Disease: GERD

Definition: Gastroesophageal reflux disease is the backflow of gastric and duodenal contents
into the esophagus. Most common upper GI disorder in the US.
Causes: The reflux is caused by an incompetent lower esophageal sphincter, pyloric stenosis, or
motility disorder.
Risk Factors: obesity, bulging of top of stomach up into diaphragm (hiatal hernia), pregnancy,
smoking, dry mouth, asthma, diabetes, delayed stomach emptying, connective tissue disorders,
such as scleroderma
Presenting S/S: dyspepsia (heartburn), epigastric pain, nausea, regurgitation, odynophagia
(painful swallowing) and dysphagia (difficulty swallowing), hypersalivation, coughing
hoarseness, or wheezing at night, eructation (belching), flatulence (gas), globus (feeling of
something in back of throat)
Diagnostic labs/tests/procedures (normal range, what it means if value is outside normal
range, questions to ask patient before procedure, how to prepare patient for
lab/test/procedure, post test/lab/procedure care): (1) 24-hour ambulatory esophageal pH
monitoring (most accurate)place small catheter through the nose into the esophagus, pt. asked
to keep diary of all activities, symptoms, pH is monitored wirelessly over the 24 hours. (2)
Esophagogastroduodenoscopy (EGD)visual examination of the esophagus, stomach and
duodenum, pt. must be NPO 6-8 hours prior, avoid NSAID, anticoagulants, aspirin for several
days before testmoderate sedationflexible tube passed down esophagusvideos, pictures &
biopsy retrievedpostop: vitals q30min until sedation wears offNPO until gag reflux returns
(usually 1-2hours)
Typical medical treatments (medicines, surgeries, procedures, nonpharmalogical treatment
if available): (1) nutrition therapy & lifestyle changes: limit or eliminate peppermint, chocolate,
coffee, fried/fatty foods, carbonated beverages, alcohol, smoking, citrus fruits, tomatoes, calcium
channel blockers, nitrates, anticholinergic drugs, acetylsalicylic acid, high levels of estrogen and
progesterone, NG tube placement; eat a low fat, high fiber diet; eat 4-6 small meals a day; avoid
eating or drinking 2-3hr before bedtime; avoid wearing tight clothes; elevate head of bed 6-12in,
weight loss if appropriate, avoid lifting heavy objects; remain upright 1-2hr after meals. (2) Drug
therapyantacids, histamine blockers, proton pump inhibitors (see meds section). (3)
Endoscopic therapy = postop nursing interventions: clear liquids for 24hrs, after 24 hours soft
diet, avoid NSAID and aspirin for 10 days, continue drug therapy as prescribes, use liquid meds
whenever possible, avoid NG tube placement for 1 month, contact HCP if s/s of chest pain,
bleeding, dysphagia, SOB, nausea, vomiting occur. (4) Surgery laparoscopic nissen
fundoplication= wrapping a portion of the gastric fundus around the sphincter area of the
esophagus (last resort option)
Nursing interventions (monitoring what key things, how to prevent complications, how to
promote bowel and bladder elimination if necessary/needed following test/lab/procedure,

patient teaching): (1) Implementing/teaching about nutrition therapy, lifestyle changes, drug
therapy, and surgery; (2) Instruct the client to avoid factors that decrease lower esophageal
sphincter pressure or irritation; (3) patient teach about their prescribed medications; (4) instruct
patient about the administration of prokinetic medication, if prescribed, which accelerate gastric
emptying
Delegation:

Disease: Bacterial Cystitis (Urinary Tract Infection-UTI)

Definition: inflammation of the bladder
Causes: usually Escherichia coli (E. coli) infection, obstruction of the urethra, allergens or
irritants (ie soaps, sprays, bubble bath, perfume wipes), bladder distension, calculus, hormonal
changes, invasive urinary tract procedures, indwelling urinary catheters, microorganisms, poor
fitting vaginal diaphragms, sexual intercourse, synthetic underwear or pantyhose, urinary stasis,
spermicides, wet bathing suits
Risk factors: using or having any one of the above causes^ plus: being female, using certain
types of birth control, completing menopause, having urinary tract abnormalities, having a
suppressed immune system
Presenting S/S: frequency, urgency, burning when urinating, voiding in small amounts, dysuria
(inability to void), nocturia, incontinence, retention (incomplete emptying of the bladder), lower
abdominal discomfort or flank pain, cloud dark foul smelling urine, hematuria, bladder spasms,
malaise, chills, fever, headache, nausea, vomiting, pyuria *(in older adults altered mentation is a
sign of UTI with less frequency and urge symptoms)
Diagnostic labs/tests/procedures (normal range, what it means if value is outside normal
range, questions to ask patient before procedure, how to prepare patient for
lab/test/procedure, post test/lab/procedure care): Urinalysis (see labs), then urine culture to
test the type of bacteria to be able to give appropriate drugs.
Typical medical treatments (medicines, surgeries, procedures, nonpharmalogical treatment
if available): (1) Nutrition therapy3000mL fluids/day, avoid caffeine, coffee, carbonated
drinks, tomato, alcohol. (2) Comfort measures warm sitz bath, heat to abdomen. (3) Drug
therapy see meds
Nursing interventions (monitoring what key things, how to prevent complications, how to
promote bowel and bladder elimination if necessary/needed following test/lab/procedure,

patient teaching): (1) patient teachingavoid alcohol, take meds as prescribed, take antibiotics
as prescribed, on schedule, and complete entire course of medicine, repeat urine culture
following treatment, prevent; (2) preventative measureuse good perineal care, wipe from front
to back, avoid bubble baths, tub baths, vaginal deodorants, void every 2-3hrs, wear cotton, avoid
tight clothes, avoid sitting in wet bathing suit for prolonged period of time, if pregnant void
every 2hrs, if menopausal use estrogen vaginal creams to restore pH, use water soluble
lubricants, void and drink water after intercourse.
Delegation rules:

Disease: Peptic Ulcer Disease (PUD)

Definition: ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus in
portions accessible to gastric secretions; erosion may extend through the muscle. The ulcer may
be referred to as gastric, duodenal, or esophageal, depending on its location. Most common are
gastric and duodenal ulcers.
Causes: Most commonly caused by H. pylori infection via the fecal-oral route. Presence of H.
pyloricytokines & neutrophils activatedepithelial cell necrosisulcer forms! AND Presence
of H. pylorireleases ureasebreaks down ureaproduces ammoniaalkaline

environmentbody releases H+ ions in response to ammoniamucosal cell damageulcer

forms! 2nd most commonly caused by NSAIDS. NSAIDSbreakdown mucosal barrierulcer
forms!
Risk factors: long term use of NSAIDS or aspirin, smoking, alcohol, caffeine (stimulate HCl),
corticosteroids (stimulate HCl), radiation therapy, family history of PUD, presence of H. Pylori
bacteria in GI, history of gastritis, stress.
Presenting S/S: Gastric Ulcer: gnawing, sharp pain in or to the left of the mid-epigastric region
occurs 30-60 min after meal. Dyspepsia (food ingestion) makes pain worse. Hematemesis (coffee
ground vomit indicating bleeding at or above the duodenojejunal junction) is more common than
melena (blood in the stool, stool appears tarry due to minimal bleeding). Duodenal Ulcer:
burning pain in the mid-epigastic area 1.5-3 hrs. After a meal and during the night (often
awakens the pt.). Melana is more common than hematemesis. Pain is often relived or lessoned by
the ingestion of food.
Diagnostic labs/tests/procedures (normal range, what it means if value is outside normal
range, questions to ask patient before procedure, how to prepare patient for
lab/test/procedure, post test/lab/procedure care): Most accurate =
Esophagogastroduodenoscopy (EGD)visual examination of the esophagus, stomach and
duodenum, pt. must be NPO 6-8 hours prior, avoid NSAID, anticoagulants, aspirin for several
days before testmoderate sedationflexible tube passed down esophagusvideos, pictures &
biopsy retrievedpostop: vitals q30min until sedation wears offNPO until gag reflux
returns(usually 1-2hours). ALSO a rapid urease test is quick and used to test for urease in the GI,
which is produced by H. pylori.
Typical medical treatments (medicines, surgeries, procedures, nonpharmacological
treatment if available): (1) Drug therapy: combination of multiple drugs (cocktail) to provide
pain relief, eliminate H. pylori, heal ulcerations, and prevent recurrence. These drugs include H2
receptor agonists, proton pump inhibitor, antacids, anticholinergic, prostaglandins, and two
antibiotics (see meds). (2) Nonpharmacological: stress relief through meditation or yoga,
vitamins and herbs (ie probiotics, vitaminB12, vitamin A, vitamin C, cranberry, dandelion,
ginger, green tea, ect.). (3) Surgery: only performed if everything else fails and risk for
complications are suspected (complications include hemorrhage, perforation, pyloric obstruction,
gastric outlet obstruction).
Nursing interventions (monitoring what key things, how to prevent complications, how to
promote bowel and bladder elimination if necessary/needed following test/lab/procedure,
patient teaching): monitor vital signs and for signs of bleeding. Patient teaching: instruct client
about a bland diet with small, frequent meals, adequate rest, avoid alcohol, caffeine, chocolate,
smoking, aspirin, NSAIDS, reduce stress.
Delegation rules:

Disease: Renal Calculi

Definition/Description: Calculi are stones that can form anywhere in the urinary tract.
Urolithiasis= presence of stones in urinary tract (urinary tract includes kidneys, ureters, bladder
and urethra). Nephrolithiasis=formation of renal (or kidney) calculi in the renal parenchyma in
the kidney~most common place of formation. Ureterolithiasis=formation of urinary calculi in the
ureters. Different types of stones: calcium oxalate calculi (most common), calcium phosphate
calculi, struvite calculi, uric acid calculi, and cysteine calculi.
Causes: Commonly these 3 things must all occur for a stone to form: (1) slow urine flow; (2)
damage to urinary epithelial; (3) decreased amounts of inhibitory substance in the urine. ALSO
metabolic defects added with the risk factors listed below commonly are the cause of stone
formation.
Risk factors: family history of stones; diet high in calcium, vitamin D, protein, oxalate, purines,
alkali; obstruction and urinary stasis; dehydration; use of diuretics (which can cause volume
depletion); UTI; prolonged use of urinary catheters; immobilization; hypercalcemia (high
calcium); hyperparathyroidism (increased parathyroid hormone increased calcium); elevated
uric acid level (ie gout)
Presenting S/S: renal colic=pain originating in the lumbar region and radiates around the side
and down to the testicles in men and to the bladder in womansuggests that the stone is in the
kidney or upper ureter-also called flank pain; ureteral colic=pain radiating towards genitalia and
thighssuggests the stone is in lower ureter or bladder;
*Other symptoms include: sharp severe pain of sudden onset; dull aching pain in the kidneys;
nausea, vomiting, pallor, and diaphoresis (sweating) during acute pain; urinary frequency with
alternating retention and dysuria (painful urination) occurs when the stone reaches the bladder;
oliguria and/or anuria occur when stone has caused an obstruction at bladder neck or urethra
signs of urinary tract infection; low-grade fever; bladder distension; vital signs may be
moderately elevated with pain; temperature and pulse are elevated when stone has caused an
infection; BP may decrease if the severe pain causes shock.
Complications of calculi if not passed or removed: (1) hydroureter= calculi occludes the
ureterblocks the flow of urineureter gets huge! (Dilates); (2) hydronephrosis=calculi blocks
at top of ureter just after leaving the kidneyurinary stasisinfection in kidneyimpairment of
renal function on side of the blockageirreversible kidney damage; (3) pain; (4)
hematuria=bloody urine due to damage of the lining of the urinary tract; (5) infection-usually
from bacteria getting into damaged/bleeding areas of epithelial lining.
Diagnostic labs/tests/procedures (normal range, what it means if value is outside normal
range, questions to ask patient before procedure, how to prepare patient for
lab/test/procedure, post test/lab/procedure care): X-ray (can easily see stone in kidney, ureter
and bladder but not urethra), urinalysis (see labs), An intravenous pyelography (IVP) is a more
sensitive x-ray that provides pictures of the kidneys, ureters, bladder and urethra. An IVP can

show the size, shape, and position of the urinary tract. During IVP, a dye called contrast material
is injected into a vein in your arm. A series of X-ray pictures is then taken at timed intervals.
Nursing Consideration with IVP: To assess for likely allergies to the dyes associated with
contrast studies, ask whether a patient has an allergy to shellfish or iodine. If they do, a CT scan
or renal ultrasonography may be used in place.
Nursing interventions (monitoring what key things, how to prevent complications, how to
promote bowel and bladder elimination if necessary/needed following test/lab/procedure,
patient teaching, conservative therapy): monitor vital signs, especially temperature for signs
of infection; monitor I/O; assess for fever, chills, and infection; monitor for nausea, vomiting,
diarrhea; encourage fluid intake up to 3000mL/day to facilitate the passage of the stone;
administer IV fluids as prescribed; provide warm baths and heat to the flank area (do not
massage!!!); administer analgesics as prescribed to relieve pain; assess the pt.s response to pain
meds; assist the pt. in performing relaxation techniques to relieve pain; encourage pt. to
ambulate, if stable, to promote the passage of the stone; turn and reposition immobilized/bedridden pt.s to promote passage of the stone; teach diet restrictions based on type of stone (see
nutritional therapy for calculi); prepare pt. for surgical procedures
Typical medical treatments (medicines, surgeries, procedures): (1) Drug therapy: at this point
no meds can treat the actual stone, meds are only given for pain. Pain med given = analgesics
(see meds); (2) as a last result and after all other options have been tried surgery may be
recommended.
3 most common types of surgical procedures can be used:
1. Cystoscopy-for stones in bladder or lower ureter; no incision is made; 1 or 2 catheters placed
up urethra to either try to dislodge stone, irrigate area around stone to flush it out, or continuous
chemical irrigation may be pushed up catheters to try to bread down and dislodge stone.
2. Extracorporeal shock wave lithotripsy (ESWL)-for stones in kidney or upper ureter; ultrasonic
waves delivered to area to break up and dislodge stone; stones are passed in urine within a few
days; preprocedure~pt. must be NPO 8hrs prior; postop~vitals (especially for tachycardia or
hypotension which would indicate bleeding or hematoma formation), I/O, pain, s/s UTI, instruct
pt. to increase fluid intake and to ambulate regularly.
3. Percutaneous lithotripsy-for stones in bladder, ureter, kidney; both an ultrasound used to break
up stones and either cystoscopy or nephroscopy is used to irrigate stone.
*If the above three do not work, there are 3 much more invasive surgerys for kidney stone
removal in pt.s that have already caused severe complications.
Delegation rules:

Disease: Benign prostatic hypertrophy (Hyperplasia) or BPH

Definition/Description: slow enlargement of the prostate gland with hypertrophy (increase in
size of the prostate cells) and hyperplasia (increase in the number of prostate cells). Enlargement
compresses the urethra, resulting in partial or complete obstruction.
Causes: unclear, likely result of aging and increased levels of androgens in prostate such as DHT
(a type of testosterone) causes hyperplasia and hypertrophybladder outlet
obstructionincreased residual urine & chronic urinary retentionurine may back up into
kidneychronic kidney disease

Risk factors: Follow the International Prostate Symptom Score. Asks 7 questions about
symptoms of BPH. Patient rates frequency of experiencing these 7 symptoms in the past month
from 0-5. (0= not at all in past month5=almost always in the past month). Score is totaled.
(Lowest Score is a 0; Highest Score is a 35). The higher the score, the more likely of developing
or already having BPH
Presenting S/S: Incomplete emptying, increased frequency, intermittency (stopping and starting
mid stream/urination), increased urgency, weak stream, straining (push harder then normal to
urinate), nocturia, hesitancy (inability to start), bladder distension, hematuria (blood in urine),
dysuria (painful urinating), bladder pain, UTIs
Diagnostic labs/tests/procedures (normal range, what it means if value is outside normal
range, questions to ask patient before procedure, how to prepare patient for
lab/test/procedure, post test/lab/procedure care): (1) Transabdominal ultrasound and
transrectal ultrasound (TRUS) imaging to see the size of the prostatept. instructed to lie on
sideprobe inserted into rectum video/pictures/biopsy taken. (2) If infection or UTI is
suspected, than urinalysis, CBC, urine culture will also be taken. (3) If cancer is suspected, a
prostate rich antigen (PSA) test is taken (if pt. has cancer this value will be elevated).
Nursing interventions (monitoring what key things, how to prevent complications, how to
promote bowel and bladder elimination if necessary/needed following test/lab/procedure,
patient teaching): Priority problem = impaired urinary elimination related to bladder outlet
obstruction. Encourage fluid intake, prepare for urinary catheterization to drain bladder, meds to
shrink prostate, meds for pain, decrease caffeine, coffee, alcohol, follow strict voiding schedule.
Typical medical treatments (medicines, surgeries, procedures, nonpharmalogical treatment
if available):

Disease: Bowel Obstruction

Small bowel obstruction:
-Abdominal discomfort or pain possibly accompanied by visible peristaltic waves in the upper
and middle abdomen
-Upper or epigastric abdominal distention
-Nausea and early profuse vomiting (may contain fecal material)
-Obstipation (no passage of stool)
-Severe fluid and electrolyte imbalances
-Metabolic alkalosis
VERSUS
Large bowel obstruction:
-Intermittent lower abdominal cramping
-Lower abdominal distension
-Minimal or no vomiting
-Obstipation or ribbon-like stools
-No major fluid and electrolyte imbalances
-Metabolic acidosis (not always present though)

- For GERD and PUD:

Antacids: allow 1 hour between antacid administration and the administration of other meds; should be taken on a regular schedule; to test effectiveness of medicine pH should be
above a 5.
*For GERD: Aluminum or Magnesium salts (Mylanta, Maalox): increase pH of gastric contents by deactivating pepsin and enhance mucosal protection: give 1hr ac, 2-3hr pc, &
@ bedtime: aluminum produces constipation while magnesium produces diarrhea
Aliginic acid and sodium bicarbonate (Gaviscon): buffers acid in stomach, useful in elevating urinary pH: give pc & @ bedtime: nausea, constipation, diarrhea, or headache: rapid
onset; beware in pt.s w/ hypertension and heart failure.
*For PUD: Magnesium hydroxide w/ aluminum hydroxide (Maalox, Mylanta): increase pH of gastric contents by deactivation pepsin: give liquid med 2hr pc & @ bedtime:
constipation, diarrhea(Mg): assess pt.s for history of renal disease and heart failure (Mg cannot be excreted by poorly functioning kidneys so toxicity can occur). Aluminum
hydroxide (Amphojel): same as above^: give liquid med 1hr pc & @ bedtime: constipation: okay in pt.s w/ renal failure.
Proton Pump Inhibiters: suppress gastric acid secretion, contraindicated in hypersensitivity, common side effects=headache, diarrhea, abdominal pain, nausea. Omeprazole
(Prilosec): *for GERD: give PO ac *for PUD: give PO @ bedtime: do not crush. Lansoprazole (Prevacid): *for GERD: give PO ac *for PUD: give PO @ bedtime: okay to crush.
Rabeprazole (Aciphex): *for GERD: give PO qd *for PUD: give PO qd pc breakfast: do not crush, wear sunblock, slow release into body. Pantoprazole(Prontix): PO qd: if giving
IV form only administer for 7-10 days without any other IV meds, do not crush. Esomeprazole(Nexium): *for GERD: PO qd or IV for 7-10 days for 10-30 minute (no less than
3min) *for PUD: PO qd 1hr ac: assess for hepatic impairment, do not give IV for with any other IV meds, do not give with digoxin, rabeprazole, or iron salts, do not crush
H2 antagonists: suppress secresion of gastric acid by blocking histamine recepters in parietal cells
Ranitidine(Zantac): *for GERD: PO bid w/ meal & @ bedtime *fer PUD: PO qd @ bedtime: side effects are uncommon, does not penetrate bloob brain barrier, not affected by
food. Famotidine(Pepcid): same as above^ med. Nizatidine(Axid): PO bid: observe for dysrhythmias, use w/ caution and reduce the dose in pt.s w/ renal disease, do not mix with
tomato or vegetable based juices.
- For UTI:
Antimicrobials/Antibiotics: reduces bacteria in urinary tract by direct killing. Classes:Sulfonamides, Fluoroquinolones, Penecilins, Cephalosporins
Urinary Antiseptics: Nitrofurantoin(Furadantin): reduce bacteria in urinary tract by inhibiting bacterial reproduction:
Bladder Analgesics: Phenazopryidine (Azo-Dine, Prodium, Pyridiate ect): reduces bladder pain and burning on urination by exerting a topical analgesic or local anesthetic effect
on the mucosa of the urinary tract. Remind pt. that this will not cure infection, will only relieve symptoms. Take with or immediately after a meal. Warn pt that urine will turn
orange or red.
Antispasmodics: Hyoscyamine (Anaspaz, Cystopaz, many others): relieves bladder spasms by inhibiting nerve stimulation to the bladder muscle, notify doc if blurred vision other
eye problems occur, confusion, dizziness, fainting spells, fast heartbeat, fever, or difficulty passing urine occur. Teach patients to wear dark sunglasses in sunlight because drug
dilates the pupil and increases eye sensitivity to light.
- For Constipation
Stool softeners (emollients): encourage bowel movements by helping liquids mix into the stool and prevent dry, hard stool masses. Does not cause a bowel movement but instead
allows the patient to have a bowel movement without straining. Pt. Teaching: (1) Liquid forms may be taken in milk or fruit juice to improve flavor. (2) results usually occur 1-2
days after the first dose. (may not occur for some until after 3-5 days). Side effect = skin rash
Bulk-forming laxative: are not digested but absorb liquid in the intestines and swell to form a soft, bulky stool. The bowel is then stimulated normally by the presence of the bulky
mass. Some, like psyllium and polycarbophil, may be prescribed to treat diarrhea. Pt. teaching: (1) Do not try to swallow in the dry form. (2) Mix with liquid following the
directions on the product label. (3) To allow bulk-forming laxatives to work properly and to prevent intestinal blockage, drink plenty of fluids during their use. (4) Each dose
should be taken with 8 z or more of cold water or fruit juice. (5) Effectiveness anywhere from 12 hrs to 2 or 3 days. Side effects: Difficulty in breathing, intestinal blockage, skin
rash or itching, swallowing difficulty (feeling of lump in throat).

LABS:
Blood Tests:
Albumin: 3.5-5g/dL
Ammonia: 10-80mcg/dL
Bicarbonate: 22-29mEq/L
BUN: 8-25mg/dL **increased: slowing of GFR/renal disease/dehydration/decreased kidney perfusion/infection/stress/GI bleed
Calcium: 8.6-10mg/dL
Chloride: 98-107mEq/L
Creatinine: 0.6-1.3mg/dL *increased: slowing of GFR/kidney impairment ~patient teaching: instruct pt. to avoid excessive exercise for 8hrs and excessive red meat intake for
24hrs before the test
Hematocrit: 42-52%(male), 35-47%(female)
Hemoglobin: 14-16(male),12-15(female)
Iron: 65-175(male), 50-170(female)
Magnesium: 1.6-2.6mg/dL
Potassium: 3.5-5.0mEq/L *increased: kidney disease/acidosis/dehydration
RBC: 4.7-6.1million/uL(male), 4.2-5.4million/uL(female) *decreased: anemia/hemorrhage; *increased: hypoxia
Sodium: 135-145mEq/L *increased: dehydration/kidney disease
WBC: 5000-10000cells/mm3 *increased suggest infection/inflammation/autoimmune disorder

Urinalysis:
Color: pale yellow
Odor: specific odor, similar to ammonia
Turbidy: clear
Specific gravity: 1.005-1.030 *increased suggests dehydration
pH: 4.6-8 *more acidic could = presence of E.coli,
glucose: <0.5g/day *hyperglycemia
Ketones: none *DM
Protein: none *presence may indicate stress, infection, recent strenuous exercise, glomerular disease
Bilirubin: none *presence suggest liver disease
Casts: none *increased indicate possible presence of calculi
Crystals: none

Leukoesterase: none *presence suggests UTI

Nitrate: None *presence suggest E.coli
Bacteria: <1000colonies/mL *increased suggest UTI and a need for urine culture test
RBC: <3cells/HPF *increased may reflect presence of tumor, stones, trauma, glomerular disorders, cystitis, or bleeding disorders within the urinary tract only.
WBC: 4cells/HPF *increased suggests infection, inflammatory process occurring, fever, exercise
Uric Acid: 250-750mg/24hr

NUTRITIONAL THERAPY FOR CALCULI (PG 864 IN SAUNDERS, PG 1511 IN MEDSURGE)