NUR212CH57

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TomWruble
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209451
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NUR212CH57
Updated:
2013-04-12 23:10:47
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nur212q1 Care Patients Esophageal Problems
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Care of Patients with Esophageal Problems
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  1. (57) Ascites
    gastroenterological term for an accumulation of fluid in the peritoneal cavity. The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis, severe liver disease or metastatic cancer, its presence can portend other significant medical problems. Diagnosis of the cause is usually with blood tests, an ultrasound scan of the abdomen, and direct removal of the fluid by needle or paracentesis (which may also be therapeutic). Treatment may be with medication (diuretics), paracentesis, or other treatments directed at the cause.
  2. (57) Eructation
    belching
  3. (57) Hiatus hernia
    protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.
  4. (57) Atelectasis
    collapse or closure of the lung resulting in reduced or absent gas exchange. It may affect part or all of one lung. It is a condition where the alveoli are deflated, as distinct from pulmonary consolidation.It is a very common finding in chest x-rays and other radiological studies. It may be caused by normal exhalation or by several medical conditions. Although frequently described as a collapse of lung tissue, atelectasis is not synonymous with a pneumothorax (abnormal collection of air or gas in the pleural space that separates the lung from the chest wall and which may interfere with normal breathing), which is a more specific condition that features atelectasis. Acute atelectasis may occur as a post-operative complication or as a result of surfactant deficiency. In premature neonates, this leads to infant respiratory distress syndrome.
  5. (57) A client with gastroesophageal reflux disease (GERD) is newly diagnosed by the nurse practitioner, who prescribes pantoprazole (Protonix) 40 mg. What teaching will the nurse provide for this client about this drug?

    A. “Be sure to take this drug every day until you feel better.”
    B. “Be aware that this drug can cause anxiety and restlessness.”
    C. “Do not crush the drug because it has a delayed release.”
    D. “Do not take the drug with tomato-based foods or drinks.”
    C. “Do not crush the drug because it has a delayed release.”

    Protonix is a delayed-release medication; the client should be informed to not crush, break, or chew delayed-release tablets. The client should continue to take the medication even after the GERD-associated symptoms are relieved; if the medication is stopped, the symptoms will return. Although clients with GERD should limit their intake of acidic foods, no specific food-drug interactions have been documented for Protonix. Anxiety and restlessness is not a common adverse effect documented with Protonix.
    (this multiple choice question has been scrambled)
  6. (57) A client has a history of gastroesophageal reflux disease and is worried about getting cancer of the esophagus. What health teaching about ways to decrease the risk for cancer will the nurse provide? Select all that apply.

    A. “Consider dieting and exercise because you are overweight.”
    B. “Drink a glass of red wine every night because it provides antioxidants.”
    C. “Join a good smoking-cessation program as soon as possible.”
    D. “Eat plenty of fruits and vegetables instead of so much junk food.”
    E. “Sleep with two pillows every night to prevent reflux when sleeping.”
    A, C, D, E

    For most clients, GERD can be controlled by nutrition therapy, lifestyle changes, and drug therapy. Weight reduction may be helpful because decreased intra-abdominal pressure often reduces reflux symptoms. Smoking cessation and limiting fatty junk food can positively affect lower esophageal sphincter pressure, decreasing reflux. Using two pillows to elevate the head 6 to 12 inches in bed can help prevent nighttime reflux. Red wine is acidic and can contribute to the symptoms associated with GERD.
  7. (57) SLP
    speech-languag pathologist
  8. (57) A 58-year-old patient is admitted for a partial esophagectomy. He has a history of alcoholism and says he quit drinking when he found out about his diagnosis. He has not smoked in 35 years. You are assigned to care for the patient after he returns from the postanesthesia care unit (PACU).

    What is the priority for care for this patient after surgery? What position will you place the patient in and why? Locate one or two sources of current evidence supporting your answer.
    Respiratory care is the highest postoperative priority for patients having an esophagectomy. Remind nursing and other staff to keep the patient in a semi-Fowler’s or high-Fowler’s position to support ventilation and prevent reflux. Ensure the patency of the chest tube drainage system and monitor for changes in the volume or color of the drainage. Evidence for this positioning can be found in the textbook and current literature related to postoperative care after an esophagectomy.
  9. (57) A 58-year-old patient is admitted for a partial esophagectomy. He has a history of alcoholism and says he quit drinking when he found out about his diagnosis. He has not smoked in 35 years. You are assigned to care for the patient after he returns from the postanesthesia care unit (PACU).

    For what postoperative complications will you monitor, and why could they occur after this surgery?
    For those who had traditional surgery, intubation with mechanical ventilation is needed for at least the first 16 to 24 hours. Pulmonary complications include atelectasis and pneumonia. Once the patient is extubated, assess for decreased breath sounds and shortness of breath every 1 to 2 hours. Monitor for manifestations of fluid volume overload, particularly in older patients and in those who have undergone lymph node dissection. Assess for edema, crackles in the lungs, and increased jugular venous pressure. In the immediate postoperative phase, monitor for myocardial ischemia by assessing hemodynamic parameters such as cardiac output, cardiac index, and systemic vascular resistance every 2 hours. Observe for atrial fibrillation that results from irritation of the vagus nerve during surgery. Fever and fluid accumulation are general signs of inflammation. Monitor for symptoms of early shock (e.g., tachycardia, tachypnea).
  10. (57) A 58-year-old patient is admitted for a partial esophagectomy. He has a history of alcoholism and says he quit drinking when he found out about his diagnosis. He has not smoked in 35 years. You are assigned to care for the patient after he returns from the postanesthesia care unit (PACU).

    The patient has a nasogastric (NG) tube in place after surgery. What nursing care will you provide for the patient related to the NG tube?
    Monitor the NG tube for patency, and carefullysecure the tube to prevent dislodgment, which can disrupt the sutures at theanastomosis. Do not irrigate or reposition the NG tube in patients who haveundergone esophageal surgery unless requested by the surgeon. The continued presence of blood in nasogastric drainage may indicate internal bleeding at the suture line. Provide oral hygiene for the patient every 2 to 4 hours while the tube is in place, or delegate and supervise this activity.
  11. (57) A 58-year-old patient is admitted for a partial esophagectomy. He has a history of alcoholism and says he quit drinking when he found out about his diagnosis. He has not smoked in 35 years. You are assigned to care for the patient after he returns from the postanesthesia care unit (PACU).

    The patient’s life partner tells you that he is worried that the patient may not be able to return to his job as a family practice physician. How might you respond to his concern?
    At this postoperative stage it is difficult to determine the patient’s ability to return to work. The nurse should provide emotional support to the patient’s life partner, listening to his worries and concerns. Referral to a social worker or case manager will provide the partner further support. However, the patient and family must wait and see how he tolerates the surgical procedure, the management of nutrition and weight, and possible other outcomes of the surgery. It is quite possible that the patient may not be able to return to his prior profession.
  12. (57) A 58-year-old patient is admitted for a partial esophagectomy. He has a history of alcoholism and says he quit drinking when he found out about his diagnosis. He has not smoked in 35 years. You are assigned to care for the patient after he returns from the postanesthesia care unit (PACU).

    With what members of the health care team might you collaborate and why?
    The health care team will also include the surgeon, anesthesiologist, and critical care nurses. These individuals will be involved in the patient’s preoperative and immediate postoperative care. Once the patient moves to a step-down or medical-surgical unit, the physicians, speech therapist, registered dietitian, and wound care nurse may also be involved in the patient’s care. The social worker, home care nurse, or case manager may be important for referrals to community or home care organizations to assist in providing care in the home. Oncology nursing care may be needed to monitor and evaluate the patient who is receiving chemotherapy at home.
  13. (57) The client has been diagnosed recently with esophageal cancer. The client states, "I'm not comfortable going to my father's birthday lunch at our family-owned restaurant because I'm afraid I'll choke in public." What is the nurse's best response?

    A. "You need to talk to your doctor about your concerns. The doctor may recommend that you enter a support group for cancer victims."
    B. "Why not take one of your antianxiety pills before going? That will keep you from worrying about everything so much."
    C. "I understand your concerns, but you can't give up your normal activities. You should go anyway and try not to worry about it."
    D. "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed."
    D. "Could you perhaps invite everyone over to cook at your home? That will allow you to be together and be more relaxed."

    This response provides psychosocial support to the client and assists the client with finding a solution to the problem.
    (this multiple choice question has been scrambled)
  14. (57) The nurse is assessing a client with gastroesophageal reflux disease (GERD). Which findings will the nurse expect to observe? Select all that apply.

    A. Blood-tinged sputum
    B. Dyspepsia
    C. Excessive salivation
    D. Flatulence
    E. Regurgitation
    B, D, E

    • Correct Feedback:
    • Correct: Dyspepsia, also known as heartburn, is one of the main symptoms of GERD.
    • Correct: Flatulence is common after eating.
    • Correct: Regurgitation (backward flow into the throat) of food and fluids is common. 

    • Incorrect Feedback:
    • Incorrect: Blood-tinged sputum is not a symptom of GERD.
    • Incorrect: Excessive salivation is not a symptom of GERD.
  15. (57) The client has undergone conventional esophageal surgery. The client's diet has been advanced to semi-solid, and feedings are well tolerated. The client reports experiencing diarrhea about 1 hour after each meal. What is the priority nursing intervention to help prevent further diarrhea?

    A. Encourage the client to take fluids between meals rather than with meals.
    B. Give the client a dose of magnesium hydroxide (Milk of Magnesia) after each meal.
    C. Advance the diet to solid food and encourage the client to eat as much as possible at meals.
    D. Ensure that the client takes adequate amounts of fluids with meals.
    A. Encourage the client to take fluids between meals rather than with meals.

    Incorrect: Magnesium hydroxide (Milk of Magnesia) is a magnesium-based antacid that can cause diarrhea.

    Correct: Diarrhea is believed to be the result of vagotomy syndrome and can be managed by taking fluids between meals rather than with meals.
    (this multiple choice question has been scrambled)
  16. (57) Which of these assigned clients will the nurse assess first after receiving change-of-shift report?

    A. Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright red drainage from the nasogastric (NG) tube
    B. Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as needed (PRN) basis
    C. Adult with gastroesophageal reflux disease who is describing epigastric pain at a level 6 (0 to 10 pain scale)
    D. Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography scan in 30 minutes
    A. Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright red drainage from the nasogastric (NG) tube

    Young adult admitted the previous day with abdominal pain who is scheduled for a computed tomography scan in 30 minutes - Incorrect: This client is stable and is scheduled for a test that does not require the nurse's immediate attention.

    Adult with gastroesophageal reflux disease who is describing epigastric pain at a level 6 (0 to 10 pain scale) - Incorrect: This client, although in pain, does not require the nurse's immediate attention.

    Middle-aged adult with an esophagogastrectomy done 2 days earlier who has bright red drainage from the nasogastric (NG) tube - Correct: The presence of blood in the NG drainage is an unexpected finding 2 days after esophagogastrectomy and requires immediate investigation.

    Older adult admitted with an ileus who has absent bowel sounds and a prescription for metoclopramide (Reglan) on an as needed (PRN) basis - Incorrect: This client is in stable condition and does not require the nurse's immediate attention.
    (this multiple choice question has been scrambled)
  17. (57) The nurse is reviewing requests for a client with possible esophageal trauma after a car accident. Which request will the nurse implement first?

    A. Give total parenteral nutrition (TPN) through a central venous catheter.
    B. Administer cefazolin (Kefzol) 1 g IV.
    C. Obtain computed tomography (CT) scan of chest and abdomen.
    D. Keep the client nothing by mouth (NPO) for possible surgery.
    D. Keep the client nothing by mouth (NPO) for possible surgery.

    Give total parenteral nutrition (TPN) through a central venous catheter. - Incorrect: Esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing, and TPN is prescribed to provide calories and protein for wound healing. Although this is important, it is not a priority for the nurse to implement first.

    Administer cefazolin (Kefzol) 1 g IV. - Incorrect: Antibiotics may be requested to prevent possible infection, but this is not the priority for the nurse to implement first.

    Obtain computed tomography (CT) scan of chest and abdomen. - Incorrect: CT of the chest and abdomen will be needed but is not the nurse's initial action.

    Keep the client nothing by mouth (NPO) for possible surgery. - Correct: Clients with possible esophageal tears should be made NPO until diagnostic testing is completed, because leakage of anything taken orally into the sterile mediastinum could occur. In addition, esophageal rest is maintained for about 10 days after esophageal trauma to allow time for mucosal healing.
    (this multiple choice question has been scrambled)
  18. (57) The nurse is reviewing the medication history for a client diagnosed with gastroesophageal reflux disease (GERD) who has been prescribed esomeprazole (Nexium). The nurse plans to contact the health care provider if the client is taking which medication?

    A. Acetaminophen (Tylenol)
    B. Furosemide (Lasix)
    C. Prednisone (Deltasone)
    D. Iron salts
    D. Iron salts

    Acetaminophen (Tylenol) - Incorrect: Acetaminophen (Tylenol) is an analgesic and does not interact with esomeprazole (Nexium).

    Furosemide (Lasix) - Incorrect: Furosemide (Lasix) is a loop diuretic and does not interact with esomeprazole (Nexium).

    Iron salts - Correct: Iron salts may alter the effects and absorption of esomeprazole (Nexium).

    Prednisone (Deltasone) - Incorrect: Prednisone (Deltasone) is a glucocorticoid and does not interact with esomeprazole (Nexium).
    (this multiple choice question has been scrambled)
  19. (57) A client has been prescribed nizatidine (Axid) for treatment of gastroesophageal reflux disease (GERD). In which beverage will the nurse instruct the client to mix nizatidine?

    A. Orange juice
    B. Apple juice
    C. Grapefruit juice
    D. Tomato juice
    B. Apple juice

    Apple juice is the preferred choice because it is not acidic and does not interact with nizatidine (Axid).

    Grapefruit and orange juice are acidic and can increase gastric acid and pain and should be avoided.

    Nizatidine (Axid) may be less potent when mixed with tomato-based, mixed-vegetable juices.
    (this multiple choice question has been scrambled)
  20. (57) The nurse is caring for a client diagnosed with esophageal cancer who is experiencing diarrhea after conventional esophageal surgery. The nurse anticipates that the health care provider will request which medication to manage diarrhea?

    A. Loperamide (Imodium)
    B. Mesalamine (Pentasa)
    C. Pantoprazole (Protonix)
    D. Minocycline (Minocin)
    A. Loperamide (Imodium)

    Diarrhea can occur 20 minutes to 2 hours after eating and can be symptomatically managed with loperamide (Imodium). Diarrhea is thought to be the result of vagotomy syndrome, which develops as a result of interruption of vagal fibers to the abdominal viscera during surgery.

    Mesalamine (Pentasa) is used to treat clients with mild to moderate ulcerative colitis.

    Minocycline (Minocin) is an antibiotic used for treatment of infection.

    Pantoprazole (Protonix) is used to treat gastroesphageal reflux disease (GERD).
    (this multiple choice question has been scrambled)
  21. (57) The nurse is observing a co-worker who is caring for a client with a nasogastric tube following esophageal surgery. Which actions by the co-worker will require the nurse to intervene? Select all that apply.

    A. Checking tube placement every 12 hours
    B. Keeping the bed flat
    C. Placing the client upright when taking sips of water
    D. Providing mouth care every 8 hours
    E. Securing the tube
    A, B, D

    The tube should be checked every 4 to 8 hours.

    The head of the bed should be elevated at least 30 degrees.

    Oral hygiene should be provided every 2 to 4 hours.
  22. (57) The nurse is caring for a client with esophageal cancer who has received photodynamic therapy (PDT) using porfimer sodium (Photofrin). What instructions will the nurse include in teaching the client about porfimer sodium? Select all that apply.

    A. Avoid sunlight for 2 weeks.
    B. Cover all exposed body areas.
    C. Follow a full liquid diet for 3 to 5 days after the procedure.
    D. Monitor for hypertension.
    E. Tissue particles may be found in the sputum.
    B, C, E

    Sunlight should be avoided for 1 to 3 months.

    Side effects are rare and may include nausea, fever, and constipation. Hypertension is not a side effect of porfimer sodium (Photofrin).
  23. (57) Pharmacology is all similar for ...
    • GERD
    • Hiatus hernia
    • Peptic ulcer disease
  24. (57) Clinical manifestations of GERD?
    • Dyspepsia (heartburn)
    • Regurgitation (may lead to aspiration or bronchitis)
    • Coughing, hoarseness, or wheezing at night
    • Water brash (hypersalivation)
    • Dysphagia
    • Odynophagia (painful swallowing)
    • Epigastric pain
    • Belching
    • Flatulence
    • Nausea
    • Pyrosis (retrosternal burning)
    • Globus (feeling of something in back of throat)
    • Pharyngitis
    • Dental caries (severe cases)
  25. (57) Nonsurgical interventions for GERD?
    • Nutrition Therapy: limit/eliminate:
    • Fatty foods
    • Caffeinated beverages, such ascoffee, tea, and cola
    • Chocolate
    • Citrus fruits
    • Tomatoes and tomato products
    • Smoking and use of other tobacco products
    • Calcium channel blockers
    • Nitrates
    • Peppermint, spearmint
    • Alcohol
    • Anticholinergic drugs
    • High levels of estrogen and progesterone
    • Nasogastric tube placement

    • (57) Lifestyle Changes:
    • 4-6 small meals
    • Do not snack in the evening, and take no food for 2 to 3 hours before you go to bed.
    • Eat slowly and chew your food thoroughly to reduce belching.
    • Remain upright for 1 to 2 hours after meals, if possible.
    • Sleep right-side lying (versus left)
    • Elevate the head of your bed 6 to 12 inches using wooden blocks, or elevate your head using a foam wedge. Never sleep flat in bed.
    • If you are overweight, lose weight.
    • Do not wear constrictive clothing.
    • Avoid heavy lifting, straining, and working in a bent-over position.
    • Chew "chewable" antacids thoroughly, and follow with a glass ofwater.

    • Medications:
    • Some drugs lower LES and cause refluc. Explore the elimination of these drugs with doc - oral contraceptives, anticholinergic, sedatives, NSAIDs, nitrates and calcium blockers.
  26. (57) Types of Pharmacological interventions for GERD?
    • Three types
    • antacids
    • histamin blockers
    • proton pump inhibitors
  27. (57) Histamin Receptor Antagonists as a  Pharmacological intervention for GERD?
    • Decrease gastric acid secretions
    • Zantac (rinitidine) and famotidine (Pepsid) - with meals and at bedtime.
    • Axid (nizatadine) - cautiously and in reduced dosages with renal disease; observe for dysrythmias; do not mix with tomota-base or mixed-vegetable juices, apple preferred.
  28. (57) Prokinetic drugs as a  Pharmacological intervention for GERD?
    • Reglan (metoclopramide) increases gastric emptying.
    • Take before meals.
    • Teach Pt to report any neurologic or psychotropic side effects such as restlessnes, anzxiety, ataxia, hallucinations or EPS
    • Long-term use produces adverse effects in up to 1/3 Pts
  29. (57) Proton Pump Inhibitors as a  Pharmacological intervention for GERD?
    Effective long-term inhibition of gastric acid production.

    e.g. omeprazole (Prilosec), lansoprazole (Prevacid), <xxx>zole (Protonic, Nexium)

    omeprazole (Prilosec) - check liver functions via AST and ALT

    • Instruct the patient to take the drug before meals.
    • Observe the patient for typical side effects: abdominal cramping, diarrhea, headache.
    • For the patient who has difficulty swallowing or has anasogastric tube, open the capsule and mix granules in apple juice (or applesauce if not tube-fed).
    • Do not crush, break, or chew delayed-release tablets.
    • Teach patient to wear sunscreen.
    • Do not give Protonix IV with other IV drugs.
    • Do not administer with digoxin, rabeprazole, or iron salts.
    • Do not give IV Nexium with other IV drugs.
  30. (57) Antacids as a Pharmacological intervention for GERD?
    Antacids cannot be taken with digoxin since it interferes with the absorption of digoxin 

    Give 1 hr before meals, 2-3 hr after meals, and at bedtime.

    Observe the patient for constipation or diarrhea. Aluminum products produce constipation, and magnesium products induce diarrhea.

    Suggest the use of combination mixtures or alternating use aluminum and magnesium products.
  31. (57) GERD and diabetes relationship
    Diabetes can weaken the lower esophageal sphincter if your blood sugars are uncontrolled for long periods of time.  It causes nerve damage in the LES.
  32. (57) Symptoms of Sliding Hiatal Hernias
    • Heartburn
    • Regurgitation
    • Chest pain
    • Dysphagia
    • Belching
  33. (57) Symptoms of Paraesophageal Hernias (rolling)
    • Feeling of fullness after eating
    • Breathlessness after eating
    • Feeling of suffocation
    • Chest pain that mimics angina
    • Worsening of manifestations in a recumbent position
  34. (57) The highest priority nursing role for Pts with hiatal hernias?
    • Teaching
    • SAME as GERD
  35. (57) Treatment of sliding and rolling hiatal hernias?
    • Sliding most often medically, e.g. antacid and histamine receptor antagonist such as ranitidine (Zantac)
    • Rolling can become stranguated, therefore early surgical repair is preferred.

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