● Gastrointestinal System:

○ Enteral Feeding: is used when a patient is unable to eat orally

■ Indications:
● Inability to eat due to a medical condition (comatose, intubated,
stroke)
● Inability to maintain adequate oral nutritional intake and need for
supplementation due to increased metabolic demands
● Pathologies that cause difficulty swallowing or increase risk of
aspiration
■ Clinical Presentation:
● Malnutrition: decreased prealbumin, decreased total iron-binding
capacity
● Aspiration pneumonia: food, vomit, etc. is inhaled into the lungs
■ Complications:
● Overfeeding: results from infusion of a greater quantity of feeding
than can be readily digested, which causes abdominal distention
and nausea and vomiting
○ Nursing Interventions:
■ Check residual volume every 4-6 hours
● It is the volume of fluid remaining in the
stomach during feeding: if it is high, the
patient is not digesting the food (let the
doctor know FIRST)
● Ex: patient is on 60 mL, but you aspirate
100 mL
■ Follow protocol for slowing or withholding feeding
for excess residual volume: let doctor know and
they will tell you to hold the feeding
■ Check the pump for proper operation and ensure
feeding infused at correct rate (probably would
want to make sure that everything works and is
running at the correct rate BEFORE you do
something; assess before doing)
● Diarrhea: occurs secondary to concentration of feeding or its
constituents
○ Nursing Interventions:
■ Slow the rate of feeding and notify the provider
■ Consult with a dietitian
■ Provide skin care and protection
 ■ Evaluate for Clostridium difficile if diarrhea
continues, especially if it has a foul odor: let doctor
know so they can take a sample
● Immediately put them on contact
precaution if you suspect C.diff
● Aspiration Pneumonia: secondary to aspiration of feeding and
can be life-threatening
○ Tube displacement is the primary cause
○ Nursing Interventions:
■ Stop the feeding immediately, turn the patient to the
side and suction the airway (PRIORITY)
■ Monitor vital signs
■ Auscultate breath sounds for increased congestion
and diminished breath sounds
■ Notify the provider and obtain chest x-ray is
prescribed
● Refeeding Syndrome: occurs when enteral feeding is started in a
patient who is in a starvation state and their body has begun to
metabolize protein and fat for energy; can be life-threatening
○ Nursing Interventions: notice how we assess/monitor first
■ Monitor for new onset confusion or seizures
■ Assess for shallow respirations
■ Monitor for increased muscle weakness
■ Notify provider and obtain serum electrolytes if
needed
○ Total Parenteral Nutrition (TPN): is a hypertonic bolus solution
■ Purpose: to prevent or correct nutritional deficiencies and minimize
adverse reaction of malnutrition
● Administered via central line, if it contains complete nutrition
■ Partial Parenteral Nutrition (PPN): less hypertonic, intended for
short-term use, and administered in a large peripheral vein (use a big
gauge)
■ Indications: any condition that affects the ability to absorb nutrition (ex:
chronic pancreatitis), has a long recovery, and creates chronic malnutrition
■ Clinical Presentation:
● Weight loss greater than 10% of their body weight and NPO or
unable to eat or drink for more than 5 days
● Muscle wasting, poor tissue healing, burns, bowel disease disorder,
acute kidney failure
 ■ Nursing Interventions:
● NEVER STOP TPN ABRUPTLY: speeding up/slowing down the
rate is contraindicated and can significantly alter blood glucose
levels
● Assess vital signs every 4-8 hours
● Change tubing and solution bag (even if its not empty) every 24
hours
● Check capillary glucose every 4-6 hours
● Keep dextrose 10% at bedside in case solution is unavailable
■ Complications:
● Metabolic: hyperglycemia, hypoglycemia, and vitamin deficiency
● Air Embolism: a pressure change during tubing changes is the
cause
● Infection: due to concentrated glucose being a medium for bacteria
○ Gastroesophageal Reflux Disease (GERD): disorder marked by backflow of
gastric or duodenal contents into the esophagus, injuring the esophagus overtime
■ Excessive reflux may occur because of an incompetent or weakened lower
esophageal sphincter (LES)
■ Treatment: diet and lifestyle changes are the primary treatment
● Antacids, H2 receptor antagonist, proton pump inhibitors, surgery
■ If left untreated, it leads to inflammation, breakdown, and Barrett’s
esophagus, which is a long-term complication
■ Barrett’s Esophagus: the lining of the esophagus changes to match the
cell lining of the intestine, causing adenocarcinoma (cancer) of the
esophagus
■ Risk Factors:
● Older patients due to delayed gastric emptying, which weakens the
esophageal sphincter
● Irritable bowel syndrome and obstructive airway disorders
(asthma, COPD, cystic fibrosis)
● Peptic ulcer disease, angina, and Barett’s esophagus
■ Associated With: tobacco use, coffee drinking, alcohol consumption,
gastric infection with H.pylori, obesity, sleep apnea, pregnancy, hiatal
hernia
■ Expected Findings:
● DYSPEPSIA (indigestion w/ heartburn) IS A CLASSIC SIGN:
after eating certain foods or fluid, which causes regurgitation
● Epigastric pain: patients report feelings of a heart attack
● Pain radiating to the neck, jaw, or back
○ Similar pain to an MI, always assess for differences
 ●Pyrosis (burning sensation in the esophagus)
●Pain the worsens when bending, straining, or laying down
●Pain that occur after eating and lasts 20 minutes to 2 hours
●Throat irritation (chronic cough, laryngitis)
●Hypersalivation and hoarseness
●Bitter taste in the mouth (caused by regurgitation)
●Pain is relieved almost immediately by drinking water, sitting
upright or taking antacids
■ Diagnostic Procedures for GERD:
● Esophagogastroduodenoscopy (EGD): patient is moderately
sedated to observe for tissue damage and to dilate structures in the
esophagus
○ The esophagus will look red (normal is pink)
○ Make sure the gag reflex comes back after procedure
● Barium Swallow: identifies hiatal hernia and structural
abnormalities, which contributes to or causes GERD
○ Laxatives must be administered after this procedure to
prevent fecal impaction
○ Barium is a white solution that lights up the structures
● Esophageal Manometry: records lower esophageal sphincter
pressure and peristaltic activity of the esophagus
● pH Monitoring: small catheter is placed through the nose and into
the distal esophagus to measure the acid amounts in the esophagus
for 24 hours
■ Complications of GERD:
● Aspiration Pneumonia: reflux of gastric fluids into the esophagus
can be aspirated into the trachea
● Barrett’s Epithelium and Esophageal Adenocarcinoma: caused
by chronic esophagitis; the body continuously heals inflamed
tissue and begins to replace normal esophageal epithelium with
pre-malignant tissue (Barrett’s epithelium)
■ Management of GERD:
● Low-fat diet and eating small meals
● Avoid caffeine, tobacco, beer, milk, foods with peppermint or
spearmint, tomatoes, and carbonated beverages
● Do not eat or drink 2 hours before bedtime (to avoid reflux)
● Elevate the head of the bed at least 30 degrees (Semi-Fowler’s)
● Do not wear tight fitting clothing
● Maintain a BMI below 30
● Sit up for 1 hour after meals
 ■ Medications:
● Proton Pump Inhibitors: pantoprazole [Protonix], omeprazole
[Prilosec], and esomeprazole [Nexium]
○ Reduces gastric acid by inhibiting the proton pump in the
gastric parietal cells that secrete gastric acid
○ Nursing Considerations:
■ Monitor for electrolyte imbalances and
hypoglycemia in patients with diabetes mellitus
■ Long-term use may cause community-acquired
pneumonia and C. diff infections
■ Long-term use places patients at risk for fractures
● Antacids: magnesium hydroxide [Milk of Magnesia], aluminum
hydroxide, and sodium bicarbonate
○ Neutralize excess acid and increases gastroesophageal
sphincter
○ Nursing Considerations: make sure there are no
contraindications with other meds like Synthroid
■ Should be taken alone
● Histamine 2 Receptor Antagonist: ranitidine [Zantac] and
famotidine [Pepcid]
○ Blocks histamine to reduce acid secretion
○ Onset is longer than antacids, but effects have a longer
duration
● Prokinetics: metoclopramide [Reglan]
○ Increase mobility of the esophagus and stomach
○ Can cause extrapyramidal effects (involuntary movement)
■ Surgical Treatment:
● Fundoplication: the fundus of the stomach is wrapped around and
behind the esophagus with a laparoscope to create a physical
barrier to help strengthen the lower esophageal sphincter (LES)
○ Only for patients who fail to respond to other
treatments
○ Hiatal Hernia: the protrusion of the stomach above the diaphragm into the
thoracic cavity through the hiatus (opening of the diaphragm), which causes
pressure on the lower esophageal sphincter; there are 2 types
■ Sliding: most common; portion of the stomach and gastroesophageal
junction move above the diaphragm
■ Paraesophageal: part of the fundus of the stomach moves above the
diaphragm, but the gastroesophageal junction remains below the
diaphragm
 ■ Health Promotion and Prevention:
● Do not eat immediately before going to bed
● Avoid fatty and fried foods, chocolate, coffee, spicy foods,
tomatoes, citrus fruits, and alcohol
● Maintain a healthy weight
● Avoid straining or excessive vigorous exercise
● Elevate the head of the bed on 6-inch blocks
● Medications are the same as GERD
○ Gastritis: inflammation of the lining of the stomach (erosive or non-erosive) and
can be acute or chronic; a common GI problem
■ Acute: rapid onset of symptoms and short duration
● Can result in gastric bleeding
● Severe form is caused by ingestion of an irritant such as a strong
acid or alkali, which can cause gangrenous tissue or perforation
● Scarring can lead to pyloric stenosis
■ Chronic: prolonged inflammation due to benign or malignant ulcers of the
stomach or by H. pylori (lives in contaminated water and/or fecal matter)
● May be associated with some autoimmune diseases, dietary
factors, medications, alcohol, smoking, or chronic reflux of
pancreatic secretions or bile
■ Non-Erosive: most common cause is infection by H.pylori
■ Erosive: caused by NSAIDs (ibuprofen, naproxen, aspirin), alcohol use
disorder, or recent radiation treatment

■ Health Promotion and Prevention:

● Follow a prescribed diet and medication regimen
● Decrease or eliminate the use of alcohol and stop smoking
● Watch for indications of GI bleeding (coffee-ground emesis and
black, tarry stool)
● Assist in reducing anxiety related to gastritis
● Eat small, frequent meals
● Avoid foods and beverages that cause irritation
● Report nausea and vomiting or blood in the stool
 ■ Manifestations:
● Acute: abdominal discomfort, headache, lassitude (lethargy),
nausea, vomiting, hiccuping
● Chronic: epigastric discomfort, anorexia, heartburn after eating,
belching, sour taste in the mouth, nausea and vomiting, intolerance
of some foods
○ May have vitamin deficiency due to malabsorption of B12
■ Diagnostic Procedures: upper GI x-ray or endoscopy and biopsy
■ Medical Management of Gastritis:
● Acute: supportive therapy
○ Do not eat alcohol and food until symptoms subside
○ If due to strong acid or alkali treatment to neutralize the
agent, avoid emetics and lavage due to danger of
perforation and damage to esophagus
● Chronic: medications, modify diet, promote rest, and reduce stress
○ Avoid alcohol and NSAIDs
○ Peptic Ulcers: erosion of mucous membranes forms an excavation in the
stomach, pylorus, duodenum, or esophagus
■ The most common peptic ulcer is in the duodenum
■ Associated with infections of H. pylori (most common cause)
■ Risk Factors: excessive secretion of stomach acid, dietary factors,
chronic use of NSAIDs, corticosteroids, severe stress, pernicious anemia,
excessive alcohol abuse, smoking, familial tendency, H.pylori, and
Zollinger-Ellison syndrome (combination of peptic ulcers, hypersecretion
of gastric acid and gastric –secretion tumors)
■ Manifestations: heartburn and vomiting may occur
● Dull, gnawing pain or burning in the midepigastrium
■ Treatment: medications, lifestyle changes, and occasional surgery
■ Gastric Ulcers:
● Pain most commonly occurs 30 to 60 mins after meals (food
exacerbates pain)
● Pain occurs less often at night
● Malnourished (weight loss)
● Hematemesis (bloody vomit)
■ Duodenal Ulcers:
● Pain occurs 1.5 to 3 hrs after a meal due to an empty stomach
● Awakening with pain during the night (more painful at night)
● Pain relieved by ingestion of food or an antacid
● Well-nourished
● Melan (black tarry stool)
■ Laboratory Testing:
● H. pylori Testing: gastric samples collected via endoscopy
● Stool Testing: stool sample to test for H.pylori antigen and for
occult blood
● Hemoglobin and Hematocrit: unexpected findings secondary to
bleeding (they will be low)
● Breathing Test: patient exhales into a collection container (at
baseline) then drinks carbon-enriched urea solution and exhales
into a collection container
○ Patient is NPO during this procedure
○ If H.pylori is present, the solution will break down and
carbon dioxide is released
■ Assessment:
● Assess pain and methods used to relieve pain
● Assess dietary intake and keep a 72 hour diet diary
● Assess for use of cigarettes and alcohol use
● Assess for use of medications such as NSAIDs
● Assess for signs and symptoms of anemia and bleeding
● Assess the abdomen
■ Nursing Management:
● Instruct the patient to avoid foods that cause distress: coffee, tea,
carbonated beverages
● Monitor for orthostatic changes in vital signs and tachycardia, as
these findings are suggestive of GI bleeding or perforation
● Administer saline lavage via nasogastric tube
● Administer medications as prescribed
● Decrease environmental stress
● Encourage rest periods
● Encourage smoking cessation and avoiding alcohol consumption
● Monitor lab results
■ Medications:
● Antibiotics: amoxicillin, clarithromycin, tetracycline: eliminates
H. pylori infection
● Histamine 2 receptors antagonists, proton pump inhibitors,
antacids, mucosal protectants (sucralfate [Carafate]; give the liquid
form and shake well before giving if the patient cannot swallow)
■ Surgical Interventions: used in patients when ulcers do not heal
following 12 to 16 weeks of medical treatment, hemorrhage, perforation or
obstruction
 ● Gastrectomy: all or part of the stomach is removed with
laparoscopic or open approach
○ Dumping Syndrome: is a complication and a group of
manifestations that occur following eating
■ A shift of fluids to the abdomen is triggered by
gastric emptying or high-carbohydrate ingestion
■ Symptoms: diarrhea, dizziness, full sensation,
palpitations, tachycardia
■ Late Symptoms: can be related to the rapid release
of blood glucose, followed by an increase in insulin
production resulting in hypoglycemia
● Vagotomy: the vagus nerve is cut to decrease gastric acid
production the stomach
● Pyloroplasty: the opening between the stomach and the small
intestine is enlarged to increase the rate of gastric emptying
○ Paracentesis: performed by inserting a needle through the abdominal wall into
the peritoneal cavity; performed to relieve abdominal ascites
■ Indication: abdominal ascites caused by cirrhosis of the liver
● Respiratory distress is the determining factor in the use of a
paracentesis to treat ascites and is how you evaluate its
effectiveness (it will be relieved if it works)
■ Manifestations: compromised lung expansion (risk for pneumonia and
atelectasis), increased abdominal girth, rapid weight gain
■ Pre-Procedure:
● Determine client’s readiness for the procedure
● Assess pertinent lab values (albumin is important)
● Signed informed consent
● Have the client void before or insert indwelling urinary catheter
● Position client in an upright position, either on the edge of the
bed with feet supported or a high-fowler’s position
● Review baseline vitals signs (need it for comparison)
● Administer IV bolus fluids or albumin, prior to or after a
paracentesis to restore fluid balance
● Administer sedation as prescribed
■ Intra-Procedure:
● Monitor vital signs
● Adhere to standard precaution
● Label specimens and send to the lab
● Between 4 to 6L fluid is slowly drained from the abdominal by
gravity
 ■ Post-Procedure:
● Maintain pressure at the insertion site for several minutes and
apply a dressing to the site
● If the insertion site continues to leak after holding pressure for
several minutes, dry sterile gauze dressings should be applied and
changed as often
● Check vital signs, record weight and measure abdominal girth
daily
● Administer IV bolus or albumin as prescribed
■ Patient Education:
● Avoid alcohol, maintain a low-fat diet, take prescribed medications
and monitor puncture site for bleeding or leakage of fluids
● Report changes in mental and cognitive status due to change in
fluids and electrolyte imbalance
● Change position slowly to decrease the risk of falls which can be
related to hypovolemia from the removal of ascitic fluids
■ Complications: hypovolemia, bladder perforation, peritonitis
○ Obesity: abnormal or excessive fat accumulation that may impair health; it is a
body mass index above 30
■ Highest rate in women, African Americans, and Hispanics
■ Increased risk for diseases, disorders, low-self esteem, depression,
diminished quality of life, and impaired body image
■ Obesity is associated with 6 to 20 year decrease in life expectancy
■ Risk for cancer increases with increased BMI
■ Likelihood of type 2 diabetes by tenfold
■ Asthma or hypertension by fourfold
■ Twice as likely to have Alzheimer's
■ Compression of the oropharynx, increased neck circumference, and
increased neck diameter can predispose the patient to obstructive sleep
apnea, respiratory failure, and obesity hypoventilation syndrome
● Obesity Hypoventilation Syndrome: daytime hypoventilation with
hypercapnia, hypoxemia, and sleep disordered breathing
■ Assessment: height and weight determine BMI
● Overweight = BMI 25 to 29.9
● Obese = BMI exceeding 30
● Severe/extreme obese = BMI exceeding 40
● Waist circumference >35 in women and > 40 in men = greater risk
for obesity
● Hip to waist ratio
 ● Lab studies: cholesterol, triglycerides, fasting blood glucose,
HA1c, liver function tests
■ Lifestyle modifications and diet changes are the best way to treat obesity
■ Medications:
● Anti-Obesity: meant to supplement diet modification and exercise
○ Indications: BMI >30; BMI >27 with related comorbidity
○ Action: inhibits gastrointestinal absorption of fats, altering
central brain receptors to enhance satiety or reduce cravings
● Orlistat [Xenical]: prevents digestion of fats; adverse reaction are
oily discharge, reduced food and vitamin absorption
● Lorcaserin: stimulates serotonin receptors in the hypothalamus in
the brain to curb appetite
● Phentermine-Topiramate [Qsymia]: suppresses the appetite and
induces a feeling of satisfaction/fullness
■ Nursing Interventions:
● Understand that obesity affects skin integrity, body mechanics,
mobility, ventilation, circulation, and pharmacokinetics
● Maintain in low-Fowler’s position to maximize chest expansion
● Continuous pulse oximetry and supplemental oxygen
● Continuous positive airway pressure (CPAP)
● Use appropriate size BP cuff
● Assess for pressure ulcers
● Monitor for DVT (compressive device if pt is immobile)
○ Bariatric Surgery: weight loss of 10-35% body weight within 2-3 years
■ Performed only if non-surgical methods have failed
■ Restrictive Surgeries: laparoscopic adjustable gastric band or
laparoscopic sleeve gastrectomy: limits the amount of food eaten at one
time due to decrease volume capacity
● Patient needs to adhere to lifestyle modifications or else the weight
will come back
■ Vertical –Banded Gastroplasty: involves creation of a new, smaller
stomach porch using staples to decrease its functional size
■ Malabsorption Surgeries: Roux-en-Y gastric bypass or simply gastric
bypass: interferes with the absorption of food and nutrients from the GI
tract
■ Pre-Procedure:
● Need to treat the underlying cause or else the weight will return
● Encourage patient to express emotions about eating behaviors,
weight, and weight loss to identify psychosocial factors related to
obesity
● Ensure that the client understands needed diet and lifestyle changes
● Prepare the client for post-op course and potential complications
● Arrange for availability of a bariatric bed and mechanical lifting
devices to prevent client/staff injury
● Apply sequential compression stockings to help prevent deep vein
thrombosis
● Assess pertinent lab results
● Explain the need for life-long follow ups
■ Planning and Goals: relief of pain, maintenance of fluid balance,
prevention of infection, adherence to diet, knowledge about vitamin
supplements, achievement of positive body image, maintain normal bowel
habits
■ Post-Procedure:
● Monitor for leak of anatomies and notify MD immediately
● Notify the MD for suspected NGT displacement
○ The NGT is typically sutured in place following stomach
surgery; do not attempt to manipulate the tube
● Provide post-op care and prevent post-op complications
● Assess the airway and O2 saturation by maintaining the client in
semi-fowler’s position
● Apply an abdominal binder as prescribed to prevent dehiscence if
there is an abdominal incision
● Resume fluids as prescribed
 ○ The first fluids can be restricted to 30 ml and is gradually
increased in volume
● Observe client to indication of dumping syndrome (cramps,
diarrhea, tachycardia, dizziness and fainting)
■ Complications: dehydration and malnutrition/malabsorption
○ Nasogastric Decompression: indicated for patients who have an intestinal
obstruction
■ An NG tube is placed and then connected to suction to relieve abdominal
distention
■ Treatment continues until obstruction is resolved
■ Obstruction can be mechanical (tumors, adhesions, fecal impaction) or
functional (paralytic ileus from surgery, trauma or GI infection)
■ Manifestations:
● Vomiting
● Absent bowel sounds (paralytic ileus) or hyperactive and
high-pitched sounds (obstruction)
● Intermittent, colicky abdominal pain and distention
● Hiccups
■ Pre-Procedure: gather necessary equipment and supplies (tube, lubricant,
suction); educate the patient on the purpose of the NG tube and the
patient’s role in insertion
● The patient must swallow when the tube is being placed
■ Post-Procedure:
● Assess and maintain proper function of the NG tube and suction
equipment
● Maintain accurate intake and output
● Assess bowel sounds, abdominal girth, return of flatus
● Encourage repositioning and ambulation to help increase
peristalsis
● Monitor tube for displacement (x-ray can confirm placement)
● Instruct client to maintain NPO status
● Assess for skin breakdown around the nose
■ Complications: electrolyte imbalance (concerned about potassium) and
skin breakdown around the nose
○ Ostomies: a surgical opening from the inside of the body to the outside
■ Can be permanent or temporary; the purpose is to rest the bowels
■ Stoma: the artificial opening created during ostomy surgery
■ Ileostomy: a surgical opening into the ileum to drain stool, which is
typically frequent and liquid since large intestine is bypassed; liquid stool
 ● Performed when the entire colon must be removed due to disease
(Crohn’s disease, ulcerative colitis)
● Instruct the client to avoid high-fiber foods for the first 2 months
after surgery, chew food well, increase fluid intake
● Evaluate for evidence of blockage when slowly adding high-fiber
foods to the diet
■ Colostomy: a surgical opening into the large intestine to drain stool
● Performed when a portion of the bowel must be removed (cancer,
ischemic injury) or for rest to heal bowels (diverticulitis, trauma)
● Ascending colon: liquid, soft stool
● Transverse colon: formed, semi-soft stool
● Sigmoid colon: near-normal stool
■ Pre-Procedure:
● Determine the client’s readiness for the procedure
● Initiate a referral to the wound ostomy care nurse for ostomy
placement marking and client teaching
● Instruct the client and a support person regarding care and
management of an ostomy
■ Post-Procedure and Nursing Interventions:
● Assess the type and fit of the ostomy appliance: must be cut to the
correct size; leave ⅛ inch between the barrier and stoma; must be
completely sealed
● Monitor for leakage (risk of impaired skin integrity)
● Monitor the appearance of stoma (should be pink and moist)
● Apply skin barriers and cream to surrounding area and allow to dry
before applying a new appliance
● Empty ostomy bag when it is ¼ to ½ way full of drainage
● Evaluate stoma output (should be more liquid and more acidic the
closer the ostomy is to the proximal small intestine)
● Provide opportunities for the client to discuss feelings about the
ostomy and concerns about it effects on the client’s life
● Evaluate ability of the client or support person to perform ostomy
care
● Educate the client regarding dietary changes and ostomy appliance
that can help manage flatus and odor
■ Patient Education: dietary changes to help manage flatus and odor
● Odor causing food: fish, eggs, asparagus, garlic, beans, dark leafy
vegetables
○ Food that decrease odor: buttermilk, cranberry juice,
parsley, and yogurt
 ● Gas-forming foods: darky leafy vegetables, beer, carbonated
beverages, dairy products, corn, chewing gum, beans; also
skipping meals and smoking
○ Foods that decrease gas: yogurt, crackers, and toast
■ Complications:
● Stoma Ischemia /Necrosis: stoma appearance should normally be
pink or red and moist
○ Signs: pale pink or bluish-purple color and dry appearance
○ If it looks black or purple, this indicates a serious
impairment of food flow and requires immediate
intervention (call the doctor)
● Intestinal Obstruction: occurs for a variety of reasons
○ Appendicitis: caused by an obstruction of the lumen or opening of the appendix;
fecaliths (hard pieces of stool) can be the initial cause of obstruction; also occurs
from trauma or stones in food like grains
■ Once obstructed, the appendix becomes ischemic, bacterial overgrowth
occurs (appendix houses the probiotics), and eventually gangrene or
perforation occurs
■ Pain in the right lower quadrant (McBurney’s point) is the hallmark sign
● When the pain stops, that means the appendix has ruptured and
peritonitis can result (a ruptured appendix is an emergency)
■ Symptoms: nausea, vomiting, constipation or diarrhea
● If a person feels pain there, they need to go to the doctor
immediately and do NOT take pain medication
■ Symptoms when it ruptures: rigid, board like abdomen is the hallmark
sign, fever that does not go away with medication, and severe abdominal
pain
■ Diagnostic Labs and Procedures:
● CBC: will show elevated WBCs due to an increase in neutrophils
● CT Scan: to reveal enlargement of the appendix by at least 6mm
(most definitive test to diagnose appendicitis)
● Rebound Tenderness: also known as Blumberg’s sign; is a clinical
sign of pain
■ Nursing Interventions: non-pharmacological approaches are first-line
● Place a cold compress (not ice) on the area (hot will rupture it)
● Keep the patient NPO before and after an appendectomy
● NEVER GIVE THEM OPIOIDS, LAXATIVES, OR
ENEMAS: they will not feel pain if the appendix ruptured
 ■ Treatment:
● Appendectomy: immediate surgery is needed to reduce the risk of
perforation; performed under general anesthesia
○ Open Appendectomy: an incision is made to remove the
appendix; goal is to not have the appendix rupture
■ A wound vac is placed to drain out all the bacteria
and stuff in the abdominal cavity; dressing needs to
be put on tight for the machine to suction correctly
■ The wound starts to heal from the inside out
○ Laparoscopic Approach: appendix is removed with a
laparoscopy; CO2 is used to inflate the organs
■ The patient will complain of shoulder pain because
the CO2 is leaving the body
■ Patients do not stay long in the hospital
■ Give analgesics for pain before ambulation
○ Post-Procedure: NPO after surgery until peristalsis returns
(they pass flatus and bowel sounds return)
■ Always use sterile technique for a dressing change;
look at the dressing for signs of bleeding and
infection and the appearance of the wound
■ Clear liquids are given first after sounds return:
broth, cranberry juice, apple juice (no pulp in it and
we can see through it)
■ Full liquids after clear is tolerated: grits, oatmeal
■ Make sure the patient is tolerating the food well;
there’s no stomach pain, nausea, or vomiting
■ Make sure they have fiber after full liquids because
they have constipation
■ Make them ambulate asap to avoid DVT,
atelectasis, pneumonia
○ Diverticular Disease: a diverticulum is a sac-like herniation of the lining of the
bowel that extends through a defect in the muscle layer;
■ Most common site is the sigmoid colon (large intestine)
■ Risk Factors: older age, low-fiber diet (major cause), straining to go to
the bathroom
■ Diverticulosis: multiple diverticula without inflammation
● Not everyone who has this will develop diverticulitis*
● If the patient has a high fiber diet, they will not get to diverticulitis
■ Diverticulitis: infection and inflammation of the diverticula caused by
bacteria, food, or fecal matter trapped in one or more sac
● If the patient has recurrent diverticulitis, scar tissue keep forming
from constant healing, which can cause a bowel obstruction*
● Manifestations:
○ Acute abdominal pain in the left-lower quadrant
○ Nausea and vomiting
○ Fever and chills
○ Tachycardia
■ The above symptoms are all mild symptoms: the
patient will be sent home and ordered to stay NPO
until the bowel starts to heal
● If the patient is having moderate to severe symptoms (severe pain,
high fever); they have to be kept NPO and be hospitalized; you
have to give them IV hydration; antibiotics; and pain medication;
the doctor will put in an NG tube to drain all that stuff from the
stomach (because we want it to rest)
● Patient Education:
○ Instruct the client who has mild diverticulitis to do self-care
at home: take medications and get adequate rest
○ Consume a clear liquid diet unit manifestation subside, then
a low-fiber diet as tolerated
○ Add fiber to the diet once solid foods are tolerated without
other manifestations
○ Avoid seeds or indigestible material, which can block
diverticulum (nuts, popcorn, seeds)
○ Instruct client to avoid drinks that can irritate the bowel
(avoid alcohol and limit fat to 30% of daily intake)
● Medications:
○ Antimicrobials: ciprofloxacin [Cipro], metronidazole
[Flagyl], sulfamethoxazole-trimethoprim [Bactrim] for
infections
■ Observe for manifestations of thrush or vaginal
yeast infections
■ Monitor kidney and liver function
■ Decreased dose should be used for patients with
impaired kidney function
■ Patient Education: urine can darken (expected
harmless effect) and monitor for manifestations of
CNS effects (numbness of extremities, ataxia, and
seizures); report immediately
 ■ Colonoscopy: Diagnostic Procedure for Diverticular Disease
● Patient will have a bowel prep: take Bisacodyl [Dulcolax] and
Golytely to clean out the bowels
○ If the stool is clear when they go the bathroom, the bowel
prep worked
● Patient will be NPO starting midnight the night before and will be
on a clear liquid diet the day before
● Patient will be sent back if the bowel is not cleaned out enough
● DO NOT DO A COLONOSCOPY IF THEY HAVE ACTIVE
DIVERTICULITIS
■ Nursing Interventions:
● Start a clear liquid after the bowel is starting to heal
● Give a low-fiber diet if they are healing from diverticulitis: white
rice, cooked vegetables
● Give a high-fiber diet if they have diverticulosis (so stool won’t
drop into the sacs): fruits, brown rice, wheat bread
● A colostomy can be put in if it is severe to give the bowels enough
time to rest
● If it is extremely severe, they can cut out the bad part (basically if
they keep have recurring diverticulitis)
○ Intestinal Obstruction: can be mechanical or non-mechanical; it stops peristalsis
■ Mechanical: occurs when the bowel is blocked by something outside or
inside the intestine (adhesion, tumors, hernias, fecal impaction, structural
due to Crohn’s disease and diverticulitis)
■ Non-Mechanical: caused by diminished peristalsis within the bowel
(paralytic ileus)
● Can occur postoperatively due to the handling of the intestines
during surgery, inflammatory process (peritonitis, sepsis), and
electrolyte imbalance (potassium)
■ Treatment and Diagnostic Procedures: fluid and electrolyte balance,
decompressing the bowel, and relief/ removal of the obstruction
● KEEP PATIENT NPO IS THE FIRST THING YOU DO
● NG Tube with a Vent: inserted to decompress the bowel and
prevent damage to the stomach mucosa during continuous suction
○ Nursing Interventions:
■ Maintain intermittent suction as prescribed
■ Assess NG tube patency and placement
● If there’s no drainage coming out, something
is not working and it is likely that the NG
tube is not in place
 ■ Irrigate every 4 hours or as prescribed
■ Monitor and assess gastric output
■ Monitor nasal area for skin breakdown
■ Provide oral hygiene every 2 hours
■ Monitor vital signs, skin integrity, weight and I&O
● Exploratory Laparotomy: to determine the cause of obstruction
and rectify if possible
○ Nursing Considerations:
■ Ensure the client understand the type of procedure
■ Monitor for hemodynamic instability
■ Monitor bowel sounds
■ Administer IV fluids replacement and maintenance
as prescribed
■ Maintain NG tube patency and measure output
■ Expected Findings:
● Nausea and vomiting
● Abdominal pain and distended abdomen
● Fever
● Tachycardia
● Obstipation: inability to pass stool/or flatus for more than 8 hours
despite feeling the urge to defecate
● Electrolyte imbalance
■ Nursing Interventions for Non-Mechanical Obstruction:
● NPO so the bowel can rest
● Assess bowel sounds (very important)
● Provide oral care
● Administer IV fluids and electrolyte replacement
● Manage pain (once diagnosis is identified)
● Place patient in SEMI-FOWLER’S position
● Encourage ambulation to promote peristalsis
■ Nursing Interventions for Mechanical Obstruction:
● Prepare the patient for surgery (NPO) and provide pre-op nursing
care
● Withhold intake until peristalsis resumes after surgery
○ Peritonitis: life-threatening inflammation of the peritoneum and lining of the
abdominal cavity; often caused by bacteria in the peritoneal cavity
■ Manifestations:
● RIGID, BOARD-LIKE ABDOMEN IS THE HALLMARK
SIGN
● Abdominal distention
 ● Nausea and vomiting
● Rebound tenderness
● Tachycardia and fever
■ Nursing Interventions:
● Place the patient in FOWLER’S or SEMI-FOWLER’S position
(promotes drainage for peritoneal fluid and lung expansion)
● Maintain and monitor NG tube suction
● Keep the patient NPO
● Administer IV antibiotics as prescribed
● Check drainage in the Jackson-Pratt tube each shift
■ If surgery is performed: closely monitor post-op vital signs, monitor I&O,
an monitor surgical dressing for bleeding
○ Inflammatory Bowel Disease: Crohn’s disease and ulcerative colitis
■ Ulcerative Colitis: inflammation, ulcers, and edema primarily in the
rectum and rectosigmoid colon; cause is unknown (idiopathic)
● The entire length of the colon can be involved in severe cases
● There is remission and exacerbations (creates scar tissue)
● Patients are at risk for rupturing the colon (causes peritonitis)
● Manifestations:
○ Abdominal pain/cramping in the left-lower quadrant
○ Anorexia/weight loss
○ Fever
○ Diarrhea; stools with mucus, blood, or pus
○ Abdominal distention, tenderness and/or firmness upon
palpation
○ Rectal bleeding and high-pitched bowel sounds
○ Frequent trips to the bathroom
○ Hematocrit and hemoglobin is always low because they are
bleeding from the rectum
● Nursing Interventions and Patient Education:
○ Instruct the client to seek emergency care for indications of
bowel obstruction or perforation (fever, severe abdominal
pain or vomiting)
○ Instructs clients who have extreme or long exacerbations
that NPO status and administration of parenteral nutrition
promotes bowel rest while providing adequate nutrition
○ Educate the client to eat high-protein, high calories,
low-fiber foods: cook carrots, skin vegetables and fruits
like pears (skin of fruit + veggies has a lot of fiber)
 ○ Instruct the client to avoid caffeine and alcohol and to take
multivitamins that contain iron
○ Advise the client that small frequent meals can reduce
occurrence of manifestations
○ Monitor for fluids/electrolytes especially k+ due to diarrhea
○ The client will need frequent colonoscopies due to the
increased risk of colon cancer
○ A colostomy can be put in if severe
■ Crohn’s Disease: inflammation and ulceration of the GI tract, often in the
distal ileum; cause is unknown; also called regional enteritis
● All layers of the bowel can become involved, lesions are sporadic,
fistulas are common
● Ileum is the most common part infected (small intestine)
● Can involve the entire GI tract from the mouth to the anus
● Malabsorption and malnutrition can develop when the jejunum and
ileum become involved
● Requires supplemental vitamins and minerals, possible vitamin
B12 injections
● Manifestations:
○ Abdominal pain/cramps in the right lower quadrant
○ Anorexia, weight loss, and fever
○ Diarrhea with pus or mucus
○ Abdominal distention, tenderness and/or firmness
○ Steatorrhea (fatty stool)
● Interventions are the same as for ulcerative colitis
● Surgery cannot be done because it can be everywhere
○ Irritable Bowel Syndrome: a disorder of the GI system that causes changes in
bowel function
■ Cause is unknown, but it is thought to be environmental (dairy products,
caffeinated beverages, infectious agents), immunological, genetic,
hormonal and stress influenced (anxiety, depression)
■ Risk Factors: female sex, stress, eating large meals containing a large
amount of fat, caffeine intake, alcohol intake
■ Health Promotion and Disease Prevention:
● Avoid foods that trigger exacerbation, such as dairy, wheat, corn,
fried foods, alcohol and spicy foods
● Avoid alcohol and caffeinated beverages
● Consume 2 to 3L fluid per day unless contraindicated
● Increase fiber intake (appropriately 30 to 40g/day)
 ■ Manifestations:
● Cramping pain in abdomen
● Nausea with meals or passing stool
● Anorexia
● Abdominal bloating
● Belching
● Diarrhea (diarrhea-predominant IBS)
● Constipation (constipation-predominant IBS)
● Hyperactive or hypoactive bowel sounds
■ Medications for Diarrhea-Predominant IBS:
● Loperamide [Imodium]: decreases peristalsis and increases bulk
● Psyllium [Metamucil]: bulk forming laxative; discontinue for
abdominal cramping, rectal bleeding, and vomiting
○ Mix with 8 ounces of water
■ Medications for Constipation-Predominant IBS:
● Lubiprostone [Amitiza]: causes increased fluid secretion in the
intestine to promote intestinal motility; take with food and water
● Linaclotide [Linzess]: increases fluid and motility in the intestine;
can relieve pain and cramps; take daily 30 minutes before breakfast
■ Nursing Interventions and Patient Education:
● Review strategies to reduce stress: yoga, walking, jogging etc.
● Instruct the client to limit the intake of irritating foods and
beverages (gas-forming foods, caffeine, alcohol)
● Encourage a diet high in fiber and fluids
● Instruct client to keep a food diary to record intake and bowel
pattern (to adjust diet to prevent exacerbations)
● Instruct client to avoid foods that trigger exacerbations such as
dairy, wheat, corn, fried foods, alcohol, spicy foods
● Encourage client to consume 2 to 3L of water per day from food
and fluid sources
● Encourage ambulation to help with peristalsis
● Hepatitis: inflammation of the liver cells
○ Viral hepatitis is the most common type of hepatitis
○ Toxic and drug-induced hepatitis occurs secondary to the exposure to a chemical
or medication agent such as alcohol, industrial toxins or acetaminophen*
■ After exposure to a virus or toxin, the liver becomes enlarged from
inflammation
■ As the disease progress, there is an increase in inflammatory response and
necrosis, interfering with blood flow to the liver
○ Individuals can be infected with hepatitis and remain free of manifestations, and
therefore are unaware that they could be contagious
○ Health Promotion and Disease Prevention:
■ Provide community health education on transmission and exposure
■ Follow vaccination recommendations according to the CDC
■ Reinforce and use safe injection practices
● Sterile, single-use disposable needle and syringe for each injection
● Needleless systems or safety caps
■ Use proper hand hygiene (before preparing and eating food, after using the
toilet or changing diapers)
■ When traveling to underdeveloped countries, drink purified water, and
avoid sharing eating utensils and bed linens
■ Use PPE appropriate to the type of exposure
○ Types of Hepatitis:
■ Hepatitis A: transmission is fecal-oral
● Risk factors: ingestion of contaminated food or water, especially
shellfish; close personal contact with an infected individual
■ Hepatitis B: transmission is through blood; can become chronic
● Risk factors: unprotected sex with infected individual, infants born
to infected mothers, contact with infected blood, substance use
disorder (injectable substance)
■ Hepatitis C: transmission is through blood; can become chronic
● Risk factors: substance use disorder (injectable substance), blood
product or organ transplant, contaminated needle sticks, unsanitary
tattoo equipment, sexual contact
● It is the same as B, but there is no vaccine for hepatitis C
■ Hepatitis D: occurs by coinfection with hepatitis B
● Risk factor: substance use disorder, unprotected sex with infected
individual
■ Hepatitis E: transmission is fecal-oral
● Risk factor: ingestion of food or water contaminated with fecal
waste
○ Manifestations:
■ Flu-like symptoms: fatigue, decreased appetite with nausea, abdominal
pain, joint pain, fever, vomiting
■ Dark-colored urine
■ Clay-colored stool
■ Jaundice: oral mucosa is the best way to assess jaundice in a darkskin pt
○ Laboratory Findings: elevated ALT, AST, and total bilirubin (normal bilirubin is
0.3-1.0 mg/dL)
○ Nursing Interventions:
■ Most clients will be cared for in the home unless they are acutely ill
■ Enforce contact precautions if indicated
■ Provide a high-carbohydrate, high calories, low-to moderate-fat and
low-to-moderate-protein diet and small, frequent meals to promote
nutrition and healing
■ Promote hepatic rest and the regeneration of tissue:
● Administer only necessary medications
● Avoid OTC medications or herbal supplement
● Limit physical activity
■ Educate the client and family regarding measures to prevent the
transmission of the disease to others at home:
● Avoid sexual intercourse until hepatitis antibody testing negative
● Use proper hand hygiene
○ Medications: never give liver-toxic meds like Acetaminophen [Tylenol]
■ Hepatitis A: vaccine for post-exposure protection
● Immunoglobulin is recommended for patients older than 40 years,
younger than 12 months, who have chronic liver disease, who are
immunosuppressed, and who are allergic to the vaccine
■ Hepatitis B & D: no medications for acute infection, only supportive care
● Antiviral medications for chronic infections: adefovir dipivoxil
[Hepsera], interferon alfa-2b [Intron] and lamivudine [Epivir]
■ Hepatitis C: combination therapy with peginterferon alfa-2a [Pegasys]
and ribavirin [Virazole]
■ Hepatitis E: no medications, only supportive care
○ Complications of Hepatitis:
■ Liver cancer
■ Liver Failure: irreversible damage of liver cells with decreased ability and
function to meet the body’s needs
■ Cirrhosis: permanent scarring of the liver that is usually caused by chronic
inflammation
■ Fulminating Hepatitis: extremely severe and potentially fatal form of viral
hepatitis; begins with regular symptoms, then within hour a days, severe
liver failure results
■ Chronic Hepatitis: ongoing inflammation of the liver cells; increases the
risk of liver cancer
○ Diagnostic Procedures: Liver Biopsy
■ Most definitive diagnostic approach and it is used to identify the intensity
of the infection and the degree of liver damage
■ Pre-Procedure:
 ● Explain the procedure
● Witness informed consent
● Ensure the client fasts starting at midnight on the day of the
procedure (NPO)in case surgery due to a complication
■ Intra-Procedure:
● Assist the client into the SUPINE position with the upper right
quadrant of the abdomen exposed
● Instruct the client to exhale and hold for at least 10 seconds while
the needle is inserted
● Instruct the client to resume breathing once the needle is
withdrawn
■ Post-Procedure:
● Assist the client to a right side-lying position and maintain for
several hours
● Monitor vital signs and assess for abdominal pain
● Assess for bleeding from the puncture site
● Assess for manifestations of pneumothorax (dyspnea, cyanosis,
restlessness) due to accidental puncture of the pleura or lung
● Cirrhosis: excessive scarring of the liver caused by necrotic injury or a chronic reaction
to inflammation over a prolonged period of time
○ Normal liver tissue is replaced with fibrotic tissue that lacks function
○ Post-Necrotic: caused by viral hepatitis (B, C & D), some medications, or toxins
○ Laennec’s: caused by chronic heavy alcohol use disorder
○ Billary: caused by biliary obstruction of the common bile duct causing a backup
of bile in the liver, an autoimmune disease, or fat accumulation in the liver
○ Risk Factors: alcohol use disorder, chronic viral hepatitis, autoimmune hepatitis,
steatohepatitis (fatty liver disease cause by chronic inflammation), damage to the
liver caused by medications, substances, or toxins
○ Complications:
■ Esophageal Varices: enlarged/swollen veins in the esophagus
■ Portal Systemic (Hepatic) Encephalopathy: loss of brain function when
a damaged liver cannot remove toxins from the blood; causes
psychological symptoms; patient cannot consume protein (because
ammonia is the byproduct of protein, which will make it worse)
■ Portal Hypertension: elevated blood pressure in the portal vein, which
carries blood from the digestive organs to the liver
○ Health Promotion: avoid drinking alcohol and engage in an alcohol recovery
program if needed
○ Expected Findings:
■ Fatigue, pruritus, weight loss
 ■ Abdominal pain and distention
■ Hepatomegaly and splenomegaly (patient is at risk for infection bc the
spleen house the WBCs)
■ Confusion or difficulty thinking (due to buildup of ammonia in the blood
because the liver cannot get rid of it)
■ Jaundice (due to decrease in bilirubin excretion)
■ Ascites and spider angiomas (face, neck, shoulders)
■ Asterixis (coarse tremor of wrist and fingers, hand flapping)
■ Dependent peripheral edema of the extremities

○ Laboratory Findings:
■ Elevated Ammonia Levels: normal is 6-47 u/L
■ PT/INR: will be prolonged, which causes a risk of bleeding
● Normal PT = 11-13.5 seconds
● Normal INR = 0.8-1.1
■ Decreased Albumin Levels: normal is 3.5-5.5 g/dL
■ Elevated Bilirubin Levels: normal is 0.2-0.8 mg/dL
■ Decreased CBC: the values below are the normal values
● RBCs: 4.7-6.1 million (males) and 4.2-5.4 million (females)
● WBCs: 5,000-10,000
● Platelets: 150,000-400,000
● Hematocrit: 40-55% (males) and 36-48% (females)
● Hemoglobin: 13-17 (males) and 11.5-15.5 (females)
○ Nursing Interventions:
■ Monitor for decreased mental status due to elevated ammonia level
● Administer Lactulose orally or rectally to excrete ammonia (if they
have diarrhea, it means its working)
 ■ Monitor for asterixis
■ Place the patient in HIGH FOWLER’S with elevated head of bed due to
plasma volume excess and ascites
■ Monitor for skin breakdown and implement measure to prevent pressure
injuries
● Use an alternating air pressure mattress for bed-bound
patients
● Frequently turn and reposition
■ Wash the patient with cold water and apply lotion to decrease itching if
they have pruritus
■ Strictly monitor I&O, obtain daily weights, restrict fluids and sodium
if prescribed
■ Monitor vital signs and PT/INR
■ Measure abdominal girth DAILY over the largest part of abdomen if
they have ascites
■ Monitor pain level and administer analgesics as needed
■ Follow a high carb, high protein, moderate fat, and low sodium diet
● NO ALCOHOL UNDER ANY CIRCUMSTANCES (I believe that
will include products that contain alcohol, such as mouthwash)
■ Administer vitamin supplements
○ Medications:
■ Diuretics: to decrease excessive fluid in the body
■ Beta-Blockers: for patients who have varices to reduce blood pressure
and prevent bleeding
■ Lactulose [Generlac]: to promote excretion of ammonia from the body
through stool (it is a laxative; given orally or through an enema)
○ Therapeutic Procedures:
■ Paracentesis: used to relieve ascites
● Patient is sitting (High Fowler’s) must void before the procedure
to prevent perforation of the bladder
● Must check their blood pressure before, during, and after
● Never take out more than 1,000 ccs
■ Endoscopic Variceal Ligation/Endoscopic Sclerotherapy: varices are
either sclerosed or banded endoscopically
● Sclerotherapy: a solution is injected into the veins in the esophagus
to irritate the vessel, which makes it collapse and stick together to
treat bleeding and prevent future bleeding
● Ligation: bands are applied to the enlarged veins to tie them off so
they cannot bleed
 ● Must do oral care and do not let them move around too much after
the procedures
● Hypovolemia: Fluid Volume Deficit
○ Volume imbalances occur when too little or too much isotonic fluid is present
○ Osmolality imbalances occur when body fluid becomes either hypertonic or
hypotonic (ex: hyper and hyponatremia)
○ Risk Factors: increased intake of caffeine and alcohol, living in high elevations
or in dry climate, older adults
○ Expected Findings:
■ Vital Signs: hyperthermia, tachycardia, thready pulse, hypotension,
orthostatic hypotension, tachypnea, hypoxia, decreased central venous
pressure
■ Neuromuscular: dizziness, syncope, confusion, weakness, fatigue,
restlessness (coma and seizures can occur if onset is rapid)
■ GI: thirst, dry furrowed tongue, nausea, vomiting, anorexia, weight loss
■ Circulation and Skin: diaphoresis, sunken eyeballs, flattened neck veins,
cool clammy skin, poor skin turgor and tenting, diminished capillary refill
■ Renal: oliguria
○ Lab Values: increased hematocrit, BUN, and electrolytes
○ Nursing Interventions:
■ Monitor I&O and daily weight
■ Monitor vital signs
■ Monitor for changes in mental status, give IV hydration as prescribed
■ Monitor weight every 8 hours while fluid replacement is given
■ Assess gait and encourage patient to call for help when ambulating
■ Encourage the patient to change positions frequently, BUT move slowly
(due to orthostatic hypotension)
● Hypervolemia: Fluid Volume Excess
○ Isotonic expansion of the ECF caused by the abnormal retention of water and
sodium
○ Secondary to an increase in the total body sodium content
○ Patients are at risk for developing pulmonary edema or congestive heart failure
○ Causes of FVE: heart failure, kidney injury, cirrhosis of the liver, consumption of
excess table salt and other salts, excessive administration of sodium-containing
fluids
○ Expected Findings:
■ Vital Signs: tachycardia, bounding pulse, hypertension, tachypnea,
increased central venous pressure
■ Neuromuscular: weakness, headache, altered level of consciousness
■ GI: ascites, weight gain
 ■ Respiratory: crackles, cough, increased respiratory rate, dyspnea
■ Renal: polyuria
■ Circulation: peripheral edema, distended neck veins
○ Lab Findings: decreased hematocrit, hemoglobin, and BUN
○ Nursing Interventions:
■ Monitor daily weight and peripheral edema
■ Monitor I&O and assess lung sounds
■ Position the patient in semi-Fowler’s
■ Reposition frequently to prevent tissue breakdown in edematous skin
■ Monitor response to diuretics and parenteral fluids
■ Promote rest and adherence to fluid and sodium restrictions
■ Avoid sources of excessive sodium (including medications)
○ Patient Education:
■ Weigh yourself daily: notify the provider if there is weight gain of 1 to 2
lbs gain in 24hrs or a 3 lb gain in 1 week
● After the first 1/2 –lb weight gain, each additional pound of weight
is equal to 500ml retained fluid
■ Consume a low-sodium diet, read food labels, and keep a record of daily
sodium intake
■ Promote fluid restriction
● Hyponatremia:
○ A gain of water or loss of sodium resulting in a level less than 136 mEq/L
○ Risk Factors: excessive sweating, use of diuretics, kidney disease, inadequate
sodium intake, decreased secretion of aldosterone
○ Manifestations: poor skin turgor, dry mucosa, headache, decreased salivation,
decreased blood pressure, nausea, abdominal cramping, neurologic changes,
seizures, confusion, coma, altered mental status, lethargy, diminish tendon reflex
○ Nursing Interventions:
■ Administer hypertonic oral and IV fluids
■ Administer 3% sodium chloride slowly
■ Monitor sodium levels frequently
■ Encourage foods and fluids high in sodium
■ Monitor vital signs and level of consciousness
● Hypernatremia:
○ A gain of sodium in excess of water or loss of water in excess of sodium,
resulting in a sodium level of greater than 145 mEq/L
○ Most common in very old, very young, and cognitively impaired people
○ Risk Factors: water deprivation (NPO), hypertonic enteral feedings without
adequate water supplementation, heat stroke, burns, excess sodium retention,
kidney failure, Cushing’s syndrome, glucocorticoid use
 ○ Manifestations: thirst, dry mucous membranes, nausea, vomiting, anorexia,
hyperthermia, tachycardia, orthostatic hypotension, restlessness, irritability,
seizures, coma
○ Nursing Interventions:
■ Administer 0.45% normal saline (hypotonic)
■ Restrict sodium intake, avoid canned food, and salty foods
■ Assess for abnormal loss of water and low water intake
■ Assess for OTC sources of sodium
■ Monitor for changes in mental status
● Hypokalemia:
○ Increased loss of potassium from the body or movement of potassium into cells,
resulting in a potassium level less than 3.5 mEq/L
○ Causes: GI losses, medications, prolonged intestinal suctioning, recent ileostomy,
tumor of the intestine, alterations of acid–base balance, poor dietary intake,
hyperaldosteronism, kidney disease
○ Manifestations:
■ ECG changes: ST depression, flattened T wave, prolonged PR interval,
prominent U wave, dysrhythmias
■ Dilute urine, excessive thirst, fatigue, anorexia, muscle weakness,
decreased bowel motility
○ Nursing Interventions:
■ Increase dietary potassium or give IV if severe (patient must be in critical
care; IV is given if the level is less than 3)
■ Monitor for ECG changes
■ Monitor ABGs
■ Monitor for signs of digoxin (digitalis) toxicity if patient is on it
■ Monitor bowel sounds and for abdominal distention
■ Observe for shallow respirations and diminished breath sounds
● Hyperkalemia:
○ Potassium level greater than 5 mEq/L
○ Causes: impaired renal function, rapid administration of potassium, increased use
of salt substitutes, medications (ACE inhibitors), tissue trauma, acidosis
○ Manifestations: slow irregular pulse, hypotension, increased motility, diarrhea,
hyperactive bowel sounds, restlessness, irritability, weakness that causes flaccid
paralysis, paresthesias
■ ECG: premature ventricular contractions (PVCs), peaked T wave, widened
QRS, ventricular fibrillation (start CPR right away for v-fib)
○ Nursing Interventions:
■ Monitor ECG, I&O, and labs
■ Obtain apical pulse
 ■ Limit dietary potassium intake
■ Administer sodium polystyrene sulfonate [Kayexalate]
● Patient will have diarrhea, which means its working
■ Diuretics can be given (always check BP before giving)
■ Emergency Care: cocktail of calcium gluconate, IV sodium bicarbonate,
IV regular insulin and hypertonic dextrose IV, if the potassium doesn’t
drop a lot, the patient needs dialysis
● Hypocalcemia:
○ Serum calcium level less than 9 mg/dL
○ We need vitamin D to absorb calcium*
○ Causes: hypoparathyroidism (due to neck surgery's, thyroidectomy),
malabsorption (GI), osteoporosis, pancreatitis, alkalosis, transfusion of citrated
blood, kidney injury (excessive depletion), low vitamin D intake, medications
(magnesium supplements, laxatives etc decreases calcium absorption)
○ Manifestations: tetany, circumoral numbness, hyperactive reflexes, paresthesia,
hyperactive DTRs, seizures, dyspnea, laryngospasm, abnormal clotting, anxiety
■ Positive Trousseau Sign: use of B/P cuff, by inflating and watching for
hand/ fingers turning up or down)
■ Positive Chvostek Sign: stimulation of facial nerve causing twitching of
the lip upwards
○ Nursing Interventions:
■ IV calcium gluconate slowly for emergent situations
■ Monitor cardiac rhythm
■ Initiate seizure precautions
■ Oral calcium and vitamin D supplements
■ Weight bearing exercise to decrease bone calcium loss
■ Monitor airway for laryngeal spasm
■ Educate patient on consuming foods high in calcium: yogurt, milk,
spinach, collard greens
■ Teach patient to read food labels to increase dietary calcium
● Hypercalcemia:
○ Serum calcium level above 10.2 mg/dL
○ Has a high risk of mortality
○ Causes: malignancy, hyperparathyroidism, bone loss related to immobility,
diuretics (thiazide), too much Vit D, increase intake of calcium, glucocorticoids
suppress calcium absorption, lithium affects parathyroid causing phosphate
depletion which causes calcium to increase
○ Manifestations: polyuria, thirst, muscle weakness (lethargy), intractable nausea,
abdominal cramps, severe constipation, diarrhea, peptic ulcer, bone pain, kidney
stones (renal calculi)
 ■ ECG changes: shortened QT interval and dysrhythmias
○ Nursing Interventions:
■ Administer IV fluids (normal saline) to dilute serum calcium
■ Administer furosemide [Lasix] to promote excretion of calcium
■ Administer phosphate and calcitonin
■ Increase mobility
■ Encourage fluids to decrease stone formation
■ Decrease calcium rich foods and increase fiber for constipation
■ Ensure safety risk for bone fractures
● Hypomagnesemia:
○ Serum magnesium level less than 1.3 mg/dL
○ Associated with hypokalemia and hypocalcemia
○ Causes: alcoholism, GI losses, enteral or parenteral feeding deficient in
magnesium, medications (diuretics), low K+ and low ca+, limited intake of foods
rich in magnesium
○ Manifestations: Chvostek and Trousseau signs, apathy, depressed mood,
psychosis, neuromuscular irritability, muscle weakness, tremors, hypertension,
irritability
■ ECG changes: Torsade de Pointes and dysrhythmias
○ Nursing Interventions:
■ Administer magnesium sulfate IV
■ Monitor vital signs and urine output
■ Monitor for dysphagia
■ Place the patient on seizure precautions
■ Monitor cardiac rhythm
■ Eat foods high in magnesium: avocado, legumes, fish, green leafy vegs,
peanut butter, dark chocolates, milk
● Hypermagnesemia:
○ Serum magnesium level greater than 3 mg/dL
○ Causes: kidney injury, diabetic ketoacidosis, excessive administration of
magnesium, extensive soft tissue injury
○ Manifestations: hypoactive reflexes, drowsiness, lethargic, muscle weakness,
depressed respirations (depressed skeletal muscle), ECG changes, dysrhythmias
(bradycardia and heart blocks), and cardiac arrest, hypotension
○ Nursing Interventions:
■ Administer IV calcium gluconate
■ Dialysis may be needed
■ Administer loop diuretics (not for patients with renal failure)
■ Administer sodium chloride and lactated ringer’s
■ Avoid medications containing magnesium
 ■ Teach patients to avoid OTC meds with magnesium
■ Observe DTRs and changes in level of consciousness
■ Place patient on cardiac monitor
■ Place safety precautions
■ Teach patients to avoid foods high in magnesium
● Arterial Blood Gas (ABGs):
○ Respiratory Acidosis:
■ Caused by opioids, pulmonary embolism, asthma, COPD
■ Give diuretics, supplemental oxygen, intubate them if nothing else works
■ Symptoms: sudden increase in pulse, respiratory rate, and BP; mental
status changes, feeling of fullness in the head
○ Respiratory Alkalosis:
■ Caused by hyperventilation due to anxiety, pain, fever,
■ Give the patient a paper bag
■ Symptoms: lightheadedness, inability to concentrate, numbness, tingling,
sometimes loss of consciousness
○ Metabolic Acidosis:
■ Caused by diarrhea, kidney injury or failure (most common), diabetic
ketoacidosis
■ Hyperkalemia will cause it
■ Give sodium bicarbonate
■ Symptoms: headache, confusion, drowsiness, increased respiratory rate
and depth, decreased blood pressure, decreased cardiac output,
dysrhythmias, shock; if decrease is slow, patient may be asymptomatic
until bicarbonate is 15 mEq/L or less
■ Monitor potassium and calcium levels
■ Calcium levels may be low and they must be corrected before treating the
acidosis
○ Metabolic Alkalosis:
■ Caused by vomiting and stomach suctioning; also long-term diuretic use
■ Hypokalemia will cause it
■ Give sodium chloride solutions and restore fluid volume
■ Symptoms: respiratory depression, tachycardia, symptoms of hypokalemia
and hypocalcemia
○ Normal Values:
■ HCO3 = 22-26, pH= 7.35-7.45, PCO2 = 35-45
● HC03 = under 22 is acid, over 26 is base
● PH = under 7.35 is acid, over 7.45 is base
● PCO2 = under 35 is base, over 45 is bas
● Perioperative Nursing:
○ Preoperative Phase:
■ Assessment: takes place from the time a patient is scheduled for surgery
until care is transferred to the OR
● Obtain medical history, surgical history, tolerance to anesthesia,
medication use, use of herbals, substance use, culture, psychosocial
● Allergies: to medications, latex, contrast, and foods
○ Allergies to banana or kiwi = latex allergies
○ Allergy to soybean or eggs is a contraindication for the use
of propofol for anesthesia
○ Allergy to shellfish can result in a reaction to
povidone-iodine
● Assess pain level, coping mechanisms, and support systems
■ Diagnostic Procedures:
● Urinalysis: check renal function and rule out infection
● Blood type and crossmatch, CBC (fluid status, anemia, infection),
pregnancy test (fetal risk of anesthesia), clotting studies, ABGs,
chest x-rays, 12 –lead ECG
■ Informed Consent:
● Should be in writing before a non-emergency surgery
● Surgeon explains procedures, risks, benefits, complications etc.
● The nurse only witnesses the consent being signed and clarifies
information
● Legal guardian can sign if the patient is not capable
● Consent is only valid before administering psychoactive meds
● Consent form goes with the patient to the OR
● Patient must not be coerced into giving consent
■ Nursing Interventions:
● Verify that the informed consent is accurately completed, signed,
and witnessed
● Administer enemas and/or laxatives the night before for clients
undergoing bowel surgery
● Regularly check scheduled medications prescriptions; some
medications (anti-hypertensives, anticoagulants and
anti-depression can be held until after procedure)
● Ensure client is NPO
● Ensure jewelry, dentures, prosthetics, makeup, nail polish and
glasses are removed
● Establish IV access using a large-bore (18-gauge green color)
catheter for easier infusion of IV fluids or blood products
 ● Administer pre-op medications: prophylactic antimicrobials,
antiemetic, sedatives as prescribed
○ Prophylactic antibiotics are giving within 1 hour of surgical
incision
○ If the patient is on a beta blocker, give it before surgery
○ Raise side-rails after administering to prevent injury
● Ensure that the pre-op checklist is complete
● Verify the correct surgical site with the patient and healthcare team
before marking the surgical site
■ Patient Education:
● Instruct the client about the purpose and effects of preoperative
medications that will be administered
● Teach the client post-op pain control techniques (PCA pump,
immobilization, analgesic)
● Demonstrate and teach the importance of splinting, coughing and
deep breath
● Demonstrate the importance of range-of motion and early
ambulation to prevent thrombi and respiratory complication
● Instruct the client about invasive devices (drains, catheters and IV
lines)
● Teach the client regarding incentive spirometer
● Teach the client how to use a pain scale to rate pain level post-op
○ Intraoperative Phase:
■ General Anesthesia: causes loss of sensation, consciousness and reflex
when a client is undergoing major surgery or one that requires complete
muscle relaxation (opioids; fentanyl)
● Ensure that the client has signed a consent form because an adult
who has received sedation may not give legal consent
● Have the client urinate before receiving medications
● Ensure that the bed is in the low position and that the side rails are
up for safety
● Monitor airway, oxygen saturation, cardiac status, temperature
● If hypotension occurs as an adverse reaction of medication or
dehydration, lower the head of bed, administer an IV fluid bolus
and monitor
● Complications:
○ Malignant Hyperthermia: life-threatening emergency
■ Symptoms: muscle rigidity, hyperthermia, damage
to the CNS, increased CO2, decreased O2 sat,
 tachycardia, tachypnea, dysrhythmias, hypotension,
skin mottling, cyanosis, myoglobinuria
● Elevated temperature is a late manifestation
increasing as much as 111.2 F (44 C)
■ Triggered by inhalation anesthetic agents and
succinylcholine
■ Nursing Interventions:
● Stop surgery immediately
● Administer IV Dantrolene [Ryanodex]
● Administer 100% oxygen
● Obtain specimen for ABGs
● Infuse iced 0.9% sodium chloride IV
● Apply a cooling blanket: ice neck, axillae,
head, and ice lavage
● Insert an indwelling urinary catheter and
monitor output
○ Intubation problems: injury to teeth, lips and vocal cord
during intubation
○ Sore throat
○ Overdose of anesthetic especially among older adults who
has pre-existing conditions or a client who has poor liver or
kidney function
■ Local Anesthesia: causes loss of sensation without loss of consciousness;
blocks transmission along nerve, thus achieving loss of autonomic
function and muscle paralysis in a specific area of the body
■ Moderate Sedation: patient does NOT lose consciousness, but receives
induction of amnesia and analgesia (morphine, fentanyl, midazolam,
diazepam)
● Patient can respond to verbal stimuli, retain protective reflex, and
is easily arousable
● Naloxone [Narcan] to reverse opioids
● Flumazenil [Romazicon] to reverse benzodiazepines
■ Induction of Anesthesia: initiate IV access, administer pre-op meds,
secure airway patency
■ Emergence of Anesthesia: completion of surgery and removal of
assistive airway devices
○ Postoperative Phase:
■ Risk Factors for Complications:
● Immobility: respiratory compromise, thrombophlebitis, pressure
ulcers
 ● Anemia: blood loss, inadequate/decreased oxygenation, impaired
healing factors
● Hypovolemia: tissue perfusion
● Diabetes Mellitus: gastroparesis, delayed wound healing
● Coagulation Defects: increased risk for bleeding
● Obesity: respiratory compromise, post-op nausea and vomiting,
impaired wound healing, wound dehiscence and evisceration
● Immune Disorder: risk for infection, delayed healing
● Cardiovascular Disease: fluid overload, deep vein thrombosis,
arrhythmia
■ PACU: handoff report includes name, type of surgery, type and amounts
of anesthetic and analgesic agents used, vital signs, response to procedure
and medications, insertion and presence of drains, catheters, tubes; blood
transfused, medications administered
● ET tube is left in place until the patient can open airway without
support
● Assess oxygen saturation, respiratory pattern, rate, lung sounds,
and depth
● Suction accumulated secretions if the patient is unable to cough
● Encourage deep breathing and use of incentive spirometer every
1-2 hours
● Observe for internal bleeding (abdominal distention, visible
hematoma under/near the surgical site, tachycardia, hypotension,
restless, increased pain and external bleeding)
● Assess for skin color, tempt, sensation and capillary refill
● Assess and compare peripheral pulses for impaired circulation and
DVT
● Monitor ECG readings apical and peripheral pulses to determine a
pulse deficit, which can indicate a dysrhythmias
● Administer pain medication at least 30 minutes before ambulation
● Monitor fluid and electrolyte balance
● Obtain vital signs every 15 minutes
● Evaluate and treat the presence of hypotension and potential causes
(anesthesia or other medications, cardiac depression, blood loss,
pooling of blood in extremities)
○ Report a blood pressure difference of 25% from baseline, a
drop of 15-20 mm Hg in diastolic or systolic pressures,
provide heated blankets when the client arrives after a temp
is obtained and reapply if the client is hypothermic
 ○ Causes of hypothermia include decreased body fat,
age-related changes in the hypothalamus that regulates
body temperature, and decrease environmental temperature
in the surgical suites
● If the client responds to verbal stimuli, gradually elevate the head
of the bed to semi-fowler's position
● Maintain lateral position (right or left), if the client is unresponsive
or unconscious (risk of aspiration)
● Avoid placing a pillow under the knees or engaging the knee gatch
of the bed, which can decrease venous return
● Elevated legs and lower the head of the bed if hypotension or
shock develops
● Response to anesthesia: monitor level of consciousness
(weakness, restlessness, agitation, somnolence, irritability, change
in orientation), assess for movement of and sensation in
extremities, administer and antiemetic for N/V after checking
bowel sounds
● Administer pain medication as appropriate
● Input and Output: monitor for bladder distention, monitor urinary
catheters for patency, bladder scan if urine retention is suspected
● Observe drainage tubes for patency and proper function, check
dressings for excessive drainage and reinforce as needed
● Report excess drainage to the surgeon, outline drainage spots with
a pen, noting date and time
● Monitor level of consciousness and mental status, determine level
of stimulation needed for arousal (pain, touch, verbal)
○ Older adults can experience acute confusion or delirium
related to anesthesia or other medications, dehydration,
hypoxia, blood loss or electrolyte imbalance
○ Episodes of post-op delirium can last 2 days or more in
older adult clients
● Monitor recovery from anesthesia by using the ALDRETE scoring
system: 8 to 10 meets the criteria for discharge from PACU
● Maintain the patient NPO until the gag reflex and peristalsis return
(risk for paralytic ileus): pass flatus means peristalsis returned
● Irrigate NG tube with normal saline
● Encourage a diet high in calories, protein, and vitamin C for
wound healing
 ● Apply compression device and/or anti-embolism stockings,
reposition every 2 hours, ambulate, give anticoagulants and
antiplatelets to prevent DVT
■ Post-Op Complications:
● Airway Obstruction: swelling or spasm of the larynx or trachea;
signs are stridor or snoring
○ Monitor for choking; noisy, irregular respirations,
decreased oxygen saturation values, and cyanosis
○ Implement a head-tilt/chin –lift maneuver to pull the tongue
forward and open the airway
○ Keep emergency equipment at the bedside in the PACU
○ Notify the anesthesiologist, elevate HOB if not
contraindicated, provide humidified O2 and plan for
reintubation with endotracheal tube
● Hypoxia: sign is decreased oxygen saturation
○ Monitor oxygenation status, and administer oxygen as
prescribed
○ Encourage coughing and deep breathing to prevent
atelectasis
○ Position client with HOB elevated, and turn every 2 hr to
facilitate chest expansion

● Paralytic Ileus: due to absence of peristalsis

○ Monitor bowel sounds
○ Encourage ambulation
○ Advance diet as tolerated when bowel sounds or flatus are
present
○ The client can have an NG tube inserted to empty stomach
content
● Wound Dehiscence or Evisceration: spontaneous opening of the
incisional wound (dehiscence); an progress to the protrusion of the
internal organs through the incision (evisceration)
○ Monitor risk factors (obesity, coughing, moving without
splinting, poor nutritional status, infection, steroid use)
○ If wound dehiscence or evisceration occur, call for help,
stay with the client, cover the wound with a sterile towel or
dressing that is moistened with sterile saline, do not attempt
to insert organs, place in a low-fowler's position with hip
and knees bent, monitor for shock and notify the provider
immediately
 ● Deep Vein Thrombosis: caused by immobility, hypercoagulability
○ Prophylactic measures include administration of
low-low-molecular-weight heparin, low dose heparin, or
low-dose warfarin, anti-embolism stockings, pneumatic
compression devices; ranges-of-motion exercise, and early
ambulation
○ Avoid any form of pressure behind the knee with a pillow
or blanket , which can cause constriction of blood vessels
and decreased venous return
○ Avoid dangling the client’s legs for long periods of time
○ Provide adequate hydration by administering IV fluids or
encouraging increased oral fluid intake

***Look at the slides for the other stuff from test #1, like Alzhemier’s and Dementia***