GASTROINTESTINAL NURSING  Urine changes: note color, onset, notable increase

or decrease in color change, associated symptoms

HEALTH HISTORY (pain)
Presenting problem  Clay-colored stools: note onset, number/day,
associated symptoms (pain, problems with
ingestion/digestion)
 MOUTH  Increased bleeding: note ecchymoses, purpura,
 Symptoms may include dental caries, bleeding
bleeding gums, hematuria)
gums, dryness or increased salivation, odors,
difficulty chewing (note use of dentures)
 LIFESTYLE: eating behaviors (rapid ingestion,
skipping meals, snacking), cultural/religious values
 INGESTION (vegetarian, kosher foods) ingestion of alcohol,
 Changes in appetite: anorexia or hyperorexia: note
smoking
food preferences/dislikes
 Food intolerances: allergies, fluid, fatty foods
 Weight gain/loss: note symptoms/situations that  USE OF MEDICATIONS: note use of antacids,
might interfere with appetite (stress, deliberate antiemetics, antiflatulents, vitamin supplements;
weight reduction, dental problems); note average aspirin and anti inflammatory agents
weight and percent gain/loss within past 2-9 months
 Dysphagia: note level of sensation where problem  PAST MEDICAL HISTORY: childhood,
occurs, whether it occurs with foods/ fluids adult, psychiatric illness; surgery; bleeding
 Nausea: note onset and duration, existence of disorders; menstrual history; exposure to infectious
associated symptoms (weakness, headache, agents; allergies
vomiting), occurrence before or after meals
 Vomiting: note onset and duration; foods/fluids that PHYSICAL ASSESSMENT
can be maintained; associated symptoms (fever,
diarrhea)  MOUTH: Inspect/Palpate
 Regurgitation (reflux): note whether occurs with  Outer/inner lips: color, texture, moisture
ingestion of certain foods, any associated symptoms  Buccal mucosa: color, texture, lesions, ulcerations
(vomiting), occurrence with certain positions  Teeth/gums: missing teeth, cavities, tenderness,
(supine, recumbent) swelling
 Tongue: protrusion without deviation, texture,
 DIGESTION/ABSORPTION: symptoms may color, moisture
include:  Palates (hard and soft): color
 Dyspepsia (indigestion): note location of
discomfort, whether associated with certain foods,  ABDOMEN: divided into regions and quadrants;
time of day/night of occurrence, associated note specific location of any abnormality
symptoms (vomiting)  Inspect skin: color, scars, striae, pigmentation,
 Heartburn (pyrosis): note location, whether pain lesions, vascularity
radiates, whether it occurs before or after meals,  Inspect architecture: contour, symmetry, distension,
time of day when discomfort is most noticeable, umbilicus
foods that aggravate or eliminate symptoms  Inspect movement: peristalsis, pulsations
 Pain: character, frequency, location, duration,  Auscultate peristaltic sounds:
distribution, aggravating or alleviating factors  Normal: bubbling, gurgling 5-30 times/min
 Increased: diarrhea, gastroenteritis, early
 BOWEL HABITS: symptoms may include intestinal obstruction
 Constipation: note number of stools/day or week,  Decreased: constipation, late intestinal
changes in size or color of stool, alterations in obstruction, use of anticholinergics, post op
food/fluid intake, presence of tenesmus, painful anesthesia
defecation, associated symptoms (abdominal pain,  Auscultate arterial sounds: note presence or absence
cramps) of bruits in aorta/renal arteries
 Diarrhea: note number of stools/day, consistency,  Percuss for tenderness/masses; determine
quantity, odor, interference with ADL, associated distribution of tympany and dullness
symptoms (nausea, vomiting, flatus, abdominal  Liver span: normal 6-12cm dullness at
distension) midclavicular line; determine shifting dullness
(ascites)
 HEPATIC/BIIARY PROBLEMS: symptoms:  Stomach: normal tympany
 Jaundice: note location, duration, notable  Spleen: normal tympany, dullness only if
increase/decrease in degree enlarged
 Pruritus: note location, distribution, onset  Small/large intestine: normal tympany
  Bladder: normal tympany, dullness if full  Other lumen serves as an air vent to prevent
 Palpate to depth of 1cm (light palpation) to adherence of tube to intestinal mucosa
determine areas of tenderness; muscle guarding and  Balloon is inflated with special substance after
masses insertion
 Palpate to a depth of 4-8cm (deep palpation) to
identify rigidity, masses, ascites, tenderness, liver  After insertion of nasoenteric tubes, turn the client
margins, spleen to the right side. This allows passage of the tube
into the duodenum. Shortening of length of tube
LABORATORY AND DIAGNOSTIC TESTS from the outside indicates passage of the tube into
the duodenum.
 BLOOD CHEMISTRY AND
ELECTROLYTE ANALYSIS: albumin, ESOPHAGEAL BALLOON TAMPONADE
alkaline phosphatase, ammonia, amylase, bilirubin,
chloride, LDH, lipase, potassium, SGOT, SGPT,  Procedure done to control bleeding of ruptured
sodium, esophageal varices in clients with liver cirrhosis
 Sengstaken-Blakemore Tube.
 BROMSULPHALEIN (BSP)  Triple lumen tube with 2 balloons
 Instruct patient to fast for 8-12 hours before the test  Inflation of esophageal balloon
 Record weight prior to test  Compresses the ruptured esophageal varices
 Inform patient that a dye will be injected into the  Inflation of gastric balloon
arm slowly and 45 minutes later a blood sample  Serves as anchor to prevent upward
will be drawn from the opposite arm displacement of esophageal balloon
 Observe patient closely for allergic reaction  Middle lumen is connected to gastric suction
 Eating and drinking can be resumed after blood  Sponge rubber should be placed near the nares, to
sample serve as traction.
 Prevents downward displacement of the tube
Encourage client to expectorate or suction his
 HEMATOLOGIC STUDIES: Hgb, Hct, PT, 

mouth as needed to prevent aspiration.

WBC
 Keep a pair of scissors readily available.
 SEROLOGIC STUDIES: Carcinoembryonic
UPPER GI SERIES (BARIUM SWALLOW)
Antigen (CEA), hepatitis-associated antigens
 Fluoroscopic examination of upper GI tract to
determine structural problems and gastric emptying
 URINE STUDIES: amylase, bilirubin time; patient must swallow barium sulfate or other
 FECAL STUDIES: blood, fat, infectious contrast medium; sequential films taken as it moves
organisms through the system
 Freshly passed, warm stool is best specimen  Nursing Care: Pretest
 Fat or infectious organisms collect three  NPO
separate specimens and label day 1, 2 , 3  Explain that barium will taste chalky
 Nursing Care: Post
GASTRIC AND INTESTINAL  Administer laxatives
DECOMPRESSION
 Removal of fluid and gas, to prevent gastric and LOWER GI SERIES (BARIUM ENEMA)
intestinal distention. NGTs and nasoenteric tubes  Barium is instilled into the colon by enema; patient
are used for gastric and intestinal decompression retains the contrast medium while xrays are taken to
 Salem Sump tube identify structural abnormalities of the large
 double lumen NGT for decompression intestine or colon
 Air vent (blue pigtail) prevents adherence of  Nursing Care: Pretest
tube to gastric mucosa  NPO
 Other lumen is connected to low-pressure,  Enemas until clear the morning of test
continuous gastric suction  Administer laxative or suppository
 Cantor Tube  Explain that cramping may be experienced
 Single-lumen nasoenteric tube  Nursing Care: Posttest
 Balloon is inflated with special substance  Administer laxatives and fluids
before insertion
Miller-Abbot Tube

ENDOSCOPY
 Double lumen nasoenteric tube used for
decompression
(ESOPHAGOGASTRODUODENOSCOPY)
 Direct visualization of esophagus, stomach and
 Main lumen is connected to low pressure
duodenum by insertion of a lighted fiberscope
gastric suction
 Used to observe structures, ulcerations, ORAL CHOLECYSTOGRAM
inflammation, tumors; may include biopsy  Injection of radiopaque dye and xray exam to
 Nursing Care: Pretest visualize gallbladder
 NPO  Used to determine the gallbladder’s ability to
 Consent concentrate and store dye and to assess patency of
 Explain local anesthesia will be used to ease biliary duct system
discomfort and speaking during procedure is  Nursing Care: Pretest
not possible; patient should expect hoarseness  Offer lowfat meal evening before the test and
and sore throat for several days black coffee, tea or water morning of exam
 Nursing Care: Posttest  Check for iodine sensitivity and administer dye
 NPO until gag reflex returned tablets as ordered
 Asses VS and pain, dysphagia and bleeding  Nursing Care: Post Test
 Administer warm normal saline gargles for  Observe for side effects of dye, (NV, diarrhea)
relief of sore throat
LIVER BIOPSY
COLONOSCOPY  Invasive procedure where a specially designed
 Endoscopic visualization of large intestine; may needle is inserted to liver to remove a small piece of
include biopsy and removal of foreign substances tissue for study
 Nursing Care: Pretest  Nursing Care: Pretest
 NPO  Consent
 Administer laxatives for 1-3 days before exam,  NPO
enema until clear the night before test  Instruct to hold breath during biopsy
 Consent  Nursing Care: Post test
 Explain: when instrument is inserted into  Assess VS
rectum a feeling of pressure might be  Place on right side for a few minutes with
experienced pillow against the abdomen
 Nursing Care: Posttest  Observe puncture site for hemorrhage
 Observe for rectal bleeding and signs of  Assess for complications of shock and
perforation pneumothorax
 Schedule planned rest periods for patient
NURSING DIAGNOSIS
SIGMOIDOSCOPY  Actual or potential fluid volume deficit
 Endoscopic visualization of sigmoid colon  Actual or potential impairment of skin integrity
 Used to identify inflammation, lesions and remove  Disturbance in self concept; body image
foreign bodies  Alteration in nutrition: less than body requirements
 Nursing Care: Pretest  Alteration in comfort: pain
 Offer a light supper and light breakfast  Alteration in bowel elimination:
 Do bowel prep diarrhea/constipation
 Explain: sensation of an urge to defecate or  Noncompliance
abdominal cramping might be experienced  Potential for injury
 Nursing Care: Post Test  Impaired physical mobility
 Assess for signs of bowel perforation
GOALS
GASTRIC ANALYSIS  Fluid and electrolyte balance will be maintained
 Insertion of nasogastric tube to examine fasting  Patient’s skin integrity will be restored/maintained
gastric contents for acidity and volume  Patient will express feelings of self-worth
 Nursing Care: Pretest  Patient will verbalize feelings regarding the
 NPO colostomy/ileostomy
 Advise patient about: No smoking,  Patient will remain adequate weight for age, sex,
anticholinergic medication, antacids for 24 heights and body build
hours  Discomfort from abdominal distension, pruritus,
 Inform patient that tube will be inserted to stomatitis or other irritation of oral mucous
stomach via nose and instruct to expectorate membranes will be controlled/relieved
saliva to prevent buffering of secretions  Patient will develop regular bowel habits, decreased
 Nursing Care: Post Test frequency of liquid stools, and regular bowel
 Provide frequent mouth care movements
 Patient will cooperate with treatment regimen
 There will be no evidence of abnormal bleeding
 Patient will demonstrate increased strength and  Measure/record any drainage
endurance and maintenance of an optimal activity  Promote adequate nutrition
level  Administer feeding with patient in high-
fowler’s and keep head of bed elevated for 30
ENEMAS mins after meals to prevent regurgitation
 Instillation of fluid into the rectum, usually for the  Maintain feeding at room temperature
purpose of stimulating defecation  Ensure that prescribed amt of feeding be given
 Types within prescribed amt of time
 Cleansing enema (tap water, normal saline or  Weigh patient daily
soap): used to treat constipation or feces  Monitor I&O
impaction, as bowel cleansing prior to  Allow patient to see, smell and taste food
diagnostic procedures or surgery, to help before meals
establish regular bowel functions  Monitor for signs of dehydration
 Retention Enema (mineral oil, olive oil,
cotton-seed oil): usually administered to NASOGASTRIC (NG) TUBE
lubricate or soften a hard fecal mass to  Soft rubber or plastic tube inserted through a nostril
facilitate defecation and into the stomach for gastric decompression,
feeding or obtaining specimens for analysis of
NURSING CARE FOR A CLEANSING stomach contents
ENEMA  Types
 Explain procedure and breathing through mouth  Levin: single-lumen, nonvented
relaxes abdominal musculature  Salem: a tube within a tube; vented to provide
 Prepare solution and have bedpan, commode or constant inflow of atmospheric air
bathroom ready.
 Position patient and drape adequately. NURSING CARE
 Place waterproof pad under buttocks.  Monitor functioning system and ensure patency of
 Lubricate tube and allow solution to fill the tubing, the NG tube: abdominal discomfort/distension,
displacing air. nausea and vomiting and little or no drainage in
 Insert rectal tube without using force. collection bottle are all signs that system is not
 Administer solution over 5 to 10 mins. functioning properly
 Have the patient retain solution until urge to  Assess tube position: aspirate gastric contents
defecate becomes strong. to confirm that tube in stomach; inject 10 cc air
 Assess for dizziness, lightheadedness, abdominal through tube and auscultate for rapid reflux
cramps and nausea  Check that tubing is free of kinks; irrigate
 Document. every 2 to 4 hours if suction is used and before
and after each feeding
NURSING CARE FOR RETENTION ENEMA  Record amt, color and odor of drainage
 Same with cleansing enema except:  Provide measures to assure maximal comfort
 Oil is used instead of water (comes prepared in  Apply water soluble lubricant to lips and
commercial kits and given at body prevent dryness
temperature)  Keep nares free from secretions
 Administer 150-200 cc of prepared solution.  Provide periodic warm saline gargles to
 Instruct patient to retain oil for at least 30 mins prevent dryness
 Provide frequent mouth care with
toothbrush/toothpaste or flavored mouth
GASTRONOMY
washes
 Insertion of a catheter through an abdominal
If allowed, give patient hard candy or gum to
incision into the stomach where it is secured with


stimulate the flow of saliva and prevent

sutures
dryness
 Used as an alternative method of feeding, either
 Elevate head and chest during and for 1-2
temporary or permanent, for patients who have
hours after feeding
problems with swallowing, ingestion and digestion
 Monitor/maintain fluid and electrolyte balance
 Assess for signs of metabolic alkalosis
NURSING CARE (suctioning causes excessive loss of
 Maintain skin integrity: inspect and cleanse skin hydrochloride and K)
around stoma frequently; keep deep area dry to  Administer IV fluids
avoid excoriation.  If suction used, irrigate NG tube with normal
 Maintain patency of gastrostomy tube saline to decrease sodium loss
 Assess for residual before each feeding  Keep accurate I&O
 Irrigate tube before and after meals
  If suction used provide ice chips sparingly (if TYPES
allowed)  Reducible
 Monitor lab values and electrolytes  can be manually placed back into the
DISORDERS OF THE GASTROINTESTINAL abdominal cavity
SYSTEM  Irreducible
 Cannot be placed back into the abdominal
NAUSEA AND VOMITING cavity
 Nausea  Inguinal
 Feeling of discomfort in the epigastrium with a  Occurs when there is weakness in the
conscious desire to vomit; occurs in abdominal wall where the spermatic cord in
association with and prior to vomiting men and around ligament in women emerge
 Vomiting  Femoral
 Forceful ejection of stomach contents from the  Protrusion through the femoral ring; more
upper GI tract. common in females
 Emetic center in medulla is stimulated ( local  Incisional
irritation of intestine or stomach or disturbance  Occurs at the site of a previous surgical
of equilibrium) causing vomiting reflex incision as a result of inadequate healing
 Two most common manifestations of GI disease postoperatively
 Contributing Factors  Umbilical
 GI disease  Most commonly found in children
 CNS disorders (meningitis, CNS lesions)  Strangulated
 Circulatory problems (CHF)  Irreducible, with obstruction to intestinal flow
 Metabolic disorders (uremia) and blood supply
 Side effects of certain drugs (chemotherapy,
antibiotics) MEDICAL MANAGEMENT
 Pain  Manual reduction, use of truss (firm support)
 Psychic trauma  Bowel surgery if strangulated
 Response to motion  Herniorrhaphy: surgical repair of the hernia by
 Assessment Findings suturing the defect
 Weakness, fatigue, pallor, possible lethargy
 Dry mucous membrane and poor skin ASSESSMENT
turgor/mobility (if prolonged with  Vomiting, protrusion of involved area (more
dehydration) obvious after coughing) and discomfort at a site of
 Serum Na, Ca, K, decreased protrusion
 BUN elevated  Crampy, abdominal pain and abdominal distension
(if strangulated with a bowel obstruction)
NURSING INTERVENTIONS
 Maintain NPO until patient able to tolerate oral NURSING INTERVENTIONS
intake  Observe for complications such as strangulation
 Administer medications  Prepare for herniorrhaphy, provide routine pre-OP
 Phenothiazines: Chlorpromazine (Thorazine), and post-OP care
Perphenazine (trilafon), prochlorperazine  Assess for possible distended bladder,
(Compazine) particularly with inguinal hernia repair
 Antihistamine  Discourage coughing
 Other drugs to control nausea and vomiting  Assist to splint incision when coughing or
Trimethobenzamide sneezing
 Notify physician if changes in vomiting pattern  Apply ice bags to scrotal area (if inguinal
 Maintain fluid and electrolyte balance repair) to decrease edema
 Administer IV fluids  Scrotal (athletic) support may be ordered
 Record amt/frequency of vomitus  Teach
 Assess skin tone/turgor  Need to avoid strenuous physical activities for
 Monitor labs at least 6 weeks
 Report difficulty with urination
HERNIAS
 Protrusion of a viscus from its normal cavity HIATAL HERNIA
through an abnormal opening/weakened area  Types
 Occurs anywhere but most often in the abdominal  Sliding hiatal hernia
cavity  Protrusion into Thoracic cavity and back
into the abdominal cavity in relation to
position changes
  Cause: muscle weakness in the esophageal  Avoid cigarette smoking
hiatus (opening between the two domes of  Surgery
diaphragm where esophagus enters the  Nissen Fundoplication or gastric wrap-around
abdominal cavity
 Aging process, congenital muscle
weakness, obesity, trauma, surgery, or
prolonged increases in intraabdominal
pressure like heavy lifting and obesity
GASTIC CANCER
 Paraesophageal/ rolling hernia
 More common among middle-aged males
 Protrusion of fundus of the stomach and
 Predisposing factors:
greater curvature into the thorax next to
 Diet high in complex CHO, grains and salt
the esophagus. Gastric junction remains
 Smoked fish or meats and low in fresh, green,
below the diaphragm. Due to anatomic
leafy vegetables and fresh fruits
defect.
 Smoking
 Alcohol infection
CLINICAL MANIFESTATIONS  Use of nitrates
 Heartburns due to gastroesophageal reflux  Nitrite food preservatives
 Odynophagia, Dysphagia  Overheated fat products
 Dyspnea  Helicobacter pylori infection
 Abdominal pain  Chronic atrophic gastritis
 Nausea and Vomiting  Pernicious anemia
 Gastric distention, belching, flatulence  History of gastric ulcers

COLLABORATIVE MANAGEMENT CLINICAL MANIFESTATIONS

 Medications  Progressive loss of appetite
 Antacids to relieve heartburns  Gastric fullness
 Antiemetic to relieve nausea and vomiting  Dyspepsia or indigestion
 Histamine H2 Receptor Antagonists to  Positive guaiac stool exam
suppress secretion of gastric acid  Hematemesis and or melena
 Proton pump inhibitors to suppress gastric acid  Weight loss
secretion  Anemia
 Avoid drugs that lower LES pressure. To prevent  Fatigue
gastroesophageal reflux  Pain induced by eating, relieved by vomiting
 Anticholinergic  Palpable abdominal mass
 Calcium channel blocker
 Diazepam COLLABORATIVE MANAGEMENT
 Surgery
NURSING INTERVENTIONS  Total gastrectomy
 Relieve pain by antacids  Removal of stomach, esophagus is
 Modify diet. anatomosed to the jejunum.
 High CHON diet  Duodenum is not removed
 Small frequent feedings  Chemotherapy and radiation therapy
 Instruct client to eat slowly and chew food
properly. GASTRITIS
 Avoid fatty foods, cola, coffee, tea, chocolates,  Acute inflammatory conditions that causes
alcohol breakdown of normal gastric protective barriers
 Assume upright position before and after with subsequent diffusion of HCL acid into the
eating for 1 to 2 hours gastric lumen
 Avoid eating at least 3 hours before bedtime  Results in hemorrhage, ulceration and adhesion of
 Avoid evening snacks gastric mucosa
 Reduce body weight  Present in some form (mild to severe)in 50% adults
 Promote lifestyle changes  Caused by:
 Elevate head of bed 6 to 12 inches  Excessive ingestion of
 Avoid factors that increase abdominal pressure  salicylates, steroids
 Straining at stool  Alcohol
 Constrictive clothing  Food poisoning
 Heavy lifting  Large quantities of spicy
 Bending  Irritating foods in diet
 Stooping
 Vigorous coughing
ASSESSMENT  Administer medication
 Anorexia, NV, hematemesis, epigastric  Provide nursing care for patient with ulcer surgery
fullness/discomfort, epigastric tenderness  Provide teaching
 Decreased Hgb and Hct  Medication regimen
 Endoscopy: inflammation and ulceration of gastric  Take on prescribed time
mucosa  Antacids available at all times
 Gastric analysis: HCL usually increased except in  Avoid ulcerogenic drugs
atrophic gastritis  Proper diet
 Bland diet consisting 6 small meals/day
NURSING INTERVENTIONS  Eat meals slowly
 Monitor and maintain fluid and electrolyte balance  Avoid acid-producing subs (caffeine,
 Control NV alcohol, highly seasoned foods)
 Administer antiemetic  Avoid stressful situations at mealtime
 Maintain patency of NG tube  Avoid late bedtime snacks
 Provide teaching
 Avoidance of foods/medications such as spicy DUODENAL ULCERS
foods, alcohol, salicylates  Most commonly found in the first 2 cm of
duodenum
PEPTIC ULCER DISEASE  Occur more frequently that gastric ulcers
 Gastric ulcers  Characterized by gastric hyperacidity and
 Ulceration of mucosal lining of stomach; most significant increased rate of gastric emptying
commonly the antrum  Occur more often in younger men; more women
 Gastric secretions and stomach emptying rate affected after menopause; peak age 35 to 45 years
usually normal  Caused by smoking, alcohol abuse, psychologic
 Rapid diffusion of gastric acid from the gastric stress
lumen into the gastric mucosa, however,
causes an inflammatory reaction with tissue MEDICAL MANAGEMENT
breakdown Same as gastric
 Characterized by reflux into the stomach of
bile containing duodenal contents ASSESSMENT
 More often in men, in unskilled laborers, lower Pain located in midepigastrium and described as
socioeconomic groups, peak age 40-55 yo burning, cramping; usually occurs 2-4 hours after meals
 Caused by smoking, alcohol abuse, emotional and is relived by food
tension and drugs (salicylates, steroids,
Butazolidin) DIAGNOSTIC
Same as gastric
MEDICAL MANAGEMENT
 Supportive: NURSING INTERVENTION
 Rest, bland diet, stress management Same as gastric
 Drug therapy
Antacids, histamine (H2) receptor antagonist,

ULCER SURGERY
anticholinergics
 Surgery is performed when peptic ulcer disease
 Surgery
does not respond to medical management
 Various combinations of gastric resections and
 Types
anastomosis
 Vagotomy
 Severing of part of the vagus nerve
ASSESSMENT innervating the stomach to decrease
 Pain located in left epigastrium, with possible gastric acid secretion
radiation to back, usually occurs 1-2 hours after  Antrectomy
meals  Removal of antrum of stomach to
 weight loss eliminate the gastric phase of digestion
 Hgb and Hct decreased (if anemic)  Pyloroplasty
 Endoscopy reveals ulceration; differentiates ulcers  Enlargement of pyloric sphincter with
from gastric cancer acceleration of gastric emptying
 Gastric analysis: normal gastric acidity in gastric  Gastroduodenostomy (Billroth I)
ulcer, increased in duodenal ulcer  Removal of the lower portion of the
 Upper GI series: presence of ulcer confirmed stomach with anastomosis of the
remaining portion of the duodenum
NURSING INTERVENTIONS  Gastrojejunostomy (Billroth II)
  Removal of the antrum and distal portion  Avoidance of concentrated sweets
of the stomach and duodenum with  Adherence to six, small, dry, meals/day
anastomosis of the remaining portion of  Refrain from taking fluids during meals but
the stomach to the jejunum rather 2 hours after meals
 Gastrectomy  Assuming recumbent position for ½ hour after
 Removal of 60-80% of the stomach meals
 Esophagojejunostomy (Total Gastrectomy)
 Removal of the entire stomach with a loop CANCER OF THE STOMACH
of jejunum anastomosed to the esophagus  Often develop in distal third and may spread
through the walls of stomach into adjacent tissues,
NURSING INTERVENTIONS (POST) lymphatics, regional lymph nodes, other abdominal
 Ensure adequate function of NG tube organs or through the bloodstream to the lungs and
 Measure I & O bones
 Anticipate frank, red bleeding for 12-24 hours  Affects men twice; more frequent in blacks and
 Promote adequate pulmo ventilation Orientals; ages 50-70
 Place patient in mid or high fwlers position  Causes
 Teach patient to splint high upper abdominal  Excessive intake of highly salted or smoked
incision before turning, coughing and deep foods
breathing  Diet low in quantity of vegetables and fruits
 Atrophic gastritis
 Promote adequate nutrition  Achlorhydia
 After removal of NG tube, provide clear
liquids then bland diet MEDICAL MANAGEMENT
 Monitor weight daily  Chemotherapy
 Assess for regurgitation  Radiation therapy
 Eat smaller amt of food at slower pace  Treatment for anemia, gastric decompression,
 Teach nutritional support, fluid and electrolyte
 Gradually increasing food intake until able to maintenance
tolerate 3 meals/day  Surgery: type depends on location and extent of
 Daily weight lesion
 Stress reduction  Subtotal gastrectomy (Billroth I or II)
 Need to report  Total gastrectomy
 Hematemesis
 Vomiting ASSESSMENT FINDINGS
 Diarrhea  Fatigue, weakness, dizziness, shortness of breath,
 Pain NV, hematemesis, weight loss, indigestion,
 Melena epigastric fullness, feeling of early satiety when
 Weakness eating, epigastric pain (later)
 Feeling of abdominal fullness or  Pallor, lethargy, poor skin turgor and mobility,
distension palpable epigastric mass
 Dumping Syndrome
 Abrupt emptying of stomach contents into the
DIAGNOSTIC TESTS
intestine
Stool for occult blood- positive
Associated with the presence of hyperosmolar


 CEA (cancero-embryonic antigen)positive
chyme in the jejunum, which draw fluid by
Hgb and Hct decreased
osmosis from the extracellular fluid into the


 SGOT, SGPT, LDH, serum amylase elevated (if

bowel. Decreased plasma volume and
liver and pancreatic involvement)
distension of the bowel stimulates increased
 Gastric analysis reveals histologic changes
intestinal motility
 Signs and symptoms
 Weakness NURSING INTERVENTIONS
 Faintness  Give consistent nutritional assessment and support
 Palpitations  Provide care for the patient receiving chemotherapy
 Diaphoresis  Provide care for the patient with gastric surgery
 Feeling of fullness or discomfort
 Nausea and occasionally diarrhea INTESTINAL OBSTRUCTIONS
 Appear 15 to 30 mins after meals and last Mechanical Intestinal Obstruction
for 20-60 mins  Physical blockage of passage of intestinal contents
 Methods of controlling symptoms associated with with subsequent distension by fluid and gas
dumping  Caused:
  Adhesions,
 Hernias,
 Volvulus,
 Intussusception,
Inflammatory bowel disease,

CHRONIC INFLAMMATORY BOWEL
 Foreign bodies,
DISEASE
 Strictures,
 Neoplasms,
 Fecal impaction REGIONAL ENTERITIS (CROHN’S
DISEASE)
PARALYTIC ILEUS (NEUROGENIC OR  CIBD that affect both large and small intestine:
terminal ileum, cecum, and ascending colon
ADYNAMIC ILEUS)
 Granulomas that may affect all the bowel wall
 Interference with nerve supply to intestine resulting
layers with resultant thickening, narrowing and
in decreased or absent peristalsis
scarring of intestinal wall
 Caused
 Both sexes affected; more common in Jewish; two
 Abdominal surgery
age peaks 20-30 and 40-60 yo
 Peritonitis
 Cause: unknown; contributing: food allergies,
 Pancreatic toxic conditions
autoimmune reaction, psychologic disorders
 Shock
 Spinal cord injuries
 Electrolyte imbalances (hypoK) ASSESSMENT
 Right lower quadrant tenderness and pain;
 Vascular Obstructions abdominal distension
 Interference with the blood supply to a portion  NV, 3 to 4 semi-soft stools/day with mucus and pus
of the intestine, resulting in ischemia gangrene  Decreased skin turgor, dry mucous membrane
of the bowel  Increased peristalsis
 Caused by an embolus, atherosclerosis  Pallor

ASSESSMENT DIAGNOSTIC TESTS

 Small Intestine: non-fecal vomiting; colicky  Hgb and Hct decreased
intermittent abdominal pain  Sigmoidoscopy negative or reveals scattered ulcers
 Large Intestine: cramp-like abdominal pain,  Barium enema- narrowing with areas of strictures
occasional fecal-type vomitus; patient will be separated by segments of normal bowel
unable to pass stools or flatus
 Abdominal distension, rigidity, high pitched bowel MEDICAL MANAGEMENT
sounds above the level of the obstruction, decreased  Diet: High calorie, vitamin, CHON, low residue,
or absent bowel sounds distal to obstruction milk free; supplementary iron prep
 Drug therapy: antimicrobials, corticosteroids,
DIAGNOSTIC TESTS antidiarrheals, anticholinegic
 Flat-plate (xray) of the abdomen reveals the  Supplemental parenteral nutrition
presence of gas/fluid  Surgery
 Hct increased  Resection of diseased portion of bowel and
 Na, K, Cl decreased temporary or permanent ileostomy
 BUN increased
NURSING INTERVENTIONS
NURSING INTERVENTIONS  Provide nutrition while reducing gastric motility
 Monitor F&E balance  Administer TPN
 Measure NG/intestinal tube drainage  Provide high CHON, calorie, low residue diet
 Position fowler’s position- decrease pressure on with no milk products
diaphragm and encourage nasal breathing to  Weigh daily and take anthropometric
minimize swallowing of air measurements
 Prevent complications  Record and monitor characteristic of stools
 Measure abdominal girgth daily
 Assess S&S of peritonitis  Omit gas-producing foods/fluids from diet
 UO monitor
ULCERATIVE COLITIS
 Inflammatory DO of bowel; inflammation and
ulceration that starts in the rectosigmoid area and
spreads upward.
 Mucosa of bowel becomes edematous, thickened ASSESSMENT
with eventual scar formation.  Intermittent lower left quadrant pain and tenderness
 Colon consequently loses its elasticity and over rectosigmoid area
absorptive capabilities  Alternating constipation and diarrhea with blood
 More in women and Jewish; 15-40 yo and mucus
 Cause: unknown; contributory: autoimmune
factors, viral infection, allergies, emotional stress, DIAGNOSTIC TEST
insecurity  Barium enema- inflammatory process
 Hgb and Hct decreased
MEDICAL MANAGEMENT
 Mild to moderate form NURSING INTERVENTIONS
 Low-roughage diet with no milk products  Prepare for bowel surgery
 Drug Therapy  Teach
 Antimicrobials, corticosteroids,  Dietary regimen
anticholinergic, antidiarrheal,  Prevention of increased intra-abdominal
immunosuppressives, hematinic agents pressure
 Severe Form  Signs and symptoms of peritonitis
 NPO with IV and electrolyte replacement
NG tube with suction

CANCER OF COLON/RECTUM
 Blood transfusion
 Adenocarcinoma- common type of colon Ca
 Surgery
 spread by direct extension through the walls of
intestine and through lymphatic or circulatory
ASSESSMENT system. Metastasis- most often to the liver
 Severe diarrhea (15 to 20 liquid stools/day with  2nd most common site of Ca to men and women;
blood, mucus and pus); severe tenesmus, weight 50-60yo
loss, anorexia, weakness, crampy discomfort  Caused:
 Decreased skin turgor, dry mucous membranes  Diverticulosis
 Low grade fever, abdominal tenderness over the  Chronic ulcerative colitis
colon  Familial polyposis

DIAGNOSTIC TEST MEDICAL MANAGEMENT

 Sigmoidoscopy- mucosa that bleeds easily with  Chemotherapy
ulcer development  Radiation therapy
 Hgb and Hct decreased  Bowel surgery

DIVERTICULOSIS/DIVERTICULITIS ASSESSMENT
 Diverticulum  Alternating diarrhea/constipation
 Outpouching of intestinal mucosa, found in  Lower abdominal cramps, abdominal distension
sigmoid colon  Weakness, anorexia, weight loss, pallor, dyspnea
 Diverticulosis
Multiple diverticula of the colon

DIAGNOSTIC TEST
 Diverticulitis
 Stool for occult blood positive
 Inflammation of diverticula
 Hgb and Hct decreased
 Men; obese; 40-45yo
 Sigmoidoscopy- mass
 Caused:
 Barium enema-colon mass
 Stress,
 Digital rectal exam- palpable mass
 Congenital weakening of muscular fibers of
intestine
 Low fiber diet BOWEL SURGERY
 Abdominoperineal Resection
 Distal sigmoid colon, rectum and anus are
MEDICAL MANAGEMENT removed through a perineal incision and
 High residue diet
permanent colostomy is created.
 Drug therapy
 Irrigate with NSs or hydrogen peroxide, warm
 Bulk laxatives, stool softeners, anticholinergic,
sitz bath 4x/day, cover wound with dry
antibiotics
dressing and hold in place with T-binder
 Surgery
 Cancer of colon/rectum
 Resection of diseased portion of colon with
temporary colostomy
 Ileostomy
 Opening of ileum onto the abdominal surface
  Treatment of ulcerative colitis and Crohn’s  Control odor
Disease  Change pouch as necessary
 Continent Ileostomy (Kock’s pouch)  Empty or clean bag frequently
 Intraabdominal reservoir with a nipple valve is  Avoid gas forming foods
formed from the distal ileum. Pouch acts as a  Promote adequate stomal drainage
reservoir for fecal material and is cleaned at  Assess stoma color and intactness
regular interva;s by insertion of a catheter  Expect mucoid/serosanguinous drainage within
24 hours then liquid type
 Cecostomy  Assess for flatus
 Opening bet cecum and abdominal base  Irrigate colostomy as needed
temporarily diverts the fecal flow to rest the  Position patient on toilet or in high-fowler’s
distal portion of the colon after some types of position
surgery  Fill irrigation bag with desired amt of water
(500-1000cc) and hang bag so the bottom is at
 Temporary Colostomy shoulder height
 Located in ascending or transverse colon  Remove air from tubing and lubricate the tip of
 Done to rest the bowl the catheter or cone
 Remove old pouch and clean skin and stoma
 Double-barreled colostomy with water
 colon is resected and both ends are brought  Gently dilate stoma and insert the irrigation
through the abdominal wall creating two catheter or cone snugly
stomas, a proximal and a distal  Open tubing and allow fluid to enter the bowel
 Done most often for an obstruction or tumor in  Remove catheter or cone and allow fecal
the descending or transverse colon contents to drain
 Report immediately
 Loop Colostomy  Changes in odor, consistency and color of
 Often a temporary procedure whereby a loop stools
of bowel is brought above the skin surface and  Bleeding from stoma
held in place by a glass rod  Persistent constipation or diarrhea
 There is one stoma but two openings, a  Changes in contour of stoma
proximal and distal  Persistent leakage around stoma
 Skin irritation
 Permanent Colostomy
 Single stoma made when the distal portion of PERITONITIS
the bowel is removed  Local or generalized inflammation of part or all of
 Located in sigmoid or descending colon the parietal and visceral surfaces of the abdominal
cavity
 Resection with anastomosis  Initial Response: edema, vascular congestion,
 Diseased part of the bowel is removed and hypermotility of bowel and outpouring of
remaining portions anastomosed, allowing plasmalike fluid from the extracellular, vascular
elimination through the rectum and interstitial compartments, into the peritoneal
space
NURSING CARE  Later response: abdominal distension leading to
 Offer clear liquids only on day before surgery respiratory compromise, hypovolemia results in
 High calorie, low residue diet 3-5 days before decreased urinary output
surgery  Intestinal motility gradually decreases and
 Assist with bowel prep progresses to paralytic ileus
 Administer antibiotics 3-5days  Caused
 Administer enemas  Trauma (blunt or penetrating)
 Administer vit. C and K  Inflammation (ulcerative colitis, diverticulitis)
 Post-OP care  Volvulus
 Assess for signs of returning peristalsis  Intestinal ischemia
 Monitor initial stools  Intestinal Obstruction

NURSING CARE TO COLOSTOMY MEDICAL MANAGEMENT

 Prevent skin breakdown  NPO with fluid replacement
 Mild soap, water and pat dry  Drug therapy
 Use skin barrier  Antibiotics
 Assess for irritation  Analgesics
 Avoid use of adhesives on irritated skin  Surgery
  Laporotomy  Hemorrhoidectomy
 Opening made through the abdominal  Surgical excision of hemorrhoids indicated
wall into the peritoneal cavity ti determine when there is prolapse, severe pain and
the cause of peritonitis excessive bleeding
 Depending on cause, bowel resection may be  Post OP
necessary  Assess drainage every 2-3hours
ASSESSMENT  Side-lying or prone position; provide
 Severe abdominal pain, rebound tenderness, muscle flotation pad when sitting
rigidity, absent bowel sounds, abdominal distension  Sitz bath after each BM for at least 2
(if large bowel obstruction) weeks after sx
 Anorexia, NV  Report
 Shallow respirations; decreaed UO; weak, rapid  Rectal bleeding
pulse; hyperthermia  Continued pain on defecation
 Puslike drainage from rectal area
DIAGNOSTIC TEST
 WBC elevated DISORDERS OF THE LIVER
 Hct elevated  Hepatitis
 Cirrhosis of the Liver
NURSING INTERVENTIONS  Ascites
 Assess respiratory status  Esophageal Varices
 Assess characteristic of abdominal pain and  Hepatic Encephalopathy
changes over time  Cancer of the Liver
 Monitor fluid and electrolyte balance
 Position fowler’s position- localize peritoneal HEPATITIS
contents  Widespread inflammation of liver tissue with liver
cell damage due to hepatic cell degeneration and
HEMORRHOIDS necrosis
 Congestion and dilation of veins of the rectum and  Proliferation and enlargement of Kuppfer cell;
anus inflammation of the periportal areas (may cause
 Results from impairment of flow of blood through interruption of bile flow)
venous plexus  Caused: virus, exposure to medications,
 Internal (above anal sphincter) External (outside hepatotoxins
anal sphincter)
 Common 20-50 yo TYPES OF VIRAL HEPATITIS
 Predisposing factors  Hepa A (HAV), Infectious Hepatitis
 Long periods of standing  Hepa B (HBV), Serum Hepatitis
 Increased intra abdominal pressure  Hepa C (HCV), Non A, Non B Hepa or
 prolonged constipation Posttransfusion Hepa
 Pregnancy  Hepa D (HDV), Delta agent Hepa
 Heavy lifting  Hepa E (HEV), Enterically transmitted or epidemic
 Obesity Non Hepa A , Non Hepa B
 Straining at defecation  Hepa G (HGV), non A, non B, non C hepa
 Portal hypertension
ASSESSMENT
ASSESSMENT  Preicteric Stage
 Bleeding with defecation, hard stools with streaks  Flu-like sympt; malaise, fatigue
of blood  Anorexia, NV, diarrhea
 Pain with defecation, sitting or walking  Pain: headache, muscle aches, polyarthritis
 Protrusion of external hemorrhoids  Serum bilirubin and enzyme levels are elevated
 Icteric Stage
DIAGNOSTIC TEST  Jaundice
 Proctoscopy- internal hemorrhoids  Pruritus
 Hgb and Hct decreased if bleeding excessive and  Brown-colored urine
prolonged  Light-colored stools
 Posticteric Stage
MEDICAL MANAGEMENT  Increased energy levels
 Stool softeners, local anesthetics or anti-  Subsiding of pain
inflammatory creams  Minimal to absent GI symptoms
 Diet: high fiber, adequate liquids  Serum bilirubin and enzyme levels return to
normal
  Prevalent in areas where sewerage disposal is
inadequate or where communal bathing in
contaminated rivers is practiced
 Transmission
 Same with A

HEPATITIS A DIAGNOSTIC TEST

 SGPT, SGOT, Alk Phos, Bilirubin, ESR: increased
 Young children, travelers, custodial care
 WBC, lymphocytes, neutrophils: decreased
institutions
 Hepatitis A
 Incubation 15 to 20 days
HAV in stool
Feco-oral route, contaminated water or milk,


 Anti-HAV (IgG) appears after onset of
uncooked shellfish, contaminated fruits and
jaundice; peaks in 1-2 mos
vegs, poorly washed utensils,
 Anti HAV (IgM) positive on acute infection;
 Common in fall and early winter
lasts 4-6 weeks
 Associated with poor sanitation
 Hepatitis B
 Prevention
HBsAg (surface antigen): positive, develops 4-
Strict hand washing


12 weeks after infection
 Stool and needle precaution
Anti-HBsAg: negative in 80% of cases
Hepatitis A vaccine (Harvix)


 Anti-HBc: associated with infectivity,
 Immunoglobulin for household members
develops 2-16 weeks after infection
and sexual contacts
 HBeAg: disappears before jaundice
 Anti-Hbe: present in carriers, represents low
HEPATITIS B infectivity
 Young adults
 High risk: drug addicts, hemodialysis patient,
NURSING CARE
health-care personnel
 Avoid alcohol and OTC medications
 Transmission: blood or body fluids through
 High CHO, low fat foods
contaminated needle and sexual contact
 Do not donate blood
 Incubation period: 45 to 160 days, ave. 60 to 120
days
 Reservoir: blood and body secretions, saliva, CIRRHOSIS OF THE LIVER
semen, urine, nasopharyngeal washings, feces,  Chronic, progressive disease characterized by
pleural fluids inflammation, fibrosis and degeneration of liver
 Prevention parenchymal cells
 Handwashing  Destroyed liver cells are replaced by scar tissue,
 Screening blood donors resulting in architectural changes and malfunction
 Testing all pregnant women of the liver
 Needle precautions  Men; 40 to 60yo
 Hepatitis B vaccine (Engerix-B, Recombivax
HB) TYPES
 Laennec Cirrhosis
HEPATITIS C  Alcohol abuse and malnutrition; characterized
 Post-transfusion hepatitis by an accumulation of fat in the liver cells
 Drug abusers progressing to widespread scar formation
 Incubation 5 to 10 weeks  Postnecrotic Cirrhosis
 Prevention  Severe inflammation with massive necrosis as
 Handwashing a complication of viral heap
 Needle prec  Cardiac Cirrhosis
 Screening blood donor  Consequence of right sided heart failure;
manifested by hepatomegaly with some
fibrosis
HEPATITIS D
 Biliary Cirrhosis
 Coinfection of hepa B
 Biliary obstruction, usually in the common bile
 High risk: drug users, hemodialysis, frequent blood
duct; results in chronic impairment of bile
transfusion
excretion
 Prevention
 Same with hepa B
ASSESSMENT
 Fatigue, anorexia, NV, indigestion, weight loss,
HEPATITIS E
flatulence, irregular bowel habits
 Waterborne virus
 Hepatomegaly (early): pain located in the right distension with striae and prominent veins,
upper quadrant; atrophy of the liver (later); hard, abdominal pain
nodular liver upon palpation; increased abdominal  Peripheral edema, SOB
girth
 Changes in mood, alertness and mental ability; DIAGNOSTIC TEST
sensory deficits; gynecomastia, decreased axillary  K and albumin decreased
and pubic hair in males; amenorrhea in young  PT prolonged
females  LDH, SGOT, SGPT, BUN, Na increased
 Jaundice of the skin, sclera and mucous
membranes; pruritus NURSING INTERVENTIONS
 Easy bruising, spider angiomas, palmar erythema  Nutritional
 Muscle atrophy  Restrict Na to 200-500mg/day; fluids 1L/day,
high calori foods
DIAGNOSTIC TEST  Monitor edema
 SGOT, SGPT, LDH, alkaline phosphatase=  Peripheral pulses
increased  Abdominal girth
 Serum bilirubin= increased  Position
 PT= prolonged  High fowler’s position
 Serum albumin= decreased  Empty bladder before the procedure
 Hgb and Hct= decreased
 BSP= increased ESOPHAGEAL VARIC
 Dilation of the veins of the esophagus, caused by
NURSING INTERVENTIONS portal hypertension from resistance to normal
 Relieve pruritus venous drainage of the liver into the portal vein
 Tepid water then emollient lotion  Causes blood to shunted to the esophagogastric
 Keep nails short veins, resulting in distension, hypertrophy and
 Cool, moist compress increased fragility
 Nutritional  Caused by portal hypertension (liver cirrhosis,
 Small frequent feedings alcohol abuse), swallowing poorly masticated food,
 High calorie, low to mod CHON, high CHO, increased intra-abdominal pressure
low fat, vit A, B, C, D, L and folic acid
 Infection MEDICAL MANAGEMENT
 Reverse isolation  Iced normal saline lavage
 Frequent turning and skin care  Transfusions with fresh whole blood
 Vitamin K therapy
ASCITES  Sengstaken-Blakemore tube
 Accumulation of free fluid in the abdominal cavity  Intra-arterial or IV vasopressin
 Caused: cirrhotic liver damage, which produces
hypoalbuminemia, increased portal venous pressure SURGERY FOR PORTAL HYPERTENSION
and hyperaldosteronism  Ligation of esophageal and gastric veins to stop
acute bleeding
MEDICAL MANAGEMENT  Portacaval shunt
 Supportive  End-to-side or side to side anastomosis of the
 Modify diet, bedrest, salt poor albumin portal vein to the inferior vena cava
 Diuretic therapy  Splenorenal shunt
 Surgery  End to side or side to side anastomosis of the
 Paracentesis splenic vein to the left renal vein
 LeVeen Shunt (peritoneal-venous shunt)  Mesocaval shunt
 used in chronic, unmanageable ascites  End to side or use of graft to anastomose the
 Permits continuous reinfusion of ascetic inferior vena cava to the side of the superior
fluid back into the venous system through mesenteric vein
a silicone catheter with a one-way
pressure sensitive valve ASSESSMENT
 Anorexia, NV, hematemesis, fatigue, weakness
ASSESSMENT  Splenomegaly, increased splenic dullness, ascites,
 Anorexia, NV, fatigue, weakness, changes in caput medusa, peripheral edema, bruits
mental functioning
 Position fluid wave and shifting dullness on DIAGNOSTIC TEST
percussion, flat or protruding umbilicus, abdominal  PT prolonged
 Hematest of vomitus positive  Higher in men
 Serum albumin, RBC, Hgb, Hct decreased  Prognosis: poor; disease well advanced before
 LDH, SGOT, SGPT, BUN increased clinical signs evident

NURSING INTERVENTIONS MEDICAL MANAGEMENT

 Position:  Chemotherapy and radiotherapy (palliative)
 Semifowler’s (if not shock)  Resection of liver segment or lobe if tumor is
 Monitor bleeding localized
 Administer vasopressin
 Teach ASSESSMENT
 Minimizing esophageal irritation  Weakness, anorexia, NV, weight loss, slight
 Avoid salicylates, alcohol, use of antacids, hyperthermia
chew foods thoroughly  Right upper quadrant discomfort/tenderness,
hepatomegaly, blood tinged ascites, friction rub
HEPATIC ENCEPHALOPATHY over liver, peripheral edema, jaundice
 Frequent terminal complication in liver disease
 Unable to convert ammonia to urea-> remain in DIAGNOSTIC TEST
systemic circulation -> cross the blood brain barrier  Blood sugar decreased
-> producing neurologic toxic symptoms  Alpha fetoprotein increased
 Caused:  Abdominal xray, liver scan, liver biopsy all positive
 GI hemorrhage
 Hyperbilirubinemia NURSING INTERVENTIONS
 Transfusions (stored blood)  Prepare for abdominal surgery plus
 Thiazide diuretics  Preop
 Uremia  Perform bowel prep
 Dehydration  Administer vit k
 Postop
ASSESSMENT  Administer 10% glucose for first 48 hours
 Early: changes in mental functioning (irritability);  Monitor blood sugar
insomnia, slowed affect; slow slurred speech;  Assess for bleeding
impaired judgment; slight tremor; Babinski’s reflex,  Assess for hepatic encep
hyperactive reflexes
 Progressive: asterixis, disorientation, apraxia, CHOLECYSTITIS/CHOLELITHIASIS
tremors, fetor hepaticus, facial grimacing  Cholecystitis
 Late: coma, absent reflexes  Acute or chronic inflammation of gallbladder,
occurs within the walls of the gallbladder and
DIAGNOSTIC TEST creates thickening accompanied by edema.
 Serum ammonia- increased  Consequently, there is impaired circulation,
 PT prolonged ischemia and eventual necrosis
 Hgb and Hct decreased  Commonly associated with gallstones.
 Cholelithiasis
NURSING CARE  Formation of gallstones, cholesterol stones
 Restrict CHON in diet, high CHO intake and vit K most common variety
 Adminster enemas, cathartics, intestinal antibiotics  Women after 40; post menopausal women on
and lactulose estrogen therapy and obese
 Keep side rails up; provide artificial tears/eye patch  Stone formation caused by genetic defect of bile
 Avoid acetaminophen, phenothiazines, gold composition, gallbladder/bile stasis, infection
compounds, methyldopa  Acute cholecystitis follows stone impaction,
 Maintain bedrest adhesions, neoplasms may also be implicated

CANCER OF THE LIVER MEDICAL MANAGEMENT

 Primary cancer of the liver is extremely rare  Supportive treatment
 Common site for metastasis because of liver’s large  NPO with NGT and IV fluids
blood supply and portal drainage  Diet modification with administration of fat-soluble
 Primary cancers of the colon, rectum, stomach, vitamins
pancreas, esophagus, breast, lung and melanomas  Drug therapy
frequently metastasize to the liver  Narcotic analgesics (Demerol)
 Enlargement, hemorrhage and necrosis; primary  Anticholinergic
liver tumors often metastasize to the lung  Antiemetic
 Surgery  Decreased bowel sounds
 Cholecystectomy/choledochostomy  Fever

ASSESSMENT DIAGNOSTIC TEST

 Epigastric or right upper quadrant pain, precipitated  WBC increased
by heavy meal or occurring at night  Elevated acetone in urine
 Intolerance for fatty foods (NV, sensation of
fullness) NURSING INTERVENTIONS
 Pruritus, easy bruising, jaundice, dark amber urine,  Administer antibiotics/antipyretic
steatorrhea  Prevent perforation
 Do not give enemas
DIAGNOSTIC TEST
 Direct bilirubin transaminase, alkaline phosphatase, PANCREATITIS
WBC, amylase, lipase: all increased  Inflammatory process with varying degrees of
 Oral cholecystogram (gallbladder series): positive pancreatic edema, fat, necrosis or hemorrhage
for gallstone  Proteolytic and lipolytic pancreatic enzymes are
activated in the pancreas rather than the duodenum,
NURSING INTERVENTIONS resulting in tissue damage and autodigestion of the
 Administer pain reliever pancreas
 Small, frequent meals  Caused:
 Provide care to relieve pruritus  Alcoholism
 Biliary tract disease,
CHOLECYSTECTOMY/  Trauma
CHLODECHOSTOMY  Viral infection
 Cholecystectomy  Penetrating duodenal ulcer
 Removal of the gallbladder with insertion of a  Abscesses
T-tube into the common bile duct  Drugs (steroids, thiazide diuretics and oral
 Choledochostomy contraceptives)
 Opening of common duct, removal of stone  Metabolic disorder (hyperparathyroidism,
and insertion of T tube hyperlipidemia)

NURSING CARE (POST OP) MEDICAL MANAGEMENT

 Monitor t-tube  Drug therapy
 Connected to closed gravity drainage  Analgesic
 Avoid kinks, clamping or pulling of tube  Smooth-muscle relaxant
 Expect 300-500 cc bile colored drainage first  Anticholinergic
24 hours, then 200cc/24 hours for 3-4days  Antacids
 Monitor color of urine and stools (stools will  H2 receptor antagonist, vasodilators, Ca
be light if bile is flowing through T tube) gluconate
 Assess for signs of peritonitis  Diet modification
 Teach  Peritoneal lavage
 6 weeks no heavy lifting  Dialysis
 Report: fever, jaundice, pain, dark urine, pale
stools, pruritus ASSESSMENT
 Pain located in left upper quadrant radiating to
APPENDICITIS back, flank or substernal area; aggravated by eating
 Inflammation of appendix that prevents mucus from  Vomiting, shallow respirations (with pain),
passing into the cecum; if untreated, ischemia, tachycardia, decreased or absent bowel sounds,
gangrene, rupture and peritonitis occur abdominal tenderness with muscle guarding,
 Caused by mechanical obstruction (fecaliths, positive Grey Turner’s spots (ecchymosis on
intestinal parasites) or anatomic defect; may be planks) and positive Cullen’s sign (ecchymosis of
related to decreased fiber in diet periumbilical area)

ASSESSMENT DIAGNOSTIC TEST

 Diffuse pain, localizes in lower right quadrant  Serum amylase and lipase, urinary amylase, blood
 NV sugar, lipid levels: increased
 Guarding abdomen, rebound tenderness, walks  Serum Ca decreased
stooped over  CT scan-enlargement of pancreas
NURSING INTERVENTIONS
 Withhold food/fluid and eliminate odor and sight of
food to decrease pancreatic stimulation
 Maintain NG tube
 Nonpharmacologic measures
 Knee-chest (fetal position)
 Quiet, restful environment
 Teach
 High CHO, CHON, low fat
 Small frequent feeding
 Avoid caffeine and alcohol
 Report
 Continued NV
 Abdominal distension with increasing fullness
 Persistent weight loss
 Severe epigastric or back pain
 Frothy/foul-smelling BM
 Irritability, confusion, persistent elevation of
temp

CANCER OF PANCREAS
 Pancreatic tumors are adenocarcinomas and half
occur in head of pancreas
 Tumor growth results in common bile duct
obstruction with jaundice
 Men; 45 -65yo
 Contributing: chemical carcinogens, smoking, high
fat diet, DM

MEDICAL MANAGEMENT
 Radiation therapy
 Whipple’s procedure (pancreaduodenectomy)
 Resection of the proximal pancreas, adjoining
duodenum, distal portion of the stomach and
distal segment of the common bile duct
 Drug therapy
 Pancreatic enzymes; OHA or insulin, bile salts
necessary after surgery
 Chemotherapy

ASSESSMENT
 Anorexia; rapid, progressive weight loss; dull
abdominal pain located in upper abdomen or left
hypochondriacal region with radiation to the back,
related to eating; jaundice

DIAGNOSTIC TEST
 Increased serum lipase (early)
 Increased bilirubin (conjugated)
 Increased serum amylase

NURSING INTERVENTIONS
 Teach
 Eat small frequent meals of a low-fat, high
calorie diet with vitamin supplements