NCMB316 LECTURE: Exam Week

06
BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
Bachelor of Science in Nursing 3YB
Professor: Dr. Potenciana A. Maroma
Prelim Topics: blood vessels, nerve endings, lymph nodules, and
• Intro to Gastrointestinal System lymphatic vessels.
• GERD, Gastritis, PUD, Dumping • Muscular layer- The muscularis externa is a muscle layer
• Crohn's Disease, Ulcerative Colitis, Intestinal typically made up of an inner circular layer and an outer
Obstruction, etc. longitudinal layer of smooth muscle cells.
• Hepatitis, Liver Cirrhosis, Esophageal Varice, etc. • Serosa - The serosa is the outermost layer of the wall that
• Endocrine System & Pituitary Disorders consists of a single layer of flat serous fluid-producing cells,
the visceral peritoneum.
GASTROINTESTINAL SYSTEM
Introduction
• G.I. tract (alimentary canal)
- Mouth
- Esophagus
- Stomach
- Intestines (small & large)
- Rectum
• Accessory organs
- Salivary glands
- Liver
- Gallbladder
- Pancreas
Functions:
- Adult G.I. tract is about 25 feet long (mouth to anus)
1) Secretion (HCl, bile, enzymes)
2) Digestion (mechanical & chemical process) –
pagdadaanan ng food for further digestion. Enzymes ang
tumutulong para mag digest ng mabilis ang pagkain. To
speed it up it is known at catalyst.
3) Absorption (CHYME – liquid in nature) – dito na ma absorb
ang mga nutrients.
4) Motility
5) Elimination

GI System 4 layers
• Mucosa – The mucosa is the innermost layer, a moist
membrane that lines the cavity, or lumen, of the organ; it
consists primarily of a surface epithelium, plus a small Blood Supply
amount of connective tissue (lamina propria) and a scanty - Blood supply to the GI tract originates from the aorta &
smooth muscle layer. branches to the many arteries throughout the length of the
• Submucosa - The submucosa is found just beneath the tract.
mucosa; it is a soft connective tissue layer containing

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Oral Cavity
• Buccal mucosa – mucous membrane lining the inside of
the mouth
• Lips – external to the mouth & are pink-red
• Tongue – involve in speech, taste & mastication (chewing)
• Hard & soft palate – forms the roof of the mouth
• Teeth – 32 permanent teeth in adults; important for speech
& mastication
• Salivary glands – parotid, submandibular, sublingual
glands; secretes mucin & salivary amylase (ptyalin)
breakdown of CHO; 1 liter of saliva is produced/day
• Pharynx (Throat) – extends from the soft palate to the
esophagus

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- Guarded at both ends by the cardiac & pyloric sphincters

- Rugae (folds of mucosa & submucosa)
• parietal cells – secretes HCL
• chief cells – pepsinogen, IF
Three Phases of Gastric Secretion
1) Cephalic phase
- begins w/ sight, smell & taste of food
- vagus & GI nerve plexuses initiates secretory &
contractile activities
2) Gastric phase
- begins w/ the presence of food in the stomach
- Gastric juice (HCL + hormones + enzymes)  FOOD 
CHYME
- G cells  hormone gastrin  promotes secretion of
HCL & pepsinogen
- HCL  converts pepsinogen to active pepsin (digestion
of CHONS)
- Mucus & bicarbonate secretions (protects stomach
Esophagus from mechanical & chemical damage
- a muscular canal about 10 inches (24cm) long; extends 3) Intestinal phase
from the pharynx to the stomach. - begins as the chyme passes from the stomach into the
- Function: propel food & fluids from the pharynx to the duodenum
stomach & prevent reflux of gastric contents into the - mediated by secretin (inhibits further acid production &
esophagus. (reflux – meron syang lower esophageal decreases gastric motility)
sphincter, kunwari un food mo nakarating sa stomach,
hindi na pwede bumalik sa esophagus)
• Upper esophageal sphincter (UES) – closed when at rest
to prevent air in esophagus.
• Lower esophageal sphincter (LES) – normally closed
when at rest to prevent reflux of gastric contents into
the esophagus.

Stomach
- location: midline & LUQ of the abdomen
- anatomic regions of the stomach:
• Cardia
• Fundus
• Corpus or Body
• Pylorus or Antrum

Small Intestine
- major organ of absorption of the G.I. system
- longest (16-19 feet)
- most convoluted portion of GIT
- 3 regions:
• duodenum (12”),
• jejunum (8’)
• ileum (8’ – 12’)

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Pancreas
- A fish shaped gland that lies retro-peritoneally in the upper
abdominal cavity behind the stomach and extends
horizontally from the duodenal C-loop to the spleen
- Divided into head, body & the tail
- Function:
• Exocrine: 80% of the organ; acinar cells secretes
enzymes
• Endocrine: 20% of the organ; islets of langerhans
secretes hormones

NOTE: Intestinal cells produce cells that secretes

enzymes & hormones
• Secretin
- secreted by duodenum in the presence of HCL
- stimulates secretion of pancreatic juice & bile in the
liver
• Pancreozymin
- secreted by duodenum in the presence of HCL &
peptides
- stimulates secretion of pancreatic juice
• Cholecystokinin
- secreted by duodenum in the presence of amino acids
& fatty acids
- stimulates secretion of pancreatic enzymes & bile in the
gallbladder Liver
- Largest internal organ in the body located in the RUQ of the
Large Intestine abdomen
- extends from the ileo-cecal valve to the anus (about 5-6 - 2 major regions: right & left lobe
feet) - About 1500 ml of blood flows through the liver q min.
- Functions: - Performs more than 400 functions in 3 major categories:
• Movement • Storage (copper, iron, magnesium, Vit.B2, B6, B12, A, D,
• Absorption (H2O & é) E, K, folic acid)
• Elimination • Protection (phagocytic kupffer cells, detoxifies
potentially harmful compounds such as drugs,
chemicals & alcohol)
• Metabolism (breakdown of amino acids forming urea,
synthesis of plasma chons, CHO metabolism & Fat
metabolism)
• It produces BILE (for emulsification of fat)

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Gallbladder - Diet history

- Pear-shaped bulbous sac that is located in a depression on - Socioeconomic status
the inferior surface of the liver - Current health problem: PAIN (common complaint)
- It has 3 portions: neck, body, fundus The mnemonic PQRST may be helpful in assisting the
- Drained by cystic duct that joins with the hepatic duct to nurse to organize the current problem assessment
form the common bile duct • Precipitating or palliative - What brings it on? What makes
- Function: collects, concentrates & stores bile it better?
• Quality or quantity - How does it look, feel or sound? How
Summary of the Physiology of Digestion & Absorption: intense/ severe is it?
1) Digestion: Physical/Mechanical & Chemical breakdown of • Region or radiation - Where is it? Does it spread anywhere?
food into absorptive substances • Severity scale - How bad is it (on scale of 1 to 10)?
2) Initiated in the mouth where food mixes with saliva and • Timing - Onset, duration & frequency
starch is broken down Physical Assessment
3) Food then passes into the esophagus where, it is - comprehensive examination of the client’s nutritional
propelled into the stomach status, the mouth & pharynx, the abdomen & the
4) In the stomach, food is processed by gastric secretions extremities
into a substance called chyme - Anthropometric measurement - evaluates nutritional
5) In the small intestine, CHO are hydrolyzed to status height, weight, BMI
monosaccharide, fats to 2-glycerol and fatty acids; and Abdomen
proteins to amino acids to complete the digestive process - empty the bladder; lie in a supine position with knees bent,
6) When chyme enters the duodenum, mucus is secreted to keeping the arms at the sides (prevent abdominal muscle
neutralize hydrochloric acid; in response to release of tension)
secretin, pancreas releases bicarbonate to neutralize acid - RUQ, LUQ, LLQ, RLQ
chyme - if areas of pain are noted from the history, this area is
7) Cholecystokinin and pancreozymin (CCK-PZ) are also examined last in the examination sequence to prevent
produced by the duodenal mucosa; stimulate contraction abdominal muscle tension
of the gallbladder along with relaxation of the sphincter of - Observe the client’s face for signs of distress or pain
Oddi (to allow bile to flow from the common bile duct into - 4 techniques used: IAPePa (usual: IPaPeA) – Inspection,
the duodenum), and stimulate release of pancreatic Auscultation, Percussion, Palpation
enzymes - Cullen’s sign
8) Absorption • presence of ecchymosis (bruising) around the
a) intestinal cells to absorb nutrient molecules umbilicus indicates intra-abdominal bleeding
(monosaccharides, amino acids and fatty acids) - Observe also for abdominal movements
b) villi increase the surface area for absorption, most • rarely seen on inspection
especially in the small intestine
• indicates intestinal obstruction
Auscultation
AGING & THE DIGESTIVE SYSTEM
• High pitched gurgles air & fluid movement
- Physiologic changes occur as individuals age, especially
- q 5-15 seconds / 5-30 sounds /min
when they become 65 years of age or older
- Diminished or absent (abdominal surgery, peritonitis,
- Overall changes of the digestive system associated with
paralytic ileus) Hypoactive- 1-2 sounds in 2 min.
aging includes:
Hyperactive-> 30 sounds/min. Absent- no sounds in 3-
• secretory mechanism 5 min.
• motility of the digestive organs
• Borborygmus
• Loss of strength & tone of the muscular tissue & its - loud gurgling sounds due to hypermotility of the bowel
supporting structures (diarrhea, gastroenteritis, above a complete intestinal
• changes in neurosensory feedback regarding enzyme & obstruction)
hormone release • Bruit “swooshing sounds”
- Indicates aneurysm especially if heard over the aorta; if
Assessment Techniques heard… DO NOT percuss/palpate abdomen!!! –
History mamamatay pasyente mop ag naputok ang aneurysm
- Demographic data - age, gender, culture, occupation Percussion
- Family history & genetic risk - Determine & estimate the size of solid organs (liver &
- Previous G.I. disorders, abdominal surgeries spleen)
- Medications - detect presence of masses, fluid, and air
• aspirin, NSAIDs (PUD, GI bleeding) - Tympanic – high pitched, loud musical sound of an air-
• laxatives & enemas (causes dependence on such filled intestine
stimulation and cause constipation) - Dull – medium pitched, softer, thudlike sound over a solid
- Travel history organ (liver)

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Upper GI Series & Small Bowel Series

- x-ray visualization from the oral pharynx to the
duodenojejunal junction
• detect disorders of structure or function of esophagus
(barium swallow), stomach or duodenum
- small bowel follow-through (SBFT) (up to the ileocecal
junction)
Palpation - Client preparation:
- Determine the size & location of abdominal organs & • 8° NPO before the procedure
assess presence of masses or tenderness • withhold opiod analgesics & anticholinergics 24° before
- Blumberg’s sign – rebound tenderness (pain felt on the test ( motility)
release of fingers pushing & placed at a 90° angle in • need to drink around 16 ounces of barium preparation
relation to the abdomen)

Diagnostic Assessment
• Blood Tests
- CBC – GI bleeding; anemia - Flouroscopy is used to trace the barium through the
- PT – liver damage; prolonged PT (liver is the main site of esophagus & stomach
all proteins involved in coagulation) - After the procedure:
- serum é – GI malabsorption, excessive vomiting or • plenty of fluids to eliminate barium
diarrhea • mild laxative or stool softener can be given
- AST, ALT – liver disorders (ex; viral hepatitis) • advise client that stool may be chalky white for 24-48°
- Serum amylase & lipase – best indicator of acute as barium is excreted
pancreatitis if elevated within 24° - 5 days Lower GI Series (Barium Enema)
- Bilirubin – important in the evaluation of liver & biliary - radiographic visualization of the large intestine
tract functioning - Detect bowel obstruction from the twisting of the colon
- Serum ammonia – hepatic function; ammonia is upon itself (volvulus)
normally used to rebuild a.a. or is converted to urea for - Contraindication: suspected colon perforation or fistula;
excretion cardiac arrest when barium enter venous circulation
• Urine Tests - Client preparation:
- Urine amylase – acute pancreatitis; remains high even • clear liquids only 12 -24° before procedure to reduce
after serum levels return to normal amount of fecal matter in the bowel but NPO after
- Urobilinogen – hepatic & biliary obstruction midnight on the night before the test
• Stool Tests • potent laxatives (Magnesium citrate) or cleansing
- FOBT (Fecal Occult Blood Test) – G.I. bleeding enema is performed the evening before the test
- Parasitic infection - After the procedure:
- Fecal fats (steatorrhea & malabsorption) • advise client to drink plenty of water to assist in
• Plain abdominal X-rayFlat plate of abdomen eliminating the barium (chalky white stool for 24-72°
- masses, tumors & strictures or obstructions until all barium is expelled)
- no special preparation of the client required • laxatives can be given

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Percutaneous Transhepatic Cholangiography (PTC) Before the Procedure

- Iodinated dye instilled via a percutaneous needle inserted - Commonly used medications:
through the liver into the intrahepatic ducts (needle is • Midazolam HCL
inserted under x-ray visualization) • Meperedine (Demerol) Sedation
- Rarely done as a diagnostic procedure anymore
• Fentanyl
- After the procedure: client is placed on the right side;
• Atropine - dry secretions
observe for signs of bleeding, hematoma, ecchymosis or
• Local anesthetic - sprayed to inactivate gag reflex &
bile leakage
facilitate passage of tube
- Client is place in left lateral decubitus (Sim’s or side-lying)
position during the procedure
After the procedure
- monitor VS q30mins until sedation wears off; put siderails
up
- NPO until gag reflex returns (usually in 1-2°) to avoid
aspiration
- monitor for signs of perforation
• Pain
• Bleeding
• Fever
Endoscopic Retrograde Cholangiopancreatography (ERCP)
- Visual and radiographic examination of the liver,
gallbladder, bile ducts & pancreas to identify cause &
location of obstruction; after cannula is inserted into the
Computed Tomography (CT Scan) common bile duct, radio-opaque dye is inserted followed
- Noninvasive cross-sectional x-ray visualization detecting by several x-ray images
tissue densities & abnormalities in the abdomen & the - Physician may perform a papillotomy, a small incision in
structures in it the sphincter around the ampulla of vater, to remove
- performed with (ask about allergies to seafood & iodine!!!) gallstones preparation: same as endoscopy
or without contrast medium
- No particular follow-up care is needed after a CT scan
unless sedatives were administered; monitor VS until client
is fully awake
Endoscopy
- Direct visualization of the GI tract by means of a flexible
fiberoptic endoscope
- Usually done to evaluate bleeding, ulceration,
inflammation, masses, tumors & cancerous lesions
Esophagogastroduodenoscopy
- Visual examination of the upper GI

Colonoscopy
- endoscopic examination of the large bowel
- use to evaluate the cause of chronic diarrhea, locate the
source of bleeding, obtain tissue biopsy specimens or
remove polyps
- Preparation:
• liquid diet for 12-24°, NPO 6-8° before the procedure
• clean the bowel the evening before the procedure
(laxatives, suppositories, cleansing enemas)
• sedation of client
• Atropine sulfate is kept available in case of bradycardia
resulting from vasovagal response
- After the procedure:
• check VS q15mins until stable; siderails up; observe
signs of perforation (pain & hemorrhage)

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Proctosigmoidoscopy
- Endoscopic examination of the rectum & sigmoid colon
using flexible or rigid scope
- Purpose: screen for colon cancer, investigate source of GI
bleeding, diagnose or monitor inflammatory bowel disease
- Preparation: liquid diet for at least 24° before the
procedure; laxative (evening), cleansing enema (a.m.
Before the procedure)
- Position: left side in the knee-chest position
- No sedation is required
- Inform the client that mild gas pain & flatulence may be
experienced from the air instilled into the rectum during
the procedure
- If biopsy was obtained, a small amount of bleeding may be
observed; instruct the client that excessive bleeding
should be reported immediately to the health care provider Assessment Findings
Gastric Analysis • Heartburn
- Measures the HCL & pepsin content for evaluation of - substernal or retro- sternal burning sensation
aggressive gastric & duodenal disorders (Zollinger-Ellison - pain radiate to the neck, jaw, back (mimic ANGINA or
syndrome) MI)
- Alcohol, tobacco & medications that may affect gastric
• Regurgitation
secretion are avoided for 24° before the study
- warm fluid traveling up the throat (sour or bitter taste)
- NGT is inserted & gastric residual contents are aspirated
- danger for aspiration (note for crackles in the lungs)
Ultrasound
• Hypersalivation “water brash”
- Sound waves are passed through the body via a transducer
• Dysphagia (Difficulty of swallowing)
and echoes are converted into images and photograph for
analysis • Odynophagia (Painful swallowing)
- Commonly used to image soft tissues such as liver, spleen, • Barrett’s epithelium
the pancreas, gallbladder (biliary system) - change of the normal squamous cell epithelium to
- Full bladder is necessary for accurate visualization (1-2 l columnar epithelium
of fluid) - more resistant to acid as a result of healing process
brought about by the inflammation
GERD, GASTRITIS, PUD, DUMPING SYNDROME - considered pre-malignant ( risk of CANCER) in
Gastroesophageal Reflux Disease (GERD) clients with prolonged GERD
- Backward flow (reflux) of stomach contents into the Other manifestations:
esophagus resulting to inflammatory changes of the • Chronic cough especially at night (due to position), asthma
esophageal mucosa • Eructation (belching)
- Hallmark of GERD: reflux esophagitis (acute symptoms of • Flatulence (gas)
inflammation) • Bloating after eating
• Nausea & Vomiting
Diagnostic test:
- Most accurate method: 24-hour ambulatory pH
monitoring
- small catheter is placed through the nose into the distal
esophagus, pH is continuously monitored & recorded)
• Endoscopy (esophagogastroduodenoscopy)
• Esophageal manometry “motility testing”
- water-filled catheters are inserted via the client’s nose or
mouth & slowly withdrawn while measurements of LES
pressure & peristalsis are recorded); not specific enough to
establish a diagnosis of GERD
Causes Nursing interventions:
• inappropriate relaxation of the LES/  tone of LES • Diet therapy
• gastric volume or intra-abdominal pressure is elevated - limit or eliminate foods that decrease LES pressure
• delayed gastric emptying (chocolate, fatty foods, caffeinated beverages such as
coffee, tea, & cola, peppermints, alcohol)
- restrict spicy & acidic foods (orange juice, tomatoes)
- carbonated beverages ’s pressure in the stomach

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• Lifestyle changes Gastritis

- sleep in the left lateral (side-lying) position to minimize - Gastritis is an inflammation of the gastric mucosa, is
the nighttime episodes of reflux classified as either acute or chronic.
- Incidence: The incidence of gastritis is highest in the fifth
and sixth decades of life; men are more frequently affected
than women. The incidence is greater in clients who are
heavy drinkers and smokers.
Acute Gastritis
• Etiology and Risk Factors:
- It usually stems from ingestion of a corrosive, erosive,
or infectious substance.
- Aspirin and other non-steroidal anti-inflammatory drugs
(NSAIDs), chemotherapeutic drugs, steroids, acute
alcoholism and food poisoning (typically caused by
Staphylococcus organisms) are common causes.
- Food substances including excessive amounts of tea,
carbonated drinks and pepper can precipitate acute
gastritis. Foods with a rough texture or those eaten at
an extremely high temperature can also damage the
stomach mucosa.
- Acute gastritis is usually of short duration unless the
gastric mucosa has suffered extensive damage.
Pathophysiology
- The mucosal lining of the stomach normally protects it
from the action of gastric acid. This mucosal barrier is
composed of prostaglandins.
Due to any cause
↓
This barrier is penetrated
↓
Hydrochloric acid comes into contact with the mucosa
↓

Injury to small vessels

Drug therapy ↓
• Antacids Edema, hemorrhage, and possible ulcer formation
- neutralizes HCL & deactivating pepsin Clinical Manifestation
- Aluminum Hydroxide, Magnesium Hydroxide, Maalox,
• Epigastric discomfort
Mylanta
• Feeling of fullness, early satiety
• Histamine2 (H2) Receptor Antagonist
- ’s acid production of parietal cells • Cramping
- Famotidine, Ranitidine (Zantac), Cimetidine (Tagamet), • Belching
Nizatidine • Flatulence
• Proton pump inhibitors (PPI’s): main treatment for GERD • Severe nausea and vomiting
- inhibition of proton pump of the parietal cell thereby  • Hematemesis
acid secretion • Sometimes GI bleeding is the only manifestation
- Omeprazole, Lansoprazole, Rabeprazole, Pantoprazole, • When contaminated food is the cause of gastritis, diarrhea
Esomeprazole; usually develops within 5 hours of ingestion
• Metoclopramide (Reglan) Diagnostic Findings
-  gastric emptying - Diagnosis is based on a detailed history of food intake,
• Endoscopic Therapy medications taken, and any disorder related to gastritis.
- Stretta procedure – the physician applies - The physician may also perform a gastroscopy.
radiofrequency energy through needles placed near Medical Management
gastroesophageal junction inhibiting the vagus nerve - Anti – emetic drugs like Inj. Perinorm or Tab, Domperidone
thus reducing the discomfort of the client. It will are frequently effective in vomiting.
reshape the ring of muscles in the lower esophagus. - Antacids, H2 Blockers like cimetidine, Ranitidine, or
• Surgical management: Laparoscopic Nissen Famotidine are effective to reduce the pain.
Fundoplication - GOLD STANDARD

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- If ingestion of NSAIDs is a problem, a prostaglandin E1 Complications

(PGE1) analog may be prescribed to protect the stomach - Bleeding
mucosa and inhibit gastric acid secretion. - Pernicious anemia
Diet Therapy - Gastric cancer
- Initially foods and fluids are withheld until nausea and Medical Management
vomiting subside. - Discomfort may lessen with a bland diet, small frequent
- Once the client tolerates food, the diet includes meals, antacids, H2 receptor antagonists, proton pump
decaffeinated tea, gelatin, toast, and simple bland foods. inhibitors, and avoidance of food that cause
- The client should avoid spicy foods, caffeine and large, manifestations.
heavy meals. - If H.pylori bacteria are present, anti-biotics and other
- In the continued absence of nausea, vomiting and bloating, medications are administered to eliminate the bacteria.
the client can slowly return to a normal diet. - If 1 week of this regimen does not succeed in eliminating
Chronic Gastritis the bacteria, the regimen may be repeated for an
- 3 forms additional week.
- Superficial gastritis, which causes a reddened, edematous - If pernicious anemia develops, intramuscular injections of
mucosa with small erosions and hemorrhages. vitamin B12 may be administered monthly for the
- Atrophic gastritis, which occurs in all layers of the remainder of the client’s life.
stomach, develops frequently in association with gastric Nursing Management
ulcer and gastric cancer, and is invariably present in
Nursing Diagnosis:
pernicious anemia; it is characterized by a decreased
1) Acute pain related to irritated stomach mucosa.
number of parietal and chief cells.
2) Imbalanced nutrition, less than body requirement,
- Hypertrophic gastritis, which produces a dull and nodular
related to inadequate intake of nutrition.
mucosa with irregular, thickened, or nodular rugae;
3) Risk for imbalanced fluid volume related to
hemorrhages occur frequently.
insufficient fluid intake and excessive fluid loss
Etiological Factors subsequent to vomiting.
- Infection with Helicobacter pylori bacteria or gastric 4) Anxiety related to treatment.
surgery may lead to chronic gastritis. 5) Deficient knowledge about dietary management and
- After gastric resection with a gastro- jejunostomy, bile and disease process.
bile acids may reflux into the remaining stomach, causing
gastritis. Peptic Ulcer Disease
- H.Pylori infection can lead to chronic atrophic gastritis.
- Age is also a risk factor; chronic gastritis is more common
in older adults.
Pathophysiology
The stomach lining first becomes thickened and
erythematous and then becomes thin and atrophic.
↓
Continued deterioration and atrophy
↓
Loss of function of the parietal cells
↓
Acid secretion decreases
↓
Inability to absorb vitamin B12
↓ Causes
Development of pernicious anemia - Break in the mucosal barrier
Clinical Manifestation o mucus & bicarbonate secretion (1st line of defense in
- Manifestations are vague and may be absent because the pH maintenance)
problem does not cause an increase in hydrochloric acid. o Gastromucosal PG (’s barrier resistance to
Assessment may reveal ulceration)
o adequate blood supply
o Anorexia
o pyloric sphincter dysfunction (bile may enter stomach &
o Feeling of fullness
cause damage to lipid plasma membrane of gastric
o Dyspepsia
mucosa)
o Belching
o delayed gastric emptying
o Vague epigastric pain
o H. pylori infection
o Nausea
Note: There is normal gastric acid secretion!!!
o Vomiting
o Intolerance of spicy and fatty foods
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Complications of PUD
• Hemorrhage – most serious complications; hematemesis
(coffee-ground blood) usually indicates upper GI bleeding
• Perforation – surgical EMERGENCY!!!
• Gastroduodenal contents leaks into the surrounding
abdomen
• Sharp pain, client becomes apprehensive assuming knee-
chest position, chemical peritonitis occurs, bacterial
septicemia & hypovolemic shock follows.
• Peristalsis diminishes & paralytic ileus develops.
Laboratory assessment
• Duodenal ulcer: causes •  Hgb/Hct (indicates bleeding)
- rapid emptying of food in the stomach • (+) occult blood in stool specimen
- acid-bolus delivery, reduce buffering effect of food • Endoscopy (EGD) reveals ulceration; BIOPSY is usually
to duodenum done to detect H. pylori infection & to rule out
-  secretion of acid is triggered also by CHON rich MALIGNANCY!!!
food, Ca++, vagal excitation • Gastric analysis: normal gastric acidity in gastric ulcer (
- H. pylori produces urease in duodenal ulcer
- Urease hydrolyzes urea to ammonia Medical/ Nursing Management
- H+ ions are released in response to the presence of - Supportive (rest, bland diet, stress management)
ammonia  further gastric mucosal damage • Drug therapy:
o Antacids
o H2-receptor antagonists
o Proton pump inhibitors
o Anticholinergics (gastric juice secretion)
Probanthine, Pirenzepine
o Antibiotic for H. pylori infection (Metronidazole
(Flagyl), Tetracycline & Pepto-bismol)
• Surgery: various combinations of gastric resections and
anastomosis
- Performed when PUD does not respond to medical
management
• Gastroduodenostomy (Billroth I):
- distal end of the stomach is removed, and the
remainder is anastomosed to the duodenum
• Gastrojejunostomy (Billroth II):
- removal of the antrum and distal portion of the
Other factors that contributes PUD: stomach and duodenum with anastomosis of the
• drugs (aspirin, ibuprofen) remaining portion of the stomach to the jejunum
• cigarette smoking • Vagotomy:
• chronic anxiety - Transection of vagus nerve that eliminates the acid-
• Type A personality secreting stimulus to gastric cells & causing a
decrease gastric acid secretion
• Pyloroplasty: performed in conjunction with vagotomy to
widen the exit of pylorus to facilitate emptying of stomach
contents
• Subtotal Gastrectomy: removal of 75% - 85% of the
stomach
• Antrectomy: removal of the antrum of the stomach to
eliminate the gastric phase of digestion
• Gastroenterostomy:
- creating a passage between the body of the stomach &
the jejunum to permit neutralization of gastric acid by
regurgitation of alkaline duodenal contents into the
stomach
• Esophagojejunostomy (total gastrectomy)
- removal of the entire stomach with a loop of jejunum
anastomosed to the esophagus
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• Routine preoperative nursing care: - occurs 1½ - 3hrs p.c.

- informed consent, NPO, Medications - due to rapid entry of high-CHO food into the jejunum 
• Postoperative nursing care: Hyperglycemia   insulin release  Rebound
- Provide routine post-op care hypoglycemia
- Ensure adequate function of NG tube - Symptoms: dizziness, light-headedness, palpitations,
- Measure drainage accurately to determine necessity for diaphoresis & confusion
fluid and electrolyte replacement; notify physician if
there is no drainage. Anticipate frank, red bleeding for
12-24°; Do not manipulate the tube and ensure its
patency
- Promote adequate pulmonary ventilation
- Place client in mid- or high-Fowler’s position to
promote chest expansion; Teach client to splint high
upper abdominal incision before turning, coughing, and
deep breathing
• Promote adequate nutrition.
- After removal of NG tube, provide clear liquids with
gradual introduction of small amounts of bland food
at frequent intervals; Monitor weight daily. Assess for
• Dietary Management:
regurgitation; if present, instruct client to eat smaller
- Decrease the amount of food taken at one time &
amounts of food at a slower pace
eliminating liquids ingested with meals
• Provide client teaching and discharge planning
- Instruct client to consume a high-CHON ( colloidal
concerning
osmotic pressure), high-fat, low- to moderate-CHO
- Gradually increasing food intake until able to tolerate 3-
diet
meals/day
- Daily monitoring of weight
CROHN'S DISEASE, ULCERATIVE COLITIS, INTESTINAL
- Stress-reduction measures
OBSTRUCTION, PERITONITIS, APPENDICITIS,
- Need to report signs of complications to physician
DIVERTICULITIS, HEMORRHOIDS
immediately (hematemesis, vomiting, diarrhea, pain,
melena, weakness, feeling of abdominal
fullness/distension)
- Methods of controlling symptoms associated with
Dumping syndrome

Dumping Syndrome
- Constellation of vasomotor symptoms after eating,
especially following after billroth II procedure
- There is rapid gastric emptying into the small intestine
causing abdominal distention (shifting of fluids to the GUT)

Crohn’s Disease

• Early manifestation:
- occur w/in 30mins
- an idiopathic inflammatory disease of the small intestine
- Symptoms: vertigo, tachycardia, syncope, sweating,
(60%), the colon (20%), or both
pallor, palpitations & desire to lie down
- terminal ileum: the site most often affected
• Late dumping syndrome:
- Causes
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• Unknown, thought to be autoimmune Age/ Peak 15 – 40 years 15 – 25 years

• M. paratuberculosis incidence 55 – 65 years
• Genetic predisposition (1st degree & identical twins) ; stool with pus severe; stool with
Pathology Bleeding and mucus blood, pus and
- Deep fissures & ulceration develops  bowel fistulas  mucus
diarrhea & malabsorption Fistulas Common Rare
- Chronic pathologic changes include thickening of the Rectal 20% 100%
bowel wall  narrowed lumen & strictures  obstruction involvement
5 – 6 soft loose 20 – 30 watery
Diarrhea
stool/ day stool/ day
Abdominal pain + +
Weight loss + +
TPN Diet, TPN
Steroids Steroids
Azulfidine Azulfidine
Intervention
(Sulfasalazine) (Sulfasalazine)
Ileostomy Ileostomy
Proctocolectomy

Assessment Findings Crohn’s Disease VS Ulcerative Colitis

• Abdominal distention, masses, visible peristalsis
• Diarrhea (steatorrhea is common & sometimes bloody)
• constant abdominal pain
• low-grade fever
• weight loss (80% of clients)
• Be aware NURSE!!! to detect clinical manifestations of
peritonitis, bowel obstruction & nutritional & fluid
imbalances!!!

Ulcerative Colitis
- Ulcerative and inflammatory condition of affecting the
mucosal lining of the colon or rectum
- Cause: unknown
- Assessment findings:
• Anorexia
• Weight loss
• Fever,
• Severe diarrhea with Rectal bleeding
• Anemia
• Dehydration
• Abdominal pain and cramping

Regional ENTERITIS
Ulcerative Colitis
(Crohn’s Disease)
Transmural Mucous Ulceration Nursing Interventions
Characteristic • Maintain NPO during the active phase
Ileum Rectum/ cecum
Unknown Unknown • Monitor for complications like severe bleeding,
Cause Familial Familial dehydration, electrolyte imbalance
Environmental Emotional stress • Monitor bowel sounds, stool and blood studies

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• Restrict activities • Vascular obstructions – interference with the blood

• Administer IVF, electrolytes and TPN if prescribed supply to a portion of the intestine, resulting in
• Instruct the patient to avoid gas-forming foods, milk intestinal ischemia and gangrene of the bowel; caused
products and foods such as whole grains, nuts, RAW fruits by an embolus, atherosclerosis
and vegetables (SPINACH), pepper, alcohol and caffeine Assessment Findings
• Diet progression- clear liquid LOW residue, high protein • high-pitched bowel sounds above the level of the
diet obstruction
• Administer drugs • decreased or absent bowel sound below the obstruction
- anti-inflammatory Complete Intestinal Obstruction
- antibiotics • Cardinal Signs and Symptoms
- steroids - Abdominal pain
- bulk-forming agents and vitamin/iron supplements - Abdominal distention
- Vomiting
Intestinal Obstruction - Obstipation
- It is defined as interference with the forward flow of • Other signs/sx
intestinal contents. It can be partial or complete & are - Malnutrition
classified as mechanical or non-mechanical - Flatulence
Mechanical Intestinal Obstruction - Weakness
- Physical blockage of the passage of intestinal contents - Electrolyte Imbalances
with subsequent distension by fluid and gas - Ascites
- Causes:
• Adhesions (bands of granulation & scar tissue that
develop as a result of an inflammatory response
encircling the intestines & constricting its lumen)
• Hernias- protrusion of an organ or structure thru a
weakened abdominal muscle, can be congenital or
acquired defect
• volvulus (twisting of the intestine)
• intussusceptions (telescoping of a segment of the
intestine within itself)
• inflammatory bowel disease, foreign bodies, strictures,
neoplasms, fecal impaction

Diagnostic Tests
• Flat-plate & upright abdominal x-rays reveals the presence
of gas and fluid
•  Hgb/Hct, BUN & Creatinine (indicative of dehydration)
•  serum Na+, Cl-, K+
• sigmoidoscopy, colonoscopy, barium enema, CT scan
Nursing Interventions
• Monitor F&E balance, prevent further imbalance; keep
client NPO and administer IV fluids as ordered
• Most clients w/ an obstruction have at least an NGT.
Accurately measure the drainage from NG/intestinal tube
Non Mechanical Intestinal Obstruction • Put in fowler’s position (alleviate pressure on diaphragm)
- “paralytic”, “neurogenic” or “adynamic ileus” • Encourage nasal breathing to minimize swallowing of air
- brought about by interference with the nerve supply to the and further abdominal distension
intestine resulting in decreased or absent peristalsis • Institute comfort measures associated with NG intubation
- Causes: and intestinal decompression
• handling of the intestine during abdominal surgery Prevent complications
• Hypokalemia  Measure abdominal girth daily to assess for increasing
• Peritonitis abdominal distension
• Shock  Assess for S/Sx of peritonitis
 Monitor urinary output
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Drug Therapy/Surgery Management

• Antiemetic • NPO with fluid replacement
• Antispasmodic • Drug therapy: antibiotics to combat infection, analgesics
• Pain reliever- narcotic analgesic for pain
• Antibiotic • NGT is inserted to relieve abdominal distention
• Antihelminthic- if caused by bolus of ascaris • Peritoneal lavage with warm saline
• Electrolyte replacement • Insertion of drainage tubes
• Surgery- depends on the cause • Fluid, electrolyte and colloid replacement, like albumin,
1) Exploratory Laparotomy dextran, TPN solutions
2) Removal of the tumor- with end to end anastomosis
3) Adhesiolysis

Peritonitis • Surgery
- Local or generalized inflammation of part or all of the 1) Laparotomy: opening made through the abdominal wall
parietal and visceral surfaces of the abdominal cavity into the peritoneal cavity to determine the cause of
Pathology peritonitis
• Initial response 2) Depending on cause, bowel resection may be
- edema necessary
- vascular congestion Nursing interventions
- hypermotility of the bowel and outpouring of plasma- • Assess respiratory status for possible distress.
like fluid from the extracellular • Assess characteristics of abdominal pain and changes
- vascular over time.
- interstitial compartments into the peritoneal space • Administer medications as ordered.
• Later response • Perform frequent abdominal assessment
- abdominal distension leading to respiratory • Monitor and maintain F&E balance; monitor for signs of
compromise septic shock.
- hypovolemia results in decreased urinary output • Maintain patency of NG or intestinal tubes
- Intestinal motility gradually decreases and progresses • Encourage deep breathing exercises
to paralytic ileus • Place client in Fowler’s position to localize peritoneal
• Causes contents
- Caused by trauma (blunt or penetrating) • Provide routine pre- and post-op care if surgery ordered
- Inflammatory conditions
- ulcerative colitis, diverticulitis, pelvic inflammatory Appendicitis
disease - Inflammation of the vermiform appendix that prevents
- Ischemia mucus from passing into the cecum; if untreated,
- Ruptured appendix ischemia, gangrene, rupture, and peritonitis occur
- Perforated peptic ulcer - Occurs in about 7% of the population and affects males
- UTI more often than females
- Bowel obstruction (volvulus, intestinal obstruction) - Causes:
- Bacterial invasion • mechanical obstruction (fecaliths, calcium-phosphate
- Peritoneal dialysis rich mucus & inorganic salts, worms, tumors, viral
Assessment Findings infection, inflammation)
• Severe abdominal PAIN, rebound tenderness, muscle • may be related to decreased fiber in the diet and high
rigidity, absent bowel sounds, abdominal distension intake of refined carbohydrates
• Anorexia, N&V • kinking of appendix
• Shallow respirations; decreased urinary output; weak,
rapid pulse; fever
• Signs of shock
- Tachycardia
- Tachypnea
- Oliguria
- Restlessness
- Weakness
- Pallor
- Diaphoresis
Diagnostic Tests
• WBC elevated WBC (20,000/cu. mm. or higher)
• Hct elevated (if hemoconcentration)
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Pathophysiology Diagnostic Tests

Obstruction of the appendix lumen (mucosa continues to •  WBC (above 10,000/cu.mm.)
secrete fluids until pressure w/in the lumen exceeds venous • Ultrasound & Abdominal x-ray (detection of fecalith)
pressure) Nursing Interventions
 • Administer antibiotics/antipyretics as ordered
blood flow to appendix, mucosal Inflammation and bacterial • Prevent perforation of the appendix; don’t give enemas or
proliferation cathartics or use heating pad
 • In addition to routine pre-op care for appendectomy
gangrene develops w/in 24-36° due to hypoxia - Give support to parents if seeking treatment was

delayed
Abscess
- Explain necessity of obtaining lab work prior to surgery

Peritonitis
Diverticulitis
Assessment Findings
- Acute inflammation and infection caused by trapped fecal
• Pain starts at the epigastric or umbilical region & becomes
material and bacteria
localized in the “Mc Burney’s point” (midway between the
- Diverticulum is outpouching of the mucosal lining of the GI
umbilicus and the anterior iliac crest)
tract commonly in the colon
- “Blumberg sign” = Rebound tenderness
- Diverticula/ Diverticulosis are multiple outpouchings
- “Psoas sign” = pain with extension of right hip
- Causes:
- “Rovsing’s sign” = right quadrant pain when the left is
• Low fiber diet
palpated
- “Obturator sign” = pain on passive internal rotation of • chronic constipation
the flexed thigh • obesity
- Nausea & Vomiting Assessment
- Anorexia • Dull, steady, cramp-like lower left quadrant abdominal
- Decreased bowel sounds PAIN worsens with movement, coughing or straining
- Fever, low grade (38 – 38.5°C) • Low – grade fever
- High grade fever = Ruptured!!! • Chronic constipation with episodes of diarrhea
• Nausea and vomiting
• Abdominal distention and tenderness
• Occult bleeding, rectal bleeding, change in bowel
movement
• Signs and symptoms of peritonitis due to development of
abscess or perforation
Diagnostic Test
• Colonoscopy
• sigmoidoscopy
• visualization of diverticula
• CBC may reveal increased WBC
• Barium enema is NOT usually ordered in cases of acute
inflammation because of possibility of perforation
Nursing Management
• High fiber diet
• Liberal fluid intake of 2,500 to 3,000 ml/day.
• Avoid nuts and seeds which can be trapped in the
diverticula.
• Bulk – forming laxatives are ordered to restore normal
bowel pattern
• IVF and medications
• During an acute episode:
- Bed rest
- NPO, then clear liquids to rest the bowel
- Avoid high fiber foods to prevent further irritation of the
mucosa
- Gradually increase the fiber when the infection/
inflammation subsides

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Hemorrhoids • Avoid constipation by adhering to these practice :

- These are dilated blood vessels beneath the lining of the - High – fiber diet, High fluid intake, Regular exercise
skin in the anal cana - Regular time for defecation, Use stool softener until
- Types: healing is complete
1) External hemorrhoids – occur below the anal sphincter • Notify physician for the following:
2) Internal hemorrhoids – occur above the anal sphincter - Rectal bleeding
- Causes - Suppurative drainage
• Chronic constipation - Continued pain on defecation
• Pregnancy - Continued constipation
• Obesity
• Prolonged sitting or standing HEPATITIS, LIVER CIRRHOSIS, ESOPHAGEAL VARICE, ETC.
• Wearing constricting clothing Major Functions of The Liver
• Disease conditions like liver cirrhosis, RSCHF • Bile production and excretion
Assessment • Excretion of bilirubin, cholesterol, hormones and drugs
• Constipation in an effort to prevent pain or bleeding • Metabolism of CHO, CHON and fats
associated with defecation • Storage of glycogen, vitamins and minerals
• Anal PAIN • Synthesis of plasma proteins, such as albumin and
• Rectal bleeding (usually bright red- hematochezia) clotting factors
• Anal itchiness • Detoxification
• Mucous secretion from the anus
• Sensation of incomplete evacuation of the rectum
• Internal hemorrhoids may prolapse, usually painless.
External hemorrhoids are usually painful

Nursing Management
• High fiber diet
• liberal fluid intake
• Bulk laxatives
• Hot Sitz bath, warm compress, witch hazel cream can be
applied to decrease size
• Local anesthetic application – Nupercaine Hepatitis
Surgery
• Hemorrhoidectomy
• Sclerotherapy (5% phenol in oil)
• Cryosurgery-use cooled gas or liquid to freeze the external
hemorrhoid
• Rubber band ligation (done only if hemorrhoids are
INTERNAL)
• Pre-op Care
- Low residue diet to reduce the bulk of stool
- Stool softeners
• Post-op Care Hepatitis A B C D E
o Promotion of comfort - Infectious inflammation of the liver parenchyma caused
- Analgesics as prescribed by viruses.
- Post-op position: Side – lying position or prone - Widespread inflammation of the liver tissue
position - Liver cell damage due to hepatic cell degeneration and
- Hot sitz bath 12 to 24 hrs. post-op to promote necrosis
comfort and hasten healing - Proliferation and enlargement of the kupffer cells
o Promotion of elimination - Inflammation of the periportal areas causing interruption of
- Stool softeners are given as prescribed bile flow
- Analgesic before initial defecation Viral Hepatitis A
- Encourage the client to defecate as soon as the urge - RNA virus transmitted via fecal-oral route.
occurs - Poor hygiene or contaminated food and shellfish increase
- Enema as prescribed, using a small – bore rectal risk of transmission
tube - Incubation period: 15 – 45 days
Patient Teaching - Practice food hygiene to prevent hepatitis A
• Clean rectal area thoroughly after each defecation
• Sitz bath at home especially after defecation
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- Incubation: 2 weeks - 6 months

- High risk of progression to chronic form (70 – 80%)
- Associated with extrahepatic manifestations commonly:
mixed cryoglobulinemia and polyarteritis nodosa

Viral Hepatitis B
- DNA virus, identified in all body fluids: blood, saliva,
synovial fluid, breast milk, ascites, cerebral spinal fluid, etc.
- Transmitted by blood and body fluids (saliva, semen,
vaginal secretions): often from contaminated needles
among IV drug abusers; intimate/sexual contact
- Accounts for 50% of cases of fulminant hepatitis
- In an adult who develops acute hepatitis B, there is
approximately 10% chance that it will progress into chronic Viral Hepatitis D
hepatitis; in the neonate the chance is 90% for chronic - RNA virus that infects either simultaneously with hepatitis
hepatitis. B or as a super-infection in a person with chronic hepatitis
- Incubation period is very long: 1 - 6 months B
- Hepatitis D infection cannot occur unless there is current
and ongoing replication of the hepatitis B virus
- Overall, this infection carries the highest risk among acute
viral hepatitis for fulminant disease; the risk is even greater
in super-infection
- Predominantly seen in patients exposed to blood products
(drug addicts and hemophiliacs). If anti-hbs antibodies are
present, then that person is immune to hepatitis B and D
Viral Hepatitis E
- Similar to Hepatitis A with fecal or oral transmission,
there is no chronic form
- The risk of fulminant disease has been described mainly in
pregnant patients

Viral Hepatitis C Assessment findings

- RNA virus generally transmitted predominantly by blood • Preicteric stage (prodromal phase) = 1 week
products - Anorexia (major manifestation), N&V, fatigue,
- Currently the most common hepatitis among IV drug constipation or diarrhea, weight loss
abusers and in prisons - RUQ discomfort, hepatomegaly, splenomegaly,
- Before 1990 it accounted for 90% of transfusion hepatitis lymphadenopathy

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• Icteric stage
- Fatigue, weight loss, light-colored stools, dark urine
- Continued hepatomegaly with tenderness,
lymphadenopathy, splenomegaly
- Jaundice, pruritus
• Posticteric stage
- Fatigue, but an increased sense of well-being,
hepatomegaly gradually decreasing
Collaborative Management
• Promotion of rest to relieve fatigue
• Maintenance of food and fluid intake
• 3,000 ml/day of fluids for fever and vomiting; monitor I and
O, weight • Types
• Well – balanced diet; encourage fruit juices and non- o Laênnec’s cirrhosis
carbonated beverages - associated with alcohol abuse and malnutrition;
• Fats may need to be restricted characterized by an accumulation of fat in the
• Alcoholic beverages should be avoided liver cells, progressing to widespread scar
formation.
• Prevention of injury
o Postnecrotic cirrhosis
• advise client to use soft toothbrush or swabs
- results in severe inflammation with massive
• administer Vitamin K as ordered
necrosis as a complication of viral hepatitis
• Provision of comfort measures o Cardiac cirrhosis
• Relaxing baths, backrubs, fresh linens and quiet dark - occurs as a consequence of RSHF; manifested by
environment hepatomegaly with some fibrosis.
• Relieve pruritus through the following measures: o Biliary cirrhosis
- Use of cool, light, non-restrictive clothing - associated with biliary obstruction, usually in the
- Use of soft, dry, clean bedding, use of warm baths common bile duct; results in chronic impairment
- Application of emollient creams and lotions to dry skin. of bile excretion
- Maintenance of a cool environment Assessment
- Administration of antihistamines as ordered • Anorexia, weakness, weight loss (liver is unable to
- Use of diversional activities, e.g. reading, TV and radio metabolize nutrients and store fat-soluble vitamins)
• Fever (in response to tissue injury)
Liver Cirrhosis
• Jaundice, pruritus, tea colored urine (due to bilirubin in
- Chronic, progressive disease characterized by
the blood)
inflammation, fibrosis, and degeneration of the liver
• remember!!! bilirubin is conjugated initially before
parenchymal cells
excretion
- Destroyed liver cells are replaced by scar tissue, resulting
• Increased Bleeding tendencies. (liver is unable to store Vit.
in architectural changes & malfunction of the liver
K. There is also impaired production of clotting factors)
Portal HPN

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Pathology
1) In portal hypertension
- plasma shift into interstitial spaces within the liver due
to the increase pressure. The collection of fluids shifts
out of the Glisson’s capsule and accumulate in the
peritoneal cavity
2) The liver is unable to metabolize protein, thereby
hypoalbuminemia occurs
- result to decreased oncotic pressure, fluids shift out of
the IVC, and accumulate in the peritoneal cavity.
3) The liver is unable to excrete adrenal cortex hormone, one
of which is aldosterone
- Hyperaldosteronism leads to retention of sodium and
water
4) Esophageal varices = 2° to backpressure
5) Internal hemorrhoids, leg varicosities, and dependent
edema
- due to venous stasis, increasing hydrostatic pressure. • Males (estrogen) will result to:
This leads to shifting of plasma into interstitial space - Decreased libido, Impotence, Fall of body hair, Atrophy
Consequences of Portal HPN: of testicles, gynecomastia
• Hepatomegaly= initially, then the liver shrinks in size as • Females (androgen)
fibrosis replaces the liver parenchyma - Hirsutism
• Splenomegaly= due to increased backpressure of the - acne
blood - deepening of voice
• Caput medusae (dilated veins over the abdomen) - Virilism (development or premature development of
• Spider angioma (telangiectasia / dilated capillaries over male secondary sexual characteristics)
the face and anterior trunk)= due to increased estrogen
• Palmar erythema. This is also due to elevated estrogen Hepatic Encephalopathy
level in males. - Accumulation of AMMONIA because the liver cannot
convert ammonia into urea that can lead to hepatic coma
• Ascites
(Ammonia is by product of CHON metabolism)
- initial manifestations: BEHAVIORAL changes and MENTAL
changes
- Other findings in advanced stages are:
• asterixis – flapping tremors of the hands
• confusion / disorientation
• delirium / hallucination
• fetor hepaticus - disagreeable odor from the mouth
• coma
Diagnostic tests
• SGOT or AST, SGPT, LDH, alkaline phosphatase increased
• Serum bilirubin increased
• PT prolonged
• Serum albumin decreased
• Hgb/Hct decreased

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Medical Management may develop higher in the esophagus or extend into

• Bedrest the stomach
• Hepatic protector- Essentiale, Godex o Causes:
• Betablockers - Commonly caused by PORTAL hypertension secondary
• Blood transfusion to liver cirrhosis
• Diuretic
• Vitamin K
• Antibiotics- Neomycin
• Paracentesis
• Albumer infusion
• Antihistamine
• Laxative
• Enema
• Diet- low sodium, high CHO, Low CHON, Low fat
Nursing interventions
• Provide sufficient rest and comfort
- Provide bed rest with bathroom privileges. Assessment Findings
- Encourage gradual, progressive, increasing activity with • Hematemesis (vomiting of bright red blood)
planned rest periods. • Melena (passing out of black, tarry stools)
- Institute measures to relieve pruritus. • Hepatomegaly
o Do not use soaps and detergents • Splenomegaly
o Bathe in tepid water followed by application • Jaundice
of an emollient lotion. • Ascites
o Provide cool, light, nonrestrictive clothing. • Signs of SHOCK!!! (Tachycardia, Hypotension, Tachypnea,
o Keep nails short to avoid skin excoriation Cold clammy skin)
from scratching. Diagnostic Evaluation
o Apply cool, moist compresses to pruritic • Upper GI endoscopy to identify the cause & site of bleeding
areas. • Serum liver function test
• Promote nutritional intake Nursing Interventions
- Encourage small frequent feedings. • Monitor VS strictly (note: signs of shock), LOC
- Promote a high-calorie, low- to moderate- protein, high • Maintain NPO, Monitor blood studies
CHO, low-fat diet, with supplemental vitamin therapy • Administer O2, Blood Transfusion, Vasopressin (Pitressin)
(vitamins A, B- complex, C, D, K, and folic acid) • Assist in NGT and Sengstaken-Blakemore tube insertion
for balloon tamponade
Prevent infection
• Prevent skin breakdown by frequent turning and skin care.
• Provide reverse isolation for clients with severe
leukopenia; pay special attention to hand-washing
technique.
• Monitor WBC.
• Monitor/prevent bleeding.
• Administer diuretics as ordered
• Provide client teaching & D/C planning concerning:
• Avoidance of agents that may be hepatotoxic (sedatives,
opiates, or OTC drugs detoxified by the liver)
• How to assess for weight gain and increased abdominal
girth
• Avoidance of persons with upper respiratory infections
• Recognition and reporting of signs of recurring illness (liver
tenderness, increased jaundice, increased fatigue, • Never leave the patient unattended during esophageal
anorexia) balloon tamponade
• Avoidance of all alcohol • Closely monitor the lumen pressure
• Avoidance of straining at stool, vigorous blowing of nose • Check VS q30 minutes. Maintain drainage and suction on
and coughing, to decrease the incidence of bleeding the suctions ports
o Dilated tortuous veins usually found in the
• Watch for signs of respiratory distress while the tube is in
submucosa of the lower esophagus; however they
place. If this will happen, call another nurse to notify the

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physician and quickly pinch the tube at the patient’s • Provide small, frequent meals of modified diet, low fat (if
nose and cut it with scissors, remove the tube oral intake allowed)
• Deflate the esophageal balloon for about 30 minutes every • Provide care to relieve pruritus
8-12 hours • Provide care for the client with a cholecystectomy or
• Provide frequent mouth and nose care choledochostomy
Surgical Management Medical management
• Endoscopic sclerotherapy • Supportive treatment: NPO with NG intubation and IV fluids
- sclerosing agent is injected directly into the varix with • Diet modification with administration of fat- soluble
a flexible fiberoptic endoscope to promote vitamins
thrombosis & sclerosis of bleeding sites • Drug therapy
• Endoscopic Variceal ligation (variceal banding) • NSAIDS- Ketorolac
• Shunt procedures o Narcotic analgesics for pain
o Morphine vs Demerol
Cholelithiasis o Anticholinergics (atropine) may be used for pain
- “gallstones” o Antiemetics
- FAT, FEMALE, FORTY, FERTILE Surgery
- More common in women after age 40 (estrogen therapy), • Cholecystectomy with choledochotomy
women taking oral contraceptives, and in the obese - removal of the gallbladder with insertion of a T-tube
• Cholecystitis into the common bile duct if common bile duct
- acute or chronic inflammation of the gallbladder exploration is performed
• Theory of Stone formation: • Choledochotomy
Metabolic factors (obesity, pregnancy, DM, - Opening of common duct, removal of stone, and
hypothyroidism,stasis) MAY all lead to insertion of a t-tube
stagnation of bile in the gallbladder • Laparoscopic cholecystectomy
- Performed via laparoscopy for uncomplicated cases
when client has not had previous abdominal surgery
• Cholecystostomy
excessive absorption of water - Opening of the gallbladder to remove stones
Nursing Interventions
• Provide routine pre-op care
• Provide routine post-op care
• Position client in semi-Fowler’s or side-lying positions;
precipitation of salts (stones) reposition frequently.
- Gallstones are composed primarily of cholesterol (80%), • Splint incision when turning, coughing, and deep breathing
bile salts, Ca++, bilirubin & CHONs • Maintain/monitor functioning of T-tube
Assessment Findings - Ensure that T-tube is connected to closed gravity
• Most patients are asymptomatic. drainage.
• When symptomatic; PAIN in RUQ and epigastric pain - Avoid kinks, clamping, or pulling of the tube.
lasting approximately 30 min. - Measure and record drainage every shift
• Fever & leukocytosis (WBC) - Expect 300 – 500 ml bile-colored drainage for the 1st 24°
• Charcot triad then 200 ml/24° for 3 - 4 days
o fever - Assess for signs of peritonitis
o jaundice - Monitor color of urine and stools (stools will be light
o pain in RUQ pain (ascending cholangitis) colored if bile is flowing through T tube but normal color
• Intolerance for fatty foods (steatorrhea, N&V, sensation of should reappear as drainage diminishes)
fullness) - Assess skin around T-tube; cleanse frequently and keep
• Pruritus, easy bruising, dark amber urine dry
Diagnostic Tests • Provide client teaching and discharge planning concerning
• Direct bilirubin, transaminase, alkaline phosphatase, WBC, - Adherence to dietary restrictions
amylase, lipase: all increased - Resumption of ADL
• Oral cholecystogram (gallbladder series): positive for o avoid heavy lifting for at least 6 weeks
gallstone o resume sexual activity as desired unless ordered
Nursing interventions otherwise by physician
• Administer pain medications as ordered and monitor for - clients having laparoscopy cholecystectomy
effects. usually resume normal activity within two weeks
• Administer IV fluids as ordered. o Recognition and reporting of signs of complications
(fever, jaundice, pain, dark urine, pale stools,
pruritus)
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Pancreatitis o Frothy/foul-smelling bowel movements

- An inflammatory process with varying degrees of o Irritability, confusion, persistent elevation of
pancreatic edema, fat necrosis, or hemorrhage temperature (2 days)
- Proteolytic and lipolytic pancreatic enzymes are activated Medical Management
in the pancreas rather than in the duodenum, resulting in • Drug therapy
tissue damage and autodigestion of the pancreas - Analgesics (MORPHINE) to relieve pain. NO to
- Occurs most often in the middle aged DEMEROL, because of its toxic effects to the brain.
- Causes: - Smooth-muscle relaxants to relieve pain
• Alcoholism/ alcohol abuse o papaverine, nitroglycerin
• Biliary tract disease/ biliary obstruction - Anticholinergics to decrease pancreatic stimulation
• Trauma, viral infection, peptic ulcer disease, abscesses o atropine, propantheline bromide
• Drugs (anti hypertensives, steroids, thiazide diuretics, o Antacids to decrease pancreatic stimulation
antimicrobials, immuno suppressives, oral o H2-antagonists, vasodilators, calcium
contraceptives) gluconate
• Metabolic disorders (hyperparathyroidism, - Diet modification
hyperlipidemia) - NPO usually for a few days to promote GIT rest
• Unknown/ autoimmune - Peritoneal lavage
Assessment Findings - Dialysis if the condition is severe
- Pain (LUQ radiating to back, flank, or substernal area)
accompanied by DOB (shallow respiration with pain), ENDOCRINE SYSTEM AND PITUITARY DISORDERS
aggravated by eating - Composed of ductless glands that releases hormones
- N&V, decreased/absent bowel sounds, directly into the bloodstream
- Abdominal tenderness w/ muscle-guarding - Hypothalamus control most of the endocrinal activity of
- (+) Grey Turner’s spots (ecchymoses on flanks) the pituitary gland
- (+) Cullen’s sign (ecchymoses of periumbilical area) - Secretes RELEASING HORMONES: GHRH, CRH, TRH,
- Tachycardia GnRH, PRH
Diagnostic Tests • Pituitary Gland (Hypophysis) - Divided into 2 lobes:
• Serum amylase (>300 somogyi units) & lipase - Anterior Pituitary (Adenohypophysis)
• urinary amylase o 70% of the gland
• blood sugar o Found in the sella turcica, a depression in the
sphenoid bone at the base of the brain
• lipid levels
o Secretions: GH, PRL, ACTH, TSH, LH, FSH,
• Serum calcium
MSH
• CT scan: enlargement of the pancreas
- Posterior Pituitary (Neurohypophysis)
Nursing Interventions
o Stores & secretes ADH & Oxytocin produced by
• Administer analgesics, antacids, and anticholinergics as the hypothalamus
ordered, monitor effects
• Withhold food/fluid and eliminate odor and sight of food
from environment to decrease pancreatic stimulations
• Maintain NGT and assess for drainage.
• Institute Non-pharmacologic measures to decrease pain.
o Assist client to positions of comfort (knee chest, fetal
position)
o Teach relaxation techniques and provide a quiet, restful
environment.
• Provide client teaching and discharge planning
concerning
• Dietary regimen when oral intake permitted
o High CHO, high CHON, low-fat diet
o Eating small, frequent meals instead of three large
ones
o Avoiding caffeine products
o Eliminating alcohol consumption
o Maintaining relaxed atmosphere after meals - Disorders are generally grouped into:
• Recognition/reporting of signs of complications o HYPER - when the gland secretes excessive
o Continued N&V hormones
o Abdominal distension with increasing fullness o HYPO - when the gland does not secrete enough
o Persistent weight loss hormones
o Severe epigastric or back pain
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- Hyper and Hypo can be classified as: o Diagnostic Test: Water deprivation test
o PRIMARY - when the Gland itself is the problem • Oxytocin
o SECONDARY - when the problem is the pituitary or o released during childbirth to cause uterine
the hypothalamus contraction
- Growth hormone (Somatotropin) o responsible for the “let-down” reflex of milk
o Growth of body tissues and bone ejection
• Hyper-secretion:
- GIGANTISM (children) Pituitary Gland Disorders
- ACROMEGALY (adults) Hyperpituitarism
- Hypo-secretion of GH: Dwarfism - Chronic, progressive hyper-function of the anterior
• Prolactin (Mammotropic/ Lactotropic Hormone) pituitary resulting in oversecretion of one or more of the
- Mammary tissue growth and lactation. anterior pituitary hormones
• Hypersecretion: - Etiologic factors:
- Galactorrhea (abnormal breast-milk production) o Tumor and hyperplasia (Benign pituitary
• Hypo-secretion: adenoma, hyperplasia of pituitary tissue)
- Absence of milk during lactation o Prolactinomas (prolactin-secreting tumors)
• ACTH (Adrenocorticotropic Hormone) account for 60 to 80% of all pituitary tumors
- Stimulates adrenal cortex to secrete the adrenal - GH-producing adenomas
hormones cortisol and aldosterone Assessment Findings
- Hyper-secretion: • Acromegaly
o Cushing’s Syndrome - gradual, marked enlargement of the bones of the face,
- Hypo-secretion: jaw, hands and feet. There can be diaphoresis,
o Addison’s Disease hyperglycemia, oily skin and hirsutism
- TSH (Thyroid Stimulating Hormone) • Gigantism
o Stimulates the thyroid gland to secrete T3 and T4 - proportional overgrowth of all body tissues with
- Hyper-secretion: remarkable height
o Hyperthyroidism • Neurologic manifestations
- Hypo-secretion: - Headache
- Hypothyroidism - Somnolence, Behavioral changes, seizures
- Gonadotropin (FSH/ LH) - Signs and symptoms of increased ICP
• Affect growth, maturity and functioning of primary and - Disturbance in appetite, sleep, temperature
secondary sex characteristics regulation and emotional balance due to
• They influence the gonads (ovaries and testes) to hypothalamic involvement
secrete gonadal hormones- estrogen, progesterone, - Visual disturbances due to the compression of the
testosterone optic chiasm above the pituitary gland:
• Hyper-secretion: - Hemianopsia or scotomas or blindness
o precocious puberty - SCOTOMA “blindspot in vision”
• Hypo-secretion Diagnostic Tests
o Males: impotence,  production of spermatozoa • skull x-ray, CT scan, MRI (tumor or pituitary enlargement)
o Females: no ovulation, no menstruation, • Plasma GH levels determination: increased
infertility • Adult male-.4-10ng/ml
- MSH (Melanocyte Stimulating Hormone) • Female-1-14ng/ml
• Stimulates the skin melanocytes to produce the • Child- 10-50ng/ml
pigment melanin
• Hypersecretion:
o Bronze appearance of the skin
(hyperpigmentation)
• Hyposecretion:
o Albinism (hypopigmentation)
- ADH (Antidiuretic Hormone / Vasopressin)
• causes the renal retention of water (not affecting
sodium) in the renal tubules
• It can also cause vasoconstriction; “vasopressin”
• Hyper-secretion:
o SIADH - excessive retention of water by the renal Medical Management
tubules: - Surgery
• Hypo-secretion: o Removal of pituitary gland
o DI - inability of the renal tubules to retain water o Transphenoidal hypophysectomy

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- Radiation - Advise patient NOT to brush the teeth for 2 weeks to

- Pharmacotherapy avoid injury to the suture lines
o Bromocriptine (Parlodel) is used to treat - Find alternative measures for oral care like mouthwash
- amenorrhea, a condition in which the Hypopituitarism
menstrual period does not occur; - Hypo-function of pituitary gland causing deficiencies in
- infertility (inability to get pregnant) in women both the pituitary hormones and the hormones of the
- abnormal discharge of milk from the breast target glands
- Hypogonadism - Clinical Manifestation:
- Parkinson's disease o Observed when 75% of the pituitary gland is
- inhibit the synthesis of GH & prolactin dysfunctional
Nursing Management: Surgery o Metabolic dysfunction
Pre-operatively: Health Teaching o Sexual immaturity
- explain to the patient that this surgery will remove the o Growth retardation
tumor from the pituitary gland o Hypo-function of pituitary gland causing
- A nasal catheter and nasal packing are expected in the deficiencies in both the pituitary hormones and the
nasal cavity for a day hormones of the target glands
- Indwelling catheter will be inserted (to monitor UO) – o Observed when 75% of the pituitary gland is
Diabetes Insipidus can be a complication of the surgery dysfunctional
- Review all patient’s medication regimen and provide o Metabolic dysfunction
routine pre-op care o Sexual immaturity
Post-operatively: o Growth retardation
• Causes:
- Strictly keep the patient on BED rest for 24° and
o Trauma
encourage ambulation on day 2
o Tumor
- position the patient fowler’s to avoid tension on the
o Vascular lesion
suture line and to avoid increased intracranial pressure
o Surgery / radiation of pituitary gland
- Remind the patient NOT to sneeze, forcefully cough, bend
o Congenital
over and blow the nose for several days to avoid disturbing
the suture lines Assessment Findings
- Mild analgesic can be given for headache • Hemianopsia / headache (if due to tumor)
- Anticipate the patient to manifest signs and symptoms of • Weight loss, emaciation
DI after surgery • Varying signs of hormonal disturbances depending on
- Be alert for  thirst and  UO w/ low SG which hormones are being under-secreted
- Replace fluids and administer IV vasopressin as - menstrual dysfunction
ordered. DI should resolve in 72° - hypometabolism
- Report outputs above 900 ml / 2 hours or - adrenal insufficiency
specific gravity below 1.004 (D. Insipidus) - growth retardation
- Arrange for a visual field testing because progressive Diagnostic Tests
visual field defects may indicate bleeding • Skull x-ray, CT scan, MRI (reveal pituitary tumor)
- Be alert for potential leakage of CSF from the operative • Blood examination:
site •  plasma hormone levels (depending on specific hormones
- If rhinorrhea is present, test the discharge for glucose and under-secreted)
if positive, report to the physician of the CSF leakage
Collaborative Management
Nursing Management
- Provide emotional support to help patient cope with an - specific treatment depends on cause
altered body image o Tumor: surgical removal or irradiation of the
- Perform range of motion exercises to promote maximum gland
joint mobility and prevent injury due to muscle weakness o Regardless of cause, treatment will include
- Keep skin dry and avoid using oily lotion replacement of deficient hormones (HRT):
- Provide safety measures because pituitary tumor can - Corticosteroids
cause visual disturbances. Approach the patient to the - Thyroid hormone
unaffected side if he has hemianopsia. - Sex hormones, gonadotropins
- Deal with the mood swings appropriately
- Home teaching include: emphasizing that hormone
replacement is needed lifetime, wear an ID, have regular
follow-up GOOD LUCK EVERYONE!!
• Home care instruction
- Explain the need to take the medication as prescribed
- Report progressive visual changes, excessive urination

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