Osteoarthritis, Rheumatoid Arthritis, and Other Musculoskeletal Disorders, Exams of Nursing

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1. Osteoarthritis (Overview) pg. 1282: - Correct Answer Most common arthritis. Also called DJD (Degenerative Joint Disease). Progressive deterioration and loss of joint cartilage. Idiopathic or secondary (synovitis).
2. Osteoarthritis Pathophysiology: - Correct Answer Enzymatic degradation; Loss of proteoglycans and collagen in cartilage; Surface ulcerations and deep fissures develop; Osteoarthritis
3. Osteoarthritis Risk Factors: - Correct Answer Genetic factors; Obesity; Increasing age; Smoking; Repetitive activities
4. Osteoarthritis Incidence: - Correct Answer Incidence of OA after 50 is twice as great in women (age, gender and activities important hx). Before age 50, men are more often affected than women
5. Osteoarthritis Cartilage: - Correct Answer Normal articular Cartilage and Abnormal articular cartilage. Normal looks like fluffy egg white. Abnormal is thinning, torn and worn cartilage, less elastic, less able to resist impact
6. Osteoarthritis - Etiology and Pathophysiology: - Correct Answer Incongruent joint surfaces create:Uneven distribution of stress across the joint; Reduction in motion; Joint pain, also adds to muscle atrophy; Loss of function; Joint effusion - swelling, inflammatory process (excessive fluid—mostly knees (from cartilage breakdown)
7. Osteoarthritis What: - Correct Answer unilateral, asymmetrical. Secondary synovitis (is inflammatory). Early pain and stiffness. Loss of joint motion. Noticeable swelling (look and feel). Some most commonly involved joints: HANDS. Distal interphalangeal (DIP), Proximal interphalangeal (PIP), Metacarpophalangeal joint (MCP). Other most commonly involved joints: Cervical and lower lumbar vertebrae, Weight-bearing joints (hips, knees), Metatarsophalangeal (MTP)
8. Osteoarthritis -Clinical Manifestations: - Correct Answer See Chart on pg. 1283- by affected site. Joint pain (The #1 clinical manifestation) Predominant symptom, Relieved by rest in early stages, May become worse as barometric pressures fall before inclement weather. No systemic manifestations, possibly some referred pain and nerve involvement. Osteoarthritis -Clinical Manifestations: Joint pain Affects joints asymmetrically Why? Early morning stiffness, Resolves within 30

minutes, stiffness—not pain--- usually decreases with motion. Sciatic nerve pain - referred pain, i.e. Hip pain sending down legs. Paresthesias. Decreased ROM/flexion contractures. Crepitus (grating noise with movement). Joint enlargement. Deformity. Heberden's nodes. DIP joints. Indication of osteophyte formation - Bone spur. ~even though its an "asymmetrical" condition, often with older, post menopausal women and hands, bilateral involvement. Bouchard's nodes. PIP joints

9. Osteoarthritis -Diagnostic Studies: - Correct Answer X-Rays......CT Scans; MRI; Bone Scans; Arthroscopy; Lab studies may show associated or related illnesses; ↑ ESR may be normal or slightly elev. Tends to rise with age and infection; ↑ C- reactive protein (with synovitis)
10. Osteoarthritis -Collaborative Care: - Correct Answer Primary goals: Control discomfort to maintain and improve joint function. Pain and inflammation management: Prevent disability.
11. Osteoarthritis Nursing Considerations Drug Therapy: - Correct Answer NSAIDs; Acetaminophen, ASA, Ibuprofen, Capsaicin (topical-minimal side effects) (no tight clothing w/this topical med, & can cause burning sensation). Short term; Monitor max dosage/24hr; Dark, tarry stools; Dyspepsia ; Selective COX- inhibitors; Celebrex (contraindicated for pt w/Sulfa Drug allergy); Corticosteroids Injected in joint (intra-articular injections); Hyalgan (if allergic to eggs = no Hyalgan) and Synvisc. Joint injections for the knee; Synthetic joint fluid implants; Replace natural hyaluronic. Muscle relaxants, Flexeril. Analgesic; Tramadol (controlled substance). Opioids; Norco, Dilaudid: Lowest dose possible, Confusion, Sedation, Respiratory depression (always w/opioids), Hallucinations, Mild stimulant laxative/stool softener (hydration), Narcan can reverse a opioid overdose, Romazacam can reverse Xanax overdose
12. Osteoarthritis Heat and cold applications: - Correct Answer May help reduce pain and stiffness, Ice is not used as often as heat. Ice: Acute inflammation. Heat: Stiffness
13. Osteoarthritis Rest and joint protection: - Correct Answer Rest during any periods of acute inflammation. Immobilization not to exceed one week. Physical Therapy consult. Evaluate and Treat
14. Osteoarthritis Nutritional therapy and exercise: - Correct Answer Weight- reduction plan (walking good, running not good), No jogging! No football! Stop smoking. Neck and back exercises to build strength. Low impact aerobic activities. Range of motion exercises. Swimming and water therapy. Resistance exercise. Golf. Yoga. Complementary and alternative therapies: Acupuncture; Arthroscopy (can treat & also diagnose)

15. Joint Arthroplasty: - Correct Answer Reconstruction or replacement of a joint. Artificial prosthesis inserted to replace joint surface. Cemented or uncemented joint. Cemented more common in older adults d/t osteoporosis/osteoarthritis. Uncemented joint takes longer to heal. Patient younger, less likely to osteoarthritis
16. Joint Replacement Surgeries Hip and Knee: - Correct Answer Indications: Manages pain of OA, Improves mobility, Osteonecrosis -Lack of blood flow: Trauma, Chronic steroid therapy
17. Total Joint Arthroplasty: - Correct Answer Contraindications, Infection, Advanced osteoporosis, Rapidly progressive inflammation
18. Total Hip Arthroplasty Indications: - Correct Answer Pain interrupts sleep, Pain limits ADLs, Drug therapy no longer controls pain, Patient able to participate in PT postop
19. Total Hip Arthroplasty Pre-op teaching: - Correct Answer PAIN. Discontinue drugs that prevent clotting x one week. NSAIDs. Hormone replacement: May have epoetin (EPOGEN - erythropoietin (RBC) produced) with or without iron prescribed several weeks preop. Prevents anemia postop. Prepare pt. for post op expectations. Use of trapeze over bed. Physical therapy. SCDs/anticoagulation (low dose Lovenox). Pulmonary toiletry (TCDB, incentive spirometer). Pain control (PCA Pump) Family can NEVER hit the button for the Pt. Core Measure SCIP Surgical Care. Skin Prep CHG, CHG wipes morning of, Abx before 1st cut, 1 dose Abx post-op, Foley Cath (d.c. Post-op day 1). Nursing Implications
20. Total Hip Arthroplasty Post-op: - Correct Answer Prevent complications! Dislocation. Abduction pillow or splint. No hip flexion beyond 90 degrees (don't bend forward). Assess for pain, rotation (i.e. one foot starts rotating inwards), extremity shortening. Infection: Aseptic technique, Hand washing, Culture drainage if change (COCA, color, odor, consistency, amount), Monitor temperature- Older patient may not have fever, Altered mental state. Report excessive inflammation or drainage to physician. Venous thromboembolism: TEDs and/or SCDs. Anticoagulant - lovenox (watch creatinine for elevation, and kidney function) Low molecular weight heparin(?)
21. Total Hip Arthroplasty Post-op Continued: - Correct Answer Encourage fluid intake. Watch for redness, swelling, or pain (lower extremities). Observe for changes in mental status. Do not massage legs!! Remove SCDs for 1 hour during shift, otherwise on at all times, even if sitting in chair. Neurovascular assessment: 6 "Ps": pain, pallor, pulsless, paralysis, paresthesia, poikilothermia (cold) Changes report to surgeon. Compare affected leg with unaffected leg: Color, Temperature, Distal pulses, Capillary refill, Movement, Sensation. Out of bed day after surgery (POD1). No hip flexion greater than 90 degrees!! (DON'T

BEND FORWARD). Raised toilet seats (bedside commode). Straight-back chairs. Reclining wheelchairs

22. Total Knee Arthroplasty: - Correct Answer Preoperative -Similar to THA (Total Hip Arthroplasty). Postoperative - Similar to THA. Minus Hip abduction. Ice packs. CPM (continuous Passive Motion Machine). Neutral position. Teach no kneeling or deep knee bends EVER.
23. Osteoarthritis Nursing Diagnoses: - Correct Answer Acute and chronic pain - need descriptive of the pain, is it r/t post-op acute, or is it the OA pain and needs to be treated w/heat pad. Impaired physical mobility. Disturbed sleep pattern. Readiness for Enhanced Self-Care. Risk for injury - infections. Risk for falls
24. Osteoarthritis - Nursing Process Planning: - Correct Answer Overall goals: Maintain or improve joint function, Use joint protection measures. Achieve independence of self-care. Pharmacologic strategies to manage pain
25. Rheumatoid Arthritis pg. 1291 What: - Correct Answer Rheumatoid Arthritis (RA). A chronic, systemic autoimmune disease (NOT WEAR AND TEAR LIKE OA). Characterized by inflammation of connective tissue in the diarthrodial (synovial) joints. Typically have periods of remission and exacerbation. Unknown etiology
26. RA WHO: - Correct Answer Affects all ethnic groups. Can occur at any time of life. Incidence ↑ with age often ages 25-55. Women are affected 2-3 times more frequently than men (?estrogens?). Incidence ↑ in European Americans. Smoking appears to be a link
27. Rheumatoid Arthritis (RA) Etiology: - Correct Answer Autoimmunity - Changes begin when a susceptible host experiences an initial immune response to an antigen (like a viral infection). Antigen triggers the formation of an abnormal immunoglobulin G (IgG). Maybe influenced by environmental factors or ????
28. Rheumatoid Arthritis (RA) (listen at 1 hr 11 mins) Pathophysiology: - Correct Answer RA is characterized by the presence of autoantibodies (rheumatoid factor [RF]). RF and IgG form immune complexes that ___Joint changes from chronic inflammation begin when the hypertrophied synovial membrane invades the surrounding. Cartilage. Ligaments. Tendons. Joint capsule
29. Rheumatoid Arthritis (RA) - Clinical Manifestations: - Correct Answer Nonspecific manifestations may precede the onset of arthritic complaints: Inflammation, Low-grade fever, Fatigue, Weakness, Anorexia, Paresthesias.
30. Onset of RA can be either: - Correct Answer Acute and severe, Slow and progressive. Stiffness becomes more localized in the following weeks to months.

Some patients report a history of precipitating stressful events. Research has been unable to correlate such events directly with the onset of RA

31. RA Specific articular involvement: - Correct Answer Pain, Stiffness, Limitation of motion, Signs of inflammation: Heat, Swelling, Tenderness
32. RA Joint symptoms: - Correct Answer occur symmetrically and frequently. Small joints of the hands and feet. Larger peripheral joints. Wrists, elbows, shoulders, knees, hips, ankles, and jaw. Cervical spine. Often experience joint stiffness after periods of inactivity. Morning stiffness may last from 60 minutes to several hours or more. Joints become tender, painful, and warm to the touch
33. RA Joint pain: - Correct Answer ↑ with motion, Varies in intensity, May not be proportional to the degree of inflammation, Tenosynovitis, Difficult for patients to grasp objects. Inflammation and fibrosis of the joint capsule and supporting structures may lead to deformity and disability
34. RA Subluxation: - Correct Answer Atrophy of muscles and destruction of tendons around the joint cause one articular surface to slip past the other
35. Rheumatoid Arthritis (RA) - Extraarticular Manifestations (recording at 1hr 18 min): - Correct Answer RA can affect nearly every system of the body. Two most common associated syndromes: Rheumatoid nodules can cause other problems, vascular, major organs, brain. Sjögren syndrome
36. Rheumatoid Arthritis (RA) - Rheumatoid Nodules: - Correct Answer Affect 25% of all patients with RA, High titers of RF. Firm, nontender, granuloma-type masses. Usually over the extensor surfaces of joints, ulnar surfaces of arms, Achilles; fingers and elbows. Nodules at the base of the spine and back of the head are common in older adults. Develop insidiously. Can persist or regress spontaneously.Usually not removed
37. Rheumatoid Arthritis (RA) - Complications Pg 1295-image: - Correct Answer CVD, Pleural disease, Scleritis, Sjogrens syndrome, Pericarditis, Splenomegaly, Anemia, Carpel Tunnel syndrome, Joint effusions
38. Rheumatoid Arthritis (RA) Diagnostic Studies: - Correct Answer Box 40-5 pg
    1293. Accurate diagnosis essential. For appropriate treatment. Prevention of unnecessary disability. ESR and C-reactive protein (CRP) indicators of active inflammation. Anti-CCP (more specific than, identifies antibodies circulating) and RA Factor (aka RF Factor) (can be positive w/other autoimmune disease) Pg. 973 in ATI read about titers. History: duration of joint symptoms>6 weeks. X-rays: shows typical changes/deformity. CT: determine cervical spine involvement. MRI: to determine more spine and other tissue involvement (for inflammation and/or other connective tissue involvement). Synovial Fluid. ARA Criteria pg. 1293 Box

40-3 - Listen at 1hr 26 min. .....Elevated acute phase response, symptom duration > 6 wk

39. Rheumatoid Arthritis (RA) Collaborative Care: - Correct Answer Care of the patient with RA. Drug therapy and education. Nutritional issues. Physical therapy- Joint motion and muscle strength. Occupational therapy- Upper extremity function. Assistive devices and strategies
40. Rheumatoid Arthritis (RA) Drug Therapy: - Correct Answer Cornerstone of RA treatment- Disease-modifying anti- rheumatic drugs (DMARDs). Potential to lessen the permanent effects of RA. Choice of drug depends on. Disease activity. Patient's level of function. Hep B or C status. TB screening performed (bc these drugs can...). See Table 40-5. NSAIDs commonly used. If used alone, help manage manifestations of RA not the RA itself. Nonsteroidal anti inflammatory drugs (NSAIDs) and DMARDs. DMARDs suppresses inflammation and decreases disease progression on bones (induce remission). Nonbiologic and Biologic classification drugs
41. Rheumatoid Arthritis (RA) Nutritional Therapy: - Correct Answer Balanced diet. Calcium, anti-oxidants, omega 3 oils maybe. Weight loss may result. From loss of appetite and/or Inability to shop for and prepare foods. Corticosteroids or immobility may result in unwanted weight gain (water retention). Weight slowly adjusts to normal several months after cessation of therapy
42. Rheumatoid Arthritis (RA) Surgical Interventions: - Correct Answer Arthrodesis (can also get synovial fluid for testing during procedure) Joint Fusion: Improves joint stability. Arthroplasty Total Joint replacement: Indicated for joint replacement if joint deformed or destroyed.
43. Goals in the management of RA: - Correct Answer Reduction of inflammation. Management of pain. "Flare." Pain may become unbearable. Until pain is controlled, mobility is a secondary problem. Infection may lead to a "flare." Infection does not result from a "flare." Nursing diagnosis = acute pain. Maintenance of joint function. Prevention or correction of joint deformity
44. Rheumatoid Arthritis (RA) Nursing Considerations: - Correct Answer Regarding RA patients and their pain: It is debilitating and unrelenting—sometimes worse than others. When taking history ascertain: Has patient sought alternative pain relief measures? Acupuncture, hypnosis, cultural, meds/treatments from other countries. Especially: plasmaphoresis, stem cell, gene therapy (all this is important to the nurse!!!)
45. Rheumatoid Arthritis (RA) Nursing Interventions: - Correct Answer Helpful measures: Hot showers (have safety bars, chairs, special showers, lifts). Adequate rest, proper positioning with support. Hot or cold packs appropriate size/weight; Warm packs to joints; Cold packs for swelling; relieve stiffness, pain,

and muscle spasm. Cold (≤10 to 15 minutes at a time). Beneficial during periods of disease exacerbation. Moist heat (≤20 minutes at a time). Relief of chronic stiffness

46. Rheumatoid Arthritis (RA) Education For Home Care: - Correct Answer Comprehensive program to meet goals: Drug therapy, Rest, Heat and cold applications (also room temps), Exercise: OT and PT consults (ROM exercises), Alternative Therapies, Patient and family teaching (include safety issues: equipment, rugs, monitoring of nutritional intake, monitoring of changes, skin, stool color/consistency, changes in level of consciousness, vital signs... Alternate rest and activity throughout the day: Use only one small pillow (alignment), Relieve fatigue and pain. Patient should rest before becoming exhausted. Help patient find ways to modify daily activities. Energy conservation. Work simplification techniques: Work should be done in short periods, Schedule rest breaks, Spread work throughout the week. Time-saving joint protection devices. Gentle range-of-motion exercises. Daily: keep joints functional. Emphasize that usual daily activities. Do not provide adequate exercise to maintain joint function. During acute inflammation - Exercise should be limited. Limit due to pain
47. Rheumatoid Arthritis (RA) Psychologic Support. - Correct Answer The patient is constantly threatened by problems: Chronic Pain and fatigue, Decreased physical activity, Loss of self-esteem, Altered body image, Fear of disability and deformity, Sexuality
48. Rheumatoid Arthritis (RA) Nursing Diagnosis. - Correct Answer Chronic Pain, Coping, Caregiver Role Strain, Impaired Physical Mobility, Fear, Imbalanced Nutrition: less than body requirement
49. Systemic Lupus Erythematosus pg. 1302 (Statistics) - Correct Answer SLE affects 1 persons per 2,000 in US. Most cases occur in women of childbearing years. 30 times greater than men. African, Asian, and Native Americans three times more likely to develop than whites. Etiology unknown: Genetic influence and Environmental factors. Certain medications (there are some med induced SLE pg. 964 ATI, resolves when meds d.c.). Oral contraceptives and HRT (hormone replacement therapy)
50. Systemic Lupus Erythematosus (SLE)- What is it? - Correct Answer Chronic multisystem inflammatory disease. Associated with abnormalities of immune system. Predominately affects skin, joints, lungs, heart, and renal, hematologic, and neurologic systems. How/why so bad? Vasculitis—direct tissue damage of organs/systems AND/or indirect due to decreased blood/oxygenation
51. Systemic Lupus Erythematosus (SLE) Pathophysiology: - Correct Answer Disordered T-cell function leading to hyperactive B cells. Autoantibodies against normal body components. Immune Complexes. Form when autoantibodies bind with their target tissue. Are deposited in connective tissues of blood vessels,

lymphatic vessels, and other tissues. Triggered by toxins, organisms (bacteria and/or viruses)

52. Systemic Lupus Erythematosus (SLE) Manifestations Initially: - Correct Answer Fever, anorexia, weight loss, multiple arthralgias and symmetric polyarthritis. (painful or swollen joints and muscle pain, but no deformities, possibly joint necrosis though). Unexplained fever. Red rash, especially on the face. Alopecia
53. Systemic Lupus Erythematosus (SLE) Manifestations Hematologic: - Correct Answer Formation of antibodies against blood cells. Anemia. Leukopenia. Thrombocytopenia. Heavy impact on vascular system, can lead to end organ damage
54. SLE Other Manifestations: - Correct Answer Pale, cyanotic fingers and toes (vasculitis manifestation). Peripheral and periorbital edema (renal manifestation). Sensitivity to sunlight. Cognitive dysfunction (neurological manifestations). Mouth ulcerations. Enlarged glands. Extreme Fatigue (lymphatic and hematologic manifestation)
55. SLE Complications: - Correct Answer Kidney failure and infections are leading cause of death: Nephritis; Proteinuria; Glomerulonephritis. Infection: SLE increases susceptibility to infections, Due to disease and/or treatment. Fever should be considered serious: It is classic sign of exacerbation!
56. SLE Manifestations: - Correct Answer Good to learn and teach patients to wear medical alert tag. Warning Signs of FLARE. Pg 1307. Increased fatigue. Pain, abdominal discomfort. Rash. Headache. Fever. Dizziness. Multisystem Involvement of SLE.
57. SLE Diagnostic Studies: - Correct Answer Diagnosed primarily on a distinct criteria relating to: patient history; physical examination; laboratory findings: ANA, anti-DNA antibody testing, ESR, Serum complement levels, CBC, Urinalysis, Kidney biopsy
58. SLE Drug Therapy: - Correct Answer NSAIDs. Antimalarial drugs -For skin and arthritic manifestations. Corticosteroid therapy - Indicated for severe and life- threatening manifestations:(vasculitis, renal failure, pericarditis) High doses, also may be indicated for long term.More complications possible due to steroid therapy. Immunosuppressive drugs
59. SLE Treatments: - Correct Answer Avoid Sun exposure. Avoid oral contraceptive use. Complications: Renal- Hemodialysis or peritoneal dialysis
60. SLE Education: Home Care - Correct Answer Emphasize health teaching. Reiterate adherence to treatment does not necessarily halt progression.

Encourage hope as progress has been made. Support groups (lupus, arthritis). Minimize exposure to precipitating factors (sun, skin, kidney, "toxic meds")

61. SLE Nursing Diagnosis: - Correct Answer Psychosocial Issues: Isolation, self- esteem, and body image disturbance; Anxiety. Readiness for Enhanced Self- Health Management. Physical Issues: Impaired Skin Integrity; Ineffective Protection
62. Gout pg. 1276 Primary gout: - Correct Answer genetic predisposition to errors of purine metabolism result is retention of uric acid. Most of cases: middle-aged men age onset of 40-50, but also older men or postmenopausal women
63. Gout Secondary gout: - Correct Answer any age/gender, find and treat underlying cause (crash diets, diuretics, chemo or other harsh drugs, certain leukemia type diseases)
64. Gout Risk Factors: - Correct Answer Non-modifiable: Male, age. Female, post- menopause. Modifiable: HTN, Obesity, Metabolic Syndrome, Type 2 DM, CKD, Medications, especially ASA. Gout Etiology: Aggravated by increased intake of foods containing purines (which metabolize to uric acid). Dense meats such as beef kidneys, livers and brains, sweetbreads, anchovies, sardines, liver, and herring. Pain caused by deposits of uric acid crystals in the articular, periarticular, and/or subcutaneous tissue
65. Gout pg. 1276 Pathophysiology: - Correct Answer High levels of uric acid (urate) in blood from excess in body. Deposits in synovial fluid. Gouty arthritis results. Often Great Toe affected. Deposits in subcutaneous tissue. Tophi results (white nodules). Deposits as crystals in kidneys. Kidney stones result. Acute kidney injury possible
66. Gout Manifestations: - Correct Answer Rapid onset of swelling, intense pain (red/hot/joint), maybe low-grade fever. Acute so painful—pts seek treatment/relief. Subsides in 2-10 days. asymptomatic between attacks. successive attacks tend to increase in frequency and last longer
67. Gout Complications: - Correct Answer If untreated: Kidney disease from kidney stones which can obstruct urine flow, leads to AKI
68. Gout Diagnostics: - Correct Answer Pain evaluation, visual examination. Elevated serum uric acid > 8.5 mg/dl and. 24 hour urine collection for uric acid levels. >750mg/24 hr. ESR. Joint aspiration of crystals of sodium urate (always chance of infectious process with joint aspiration). Usually will have additional renal function tests: BUN, creatinine
69. Gout Drug Therapy: - Correct Answer (Acute) Colchicine, dramatic pain relief NSAIDs, corticosteroids, avoid aspirin. (Chronic) allopurinol (Zyloprim) Uricosuric

drugs: probenicid (Benemid) helps increase release of uric acid by body. Tell patient these drugs may make thirsty. NOTE: Aspirin negates these drug's actions

70. Gout Treatment/Interventions/Goals: - Correct Answer Nutrition: Foods low in purines and avoid alcohol. Weight -(reduction always the answer!). Encourage fluid intake (3000 ml per day) bed rest and joint support. Use of cradle to protect feet from sheets. Pain Management. Stress Management
71. Osteoporosis (Overview) p. 1267: - Correct Answer Chronic, progressive metabolic bone disease characterized by Porous bone, Low bone density, Primary (menopausal), Secondary (medication or immobilization or other disease process )
72. Osteoporosis Statistics: - Correct Answer 44 million people in the US have some degree of osteoporosis. 8 million women and 2 million men in US. 1. million osteoporosis related fractures per year (US)
73. Osteoporosis Incidence: - Correct Answer Eight times more common in women than men for several reasons: Lower calcium intake than men; Less bone mass because of smaller frame; Bone reabsorption begins earlier and accelerates after menopause
74. Osteoporosis Pathophysiology: - Correct Answer Bone (osteoclastic activity) resorption exceeds bone (osteoblastic activity) formation. Rate of bone loss varies among individuals, skeletal sites. Occurs most commonly in wrist, spine, hips
75. Osteoporosis Manifestations: - Correct Answer Often termed the "silent disease" because there are no symptoms. Later manifestations include: Sudden strain, Fractures (often xray for fx is first sign), Back pain, Loss of height, Spinal deformities (progressive curvature); Acute: Pain radiates around flank into the abdomen, Chronic: Slow vertebral collapse; Dorsal kyphosis and cervical lordosis
76. Osteoporosis Diagnostics: - Correct Answer History and physical exam; Bone mineral density (BMD); Dual-energy x-ray absorptiometry (DEXA); CT Scan of spine, hip; CBC; Serum and urineCalcium; Parathyroid lab; Vitamin D Lab
77. Osteoporosis Complications: - Correct Answer Fractures. Some spontaneous, others with everyday activities. Wrists. Increase in frequency until age 60. Pelvis. Incidence increases after age 70, doubling every 5 yrs thereafter
78. Osteoporosis Nursing Care: - Correct Answer Focus on teaching proper nutrition: Calcium and Vit. D supplements, sun, exercise (for bone health); Less carbonated drinks, alcohol (for fx. prevention). Good sources of calcium: Milk and milk products (Dairy); Green leafy vegetables; Seafood; Almonds and Hazelnuts.

Supplemental vitamin D may be recommended Why? Exercise should be encouraged to build up and maintain bone mass. Patients should be instructed to quit smoking. Cut down on alcohol intake to decrease losing bone mass. Nutritional counseling young ladies

79. Osteoporosis Drug Therapy: - Correct Answer Estrogen replacement after menopause (til age 50). Calcitonin-a thyroid hormone inhibits loss of bone—can be intranasal, needs refrigerated. Bisphosphonates inhibit osteoclast-mediated bone resorption. Examples: etidronate (Didronel), alendronate (Fosamax). Take on empty stomach prior to meals. Sit upright for 30 minutes after taking, heartburn possible
80. Osteoporosis Nursing Diagnosis: - Correct Answer Risk for Injury; Readiness for Enhanced Self-Health Maintenance; Readiness for Enhanced Self-help Management; Acute Pain
81. Osteomyelitis (Overview) p. 1311-1314: - Correct Answer Osteomyelitis is a severe infection of the: Bone and may include--bone marrow, and/or surrounding soft tissue. This condition is limb and possibly life threatening!
82. Osteomyelitis Etiology: - Correct Answer Common infecting microorganisms: Staphylococcus aureus (skin, IV drug abuse, IV catheters, dialysis, dental, foreign body (implant or prosthetic device). Salmonella from GI tract sources. Pseudomonas aeruginosa (gram neg) from dog bites, accidents, penetrating trauma. Acute is most often in children. Chronic most often in adults
83. Osteomyelitis Etiology: - Correct Answer Increased risk with immune suppression. Malnutrition, alcoholism, diabetes, kidney or liver disease. Smoking- (doesn't help with circulation). Can be different etiology also depending on area effected
84. Osteomyelitis Pathophysiology: - Correct Answer Microorganisms, could be direct via penetration trauma, surgery, etc. or from surrounding tissue or skin enter the bone and lodge in an area in which circulation slows. Microorganisms grow resulting in an increase in pressure because of the non-expanding nature of bone and increase in fluids and exudate. Results in further loss of blood, O2, to tissues
85. Osteomyelitis Indirect Entry: - Correct Answer The pelvis and vertebrae are some common sites of infection. Adult with compromised blood supply at greatest risk for chronic infection
86. Osteomyelitis Direct Entry: - Correct Answer The ↑ in pressure eventually leads to ischemia and vascular compromise of the periosteum then bone. Eventually the infection passes through the bone cortex and marrow cavity, resulting revascularization and necrosis. Direct Entry: Once ischemia occurs, the bone

dies. The area of devitalized bone eventually separates from the surrounding living bone, forming sequestra, fluid and exudate (pus), abscess formed- hard to treat d/t lack of blood supply

87. Acute Osteomyelitis Manifestations: - Correct Answer Systemic: Fever (101+), chills, night sweats, restlessness, nausea, malaise. Local: Constant bone pain, swelling, tenderness, warmth at infection site, pain increases with movement to affected part.
88. Chronic Osteomyelitis Manifestations: - Correct Answer Bone infection that has failed to respond to the initial course of antibiotic therapy, or was misdiagnosed or inadequately treated.Clinical Manifestations: Systemic signs may be diminished. Ulceration of the skin, sinus tract formation; Localized pain, drainage from affected area
89. Osteomyelitis Diagnostics: - Correct Answer Wound culture; bone tissue biopsy; Blood cultures; Elevated blood leukocyte, sed rate, CRP; X-ray doesn't show until later; Radionuclide Bone scans show lack of vascularization; CT and/or MRI to determine extent of involvement
90. Osteomyelitis Treatments: - Correct Answer Broad Spectrum Antibiotics Therapy: Usually lengthily, need long term IV access. Cultures or bone biopsy: Done Before drug therapy is initiated. If antibiotic therapy is delayed: Surgical debridement and decompression are often necessary; To remove necrotic tissue and release pus from periosteum; Drains possible
91. Osteomyelitis Nursing Management: - Correct Answer Acute Intervention: Avoid excessive manipulation of involved extremity; Painful possibly prone to fractures; Sterile dressings; Wound care isolation precautions; Prevention of complications w/ immobility; Monitor for complications of antibiotic therapy; Monitor Labs for Therapeutic levels- watch for toxicity levels; Notify provider if antibiotic levels toxic- dose adjustment needed
92. Osteomyelitis Interprofessional Care: - Correct Answer Hyperbaric oxygen therapy of 100% oxygen may be administered; Orthopedic devices may need to be removed; Myocutaneous flaps/skin/bone grafting may be necessary if destruction is extensive; Amputation of the extremity may be necessary to preserve life and improve the quality of life. For suspected bone infection and/or bone ischemia. Surgical treatment: Removal of the poorly vascularized tissue and dead bone; debridement. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted at this time to aid in combating the infection. After debridement the wound may be left "open" or may be closed, and a suction system is inserted (wound vac). Intermittent or constant irrigation of the affected bone with antibiotics may also be initiated. Vigorous and prolonged IV antibiotic therapy is the treatment of choice for acute osteomyelitis as long as bone ischemia has not yet occurred. Parenteral Antibiotics: Nafcillin, Cefazolin,

Ceftriaxone, Vancomycin. Chronic osteomyelitis: Oral antibiotic therapy with a fluoroquinolone (e.g., ciprofloxacin) for 6-8 weeks may be prescribed instead of IV antibiotics OR additionally after long term IV ABX. Osteomyelitis. Discharge Planning: Patients are discharged to home care with IV antibiotics delivered via: Central venous catheter or PICC; IV antibiotic therapy is continued in the home or Skilled Nursing Facility (SNF); 4-6 weeks or as long as 3-6 months; Condition can be problematic for years.

93. Gastrointestinal System Anatomy: - Correct Answer GI system starts with the mouth and ends with the anus. This includes: Mouth, Pharynx, Esophagus, Stomach, Small and Large intestine
94. GI System: Accessory Digestive Organs: - Correct Answer Liver, gallbladder, and pancreas
95. Functions of GI SystemPhysiology: - Correct Answer Ingestion, Movement, Secretion, Mechanical digestion, Chemical digestion, Absorption
96. GI Digestive Processes - First, Nutrition needed: - Correct Answer Process by which the body ingests, absorbs, transports, uses, and eliminates nutrients in food
97. What are Nutrients? - Correct Answer Substances found in food and used by body to promote growth, maintenance, and repair.
98. Nutrients Physiology: - Correct Answer Provide more than 70% of energy expended daily is to maintain our BMR (basal metabolic rate). Responsible for providing energy and work as building blocks for growth and tissue repair. After fats and carbs absorbed and metabolized, excess is stored in adipocytes and this excess is stored as triglycerides. Body breaks down triglycerides in fat cells when needed to provide energy
99. Nutrients Carbohydrates: - Correct Answer Sugars and starches. Plant foods primary source. Converted primarily to glucose after ingestion, digestion and metabolism. Excess intake can result in obesity, cavities and elevated plasma triglycerides
100. Nutrients Proteins: - Correct Answer Complete- animal products, most amount of amino acids. Incomplete- non-animal sources. Important for maintaining skin, connective tissue plus repair, plasma proteins, hemoglobin. Positive vs. negative nitrogen balance. Excess intake leads to weight gain. Deficient intake leads to weight loss, tissue wasting, edema and anemia
101. Nutrients Fats: - Correct Answer Also known as lipids (phospholipids, cholesterol, triglycerides). Necessary for structure and body functioning. Triglycerides major energy for liver and skeletal muscle cells. Need dietary fats to

absorb fat-soluble vitamins (A,D,E,K). Excess stored as adipose tissue. Good to protect organs. Too much contributes to obesity. Cholesterol in skin activated by sun becomes Vitamin D

102. Vitamins: - Correct Answer Facilitate the body's use of nutrients. Fat soluble (A,D,E,K) or water soluble (B, C), B12 requires intrinsic factor for absorbtion. All but Vit. D and K must be ingested in food or taken as supplements. Fat soluble are stored in body and can become toxic. See table 21- 1 for RDA and food sources for each vitamin pp. 540-
103. Minerals: - Correct Answer Potassium, magnesium, sodium, chloride, calcium, phosphorus
104. Responsibilities of Mouth (GI Component): - Correct Answer Also called oral or buccal cavity. Adults have 32 teeth. Mastication (breakdown and grind food). Saliva moistens food, forms food bolus, dissolves food chemicals to facilitate taste, and provides enzymes to start chemical breakdown of starches
105. Responsibilities of Pharynx: - Correct Answer Oropharynx and laryngopharynx. Moves food via peristalsis to the esophagus. Facilitates passage of food
106. Responsibilities of Esophagus: - Correct Answer Passageway for food to the stomach. Epiglottis- protects larynx/trachea during swallowing fluids or solids. Gastroesophageal sphincter-prevents regurgitation of food
107. Responsibilities of Stomach: - Correct Answer Cardiac region, fundus, body, and pylorus. Storage reservoir. Gastric juices and churning action facilitate mechanical breakdown of food resulting in substance called Chyme
108. Responsibilities of Small Intestine: - Correct Answer Begins at pyloric sphincter, ends at ileocecal junction. 3 regions: Duodenum- pancreatic enzymes and bile enter here. Jejunum. Ileum-terminal end of small intestine. Majority of food is chemically digested and absorbed in small intestine. Carbohydrates, proteins, lipids are digested by various pancreatic enzymes
109. Responsibilities of Large Intestine: - Correct Answer Begins at ileocecal valve, terminates at anus. 3 regions: Ascending, Transverse, Descending. Indigestible food residue and some water enter large intestine. Absorbs water, salts, and vitamins. Valsalva maneuver
110. Large Intestine (Liver and Gallbladder): - Correct Answer Liver - Organ made of lobules which consist of hepatocytes and Kupffer cells. Circulation to lobules exist by way of hepatic artery, hepatic vein and bile duct. This allows perfusion and filtering of blood. Bile production is the liver's primary digestive

function. Substance necessary to emulsify, promote absorption of fats. See box 21-1 for Major metabolic and digestive functions of Liver.

111. Large Intestine (Liver and Gallbladder): - Correct Answer Gallbladder - Storage for bile, found under the Liver. Bile secreted when fats enter the duodenum for digestion
112. Exocrine Pancreas: - Correct Answer Primary enzyme-producing organ of digestive system. Acini: Cells which secretes alkaline pancreatic juice that neutralizes acidic chyme in duodenum. Lipase and Amylase are enzymes also secreted in pancreatic juices and help break down fats and starches
113. GI's Work: - Correct Answer Collectively all parts of GI system work to ingest, digest, absorb, and transport nutrients to body cells. After transport, cells work to metabolize nutrients so energy is produced to maintain life and this is considered catabolism and anabolism. Energy from the breakdown of carbohydrates is achieved by catabolism. Proteins formed from amino acids is achieved by anabolism
114. Assessing GI Function (Overview): - Correct Answer To support diagnosis of specific disease. To provide information to identify or modify appropriate medication or therapy to treat disease. To help nurse monitor patient's responses to treatment, interventions. Nurse responsible for explaining procedure, supporting, documenting, and monitoring results. Nurse collects data in health history regarding possible genetic anomalies (family history) related to nutritional status
115. Nutrition Screening/History: - Correct Answer Nurses explore patients usual eating habits. Food, alcohol, supplements, ethnic and cultural considerations, specific food likes or dislikes, food allergies. Assess the GI system by c/o nausea, vomiting, last BM, diarrhea, rectal blood, indigestion and duration of abnormal symptoms. Prior gastric surgeries. Medical conditions which affect GI system. Physical Assessment and documentation. Assess laboratory results for nutritional status.
116. GI Physical Assessment: - Correct Answer Techniques of inspection, auscultation, percussion and palpation. LOOK, LISTEN, and then FEEL abdomen! Ensure privacy. Explain what will happen during examination. Body system approach. Head-to-toe (from mouth to anus) Goal: to identify patient problems
117. GI Documentation: - Correct Answer Practice narrative charting for Abdominal assessment
118. GI Age-Related Changes teeth: - Correct Answer Increase in periodontal disease, fractures of teeth.

119. GI Age-Related Changes Taste: - Correct Answer declines.
120. GI Age-Related Changes Saliva: - Correct Answer function declines in ability to breakdown starches.
121. GI Age-Related Changes Esophageal motility: - Correct Answer increased risk of aspiration.
122. GI Age-Related Changes Stomach: - Correct Answer increased risk of gastric irritation.
123. GI Age-Related Changes Liver: - Correct Answer increased risk of gallstones.
124. GI Age-Related Changes Small intestine: - Correct Answer decreased ability to absorb vitamins/minerals leading to nutritional anemias (iron and pernicious)
125. GI Age-Related Changes Constipation: - Correct Answer increased
126. GI Diagnostics: - Correct Answer Comprehensive Metabolic Panel. Albumin, pre-albumin. CBC. Liver enzymes. Pancreatic enzymes. Barium Swallow (upper GI series). Upper GI endoscopy. Abdominal ultrasound. MRI of Stomach. CT Scan Abdomen (liver, biliary tract, pancreas, GI tract, gallbladder). Barium enema. Colonoscopy. Guaiac stool. Sigmoidoscopy. Small Bowel series. Stool Culture. ERCP. MRCP. Liver biopsy
127. GI Diagnostic Patient Teaching: - Correct Answer Preparing patient for diagnostic tests. Monitoring results. Encourage and teach healthy dietary habits. Assess needs and design teaching to accommodate patient learning
128. Obesity- an overview: - Correct Answer One of the most prevalent, preventable health problems plaguing the US. More than 30% of men and women obese. Most accurate calculation for obesity is to figure Body Mass Index (BMI). 1 in 20 Americans BMI is > 40. Healthy weight BMI is 18.5 24.9. Overweight is 25.0-29.9. Obese is 30.0 and > Bariatrics a growing field of study www.cdc.gov/healthyweight/assessing/BMI/adult_bmi/
129. Obesity Risk Factors: - Correct Answer Genetics. Physiologic, Psychologic, Environmental, Sociocultural
130. Obesity Pathophysiology: - Correct Answer Occurs when excess calories are stored as fat. Appetite, CNS, Emotional factors, and hormones. Central and Lower body obesity. Sarcopenic obesity

131. Obesity Complications: - Correct Answer Atherosclerosis; Hypercholesterolemia; Hypertension; CVA; Sleep Apnea; Colon Cancer; Chronic Cholecystitis; Osteoarthritis; Metabolic Syndrome; Diabetes mellitus, type 2; Breast and endometrial cancers; Depression
132. Diagnosing Obesity: - Correct Answer BMI, Anthropometry, Waist Circumference, Thyroid Profile, Serum Cholesterol and Lipid profile
133. Obesity Medications: - Correct Answer Depending on each individual case, weight loss medications may be recommended if BMI>30. See Table on Page 567 for appetite suppressants and lipase inhibitors
134. Obesity Treatments: - Correct Answer Treatment is ongoing and individualized. Biggest hindrance: setting unrealistic goals. Exercise. Caloric reduction. Behavior modification. Surgery
135. Bariatric Surgeries: - Correct Answer Individuals must meet these criteria: BMI>40 and failed attempts to lose weight or BMI>35 and obesity-related comorbidities. Can tolerate surgery. Free of addictions (ETOH and drugs)
136. Types of Bariatric Surgeries Restrictive procedures: - Correct Answer Vertical gastroplasty (VGB). Adjustable gastric banding (AGB). These types of bariatric surgeries are reversible and less effective long term
137. Type Bariatric Surgery Malabsorptive procedures with restrictive component: - Correct Answer Roux-en-Y gastric bypass. Vertical sleeve gastrectomy. Biliopancreatic diversion with duodenal switch
138. Bariatric Surgeries Vertical banded gastroplasty: - Correct Answer Also known as stomach stapling where surgeon cuts hole in stomach below esophagus. Staples applied to create small upper stomach section. Restrictive band anchored at distal portion of new section. Advantages: Slows digestion creating feeling of satiety. Disadvantage: Nausea and vomiting if too much food consumed, pouch can overstretch over time
139. Bariatric Surgeries Adjustable Gastric Banding: - Correct Answer Hollow band of silicone rubber placed around upper portion of stomach. Adjustable saline inflation of band via SQ port restricts food passage through stomach. Advantages: fewer nutritional deficiencies, safest procedure. Disadvantage: vomiting post-op, band breaking, few maintain weight loss over 10 year period
140. Bariatric Surgeries Gastric bypass: - Correct Answer Newly constructed small stomach pouch. Jejunum is attached to new pouch. Advantage: Restricted food intake, promotes weight loss. Disadvantage: consumed nutrients have limited absorption, adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance

141. Bariatric Surgeries Vertical Sleeve Gastrectomy: - Correct Answer Now used as a stand alone bariatric surgery for high risk patients. Majority of stomach removed, leaving only a portion resembling a sleeve. Advantage: restricts intake and slows digestion with increased satiety. Disadvantage: potential for long-term vitamin deficiencies
142. Bariatric Surgeries Biliopancreatic diversion with duodenal switch (BPD- DS): - Correct Answer Majority of stomach removed and stomach sleeve formed. Duodenum and jejunum are bypassed and iliem connected directly to newly formed stomach sleeve. Advantage: restricts intake and slow digestion, significantly reduces obesity related comorbidities. Disadvantage: More complex surgery, carries higher risk of nutritional deficiencies as absorption affected, irreversible
143. Bariatric Surgery Post-OpComplications: - Correct Answer Anastomosis leak resulting in peritonitis. Abdominal wall hernia. Wound infections. DVT. Gallstones. Nutritional deficiencies and GI symptoms. Nausea, belching, bloating, vomiting diarrhea, weakness, syncope. Dumping syndrome precipitated by high simple carb diet intake
144. Bariatric Surgery Post-Op Nursing Care: - Correct Answer Weigh daily. Maintain NGT patency and prescribed suction until d/c'd. Assess bowel function, respiratory function, and circulation. DVT prophylaxis. Maintain IVF and parenteral nutrition as ordered until po intake allowed. Dietary Consult. Monitor BG as ordered. Pain control. TCDB q 2 hours while splinting/reinforcing abdominal incision. Provide meticulous wound care with strict aseptic technique. Encourage patient to talk about fears and encourage participation in decision making. Also see ATI 10th ed. Ch. 47 pg. 300
145. Enteral Nutrition Why is this indicated? - Correct Answer Used to meet calorie and protein requirements. Who qualifies? Patients with: Dysphagia, Unresponsiveness, Oral or neck surgery/trauma, Anorexia, Serious illness not allowing po intake
146. Enteral Nutrition (EN): - Correct Answer Tube feedings via small bore, soft nasogastric or nasoduodenal tube with weighted tip. Verify correct placement before use. Initiate feedings with prescribed formula at prescribed rate. Bolus feedings with syringe or continuous feedings via feeding pump. Check residuals q 4 hours, maintain patency. HOB 30 degrees ALWAYS!! Aspiration and diarrhea most common complications.
147. Parenteral Nutrition (PN): - Correct Answer Indicated for patients who have undergone major surgery or trauma or are seriously malnourished- both short term and long term. Intravenous administration of nutrition. Amino acids, electrolytes, carbs, fats, insulin~ all in one solution! Administered in a central vein

ONLY. Subclavian vein central line or PICC (Basilic vein). Placement confirmed before use!!! Aseptic technique with accessing central line. Risk of CLABSI (central line associated bloodstream infection). Priority of Nursing care with PN: Record baseline nutritional status and monitor for improvement with PN. Assure correct PN formula and rate with 2 nurses- HIGH ALERT d/t insulin and hyperosmolar contents (D10W)

148. Parenteral Nutrition Complications: - Correct Answer Central line insertion problems: Pneumothorax, improper positioning brachial plexus injury. Fluid Overload. Infection.Metabolic- Glucose intolerance, metabolic acidosis with renal impairment
149. Nursing Diagnosis Obesity: - Correct Answer Imbalanced Nutrition: More than body requirements. Activity Intolerance. Chronic Low Self-Esteem. Goals. Ensure patient maintains adequate nutrition with nutrient recommendations. Ensure patient performs ADLs with improvement independently before discharge. Ensures patient engaged in learning lifestyle changes with return demonstration
150. Esophageal Cancer: - Correct Answer Uncommon malignancy. High mortality rate if it does happen. Symptoms not recognized until late in disease course
151. Esophageal Cancer Risk Factors: - Correct Answer 7th leading cause of CA deaths in Men. More common in men than women. More common in blacks than whites. Most occur in lower 1/3rd of esophagus. Usually occurs after age
152. Cigarette smoking and Chronic Alcohol use. Ingested carcinogens. Physical mucosa damage. Chronic gastric reflux
153. Esophageal Cancer Pathophysiology: Adenocarcinoma - Correct Answer Incidence increasing. Changes columnar epithelium cells (dysplasia). Spreads to adjacent and supraclavicular lymph nodes, liver, lungs
154. Esophageal Cancer Pathophysiology: Squamous cell carcinoma - Correct Answer Decreasing incidence. Changes squamous cells of esophagus
155. Esophageal Cancer Manifestations: - Correct Answer Progressive dysphagia. Recent weight loss. Anemia. GERD-like symptoms. Chest Pain. Persistent Cough
156. Esophageal Cancer Diagnosis - Correct Answer Barium Swallow, Esophagoscopy, Chest x-ray, CT scan, MRI, CBC
157. Esophageal Cancer Treatments - Correct Answer Mortality is high given usual detection of advanced disease. Combined Chemotherapy and radiation first to shrink tumor. Surgery (will be in ICU post-op). Resect tumor of affected

part of esophagus with possible anastomosis of stomach to remaining esophagus. Lymph node resection

157. Ulcer Prophylaxis Medications: - Correct Answer PPI ( proton pump inhibitors) reduce the amount or effect of hydrochloric acid on gastric mucosa. Protonix IV. Not compatible with other IV drugs. Must administer SLOW IVP (over 2 minutes)
158. Esophageal Cancer Surgical Complications: - Correct Answer Leaking at anastomosis. Respiratory complications. Pneumonia. ARDS. Cardiac arrhythmias. Infection. Sepsis
159. Esophageal Cancer Nursing Care: - Correct Answer Respiratory support is #1 priority- patent airway always!!! Nutrition, Support needed/supplementation, Psychological Support
160. Stomach Cancer a.k.a. Gastric Cancer Incidence - Correct Answer Ranks #2 behind skin cancer. Incidence is highest in Hispanics, African Americans, and Asian Americans. Men are affected nearly twice as often as women. Older adults more likely to develop, mean age is 63. Lower socioeconomic groups have higher rates of gastric cancer. 5 year survival for patients
161. Stomach Cancer Risk Factors: - Correct Answer Genetic predisposition. H.Pylori infection- a gram negative spiral bacterium. Chronic gastritis. Pernicious anemia. Gastric polyps. Smoking or carcinogenic factors in diet (nitrates). Acholydria. Partial gastric resection
162. Stomach Cancer Pathophysiology: - Correct Answer Adenocarcinoma- most common type. Distal portion of stomach (antrum or pyloric region)- most frequent site. Local lesion starts (in situ). Progresses to involve mucosa (early ca.) Spreads to surrounding tissues in stomach. Adjacent organs at risk for metastasis (liver) via blood/lymph supply from stomach
163. Stomach Cancer Manifestations: - Correct Answer Early symptoms are vague. Feeling of satiety, anorexia, indigestion. Sometimes vomiting. Usually not detected until in advanced stages. Burning pain in stomach not relieved by antacids (Maalox, Mylanta, Tums). Weight loss. Cachectic. Occult blood in stool (GI Bleed)
164. Stomach Cancer Diagnostics: - Correct Answer CBC, H&H, Upper GI endoscopy with biopsy, Upper GI x-rays with barium swallow, Abdominal ultrasound

165. Stomach Cancer Treatments: - Correct Answer Medications for gastritis prevention, Surgery, Partial Gastrectomy, Total Gastrectomy, Chemotherapy pre- op, Chemotherapy and Radiation post-op, Palliative care for advanced disease
166. Stomach Cancer Medication Treatments: - Correct Answer PPIs - omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (Protonix)...reduce the effect of hydrochloric acid on gastric mucosa. H2 Blockers - cimetidine (Tagament), ranitidine (Zantac), famotidine (Pepcid)...reduce the effect of hydrochloric acid on gastric mucosa. Sucralfate (Carafate)...coats gastric mucosa from damaging affects of hydrochloric acid and pepsin
167. Gastrectomy Procedure Complications: - Correct Answer Dumping syndrome. Most Commons complication. Occur 5-30 minutes after eating. Manifestations include: Nausea, Epigastric pain with cramping, Borborygmi (loud, hyperactive bowel sounds), Anemia, Decreased absorption of vitamins, Folic acid, calcium and Vitamin D
168. Stomach Cancer Nursing Care: - Correct Answer Thorough health assessment. Includes both nutritional history, GI problems, weight loss. Physical assessment. Pain assessment. Monitoring and preventing potential complications. Lab work, daily weights, intake and output (including meals). Maintaining PN and IVF. If surgery performed: Incision care, maintenance of tubes/drains, prevent infection (pulmonary, GI, skin). Psychosocial support. Anticipate Discharge needs
169. Inflammatory Bowel Disease (Overview): - Correct Answer Consists of 2 conditions. Ulcerative Colitis and Crohn's disease. Ulcerative Colitis Etiology unknown, maybe genetic or environmental. Tends to run in families. Abnormal immune response to microorganisms in gut possible. Overactive immune response. American Jews have highest incidence. Incidence increasing in African Americans
170. Ulcerative Colitis Pathophysiology: - Correct Answer Inflammatory bowel disorder. Usually affects end colon (rectum & sigmoid colon) with disruption of mucosa, can progress proximally (can move up from end). Pinpoint mucosal hemorrhages occur and cryptic abscesses develop. (It's a Red inflamed colon). Abscesses penetrate mucosa leading to necrosis and sloughing of bowel. Tissue becomes friable (falls apart) and ulcerated, bleeding easily. Characterized by remissions and exacerbations (flare-ups). Fulminant colitis: Entire colon affected.
171. UC Manifestations: - Correct Answer Diarrhea. Stools with mucus, blood. (blood in stool w/UC). Less than 4 stools per day, can occur during night as well. Fulminant UC: Diarrhea can be 5-30 bloody stools per day. LLQ cramping. Fatigue - d/t anemia. Anorexia -hypoalbuminemia. Weight loss. Weakness. High pitch bowel sounds, Abdominal pain, abdominal distention, bloating.

172. UC Systemic Manifestations: - Correct Answer May occur with Fulminant Colitis. Includes: Athritis, Uveitis, Thromboemboli, Stones in Kidneys and gallbladder, Liver hepatitis. Sometimes pt has these symptoms first before the flare up.
173. UC Complications: - Correct Answer Hemorrhage (lower GI Bleed). Toxic Megacolon: A condition of colon paralysis with dilation of transverse colon. Triggered by medications for bowel, electrolyte imbalances. Fever, tachycardia, hypotension, dehydration, Abdominal pain and cramping. Colon perforation. Peritonitis. Colon Cancer
174. UC Diagnostics: - Correct Answer Stool culture (pt states had lot BM's, look for blood, and rule out parasites), CBC (look at H&H for anemia) , ESR or CRP (inflammatory markers, can be elevated), Serum albumin (low bc anorexic), Vitamins (B low, K+, Mg, Ca), Colonoscopy (if suspected UC for biopsy; bowel prep), Barium x-ray study (Barium enema)
175. Crohn's Disease: - Correct Answer Also an inflammatory bowel disease. Can affect any portion of GI tract from mouth to anus. Usually affecting terminal ilium and ascending colon. Chronic and relapsing
176. Crohn's Pathophysiology: - Correct Answer Inflammatory process of mucosa that resembles shallow ulcers. Can progress to involve all layers of intestinal wall. Deeper ulcerations, lesions and fissures possible with progression. Thickening, loss of bowel wall flexibility. (Starts w/ulcers. Fistulas = tunneling hole, fistula more common and can communicate (vagina common area) and essentially bowl contents come out of vagina) (terminal ilium, malabsorption occurs)
177. Crohn's Local Manifestations: - Correct Answer Persistent diarrhea. Stool liquid or semi formed. Typically does not contain blood. Abdominal pain in RLQ. Relieved by deification. Palpable mass in RLQ possible
178. Crohn's Systemic manifestations possible: - Correct Answer Fever; Fatigue, malaise; Weight loss; Anemia
179. Crohn's Complications: - Correct Answer Intestinal (bowel) obstruction, Perforation, Fistula formation, Abscess, Perianal problems (fissures, fistulas, abscesses, and stenosis), Increased risk of small and large intestine cancer
180. Crohn's Diagnosis: - Correct Answer Same as Ulcerative Colitis. Except w/Crohn's entire colonoscopy needed because it can be from mouth to anus and can "skip" around, meaning not all connected. Need to know extent of disease with health history. Inflammatory markers may not be elevated like UC. Tissue biopsy.

181. Crohn's Medications: - Correct Answer Sulfasalazine - Sulfonamide antibiotic and anti-inflammatory. Induce remission (goal). Contraindicated it pf allergic to Sulfa drugs. Acts on colon mucosa to inhibit inflammatory process. Mesalamine - Anti-inflammatory drug but does contain sulfa, does not have the adverse effects that Sulfasalazine has. Corticosteriods. Acute exacerbation, can be administered rectally to minimize systemic effects. Antidiarrheals
182. Crohn's Dietary Treatments Individualized: - Correct Answer NPO possible for bowel rest- for acute exacerbation. Possible TPN during acute phase. Eliminate milk and milk products. Increased dietary fiber (soluble fiber to help bulk up the stool, not insoluble which will promote stool and we don't want that). To reduce diarrhea. Contraindicated if patient diagnosed with intestinal strictures. Elemental diet such as 'Ensure' supplementation. Complementary and Alternative therapies: Peppermint tea, aromatherapy, stress reduction techniques
183. Crohn's Surgical Interventions Indications: - Correct Answer If complications occur or failure of medical regime
184. Crohn's Types of surgery: - Correct Answer Colectomy. Surgical resection and removal of colon. Total Colectomy with a ilieal pouch-anal anastomosis (IPAA). Temporary or loop ilieostomy performed simutaneouly
185. Crohn's Surgical Interventions: - Correct Answer Ostomy: Opening between intestine, abdominal wall. Name of ostomy depends on location of stoma. Ileostomy-colon, rectum, and anus removed, known as Total Proctocolectomy with permanent ileostomy). Loop ileostomy. Continent ileostomy (Kock pouch)
186. Crohn's Surgery Nursing Care Routine Post-op care plus... - Correct Answer Assess stoma and ostomy pouch. Assess for bleeding. Healthy stoma appears pink or red and moist. Starts to function with dark green, odorless drainage. Assess periostomal skin. Report allergic or contact dermatitis, purulent ulcerated areas surrounding stoma, red/bumpy/itchy rash, or bulging around stoma. Patient education and support. (pt is discharged, Ostomy nurse (aka Wound Care Nurse) tell pt how to care for ostomy & cleaning. We teach pt about foods to help decrease odor (yogurt = low odor, broccoli = bad odor) self management, support groups.) Allow patient time to express fears, concerns
187. Crohn's Nursing Diagnosis: - Correct Answer Diarrhea. Disturbed Body Image. Imbalanced Nutrition: less than body requirements
188. Crohn's Collaborative Care: - Correct Answer Encourage self- acceptance. Daily self-management including family assistance. Case Management for resources: Community referrals and support. Crohn's and Colitis Foundation. United Ostomy Association, Inc.

189. Colorectal Cancer: - Correct Answer Third most common diagnosed cancer in US. Incidence equal between women and men. Higher among African Americans than Whites. Hispanic men and women have lower rates than non- hispanics
190. Colon Cancer Risk Factors: - Correct Answer Age over 50. Diet (plays a huge role, carbs, fats, etc.) Polyps (pouch/bumps). Genetics (1st degree family member = higher risk, i.e. Mom/Dad). Inflammatory bowel disease (IBD). Obesity, smoking and alcohol use
191. Colon Cancer Pathophysiology: - Correct Answer Majority begin as adenomatous polyps. Evolve into adenocarcinomas. The descending colon most common area (sigmoid colon and rectum). Spreads by extension to involve entire bowel wall/circumference. Metastasis to regional lymph nodes promotes distal metastasis. May spread by "seeding" of tumor when tumor invades peritoneal cavity or during surgery
192. Colon Cancer Manifestations: - Correct Answer Manifestations may not appear until advanced disease. 5-15 years until manifestations occur. Rectal bleeding is often the initial sign. Some patients contribute this to hemorrhoids. Fatigue. Change in bowel habits. Pain, anorexia, and weight loss- advanced disease
193. Colon Cancer Complications: - Correct Answer Bowel Obstruction. Patient will manifest with severe pain, nausea, vomiting. Bowel perforation. Metastasis
194. Colon Cancer Screening and Prevention: - Correct Answer Colonoscopy at age 50 and every 10 years thereafter, unless 1st degree relative family history- age 40!!!!! Diet, BIG! High in natural foods. Low in saturated fats. Get moving!! Regular exercise. Limit alcohol consumption and quit smoking
195. Colon Cancer Diagnosis: - Correct Answer Laboratory tests, Fecal occult blood, CBC, Carcinoembryonic antigen (CEA), Sigmoidoscopy, Colonoscopy (w/conscious sedations) with tissue biopsy, Chest x-ray, CT scan, MRI.
196. Colon Cancer Surgery: - Correct Answer Surgical resection of tumor, adjacent colon and regional lymph nodes. Anastomosis or remaining bowel. Colostomy. May be required. Sigmoid most common, but others may be indicated depending on tumor location. Nursing Care- see box page 675. (Sigmoidoscopy pt doesn't have to have conscious sedation.) Post op care - NG tube
197. Colon Cancer Chemotherapy: - Correct Answer Indicated post-op. After patient stable hemodynamically. Stage II and III, reduces rate of occurrence when combined with radiation. Otherwise, slows progression of metastasis in

distant organs in advanced disease. Many types of chemotherapeutic regimens. 5-FU and leucovorin (harsh). Monoclonal antibodies. Complications: Immunosuppression, bruising, fatigue, hair loss, mouth sores

198. Colon Cancer Nursing Diagnosis and Care: - Correct Answer Acute Pain; Knowledge deficit; Denial; Grieving; Imbalanced Nutrition, less than body requirements; Impaired skin integrity
199. Gallbladder and Heptic Disorders: Cholecystitis Pathophysiology - Correct Answer Inflammation of the gallbladder. Acute occurrence. Chemical irritation and bacterial inflammation. Abrupt onset. Retained bile, stone formation common (80% cholesterol), obstruction common, ischemia GB wall. Bacteria sets in, inflammatory response follows. Chronic- Occurs from repeated bouts of acute cholycystitis. Doesn't always present with symptoms
200. Cholecystitis Risk Factors: - Correct Answer Gallstones; Native Americans; Obesity, hyperlipidemia; Bariatric surgery; Female, fat, 40, fair complexion (true); Diabetics, biliary stasis
201. Cholecystitis Manifestations: - Correct Answer Acute; Biliary colic- pain in RUQ of Abdomen; May radiate to back, right scapula or shoulder; Anorexia, nausea, and vomiting, dyspepsia. Chronic; Could be asymptomatic, or very vague
202. Cholecystitis Acute Complications: - Correct Answer Empyema; Gangrene; Perforation; Can result in life threatening peritonitis, abscess formation; Fistula formation; ileus
203. Cholecystitis Diagnostics: - Correct Answer Labs: Serum bilirubin; CBC; Amylase and lipase; US of gallbladder; HIDA Scan
204. Cholecystitis Treatments: - Correct Answer Medications: Not commonly used to dissolve stones, costly. If infection suspected, antibiotics; Opioid analgesics for acute attacks. Diet modification. Bowel rest during attack. Dietary fat restricted (stay away from dairy creams and white flour!). Lithotripsy. Ultrasound is used to align the stones with shock wave to disintegrate. Positioning patient is key. Conscious sedation. Pain expected with gallbladder contracting to remove stones
205. Cholecystitis Surgery: - Correct Answer Laparoscopic cholecystectomy. Minimally invasive, carries decreased risk for gallbladder removal. Laparotomy (open cholecystectomy). Surgically opening abdomen to remove gallbladder. Associated with more complications. Choledochostomy. Draining of the gallbladder, may require t-tube placement in bile duct to maintain patency of bile duct