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Heartburn or pyrosis is a painful or burning sensation in the esophagus, just below the breastbone caused by regurgitation of gastric acid. The pain often rises in the chest and may radiate to the neck or throat. more...

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Heartburn is also identified as one of the causes of asthma and chronic cough.


The sensation of heartburn is caused by exposure of the lower esophagus to the acidic contents of the stomach. Normally, the lower esophageal sphincter (LES) separating the stomach from the esophagus is supposed to contract to prevent this situation. If the sphincter relaxes for any reason (as normally occurs during swallowing), stomach contents, mixed with gastric acid, can return into the esophagus. This return is also known as reflux, and may progress to gastroesophageal reflux disease (GERD) if it occurs frequently. Peristalsis, the rhythmic wave of muscular contraction in the esophagus, normally moves food down and past the LES and is responsible for ultimately clearing refluxed stomach contents. In addition, gastric acid can be neutralized by buffers present in saliva.


Foods that may cause Heartburn:

  • Alcohol
  • Coffee, tea, cola, and other caffeinated and carbonated beverages
  • Chocolate
  • Citrus fruits and juices
  • Tomatoes and tomato sauces (such as pizza and pasta sauce)
  • Spicy foods and fatty foods (including full-fat dairy products)
  • Peppermint and spearmint
  • Dry fruits such as peanuts


Physicians typically diagnose gastroesophageal reflux disease (GERD) based on symptoms alone. When the clinical presentation is unclear, other tests can be performed to confirm the diagnosis or exclude other disorders. Confirmatory tests include:

Ambulatory pH Monitoring

A probe can be placed via the nose into the esophagus to record the level of acidity in the lower esophagus. Because some degree of variation in acidity is normal, and small reflux events are relatively common, such monitors must be left in place for at least a 24-hour period to confirm the diagnosis of GERD. The test is particularly useful when the patient's symptoms can be correlated to episodes of increased esophageal acidity.

Upper Gastrointestinal (GI) Series

A series of x-rays of the upper digestive system are taken after drinking a barium solution. These can demonstrate reflux of barium into the esophagus, which suggests the possibility of gastroesophageal reflux disease. More accurately, fluoroscopy can be used to document reflux in real-time.


In this test, a pressure sensor (manometer) is passed through the mouth into the esophagus and measures the pressure of the lower esophageal sphincter directly.


The esophageal mucosa can be visualized directly by passing a thin, lighted tube with a tiny camera attached (an endoscope) through the mouth to examine the esophagus and stomach. In this way, evidence of esophageal inflammation can be detected, and biopsies taken if necessary.


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Plastic surgery rates on the rise in older adult population
From AORN Journal, 5/1/02

Seven percent of cosmetic procedures performed in 2000 were performed on women and men age 65 and older, according to a Feb 1, 2002, news release from the American Society for Aesthetic Plastic Surgery. Since 1997, the number of cosmetic procedures performed on people in this age group has increased by 352%. There are special considerations when performing plastic surgery on people of this age group, but age is not a contraindication to surgery.

One of the factors that affects the quality and longevity of cosmetic surgery results is skin elasticity, which diminishes with age. Patients who wait until later in life to undergo their first cosmetic procedure may not see the same results as a younger patient or a person who has undergone previous cosmetic procedures, but results still can be dramatic.

For older patients, surgical techniques may need to be altered. When performing a facelift on patients with thinning hair, for example, the surgeon may need to place incisions to better camouflage scars. Older patients also may choose to have their earlobes reduced when undergoing a facelift because earlobes grow and stretch with age and may look out of proportion after a facial procedure.

When performing eyelid surgery on older patients, tissue removal may need to be more conservative because patients may have a greater tendency to develop "dry eye." Older adults may prefer to have several mild facial peels as opposed to one deep chemical peel because their skin is thin. They also may need a modified "tummy tuck" when undergoing lipoplasty to get rid of excess skin that has lost its elasticity.

Extra precautions may be necessary for older patients with certain types of medical conditions. This may mean that additional medical personnel are needed during the procedure or that the procedure should be performed in a hospital. Special accommodations increase the cost of surgery. Patients age 65 and older also may require longer recovery periods than younger patients. Their bruising may take longer to subside, and incisions may take longer to heal.

Older Patients Benefit From Modified Cosmetic Plastic Surgery Techniques (news release, New York: American Society for Aesthetic Plastic Surgery, Feb 1, 2002) (accessed 5 Feb 2002).



1. One or more of the following lines of defense fail, allowing noxious content of the stomach to have increased contact time with the esophagus, except

a. allowing hydrogen ions to enter the cells of the esophagus.

b. buffering of gastrointestinal (GI) fluid content.

c. mechanical barrier from the stomach.

d. peristalsis of the esophagus.

2. Swallowed saliva and esophageal bicarbonate secretions buffer the normally acidic GI fluids to a pH

a. greater than two.

b. less than six.

c. greater than four.

d. less than eight.

3. Over time, acute and chronic inflammation occurs after multiple recurrent reflux events, leading to

a. decreased motility and possibly gastroesophageal reflux.

b. gastroesophageal reflux and possibly esophageal stricture formation.

c. hemorrhagic gastritis and possibly esophageal stricture formation.

d. GI obstruction and possibly hemorrhagic gastritis.

4. What organs initially are responsible for food digestion and bodily nourishment?

a. stomach, colon, liver, and small intestine

b. mouth, pancreas, colon, and pharynx

c. stomach, small intestines, liver, and pancreas

d. mouth, pharynx, esophagus, and stomach

5. -- and -- of solids and liquids start the digestive process.

a. Hydrolysis/mastication

b. Mastication/emulsification

c. Hydrolysis/emulsification

d. Mastication/catalysis

6. The lower esophageal sphincter (LES) is

a. an area of circular muscle fibers at the level of the diaphragm that relax to admit ingesta.

b. a band of circular fibers around the lower end of the common bile duct.

c. a double set of circular smooth bowel muscles at the opening of the anus.

d. a group of circular fibers arranged in a narrow band that constrict the dilation pupillae.

7. The stomach consists of the

a. LES, splenic flexure, and crura.

b. gastric flexure, body, and antrum.

c. fundus, body, and antrum.

d. antrum, LES, and crura.

8. The -- has surgical landmark value but plays no significant part in the disease process.

a. pancreas

b. caudate lobe of the liver

c. diaphragm

d. duodenum

9. Patients who suffer from typical symptoms of gastroesophageal reflux disease (GERD) complain about

a. dysphagia, odynophagia, hematemesis, or melena.

b. reflux asthma, hoarseness, pharyngitis, or pyrosis.

c. chronic halitosis and reflux asthma caused by gastric contents being aspirated in the airway.

d. heartburn and reflux of gastric contents into the esophagus when bending over or lying down.

10. Noninvasive medical treatment includes all of the following except

a. weight loss and dietary changes.

b. increased physical exercise.

c. medications.

d. bed rest.

11. Substances known to decrease lower esophageal sphincter pressure (LESP) that should be avoided in patients with GERD include

a. tobacco, caffeine, nuts, and mint.

b. calcium, alcohol, tobacco, and chocolate.

c. nuts, alcohol, mint, and calcium.

d. alcohol, chocolate, mint, and tobacco.

12. Open antireflux procedures were not performed on a regular basis for all of the following reasons except

a. increased morbidity and mortality.

b. long postoperative hospital stay.

c. collateral organ damage.

d. high failure rate.

13. The incidence of recurrent heartburn after laparoscopic Nissen fundoplication is -- and does not appear to be clinically significant.

a. less than 2%

b. approximately 5%

c. less than 10%

d. approximately 12%

14. A manometry study is indicated to rule out

a. abnormal motility.

b. carcinoma.

c. ulcerations.

d. strictures.

15. An open Nissen fundoplication procedure primarily is indicated for

a. Barrett's esophagus or unsuccessful medication treatment.

b. complex esophageal processes or Barrett's esophagus.

c. esophageal strictures or desire not to take medications long term.

d. complex esophageal processes or inability to pay for long-term medication treatment.

16. -- also can be monitored during a manometry study.

a. Thoracic aorta abnormalities

b. Esophageal diverticuli

c. Intra-abdominal pressure changes

d. Intrathoracic pressure changes

17. Patients who suffer from GERD have an LESP

a. between 5 mm Hg and 15 mm Hg.

b. less than 10 mm Hg.

c. between 10 mm Hg and 45 mm Hg.

d. greater than 40 mm Hg.

18. Atypical GERD symptoms include all of the following except

a. regurgitation.

b. nonobstructional dysphagia.

c. aspiration-induced asthma.

d. dental decay.

19. The most accurate gauge of acid being present in the esophageal lumen is a

a. manometry study.

b. upper gastrointestinal study.

c. esophagogastroduodenoscopy.

d. 24-hour pH monitoring examination.

20. Evidence suggests unequivocally that acid reflux is present if acid remains in the esophagus -- of the time.

a. less than 4%

b. 4% to 7%

c. 8% to 12%

d. 10% to 15%

21. A type -- hiatal hernia exists if the gastroesophageal junction and a portion of the stomach protrude into the mediastinum.

a. one

b. two

c. three

d. four

22. Sliding of the hernia is stress dependent and varies in severity depending on the volume present in the stomach.

a. true

b. false

23. Patients older than age 40 must undergo the following preoperative examinations:

a. electrocardiogram (EKG), urinalysis, and chest x-ray.

b. complete blood count (CBC), EKG, and chest x-ray.

c. EKG, CBC, and electrolyte profile.

d. electrolyte profile, chest x-ray, and treadmill.

24. The anesthesia classification for patients undergoing outpatient surgery should not exceed American Society of Anesthesiology class

a. I

b. II

c. III

d. IV

25. Droperidol is administered preoperatively to

a. prevent or reduce postoperative nausea and vomiting (N&V).

b. induce relaxation and drowsiness.

c. decrease secretions and block cardiac vagal reflexes.

d. produce sedation.

26. Ondansetron hydrochloride is administered postoperatively

a. to reverse neuromuscular blockers.

b. to prevent hypotension.

c. to treat short-term acute pain.

d. to prevent N&V.

27. The minor instrument set is placed on the back table to be used

a. during the procedure for retraction.

b. at the end of the procedure for wound closure.

c. during the procedure for dissection.

d. at the beginning of the procedure for trocar placement.

28. All of the following interventions are applicable to decrease the risk of infection for the patient undergoing laparoscopic Nissen fundoplication except

a. assesses renal status (eg, renal function studies, urinalysis, health history) preoperatively.

b. ensures that the patient is well hydrated with parenteral fluids.

c. inspects the wound during wound closure.

d. washes the wound and surrounding area to ensure that preoperative prep solution and blood are removed.

29. Which of the following nursing diagnoses would be applicable for the patient undergoing laparoscopic Nissen fundoplication?

a. Risk for activity intolerance related to intraoperative positioning.

b. Risk for ineffective breathing patterns related to hypothermia.

c. Risk of imbalanced nutrition related to inability to ingest food.

d. Risk for sleep pattern disturbances related to gastroesophageal reflux.

30. Which of the following interim outcome criteria would be applicable for the nursing diagnosis "Acute pain related to tissue trauma secondary to surgical procedure?"

a. Patient's vital signs and oxygen saturation levels remain within expected values.

b. Patient will consume an adequate amount of fluids and nutrients to meet the basal metabolic needs of the postoperative period.

c. Patient will maintain body weight or lose no more than 20 lbs after surgery.

d. Patient does not demonstrate nonverbal pain behaviors.

31. The RN first assistant (RNFA) at the surgery center is responsible for all of the following tasks except

a. accompanying the patient to the postanesthesia care unit and writing discharge orders.

b. providing preoperative and postoperative patient education.

c. operating the camera intraoperatively.

d. using the nonlocking bowel grasper to retract and create counter traction.

32. After placing the patient in the low lithotomy position, the nurse carefully abducts the patient's legs and

a. ensures that the patient's femerol, obturator, and sciatic nerves are not injured.

b. externally rotates the patient's legs for improved perineal exposure.

c. inserts an indwelling urinary catheter.

d. pads the sacrum to prevent sacral injury.

33. Preemptive anesthesia refers to

a. the surgeon injecting local anesthesia in the preoperative admitting area.

b. the anesthesia care provider assessing the patient in the preoperative area.

c. the anesthesia care provider ordering sedation to be administered preoperatively.

d. the surgeon injecting local anesthesia into the incisional sites before making the initial incision.

34. Why is the OR bed repositioned to reverse Trendelenburg's during the procedure?

a. to allow the scrub person adequate room to stand between the patient's legs

b. to treat concurrent hypotension experienced with retraction of the peritoneal wall

c. to allow the RNFA adequate room to stand between the patient's legs

d. to increase the visual field by allowing gravity to assist in retraction

35. How does the surgeon minimize potential bleeding when passing the stomach posterior to the esophagus to create the fundus wrap?

a. by injecting lidocaine with epinephrine locally as a hemostatic agent

b. by separating the right crus muscle from the esophagus to develop an avascular plain

c. by applying gelatin sponge or cellulose gauze topically to attain hemostasis

d. by using 0 absorbable endoscopic stitches as necessary to make the area avascular

36. The patient is not required to void before being discharged from the surgery center.

a. true

b. false

37. All of the following are postoperative dietary instructions following laparoscopic Nissen fundoplication except

a. remain on a liquid diet for five days.

b. do not consume carbonated beverages.

c. advance from soft to full diet during the next two to four weeks.

d. advance from soft to full diet during next five to six weeks.

38. Shoulder pain is common after undergoing laparoscopic abdominal surgery, so the RNFA instructs the patient to

a. take antiflatulant medications routinely every four to six hours for 48 hours.

b. lie on the affected side with a pillow under the hip, which allows the gas to move from the diaphragm to the pelvic area.

c. take antiflatulant medications as needed every two to four hours for 48 hours.

d. remain on bed rest for 24 hours.

39. A long-term, follow-up visit is scheduled for six months later for all of the following reasons except to

a. ensure that there are no problems with excessive weight gain.

b. ensure that there are no problems with swallowing difficulties.

c. ensure that there are no problems with excessive weight loss.

d. assess nutritional status.

40. In the case study, the patient desired medical treatment before surgery so the surgeon prescribed

a. pancreatic enzymes.

b. nonsteroidal anti-inflammatory medication.

c. proton pump inhibitor medication.

d. analgesics and antipyretics.

AORN, Association of periOperotive Registered Nurses, is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. AORN recognizes this activity as continuing education for registered nurses. This recognition does not imply that AORN or the ANCC's Commission on Accreditation approves or endorses any product included in the activity. AORN maintains the following state board of nursing provider numbers: Alabama ABNP0075, California CEP13019, and Florida FBN 2296. Check with your state board of nursing for acceptability of education activity for relicensure.

Professional nurses ore invited to submit manuscripts for the Home Study Program. Manuscripts or queries should be sent to Editor, AORN Journal, 2170 S Parker Rd, Suite 300, Denver, CO 802315711. As with oil manuscripts sent to the Journal, papers submitted for Home Study Programs should not have been previously published or submitted simultaneously to any other publication.

COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group

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