonate solution or warm saline

• ✅ Normal saline rinses every 4 hours while awake (or as desired)

• ✅ Chlorhexidine oral rinse (if prescribed - helps prevent infection)

Moisturizing:

• ✅ Water-based lubricant for lips and oral mucosa

• ✅ Lip balm or water-soluble jelly to prevent cracked lips

Medication Instructions

Know the difference:

• Some medications are for swish and swallow

• Some are for rinse only (spit out)

• Some are taken orally (swallowed as pills)

Take all antibiotics as prescribed - even if you feel better before finishing them

Dietary Choices

• Choose foods that won't irritate the oral cavity

• Avoid hot, spicy, acidic, or rough-textured foods if mouth is sensitive

When to Seek Help

Report to your healthcare provider:

• Mouth ulcers or sores

• Signs of infection

• Persistent pain despite treatment

• Reduced tissue integrity in the mouth

Additional Support

If experiencing persistent oral pain (especially related to chemotherapy/radiation), consider joining a support group for coping strategies.

Viscous lidocaine teaching precautions (MC)

-Teach patients to use viscous lidocaine with extreme caution

-Lidocaine causes a topical anesthetic effect, so patient may not easily feel burns from hot liquids

-Make sure to swish around mouth to ensure that it coats the entire oral cavity

-As sensation in the mouth and throat decreases, the risk for aspiration rises

Risk factors that can cause stomatitis (MC)

Infectious Causes

Viral:

• Herpes simplex virus (causes herpes simplex stomatitis)

Fungal:

• Candida albicans → candidiasis (moniliasis)

  • More common in older adults

  • Long-term antibiotic therapy destroys normal flora, allowing Candida overgrowth

Bacterial:

• Opportunistic bacterial infections (especially in immunocompromised patients)

Medical Treatments

• Chemotherapy

• Radiation therapy

• Steroid drug therapy

Nutritional Deficiencies

• Complex B vitamins

• Folate

• Zinc

• Iron

Immunologic Factors

• Immunocompromised status

• Cell-mediated immune system activation (may be related to genetic predisposition)

Irritants

• Tobacco use

• Alcohol use

Food Allergies/Triggers

Foods that may trigger allergic responses causing aphthous ulcers:

• Coffee

• Potatoes

• Cheese

• Nuts

• Citrus fruits

• Gluten

Systemic Disease

• Various systemic diseases can contribute to stomatitis development

Trauma

• Physical trauma to oral mucosa (traumatic ulcers)

Assessment findings of GERD (SATA)

Mnemonic: GERD PAINS

G - Gastric contents reflux

• Regurgitation (sour or bitter taste)

• Water brash (rare) - fluid sensation in throat WITHOUT sour/bitter taste

E - Esophageal/Epigastric discomfort

• Dyspepsia (indigestion) - main symptom

• Lasts 20 minutes to 2 hours after meals

• Worsens when lying down

R - Radiating chest pain

• May mimic cardiac pain

• Can radiate to neck, jaw, or back

• Severe indigestion felt in chest

D - Dysphagia (if complications develop)

• Related to esophageal stricture or Barrett's esophagus

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P - Positional worsening

• Symptoms worsen when:

  • Bending over

  • Straining

  • Lying down

A - Abdominal symptoms

• Abdominal discomfort

• Feeling uncomfortably full

• Nausea

• Bloating

I - Inhalation concerns

• Crackles in lung fields (indicates aspiration)

• Important to auscultate lungs during assessment

N - Nocturnal symptoms

• Symptoms typically occur after meals

• Worsen at night when lying down

S - Stomach gas symptoms

• Flatulence

• Eructation (belching)

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Quick Relief Signs

Symptoms usually improve with:

• ✅ Drinking fluids

• ✅ Taking antacids

• ✅ Maintaining upright posture

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Key Assessment Points

Severity indicator: With severe GERD, discomfort occurs after each meal and lasts 20 minutes to 2 hours

Delayed treatment: Patients often delay seeking help because they don't view indigestion as serious

Critical assessment: Always auscultate lungs for crackles (aspiration risk)

Complications of untreated GERD (SATA)

ABSCHAL

A - Aspiration pneumonia

• Serious risk from refluxed gastric contents entering lungs

B - Barrett's esophagus

• Premalignant condition

• Body replaces normal squamous cells with columnar epithelium (Barrett's epithelium)

• More resistant to acid BUT increases cancer risk

• Develops during healing process

S - Stricture (esophageal)

• Narrowing of esophageal opening

• Results from fibrosis and scarring during healing

• Leads to progressive difficulty swallowing

C - Cardiac disease

• Increased risk with uncontrolled reflux

H - Hemorrhage

• Serious concern with uncontrolled esophageal reflux

A - Asthma

• Triggered by uncontrolled reflux

L - Laryngitis & other complications

• Laryngitis from acid irritation

• Dental decay from chronic acid exposure

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Key Points to Remember

Most serious complications:

• Barrett's esophagus (cancer risk)

• Aspiration pneumonia

• Hemorrhage

Mechanism: Prolonged acid exposure → inflammation → healing with fibrosis/scarring → structural changes

Nighttime risk: Reflux is worse at night because:

• Supine position

• Secretions don't drain with gravity

• Prolonged esophageal acid exposure

Progressive nature: Uncontrolled GERD leads to increasingly serious complications over time

Reportable GERD assessment finding (MC)

🚨 MOST URGENT → LEAST URGENT

1⃣ CRITICAL - Report Immediately

Crackles in lung fields

• Indicates aspiration of gastric contents

• Risk for aspiration pneumonia

• Requires immediate intervention

Chest pain radiating to neck, jaw, or back

• Can mimic cardiac pain

• Must rule out myocardial infarction first

• Never assume it's "just GERD" without cardiac evaluation

2⃣ URGENT - Report Same Day

Severe dysphagia (difficulty swallowing)

• May indicate esophageal stricture

• Risk for Barrett's esophagus

• Potential complication requiring intervention

Hematemesis or signs of bleeding

• Indicates hemorrhage complication

• Requires immediate medical evaluation

Severe pain lasting >2 hours despite interventions

• Unrelieved by fluids, antacids, or upright position

• May indicate worsening esophagitis or complications

3⃣ IMPORTANT - Report Within 24-48 Hours

Progressive worsening of symptoms

• Symptoms occurring after each meal

• Increasing frequency or severity

• Indicates need for treatment adjustment

New onset of regurgitation with sour/bitter taste

• Suggests worsening reflux

• May need medication adjustment

Symptoms interfering with sleep/daily activities

• Chronic nighttime symptoms

• Inability to lie flat

• Affects quality of life

4⃣ ROUTINE - Report at Next Scheduled Visit

Typical GERD symptoms responding to treatment:

• Dyspepsia (indigestion) relieved by antacids

• Eructation (belching)

• Flatulence

• Mild abdominal discomfort

• Bloating

• Nausea

Symptoms improved by:

• Drinking fluids

• Maintaining upright posture

• Taking prescribed medications

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Key Teaching Point

Always report chest pain immediately - healthcare providers must differentiate between cardiac and GERD-related pain through proper assessment.

Risk factors of GERD (SATA)

GERD FLAMPS

G - Genetic predisposition

• Strong genetic connection associated with GERD development

E - Eating patterns

• Large meals increase stomach volume and pressure

• Delay gastric emptying

R - Reflux-triggering foods

• Peppermint, chocolate

• Fatty/fried foods

• Caffeine, carbonated beverages

• Spicy and acidic foods (orange juice, tomatoes)

D - Drugs that lower LES pressure

• Oral contraceptives

• Anticholinergic agents

• Sedatives

• NSAIDs (e.g., ibuprofen)

• Nitrates

• Calcium channel blockers

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F - Factors increasing intraabdominal pressure

• Pregnancy

• Tight belts or abdominal binders

• Bending over

• Ascites

L - Lifestyle choices

• Smoking

• Alcohol use

• Contribute very significantly to GERD

A - Anatomical compromise

• Nasogastric (NG) tube - keeps cardiac sphincter open

• Allows acidic contents to enter esophagus

M - Medical conditions

• Obstructive sleep apnea - patients report frequent GERD episodes

P - Position during sleep

• Supine position at night

• Secretions don't drain with gravity

• Causes prolonged esophageal acid exposure

S - Sphincter dysfunction

• Compromised (relaxed) LES allows gastric contents to reflux

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Key Points

Lifestyle is crucial: While genetics play a role, lifestyle choices contribute very significantly to GERD development

Nighttime risk: Sleep apnea + supine position = increased reflux episodes

Medication review: Always assess patient's current medications for drugs that lower LES pressure

GERD discharge teachings (SATA)

GERD Discharge Teaching Mnemonic:

MEALS HELP

M - Medication adherence

• Properly adhere to drug therapy to minimize GERD pain

• Continue antacids, H2 blockers, or PPIs as prescribed

• Don't stop medications without provider guidance (high recurrence rate)

• Discuss eliminating drugs that cause reflux with provider

E - Eating modifications

• 4-6 small meals daily instead of 3 large ones

• Eat slowly and chew thoroughly

• Avoid eating close to bedtime

A - Avoid trigger foods

• Limit/eliminate: peppermint, chocolate, fatty/fried foods

• Avoid: caffeine, carbonated beverages

• Restrict: spicy and acidic foods (orange juice, tomatoes) until healed

L - Lifestyle changes

• Stop smoking

• Limit/eliminate alcohol

• Avoid tight belts or abdominal binders

• Avoid bending over after meals

S - Sleep positioning

• Elevate head of bed or use wedge pillow

• Maintain upright position after eating

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H - Health monitoring

• GERD is a chronic disorder requiring ongoing management

• Watch for signs of complications

E - Emergency signs to report

• Severe dysphagia (esophageal stricture)

• Chest pain (rule out cardiac causes)

• Signs of bleeding

• Crackles/respiratory symptoms (aspiration)

L - Link to resources

• Work with registered dietitian nutritionist (RDN) for meal planning

• Join local support groups for GERD

• Use online communities for credible information

• Try apps like MyFitnessPal or MyPlate for healthier diet tracking

P - Pressure reduction

• Avoid activities that increase intraabdominal pressure

• Maintain healthy weight (if applicable)

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Key Discharge Messages

✅ GERD is chronic - requires lifelong management
✅ Continue basic antireflux regimen even after surgery (high recurrence)
✅ Treat more aggressively in older adults
✅ Don't delay seeking help if symptoms worsen

Specific diagnostic test for HH (MC)

Most Specific Test

Barium swallow study with fluoroscopy

• Gold standard for identifying hiatal hernia

• Rolling hernias (types II-IV) are usually clearly visible

• Sliding hernias (type I) can be observed when patient moves through positions that increase intraabdominal pressure

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Additional Diagnostic Tests

Esophagogastroduodenoscopy (EGD)

• Used to visualize sliding hernias specifically

• Views both esophagus and gastric lining

• Helpful when barium swallow is inconclusive

High-Resolution Manometry (HRM) with Esophageal Pressure Topography (EPT)

• Identifies larger sliding hiatal hernias

• Measures esophageal pressure and function

Chest X-ray

• Part of acute abdomen series

• May reveal hiatal hernia incidentally

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Key Points

Type matters: Rolling hernias are easier to visualize than sliding hernias

Sliding hernias: Require positional changes during imaging because they move freely and slide in/out of chest with changes in position or intraabdominal pressure

Most patients are asymptomatic: Many hiatal hernias are discovered incidentally during imaging for other conditions

Symptoms similar to GERD: When symptomatic, patients experience GERD-like symptoms that worsen after meals or when supine

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Clinical Assessment

Obtain history and perform physical assessment as you would for GERD patients, since symptoms overlap significantly.

Laparoscopic Nissen fundoplication (LNF) surgical procedure for HH post op complication to report STAT (MC)

🚨 CRITICAL - Report Immediately

Respiratory Distress

• Dyspnea, tachypnea, decreased oxygen saturation

• Crackles or diminished breath sounds

• May indicate pneumothorax or hemothorax

• LNF involves working near the diaphragm

Signs of Bleeding/Hemorrhage

• Tachycardia, hypotension

• Decreased hemoglobin/hematocrit

• Abdominal distention with rigidity

• Bloody drainage from surgical sites

Severe Chest or Abdominal Pain

• Unrelieved by prescribed analgesics

• May indicate perforation, leak, or other surgical complication

Fever with Tachycardia

• Temperature >38.5°C (101.3°F)

• May indicate infection, abscess, or anastomotic leak

Inability to Swallow or Severe Dysphagia

• "Wrap is too tight" - fundoplication may be overly restrictive

• Risk for aspiration

• Patient unable to tolerate oral intake

Nausea/Vomiting

• Especially concerning if patient cannot vomit effectively (wrap prevents normal vomiting mechanism)

• Risk for aspiration

• May indicate obstruction

Abdominal Distention

• "Gas-bloat syndrome" - inability to belch or vomit

• Accumulation of gas causing severe discomfort

• May require decompression

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Key Post-Op Monitoring Points

Chest tube (if transthoracic approach):

• Monitor drainage amount, color, consistency

• Assess for air leaks

• Report sudden changes

Nasogastric tube (if present):

• Maintain patency

• Monitor output

• Report if not draining properly

Surgical sites:

• Assess for signs of infection

• Monitor laparoscopic port sites for bleeding or drainage

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Remember

LNF has fewer complications than open fundoplication, but complications can still occur and require immediate intervention when they do.

LNF Discharge teaching (SATA)

LNF Discharge Teaching Mnemonic:

SOFT DIET

S - Surgical site care

• Monitor incisions for redness, swelling, heat, drainage, increased pain

• Report promptly to surgeon if signs of infection occur

• Proper handwashing to prevent infection

O - Opioid precautions

• Do not drive or operate heavy machinery while taking oral opioids for pain

• Use as prescribed for pain management

• Expect soreness and discomfort (not severe acute pain) - this is normal

F - Follow-up care

• Telephone follow-up typically occurs day after surgery

• Attend all scheduled appointments

• Contact surgeon with concerns

T - Transition timeline

• Discharge in 3-5 hours after laparoscopic procedure (depending on anesthesia recovery)

• Avoid strenuous activity for several days before returning to work

• Arrange for adult to drive you home and stay with you rest of the day

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D - Diet modifications

• Start with liquids, advance as tolerated

• High protein, calories, and vitamins promote wound healing

• May need supplemental vitamin C, iron, zinc to aid healing

I - Intestinal management

• Stool softener may be needed to prevent constipation

• Avoid straining

E - Emergency signs to report

• Severe dysphagia (inability to swallow)

• Uncontrolled pain - notify surgeon if pain not relieved or suddenly increases

• Fever, bleeding, respiratory distress

• Severe nausea/vomiting

• Abdominal distention

T - Tube/drain awareness (if applicable)

• Understand purpose of any drains

• Do not kink or pull drains

• May cause mild discomfort but shouldn't be painful

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Key Messages

✅ NPO before surgery - follow surgeon's specific instructions
✅ Resume other medications - drug reconciliation completed before discharge
✅ Complete antibiotic course if prescribed, even if feeling better
✅ Normal recovery includes soreness, not severe pain

Complications of Peptic Ulcer Disease (SATA)

-Peptic ulcer disease is a condition that results when GI mucosal defenses become impaired within the small intestine

-Caused by H. pylori

1. Hemorrhage (Most Serious) 🩸

Most common serious complication that tends to occur more often with gastric and stress ulcers, especially in older adults.

Signs & Symptoms:

• Hematemesis: Vomiting bright red or coffee-ground blood (indicates bleeding at or above duodenojejunal junction)

• Melena: Dark, "tarry" stools from occult blood (more common with duodenal ulcers)

• Massive bleeding (>1 L/24 hr): Hypotension, chills, palpitations, diaphoresis, weak/thready pulse (hypovolemic shock)

• Mild bleeding (<500 mL): Weakness, mild perspiration

Key Point: Many patients have a second bleeding episode if H. pylori remains untreated or without H₂ antagonist/PPI therapy.

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2. Perforation ⚠ SURGICAL EMERGENCY

Occurs when ulcer erodes through entire stomach or duodenal wall, leaking GI contents into peritoneal cavity.

Classic Presentation:

• Sudden, sharp midepigastric pain spreading over entire abdomen

• Rigid, boardlike abdomen (peritonitis)

• Patient assumes fetal position to decrease abdominal muscle tension

• Apprehension

Complications: Bacterial septicemia, hypovolemic shock, paralytic ileus, diminished peristalsis

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3. Pyloric (Gastric Outlet) Obstruction

Blockage at the pylorus from scarring, edema, or inflammation.

Manifestations:

• Abdominal bloating

• Nausea and vomiting (from gastric stasis and dilation)

• Metabolic alkalosis (from loss of hydrogen and chloride ions in vomitus)

• Hypokalemia (from vomiting or metabolic alkalosis)

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4. Intractable Disease

Ulcers that no longer respond to conservative management or recur despite treatment.

Characteristics:

• Recurrent pain despite treatment

• Symptoms interfere with activities of daily living

• May result from complications, excessive stressors, or inability to adhere to therapy

• Requires referral to gastroenterology specialist

5. Peritonitis IS a Complication of PUD

Peritonitis occurs as a direct result of perforation, which is one of the four major complications of peptic ulcer disease.

How It Happens:

When a peptic ulcer becomes so deep that it erodes through the entire thickness of the stomach or duodenum, the GI contents leak into the peritoneal cavity, causing peritonitis (infection of the peritoneum).

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Clinical Presentation:

Classic Signs of Peritonitis from PUD Perforation:

• Rigid, boardlike abdomen with rebound tenderness

• Intense pain - sudden, sharp midepigastric pain spreading over entire abdomen

• Fetal position - patient assumes this to decrease abdominal muscle tension

• Initially hyperactive bowel sounds that diminish as infection progresses

• Apprehension

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Why It's Life-Threatening:

Patients can become severely ill within hours due to:

• Bacterial septicemia

• Hypovolemic shock

• Paralytic ileus (diminished peristalsis)

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Treatment:

Peptic ulcer perforation with peritonitis is a surgical emergency!

Interventions include:

• Emergency surgery (exploratory laparotomy or laparoscopy) to repair perforated organ

• Peritoneal irrigation with antibiotic solutions

• Drain placement for cavity drainage and post-op irrigation

• Broad-spectrum antibiotics

• Monitoring for septic shock

Duodenal ulcer complication (SATA)

Duodenal Ulcer Complications

Duodenal ulcers share the same four major complications as all peptic ulcer disease:

1. Hemorrhage 🩸

Key Difference: Duodenal ulcers more commonly present with melena (dark, tarry stools) rather than hematemesis, though both can occur.

Signs:

• Melena: Dark, "tarry" stools from occult blood (more common with duodenal ulcers than gastric ulcers)

• Hematemesis: Coffee-ground or bright red vomitus (indicates upper GI bleeding)

• Hypovolemic shock with massive bleeding

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2. Perforation ⚠ SURGICAL EMERGENCY

When the duodenal ulcer erodes through the entire duodenal wall:

Classic Presentation:

• Sudden, sharp midepigastric pain spreading across abdomen

• Rigid, boardlike abdomen (peritonitis)

• Fetal position to reduce abdominal tension

• Apprehension

Life-Threatening Sequelae:

• Bacterial septicemia

• Hypovolemic shock

• Paralytic ileus

• Diminished peristalsis

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3. Pyloric (Gastric Outlet) Obstruction

Blockage occurs at the pylorus from scarring, edema, or inflammation of the duodenal ulcer.

Manifestations:

• Vomiting from gastric stasis and dilation

• Abdominal bloating

• Metabolic alkalosis

• Hypokalemia

Treatment:

• Nasogastric decompression (typically 72 hours)

• Restore fluid and electrolyte balance

• Correct metabolic alkalosis and dehydration

• May require surgical intervention if medical therapy fails

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4. Intractable Disease

Duodenal ulcers that don't respond to treatment or keep recurring.

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Prevention of Recurrence:

Many patients experience second bleeding episodes if:

• H. pylori infection remains untreated

• Therapy doesn't include H₂ antagonist or PPI

Priority of care when changes in Peptic ulcer disease? Check later

🚨 IMMEDIATE PRIORITIES:

1. HEMORRHAGE (Life-Threatening Emergency)

Assess for signs of active bleeding:

• Hematemesis (bright red or coffee-ground vomit)

• Melena (dark, tarry stools)

• Hypotension, weak thready pulse

• Chills, palpitations, diaphoresis

Immediate interventions:

• Fluid resuscitation - start isotonic solutions (0.9% NS, LR) immediately

• Insert large-bore IV catheters (two if possible)

• Monitor vital signs continuously

• Administer packed RBCs as ordered

• Fresh frozen plasma if PT >1.5x control

• Monitor hematocrit, hemoglobin, coagulation studies

• Keep patient NPO for potential endoscopy

2. PERFORATION (Surgical Emergency)

Assess for:

• Sudden, sharp midepigastric pain spreading over entire abdomen

• Rigid, boardlike abdomen

• Patient in fetal position

• Diminished peristalsis → paralytic ileus

Immediate action:

• Notify provider immediately - surgical emergency

• Monitor for septicemia and shock

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Priority Order:

FIRST: Assess for hemorrhage (most common serious complication)

• Monitor hemodynamic status

• Check for bleeding signs

• Prepare for volume replacement

SECOND: Assess for perforation (less common but surgical emergency)

THIRD: Monitor for pyloric obstruction

• Vomiting from gastric stasis/dilation

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Key Nursing Actions:

✅ Continuous monitoring of vital signs and fluid status
✅ Intake/output tracking (especially in older adults - prevent fluid overload)
✅ Electrolyte monitoring (losses from vomiting/NG suction)
✅ Prepare for endoscopic therapy (EGD with injection, heat, or clipping)
✅ Administer acid suppression (PPIs after bleeding controlled)

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Remember: Blood loss >1 L/24 hours = hypovolemic shock - this is your #1 priority to prevent death.

Quadruple therapy patient teaching (MC)

What It Is:

Quadruple therapy combines four medications to treat H. pylori infection:

1. Proton pump inhibitor (PPI) - reduces stomach acid

2. Two antibiotics (e.g., metronidazole + tetracycline OR clarithromycin + amoxicillin)

3. Bismuth subsalicylate (usually taken if patient is allergic to penicilin)Wh

Duration: 10-14 days

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Key Teaching Points:

Bismuth Subsalicylate:

✅ Expected Side Effects:

• Black discoloration of stools and/or tongue - this is temporary and harmless

• Reassure patients this is normal and will resolve after stopping medication

⚠ Critical Safety:

• DO NOT take aspirin while on bismuth therapy

• Both contain salicylic acid → risk of salicylate overdose

• Check all OTC medications for aspirin/salicylates

Why Bismuth Works:

• Prevents H. pylori from binding to stomach lining

• Stimulates mucosal protection

• Increases prostaglandin production

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Who Gets Quadruple Therapy:

Often prescribed for patients with penicillin allergies (since it allows alternatives to amoxicillin)

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General Medication Adherence:

• Complete the full course (10-14 days) even if feeling better

• Take medications exactly as prescribed

• Don't skip doses - incomplete treatment can lead to:

  • Treatment failure

  • Ulcer recurrence

  • Continued H. pylori infection

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Goals of Treatment:

1. Eliminate H. pylori infection

2. Heal ulcerations

3. Provide pain relief

4. Prevent recurrence

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Follow-Up:

Emphasize importance of follow-up testing to confirm H. pylori eradication after completing therapy.

What is the difference between triple and quadruple therapy?

Triple Therapy (PPI-Based)

3 Medications:

1. Proton pump inhibitor (PPI) - such as lansoprazole

2. Two antibiotics:

   • Metronidazole + tetracycline, OR

   • Clarithromycin + amoxicillin

Duration: 10-14 days

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Quadruple Therapy

4 Medications:

1. Proton pump inhibitor (PPI)

2. Two antibiotics (same combinations as triple therapy)

3. Bismuth subsalicylate ← This is the key difference

Duration: 10-14 days

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Key Differences:

Feature	Triple Therapy	Quadruple Therapy
Number of drugs	3 medications	4 medications
Bismuth included?	❌ No	✅ Yes
Common use	Standard first-line treatment	Penicillin-allergic patients

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Why Add Bismuth?

Bismuth subsalicylate provides additional benefits:

• Inhibits H. pylori from binding to mucosal lining

• Stimulates mucosal protection

• Increases prostaglandin production

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Patient Teaching for Quadruple Therapy:

Since bismuth is added, patients need extra education:

⚠ Critical Safety:

• Cannot take aspirin with bismuth (both are salicylates → overdose risk)

✅ Expected Side Effect:

• Black stools and/or tongue - temporary and harmless

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Clinical Decision:

Primary health care providers may prefer quadruple therapy for patients who are allergic to penicillin-based medications, as it provides flexibility in antibiotic selection while adding bismuth's protective benefits.

Both regimens share the same goals: eliminate H. pylori, heal ulcerations, provide pain relief, and prevent recurrence.

GI bleeding assessment findings (SATA)

Upper GI Bleeding

Hematemesis:

• Bright red vomitus - indicates active, rapid bleeding

• Coffee-ground vomitus - indicates slower bleeding (blood partially digested by gastric acid)

Melena:

• Dark, "tarry" stools - indicates occult blood digested in small intestine

• More common with duodenal ulcers than gastric ulcers

---

Lower GI Bleeding

Hematochezia:

• Bright red blood in stool

• Indicates bleeding from lower GI tract (colon, rectum)

Occult Blood:

• Microscopic blood detected by fecal occult blood test (FOBT) or fecal immunochemical test

• May not be visible to naked eye

---

Signs of Significant Blood Loss

Hypovolemic Shock (>1 L blood loss/24 hr):

• Hypotension

• Orthostatic blood pressure changes - priority assessment

• Weak, thready pulse

• Tachycardia, palpitations

• Chills

• Diaphoresis (cold, clammy skin)

• Dizziness with position changes

---

Physical Assessment:

Abdominal Exam:

• Tenderness

• Rigidity (if perforation with peritonitis)

• Distention

• Bowel sound changes

Vital Signs:

• Monitor for hypotension

• Check orthostatic BP (lying, sitting, standing)

• Assess pulse quality and rate

---

Laboratory Findings:

• CBC - detects anemia (GI bleeding is most frequent cause in adults)

• Hemoglobin & Hematocrit - decreased with blood loss

• Prothrombin time (PT) - evaluates clotting factors

• Positive FOBT - indicates GI tract bleeding

---

Associated Symptoms:

Acute Gastritis with Bleeding:

• Rapid onset epigastric pain

• Dyspepsia (heartburn)

• Nausea and vomiting

Peptic Ulcer Disease:

• Epigastric pain

• May present with hemorrhage as first symptom (life-threatening emergency)

---

Priority Nursing Actions:

1. Assess fluid status - orthostatic BP, vital signs

2. Monitor intake and output

3. Assess for signs of shock

4. Monitor older adults for dehydration and fall risk from dizziness

GI bleeding >0.5 mL/min requires close monitoring and may need GI bleeding scan to localize source.

GI Bleeding Assessment - Memory Aid

Great idea! Here's an easy-to-remember format:

BLEEDING Signs Mnemonic:

B - Bright red vomitus (hematemesis - active bleeding)
L - Liquid black stools (melena - upper GI)
E - Emergent vitals (hypotension, tachycardia)
E - Exam findings (rigid abdomen, tenderness)
D - Decreased labs (low Hgb, Hct)
I - Orthostatic changes (dizziness, BP drop when standing)
N - Nausea/vomiting
G - GI pain (epigastric)

---

Shock Signs - "CHILLED":

C - Cold, clammy skin
H - Hypotension
I - Increased heart rate
L - Low pulse quality (thready)
L - Loss of consciousness risk
E - Extreme diaphoresis
D - Dizziness

---

Priority Assessment = "ORTHOSTATIC BP"

Most critical finding for significant blood loss!

Risk factors of gastritis (SATA)

Gastritis Risk Factors - Memory Aid

"GASTRITIS" Mnemonic:

G - Germs (H. pylori infection - most common cause)
A - Alcohol use
S - Smoking
T - Toxins/endotoxins (contaminated food, staphylococcal)
R - Rx drugs (NSAIDs, aspirin, corticosteroids)
I - Insufficient stress management
T - Trauma (critical illness, burns, surgery)
I - Inadequate diet (unbalanced nutrition)
S - Sedentary lifestyle (lack of exercise)

---

Additional Risk Factors:

Social Determinants:

• Financial difficulties - limited access to healthy food

• Family responsibilities - little time for self-care

• Lack of resources for stress management

Medical Conditions:

• Autoimmune disorders

• Bile reflux

• Pernicious anemia

---

Select All That Apply - Quick Checklist:

✅ H. pylori infection
✅ NSAID/aspirin use
✅ Alcohol consumption
✅ Smoking
✅ Stress (without management techniques)
✅ Poor diet
✅ Lack of exercise
✅ Contaminated food (food poisoning)
✅ Critical illness/trauma

---

Prevention Focus:

Remember the 3 pillars of prevention:

1. Balanced diet

2. Regular exercise

3. Stress-reduction techniques (aerobic exercise, meditation, yoga)

Avoid: Smoking and alcohol

---

NCLEX Tip:

For select-all questions, watch for:

• Lifestyle factors (smoking, alcohol, diet, exercise, stress)

• Medications (NSAIDs, aspirin, steroids)

• Infections (H. pylori, food poisoning)

• Social factors (financial barriers, lack of resources)

Status post partial gastrectomy patient teaching (SATA)

Post-Gastrectomy Teaching - Memory Aid

"DUMPING" Mnemonic for Patient Education:

D - Divide meals (small, frequent meals - 5-6 per day)
U - Uncouple liquids from solids (NO liquids with meals)
M - Minimize carbs (low to moderate carbohydrate diet)
P - Protein priority (high-protein foods)
I - Increase fat (high-fat diet)
N - No lying down after eating... wait, YES lie down!
G - Go slow (eat and drink slowly, stop before feeling full)

---

Dumping Syndrome - Two Types:

Early Dumping (within 20 min):

• Vertigo, tachycardia, syncope

• Sweating, pallor

• Palpitations, desire to lie down

• Action: LIE DOWN immediately

Late Dumping (1-3 hours later):

• Dizziness, light-headedness

• Palpitations, diaphoresis, confusion

• Caused by excessive insulin release

---

Select All That Apply - Quick Checklist:

✅ Eat small meals (5 tablespoons initially)
✅ High-protein, high-fat diet
✅ Low to moderate carbohydrates
✅ NO liquids with meals (drink between meals)
✅ Eat and drink slowly
✅ Stop eating before feeling full
✅ Lie down if dumping symptoms occur
✅ Avoid fatty foods initially... wait, include fats!
✅ Avoid high-sugar foods
✅ Report infection signs (fever, redness, drainage)
✅ Keep follow-up appointments with surgeon and dietitian

---

Diet Progression (Post-Op):

1. Clear liquids (1-ounce cups)

2. Full liquids (at discharge)

3. Pureed foods (~1 week) - 5 tablespoons per meal

4. Soft foods (several weeks later)

5. Solid, nutrient-dense foods (~8 weeks post-op)

---

NCLEX Strategy:

Look for:

• ✅ Small, frequent meals

• ✅ Separate liquids from meals

• ✅ High-protein, high-fat, low-carb

• ✅ Lying down with symptoms

• ✅ Avoiding high-sugar foods

Watch out for:

• ❌ Large meals

• ❌ Drinking with meals

• ❌ High-carbohydrate diet

• ❌ Standing/walking with dumping symptoms

Nutrition teaching (MC)

• Teach adults to ensure a diet high in fiber, including eating fruits, vegetables, and whole grains, and drinking 8 to 12 glasses of water each day unless medically contraindicated

• You can increase fiber intake by eating whole grains, legumes, fresh fruits, and vegetables

• Minimum amount of fluids needed to be taken daily to prevent constipation is 2000 mL

• Avoid dependency on laxatives

• Key note: High fiber diet + adequate fluids = normal elimination

Key Components to Include:

1. Comprehensive Assessment:

✅ 24-hour food recall - what patient ate yesterday
✅ Food frequency - how often foods are consumed
✅ Usual eating habits
✅ Recent appetite or intake changes
✅ Ability to chew and swallow
✅ Weight history - especially unintentional loss
✅ Food access - consider food deserts (limited access to fresh, nutritious food)

2. Individualized Planning:

✅ Collaborate with RDN (Registered Dietitian Nutritionist)
✅ Diet must meet patient's needs, habits, and lifestyle
✅ Must be realistic for the patient
✅ Consider cultural and personal preferences

3. Specific Diet Components:

✅ Calorie requirements - based on resting metabolic rate and activity
✅ Macronutrients - protein, carbs, fats
✅ Micronutrients - vitamins and minerals
✅ Hydration needs

4. Monitoring & Follow-up:

✅ Weight monitoring - 5% loss in 30 days or 10% in 6 months = significant
✅ Laboratory values - albumin, prealbumin for malnutrition
✅ Physical signs - skin, hair, nails (dry skin, brittle hair/nails indicate malnutrition)

---

Multiple Choice Strategy:

CORRECT answers typically include:

• ✅ Individualized to patient's lifestyle and preferences

• ✅ Collaboration with RDN

• ✅ 24-hour dietary recall

• ✅ Assessment of food access and barriers

• ✅ Realistic, achievable goals

INCORRECT distractors often:

• ❌ One-size-fits-all approach

• ❌ Ignoring patient preferences

• ❌ No interdisciplinary collaboration

• ❌ Unrealistic restrictions

---

Special Populations:

Older Adults:

• Screen within 24 hours of admission (Joint Commission standard)

• Use MNA® (Mini Nutritional Assessment) tool

• Monitor for vitamin D, calcium, iron deficiencies

Important notes

• Review medications and see how they interact with supplemental nutrition, especially iron. Iron is best taken immediately before or during a meal

• Educate patients on how stools will appear. Iron will cause constipation.

• Educate patient when to contact HCP, especially with signs of infection or difficulty breathing

Gastroenteritis family teaching (MC)

-IMPORTANT: DO NOT SHARE PERSONAL ITEMS. PRACTICE HAND HYGIENE. KEEP EVERYTHING OT YOURSELF TO PREVENT SPREAD

Key Teaching Points:

Assessment & History:

• Recent travel to tropical regions (Asia, Africa, Mexico, Central/South America)

• Food exposure within 24-36 hours:

  • Fast food restaurants

  • Farmer's markets/grocery stores

  • Raw/undercooked foods (oysters, sushi, rare meat)

  • Contaminated produce (spinach, lettuce)

Expected Symptoms:

1. Nausea and vomiting (occur FIRST)

2. Abdominal cramping (follows)

3. Diarrhea (follows cramping)

High-Risk Populations:

• Older adults

• Immunocompromised patients

• Watch for: weakness, cardiac dysrhythmias from hypokalemia (potassium loss from diarrhea)

---

Home Care Instructions:

Perianal Skin Care (PRIORITY):

✅ Avoid toilet paper
✅ Gently clean with warm water or absorbent material
✅ Pat dry thoroughly but gently
✅ Apply protective barrier cream between stools
✅ Use special prepared skin wipes
✅ Sitz baths 10 minutes, 2-3 times daily for comfort

Why? Frequent stools rich in electrolytes and enzymes irritate skin

Fluid & Electrolyte Monitoring:

• Watch for signs of dehydration

• Monitor for weakness or irregular heartbeat (hypokalemia)

• Seek medical attention if symptoms worsen

---

Multiple Choice Strategy:

Look for answers about:

• ✅ Perianal skin care techniques

• ✅ Avoiding toilet paper

• ✅ Using warm water/barrier creams

• ✅ Monitoring for dehydration/electrolyte imbalances

• ✅ Food safety education

Watch out for distractors:

• ❌ Immediate antibiotic use (not always needed)

• ❌ Restricting all fluids

• ❌ Using harsh soaps on perianal area

Colostomy care and patient teaching (SATA)

Colostomy Care & Teaching - Select All Guide

"POUCH CARE" Mnemonic:

P - Pouch system selection (proper fit to stoma)
O - Observe stoma (color, integrity, protrusion)
U - Understand appliance types (one-piece vs. two-piece)
C - Correct measurement (opening size to avoid trauma)
H - Handwashing (prevent infection)

C - Control odor (filters, deodorizers, breath mints)
A - Avoid certain foods (gas-producing vegetables)
R - Regular skin assessment (peristomal area)
E - Education on complications (leakage, skin breakdown)

---

Select All That Apply - Checklist:

Stoma Assessment:

✅ Should be reddish pink to dark red and moist
✅ Protrudes 1-3 cm (commonly 2 cm)
✅ May be slightly edematous initially
✅ Small amount of bleeding is normal early on
✅ Check frequently in first 6-8 weeks

Pouch System Selection:

✅ Flat, firm abdomen - flexible OR nonflexible system
✅ Lateral creases/folds - flexible system
✅ Deep creases/flabby abdomen/retracted stoma - convex appliance with belt
✅ Measure stoma for correct opening size
✅ Opening must cover peristomal skin and avoid stoma trauma

Odor & Gas Control:

✅ Use charcoal filters or pouch deodorizers
✅ Place breath mint in pouch
✅ DO NOT put aspirin in pouch (causes stoma ulceration)
✅ Avoid gas-producing foods when concerned about flatus
✅ Use vented pouches with deodorizing filters

Patient Education:

✅ Teach psychomotor skills before discharge
✅ Provide adequate practice time with equipment
✅ Include family/caregivers in teaching
✅ Address psychosocial concerns (body image, self-esteem)
✅ Teach about leakage prevention and sexual adjustments
✅ Sigmoid colostomy may use irrigation OR diet regulation

General Care:

✅ Proper handwashing technique
✅ Monitor for infection signs
✅ Check pouch system for proper fit and leakage
✅ Assess peristomal skin condition regularly

---

NCLEX Tips:

Watch for distractors:

• ❌ Aspirin in pouch

• ❌ Wrong appliance for body type

• ❌ No family involvement

Complication of ostomy surgery to report (SATA)

Report any of these early postoperative stoma problems to the surgeon immediately:

• Stoma ischemia and necrosis, will appear dark red, purple, or black

• If it is pale, dusky, or cyanotic (blusish), then it indicates that there is poor blood supply/circulation. Medical emergency due to risk of tissue necrosis.

• If it is very pale or white, it indicates inadequate perfusion. Requires immediate assessment.

• Stoma retraction (pulling below skin level)

• Severe edema

• Continuous heavy bleeding

• Peristomal skin breakdown

• No stool output after 2-3 days post-op

• Foul odor with skin changes (infection)

• Pouch leakage (improper fit)

• Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal wall)

Timeline Expectations:

• Initial post-op: Slight edema and small bleeding = normal

• Resolves: Within 6-8 weeks

• Stoma function begins: 2-3 days after surgery

Body image issues ileostomy (MC)

Nursing Interventions for Body Image:

Pre-Operative:

✅ Explain expected postoperative appearance before surgery
✅ Describe incision location and appearance
✅ Discuss that scars will fade and edema will lessen with time
✅ Prepare patient that scars may be red and raised initially but improve in first few months

Post-Operative:

✅ Encourage patient to look at stoma when ready - don't push
✅ Do NOT force immediate acceptance of body image change
✅ Allow patient to progress at their own pace
✅ Provide objective listening and support

Family/Significant Other Involvement:

✅ Include family in teaching (if patient desires)
✅ Recognize that family response affects patient's self-esteem
✅ Family may need support accepting changes
✅ Help family communicate feelings to patient
✅ Provide objective listener for family concerns

---

Multiple Choice Strategy:

CORRECT answers typically include:

• ✅ Allow patient to view stoma when ready (patient-paced)

• ✅ Provide realistic expectations pre-operatively

• ✅ Include significant others in education

• ✅ Acknowledge that body image reflects how others respond

• ✅ Offer objective support without judgment

• ✅ Reassure that appearance improves with time

INCORRECT distractors often:

• ❌ Force patient to look at stoma immediately

• ❌ Rush acceptance of body changes

• ❌ Exclude family from teaching

• ❌ Minimize patient's concerns

• ❌ Ignore significant other's needs

---

Key Concepts:

Body image is influenced by:

• Patient's own perception

• Response of significant others/family

• Time for adjustment

• Support system quality

Therapeutic approach:

• Patient-centered pacing

• Realistic preparation

• Family inclusion

• Non-judgmental support

---

Red Flags to Report:

• Depression lasting >2 weeks affecting ADLs

• Inability to participate in self-care

• Social isolation

• Refusal to learn ostomy care

→ Refer to mental health professional if needed

EHR reportable assessment finding of Crohn’s disease and Ulcerative colitis (MC)

EHR Reportable Assessment Findings

Crohn's Disease:

Vital Signs/General:

• Fever (common with fistulas, abscesses, severe inflammation)

• Tachycardia with fever (may indicate dehydration, infection)

Gastrointestinal:

• Diarrhea (5-6 times/day with soft, loose stool)

• Steatorrhea (fatty diarrheal stools)

• Bright red blood in stool

• Abdominal pain

• Abdominal distention, masses

• Decreased or absent bowel sounds (severe inflammation/obstruction)

• High-pitched or rushing bowel sounds (narrowed bowel loops)

• Muscle guarding, rigidity, tenderness

Perianal:

• Ulcerations

• Fissures (cracks, tears, splits in skin)

• Fistulas

Systemic/Complications:

• Unintentional weight loss

• Anemia (low folic acid, vitamin B12, albumin)

• Elevated C-reactive protein and ESR (inflammation)

• Pyuria (WBCs in urine - infection from fistula)

• Electrolyte imbalances (potassium, magnesium losses)

---

Ulcerative Colitis:

Vital Signs:

• Low-grade fever (99-100°F in mild disease)

• Fever >101°F (38.3°C) - REPORT IMMEDIATELY

• Tachycardia (may indicate dehydration, peritonitis, bowel perforation)

• Palpitations - REPORT

Gastrointestinal:

• Increased diarrhea - REPORT

• Severe abdominal pain - REPORT

• Abdominal distention along colon

• Nausea/vomiting - REPORT

Extraintestinal:

• Inflamed joints (arthritis)

• Mouth lesions/sores

• Vision problems

• Skin disorders

---

Critical "Red Flags" to Document & Report:

🚨 Fever + tachycardia = possible dehydration, peritonitis, perforation
🚨 Fever >101°F
🚨 Severe abdominal pain
🚨 Increased diarrhea
🚨 Nausea/vomiting
🚨 Palpitations
🚨 Signs of infection (especially in immunosuppressed patients)

---

Key Point: Both conditions share similar reportable findings, but UC patients should be taught specific thresholds (fever >101°F, increased diarrhea, severe pain) that require immediate provider notification.

Priority care intervention of a draining fistula (SATA)

Select All That Apply - Look For:

✅ Skin Protection & Care

• Prevent skin irritation and excoriation (TOP PRIORITY)

• Apply skin barriers or dressings (for drainage <100 mL/24 hrs)

• Use pouching systems (for heavily draining fistulas)

• Apply antifungal powder around fistula (prevent/treat Candida)

• Insert drains to manage drainage

✅ Nutrition & Electrolyte Management

• Nutritional therapy (malnutrition is common complication)

• Electrolyte replacement (losses from drainage)

• High protein diet (promotes healing)

• Vitamin C supplementation (wound healing)

• Zinc, iron, other vitamins (tissue repair)

✅ Infection Prevention

• Prevent systemic infection (major complication)

• Proper handwashing technique

• Monitor for signs of infection

• Incision and drainage (I&D) if abscess present

✅ Wound Assessment & Monitoring

• Measure effluent (output) with pouch system

• Assess drainage amount, color, odor

• Monitor for abscess formation

• Assess for fissures

---

Why These Are Priorities:

Skin breakdown occurs because:

• Enzymes and bile in stool cause irritation

• Constant moisture macerates skin

• Risk for Candida infection

Nutrition/electrolytes are critical because:

• Fistulas cause malnutrition

• Fluid and electrolyte losses through drainage

• Healing requires adequate protein and vitamins

Infection prevention matters because:

• Systemic infections are common with multiple fistulas

• Abscesses require immediate I&D

• Immunosuppressed patients at higher risk

---

SATA Strategy:

CORRECT answers typically include:

• ✅ Skin barrier application

• ✅ Pouching system for heavy drainage

• ✅ Antifungal powder

• ✅ Nutritional support/high protein

• ✅ Electrolyte monitoring/replacement

• ✅ Infection prevention measures

• ✅ Proper handwashing

INCORRECT distractors might be:

• ❌ Restricting fluids

• ❌ Low-protein diet

• ❌ Leaving skin exposed without protection

• ❌ Ignoring drainage measurement

---

Key Takeaway: Fistula management focuses on the "3 S's": Skin, Sustenance (nutrition), Sepsis prevention

Alosetron for IBS-D (MC)

Alosetron is a medication specifically for diarrhea-predominant IBS (IBS-D)

---

⚠ CRITICAL Safety Information:Black Box Warning - Serious Risks:

• Ischemic colitis (reduced blood flow to colon)

• Severe constipation (can lead to complications)

• Hospitalization and surgery may be required

• Deaths have been reported

Prescribing Restrictions:

• Women ONLY with severe chronic IBS-D

• Must have failed conventional therapy

• Requires signed patient-provider agreement

• Available only through restricted distribution program

---

Who Should NOT Take It:

❌ Patients with constipation
❌ History of:

• Chronic/severe constipation

• Intestinal obstruction

• Stricture, toxic megacolon

• GI perforation or adhesions

• Ischemic colitis

• Impaired intestinal circulation

• Thrombophlebitis

• Hypercoagulable state

❌ Crohn's disease or ulcerative colitis
❌ Diverticulitis

---

Patient Teaching - STOP Drug & Call Provider If:

🚨 Constipation develops
🚨 Rectal bleeding
🚨 Bloody diarrhea
🚨 New or worsening abdominal pain

---

Nursing Considerations:

Before Administration:

• Verify patient is female with severe chronic IBS-D

• Confirm signed agreement on file

• Review contraindications

Monitoring:

• Assess bowel patterns regularly

• Watch for signs of ischemic colitis or constipation

• Educate on warning signs requiring immediate reporting

Documentation:

• Record bowel movements, consistency

• Note any adverse effects

• Document patient education provided

---

Key Takeaway:

Alosetron is a high-risk medication with serious potentially life-threatening complications. It's reserved for women with severe IBS-D who haven't responded to other treatments and requires careful monitoring and patient education about stopping immediately if constipation or abdominal pain develops.

Drug Therapy for IBS-C (SATA)

Bulk-Forming Laxatives:

Psyllium Hydrophilic Mucilloid

• When to take: At mealtimes with a glass of water

• How it works: Hydrophilic properties prevent dry, hard, or liquid stools

• Example: Metamucil

---

Prescription Medications:

Lubiprostone

• Approved for: Women with IBS-C

• How it works: Increases fluid in intestines to promote bowel elimination

• Patient teaching: Take with food and water

Linaclotide ⭐ (Newer Drug)

• How it works:

  • Stimulates guanylate cyclase receptors in intestines

  • Increases fluid and promotes bowel transit time

  • Also relieves pain and cramping associated with IBS

• Patient teaching: Take once daily about 30 minutes before breakfast

---

Complementary Approaches:

Probiotics

• Recommended for patients with increased intestinal bacterial overgrowth

• Effective for reducing bacteria and alleviating GI symptoms

Peppermint Oil Capsules

• Evidence supports effectiveness in reducing IBS symptoms

---

Lifestyle Interventions:

✅ Regular exercise - manages stress and promotes regular bowel elimination
✅ Stress management - relaxation techniques, meditation, yoga
✅ Personal counseling - if stressful work/family situations present

---

Key Teaching Points:

Hydration is critical - all laxatives require adequate water intake

Timing matters:

• Bulk-forming laxatives → with meals

• Linaclotide → 30 min before breakfast

• Lubiprostone → with food and water

Holistic approach works best - combine medications with stress management, exercise, and dietary modifications

Skin care for IBS (SATA)

Select All That Apply - Look For:

✅ Gentle Cleansing:

• Avoid toilet paper - causes irritation with frequent wiping

• Use warm water to gently clean the anal/perianal area

• Use absorbent material instead of toilet paper

• Medicated wipes are soothing for tender/sensitive rectal areas

• Apply cream, oil, or gel to damp warm washcloth to remove stool stuck to open skin

• Special prepared skin wipes can be used

✅ Thorough Drying:

• Gentle but thorough drying after cleansing

• Pat dry (don't rub)

✅ Protective Barriers:

• Apply protective barrier cream between stools

• Use petroleum jelly-like barrier to prevent contact of moisture/stool with skin

• Skin barriers for fistula drainage <100 mL/24 hrs

• Pouching systems for heavily draining fistulas

✅ Healing Products:

• Moisturizing and healing cream (part of ostomy manufacturer systems)

• Skin-cleaning solution (specialized products)

• Antifungal powder around fistulas to prevent/treat Candida

✅ Comfort Measures:

• Sitz baths for 10 minutes, 2-3 times daily

---

Why Skin Care is Critical:

Frequent loose stools contain:

• Electrolytes

• Enzymes (digest skin)

• Bile (irritates skin)

Result: Skin irritation, excoriation, breakdown, Candida infection

---

SATA Strategy - CORRECT Answers:

✅ Avoid toilet paper
✅ Use warm water for cleansing
✅ Apply protective barrier cream between stools
✅ Use medicated wipes
✅ Sitz baths 2-3 times daily
✅ Gentle thorough drying
✅ Pouching systems for heavy drainage
✅ Antifungal powder for fistulas

INCORRECT Distractors:

❌ Vigorous scrubbing with soap
❌ Using rough toilet paper frequently
❌ Leaving area moist
❌ Applying alcohol-based products
❌ Skipping barrier protection

---

Key Principle: Gentle cleansing + thorough drying + protective barriers = prevention of skin breakdown

Assessment questions to ask for Irritable bowel disease (SATA)

Select All That Apply - Look For:

✅ Medical History:

• Family history of IBD

• Previous and current therapy for the illness

• Dates and types of surgery

• Recent exposure to antibiotics (past 2-3 months) - rule out C. difficile

• Recent use of NSAIDs (can trigger flare-ups)

• Travel to or emigration from tropical areas

✅ Nutrition History:

• Intolerance of milk and milk products

• Intolerance of fried, spicy, or hot foods

• Unintentional weight loss

• Anorexia

✅ Bowel Elimination Pattern:

• Color of stools

• Number/frequency of stools

• Consistency of stools

• Character of stools (blood present?)

• Tenesmus (feeling of incomplete evacuation)

• Relationship between diarrhea and:

  • Timing of meals

  • Emotional distress

  • Activity

✅ GI Symptoms:

• Abdominal pain

• Fatigue

• Fever

✅ Extraintestinal Manifestations:

• Arthritis/joint inflammation

• Mouth sores/lesions

• Vision problems

• Skin disorders

✅ Psychosocial Impact:

• Understanding of the illness

• Impact on lifestyle

• Anxiety about stool frequency/blood

• Fear of fecal incontinence

• Feeling "tied to the toilet"

• Activities limited outside home

• Depression

• Association of eating with pain/cramping

---

SATA Strategy - CORRECT Answers:

✅ Family history of IBD
✅ Recent antibiotic use
✅ NSAID use
✅ Stool frequency and characteristics
✅ Presence of blood in stool
✅ Food intolerances (milk, fried, spicy foods)
✅ Extraintestinal symptoms (joints, mouth, vision, skin)
✅ Relationship of diarrhea to meals/stress
✅ Impact on lifestyle and activities
✅ Recent travel history

INCORRECT Distractors:

❌ Only asking about current symptoms
❌ Skipping psychosocial assessment
❌ Ignoring medication history
❌ Not exploring extraintestinal manifestations

Chronic IBD Nursing care (SATA)

Select All That Apply - Look For:

✅ Pain Management:

• Multimodal pharmacologic and nonpharmacologic measures

• Assist in reducing/eliminating pain-causing factors

• Nutrition changes to decrease cramping/bloating

• Antidiarrheal drugs (use cautiously - risk of toxic megacolon)

• Monitor for increased pain (may indicate peritonitis)

✅ Skin Care:

• Medicated wipes for tender rectal areas

• Skin-cleaning solution, moisturizing cream, petroleum barrier (ostomy manufacturer systems)

• Prevent perineal irritation from loose stools

✅ Medication Management:

• 5-aminosalicylates (sulfasalazine, mesalamine) for mild-moderate disease

• Glucocorticoids (prednisone) during exacerbations

• Immunosuppressants/immunomodulators

• Teach about side effects and adverse drug events

• Folic acid supplement with sulfasalazine

✅ Patient Education:

• Nature of UC: acute episodes, remissions, symptom management

• Report signs of infection (especially on immunosuppressants)

• Avoid crowds and infected individuals

• Report exacerbation symptoms: fever >101°F, tachycardia, increased diarrhea, severe abdominal pain

✅ Nutritional Support:

• Avoid gas-producing foods (nuts, raw cabbage, corn, celery, popcorn)

• Adequate salt and water (especially with ostomy)

• Vitamin B12 supplementation if terminal ileum removed

✅ Ostomy Care (if applicable):

• Collaborate with CWOCN for teaching

• Effective pouching system (3-7 day adhesive barrier)

• Prevent enzyme drainage from irritating skin

✅ Ongoing Monitoring:

• Respiratory care, incision care, wound healing post-surgery

• Monitor for extraintestinal problems (joint/skin)

• Arrange home care services if needed

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SATA Strategy - CORRECT:

✅ Multimodal pain management
✅ Perineal skin protection
✅ Patient education on disease nature
✅ Medication teaching (side effects, when to call provider)
✅ Infection prevention measures
✅ Nutritional modifications
✅ Ostomy care coordination
✅ Monitor for complications

INCORRECT Distractors:

❌ Prolonged antidiarrheal use
❌ Ignoring psychosocial needs
❌ Skipping medication education

Priority nursing care total enteric nutrition (TEN) infusion (MC)

🎯 PRIORITY: SAFETY

The nursing priority for patients receiving TEN is SAFETY - preventing, assessing, and managing complications.

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Key Nursing Responsibilities:

✅ Tube Care & Maintenance:

• Responsible for care and maintenance of feeding tube

• Responsible for enteral feeding administration

✅ Prevent Tube Obstruction:

• Most common problem = obstructed ("clogged") tube

• Follow facility protocols for flushing and maintenance

✅ Monitor for Complications:

Tube-Related:

• Tube misplacement and dislodgment

• Obstructed tube

Feeding-Related:

• Refeeding syndrome

• Abdominal distention

• Nausea/vomiting

• Fluid and electrolyte imbalances (often with diarrhea)

✅ Administration Methods:

Bolus Feeding:

• Intermittent feeding at set intervals (typically every 4 hours)

• Manual or via pump/controller

Continuous Feeding:

• Small amounts continuously infused (gravity or pump)

• Similar to IV therapy

Cyclic Feeding:

• Continuous feeding with scheduled "down time" (usually 6+ hours)

• Down time typically in morning for bathing/treatments

✅ Follow Provider Orders:

• Type, rate, and method of tube feeding

• Amount of additional water ("free water") needed

✅ Patient Monitoring:

• Early detection prevents complications

• Careful monitoring essential for patient safety

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Key Takeaway:

SAFETY FIRST - TEN nursing care prioritizes preventing complications through:

• Proper tube maintenance

• Vigilant monitoring

• Early detection of problems

• Following prescribed administration protocols

Complication of TEN and nursing action (MC)

Easy to Memorize! 🎯"TREND" Mnemonic for TEN Complications:

T - Tube obstruction ("clogged tube") - MOST COMMON

• Action: Flush regularly with water; follow prevention protocols

R - Refeeding syndrome

• Action: Monitor electrolytes closely, especially in malnourished patients

E - Electrolyte & fluid imbalances (often with diarrhea)

• Action: Strict I&O monitoring; replace electrolytes as needed

N - Nausea/vomiting & abdominal distention

• Action: Check residuals; slow rate; elevate HOB 30-45°

D - Dislodgment & misplacement

• Action: Verify placement before each feeding; secure tube properly

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Priority Nursing Focus = SAFETY

The nursing priority for patients receiving TEN is safety, which includes:

• Preventing complications

• Assessing for early signs

• Managing complications promptly

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Quick Prevention Tips:

✅ Monitor carefully - early detection prevents serious problems

✅ Elevate head of bed 30-45° during and after feeding

✅ Flush tubes regularly to prevent obstruction

✅ Verify placement before administering feeding

✅ Track I&O strictly including all drainage

✅ Watch electrolytes especially potassium, phosphorus, magnesium

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Complication Categories:

Tube-related:

• Obstruction (clogged)

• Misplacement

• Dislodgment

Formula-related:

• Refeeding syndrome

• Fluid/electrolyte imbalances

• Diarrhea

• Abdominal distention

• Nausea/vomiting

Assessing small bore NG tube placement (MC)

Assessment - Easy Memory Guide!

🎯"X-RAY FIRST" Rule ⚠

Small-bore tubes = X-ray REQUIRED before first use

• Unlike large-bore tubes, you CANNOT use pH testing or auscultation alone

• X-ray is the GOLD STANDARD for verification

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Why Small-Bore is Different:

Small-bore feeding tubes are:

• Softer and more flexible than large-bore tubes

• Higher risk of misplacement into lungs

• Cannot be verified by traditional bedside methods alone

• Radiopaque line visible on x-ray shows exact position

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"NEVER FEED" Without Verification:

❌ DO NOT start feeding until x-ray confirms placement

❌ DO NOT rely only on:

• Auscultation (air insufflation/"whoosh" test)

• Aspirate appearance alone

• External tube markings alone

✅ DO wait for x-ray confirmation before first feeding

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Ongoing Assessment (After Initial X-ray):

Once placement is confirmed, monitor for displacement by checking:

"MARKS" Mnemonic:

M - Markings at naris/mouth - note depth and check regularly

A - Aspirate - check for gastric contents before each feeding

R - Respiratory distress - coughing, dyspnea = possible lung placement

K - Keep secured - prevent pulling/tugging that causes dislodgment

S - Symptoms - nausea, vomiting, distention may indicate malposition

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Red Flags for Displacement:

🚩 Tube marking has moved outward

🚩 Patient coughing or respiratory distress

🚩 Unable to aspirate gastric contents

🚩 Abdominal distention or discomfort

🚩 Patient reports tube feels different

→ STOP feeding and notify provider for repeat x-ray

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Key Takeaway:

Small-bore = X-ray mandatory before first use

Large-bore = Can use bedside methods (pH, auscultation, aspirate)

Gastrostomy tube care (MC)

General Principles from Enteral Nutrition Care:

Tube Patency:

• Flush regularly with water to prevent obstruction (the most common TEN complication)

• Follow agency protocols for flushing frequency

Safety Priority:

• Monitor for complications: tube dislodgment, infection at insertion site, leakage

• Verify tube placement before each feeding

Feeding Administration:

• Can use bolus, continuous, or cyclic feeding methods

• Follow provider's orders for type, rate, and amount

• Check gastric residuals per agency policy (typically every 6 hours)

Monitoring:

• Watch for abdominal distention, nausea, vomiting

• Track intake and output

• Assess for signs of infection at stoma site

• Clean insertion site regularly

• Inspect for signs of:

  • Skin breakdown

  • Infection

  • Redness, drainage, or odor

• Keep area clean and dry

Assessment findings of Appendicitis (MC)

"APPENDIX" Mnemonic:

A - Anorexia (loss of appetite) - frequent symptom

P - Pain sequence matters! Abdominal pain → THEN nausea/vomiting

• (Opposite = gastroenteritis)

P - Pain migration: Starts epigastric/periumbilical → shifts to RLQ

E - Elevated WBC (10,000-18,000/mm³)

• 20,000 = possible perforation!

N - Nausea and vomiting (AFTER pain starts)

D - Distention may occur

I - Increased pain with cough or movement

X - "X marks the spot" = McBurney point (RLQ tenderness)

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Classic Pain Pattern (Most Important!):

1. Initial: Cramping pain in epigastric or periumbilical area

2. Progression: Pain becomes more severe

3. Localization: Shifts to RLQ (McBurney point) - between anterior iliac crest and umbilicus

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Physical Assessment Findings:

"RRR" for Physical Exam:

R - Rebound tenderness (pain after release of pressure)

R - Rigidity (muscle guarding on palpation)

R - RLQ pain at McBurney point

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Red Flags for Perforation/Peritonitis:

🚩 Pain relieved by bending right hip or knees

🚩 Pain increases with cough or movement

🚩 Temperature >101°F (38.3°C)

🚩 Rising pulse rate

🚩 WBC >20,000/mm³

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Lab & Diagnostic Findings:

WBC Count:

• Moderate elevation: 10,000-18,000/mm³

• "Shift to the left" (increased immature WBCs)

• 20,000/mm³ suggests perforation.

Imaging:

• Ultrasound: enlarged appendix

• CT scan: may reveal fecaloma (fecal "stone")

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Key Nursing Assessment Points:

✅ Track symptom sequence - pain before vomiting = appendicitis

✅ Complete pain assessment - location, quality, radiation

✅ Monitor for perforation signs - fever, tachycardia

✅ Keep NPO - prepare for probable surgery

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When would you question a provider’s order for appendicitis? (MC)

-Ruv Notes: You would question laxatives or enemas because having an increased bowel movement can increase the risk of perforation.

Orders to QUESTION:

1. Laxatives or Enemas 🚫

• NEVER give - can cause perforation!

• Increased peristalsis puts pressure on inflamed appendix

2. Heat Application to Abdomen 🚫

• NEVER apply heat - increases inflammation

• Can accelerate perforation risk

3. Oral Intake/Food 🚫

• Patient should remain NPO

• Prepares for probable surgery

• Prevents worsening inflammation

4. Palpating Abdomen Repeatedly 🚫

• Avoid excessive palpation

• Can trigger perforation

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Appropriate Orders (Do NOT Question):

✅ NPO status - standard preparation for surgery

✅ IV fluids - maintain hydration

✅ Pain management - opioid analgesics are appropriate

• Ensure adequate pain control BEFORE surgical intervention

✅ IV antibiotics - especially if perforation suspected

✅ Surgical consult/preparation - appendectomy needed ASAP

✅ Lab work - CBC to monitor WBC count

✅ Imaging - ultrasound or CT scan for diagnosis

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Key Principle:

Anything that increases pressure, inflammation, or peristalsis in the abdomen = DANGEROUS

The inflamed appendix can perforate, leading to peritonitis - a life-threatening complication.

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Red Flag Orders:

🚩 "Give MiraLAX"

🚩 "Apply heating pad to abdomen"

🚩 "Patient may have clear liquids"

🚩 "Give Fleet enema"

→ Clarify with provider immediately!

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When in Doubt:

Ask yourself: "Could this order increase the risk of perforation?"

If YES → Question it!

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Critical Thinking Tip: Remember that appendicitis is a surgical emergency. Most interventions focus on preparing for surgery and preventing complications, NOT treating conservatively with bowel interventions.

Assessment findings of Celiac disease (SATA)

Gastrointestinal Symptoms:

✅ Anorexia (loss of appetite)

✅ Diarrhea

✅ Constipation (can alternate with diarrhea)

✅ Steatorrhea (fatty, greasy stools)

✅ Abdominal pain

✅ Abdominal bloating

✅ Abdominal distention

✅ Weight loss

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Key Pattern to Remember:

Celiac disease has VARYING symptoms - patients may have:

• Classic GI symptoms

• Atypical symptoms affecting multiple body systems

• NO symptoms at all (some patients are asymptomatic!)

Cycles of remission and exacerbation - usually related to diet adherence

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What You WON'T See:

❌ Weight gain - weight LOSS is typical

❌ Fever - not a primary symptom

❌ Acute RLQ pain - pain is generalized abdominal

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Important Complications to Know:

⚠ Malabsorption - leads to nutritional deficiencies

⚠ Bowel wall atrophy - from chronic inflammation

⚠ Increased cancer risk:

• Non-Hodgkin lymphoma

• GI cancers

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Diagnosis Clues:

• Screening blood test

• Endoscopy for confirmation

• Symptoms related to gluten intake

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SATA Strategy:

SELECT these if you see them:

• Any classic GI symptom (diarrhea, constipation, steatorrhea, bloating, distention, pain)

• Anorexia

• Weight loss

• Atypical symptoms affecting other body systems

• Malabsorption indicators

DO NOT SELECT:

• Fever

• Weight gain

• Acute localized pain (like RLQ)

• Symptoms unrelated to GI/nutritional status

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Memory Tip:

Think "CHRONIC INFLAMMATION = MALABSORPTION"

The inflamed small intestine can't absorb nutrients properly → leads to GI symptoms, weight loss, and nutritional deficiencies.

MNEMONIC:

CELIAC

C - Constipation (or diarrhea - can alternate!)

E - Eating causes issues (gluten triggers symptoms)

L - Loss of weight (from malabsorption)

I - Intestinal pain (abdominal pain, bloating, distention)

A - Anorexia (loss of appetite)

C - Cancer risk (non-Hodgkin lymphoma, GI cancers)

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Bonus: "FATTY STOOLS"for Steatorrhea

F - Fatty stools (steatorrhea - key finding!)

A - Atrophy of bowel wall

T - Triggers = gluten in diet

T - Testing = blood screening + endoscopy

Y - Yo-yo pattern (remission and exacerbation cycles)

Malnutrition assessment findings of obesity (SATA)

Assessment Findings to SELECT:Psychosocial/Emotional:

✅ Depression (especially if symptoms >2 weeks affecting ADLs)

✅ Embarrassment about weight

✅ Fear of judgment due to stigma

✅ Reluctance to discuss weight

✅ Failed weight loss attempts (history of)

Physical/Anthropometric:

✅ BMI ≥30 (obesity classification)

✅ Increased health risks when BMI >24.9

✅ Waist circumference measurements (central obesity indicator)

Dietary/Lifestyle History:

✅ High-fat diet consumption

✅ High-cholesterol diet

✅ Saturated fat intake (increases LDL)

✅ Trans fatty acids (TFAs) in diet

✅ Physical inactivity/sedentary lifestyle

Medical History:

✅ Medications causing weight gain (long-term use)

✅ Lack of time for physical activity (barrier)

✅ Decreased mobility due to health conditions

✅ Comorbidities: CAD risk, diabetes risk

Patient Perception:

✅ May NOT view weight as a problem (affects treatment planning)

✅ Health beliefs about being overweight (varies by patient)

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What You WON'T Select:

❌ Malnutrition - obesity IS a form of malnutrition, but not undernutrition

❌ Low BMI - obesity = BMI ≥30

❌ Protein deficiency - not typical in obesity

❌ Acute illness symptoms - obesity is chronic

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Key Assessment Approach - "RESPECT":

R - Rapport

E - Environment that is safe

S - Safety and privacy ensured

P - Privacy

E - Encourage realistic goals

C - Compassion

T - Tact in conversation

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SATA Strategy:

Focus on these categories:

• Psychosocial impact (depression, stigma, embarrassment)

• Dietary patterns (high-fat, high-cholesterol, saturated fats)

• Lifestyle factors (inactivity, barriers to exercise)

• BMI/anthropometric data (≥30, increased health risks)

• Medication history (drugs causing weight gain)

• Patient perception (may not see weight as problem)

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Critical Point: Obesity assessment is holistic - includes physical measurements, dietary history, psychosocial factors, AND patient's own perception of their weight!

Malnutrition Assessment Findings

Within 24 hours of admission:

• Inspection

• Measured height and weight

• Weight history

• Usual eating habits

• Ability to chew and swallow

• Recent changes in appetite or food intake

Screening tools:

• Mini Nutritional Assessment (MNA®)

• Adult Malnutrition Screening and Nutrition Intervention

• 5% unintentional weight loss in 30 days

• 10% weight loss over 6 months

Skin, Hair, and Nails:

• Very dry skin

• Brittle hair and nails

• Reddened or open skin areas

Body Systems to Examine:

• Hair and eyes

• Oral cavity

• Nails

• Musculoskeletal system

• Neurologic system

• Height and weight (same scale, same clothing each time)

• Body Mass Index (BMI) calculation

• Use knee height caliper for patients who cannot stand

• Wheelchair or bed scales for nonambulatory patients