NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Gastrointestinal System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: General Gastrointestinal Conditions

Focus topic: Medical–Surgical Nursing

Definition: General symptoms of the gastrointestinal tract that may occur singly or concurrently and may be due to a wide variety of causes.

Medical–Surgical Nursing: Anorexia

Focus topic: Medical–Surgical Nursing

Definition: Loss of appetite.

Assessment
A. Assess for physiological basis for anorexia.

  • Most illnesses, especially active stages of infections and disorders of the digestive organs, cause anorexia.
  • Physical discomfort.
  • Constipation.
  • Fluid and electrolyte imbalances.
  • Oral sepsis.
  • Intestinal obstruction.

B. Assess for psychological source of anorexia.

  • Fear and anxiety.
  • Depression.
  • Anorexia nervosa.

C. Assess for mechanical problems resulting in anorexia.

  • Improperly fitting dentures.
  • Excessive amounts of food.

Implementation
A. Be aware of client’s eating habits, food likes and dislikes, and cultural and religious beliefs regarding food.
B. Permit choices of food when possible.
C. Show interest, but do not force client to eat.
D. Provide a pleasant environment.
E. Serve small, attractive portions of food.

Medical–Surgical Nursing: Nausea and Vomiting

Focus topic: Medical–Surgical Nursing

Definitions: Nausea is a feeling of revulsion for food, accompanied by salivation, sweating, and tachycardia. Vomiting is the contraction of the expiratory muscles of the chest, spasm of the diaphragm with contraction of the abdominal muscles, and subsequent relaxation of the stomach, allowing the gastric contents to be forced out through the mouth.

Characteristics
A. Accompanying symptoms: decreased blood pressure, increased salivation, sweating, weakness, faintness, paleness, vertigo, headache, and tachycardia.
B. Vomiting centers.

  • Chemoreceptor emetic trigger zone.
  • Vomiting center in the medulla.

C. Stimulation of vomiting centers.

  • Impulses arising in the gastrointestinal tract.
  • Impulses from cerebral centers.
  • Chemicals via the bloodstream to the centers.
  • Increased intracranial pressure.

Assessment
A. Assess for cerebromedullary causes.

  • Stress, fear, and depression.
  • Neuroses and psychoses.
  • Shock.
  • Pain.
  • Hypoxemia.
  • Increased intracranial pressure.
  • Anesthesia.

B. Assess for toxic causes.

1. Drugs ingested.
a. Direct action on the brain.
b. Irritant effects on the stomach or the small
bowel.
2. Food poisoning—ask about foods recently
ingested.
3. Acute febrile disease—evaluate temperature.

C. Evaluate possible visceral causes.

  • Allergy.
  • Intestinal obstruction—evaluate bowel
    sounds.
  • Constipation.
  • Diseases of the stomach.
  • Acute inflammatory disease of the abdominal
    and pelvic organs.
  • Pregnancy.
  • Cardiovascular diseases.
  • Visceral disease.
  • Motion sickness.

D. Check for severe hypovitaminosis, especially B vitamins.
E. Assess for eating patterns—fasting or starvation.
F. Check for endocrine disorders, such as hypothyroidism and Addison’s disease.
G. Observe character and quantity of emesis.
H. Evaluate hydration status and fluid and electrolyte balance.
I. Check daily weights.
J. Assess for complications—alkalosis, convulsions or tetany, atelectasis, or pneumonitis.

Implementation
A. Administer drugs: antiemetics, antihistamines, phenothiazines.
B. Monitor parenteral fluid and electrolyte replacements.
C. Perform gastric decompression.
D. Closely monitor prolonged vomiting, as hemorrhage could result.
E. Monitor hydration status, as dehydration will result in electrolyte imbalance leading to alkalosis.
F. Monitor for aspiration of vomitus, which may cause asphyxia, atelectasis, or pneumonitis.
G. Protect the client from unpleasant sights, sounds, and smells.
H. Promptly remove used emesis basin and equipment.
I. Promptly change soiled linens and dressings.
J. Ventilate room and use unscented air fresheners.

Medical–Surgical Nursing: Constipation and Diarrhea

Focus topic: Medical–Surgical Nursing

Definitions: Diarrhea is a condition characterized by loose, watery stools resulting from hypermotility of the bowel (not determined by frequency). Constipation is the undue delay in the evacuation of feces, with passage of hard and dry fecal material.

Assessment
A. Assess all other systems of the body to determine causal factors.
B. Assess for constipation.

  • Lack of regularity.
  • Psychogenic causes.
  • Drugs such as narcotics.
  • Inadequate fluid and bulk intake.
  • Mechanical obstruction.

C. Assess for diarrhea.

  • Fecal impaction.
  • Ulcerative colitis.
  • Intestinal infections.
  • Drugs such as antibiotics.
  • Neuroses.

D. Evaluate hydration status.
E. Assess for presence of metabolic acidosis.
F. Assess for fecal impaction—pain.
G. Observe the condition of the stool, such as color, odor, shape, consistency, amount, and any unusual features, such as mucus, blood, or pus.

Implementation
A. Administer drugs—laxatives and cathartics.

  • Laxative may be used temporarily to relieve constipation, but regular use will cause loss of bowel tone.
    a. Bulk-forming/fiber (Metamucil, psyllium seed, bran) stimulates peristalsis.
    b. Milk of magnesia alters stool consistency to stimulate peristalsis.
    c. Lubricants, such as mineral oil, soften stool.
    d. Dulcolax (bisacodyl) stimulates colon; cascara, castor oil.
    e. Stool softener; Colace, Surfak (docusate).
    f. Miralax (polyethylene glycol an osmotic laxative).
  • Antidiarrheals, such as absorbents, astringents, and antispasmodics, may relieve symptoms.
    a. Mild diarrhea: Oral fluids replace lost fluids.
    b. Moderate diarrhea: drugs that decrease motility (Lomotil [diphenoxylate/atropine] and Imodium [loperamide]).
    c. Severe diarrhea caused by infectious agent: antimicrobials and fluid replacement.
    d. Anticholinergics (atropine) reduce bowel spasticity. Used to treat irritable bowel and diarrhea caused by peptic ulcer disease.

B. Provide fluid and electrolyte replacement therapy to correct imbalances—IV therapy may be necessary to replace fluids.
C. Diet high in nutrients and calories—give supplements of vitamins (especially fat-soluble A,
D, E, and K).
D. Prevent skin excoriation with emollients, powder, and cleanliness.
E. Change soiled linens and dressings.
F. Ventilate room.

Medical–Surgical Nursing: Disorders of the Upper Gastrointestinal Tract

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Oral Infections

Focus topic: Medical–Surgical Nursing

Definition: Stomatitis is an inflammation of the mouth; glossitis is an inflammation of the tongue; and gingivitis is an inflammation of the gums.

Characteristics
A. Causes may be mechanical, chemical, or infectious.
B. Types.

  • Herpes simplex—a group of vesicles on an
    erythematous base.
    a. Usually located at the mucocutaneous junction of the lips and face.
    b. Caused by a virus that may be activated by sunlight, heat, fever, digestive disturbances, and menses.
    c. Antimicrobial treatment is not effective unless there is secondary bacterial infection. Treated with Zovirax (acyclovir).
    d. Treated symptomatically.
  • Vincent’s angina (trench mouth)—purplish-red gums covered by pseudomembrane.
    a. Caused by fusiform bacteria and spirochetes.
    b. Symptoms include fever, anorexia, enlarged cervical glands, and foul breath.
    c. May be acute, subacute, or chronic.
  • Aphthous ulcers (canker sores).
    a. Unknown etiology.
    b. Usually less than 1 cm in diameter.
    c. Duration—lasts weeks to months.
    d. Very painful, shallow erosions of the mucous membranes.
    e. Well circumscribed with a white or yellow center, encircled by a red ring.

Assessment
A. Assess for anorexia.
B. Evaluate excessive salivation.
C. Check for foul breath.
D. Evaluate condition of gums and tongue.
E. Assess for jagged teeth or mouth breathing.
F. Check for foods or drinks that result in allergies.
G. Assess for presence of infection.

Implementation
A. Remove cause.
B. Provide frequent, soothing oral hygiene.
C. Administer topical medications or systemic antibiotics.
D. Provide a soft, bland diet.
E. Administer pain medications as needed.
F. Avoid alcohol-based mouthwashes.

Medical–Surgical Nursing: Disorder of the Salivary Glands

Focus topic: Medical–Surgical Nursing

Definition: Salivary gland infection is an inflammation (parotitis or surgical mumps) usually caused by Staphylococcus aureus.

Assessment
A. Assess for pain.
B. Check temperature.
C. Assess for enlargement of glands.
D. Assess for dysphagia.

Implementation
A. Administer preventive measures.

  • Keep the glands active; calculus or calculi (stones) form when the gland is inactive.
  • Provide adequate fluids.
  • Give oral hygiene.

B. Provide warm packs.
C. Administer antibiotics.
D. Monitor hydration.
E. Care for incision.
F. Observe for drainage.

Medical–Surgical Nursing: Malignant Tumors of the Mouth

Focus topic: Medical–Surgical Nursing

Definition: Cancer of the mouth is a malignant tumor (squamous cell carcinoma) and usually affects the lips, the lateral border of the tongue, or the floor of the mouth.

Assessment
A. Assess for lesions that tend to be painless and hard and ulcerate easily.
B. Assess for poor oral hygiene.
C. Check for chronic irritation.
D. Evaluate for chemical and thermal trauma (tobacco, alcohol, and hot, spicy foods).
E. Assess for metastasis by local extension.

  • Cause symptoms by occupying space and exerting pressure.
  • Usually fibromas, lipomas, or neurofibromas.

Implementation
A. Provide postsurgical interventions.
B. Monitor for complications.

Medical–Surgical Nursing: Radical Neck Dissection

Focus topic: Medical–Surgical Nursing

Definition: Removal of lateral lymph nodes and tissue, submandibular gland, jugular vein, sternocleidomastoid muscle, spinal accessory nerve, and surrounding tissue of neck.

Assessment
A. Assess for patent airway.

  • Observe for airway obstruction (wheezing, stridor, retraction).
  • Observe for respiratory distress, stertorous, labored breathing, increased respirations, and cyanosis.

B. Observe for edema that could constrict trachea.
C. Watch for difficulty in swallowing if allowed oral fluids. Difficulty may indicate nerve damage. If radical procedure, client will probably be fed through either nasogastric (NG) tube, gastrostomy, or IV therapy.
D. Observe dressings for hemorrhage, which could lead to respiratory embarrassment.
E. Assess vital signs for indications of bleeding and infection.
F. Assess for infection; increase in temperature, foul odor to dressings.

G. Observe for carotid rupture or chylous fistula— milky drainage.
H. Assess catheter drainage and suture lines.
I. Evaluate wound healing.
J. Observe for lower facial paralysis indicating facial nerve injury.
K. Assess mental state for depression, damage to self- image, feelings of loss, etc.

Implementation
A. Maintain adequate respiratory function.

  • Place in high-Fowler’s position.
  • Monitor for respiratory distress.

B. Suction to prevent aspiration and pneumonia.

C. Administer oxygen as needed.
D. Encourage intake of fluids, which is necessary to thin secretions.
E. Provide care for laryngectomy (frequently performed with radical neck dissection).

  • Use mist mask.
  • Clean laryngectomy tube as you would tracheostomy tube.

F. Change dressings frequently to prevent infection.

  • Drains are frequently placed in surgical site; Hemovac is the drain most commonly used.
  • Observe for drainage (amount, type, odor, color).

G. Give oral hygiene every 2–4 hours.
H. Develop means to communicate, as client will not be able to talk postoperatively if laryngectomy was also performed.

  • Provide method of writing for the first few days.
  • Explain to client that hoarseness is usual for the first few weeks.
  • Provide bell or readily accessible means of communication for client to decrease anxiety following surgery. Answer bell or call light immediately.

I. Provide privacy for client.
J. Develop nurse–client relationship, as client may be depressed, may suffer feelings of loss, and may need to verbalize concerns about self-image.
K. Teach or follow through with rehabilitation exercises for head and shoulder.

  • Rotate neck, tilt head to both sides, and drop chin to chest.
  • Swing arm on operated side in arc to extend range of motion.

L. Provide general postoperative care.

Medical–Surgical Nursing

Medical–Surgical Nursing: Cancer of the Larynx

Focus topic: Medical–Surgical Nursing

Definition: Cancer of the voice box and other surrounding structures.

Characteristics
A. Factors that increase risk.

  • Age—occurs most often in people older than age 55.
  • Gender—men are four times more likely than women.
  • Race—increased in African Americans.
  • Smoking.
  • Alcohol.
  • Personal history of head and neck cancer.
  • Occupational—workers exposed to sulfuric acid mist, nickel, or asbestos have increased risk of disease.

B. Clinical manifestations.

  • Hoarseness.
  • Burning while drinking hot or acidic food.
  • Dysphagia.
  • Foul breath.
  • Enlarged cervical nodes.
  • Weight loss.
  • Malaise.
  • Pain radiating to the ear.

Medical–Surgical Nursing: Laryngectomy

Focus topic: Medical–Surgical Nursing

Definition: Removal of the voice box and other surrounding structures. May be partial or complete, which depends on the location and involvement of the tumor.

Characteristics
A. Total laryngectomy and radical neck dissection—procedure of choice for cancer under following circumstances:

  • If tumor does not extend more than 5 mm up base of tongue or below upper edge of cricoarytenoid muscle.
  • If there is no evidence of distant metastasis.

B. Epiglottis, thyroid cartilage, hyoid bone, cricoid cartilage, and part of trachea are removed.
C. Stump of trachea is brought out to neck and sutured to skin. The pharyngeal portion is closed, and breathing through nose is eliminated.
D. Accompanied by radical neck dissection if neck tissue and lymph nodes are involved.

Assessment
A. Assess drainage from wound suction for amount, type, color, and odor.
B. Assess for carotid artery hemorrhage.
C. Evaluate lung fluids for atelectasis and pneumonia.
D. Monitor for complications.

  • Mucus plug.
  • Bleeding from stoma or incision.
  • Infection at incision site.
  • Respiratory infection.

Implementation
A. Observe for hypoxia.

  • Early signs: increased respirations and pulse, apprehension, restlessness.
  • Late signs: cyanosis, dyspnea, swallowing difficulties.

B. Position in semi-Fowler’s position or higher. Prevent forward flexion on the neck to reduce edema and help to keep airway open.
C. Suction frequently using sterile technique until area has healed; then use clean technique.
D. Place pressure on neck wound for hemorrhage around site.
E. Instruct client regarding means for communication, as he or she will not be able to speak immediately postoperatively.
F. Speech rehabilitation is utilized after surgical area has healed.

G. Nutrition.

  • NPO 7 days.
  • NG or gastrostomy tube and total parenteral nutrition (TPN).
  • Thick fluids introduced first. Have suction available.
  • Avoid sweet foods as they increase salivation and can decrease appetite.
  • Rinse mouth with warm water or brush teeth after eating.

H. Teaching.

  • Teach ways to handle increased mucus production.
  • Keep stoma clear of excess mucus.
  • Wear a nonrestricting bib to conceal mucus.
  • Cleanse peristomal skin bid.
  • Use nebulizer or humidifier.
  • Assure that taste and smell will adapt over time.
  • Cover stoma while showering.
  • Avoid swimming.
  • Avoid powders and aerosols.
  • Carry medical alert information.

Medical–Surgical Nursing: Gastroesophageal Reflux Disease

Focus topic: Medical–Surgical Nursing

Definition: Backward flow (reflux) of gastric contents into the esophagus; suffered by 15–20% of adults.

Assessment
A. Assess for heartburn after meals.
B. Check for regurgitation of material into the mouth.
C. Assess for difficulty or pain in swallowing—pain may be severe.

Implementation
A. Monitor antacids (Maalox) for mild or moderate conditions.
B. Explain use of histamine2 receptor blockers (Tagamet [cimetidine], Zantac [ranitidine]) to reduce acid production.
C. Monitor use of proton-pump inhibitors (PPIs) such as Prilosec (omeprazole) or Prevacid (lansoprazole) to reduce gastric secretions and relieve symptoms.
D. Suggest dietary changes such as reduction in fat, coffee, and spicy foods, and cessation in smoking (which increases acidity).

Medical–Surgical Nursing: Esophageal Varices

Focus topic: Medical–Surgical Nursing

Definition: Tortuous, dilated veins in the submucosa of the lower esophagus, possibly extending into the fundus of the stomach or upward into the esophagus; caused by portal hypertension and often associated with cirrhosis of the liver.

Assessment
A. Assess for bleeding.
B. Check for hypotension.
C. Evaluate neck veins for distention.

D. Assess for nutritional status.
E. Evaluate indications that lead to suspected varices.

  • Hematemesis.
  • Hematochezia (rectal bleeding).
  • History of alcoholism.

F. Observe for strain of coughing or vomiting, which could result in esophageal rupture.

Implementation
A. Carefully observe vital signs, watching for hemorrhage and shock. (Goal is to restore hemodynamic status.)
B. Maintain prescribed pressure levels in balloon tamponade (infrequently used today, kept in place for 12 hours or less depending on other definitive therapies used).

  • Provide frequent oral hygiene and aspiration of the mouth and throat because the client cannot swallow saliva with the balloons in place.
  • Prevent esophageal erosion by deflating the balloons (only with physician’s order).
  • Safety measure: Keep scissors at bedside. If tube dislodges and causes obstruction, cut tube to deflate balloons.
  • Prevent nasal breakdown.
    a. Keep nostrils lubricated and clean.
    b. Provide foam rubber padding to reduce pressure at nares.
  • Observe for sudden respiratory crisis, which may occur with aspiration or upward displacement of the balloons.

C. Maintain fluid and nutritional balance.
D. Observe for complications of active bleeding varices.

  • Hypovolemia.
  • Hepatic encephalopathy due to increased ammonia production as blood protein is metabolized.
  • Metabolic imbalances due to acid–base and electrolyte disturbances.

E. Comfort family and client.

  • Explain procedures and utilize nursing comfort measures.
  • Use sedatives and narcotics judiciously because the liver is usually impaired in its ability to detoxify.

Medical–Surgical Nursing

Medical–Surgical Nursing: Esophageal Hernia (Hiatal Hernia)

Focus topic: Medical–Surgical Nursing

Definition: In esophageal hernia, a portion of the stomach herniates through the diaphragm and into the thorax (also called diaphragmatic hernia).

Characteristics
A. Congenital weakness.
B. Trauma.
C. Relaxation of muscles.
D. Increased intra-abdominal pressure.
E. Manifestations range from none to acutely severe manifestations.

Assessment
A. Assess for heartburn and substernal discomfort or pain.
B. Assess for dysphagia.
C. Check for vomiting pattern.
D. Reflux.
E. Indigestion or feeling of fullness.
F. Assess for complications.

  • Ulceration.
  • Hemorrhage.
  • Regurgitation and aspiration of gastric contents.
  • Incarceration of stomach in the chest, with possible necrosis, peritonitis, and mediastinitis.

G. Diagnostic tests.

  • Esophagogastroduodenoscopy (EGD).
  • Barium swallow.

Implementation
A. Provide small, frequent meals, avoiding highly seasoned foods.
B. Maintain upright position during and after meals.
C. Give antacids after meals and at bedtime.
D. Elevate head of bed to avoid regurgitation while eating and for 30 minutes after meal.
E. Avoid anticholinergic drugs, which delay emptying of the stomach.
F. Prevent constricting clothing around the waist and sharp, forward bending.
G. Monitor medical treatment.

  • Reduction of stomach distention.
  • Reduction of stomach acidity.
  • Reduction of increased levels of intra-abdominal pressure.

H. Give postoperative care for surgical reduction of hernia, via a thoracic or abdominal approach.

  • Surgery is indicated when the risk of complications or reflux is severe.
  • Surgical approach reinforces the lower esophageal sphincter (LES) to restore sphincter competence and prevent reflux. A portion of the stomach fundus is wrapped around the distal esophagus to anchor it and reinforce the LES.
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Medical–Surgical Nursing: Esophageal Lesions

Focus topic: Medical–Surgical Nursing

Characteristics
A. Benign lesions.

  • Leiomyoma most common type.
  • Asymptomatic.

B. Malignant lesions.

  • Usually occur in lower two-thirds of esophagus.
  • Mainly affect men over age 50.
  • Smoking and alcohol are risk factors.
    a. Poor prognosis (< 5 years survival) due to early lymphatic spread and late development of symptoms.
    b. Dysphagia is the most common symptom.
    c. Diagnosis made by barium swallow, esophagoscopy, biopsy.

C. Treatment.

  • Surgical excision.
  • Radiation therapy (fistulas may be a complication).

Assessment
A. Assess for extent of lesions.
B. Evaluate vital signs.
C. Observe for poor nutritional status.
D. Observe for complications of ulceration and hemorrhage, fistula formation, and pneumothorax in end-stage disease.

Implementation
A. Maintain fluid and electrolyte balance.
B. Manage nutrition needs (hyperalimentation therapy may be used).
C. Administer gastrostomy tube feedings, if ordered.
D. Monitor client’s ability to handle secretions.
E. Provide emotional support.

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