116 Theory Notes
116 Theory Notes
116 Theory Notes
❖ Metabolism
➢ Chemical processes occurring within a living cell or organism necessary for the maintenance of life
➢ digesting food and nutrients
➢ Ways when we do metabolism: breathing, muscles contract, kidneys are filtering waste products
❖ Review of Diagnostic Tests
➢ Serum Laboratory tests:
■ CBC
■ Prothrombin/ Partial Thromboplastin Time
■ Liver Function Tests
■ Serum Amylase, Lipase
● Increase = pancreatic injury
■ Triglycerides
➢ Stool Examination
➢ Abdominal Ultrasonography
■ non invasive using high freq sound waves, useful in large gallbladder, gallstones, ADvantage: not
expensive/low cost, does not need an ionizing radiation, no noticeable side effects ,immediate results)
➢ CT-scan of the abdomen
■ clearer outline of abdo structures, cross sectional images of organs
■ Use for detecting and localizing inflammatory conditions of colon (appendicitis
■ Can eval liver, spleen, kidney and pancreas
■ Done thru with or without IV contrast agents(
● for better enhancement: contrast agents are used so it is needed to
◆ ask if client is allergic to the agent, Iodine, shellfish,
◆ assess the creatinine levels to eval kidney function
● If pt is given sodium bicarbonate - adm one hr before and 6 hrs after iv contrast to give protective
measure to kidneys
➢ MRI of the Abdomen
■ Supplement Ultrasound and Ct, non invasive tech and
■ Useful in eval abdominal soft tissues , blood vessels and fistulas
■ Has a ferum magnetic - metal with iron that can be attracted to magnet =injury like burns
● Nursing reqs before: remove jewelries/metal devices, ask if client has pacemaker, NPO 6-8hrs prior,
remove implants, inform may take 60-90 mins long, explain positioning, what equipment looks like
9lessen anxiety for claustrophobic pt)
➢ Upper GI Series /Upper GI Fluoroscopy
■ Aka: Barium Swallow
■ Radiographic exams/ x ray exam that visualizes the esophagus, stomach and duodenum
➢ Endoscopy / Esophagogastroduodenoscopy - endoscope or scope is onserted via mouth
➢ Endoscopic Retrograde Cholangiopancreatography (ERCP -endoscope plus xray (helpful pancreatitis, common bile
duct stones)
■ NPO 8 hrs prior
■ Local anesthetics via gargle or spray - gag reflux is inactivated or less
➢ Lower GI Series/Lower GI FLuoroscopy
■ Aka Barium Enema
■ Visualizing the colon
➢ Colonoscopy
■ Fiber optic scope inserted via anus
Assessment Assessment
PAIN Recurrent attack of severe abdominal (epigastric) and
Severe epigastric/LUQ back pain with vomiting
Radiate to back and shoulder: Boring-feeling Link with meals(you can experience pain), unrelieved by
something in body and contin food or antacid
Occurs after heavy meal or alcohol ingestion Anorexia (have fear if they eat they will feel pain),
Abdo pain=unrelieved by antacids Weight loss - fat malabsorption
Tender from irritation and edema Constipation, fever, Jaundice, muscle wasting
Vomiting, dec BS, Edema (it can be in feet, legs, and hands this is due to
Abdo distention and RIGID (sign of peritonitis) protein malabsorption because the pancreas also
provide enzymes that can absorb and digest proteins so
HALLMARK SIGNS (SEVERE PANCREATITIS) it decreases the levels of the circulating albumin so
o TURNER’S SIGN -ecchymosis of flank there is protein malabsorption.
o CULLEN’S SIGN - ecchymosis of periumbilical area Steatorrhea - fruity foul smelling due to impaired fat
[pancreatic enzymes leaks to tissues=ecchymosis] digestion and the stool looks like igit because it has a
high fat content.
Diag Tests Diag Tests
ELEVATED: To confirm diagnosis but also based on s/s, labs & imaging
Amylase & lipase w/in 24 hrs ERCP (endoscopic retrograde
Bilirubin (acc w/ biliary dysfxn, gallbladder or cholangiopancreatography)
common bile duct inv) to visualize the pancreas and the common bile duct.
Glucose (pancreatic cell injury), WBC Only definitive test
DECREASED: Used to identify for calcifications of pancreatic
Calcium (fat necrosis) tissues and biopsies specimens
HgB, Hcb (in bleeding) may delineate the presence of pancreatic
Ultrasonography (for gallstones inv or blockage) pseudocyst - a cyst like appearance but not a cyst.
xray of abdo and chest (pleural effusion) A cyst filled with pancreatic fluid.
CT SCAN - reliable diagnosis MRI, CT Scan, Ultrasound
Glucose Tolerance Test - eval the pancreatic islet
cell function. If abnormal, this may indicate DM
Stool Exam - analysis of fecal fat content, confirmes
steatorrhea
Medical TX Med TX
NPO (let panc rest and reduce enzymes) “Tx is directed towards preventing/managing acute attacks,
TPN relieving pain and discomfort, manage exo/endo insuff of
Pancreatic enzyme replacement pancreas
Biliary drainage Non-opioids &non pharmaco intervs - for pain
NGT Suction (drain the pancreas= dec painful abdo Avoid alcohol
distention Insulin/opral antidiabetic agents (DM)
Intubation & Mec Vent in atelectasis Pancreatic enzyme replacement - Pancrelipase
Given with meals or snacks- aid in digs and
absorption of proteins and fats
Take meds before or during meals with water
No sign of steatorrhea (less fatty content) - sign
that replacement is effective
Pharma TX Surg TX
Pancreaticojejunostomy (Roux-en-Y)
Ranitidine, Cimetidine (h2 blockers to dec gastric side to side anastomosis of the pancreatic duct to
secretions) the jejunum allows drainage of pancreatic secretions
Pantoprazole to the jejunum = provides pain relief
Opioids (Morphine, Fentanyl) for pain Occurs within 6 months. Pain returns in a substantial
Antiemetic agents; Anticholinergic - reduce pancreatic number of patients as the disease progresses.
and gastric secretions Pancreaticoduodenectomy (Whipple resection or procedure)
removal of the head of the pancreas
First part of the duodenum, gallbladder and bile duct
is removed.
For relief of chronic pain
Usually indicated for pancreatic cancer.
Nursing management Nursing management
CHOLECYSTITIS
- Acute inflammation of gallbladder, Problem: bile could not get out (static stage or not moving) of cystic duct due to
obstruction = inflammation = chemical irritant = stasis = bacterial invasion = empyema , pus formation or infection
- Inflamed due to obstruction
- An empyema of gallbladder develops if the gallbladder becomes filled with purulent fluid. There is pus formation because of
infection.
- Bile contents are composed of fat and cholesterol
Pathophysiology
Blockage in cystic duct by gallbladder stone = impairs flow of bile from gallbladder towards duodenum = increases
pressure of gallbladder wall and mucosa
Bile can’t be moved = stasis (means it remained there for a long period of time) =chem&bacterial inflammation =
necrosis or perforation
Obstruction + inflammation+stasis of bile = chemical irritant to gallbladder = mucosa secretes mucus and other
inflam enzymes = increase distention and pressure
Stasis of bile = good place for bac invasion = peritonitis (pt feels rebounded tenderness)
Bacterial invasion = emphysema or pus formation due to infection
Assessment
CHRONIC PAIN ACUTE PAIN
VAGUE AND NON-SPECIFIC, Often asymptomatic SPECIFIC (entire RUQ, may radiate to the back, right
scapula, shoulder), lasts for 12-18HRS
Results from repeated bouts of acute cholecystitis or aggravated by movement or DBE
from persistent irritation of the gallbladder wall by Nausea and vomiting, anorexia,
the stones Fever with chills (infection)
BLUMBERG'S SIGN - Rebound tenderness, pain upon
Bacteria may be present in the bile as well removal of pressure to abdo
MURPHY'S SIGN - Pain increasing with deep inspiration
(reliable for peritoneal irritation)
Pharma TX Med TX
URSODIOL (ACTIGALL) T- TUBE INSERTION - to maintain patency of duct ad promote
well tolerated with few side effects bile passage as edema decreases
CHOLELITHIASIS
Surg TX Med TX
LIVER CIRRHOSIS
chronic , progressive liver condition - diffuse fibrotic bands of connective tissue that disrupts liver function
The last stage of liver disease, irreversible, could lead to liver failure, functional liver tissues gradually destroyed
and is replaced by fibrous scar tissue, blood flow is impaired towards the inferior vena cava w/c results to the
blood to shunt back to the lower organs also called as portal hypertension
Assessment Complications
Dull, aching pain RUQ LATE SIGNS: Portal hypertension- the blood is shunted back to the
Fever, N&V, Diarrhea lower pressure vessels, the affected vessels will be
Anorexia and malaise Liver enlargement engorged, this may affect the rectum, stomach,
Ascites, Edema Ascites esophagus = one of the manifestation of pt that has
Jaundice, Hypotension Infection and liver cirrhosis is esophageal varicose veins
Muscle wasting, weight loss
peritonitis Splenomegaly- there's backflow of blood to the splenic
Edema
Vit deficiency and
Continuous mild fever vein, there is decreased platelet, wbc, anemia,
Purpura Ascites- increased pressure in capillaries it pushes fluid
Spontaneous bruising, to the peritoneal cavity
epistaxis (because of the lack of vit K) Hepatic encephalopathy- ammonia is present in the
Sparse body hair, Gonadal atrophy brain, manifestation of this is asterixis (when the pt
wrist and fingers are observed to flap because of a brief,
rapid relaxation of wrist dorsiflex)
DECREASED:
albumin
CT scan
MRI
Radioisotope liver scans
Liver biopsy
Surg TX Nursing Management
Additional Notes:
Altered comfort: pain ass, provide non-irritating food, IV Therapy, Non-irritating diet, Diluting & Neutralizing acid/alkali,
meds No lavage for corrosive substance, Metrodinazole for h. Pylori,
Risk for imbalanced nutria: sym management Ranitidine, esomeprazole, sucrafate, NPO, start from liq to solid
Risk for FVD: I/O monitoring, adequate hydration food, Antacids
PEPTIC ULCER DISEASE
Excavation that is formed in the mucosal wall of the stomach, pylorus, duodenum and stomach
More likely in duodenum than stomach, because the duodenum is more sensitive, it cannot withstand the presence
of hydrochloric acid and pepsin unlike the stomach
Mainly in gastric-duodenal mucosa, this tissue is unable to withstand digestive reaction of gastric acid and pepsin
More frequently between ages 40-60 years
Erosion found in the circumscribe of mucosal wall
CAUSES:
A. H. pylori infection = MAIN CAUSE PATHOPHYSIOLOGY:
B. Excessive alcohol intake and smoking 1. Increased gastrin and pepsin
C. Long-term NSAID use 2. Damaged mucosa can't
D. Ingestion of milk, caffeinated beverage(high amount of ingestion) secrete mucus for protection
E. Susceptible to blood type O
STRESS ULCERS ZOLLINGER-ELLISON SYNDROME
1. CUSHING’S ULCER 2. CURLING’S ULCER Is a peptic ulcer disease caused by a gastrinoma or gastrin-
secreting tumor of the pancreas, stomach or intestines
head injury/brain occurs 72 hrs after
trauma extensive burns
high levels of HCI acid entering the duodenum = diarrhea
deeper and (antrum, stomach,
penetrating duodenum) and steatorrhea
(esophagus, stomach,
duodenum)
Assessment Med TX
B. Duodenal
Decrease pain if patient eats
Weight gain
Diagnostic Tests Complications
APPENDICITIS
Most common cause of acute surgical abdomen
Appendix- storage of solid small particles
Appendix becomes inflamed and edematous as result of either becoming kinked/occluded by a fecalith (hardened mass
of stool) tumor, foreign body; common in males
Fecalith (occluded material)=lumen is blocked, intestinal mucosa still continues to secrete the fluid = cause pressure
build up= blood flow is being restricted=can cause infection=lead to swelling= peritonitis may result, if the swelling
burst= gangrene and hypoxia may occur
Intestinal mucosa cont to secrete fluid= buildup = inflammation, blood flow is restricted due to blockage = gangrene,
hypoxia = rupture
Inflammatory process, high intraluminal pressure, RLQ pain and usually accompanied by a low grade fever
initiating a progressively severe, generalized or Anorexia
upper abdominal pain that becomes localized in RLQ Nausea and vomiting
Pain on defecation
of abdomen within a few hours
Constipation
Eventually, the inflamed appendix fills with pus from Local tenderness on McBurney's point
ileum Rovsing’s sign- pressure on LLQ and pain is felt in RLQ
Psoas sign- pain on flexion of the right thigh towards the
body will elicit pain
DIAGNOSTIC TESTS:
o X-ray
o Ultrasound
o CT scan
Assessment Medications
Diarrhea; 10-20 liquid stools each day Aminosalicylates (azulfidine)
Passage of mucus and pus Corticosteroids (prednisone)
Left lower quadrant pain immunodilators:
Intermittent tenesmus o Azathioprine
Rectal bleeding; anemia o Mercaptopurine
Weight loss o Methotrexate
Rebound tenderness o Cyclosporine
Pain at LLQ Biologic agents:
o Natalisumab- crohn’s disease
o Infliximab- ulcerative colitis
Nursing management
GOAL: reduce inflammation, suppress inapp immune
response Altered bowel elimination: Diarrhea r/t inflammatory process
Bedside commode
Nutrition and hydration Chart consistency of stools
Oral fluids and IVF therapy Fluid volume deficit r/t diarrhea, nausea
Low-residue, high protein, high calorie IVF therapy
Vitamin and iron supplement Weigh daily
Avoid cold foods and milk products( this could Encourage oral fluid intake
increase intestinal motility) Dietary restrictions for diarrhea
DIVERTICULAR DISEASE
DIVERTICULOSIS DIVERTICULITIS
Assessment Med TX
Chronic constipation; narrow stools Clear liquid initially, high fiber& low fat
Bowel irregular- constipation/diarrhea (to inc stool volume),reduce intraluminal pressure
Nausea, anorexia Bulk-forming laxatives as ordered
Bloating, abdominal distention Psyllium fiber)
Pain in LLQ Stool softeners (docusate)- to decrease intraluminal
Nursing management pressure when you defecate
Constipation r/t strictures, narrowed colon Rest the bowel
Oral fluid intake up to 2L/day withhold oral intake
Soft, fiber-rich foods NGT suctioning
Veges, cereals (increase bulk in stool) Meperidine (demerol) for pain as ordered
Exercise - no morphine (addictive)
Psyllium and stool softeners as ordered antispasmodics : oxyphencyclimine (daricon) as ordered
Oil retention enema Antibiotics for 7-10 day
Barium Enema- lower Gi, visualize colon
Module 1M: Concept of Metabolism and Alterations
in Ingestion
Structures and functions of GI system:
Mouth - consists of
lips (for speech)
oral cavity
formed by soft and hard palate,
contains the teeth : used in mastication/chewing
tongue : solid muscle mass, assist in chewing and
moving food, important in speech
three pairs of salivary glands parotid, submaxillary
and sublingual : produce saliva
Four layers (inner to outer): mucosa, submucosa,
muscle, serosa Pharynx -divided into
Main function- to supply nutrients to body cells nasopharynx, laryngeal
thru process : ingestion, digestion, absorption, oropharynx
elimination provides route for food from mouth to esophagus
Epiglottis: covers larynx during swallowing
Tonsils and adenoids: assist in preventing infection
Energy
o capacity to perform activities Patho/Disease process of alteration in ingestion
Human energy - muscle contractions ♥ Cleft lip
and heat production Caused by failure of the nasal and
Heat=calories=energy maxillary processes to fuse between the
Metabolic Rate 5th and 8th week of gestation
o Amount of energy expended in a given unit of Cleft lip POST OP CARE:
time o Choking, Logan bar, Evaluate
o 3 components: bmr airway, Feed slowly, Teaching,
Basal Metabolic Rate Lamb’s nipple, Incidence high in
o Amount of energy used in a unit time by males, Prevent crust formation
and aspiration
fasting, resting subject to maintain vital
functions
♥ Cleft palate
o 60-75%
Caused by failure of the palatine plates
o Increase in activities, thermal effect of food
to fuse between the 7th and 12th week
Aka BEE -basal en expenditure
of gestation
Nutrient
o substance that provides nourishment essential
Diagnostic exams:
for growth and the maintenance of life. Visual inspection and palpation after birth
Metabolism - processes of biochemical reactions Ultrasound or sonogram while in the uterus
occurring in the cells necessary to maintain life Surgical Management:
CHEOLIOPLASTY (left lip repair) - reqs more
Basic activities and process of the GI tract than 1 procedure
Closure of the lip-performed app 3
Ingestion - entry of food into the digestive months of age or 12 pounds
tract through the mouth Closure of the palate-performed app 1
Propulsion- movement of food through the year or within 6-18 months
GI tract Nursing Actions
Digestion -breakdown of food mechanically Suction secretions gently
into smaller bits and chemically by Place infant on side to prevent pressure and
enzymes tearing of suture line after CL surgery
Absorption - nutrients and water are Feed infant using commercial cleft lip nipple
absorbed in the intestines *Brecht or Haberman Feeder)
Defecation - removal of undigested Method: Enlarge, Stimulate, Swallow and Rest
materials from the body as waste (ESSR)
Secretion -
Instruct mother how to pump or manually
express breast milk to maintain supply at this
time
Bubble th infant well after feeding ♥ Kwashiorkor
Offer small sips of fluid (clear water) or place Maladaptive response to starvation
membranes as crust formation Protein PEMS
Keep suture line as clean as possible after ♥ Marasmus
feeding
Adaptive response to starvation
♥ Malnutrition Protein PMS
Causes:
Indicators for undernutrition:
o Inadquate food intake (main problem)
o Stunting
o Poor standard living
o Wasting
o Inadeq knowledge of optimal nutri intake
o Underweight
o Inadeq absorption
♥ Esophageal fistula/ Treacheoesophageal Fistula/
Nutrition on the 1st 1000 days of a Child
TEF
In 2015, global community adopted the
Abnormal passage between windpipe and esophagus
17LGobal Goals for Sustainabel Dev to improve
Congenital anomaly (6-8 weeks)
people’s lvies by 2030
Goal 2: Zero Hunger - pledges to end hunger, Life-threatening
S/S:
achieve good security, improve nutri and
o Copious, fine, frothy bubles of mucus in mouth and
promote sustainable agriculture and si the
sometimes in nose
priority of World Food Programme. o Rattling respirations
Malnutrition in the Phils o Episodes of coughing, choking, cyanosis (3C)
Metro manila (CNN Phils, May 2, 20170 - acc
Med/Sug tx:
to Save the Children Foundation 1 in 3
o Gastrostomy feeding /TPN
children below 5 yo in the Philippines is
o Closing of fistula and gastrostomy tube
malnourished
insertion (to minimize GERD)
Food And nutrition Research Institute: 26% of
o Anastomosis
children up to 2 yo suffer from chronic
malnutri, the highest number in 10 years Complicaiton:
Many children, including those in poor o Aspiration Pneumonia
communities, may have access to food, but Objectives of care:
they’re not eating right, because parents lack o Airway will remain patent
basic knowledge on proper nutri o Hydration maintained
o Family teaching
Obs for esophageal stricture-dysphagia,
increased drooling, coughing, choking
Gastrostomy, care and feeding
Malignant TEFS
Individualized and started promptly
Palliative care
o Relief of obstruction
o Diversion fo contamination from Respi
Tract
Procedures
o Endoprosthesis (covered self-expandable
metal stent/SEMS)
o Esophageal exclusion or bypass, resection
or direct closure
Functional obstruction
the intestinal musculature cannot propel the Two Classifications:
contents along the bowel, more on
problems on the muscles in the Small Bowel Obstruction
intestines Large Bowel Obstruction
blockage is temporary and the result of
manipulation of the bowel during surgery
examples
o amyloidosis, muscular dystrophy,
endocrine disorders [diabetes] or
neurologic disorders[ Parkinson’s
disease])
Pathophysiology:
Due to intestinal obstruction, there is accumulation of intestinal contents, fluid and gas on the upper
part of the intestinal obstruction =abdominal distention and retention of fluid that reduces absorption
of fluids and stimulates more gastric secretions = increasing distention = increases pressure in within
intestinal lumen =decrease in venous and arteriolar capillary pressure= edema, congestion, necrosis
and eventual rupture or perforation of the intestinal wall, with resultant peritonitis.
S/S Nursing Management
Ileum obstruction
fecal vomiting
Medical Management
o characteristic of vomitus: client will vomit
first the stomach contents, then the bile- Decompression of bowel through a NGT
stained contents of the duodenum and the Mandatory monitoring of bowel ischemia
jejunum, and finally, w/ each paroxysm of Administration of IV fluids before surgery
pain, the darker, fecal-like contents of the
ileum)
Surgical Management
Pathophysiology:
dramatic because if the blood supply to the colon is not disturbed = not have a lot of complications
if there is a cut off of blood supply, intestinal strangulation, necrosis = life-threatening
Adenocarcinoid tumors account for majority of large bowel obstructions
Pathophysiology
Congenital or acquired muscle weakness, Increased intra-abdo pressure,
Obesity, pregnancy, lifting of heavy objects, abdominal distention, coughing, ascites = weakens
collagen - widens the spaces at the inguinal ligament = defects in the muscle wall = presence of
lump or protrusion in the area (s/s)
FIVE TYPES
Indirect Inguinal hernia Direct inguinal hernia Femoral Hernia
A sac formed from the Passes through a weak point in Protrudes through the
peritoneum that contains a the abdominal wall femoral ring
portion of the intestine or Occurs more in older adults A plug of fat in the femoral
omentum canal enlarges and pulls
Pushes downward at an peritoneum and urinary
angle into the inguinal canal bladder into the sac
Common in males because Common in obese or
the follow the tract that pregnant woman
develops when the testis
descends into the scrotum Umbilical hernia Incisional/Ventral hernia
before birth
In males = becomes large Congenital - appear in Occurs at the site of a prev
and descends in the scrotum infancy surgical incision due to
Acquired - result from inadeq healing of incision
increasing abdo pressure, caused by post op wound
common in people who are infection, inadeq nutrition
obese and obese
CLASSIFICATIONS
Reducible hernia Strangulated hernia Irreducible hernia/
incarcerated
Contents of the hernial Blood supply to the
sac can be placed back into the herniated segment of the bowel is Cannot be reduced or
abdominal cavity by gentle cut off by pressure from the hernia placed back into the
pressure ring = ischemia & obstruction of abdominal cavity,
During assessment - lump bowel = necrosis and possibly Reqs immediate cervical
or protrusion disappear when bowel perforation evaluation
client is lying flat Never forcibly reduced
o Ask the client to because it can cause strangulated
strain or perform valsalva intestine to rupture, never force a
maneuver - bulging of hernia
hernia S/s:
o Ask client to cough o Abdo distention
o Auscultate bowel o Absence of bowel
sounds - absence indicates sounds
obstruction and strangulation o Nausea, vomiting
,pain, fever, tachycardia
Assessment
Perform an abdominal assessment
Client is lying down For male client suspects a hernia in the groin
Client is standing
Have the client stand
For inguinal hernia Use index finger on the right hand on the
Health care provider gently examines the client’s right side and left hand on the left side
ring and its contents by inserting a finger in Examiner invaginates the loose scrotal skin with
the ring and noting any changes when the the index finger, following the spermatic cord
client coughs upward to the external inguinal cord
Ask client to cough - palpate hernia
Never forcibly reduced because it can cause
strangulated intestine to rupture, never force a
hernia
Nonsurgical Management Nursing Management
Truss
A pad made with firm material Thorough Physical Exam
Held in place over the hernia with a belt to help Pre op - NPO (most important pre op
keep the abdominal contents from protruding into preparation)
the hernial sac.
Post op:
For patients who are not a surgical candidate.
Often given to older male clients and has multiple o difficulty in voiding (immediate postop prob)
health problems. Encourage male clients to stand to allow a more
Most likely given to clients with inguinal hernia. natural position for gravity to facilitate voiding
Applied only after the physician has reduced the and bladder emptying.
hernia, if it is none incarcerated. Let the client hear a dashing sound of water that
applies the truss upon patient awakens. stimulates voiding.
As a nurse, teach the client to assess the skin
Let the client have a fluid intake of at least 1,500-
under the truss daily and protect it with a light
layer of powder to check if there are any sores 2,500mL to prevent dehydration, maintain urinary
function, minimize constipation and to allow the
Surgical Management client to void.
o Avoid coughing (Place a pillow on the abdomen of
Herniorrhaphy the pt and then that’s when you let the pt cough)
o Teach the client to rest for several days
Surgery of choice, open the client and perform
herniorrhaphy, o Remind the client to observe the small incisions for
The end result should have a mesh. redness, induration, heat, drainage and increased
Minimally Invasive Inguinal Hernia Repair pain and report their occurrence to the surgeon.
(MIIHR) through a laparoscope (The surgeon Especially if you are just having MIIHR there will be
makes several small incisions, identifies the just a small incision so always check if there are any
defect, and covers the weakened area with a
signs of inflammation with those incisions.
mesh patch on the inside of the abdominal wall.
o Encourage deep breathing
Hernioplasty o Assist in placing scrotal support and ice bags and
The surgeon reinforced the weakened outside elevate to the scrotum to prevent swelling
muscle with a mesh patch. o Instruct the client to keep the wound dry and clean
with antibacterial soap and water.
INTUSSUSCEPTION
One part of the intestine slips into another part located below or above - “telescoping of the intestine”
more common in infants (3rd month - 3 yo, peak: 5th-9th month) & adults (common in male, w/ cystic
fibrosis)
Most common site: ileocecal valve (inv ileum and the cecum) - cause is Unknown.
Sigmoid Volvulus - most Mesentery is twisted = blood flow Sigmoidoscopy (the probe is only
common and common during is cut off = infarction inserted to the sigmoid part of the
pregnancy (fetus can cause Intermittent vomiting colon)
displacement and twisting of the Recurrent abdominal pain Treatment for sigmoid volvulus
colon), abdo adhesions Abdominal distention Untwist and decompress the
Middle aged and elderly - most Lower GI bleeding/bloody stool colon to relieve pressure
common symptom: chronic Colonoscopy (probe is inserted in
constipation Diagnostic Findings the colon)
May be used to resolve cecal
Cecal Volvulus (affects the Upper GI series - definitive volvulus
cecum) procedure for infants. It is what
Young adults (most we also call the barium swallow Surgical Management
common) in which the client is asked to
Abdominal mesentery didn’t take in the barium solution so Untwisting of the colon
develop normally that we will have a clear view Attaching the intestine up
of the affected area. against the abdominal wall to
Midgut Volvulus Abdominal X-ray - shows a coffee prevent it from twisting
Twisting of the small intestine, bean image Bowel resection - infarction
dueto abno dev of fetus Barium enema - shows a bird's (removing the part of the colon
Common in babies and small beak shape. which has the infarction due to the
children
volvulus)
ASCARIS BOLUS
there is a ball of ascaris worms into the intestine = obstruction
Ascaris lumbricoides is the largest of the intestinal nematodes affecting humans, measuring 15-35
cm in length in adulthood.
Pathophysiology:
“Fertilized eggs passed in feces = Infective larva develops within egg in soil = man ingests eggs in
food or soil = Intestine = Venous system = Lungs = Trachea = Esophagus = Adult worms in
intestine (live for 6-24 months = cause partial or complete bowel obstruction)”
“egg ingestion to new egg passage takes 9 weeks + 3 weeks needed for egg moting before capable of
infecting new host. Eggs are not shed in stool until roughly 40 days after the de of the pulmonary symp”
S/S Diagnostic Findings Surgical Management
PERITONITIS
Inflammation of the peritoneum (the serous membrane lining of the abdominal cavity and covering the
viscera)
CAUSES: Bacteria Inf (common: e coli, klebsiella, proteus pseudomonas and streptococcus), Injury/
Trauma, Inflam from organ that extends to the cavity, Abdo surgical procedures/ peritoneal dialysis
S/S Pathophysiology
Diffuse pain-constant-localized-more intense over
the site of pathologic process (site of the maximal Leakage of contents from abdominal organs
peritoneal irritation) into the abdominal cavity( there is
Abdomen- extremely tender and distended and inflammation,infection, ischemia, trauma, and
muscles become rigid tumor perforation)
Rebound tenderness and paralytic ileus Bacterial proliferation occurs
Diminished perception of pain (if peritonitis occur of Edema of the tissues results, and exudation of
people receiving corticosteroids and analgesics) fluid develops in a short time
Anorexia, nausea and vomiting Fluid in the peritoneal cavity= turbid w/ high
Peristalsis is diminished amounts of protein, WBC, cellular debris and
Inc Temp & PR blood (the immediate response of the
Hypotensive- progression of peritonitis intestinal tract is hypermotility, ff by paralytic
ileus with an accumulation of air and fluid in
Diagnostic Findings the bowel)
Monitor for signs and No passage of stool within 24 to 48 Low level defect
symptoms of infection hours after birth o Rectum descends through
presence of an anal membrane puborectalis muscle
missing or misplaced opening to the
side lying with legs flexed o functional anal sphincters
anus
or prone external fistula to the perineum or o no connection with the
GUT urinary tract
teach SO on how to take
temperature via axillary High level defect
route Surgical TX
o Rectum ends above
Anoplasty + daily manual dilations
(Low level defect) puborectalis muscle it is
Toilet training ineffective
closing any small tube like o non-functional anal
Karaya gum powder (onto openings (fistulas) creating an sphincters
the ostomies) anal opening and putting the
Easy to use rectal pouch into the anal Tests
absorbs moisture opening
for better Abdominal x-ray overview of the
Temporary Colostomy anatomical location
adhesion closure: 6months - 1yr abdominal ultrasound
Soothes and helps
rectal thermometer is insert
to heal sore skin
and
alcohol free
HEMORRHOIDS
Presence of dilated portions of veins in the anal canal, common in men
unnaturally swollen or distended veins in the anorectal region
There is a shearing in the mucosa during defecation results in the he sliding of the structure in the wall
of the anal canal including the hemorrhoidal and vascular tissues
The increased pressure on the hemorrhoidal tissue actually due to pregnancy Initiate hemorrhoids or
aggravate existing hemorrhoids
Causes S/S
Meds: Anticholinergic, Antidepressants anti- fewer than three bowel movements per week
hypertensives, diuretics and opioids (side effects) abdominal distension
erectile or anal disorders (hemorrhoids & fissures) pain & pressure on the lower abdo & rectum
obstructions (vowel tumors) decreased appetite, headache, fatigue
metabolic and neurologic, neuromuscular conditions indigestion
(sprong disease, parkinson's parkinson's disease, sensation of incomplete evacuation and straining
endocrine disorders: hypothyroidism, at stool and elimination of small volume lumpy
pheochromocytoma, lead poisoning and connective hard and dry stools that req manual removal
tissue disorders such as SLE)
weakness immobility debility fatigue and inability to Complications
increase intra-abdominal pressure to facilitate the
passage of stools (emphysema, spinal cord injury) Hypertension - due to straining
not taking time to defecate or ignoring the urge to Fecal impaction - feces cant expelled= manual
defecate = rectal mucous membrane and the removal
musculature becomes insensitive to the presence of
Hemorrhoids - passage of perianal vascular
the fecal masses = reqs stronger stimulus
congestion causing by straining
consequently required to produce the necessary
Anal fissures - hard stool = tears anal lining
peristaltic rush for defecation and
Mega pollen
aging = decrease in muscle tone
- common in infants & adults
dietary habits (low consumption of fiber or water)
- a dilated anatomic colon caused by fecal
lack of regular exercise and stress
mass that obstructs the passage of the
colon contents
Management Nursing management
sit onto the toilet with legs supported and to utilize Inform how to defecate properly
the gastrocolic reflex emphasize importance of responding to the urge to
following a meal and warm milk, gastrocolic defecate
reflex it is the peristaltic movement of the large describe how to establish a bowel routine
bowel occurring 5-6 times daily that are triggered Best time to defecate is after meal
by this tension of the stomach provide dietary information: suggest eating high
not recommended: 90 degree angle in sitting into residue high fiber foods such as fruits and
the toilet, you need to have a 35 degree angle, vegetables, adding bran daily must be introduced
(can really push right) gradually and increase fluid intake unless
routine exercise to strengthen abdominal muscles. contraindicated to the client
Biofeedback helps to relax the sphincter explain how to exercise, increased ambulation and
mechanism to expel stool. abdominal muscle toning = increase muscle
25 to 30 grams of fiber per day strength and help propel colon contents
Laxatives: bulk forming agents (fiber laxatives describe abdominal toning exercises to contract
saline and osmotic agents, lubricants and the abdominal mass muscles like 4 times daily and
stimulants and fecal softeners) leg the chest lip lifts 10 to 20 times each day to
prevent constipation
long-term laxative normal position in defecating is semi-squatting
bulk forming + osmotic
= maximizes the use of the abdominal muscles
laxative (not overuse= rebound effect)
and force of gravity
Enemas and rectal suppositories Educate patients to avoid overuse of stimulant
not recommended for treating constipation laxatives because it will result constipation.
unless there is rectal evacuation.
Glycerin suppository
first line therapy ff by sakodal suppositories and
mini-enemas.
Module 4M: Disturbances in Glucose Metabolism
Pancreas
Plays a big role in digestion.
It is located inside our abdomen just behind our stomach. It is about the size of our hand.
During digestion, our pancreas makes pancreatic juices called enzymes. These enzymes break down sugars, fats, and
starches. It also helps our digestive system by making hormones - these are chemical messengers that travel to our
blood.
Pancreatic hormones help regulate our blood sugar levels and appetite. It stimulates stomach acid and tells the
stomach when to empty. It has two fxns: exocrine and endocrine. Exo= ducts, endo=blood.
The bulk of the pancreas is composed of exocrine cells that produce enzymes to help with the digestion of food. These
exocrine cells/ acinar cells release their enzymes into a series of progressively larger tubes called ducts that eventually
join together to form the main pancreatic duct. The main pancreatic duct runs the length of the pancreas and drains the
fluid produced by the exocrine cells into the duodenum.
The second fxnal component of the pancreas is the endocrine pancreas. It is composed of small islands of cells,
called the islets of langerhans. They don’t release their secretions into the pancreatic ducts, instead they release
hormones such as insulin and glucagon into the bloodstream and help control blood sugar levels.
The pancreatic islets are small islands of cells that produce hormones that regulate blood glucose levels. Hormones
produced in the pancreatic islets are secreted directly into the blood flow by five different types of cells. The endocrine
cells subsets: alpha, beta and delta cells. Other two types of cells in the pancreas (more on exocrine fxns): Gamma and
epsilon cells
Gamma cells produce pancreatic polypeptides and make up 3 to 5% of the total islet cells. Pancreatic polypeptide
regulates both the endocrine and exocrine pancreatic functions or secretions.
Epsilon cells that produce ghrelin and make up less than 1% of total islets cells is a protein that stimulates hunger.
ALPHA CELLS
Produces glucagon and makes up 15-20% of total islet cells. It is a hormone that raises blood sugar levels by stimulating
the liver to convert glycogen into glucose.
It is the first endocrine cell inside the islet of langerhans.
Secretes glucagon to increase blood glucose levels.
It undergoes:
Glycogenolysis - glycogen to glucose
Gluconeogenesis - a non carb is turned into glucose
Lipolysis - fat breakdown & ketone formation.
Types of Pancreatic Cells:
ALPHA CELLS
BETA CELLS
o Only cells in the body w/ natural capacity to make insulin = last and only hope for regulating blood glucose levels
on its own
o secretes insulin and amylin
o Make up 65%-80% of the total islet cells
o Insulin lowers blood glucose levels by stimulating cells to intake glucose = enhances membranes transport of
glucose, responsible for a disease and important for treatment
Main task: help turn food into energy. After food is eaten, carbs are broken down in the sugar glucose,
then enters blood stream for distribution
Key that opens the cell to glucose
Insulin is a hormone and a protein (manufactured in the body using information in the genes
o Amylin slows gastric emptying, prevents spikes of blood glucose levels
o Exemptions: This is because these cells don't use GLUT4 for importing glucose, but rather, another transporter
that is not insulin-dependent.
brain - Blood brain barrier stops insulin from entering in the brain
Liver -
intestinal mucosa -
o Glycogenesis = glucose= glycogen - stored energy
When insulin concentrations are low, GLUT4 glucose transporters are present in cytoplasmic vesicles, where they are
useless for transporting glucose. Binding of insulin to receptors on such cells leads rapidly to fusion of those vesicles with
the plasma membrane and insertion of the glucose transporters, thereby giving the cell an ability to efficiently take up
glucose. When blood levels of insulin decrease and insulin receptors are no longer occupied, the glucose transporters are
recycled back into the cytoplasm.
Target= Customized/Individual
eAG/A1C
Average of glucose levels 24H/day
A1C-extending to within 2-3 months
Helps us manage diabetes by confirming self test results by the physician, judging whether a treatment plan is working,
showing how a healthy choice can help in diabetes control
% mg/dl mmol/L
6 126 7.0
7 154 8.6
8 183 10.1
9 212 11.8
10 240 13.4
Carbohydrate Metabolism
Sum of the anabolic and catabolic processes of the body involved in the synthesis and breakdown of CHO (principally:
glucose, fructose, and galactose)
Symptoms of CHO deficiency: fatigue, depression, electrolyte imbalance and body protein breakdown
20:59
Types of CHO
Simple (Monosaccharides)
is any of the basic compounds that serves as a building block of carbohydrates.
The term sugar can refer to both monosaccharides and disaccharides.
Monosaccharides are the simple sugar, since they are the most fundamental type of sugar or glucose.
This means that they cannot be broken down any further into simpler sugar by hydrolysis.
Nevertheless monosaccharides can combine with each other to form more complex types.
Glycosidic bonds also called glycosidic linkages are the covalent bonds that join the monosaccharides.
Examples:
1. Glucose: blood sugar, Major fuel of the body.
2. Fructose: from fruit sugar
3. Galactose: from milk sugar
These are all readily absorbed by the small intestines, and because of their structure they are also the hexoses.
monosaccharides perform vital biological roles. Just like other carbohydrates are an important source of nutrition.
They are consumed and metabolized to derive metabolic energy and ATP that fuels various biological activities.
Simple Disaccharides
are composed of two monosaccharides joined together by the glycosidic bond or glycosidic linkage.
Maltose:
Glucose + Glucose
sweetener, a nutrient in infant feeding in bacteriological culture media,
Also used in pastries it makes bread dough rise when CO2 is produced and released during the conversion of starch into maltose by
reacting the starch with enzymes.
Sucrose:
Glucose + Fructose combined in condensation reaction.
Digested or broken down into its monosaccharide units through hydrolysis, with the help of enzyme sucrose.
sucrose is extracted from plants (sugar cane/ sugar beets) and processed to a refine to be marketed as a common cable sugar.
used as a sweetening agent in food and beverages.
Lactose
Glucose + Galactose
is produced naturally and is present in milk of mammals including humans.
It is collected from Bovine to be used in preparing infant formulas.
a cow's milk has a particular about 4.7% of lactose.
people who are lactose intolerant cannot digest or breakdown lactose, this becomes food for gas producing flora, this could lead to
GI disturbance and flatulence.
Lactose can be converted into lactic acid.
microorganisms such as lactobacilli can convert lactose to lactic acid which is used in the food industry.
An example is the production of dairy products like yogurt and cheese.
Disaccharides:
made up of 2 monosaccharides
Oligosaccharides:
made up of more than 2 monosaccharides
has shorter chains than polysaccharides.
Polysaccharides:
are a type of macromolecule composed of monosaccharides units.
multi saccharides: cellulose, starch and glycogen
Simple sugars are transported to the cells of other tissues, specially to the liver and bloodstream.
The glucose in the blood may be utilized by the body to produce ATP, otherwise it is transported in the liver together
with the galactose and fructose which are largely converted into glucose for storage as glycogen.
Glycogen:
Storage form of energy in the body, made up of glucose units in the liver, muscle cells and fat cells for later use.
The remaining carbohydrates not absorb by the small intestine, enter the large intestine, the got flora in the colon
metabolizes them anaerobically, example: fermentation as such this leads to production of gases.
Like hydrogen, CO2 and methane and fatty acids such as acetate and mucirate that immediately metabolize the body.
The gases in the turner excreted via breathing them out erruptation or burping or flatulence.
To conclude, carbohydrate metabolism is one of the fundamental or basic biochemical processes in our body, it enables
us to perform our daily activities as it constantly supplies our living cells with energy.
Glucose metabolism
Glycolysis = glucose (enters cytoplasm) = 2 pyruvate = 2 atps and electrons
Rbc (don’t have mitochondria) - pyruvate changes to lactate (anaerobic process)
Cells with mitochondria + oxygen, pyruvate will transfor in to acetyl Co-a, enter krebs or citric
cycle = electrons and 2 atp = Oxygen will enter oxydative phosphorylation (30-34 atp will be
produced)
Increase # of atps = acetyl co-a will not enter krebs cycle, convert to fatty acids
Type 1 = autoimmune, destroy insulin cells = body doesn’t produce insulin during intake of
carbs = glucose cant get in cells = body compensate thru kidneys = increase urination = thirsty
, urine contains glucose (med for bacterial = thrush or genital itching), blood contains glucose=
wounds heals slowly, blurred vision, lethargic, fatigue. Body destroy fats = weight loss, glucose
builds up in the front of the eye =liq in the lens to become cloudy= blurred vision,
Type 2 (90% of cases) common in over 40 in white, 25 in asian, either body isnt prod insulin
enough or insulin isnt working properly =overweight. Glucose cant get in the cells because filled
with fats = body prod insulin and glucose, cells needs energy and release sotred insulin = cant
cope anymore and wears out, s/s : come slowly and asymptomatic , lvie for 10 yrs before thery
realize they have it . needs exercise and food, progressive condition=needs meds
Cbs sliding scale - capillary blood sugar - guide for injecting insulin, found in the doctor order’s sheet
NPH (neutral protamine hagedorn (cloudy
Humulin R (clear)
Clear to cloudy to prevent mixing of insulin
Insulin injection log - sheet for writing the amount , site, blood sugar level, date and time
Medical management goal: restore or manage glucose levels at the normal level
Nursing maangement goal: empowerment
Normal blood glucose level for a nondiabetic based on ADA, 2021: 60-100mg/dL
● Diabetes Mellitus
● Diabetic Ketoacidosis
● Hyperglycemic Hyperosmolar nonketotic Syndrome =hypoglycemia
● Hypoinsulinism
● Hypoglycemia
Adrenergic =epi increases=shakiness, nervousness, hunger, diaphoresis, pallor
Neuroglycopenic= confusion,headache, mental illness, inabiltiy to concentrate, slurred speech
and vision, lethary, severe drowsiness,
Type 1: juvenile
Type 2: adult onset
Lipid profile or panel - fats is related form glucose uptake (risk for atherosclerosis)
Type 1: juvenile, abrupt or sudden onset, little or no insulin, mostly thin, prone to ketosism 3 p
+fatigue + weight loss
Type 2: adult onset, lead to HHNS (hyperglycemic, hyperosmolar non ketotic syndrome)