Question

Objective: The student will apply course objectives through evaluating patient assessments, identifying treatment options and developing teaching plans for patients with obesity, peptic ulcer disease (PUD) and gastroesophageal reflux disease (GERD).

Part I: Obesity & Bariatric Surgery

A 32-year-old obese patient has come to the bariatric outpatient center to have an initial evaluation. The patient reports that they were always overweight, even as a child. The patient states that they are frustrated because they gained 100 pounds over the last 2 – 3 years. The patient denies a history of diabetes; however, reports pain in their knees, hypertension, and sleep apnea. The patient lives alone and rarely leaves the house for social activities. The patient tells the nurse that they are beginning to feel isolated and lonely.

The nurse records the following assessment:

Height: 68 inches

Weight: 316 lbs.

Waist circumference: 56 inches (141 cm)

Vital signs: BP 172/96, HR 92, RR 24, SpO₂ 97%

Fasting blood glucose: 146

Total cholesterol: 250

Triglycerides: 312

A1C: 9.6

HDL: 30

1. Determine the patients BMI using the following mathematical calculation and state the weight status associated with the calculated BMI using the definitions in the box below.

BMI (kg/m²) = weight in pounds x 703 = _____________

(Height in inches) ²

BMI	Weight Status
Below 18.5	Underweight
18.5 – 24.9	Normal
25.0 – 29.9	Overweight
30.0 and Above	Obese
40	Morbid Obesity

2. Using the algorithm provided at the back of the handout and the patient’s calculated BMI; discuss recommended treatment options assuming the patient is willing to lose weight. Be sure to indicate which numbers on the path of the algorithm you choose.

3. Identify 2 additional recommendations/interventions that can be made based on the patient’s assessment findings listed above.

1. ______________________________________________________

______________________________________________________

2. ______________________________________________________

______________________________________________________

4. The patient returns to the clinic 2 months later feeling frustrated because the treatment plan, identified by the algorithm, has been unsuccessful. The patient tells the nurse “I am seriously considering weight loss surgery.” Based on the patient’s history and assessment findings, identify at least 2 additional evaluations and treatment options would be recommended for this patient?

1. ______________________________________________________

______________________________________________________

2. ______________________________________________________

______________________________________________________

3. ______________________________________________________

______________________________________________________

5. The patient is scheduled for bariatric bypass surgery. During pre-operative teaching, the patient states that he is particularly concerned about complications related to the surgery. From the list of complications, select the complications that are specific to bariatric bypass surgery. (Select all that apply)

1. Postprandial hypoglycemia
2. Wound infection
3. Deep vein thrombosis
4. Visceral pain
5. Dumping syndrome
6. Bile acid gastritis
7. Wound dehiscence

6. The nurse is discharging the patient home after bariatric surgery. Which dietary instructions would the nurse include in the teaching plan at discharge? (Select all that apply)

A. Eat 3 large meals a day

B. Calories should contain mostly high fat and simple carbohydrates

C. Avoid drinking fluids while eating meals

D. Rest for 30 minutes following each meal

E. Initial meals for the first few months will need to be liquid or pureed

Part II: Peptic Ulcer Disease (PUD)

7. The HCP prescribed an esophagogastroduodenoscopy (EGD) at an outpatient facility for a patient with peptic ulcer disease. Which points would the nurse teach the patient about EGD testing? (Select all that apply)

A. Advise the patient that they will need a ride home after the test

B. Tell the patient to take their antacids the morning before the procedure

C. Recommend to the patient to make an appointment with their HCP for 2 weeks after the test

D. Explain that they will need to start taking warfarin daily beginning three days before the test.

E. The nurse will be checking to see if they have a gag reflex before they can eat or drink anything after the test

8. The HCP prescribed an upper GI series (barium swallow) for a patient with symptoms of peptic ulcer disease and GERD. Which points would the nurse teach the patient about upper GI testing? (Select all that apply)

1. Tell the patient to eat or drink nothing after midnight before the test
2. Explain that the patient should report to the HCP if they become constipated after the test
3. Advise the patient that their stools will be red in color for a couple of days after the test
4. The patient should avoid fluids for a few days after testing
5. Tell the patient to take all medications as prescribed the morning of the test

9. Which statement made by a patient with peptic ulcer disease indicates that the patient has an understanding of their diet?

1. "I can eat foods that don't cause me to have any stomach pain."
2. "I should substitute coffee for tea."

C. "I must eat bland foods at least six times a day."

D. "I should eliminate all milk and milk products."

Part III: Ulcer Perforation

10. A patient with a duodenal ulcer is hospitalized due to a suspected perforation of the duodenum in the area of the ulcer. Which IV fluid is most appropriate for this patient?

A. D5W in 0.45% NaCl.

B. Lactated Ringer's solution.

C. Dextrose 5% in water (D5W).

D. 0.45% NS + 10 mEq KCL

11. Which assessment findings indicate to the nurse that the patient is experiencing a perforation of a peptic ulcer? (Select all that apply)

1. Decreased bowel sounds
2. Projectile vomiting of undigested food
3. Grunting, shallow respiration
4. Rigid, board-like abdomen
5. Shoulder pain
6. Sudden, severe upper abdominal pain
7. Upper abdominal swelling
8. Visible peristaltic waves

12. Which intervention would the nurse anticipate to be prescribed for a patient with a perforation due to a duodenal ulcer?

A. Preparation for a colonoscopy

B. Administration of oral corticosteroids

C. Insertion of a nasogastric tube (NGT)

D. Insertion of a gastrostomy tube (GT)

13. A patient is being treated for a perforated gastric ulcer and is admitted to the intermediate care unit. The admission nurse notices that the patient appears visibly anxious. The nurse asks the patient about how they are feeling. The patient states, “I can't afford to be away from work right now because I have so many responsibilities.” Which nursing diagnosis reflects the patient’s priority need at this time?

A. Risk for infection

B. Risk for injury

C. Self-care deficit

D. Ineffective coping

14. The primary healthcare provider prescribed pantoprazole 40 mg IVPB in 50 mL 0.9% NS BID over 15 minutes. The medication was reconstituted with 10 mL of NS with a resulting concentration of 4mg/mL. At what rate would the nurse set the pump in mL/h?

Part IV: Match the Medication

15. Match each item in the first column to the correct item in the second column

____ 1. Antibiotic to eliminate H. pylori A. clarithromycin

____ 2. A synthetic prostaglandin with B. famotidine

antisecretory and protective effects

____ 3. Blocks ATPase enzyme and secretion C. misoprostol

of HCl acid

____ 4. Covers the ulcer and protects it from D. omeprazole

erosion

____ 5. Reduces acid secretion by blocking E. sucralfate

histamine-2 receptors

Part V: PUD Surgical Treatment

16. Which description about the Billroth II procedure is correct?

1. Distal two thirds of the stomach will be removed with anastomosis of the gastric stump to the jejunum.
2. Distal one-half of the stomach will be removed with anastomosis of the gastric stump to the duodenum.
3. Pyloric sphincter will be enlarged to promote gastric emptying with severance of the
4. Pyloric sphincter will be enlarged to promote gastric emptying with severance of the vagus nerve to decrease gastric secretions.
5. Stomach will be stapled horizontally with resection and connection of the jejunum to the stomach and the distal duodenal stump to the jejunum.
6. 17. Which prescribed intervention would a nurse expect to implement for a patient who is postoperative Billroth II 16 hours ago and has an NGT to low intermittent wall suction?

7. A. NPO, call health care provider if any bleeding from NGT and PCA as ordered

   B. Ice chips by mouth, irrigate NGT q2h with 0.9% NS and bed rest

   C. NPO, NGT to low intermittent wall suction, PCA as ordered, out of bed with assistance

   D. Bowel assessment, check for NGT placement and reposition tube as necessary every 4h and PCA as ordered

   18. Which interventions would the nurse delegate to a nursing assistant for a patient who is post-operative gastric surgery? (Select all that apply)

   A. Reinforce NPO status

   B. Verify correct NGT placement

   C. Remind the patient to use the incentive spirometry

   D. Assist the patient to get back to bed after sitting in the chair

   E. Remind the patient to take the medications that the nurse left at the bedside

   Part VI: Gastroesophageal Reflex Disease (GERD)

   19. Which points would be included in a teaching plan for a patient who was diagnosed with GERD? (Select all that apply)

8. Encourage a snack before bedtime
9. Encourage small frequent meals
10. Lie down 30 minutes after eating
11. Encourage the patient keep the head of bed elevated
12. Avoid tight fitting clothing
13. Which statement made by a patient with GERD indicates that the patient has an understanding of their diet?
14. "I can eat foods that don't cause me to have any stomach pain"
15. "I should substitute coffee for tea"
16. "Chewing spearmint gum after eating meals can help to decrease my symptoms"
17. "I should limit my intake of milk and milk products especially at night

Answer 1

1.BMI

Given

Weight 316 lbs

Height:68 inches

BMI:316*703/(68)²

=222148/(68)²

=222148/4624

=48kg/m2

The patient is morbidly obese

2.The treatment options for this patient are

• Lifestyle changes (Diet modification, excercise)
• Medication (to reduce appetite)
• Surgery

3.The additional interventions reqiired for this patient are

1. Controlling the blood sugar levels as the fasting blood glucose is high(risk for diabetes)
2. The cholesterol levels has to be decreased as the levels are high (risk for cardiovascular issues)

4.The additional evaluation and treatment options for this patient are

• Thyroid profile as alteration in this can cause difficulty to reduce weight
• Cardiovascular evaluation as the cholesterol,blood pressure are elevated
• The bariatric surgery is the treatment option for this patient.