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Gastrectomy for Stomach Carcinoma
JUNE 1988, VOL. 47, NO 6
AORN J O U R N A L
PERIOPERATIVE PATIENTCARE Donna M. Feickert, RN; Elizabeth Jillson, RN; Therese Palazzo, RN
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lthough cancer of the stomach has been declining for the past 40 years, it is still the seventh leading cause of death among males in the United States.' Males are affected twice as often as females, and the mean age is 55 years.* Stomach cancer is not as common in the United States as in Japan, parts of Europe, and the Central and South American Andes? The disease is seen more frequently in low socioeconomic groups. Early signs and symptoms often mimic common benign conditions and include heartburn, vague abdominal discomfort, mild anorexia, and weight loss. These symptoms are often mistaken for ulcer symptoms and treated as such. Because the symptoms of stomach cancer are often vague and insidious, medical attention is usually not sought until the disease has progressed beyond the curative stage. Unfortunately, pain and vomiting are late signs and carry a poor prognosis.
Etiologv
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lthough the cause of stomach cancer is unknown, a number of contributing factors have been identified. Environment. A history of exposure to radiation and/or trace elements in the soil are common in gastric cancer patients' histories. Studies of immigrants to the United States demonstrate a correlation between early life exposure to radiation and/or radioactive substances and later development of gastric carcinoma! 1396
Genetic. Gastric cancer is often seen in more than one generation, which leads to a theory of familial predisposition.5 It is not known, however, whether that predisposition is genetic or simply exposure to the same risk factors from one generation to the next. Pernicious anemia. Gastric cancer occurs five times more frequently in patients with pernicious anemia.6 This is thought to be related to the high nitrate concentration found in the blood of pernicious anemia patients. The nitrates are thought to combine with bacteria found in gastric juices to produce carcinogenic compounds. Chronic atrophic gastritis. A positive correlation between the presence of chronic atrophic gastritis and the risk for the development of gastric cancer also has been ider~tified.~ Diet. A diet high in smoked fish is believed to be a risk factor because of the high amount of nitrate compounds found in the food.8 In addition, cereals and fried, cured, and salty foods may play a role in the development of gastric cancer.
Pathologv/Prognosis
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ost stomach cancers are adenocarcinomas. Staging of the disease is performed either during the work-up process and/ or at the time of surgery. The following are commonly used stages for gastric cancer^.^ Stage IA-is confined to the mucosa, Stage IB-invades submucosa but not serosa, Stage IC-penetrates the serosa,
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Stage 11-involves the gastric wall with or without perigastric lymph node involvement in the vicinity of the tumor, Stage 111-involves distant perigastric lymph nodes, Stage IV-involves distant metastasis (other organ involvement, such as liver or lung). Mortality is determined not by the disease itself, but by the stage and location of the disease on presentation of symptoms. A delay of six months to one year from the onset of symptoms to the diagnosis of gastric cancer is not unusual. Patients diagnosed in the early stages (IA and IB) of the disease have a cure rate of 90% with surgery.1° Cure rates drop significantly as disease stages advance. Ten percent of patients with Stage IV cancer have a less than five-year survival rate." These statistics point to the need for thorough screening of patients with ulcerlike symptoms. Surgical resection is the only acceptable treatment for cancer of the stomach. Antineoplastic agents and radiation therapy have had little effect on the outcome of these patients. Surgical resection is used either to cure (in the early stages)
Donna M. Feickert
or for palliation (in the later stages). The types of surgical procedures performed include subtotal, total, or proximal-partial gastrectomies.
Preoperative Care
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reoperative assessment of the gastrectomy patient includes a history and physical and an in-depth gastrointestinal (GI) assessment. Physical examination includes skin condition (scars and color), shape of the abdomen (convex or concave), height compared to weight, presence or absence of bowel sounds, and presence of masses, fluid, and pain. The history should include questions on the following: food intake and allergies, eating patterns, difficulty swallowing, indigestion and anorexia, nausea and vomiting, hematemesis, and medications taken for GI disturbances, recent weight gain or loss, bowel and bladder patterns, and stress, exercise, and exposure to hazardous materials.
Elizabeth Jillson
Donna M. Feickert, W,MSN, CS, is a surgical clinical specialist, St Barnabas Medical Center, Livingston, NJ. She earned her BSN from the Universily of Maryland, Baltimore, and her MSN from the University of Pennsylvania, Philadelphia. Elizabeth Jillson, M, BSN, ir a clinical OR nurse/preceptor, Hackensack (NJ) Medical Center. She earned her BSN from Rutgers University College of Nursing, Newark, NJ.
Therese Palazzo
Therese Palazzo, RN,MHA, ir a nurse clinician for the OR/PACU/day accommodation room, Hackensack (NJ) Medical Center. She earned her BSN from D'Youville College, Buffalo, NI: and her master of science degree in health care adminfitrationfrom Long Island (NY) Universiv. The authors acknowledge Andrew Kagan, MD, generaUvascular surgeon, Hackensack (NJ) Medical Center, for his assistance. 1397
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Fig 1. Anatomy of the stomach and surrounding structures. The GI assessment includes inspection, auscultation, percussion, and palpation (in that order) of all four quadrants. In addition, the patient will have an exhaustive testing process that includes laboratory testing, barium enema, upper GI series, abdominal ultrasound and/or computed axial tomography (CAT) scan, and endoscopy. A significant number of lesions also can be identified with radiological exams, however, malignancy cannot be confirmed or ruled out based on x-ray. An endoscopy with biopsy is necessary to make a definitive diagnosis. All patients have an endoscopy, but a biopsy is not always possible because of the location of the tumor. On admission, these patients are usually already physically debilitated. Obstruction of either the esophogogastric junction or the pylorus leads to anorexia, nausea, vomiting, severe weight loss, 1398
and massive fluid and electrolyte imbalances. (See Fig 1 for the anatomy of the stomach.) A major goal during the preoperative course, therefore, is to prepare the patient physically for the surgical procedure. Parenteral nutrition is given via a venous access line, and in addition, if the patient is able to tolerate oral feedings, he or she may be given high calorie and high protein supplements. The nurse monitors intake and output and calorie counts for oral supplements and checks the patient’s weight daily. The nurse assesses when the patient has appetite peaks and provides appetizing food at that time. The nurse also coordinates testing and meal schedules so that the patient will not have to skip meals unnecessarily. Fluid and electrolyte imbalances are a major concern in patients with gastric cancer. Vomiting,
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diarrhea, and decreased oral intake can all contribute to life-threatening imbalances. The nurse carefully monitors the patient’s laboratory values, as well as intake and output. Because pain is often a major symptom in these patients, and the symptom that prompted them to seek medical help, pain control is an important aspect of preoperative care. The nurse assesses the location, quality, and quantity of the pain, and what initiates it and what relieves it. The pain is often described as dull in character and does not change with food intake. Unless the cancer has metastasized, the patient’s pain is localized to the tumor site. If the patient is vomiting or has an obstruction, subcutaneous or intramuscular pain medication is used. The preoperative visits by the perioperative nurse help prepare the patient for the operative experience by providing information on what the patient can expect during,the perioperative period, helping the patient understand the surgical procedure and anesthesia, reassuring the patient and family that competent care will be provided, and minimizing the patient’s fears by allowing him or her to verbalize feeiings, concerns, and misconceptions about the perioperative experience. In addition, the preoperative assessment alerts the perioperative nurse to special conditions or patient problems that may require modification of the surgical equipment or procedure. Before patient teaching is done, the nurse assesses the patient’s anxiety level. If the patient is extremely anxious, he or she will probably understand and retain only simple, essential information. The nurse tells the patient that he or she will be NPO after midnight, even if surgery is scheduled late in the afternoon. The patient and family are told the approximate time of the procedure and that the patient will be taken to the holding room one hour before the procedure. The patient and family are also told that the procedure will last approximately 2%to 3%hours, and that the patient will be in the postanesthesia care unit (PACU) for an additional 1%hours. The nurse explains to the patient that he or 1400
she may have a sore throat postoperatively because of the breathing tube used during surgery. The patient is told that he or she will probably experience pain at the surgical site and that pain medication will be available in the PACU. The patient should be prepared for the nasogastric (NG) tube, intravenous (IV) lines, and Foley catheter that will be in place postoperatively. In addition, the nurse tells the patient that his or her vital signs will be taken frequently, and that he or she will be reminded to take deep breaths and cough during this time. On the day of surgery, the perioperative nurse gathers the necessary equipment, which includes a hyperthermia blanket, temperature-monitoring indwelling catheter, and pillows and sandbags for positioning. In addition, the nurse gathers anesthetic medications (as per the anesthesiologist), IV antibiotics (as per the surgeon), and an NG tube. The nurse also makes sure that four to six units of packed red blood cells are available. A basic intestinal set of instruments with gastrectomy and vagotomy extras, staple guns, and the surgeon’s special instruments are gathered. A basic thoracotomy set of instruments is also available in case the chest has to be opened to expose the esophagus. The circulating and scrub nurses have the room completely set up and sponges, instruments, and needles counted before the patient is brought into the room.
Intraoperative Procedures
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he circulating nurse brings the patient into the OR from the holding area and assists him or her onto the OR bed. The nurse remains at the patient’s side during anesthesia induction and intubation. After the patient is anesthetized, the nurse inserts the indwelling catheter with temperature probe and applies thigh-high sequential compression stockings to prevent emboli formation. The nurse and surgeon then place the patient in either the supine position for a vertical incision (from xiphoid process to umbilicus), or a left decubitus position for a thoracoabdominal incision, which provides access to the esophagus. Positioning and the type of incision is based on
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Surgical resection is the only acceptable treatment for cancer of the stomach. the surgeon’s preference and the size and location of the tumor. The patient’s safety is ensured in either position by anatomical support and padding, with attention to pressure points (eg, elbows, heels, and head). In the supine position, the patient’s right arm is padded and tucked at the side, and the left arm is placed on an arm board and secured with a safety strap. The patient’s head is placed on a doughnut-shaped headrest, and a leg strap is placed 2 inches above the knee. The electrosurgical dispersive pad is placed on the muscle mass area of the upper thigh. Positioning differences for the left decubitus position include that the patient’s right arm is placed on a padded arm support and a pillow is placed between the legs. Three-inch adhesive tape is placed over the hip area, and sandbags and a safety belt are used to further secure the patient in this position. After the surgeon has scrubbed and been gowned by the scrub nurse, he or she prepares the surgical site with povidone-iodine and places the drapes around the prepared area. A plastic, adhesive skin drape is applied to protect the skin edges. The surgeon then makes a vertical abdominal skin incision and opens the peritoneum. The surgeon palpates the liver, lymph nodes of the pancreas, hilus of the spleen, and other areas of possible lymph node metastasis. Based on this examination and the preoperative x-rays, the surgeon decides the amount of gastric and surrounding tissue to be resected. Resections for gastric carcinomas include subtotal gastrectomy for limited distal gastric tumors; total gastrectomy for larger, more invasive tumors; and proximalpartial gastrectomy with esophagogastric anastamosis for limited to proximal gastric tumors. These procedures also may include an omentectomy or spleenectomy, if indicated by metastasis. Frozen sections are performed on the margins
of the resection to check for submucosal tumor spread. Because proximal-partial gastrectomy is uncommon, this article will be limited to subtotal and total gastrectomies. Subtotal gastrectomy. For a subtotal gastrectomy procedure, the surgeon continues by lifting the omentum and bluntly lysing the gastropancreatic adhesions. The surgeon first manipulates the stomach and duodenum to assess whether the tumor can be resected. If it is resectable, he or she uses both sharp and blunt dissection to free the lesser curvature of the stomach, leaving lymph node-bearing tissue attached. The surgeon sharply dissects and ligates the right gastric artery and lymph nodes near the junction of the hepatic artery and divides the omentum at the predetermined level of gastric resection. The surgeon then ligates the short gastric arteries and frees the proximal duodenum and pylorus from the anterior pancreas. The surgeon begins the distal resection by applying a noncrushing clamp or gastric stapler across the duodenum beyond the pyloric ring and a parallel crushing clamp on the specimen side. The duodenum is then transected between the clamps or staples. The surgeon retracts the specimen superiorly with the crushing clamp and begins the proximal resection by again applying crushing and noncrushing clamps or gastric staplers. The surgeon transects the stomach between the clamps or staples and removes the specimen. The scrub nurse uses contaminated technique throughout the procedure, isolating scalpel, forceps, and any other instruments that come in contact with the inside of the bowel. The surgeon begins the subtotal gastrectomy anastamosis by closing the portion of the gastric pouch that will not be anastamosed to thejejunum with a two-layer technique using absorbable and nonabsorbable sutures. The surgeon identifies the 1401
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duodenojejunal junction by the ligament of Treitz and brings the loop of jejunum that is distal to the ligament adjacent to the resected stomach. This is accomplished either by bringing the loop behind the colon through an opening in the mesocolon or in front of the colon. This decision is based on the surgeon’s preference and the route that results in the least tension on the jejunal loop. The gastrojejunal anastamosis can be side to side, but more frequently is end to side (Fig 2). For the anastamosis, the scrub nurse will need sutures for a two-layer absorbable/nonabsorbable closure or gastric staples. The surgeon also closes the duodenal stump with a two-layer absorbable/ nonabsorbable suture technique or staples. The surgeon may place a sump drain in the stump to prevent blowout of the anastamosis. A vagotomy may also be done at this time to protect the gastrojejunal margin from ulceration. Total gastrectomy. For a total gastrectomy,
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the surgeon may extend the initial incision obliquely into the thorax to increase exposure of the esophagus. The entire omentum is freed from the colon and the splenic vessels are ligated leaving the spleen attached to the specimen. As in the subtotal gastrectomy, the surgeon mobilizes and transects the duodenum and ligates the right gastric artery. The surgeon dissects the gastrohepatic omentum from the liver and ligates the left gastric artery. The surgeon also divides the coronary ligament of the left lobe of the liver. The surgeon retracts and incises the phrenoesophageal ligament inferiorly and clips and divides the vagus nerves. The surgeon then frees the esophagus and brings the jejunal loop in front of the colon to the level of esophageal resection. The scrub nurse provides the surgeon with a set of crushing/noncrushing clamps, and the surgeon applies these clamps at the level of resection and transects the esophagus. The surgeon maintains 1403
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Fig 3. Types of anastamotic closures for total gastrectomy resection: (a) end to side, (b) end to side, and (c) Rouxen-Y. (All illustrations courtesy of Elizabeth Jillson.) 1404
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Special care is taken not to disturb the nasogastric tube, which could possibly injure the anastamosis site.
traction on the esophageal stump with the noncrushing clamp. Because the surgeon may begin the posterior portion of the esophagojejunal anatamosis before the specimen is removed, the specimen also provides traction on the esophagus. The esophagojejunal anatamosis is end to side with a lateral jejunojejunostomy, or end to end with a Rouxen-Y jejunojejunostomy (Fig 3). The purpose of the jejunojejunostomy in either configuration is to prevent esophageal regurgitation by allowing the bile and pancreatic fluids to bypass the esophagojejunal anastamosis. Some surgeons choose to create a jejunal pouch. The anastamosis is either sutured with two-layer absorbable/nonabsorbable stitches or stapled. Before the abdomen is closed, either Penrose or closed-suction drains are inserted in the right upper quadrant region of the abdomen. If the chest cavity is entered, chest tubes are inserted and connected to an underwater-seal drainage system. Throughout the surgical procedure the circulating nurse provides sterile supplies and warmed irrigation solutions to the sterile field and adjusts the surgical lights to provide maximum illumination. The circulating nurse assists the anesthesiologist with calculating blood loss, obtaining units of blood or other blood components for transfusion, and coordinating laboratory tests and results (hemoglobin, hematocrit, potassium, and blood gases) as necessary. In addition, the OR nurse monitors the aseptic technique practiced throughout the procedure by the surgical team and protects the patient from pressure injuries related to inappropriate leaning by team members, and pressure from the Mayo stand or instruments resting on the patient. The nurse also labels and prepares the specimens for pathology. The OR nurses perform two counts for sponges, needles, and instruments during the closure. Sterile
dressings of 4 x 4 gauze sponges are applied, and the anesthesiologist extubates the patient.
Postoperative Care
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n the PACU, the circulating nurse and anesthesiologist give a combined report to the PACU nurse. The report includes the type of anesthesia (agents and reversals), medications and fluids given in the O R (type and amount), type of drains (location and method secured) and amount of drainage, estimated blood loss, any complications in the OR, preinduction level of anxiety, and preoperative disabilities and defects. The PACU nurse monitors the patient’s vital signs and drainage from the Foley, abdominal drains, and chest tubes if inserted. The nurse applies nasal oxygen at 3 to 6 L/min and applies electrocardiogram pads for monitoring. Instructing the patient to cough and deep breathe begins in the PACU and continues in the care unit. Patients who have received preoperative teaching about pulmonary care will be more cooperative because they are aware of the importance of this exercise. The nurse assesses and documents lung sounds every four hours. To achieve adequate pulmonary functioning, it is imperative that the patient be kept comfortable and pain free. The nurse administers pain medication based on the stability of the patient’s vital signs. It is important that the nurse assesses the patient’s pain and administersmedication before the pain becomes unbearable for him or her. If the patient is comfortable, he or she will be more conducive to turning, performing leg exercises, and walking. These patients are prime candidates for emboli development and must wear antiembolic stockings. The stockings must be removed one time per shift to assess for calf pain, localized tenderness, and warmth. Special care is taken not to disturb the NG 1405
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tube, which could possibly injure the anastamosis site. The NG tube is connected to suction, and the nurse assesses the output every four hours for the first 24 hours postoperatively for frank bleeding and excessive drainage. The nurse checks with the surgeon before irrigating or repositioning the NG tube also to prevent disruption of the anastamosis site. The patient’s intake and output are carefully monitored because excessive NG tube drainage may indicate a fluid and electrolyte imbalance. The nurse assesses the patient for signs and symptoms of infection by checking the patient’s temperature every four hours for the first 48 hours postoperatively and inspecting incisions and drain sites for suture disruption, purulent drainage, redness, warmth, or tenderness. The nurse also palpates the patient’s abdomen for tenderness, rigidity, or distention that may indicate the presence of peritonitis. In addition, the nurse listens for the presence or absence of bowel soundsthere should not be bowel sounds for two to five days postoperatively. Discharge planning for the postoperative gastrectomy patient begins when the patient is admitted to the hospital. The hospital dietitian is involved in the care and planning of his or her diet. The patient must make major life-style adjustments in dietary habits. Depending on the degree of resection, the patient may have to eat six to eight small meals per day. Because of the patient’s cancer diagnosis, he or she may need a great deal of support. Social services may be involved in discharge planning to assist with the major changes occurring in his or her life. Some patients may be referred to hospices. A postoperative visit by the perioperative nurse is very beneficial to both the patient and the nurse. The patient is able to see the continuity of care provided by the perioperative nurse. And this is a perfect opportunity for the nurse to gather information that will assist with the care of other patients undergoing the same or similar surgical procedures. 0 Notes 1 . W ReMine, “The stomach,” in Maingot’s Abdominal Operations, eds. S Schwartz, H Ellis, eighth 1406
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ed, (East Norwalk, Conn: Appleton-Century-Crofts, 1985) 328. 2. W MacDonald, C Rubin, “Cancer, benign tumors, gastritis and other gastricdiseases,” in Hamion’s Principles of Internal Medicine, eds. R Petersdorf et al, 10th ed (New York City: McGraw-Hill Book Co, 1983) 1712. 3. ReMine, “The stomach,” 328. 4. Ibid 5. Zbid 6. Zbid 7. Zbid 8. Bid, 329. 9. H Douglas Jr, “Cancer of the stomach,” Surgical Oncologv, ed. E Copeland 111 (New York City: Wiley Co, 1983) 310. 10. zbid 11. ReMine, “The stomach,” 328. Suggested reading Feickert, D. “Gastric surgery: Your crucial pre- and post-op role.” RN 50 (January 1987) 24-30. Kennedy, B. “TNM classification for stomach cancer.’’ Cancer 26 (November 1970) 971-984. Kirkham, J. “Partial and total gastrectomy.” in Maingot’s Abdominal Operations. eds. S Schwartz, H Ellis, eighth ed. East Norwalk, Conn: AppletonCentury-Crofts, 1985, 839-895. Kurtz, R Sherlock, P. “Carcinoma of the stomach.” in Bockus Gastroenterology. ed. J k r k , fourth ed. Philadelphia: W B Saunders Co, 1985, 1278. McCormack, A, Itkin, J; Cloud, C. “RN master care plan: The gastric surgery patient.” RN 50 (January 1987) 31-33. Patras, A; Brozenec, S. “Gastrointestinal assessment.” AORN Journal 40 (November 1984) 726-73 1. Zollinger, R Zollinger R, Jr. Atlas of Surgical Operations. fifth ed. New York City: Macmillian Publishing Co, 1983.
Professional nurses are invited to submit manuscripts for the home study program Manuscripts or queries should be sent to the Editor, AORN Journal, 101 70 E Mississippi Ave, Denver, CO 80231. As with all manuscripts sent to the Journal, papers submitted for home study program should not have been previously publkhed or submitted simultaneously to any other publication.
AORN J O U R N A L
JUNE 1988, VOL. 47, N O 6
hxamination HOMESTUDY PROGRAM
a) b) c) d)
1. What is the ranking of stomach cancer among
2.
3.
4.
5.
6.
7.
males in the United States as a cause of death? a) second b) fourth c) fifth d) seventh How much more often are males affected with stomach cancer than females? a) twice as often b) four times as often c) seven times as often d) 12 times as often Stomach cancer is seen more frequently in higher socioeconomic groups a) true b) false Late signs and symptoms of stomach cancer include a) heartburn b) mild anorexia c) vomiting d) vague abdominal discomfort Which of the following has been identified as a contributing factor to the development of stomach cancer? a) early life exposure to radiation b) acute gastritis c) sickle cell anemia d) diet low in smoked fish and cereals Most stomach cancers are a) basal cell carcinomas b) adenocarcinomas c) squamous cell carcinomas d) Sarcomas The early stages of gastric cancer
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8.
9.
10.
11.
12.
involve the lymph nodes penetrate the serosa involve the gastric wall are confined to the mucosa and submucosa Mortality associated with gastric carcinoma is determined by the stage and location of the disease on presentation of symptoms. It is not unusual to have a delay of diagnosis after onset of symptoms of a) six months to one year b) one year to 18 months c) 18 months to two years d) two to three years Patients diagnosed in the early stages of the disease have a cure rate with surgery of a) 40% b) 60% c) 70% d) 90% Which percentage of patients with Stage IV cancer have a less than five-year survival rate? a) 5% b) 10% c) 20% d) 90% Surgical resection is the only acceptable treatment for cancer of the stomach. a) true b) false A definitive diagnosis of malignancy cannot be confirmed or ruled out in gastric cancer without a) an in-depth patient history b) inspection, auscultation, percussion, and
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palpation of all four quadrants c) an endoscopy with biopsy d) radiological exams 13. A major goal during the preoperative course is to prepare the gastric cancer patient physically for the surgical procedure. The patient is usually physically debilitated because of a) obstruction of the duodenojejunaljunction b) the extensive preoperative testing including barium enema and upper gastrointestinal (GI) series c) severe pain d) obstruction of the esophagogastricjunction or the pylorus 14. In monitoring fluid and electrolyte imbalances, the nurse assesses the patient's a) calorie count and daily weight b) intake and output and laboratory tests c) appetite peaks and provides food at those times d) schedule for testing so the patient will not have to skip meals 15. Because pain is often a major symptom in gastric cancer patients, the nurse should be aware that the pain a) is described as sharp in character b) changes with food intake c) is localized to the tumor site unless the cancer has metastasized d) always requires subcutaneousor intramuscular pain medication 16. The perioperative nurse's preoperative visits help prepare the patient for surgery by allowing him or her to verbalize feelings, concerns, and misconceptions about the perioperative experience a) true b) false 17. Resections for gastric carcinomas include a) subtotal gastrectomy for proximal gastric tumors b) total gastrectomyfor large, invasive tumors c) partial gastrectomy with esophagogastric anastamosis for limited distal gastric tumors d) total gastrectomy with esophagogastric anastamosis for proximal tumors
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18. For the subtotal gastrectomy, the surgeon
anastamoses the a) distal stomach to the duodenum b) proximal stomach to the jejunum c) esophagus to the jejunum d) esophagus to the duodenum 19. The purpose of a jejunojejunostomy is to a) prevent gastric regurgitation b) allow the bile and pancreatic fluids to bypass the gastrojejunal anastamosis c) prevent esophageal regurgitation d) create a jejunal pouch 20. The nurse must be careful not to disturb the nasogastric tube postoperatively because it a) is painful for the patient b) could disrupt drainage c) could disrupt its positioning and cause it to come out of the stomach d) could disrupt the anastamosis site
Computerized Information Helps Design Prostheses Mechanical engineers at the Massachusetts Institute of Technology, Cambridge, are generating information on how human bodies work and applying it to prostheses and artificialjoints. They are trying to create devices that can imitate the fundons and motions of normal body parts, acmrdmg to an h c l e in the March 14,1988, k u e of M & World News. The engineen analyze a walker's gait by strap ping targets on the walker's leg and using cameras to detect infrared signals from those targets. The cameras scan the targets at the rate of 300 16emitter signaLs per second and produce a video representation of a normal or pathologic gait. If the walker strolls over a sensitive pressure plate in the floor, engineers can plot vectOIs of forces and torque as each foot meets the ground The information can be displayed simultaneously in real time or recorded for playback. The computerized displays are then colorprogrammed. Computed graphs show ankle, knee, hip, or other motion with flexion, abduction, and external rotation in Merent colors. 1409
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Answer Sheet GASTRECTOMY FOR STOMACH CARCINOMA
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following objectives of this home study program achieved? (1) Identify the incidence of stomach cancer. (2) Discuss the etiology of stomach cancer. (3) State the diagnostic measures for stomach cancer. (4) Discuss the surgical procedures for treatment of stomach cancer. (5) Discuss perioperative nursing interventions for the gastrectomy patient.
(Low)
2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? (5) Was the content of the article relevant to the objectives?
3. Test question/answers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points? 4. Which other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic?
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PERIOPERATIVE PATIENTCARE Donna M. Feickert, RN; Elizabeth Jillson, RN; Therese Palazzo, RN
A
lthough cancer of the stomach has been declining for the past 40 years, it is still the seventh leading cause of death among males in the United States.' Males are affected twice as often as females, and the mean age is 55 years.* Stomach cancer is not as common in the United States as in Japan, parts of Europe, and the Central and South American Andes? The disease is seen more frequently in low socioeconomic groups. Early signs and symptoms often mimic common benign conditions and include heartburn, vague abdominal discomfort, mild anorexia, and weight loss. These symptoms are often mistaken for ulcer symptoms and treated as such. Because the symptoms of stomach cancer are often vague and insidious, medical attention is usually not sought until the disease has progressed beyond the curative stage. Unfortunately, pain and vomiting are late signs and carry a poor prognosis.
Etiologv
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lthough the cause of stomach cancer is unknown, a number of contributing factors have been identified. Environment. A history of exposure to radiation and/or trace elements in the soil are common in gastric cancer patients' histories. Studies of immigrants to the United States demonstrate a correlation between early life exposure to radiation and/or radioactive substances and later development of gastric carcinoma! 1396
Genetic. Gastric cancer is often seen in more than one generation, which leads to a theory of familial predisposition.5 It is not known, however, whether that predisposition is genetic or simply exposure to the same risk factors from one generation to the next. Pernicious anemia. Gastric cancer occurs five times more frequently in patients with pernicious anemia.6 This is thought to be related to the high nitrate concentration found in the blood of pernicious anemia patients. The nitrates are thought to combine with bacteria found in gastric juices to produce carcinogenic compounds. Chronic atrophic gastritis. A positive correlation between the presence of chronic atrophic gastritis and the risk for the development of gastric cancer also has been ider~tified.~ Diet. A diet high in smoked fish is believed to be a risk factor because of the high amount of nitrate compounds found in the food.8 In addition, cereals and fried, cured, and salty foods may play a role in the development of gastric cancer.
Pathologv/Prognosis
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ost stomach cancers are adenocarcinomas. Staging of the disease is performed either during the work-up process and/ or at the time of surgery. The following are commonly used stages for gastric cancer^.^ Stage IA-is confined to the mucosa, Stage IB-invades submucosa but not serosa, Stage IC-penetrates the serosa,
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Stage 11-involves the gastric wall with or without perigastric lymph node involvement in the vicinity of the tumor, Stage 111-involves distant perigastric lymph nodes, Stage IV-involves distant metastasis (other organ involvement, such as liver or lung). Mortality is determined not by the disease itself, but by the stage and location of the disease on presentation of symptoms. A delay of six months to one year from the onset of symptoms to the diagnosis of gastric cancer is not unusual. Patients diagnosed in the early stages (IA and IB) of the disease have a cure rate of 90% with surgery.1° Cure rates drop significantly as disease stages advance. Ten percent of patients with Stage IV cancer have a less than five-year survival rate." These statistics point to the need for thorough screening of patients with ulcerlike symptoms. Surgical resection is the only acceptable treatment for cancer of the stomach. Antineoplastic agents and radiation therapy have had little effect on the outcome of these patients. Surgical resection is used either to cure (in the early stages)
Donna M. Feickert
or for palliation (in the later stages). The types of surgical procedures performed include subtotal, total, or proximal-partial gastrectomies.
Preoperative Care
P
reoperative assessment of the gastrectomy patient includes a history and physical and an in-depth gastrointestinal (GI) assessment. Physical examination includes skin condition (scars and color), shape of the abdomen (convex or concave), height compared to weight, presence or absence of bowel sounds, and presence of masses, fluid, and pain. The history should include questions on the following: food intake and allergies, eating patterns, difficulty swallowing, indigestion and anorexia, nausea and vomiting, hematemesis, and medications taken for GI disturbances, recent weight gain or loss, bowel and bladder patterns, and stress, exercise, and exposure to hazardous materials.
Elizabeth Jillson
Donna M. Feickert, W,MSN, CS, is a surgical clinical specialist, St Barnabas Medical Center, Livingston, NJ. She earned her BSN from the Universily of Maryland, Baltimore, and her MSN from the University of Pennsylvania, Philadelphia. Elizabeth Jillson, M, BSN, ir a clinical OR nurse/preceptor, Hackensack (NJ) Medical Center. She earned her BSN from Rutgers University College of Nursing, Newark, NJ.
Therese Palazzo
Therese Palazzo, RN,MHA, ir a nurse clinician for the OR/PACU/day accommodation room, Hackensack (NJ) Medical Center. She earned her BSN from D'Youville College, Buffalo, NI: and her master of science degree in health care adminfitrationfrom Long Island (NY) Universiv. The authors acknowledge Andrew Kagan, MD, generaUvascular surgeon, Hackensack (NJ) Medical Center, for his assistance. 1397
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Fig 1. Anatomy of the stomach and surrounding structures. The GI assessment includes inspection, auscultation, percussion, and palpation (in that order) of all four quadrants. In addition, the patient will have an exhaustive testing process that includes laboratory testing, barium enema, upper GI series, abdominal ultrasound and/or computed axial tomography (CAT) scan, and endoscopy. A significant number of lesions also can be identified with radiological exams, however, malignancy cannot be confirmed or ruled out based on x-ray. An endoscopy with biopsy is necessary to make a definitive diagnosis. All patients have an endoscopy, but a biopsy is not always possible because of the location of the tumor. On admission, these patients are usually already physically debilitated. Obstruction of either the esophogogastric junction or the pylorus leads to anorexia, nausea, vomiting, severe weight loss, 1398
and massive fluid and electrolyte imbalances. (See Fig 1 for the anatomy of the stomach.) A major goal during the preoperative course, therefore, is to prepare the patient physically for the surgical procedure. Parenteral nutrition is given via a venous access line, and in addition, if the patient is able to tolerate oral feedings, he or she may be given high calorie and high protein supplements. The nurse monitors intake and output and calorie counts for oral supplements and checks the patient’s weight daily. The nurse assesses when the patient has appetite peaks and provides appetizing food at that time. The nurse also coordinates testing and meal schedules so that the patient will not have to skip meals unnecessarily. Fluid and electrolyte imbalances are a major concern in patients with gastric cancer. Vomiting,
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diarrhea, and decreased oral intake can all contribute to life-threatening imbalances. The nurse carefully monitors the patient’s laboratory values, as well as intake and output. Because pain is often a major symptom in these patients, and the symptom that prompted them to seek medical help, pain control is an important aspect of preoperative care. The nurse assesses the location, quality, and quantity of the pain, and what initiates it and what relieves it. The pain is often described as dull in character and does not change with food intake. Unless the cancer has metastasized, the patient’s pain is localized to the tumor site. If the patient is vomiting or has an obstruction, subcutaneous or intramuscular pain medication is used. The preoperative visits by the perioperative nurse help prepare the patient for the operative experience by providing information on what the patient can expect during,the perioperative period, helping the patient understand the surgical procedure and anesthesia, reassuring the patient and family that competent care will be provided, and minimizing the patient’s fears by allowing him or her to verbalize feeiings, concerns, and misconceptions about the perioperative experience. In addition, the preoperative assessment alerts the perioperative nurse to special conditions or patient problems that may require modification of the surgical equipment or procedure. Before patient teaching is done, the nurse assesses the patient’s anxiety level. If the patient is extremely anxious, he or she will probably understand and retain only simple, essential information. The nurse tells the patient that he or she will be NPO after midnight, even if surgery is scheduled late in the afternoon. The patient and family are told the approximate time of the procedure and that the patient will be taken to the holding room one hour before the procedure. The patient and family are also told that the procedure will last approximately 2%to 3%hours, and that the patient will be in the postanesthesia care unit (PACU) for an additional 1%hours. The nurse explains to the patient that he or 1400
she may have a sore throat postoperatively because of the breathing tube used during surgery. The patient is told that he or she will probably experience pain at the surgical site and that pain medication will be available in the PACU. The patient should be prepared for the nasogastric (NG) tube, intravenous (IV) lines, and Foley catheter that will be in place postoperatively. In addition, the nurse tells the patient that his or her vital signs will be taken frequently, and that he or she will be reminded to take deep breaths and cough during this time. On the day of surgery, the perioperative nurse gathers the necessary equipment, which includes a hyperthermia blanket, temperature-monitoring indwelling catheter, and pillows and sandbags for positioning. In addition, the nurse gathers anesthetic medications (as per the anesthesiologist), IV antibiotics (as per the surgeon), and an NG tube. The nurse also makes sure that four to six units of packed red blood cells are available. A basic intestinal set of instruments with gastrectomy and vagotomy extras, staple guns, and the surgeon’s special instruments are gathered. A basic thoracotomy set of instruments is also available in case the chest has to be opened to expose the esophagus. The circulating and scrub nurses have the room completely set up and sponges, instruments, and needles counted before the patient is brought into the room.
Intraoperative Procedures
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he circulating nurse brings the patient into the OR from the holding area and assists him or her onto the OR bed. The nurse remains at the patient’s side during anesthesia induction and intubation. After the patient is anesthetized, the nurse inserts the indwelling catheter with temperature probe and applies thigh-high sequential compression stockings to prevent emboli formation. The nurse and surgeon then place the patient in either the supine position for a vertical incision (from xiphoid process to umbilicus), or a left decubitus position for a thoracoabdominal incision, which provides access to the esophagus. Positioning and the type of incision is based on
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Surgical resection is the only acceptable treatment for cancer of the stomach. the surgeon’s preference and the size and location of the tumor. The patient’s safety is ensured in either position by anatomical support and padding, with attention to pressure points (eg, elbows, heels, and head). In the supine position, the patient’s right arm is padded and tucked at the side, and the left arm is placed on an arm board and secured with a safety strap. The patient’s head is placed on a doughnut-shaped headrest, and a leg strap is placed 2 inches above the knee. The electrosurgical dispersive pad is placed on the muscle mass area of the upper thigh. Positioning differences for the left decubitus position include that the patient’s right arm is placed on a padded arm support and a pillow is placed between the legs. Three-inch adhesive tape is placed over the hip area, and sandbags and a safety belt are used to further secure the patient in this position. After the surgeon has scrubbed and been gowned by the scrub nurse, he or she prepares the surgical site with povidone-iodine and places the drapes around the prepared area. A plastic, adhesive skin drape is applied to protect the skin edges. The surgeon then makes a vertical abdominal skin incision and opens the peritoneum. The surgeon palpates the liver, lymph nodes of the pancreas, hilus of the spleen, and other areas of possible lymph node metastasis. Based on this examination and the preoperative x-rays, the surgeon decides the amount of gastric and surrounding tissue to be resected. Resections for gastric carcinomas include subtotal gastrectomy for limited distal gastric tumors; total gastrectomy for larger, more invasive tumors; and proximalpartial gastrectomy with esophagogastric anastamosis for limited to proximal gastric tumors. These procedures also may include an omentectomy or spleenectomy, if indicated by metastasis. Frozen sections are performed on the margins
of the resection to check for submucosal tumor spread. Because proximal-partial gastrectomy is uncommon, this article will be limited to subtotal and total gastrectomies. Subtotal gastrectomy. For a subtotal gastrectomy procedure, the surgeon continues by lifting the omentum and bluntly lysing the gastropancreatic adhesions. The surgeon first manipulates the stomach and duodenum to assess whether the tumor can be resected. If it is resectable, he or she uses both sharp and blunt dissection to free the lesser curvature of the stomach, leaving lymph node-bearing tissue attached. The surgeon sharply dissects and ligates the right gastric artery and lymph nodes near the junction of the hepatic artery and divides the omentum at the predetermined level of gastric resection. The surgeon then ligates the short gastric arteries and frees the proximal duodenum and pylorus from the anterior pancreas. The surgeon begins the distal resection by applying a noncrushing clamp or gastric stapler across the duodenum beyond the pyloric ring and a parallel crushing clamp on the specimen side. The duodenum is then transected between the clamps or staples. The surgeon retracts the specimen superiorly with the crushing clamp and begins the proximal resection by again applying crushing and noncrushing clamps or gastric staplers. The surgeon transects the stomach between the clamps or staples and removes the specimen. The scrub nurse uses contaminated technique throughout the procedure, isolating scalpel, forceps, and any other instruments that come in contact with the inside of the bowel. The surgeon begins the subtotal gastrectomy anastamosis by closing the portion of the gastric pouch that will not be anastamosed to thejejunum with a two-layer technique using absorbable and nonabsorbable sutures. The surgeon identifies the 1401
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duodenojejunal junction by the ligament of Treitz and brings the loop of jejunum that is distal to the ligament adjacent to the resected stomach. This is accomplished either by bringing the loop behind the colon through an opening in the mesocolon or in front of the colon. This decision is based on the surgeon’s preference and the route that results in the least tension on the jejunal loop. The gastrojejunal anastamosis can be side to side, but more frequently is end to side (Fig 2). For the anastamosis, the scrub nurse will need sutures for a two-layer absorbable/nonabsorbable closure or gastric staples. The surgeon also closes the duodenal stump with a two-layer absorbable/ nonabsorbable suture technique or staples. The surgeon may place a sump drain in the stump to prevent blowout of the anastamosis. A vagotomy may also be done at this time to protect the gastrojejunal margin from ulceration. Total gastrectomy. For a total gastrectomy,
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the surgeon may extend the initial incision obliquely into the thorax to increase exposure of the esophagus. The entire omentum is freed from the colon and the splenic vessels are ligated leaving the spleen attached to the specimen. As in the subtotal gastrectomy, the surgeon mobilizes and transects the duodenum and ligates the right gastric artery. The surgeon dissects the gastrohepatic omentum from the liver and ligates the left gastric artery. The surgeon also divides the coronary ligament of the left lobe of the liver. The surgeon retracts and incises the phrenoesophageal ligament inferiorly and clips and divides the vagus nerves. The surgeon then frees the esophagus and brings the jejunal loop in front of the colon to the level of esophageal resection. The scrub nurse provides the surgeon with a set of crushing/noncrushing clamps, and the surgeon applies these clamps at the level of resection and transects the esophagus. The surgeon maintains 1403
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Fig 3. Types of anastamotic closures for total gastrectomy resection: (a) end to side, (b) end to side, and (c) Rouxen-Y. (All illustrations courtesy of Elizabeth Jillson.) 1404
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Special care is taken not to disturb the nasogastric tube, which could possibly injure the anastamosis site.
traction on the esophageal stump with the noncrushing clamp. Because the surgeon may begin the posterior portion of the esophagojejunal anatamosis before the specimen is removed, the specimen also provides traction on the esophagus. The esophagojejunal anatamosis is end to side with a lateral jejunojejunostomy, or end to end with a Rouxen-Y jejunojejunostomy (Fig 3). The purpose of the jejunojejunostomy in either configuration is to prevent esophageal regurgitation by allowing the bile and pancreatic fluids to bypass the esophagojejunal anastamosis. Some surgeons choose to create a jejunal pouch. The anastamosis is either sutured with two-layer absorbable/nonabsorbable stitches or stapled. Before the abdomen is closed, either Penrose or closed-suction drains are inserted in the right upper quadrant region of the abdomen. If the chest cavity is entered, chest tubes are inserted and connected to an underwater-seal drainage system. Throughout the surgical procedure the circulating nurse provides sterile supplies and warmed irrigation solutions to the sterile field and adjusts the surgical lights to provide maximum illumination. The circulating nurse assists the anesthesiologist with calculating blood loss, obtaining units of blood or other blood components for transfusion, and coordinating laboratory tests and results (hemoglobin, hematocrit, potassium, and blood gases) as necessary. In addition, the OR nurse monitors the aseptic technique practiced throughout the procedure by the surgical team and protects the patient from pressure injuries related to inappropriate leaning by team members, and pressure from the Mayo stand or instruments resting on the patient. The nurse also labels and prepares the specimens for pathology. The OR nurses perform two counts for sponges, needles, and instruments during the closure. Sterile
dressings of 4 x 4 gauze sponges are applied, and the anesthesiologist extubates the patient.
Postoperative Care
I
n the PACU, the circulating nurse and anesthesiologist give a combined report to the PACU nurse. The report includes the type of anesthesia (agents and reversals), medications and fluids given in the O R (type and amount), type of drains (location and method secured) and amount of drainage, estimated blood loss, any complications in the OR, preinduction level of anxiety, and preoperative disabilities and defects. The PACU nurse monitors the patient’s vital signs and drainage from the Foley, abdominal drains, and chest tubes if inserted. The nurse applies nasal oxygen at 3 to 6 L/min and applies electrocardiogram pads for monitoring. Instructing the patient to cough and deep breathe begins in the PACU and continues in the care unit. Patients who have received preoperative teaching about pulmonary care will be more cooperative because they are aware of the importance of this exercise. The nurse assesses and documents lung sounds every four hours. To achieve adequate pulmonary functioning, it is imperative that the patient be kept comfortable and pain free. The nurse administers pain medication based on the stability of the patient’s vital signs. It is important that the nurse assesses the patient’s pain and administersmedication before the pain becomes unbearable for him or her. If the patient is comfortable, he or she will be more conducive to turning, performing leg exercises, and walking. These patients are prime candidates for emboli development and must wear antiembolic stockings. The stockings must be removed one time per shift to assess for calf pain, localized tenderness, and warmth. Special care is taken not to disturb the NG 1405
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tube, which could possibly injure the anastamosis site. The NG tube is connected to suction, and the nurse assesses the output every four hours for the first 24 hours postoperatively for frank bleeding and excessive drainage. The nurse checks with the surgeon before irrigating or repositioning the NG tube also to prevent disruption of the anastamosis site. The patient’s intake and output are carefully monitored because excessive NG tube drainage may indicate a fluid and electrolyte imbalance. The nurse assesses the patient for signs and symptoms of infection by checking the patient’s temperature every four hours for the first 48 hours postoperatively and inspecting incisions and drain sites for suture disruption, purulent drainage, redness, warmth, or tenderness. The nurse also palpates the patient’s abdomen for tenderness, rigidity, or distention that may indicate the presence of peritonitis. In addition, the nurse listens for the presence or absence of bowel soundsthere should not be bowel sounds for two to five days postoperatively. Discharge planning for the postoperative gastrectomy patient begins when the patient is admitted to the hospital. The hospital dietitian is involved in the care and planning of his or her diet. The patient must make major life-style adjustments in dietary habits. Depending on the degree of resection, the patient may have to eat six to eight small meals per day. Because of the patient’s cancer diagnosis, he or she may need a great deal of support. Social services may be involved in discharge planning to assist with the major changes occurring in his or her life. Some patients may be referred to hospices. A postoperative visit by the perioperative nurse is very beneficial to both the patient and the nurse. The patient is able to see the continuity of care provided by the perioperative nurse. And this is a perfect opportunity for the nurse to gather information that will assist with the care of other patients undergoing the same or similar surgical procedures. 0 Notes 1 . W ReMine, “The stomach,” in Maingot’s Abdominal Operations, eds. S Schwartz, H Ellis, eighth 1406
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ed, (East Norwalk, Conn: Appleton-Century-Crofts, 1985) 328. 2. W MacDonald, C Rubin, “Cancer, benign tumors, gastritis and other gastricdiseases,” in Hamion’s Principles of Internal Medicine, eds. R Petersdorf et al, 10th ed (New York City: McGraw-Hill Book Co, 1983) 1712. 3. ReMine, “The stomach,” 328. 4. Ibid 5. Zbid 6. Zbid 7. Zbid 8. Bid, 329. 9. H Douglas Jr, “Cancer of the stomach,” Surgical Oncologv, ed. E Copeland 111 (New York City: Wiley Co, 1983) 310. 10. zbid 11. ReMine, “The stomach,” 328. Suggested reading Feickert, D. “Gastric surgery: Your crucial pre- and post-op role.” RN 50 (January 1987) 24-30. Kennedy, B. “TNM classification for stomach cancer.’’ Cancer 26 (November 1970) 971-984. Kirkham, J. “Partial and total gastrectomy.” in Maingot’s Abdominal Operations. eds. S Schwartz, H Ellis, eighth ed. East Norwalk, Conn: AppletonCentury-Crofts, 1985, 839-895. Kurtz, R Sherlock, P. “Carcinoma of the stomach.” in Bockus Gastroenterology. ed. J k r k , fourth ed. Philadelphia: W B Saunders Co, 1985, 1278. McCormack, A, Itkin, J; Cloud, C. “RN master care plan: The gastric surgery patient.” RN 50 (January 1987) 31-33. Patras, A; Brozenec, S. “Gastrointestinal assessment.” AORN Journal 40 (November 1984) 726-73 1. Zollinger, R Zollinger R, Jr. Atlas of Surgical Operations. fifth ed. New York City: Macmillian Publishing Co, 1983.
Professional nurses are invited to submit manuscripts for the home study program Manuscripts or queries should be sent to the Editor, AORN Journal, 101 70 E Mississippi Ave, Denver, CO 80231. As with all manuscripts sent to the Journal, papers submitted for home study program should not have been previously publkhed or submitted simultaneously to any other publication.
AORN J O U R N A L
JUNE 1988, VOL. 47, N O 6
hxamination HOMESTUDY PROGRAM
a) b) c) d)
1. What is the ranking of stomach cancer among
2.
3.
4.
5.
6.
7.
males in the United States as a cause of death? a) second b) fourth c) fifth d) seventh How much more often are males affected with stomach cancer than females? a) twice as often b) four times as often c) seven times as often d) 12 times as often Stomach cancer is seen more frequently in higher socioeconomic groups a) true b) false Late signs and symptoms of stomach cancer include a) heartburn b) mild anorexia c) vomiting d) vague abdominal discomfort Which of the following has been identified as a contributing factor to the development of stomach cancer? a) early life exposure to radiation b) acute gastritis c) sickle cell anemia d) diet low in smoked fish and cereals Most stomach cancers are a) basal cell carcinomas b) adenocarcinomas c) squamous cell carcinomas d) Sarcomas The early stages of gastric cancer
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8.
9.
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11.
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involve the lymph nodes penetrate the serosa involve the gastric wall are confined to the mucosa and submucosa Mortality associated with gastric carcinoma is determined by the stage and location of the disease on presentation of symptoms. It is not unusual to have a delay of diagnosis after onset of symptoms of a) six months to one year b) one year to 18 months c) 18 months to two years d) two to three years Patients diagnosed in the early stages of the disease have a cure rate with surgery of a) 40% b) 60% c) 70% d) 90% Which percentage of patients with Stage IV cancer have a less than five-year survival rate? a) 5% b) 10% c) 20% d) 90% Surgical resection is the only acceptable treatment for cancer of the stomach. a) true b) false A definitive diagnosis of malignancy cannot be confirmed or ruled out in gastric cancer without a) an in-depth patient history b) inspection, auscultation, percussion, and
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palpation of all four quadrants c) an endoscopy with biopsy d) radiological exams 13. A major goal during the preoperative course is to prepare the gastric cancer patient physically for the surgical procedure. The patient is usually physically debilitated because of a) obstruction of the duodenojejunaljunction b) the extensive preoperative testing including barium enema and upper gastrointestinal (GI) series c) severe pain d) obstruction of the esophagogastricjunction or the pylorus 14. In monitoring fluid and electrolyte imbalances, the nurse assesses the patient's a) calorie count and daily weight b) intake and output and laboratory tests c) appetite peaks and provides food at those times d) schedule for testing so the patient will not have to skip meals 15. Because pain is often a major symptom in gastric cancer patients, the nurse should be aware that the pain a) is described as sharp in character b) changes with food intake c) is localized to the tumor site unless the cancer has metastasized d) always requires subcutaneousor intramuscular pain medication 16. The perioperative nurse's preoperative visits help prepare the patient for surgery by allowing him or her to verbalize feelings, concerns, and misconceptions about the perioperative experience a) true b) false 17. Resections for gastric carcinomas include a) subtotal gastrectomy for proximal gastric tumors b) total gastrectomyfor large, invasive tumors c) partial gastrectomy with esophagogastric anastamosis for limited distal gastric tumors d) total gastrectomy with esophagogastric anastamosis for proximal tumors
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18. For the subtotal gastrectomy, the surgeon
anastamoses the a) distal stomach to the duodenum b) proximal stomach to the jejunum c) esophagus to the jejunum d) esophagus to the duodenum 19. The purpose of a jejunojejunostomy is to a) prevent gastric regurgitation b) allow the bile and pancreatic fluids to bypass the gastrojejunal anastamosis c) prevent esophageal regurgitation d) create a jejunal pouch 20. The nurse must be careful not to disturb the nasogastric tube postoperatively because it a) is painful for the patient b) could disrupt drainage c) could disrupt its positioning and cause it to come out of the stomach d) could disrupt the anastamosis site
Computerized Information Helps Design Prostheses Mechanical engineers at the Massachusetts Institute of Technology, Cambridge, are generating information on how human bodies work and applying it to prostheses and artificialjoints. They are trying to create devices that can imitate the fundons and motions of normal body parts, acmrdmg to an h c l e in the March 14,1988, k u e of M & World News. The engineen analyze a walker's gait by strap ping targets on the walker's leg and using cameras to detect infrared signals from those targets. The cameras scan the targets at the rate of 300 16emitter signaLs per second and produce a video representation of a normal or pathologic gait. If the walker strolls over a sensitive pressure plate in the floor, engineers can plot vectOIs of forces and torque as each foot meets the ground The information can be displayed simultaneously in real time or recorded for playback. The computerized displays are then colorprogrammed. Computed graphs show ankle, knee, hip, or other motion with flexion, abduction, and external rotation in Merent colors. 1409
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Answer Sheet GASTRECTOMY FOR STOMACH CARCINOMA
P
lease fill out the application and answer form below and the evaluation on the back of this page. Tear out the page from the Journal or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, Colorado 80231
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5. 1. Objectives. To what extent were the following objectives of this home study program achieved? (1) Identify the incidence of stomach cancer. (2) Discuss the etiology of stomach cancer. (3) State the diagnostic measures for stomach cancer. (4) Discuss the surgical procedures for treatment of stomach cancer. (5) Discuss perioperative nursing interventions for the gastrectomy patient.
(Low)
2. Content. (1) Did this article increase your knowledge of the subject matter? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? (5) Was the content of the article relevant to the objectives?
3. Test question/answers. (1) Were they reflective of the content? (2) Were they easy to understand? (3) Did they address important points? 4. Which other topics would you like to see addressed in a future home study program? Would you be interested or do you know someone who would be interested in writing an article on this topic?
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