The results of a patient's recent endoscopy indicate the presence of peptic ulcer

disease (PUD). Which of the following teaching points should the nurse provide to the
patient in light of his new diagnosis?
A. You'll need to drink at least two to three glasses of milk daily.
B."It would likely be beneficial for you to eliminate drinking alcohol."
C. Many people find that a minced or pureed diet eases their symptoms of PUD.
D. Your medications should allow you to maintain your present diet while minimizing
symptoms

"The nurse is caring for a 68 year old patient admitted with abdominal pain, nausea, and
vomiting. The patient has an abdominal mass and a bowel obstruction is suspected.
The nurse auscultating the abdomen listens for which of the following types of bowel
sounds that is consistent with the patient's clinical picture? "
A. low pitched and rumbling above the area of obstruction
B. High pitched and hypoactive below the area of obstruction
C. low pitched and hyperactive below the area of obstruction
(D). high pitched and hyperactive above the area of obstruction

"A patient with a history of peptic ulcer disease has presented to the emergency
department with complaints of severe abdominal pain and a rigid, boardlike abdomen,
prompting the health care team to suspect a perforated ulcer. Which of the following
actions should the nurse anticipate?
A. Providing IV fluids and inserting a nasogastric tube
B. Administering oral bicarbonate and testing the patient's gastric pH level
C. Performing a fecal occult blood test and administering IV calcium gluconate
D. Starting parenteral nutrition and placing the patient in a high-Fowler's position

Calcium gluconate is not a medication directly relevant to the patient's suspected

diagnosis and parenteral nutrition is not a priority in the short term
Which of these agents is a major contributing factor in the promotion of peptic ulcer
disorder?
A) Candida albicans.
B) staphyloccus infection.
C) streptococcus infection
D) Helibacter pylori infection

The nurse determines that a patient has experienced the beneficial effects of
medication therapy with famotidine (Pepcid) when which of the following symptoms is
relieved?
1. Ice tea
2. Dry toast
3. warm broth
4. plain hamburger
"A patient with a history of peptic ulcer disease has presented to the ED with complaints
of severe abdominal pain and a rigid, boardlike abdomen, prompting the health care
team to suspect a perforated ulcer. Which of the following actions should the nurse
anticiptate?
"A: Providing IV fluids and inserting a nasogastric tube
B:Administering oral bicarbonate and testing patient's gastric pH level
C:Performing a fecal occult blood test and administering IV calcium gluconate
D: Starting parenteral nutrition and placing the patient in high-fowler's position

Calcium gluconate is not a medication directly relevent to the patient's suspected

diagnosis and parenteral nutrition is not a priority in the short term
5. Which of the following drugs is a histamine blocker and reduces levels of gastric
acid?"
A. Omeprazole (Prilosec)
B. Metoclopramide (Reglan)
C. Cimetidine (Tagamet)
D. Magnesium Hydroxide (Maalox)

which is the most common upper GI problem? "

1. peptic ulcer disease
2. Crohns
3. Gerd
4. ulcerative colitis

"The nurse determines that a patient has experienced the beneficial effects
of medication therapy with famotidine (Pepcid) when which of the following
symptoms is relieved? "
A) Nausea
B) Belching
C) Epigastric pain
D) Difficulty swallowing

The nurse is reviewing the medication record of a female client with acute gastritis.
Which medication, if noted on the client's record, would the nurse question? "
a. Digoxin (Lanoxin)
b. Furosemide (Lasix)
c. Indomethacin (Indocin)
d. Propranolol hydrochloride (Inderal)

A 58 year old female with a history of Major Depressive Disorder (MDD) presents to
your office with complaints of a feeling of fullness in her throat, upper abdominal pain
and reflux. When taking her recent medical history, which of the following raises your
suspicion that she may have a sliding hiatal hernia?

A. She has been receiving vagus nerve stimulation for her MDD
B. She has been taking over the counter omeprazole for her symptoms
C. Her psychiatrist has recently switched her from Zoloft to Nortriptyline for her MDD
D. Her home blood pressure readings are around 150/82 and higher

What type of hiatal hernia more commonly leads strangulation as a severe

complication?

A. Sliding hiatal hernias

B. Hernias do not strangulate
C. Paraesophageal hiatal hernias
D. Both types equally lead to strangulation

A 55 year old male presents to his PCP with a chief complaint of heartburn and difficulty
swallowing. His provider notes a congenital short esophagus was discovered on
previous CXR. What does this discovery put the patient at risk for?

A. Obesity
B. Sliding hiatal hernias
C. GERD
D. Gastritis

A 63-year-old male presents to the ED, with sudden onset of severe CP and difficulty
swallowing. States he has frequent reflux and heartburn that worsens with bending
forward and laying down. You suspect strangulation of a paraesophageal hernia. What
is the best first test that should be ordered?

A. Upper endoscopy
B. CT of abdomen
C. Barium Study of the esophagus
D. Chest X-ray

Symptoms of a hiatal hernia include all of the following, EXCEPT:

A. Asymptomatic
B. Regurgitation
C. Constipation
D. Dysphagia
What are the 3 types of hiatal hernias?
Sliding, paraesophageal, mixed

disorder characterized by loss of the wave like contractions in the smooth muscle that
forces food through the esophagus
Achalasia

includes spasms of the

Lower esophageal sphincter

due to LACK OF
nerve stimulation of the LES

failure of relaxation does not allow food to the ____

stomach

food backs up in the ____ and it ___ causing distention and dilation
esophagous
ferments

(3) causes
damage of esophagus nerves
parasitic infection
hereditary factors

can occur at any age but increases in frequrncy with advancing ____
Age

s and sx
dysphagia
regurgitation
weight loss--stop eating due to discomfort
difficulty belching
chest pain

dx
barium esophagography* (birds beak)
x ray

endoscopy
manometry

sign
birds beak on barium esophagograohy (barium swallow)

birds beak
esophagous is dilated and then rapers in narrow segment (birds beak)

poor_____ emptying
Esophageal

tx
myotomy*
pneumatic dilation
votulinum toxin

can do this after pneumatic dilation

myotomy

tx?
sx improve up to 85% but high relapse rate
botulinum toxin

In this procedure a guide wire is passed into the stomach with the aid of an endoscope.
After the endoscope is removed, a pneumatic balloon is passed over the guide wire,
half above and half below the LES. The balloon is then rapidly inflated for 30-60
seconds, expanding the circular muscles around the diaphragm, causing them to
rupture slightly but reducing the LES pressure.
The procedure is 60-90% effective and can last for 10 years
neumatic dilation

95% success rate in alleviating symptoms of achalasia

The muscle fibers of the LES are incised without disrupting the mucosal layer of
esophagus, reducing tension. Procedure often result in GERD, so fundoplication also
performed.
Fundus of stomach wrapped around esophagus, sewn in place
Helps to strengthen LES and stop reflux
MYOTOMY

CHEMICAL BURNS
What are Chemical Burns?
Burns caused by a caustic or corrosive chemical that comes in contact with skin, eyes
or mouth. Campus has many places where chemical burns could happen. If large scale
decontamination required, get HAZMAT or fire. DO NOT CONTAMINATE OURSELVES
OR AMBULANCE. Face, hands, and arms are most likely places to be affected. Find
out substance.

S/S?
- Redness, Irritation, or burning
- Pain or numbness
- Blisters or black skin
- vision changes is eyes are affected
- Coughing or shortness of breath
- Low blood pressure
- Faintness, weakness, or dizziness
- Syncope
- Headache
- Muscle twitching or seizures
- Irregular heartbeat

Treatment?
1) remove contaminated clothing
2) Dry chemicals- brush off skin and irrigate
3) liquids flush with saline for 20 minutes
4) If chemical gets in eyes, use a NC over nose to flush eyes with saline for 20
mins

Where are the chemicals on campus?

- Discovery (chem and physics)
- Delehanty (geology)
- Marsh Life (bio/nutrition)
- Hills Agricultural (advanced bio)
- Jeffords (plant/soil)
- Stafford (microbio/molecular genetics)
- HSRF (med school)

What is Barrett's Esophagus?

a condition in which the esophageal lining is replaced by a tissue resembling intestinal
lining
What happens to the intestinal metaplasia with Barrett's esophagus?
squamous lining of lower esophagus turns into columnar epithelium (goblet cells)

What is the average age of onset for Barrett's esophagus?

55

Around what percent of people are affected with Barrett's esophagus?

1.6-6.8%

What are the risk factors? (6)

1. GERD
2. Obesity
3. Smoking
4. Age
 5. Gender
6. Ethnicity

What is GERD? What percentage of people who have GERD get Barrett's esophagus?
it occurs when the lower esophageal sphincter doesn't close properly and reflux causes
irrigation damage to esophageal cells; 5-10% of people with it get Barrett's esophagus

What are signs and symptoms of Barrett's Esophagus? (3)

1. long-term indigestion- heart burn, fullness, bloating, belching
2. difficulty swallowing food
3. losing symptoms of GERD without doing anything

How can Barrett's esophagus be diagnosed?

1. upper gastrointestinal endoscopy and esophageal biopsy - examined to

determine if Barrett's esophageal cells are present (may be difficult to diagnose)
2. screenings- periodic upper GI endoscopy and biopsy to watch for cancer
development (high/low grade dysplasia)

How can Barrett's esophagus be treated? (4)

1. Medications
2. endoscopic ablative therapies
3. endoscopic mucosal resection
4. Esophagectomy

What kind of medications are used to treat it?

acid suppressing medications (proton pump inhibitors) which prevent further
esophageal damage and allow for healing- they have not been shown to lower risk of
dysplasia or cancer though

What is endoscopic ablative therapy?

it destroys dysplastic cells in the esophagus with the use of photodynamic therapy
(laser) or radio frequency ablation (radio waves)

What is endoscopic mucosal resection and how does it treat Barrett's esophagus?
it removes Barrett's lining with endoscope but this can only be used if only the top layer
of esophageal cells are affected

What is an esophagectomy and how is it used in treatment of Barrett's esophagus?

it is the surgical removal of affected sections of the esophagus and then the esophagus
is rebuilt from stomach or small intestine

What might increase your risk of Barrett's esophagus? (3)

 1. H. pylori
2. NSAIDS and aspirins
3. Diet and nutrition

True or False: In a study, it was found that as you increase folate, Vitamin E and lutein
intake, it decreases risk of BE

How should care be provided when an object is protruding from the eye?
Immobilize the object and cover the other eye with a dressing

How should a patient be treated after being stung by a wasp?

Scrape out the stinger and wash the area

Where do most poisonings occur?

In the home

What is a foreign body?

An object in the body that does not belong there

Which method should be attempted first when trying to remove a foreign object from the
nose?
Blowing the nose

What should be done if a patient has swallowed poison and is unconscious?

Check for breathing and give artificial breaths, if needed

Which of the following is true of foreign bodies in the skin?

Needles used to remove splinters should be sterilized before use

How are objects flushed from the ear?

Place a few drops of water or oil in the ear using an eyedropper

Which of the following is NOT true of foreign bodies in the ear?

Foreign bodies in the ear cause extreme pain.

What is the number for the Poison Control Center?

1-800-222-1222

Which of the following is a sign of poisoning?

Burning and redness around the mouth and lips

Which of the following piece of information is important to relay to Poison Control and
EMS?
An open bottle lying next to the patient
What should you try first to remove a floating object in the eye?
Pull the upper eyelid down over the lower eyelid

Which of the following is true of poisonings?

A poisoning patient may vomit or have trouble breathing

What should be done if the patient has chemicals on the skin?

Wash the area thoroughly

GI Perforation
acute abdominal pain that is sudden, severe, generalized, and constant.

most common causes of GI perforation

diverticulitis
perforated peptic ulcer( pain radiates to scapula)
Crohn's disease

GI Perforation: DX
cxr (free air under the diaphragm)

GI Perforation: TX
NPO/IVF
metronidazole and cipro
cefotetan or cefoxitin (2nd generation)
amp/sublactam
piperacillin-tazobactam
Surgery

metronidazole: mechanism of action

covers anaerobes
covalently binds DNA
disrupts helical structure
inhibits nucleic acid synthesis

Esophageal Perforation: most common cause

iatrogenic( Doc did it)
classic presentation is after endoscopy

Esophageal Perforation: first study of choice

Gastrografin contrast esophagram
tx: surgery

abdominal obstruction: symptoms

severe colicky pain
absence of flatus or feces
high pitch bowel sounds
N/V
constant movement

Abdominal Obstruction: DX
CBC and lactate level (elevated)
supine and erect abdominal x ray (look for dilated loops of bowel, absence of gas in
rectum, bird's beak sign for volvulus.

Abdominal Obstruction : TX
NPO
NG suction
IVF
if volvulus (proctosigmoidoscopy /sigmoid resection
gastrografin contrast study until perforation has been ruled out.

most accurate test for GI obstruction

CT

What is the inflammation of the gastric mucosa that can be localized or diffused and
erosive or nonerosive?
Gastritis

True or False:

Mucosal changes that result from acute gastritis typically heal after several months

What is the pathophysiology of gastritis (how does it occur)?

-prostaglandins provide a protective mucosal barrier that prevents the stomach from
digesting itself ----> if there is a break in the protective barrier, mucosal injury
occurs and the injury is worsened by histamine release and vagus
stimulation. hydrochloric acid diffuses back into the mucosa and injures small
vessels.
-this back diffusion causes edema, acute inflammatory cell infiltration, and
degenerative changes in the stomach lining

Inflammation in the gastric mucosa after exposure to local irritants can result in what

type of gastritis?
acute gastritis

What is the early pathologic manifestation of gastritis?

a thickened, reddened mucous membrane with prominent rugae
True or False:

The diagnosis of acute gastritis is based solely on clinical symptoms

What type of gastritis appears as a patchy, diffuse inflammation of the mucosal lining
of the stomach?
chronic gastritis

With what type of gastritis is the function of the parietal cells (acid-secreting)

decreased and the source of intrinsic factor lost (therefor associated with the
development of pernicious anemia)?
chronic gastritis

True or False:

Chronic gastritis is associated with an increased risk for gastric cancer

Which type of chronic gastritis is nonerosive and refers to an inflammation of

the glands as well as the fundus and body of the stomach?
type A chronic gastritis

Which type of chronic gastritis usually affects the glands of the antrum but may involve
the entire stomach?
type B chronic gastritis

What is chronic atrophic gastritis characterized by?

-total loss of fundal glands
-minimal inflammation
-thinning of gastric mucosa
-intestinal metaplasia

THESE CHANGES LEAD TO PUD AND GASTRIC CANCER

What is one of the main causes of acute gastritis?
infection of H.pylori

Long-term NSAID use creates a high risk for what type of gastritis?
acute gastritis (NSAIDs ihibit prostaglandin production)

What are some common causes of acute gastritis?

-H.pylori
-NSAIDs long-term
-alcohol
-coffee
-caffeine
-spicy foods
-corticosteroids
-radiation therapy
-smoking
-ingestion of corrosive substances

Which type of chronic gastritis is associated with the presence of antibodies to

parietal cells and intrinsic factor?
type A chronic gastritis (therefore an autoimmune cause of this is likely)

What is the most common form of chronic gastritis and what is it caused by?
type B, H.pylori infection