If intolerant to enteral feeding: Consider TPN (Total Parenteral Nutrition)
🔥 Gastroesophageal Reflux Disease (GERD)
Definition: Chronic acid reflux from stomach into esophagus
Causes
Defective lower esophageal sphincter
Hiatal hernia
H. pylori infection
Obesity, stress, smoking, alcohol
Classic Symptoms
Heartburn (worse after meals/lying down)
Regurgitation
Chest pain
Indigestion
Medication Ladder
Class
Examples
Action
Antacids
Tums, Mylanta
Neutralize existing acid
H2 Blockers
Famotidine (Pepcid)
↓ acid production 70%
PPIs
-azole drugs
Block ~100% acid production
Lifestyle Modifications
Small, frequent meals
Avoid triggers (fatty foods, caffeine, chocolate)
Don't lie down for 45 min after eating
Elevate HOB
Weight loss if needed
🦠 Helicobacter Pylori
Key Fact: Hardy bacteria that survives in stomach acid!
Associated Conditions
GERD
Gastritis
Peptic ulcers
💊Triple Therapy Treatment
PPI (e.g., Omeprazole)
2 Antibiotics (amoxicillin + clarithromycin)
Sometimes add:
Bismuth (Pepto-Bismol) - mucosal protection
Sucralfate (Carafate) - coats ulcers
Important Note
Not all GERD/ulcers involve H. pylori, but if present, MUST be treated!
🩹 Peptic Ulcer Disease (PUD)
Types
Gastric Ulcer
In the stomach
Duodenal Ulcer
In duodenum (1st part of small intestine)
Diagnostic: EGD
Esophagogastroduodenoscopy
Camera visualization
Pre-procedure: NPO 6 hours
Requires consent (sedation used)
🚨Life-Threatening Complications
Perforation
Hole → peritonitis
Rigid abdomen
Rebound tenderness
GI Bleed
Ulcer erodes vessel
Melena (black tarry stool)
↓BP, ↑HR, ↓H&H
💎 Cholelithiasis (Gallstones)
Definition: Stones in the gallbladder from bile components
Classic Presentation
RUQ pain (worse after fatty meals)
Nausea and vomiting
Clay-colored stools (no bile in GI tract)
Steatorrhea (fatty stools)
Treatment: Cholecystectomy
Post-Op Education
Can eat fatty foods in SMALL amounts only
No bile reservoir → bile trickles constantly
Large fatty meal = nausea/discomfort
Monitor for Internal Bleeding
Vital Signs: ↓BP, ↑HR
Labs: ↓Hemoglobin & Hematocrit
🚫 Small Bowel Obstruction (SBO)
Causes
Internal
Mass, food bolus
External
Volvulus (twisting), stricture
Pathophysiology
Buildup → backup into stomach → vomiting → can lead to necrosis!
Signs & Symptoms
N/V, abdominal distention
Severe pain
No gas/stool passage
Decreased appetite
Nursing Interventions
NG tube for decompression (remove fluid/gas)
NPO status
IV fluids (Lactated Ringer's preferred)
Monitor bowel sounds
Monitor K+ levels (replace as needed)
💉 Total Parenteral Nutrition (TPN)
Definition: IV nutrition when GI tract cannot be used
Contents
Carbohydrates
Proteins
Lipids (often separate bag)
Vitamins and minerals
⚠️Critical Monitoring
Blood glucose checks frequently!
Direct bloodstream infusion of carbs
Excess protein → glucose conversion
High risk for hyperglycemia
When to Use TPN
Severe bowel obstruction
Severe malabsorption
Prolonged NPO status
Failed enteral feeding attempts
📋 Quick Reference Guide
Term
Meaning
Key Point
TPN
Total Parenteral Nutrition
Monitor blood glucose!
Cholelithiasis
Gallstones
RUQ pain after fatty meals
Cholecystectomy
Gallbladder removal
Small fatty meals only
Steatorrhea
Fatty stools
Poor fat digestion
CVA
Costovertebral Angle
Assess for pyelonephritis
BKA
Below-Knee Amputation
Prevent hip contracture
CSM
Circulation, Sensation, Movement
Neurovascular check
EGD
Esophagogastroduodenoscopy
NPO 6 hours before
Ready for the test?
23 challenging questions await!
🎯 Clinical Decision-Making Test
Test Your Knowledge
Instructions
23 priority-based questions
Select the BEST answer
Focus on what needs to happen FIRST
Consider life-threatening conditions
Click submit to see rationale
Remember Priority Frameworks
ABCs (Airway, Breathing, Circulation)
Maslow's Hierarchy
Acute vs Chronic
Actual vs Potential problems
Good luck!
Question 1: GU System
A 68-year-old male patient presents to the ED with severe, colicky pain that started in his right flank and now radiates to his groin. He is pacing the room, unable to find a comfortable position. Vital signs: BP 168/92, HR 110, RR 24, Temp 99.2°F. He reports his urine "looked pink" this morning.
Which nursing intervention should be implemented FIRST?
A) Return the patient to bed in high-Fowler's position
B) Apply oxygen via non-rebreather mask at 15L/min
C) Administer sublingual nitroglycerin as ordered PRN
D) Call rapid response and prepare for STAT CT angiography
Correct Answer: B
Rationale: The patient needs immediate oxygenation. While positioning (A) helps, oxygen delivery is the priority with O2 sat of 88%. Option C assumes cardiac cause. Option D is important but oxygen comes first in respiratory distress.
Question 8: Musculoskeletal System
A 70-year-old patient with osteoporosis presents with sudden severe back pain after lifting groceries. She's hunched forward and points to her mid-back. She denies leg weakness or bowel/bladder changes. Vital signs stable.
What is the PRIORITY assessment?
A) Perform straight leg raise test bilaterally
B) Assess deep tendon reflexes in lower extremities
C) Palpate the spine for point tenderness and deformity
D) Evaluate gait and balance with ambulation
Correct Answer: C
Rationale: With osteoporosis and sudden pain after lifting, compression fracture is likely. Gentle spinal palpation can identify the level and any step-off deformity. Option A tests for nerve root irritation. Option B assesses neurological function. Option D is unsafe until fracture is ruled out.
Question 9: Gastrointestinal System
A 45-year-old male with a history of alcohol abuse presents with coffee-ground emesis and black, tarry stools for 2 days. BP 92/58, HR 124, RR 22. Skin cool and clammy. Hemoglobin 7.2 g/dL (baseline unknown).
Which intervention should be completed FIRST?
A) Insert large-bore NG tube for gastric lavage
B) Establish two large-bore IV sites and begin fluid resuscitation
C) Type and crossmatch for 4 units of packed red blood cells
D) Administer pantoprazole 40mg IV push
Correct Answer: B
Rationale: The patient is in hypovolemic shock from GI bleeding. Immediate IV access and fluid resuscitation is priority to maintain perfusion. Option A helps identify bleeding but doesn't treat shock. Option C is important but IV access comes first. Option D treats the cause but not the immediate life threat.
Question 10: Gastrointestinal System
A 58-year-old female presents with severe RUQ pain radiating to her right shoulder after eating fried chicken. She's nauseated and has vomited twice. Temp 101.2°F, WBC 15,000. She's positioned on her side, knees drawn up.
What should the nurse anticipate as the PRIORITY intervention?
A) Insert NG tube to low intermittent suction
B) Administer meperidine 50mg IM for pain relief
C) Keep NPO and initiate IV fluids
D) Prepare for immediate cholecystectomy
Correct Answer: C
Rationale: With likely acute cholecystitis, NPO status and IV fluids are essential to rest the GI system and maintain hydration. Option A is for obstruction. Option B: morphine is preferred over meperidine. Option D: surgery may be needed but not emergent.
Question 11: Gastrointestinal System
A 50-year-old patient is receiving TPN via central line. The nurse notes blood glucose is 425 mg/dL (previous 180 mg/dL). The patient denies thirst or urinary changes. No signs of infection at insertion site.
What is the MOST appropriate initial action?
A) Discontinue the TPN immediately and notify the physician
B) Administer sliding scale insulin as ordered and recheck in 1 hour
C) Decrease the TPN rate by 50% and monitor blood glucose hourly
D) Send TPN bag to pharmacy to verify glucose concentration
Correct Answer: B
Rationale: Severely elevated glucose needs immediate treatment with insulin per protocol. Continuing to monitor is essential. Option A is too drastic and could cause rebound hypoglycemia. Option C doesn't adequately address hyperglycemia. Option D delays treatment.
Question 12: Gastrointestinal System
A 35-year-old patient with Crohn's disease has had an NG tube to suction for 3 days. They complain of weakness and muscle cramps. Heart monitor shows flat T waves and presence of U waves. Serum potassium pending.
Which intervention should the nurse implement FIRST?
A) Increase IV fluid rate to 150 mL/hr
B) Check that NG tube is patent and draining properly
C) Hold digoxin dose and notify physician
D) Obtain 12-lead EKG and prepare for potassium replacement
Correct Answer: D
Rationale: EKG changes indicate significant hypokalemia requiring immediate confirmation and treatment. Cardiac monitoring is essential before replacement. Option A doesn't address potassium loss. Option B doesn't help current deficit. Option C is appropriate if on digoxin but EKG/treatment is priority.
📚 Cascading Case Study
Multi-System Failure Scenario
Initial Scenario
Mary Johnson, 72 years old, is admitted to your medical-surgical unit with a 3-day history of nausea, vomiting, and decreased oral intake. PMH includes Type 2 DM, HTN, and osteoarthritis. Home medications: metformin, lisinopril, and ibuprofen PRN.
Admission Assessment:
VS: BP 94/60, HR 112, RR 24, Temp 99.8°F, O2 sat 94% on RA
Appears lethargic, oriented x2 (person, place)
Mucous membranes dry, poor skin turgor
Abdomen distended, tender to palpation, no bowel sounds heard
Follow Mary's journey through 11 critical decision points...
Question 13: Initial Priority
Mary Johnson - Admission
72-year-old with 3-day history of N/V, decreased PO intake. VS: BP 94/60, HR 112, RR 24, Temp 99.8°F. Lethargic, dry mucous membranes, distended abdomen, no bowel sounds.
Based on the initial assessment, what is the PRIORITY nursing intervention?
A) Insert NG tube to low continuous suction
B) Obtain blood glucose level and treat accordingly
C) Start IV fluids with 0.9% NS at 200 mL/hr
D) Administer ondansetron 4mg IV push
Correct Answer: C
Rationale: Patient shows signs of dehydration and hypotension requiring immediate fluid resuscitation.
Question 14: New Development
2 Hours Later:
After receiving 400mL IV fluids, Mary's BP is 102/70. NG tube inserted draining dark green fluid. She suddenly complains of severe left flank pain and nausea.
What assessment should the nurse perform NEXT?
A) Percuss for costovertebral angle tenderness
B) Check NG tube placement and patency
C) Auscultate bowel sounds in all quadrants
D) Assess pedal pulses bilaterally
Correct Answer: A
Rationale: New onset flank pain could indicate kidney stones or pyelonephritis, both complications of dehydration.
Which finding requires the MOST immediate intervention?
A) Acute kidney injury evidenced by elevated creatinine
B) Severe hypokalemia with cardiac risk
C) Urinary tract infection with bacteriuria
D) Anemia with hemoglobin 10.2
Correct Answer: B
Rationale: Potassium 2.8 is critically low and poses immediate cardiac risk.
Question 16: Fluid Overload
Day 2:
Mary is receiving IV antibiotics for pyelonephritis. Potassium has been replaced. She complains of shortness of breath. You note bilateral crackles and 2+ pitting edema. VS: BP 156/94, HR 96, RR 28, O2 sat 88% on 2L NC.
What is the PRIORITY action?
A) Increase oxygen to non-rebreather mask
B) Elevate HOB to high-Fowler's position
C) Administer furosemide 40mg IV push
D) Obtain stat portable chest x-ray
Correct Answer: B
Rationale: Positioning is the fastest intervention to improve respiratory status in fluid overload.
Question 17: Orthostatic Changes
4 Hours Later:
After receiving furosemide, Mary has produced 800mL urine. She now complains of dizziness when sitting up. BP lying: 120/76, sitting: 96/58.
What should the nurse do FIRST?
A) Return patient to supine position
B) Reduce IV fluid rate to 50 mL/hr
C) Recheck orthostatic vital signs in 30 minutes
D) Hold next dose of lisinopril
Correct Answer: A
Rationale: Immediate safety concern with orthostatic hypotension requires returning to safe position first.
Question 18: Hypoglycemia
Day 3:
Mary's kidney function is improving. She's been NPO for 3 days due to ileus. TPN is started via central line. Four hours later, she's confused and diaphoretic. Blood glucose is 42 mg/dL.
After giving D50, what is the NEXT priority?
A) Recheck blood glucose in 15 minutes
B) Decrease TPN rate by 50%
C) Send TPN bag to pharmacy for verification
D) Draw blood cultures for possible sepsis
Correct Answer: A
Rationale: Must verify treatment effectiveness before making other changes.
Question 19: Central Line Infection
6 Hours Later:
Mary spikes temp to 102.4°F. She's increasingly confused. Central line site is red and tender. WBC now 22,000.
Which intervention sequence is MOST appropriate?
A) Draw blood cultures, remove central line, start antibiotics
B) Start antibiotics, draw blood cultures, maintain central line
C) Draw blood cultures, start antibiotics, then remove line
D) Remove central line, draw peripheral cultures, start antibiotics
Correct Answer: C
Rationale: Cultures before antibiotics when possible, but don't delay antibiotics for line removal in sepsis.
Question 20: C. difficile
Day 4:
Mary is on broad-spectrum antibiotics. She develops watery diarrhea (8 episodes in 4 hours). Abdomen is distended and tender.
What should the nurse suspect and do FIRST?
A) Send stool for C. diff toxin and implement contact precautions
B) Hold antibiotics and notify physician immediately
C) Start IV fluid bolus for hypovolemia from diarrhea
D) Insert rectal tube for continuous drainage
Correct Answer: A
Rationale: Multiple antibiotics and diarrhea suggest C. diff; immediate isolation protects others.
Question 21: Hip Fracture
Day 5:
C. diff is confirmed. Mary is weak but improving. During morning care, she cries out after turning. Right hip is externally rotated and shortened.
What is the IMMEDIATE nursing priority?
A) Immobilize the leg in current position
B) Attempt gentle range of motion
C) Apply Buck's traction
D) Obtain stat hip x-ray
Correct Answer: A
Rationale: Suspected hip fracture (osteoporosis risk) requires immediate immobilization before any movement.
Question 22: New UTI
Day 6:
Post-hip pinning. Mary's blood glucose has been stable off TPN. She passes flatus and tolerates clear liquids. Kidney function normalizing. She complains of burning with urination. Foley removed yesterday.
What takes PRIORITY?
A) Encourage increased PO fluid intake
B) Obtain clean-catch urine specimen
C) Start phenazopyridine for comfort
D) Reinsertion of indwelling catheter
Correct Answer: B
Rationale: Need to identify if new infection or irritation from catheter before treatment.
Question 23: Discharge Planning
Day 7 - Discharge Planning:
Mary is medically stable. PT notes she needs assist x2 for transfers. Lives alone in two-story home.
What is the MOST important discharge planning priority?
A) Arrange home health for wound care
B) Ensure follow-up appointments are scheduled
C) Coordinate skilled nursing facility placement
D) Teach about medication changes
Correct Answer: C
Rationale: Safety is paramount; she cannot return home alone with mobility limitations.
🎊 Test Complete!
Your Score: 0/23
Score Interpretation
20-23: Excellent! Ready for advanced practice
16-19: Good understanding, review missed concepts
12-15: Fair, focus on priority frameworks
Below 12: Review content and practice more
Key Takeaways
Remember: In nursing, it's not about what's right - it's about what's RIGHT NOW. Always prioritize life-threatening conditions and use your ABC's!