THE GASTRO-INTESTINAL SYSTEM ACCESSORY ORGANS

- Review of the GIT Anatomy and Physiology

- Review of Common laboratory procedures

- Review of Common Symptoms and their

nursing interventions

- Review of common disorders of the:

Esophagus - gallbladder

Stomach - exocrine pancreas

Small intestine - liver

Large Intestine GASTROINTESTINAL TRACT

GASTROINTESTINAL SYSTEM
UPPER GIT
FUNCTION:
- consists of structures that aid in the
- DIGESTION, ABSORPTION, ELIMINATION ingestion and digestion of food
- includes the mouth, esophagus,
Digestion is chemical and mechanical
stomach, duodenum
process on the ingested food to prepare it for
assimilation by the body. Hypothalamus – satiety center

COMPOSITION - is responsible for notifying the body that

it is satisfied or has received sufficient
- ALIMENTARY CANAL, ACCESSORY food
ORGANS
LOWER GIT
PERISTALSIS
- consists of the small and large intestines
- wavelike motion that propels - digestion is completed in the small
substances within the GIT intestine, and most nutrients are
SPHINCTERS / VALVES absorbed in this part of the GIT
- the large intestine serves primarily to
- controls rate of peristalsis / prevents absorb water and electrolytes and to
regurgitation eliminate the waste products of
digestion through the feces

DIGESTIVE TRACT ANATOMY &PHYSIOLOGY

MOUTH

1. The mouth contains the lips, cheeks,

palate, tongue, teeth, salivary glands,
muscles, and maxillary bones.
2. Saliva contains the amylase enzyme
(ptyalin) that aids in digestion.
 GASTROINTESTINAL TRACT A. Mucous Glands
MOUTH 1. mucous glands are located in the
mucosa
1. Salivation
2. mucous glands prevent autodigestion
- the “thought” of food initiates saliva
by providing an alkaline protective covering.
production

a.) serous secretions - contain ptyalin for B. The Lower Esophageal (Cardiac) Sphincter
starch digestion – produced by parotid and prevents reflux of gastric contents into the
sub-maxillary glands esophagus
b.) mucous secretions - for lubrication of
C. The Pyloric Sphincter
food – produced by the buccal, sublingual
and sub-maxillary glands regulates the rate of stomach emptying
2. Mastication into the small intestine
- chewing of food D. Hydrochloric Acid
- teeth - for initial breakdown of food to
small particles kills microorganisms, breaks food into small
- it helps prevent excoriation of the lining particles, and provides a chemical
of the tract and increase rate of environment that is required by the gastric
digestion enzymes.

MAJOR STRUCTURES IN THE MOUTH E. Pepsin

teeth – to grind the food is the chief coenzyme of gastric juice, which
converts proteins into proteases and
salivary glands – moisten food and mucous
peptones
membranes and begin carbohydrate
digestion F. Intrinsic Factor
tongue – to push the food to the pharynx to is necessary for the absorption of vitamin B12.
initiate swallowing
G. Gastrin
ESOPHAGUS
controls gastric acidity
- is a hollow tube, the upper 1/3 is composed
of skeletal muscles, the rest is smooth muscle

- lined with mucous membrane → secretes

mucoid substance for protection

- the bolus of food arrives at the cardiac

sphincter of the stomach w/in 5-10 secs. after
ingestion

- the lower esophageal sphincter (LES)

prevents reflux of food in the stomach back
into the lower esophagus
STOMACH

- made up of 5 layers of smooth muscle

ANATOMY & PHYSIOLOGY
2 types of contractions:
STOMACH
1.) tonus contractions – continuous
Contains the cardia, fundus, the body, and contractions
the pylorus

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2.) rhythmic contractions – may be slow (q2-3 STOMACH
mins) or fast – responsible for the mixing of
food and peristaltic movement Gastric Secretion

Vagus nerve - The stomach secretes 1500 to 3000 ml

of gastric juice per day. Major
- supplies the nervous stimulation for the secretions are HCL, pepsin and mucus
stomach - HCL and pepsin provide the corrosive
- has both sympathetic and power of gastric secretion
parasympathetic fibers - Pepsin is the most active factor in the
- movement of food through the stomach and digestive processes of the stomach,
intestines is by peristalsis → the alternate acting to break proteins into
contraction and relaxation of the muscle polypeptides
fibers that propels the food in a wave-like - Mucus has a neutralizing effect which
motion protects the stomach mucosa

Chyme 3 Phases of Gastric Secretion

- food in the stomach 1. Cephalic Phase

- is pumped through the pyloric
- is stimulated by hunger, food odors, sight and
sphincter into the duodenum
smell, taste
STRUCTURAL LAYERS OF THE GIT
- it begins before food enters the stomach
1. Mucosa – mucous membrane
composed of three layers - is mediated by the vagus nerve, releasing
a. Epithelium acetylcholine which stimulates the parietal
cells and chief cells to secrete acid, pepsin
b. Lamina propria – connective tissue
containing blood vessels, lymph nodes and mucus
and glands: 2. Gastric Phase
▪ cardiac glands – secrete mucus
▪ chief (peptic) cells – secrete - begins with the arrival of food in the stomach
mucus and pepsinogen → - distention of the stomach and presence of
pepsin digested proteins stimulate gastrin hormone
▪ parietal cells – secrete secretion
hydrochloric acid (HCL) and
water, also produce intrinsie - Gastrin stimulates the parietal cells of the
factor stomach to secrete HCL
▪ neck cells - secrete mucus - this phase continues for several hours, until
▪ pyloric glands – secrete gastrin the acidity of gastric contents reaches pH of
and mucus 1.5
c. Muscularis mucosa – thin layer of
smooth muscle between mucosa and 3. Intestinal Phase
submucosa
- is stimulated by food entering the duodenum
2. Submucosa – connective tissue
containing blood vessels, lymph - a substance similar to gastrin is released from
channels, nerves and glands the intestines → it stimulates gastric secretion
3. Tunica muscularis – layers of smooth of pepsin and mucus
muscle produce peristaltic activity of
- when the pH in the duodenum decreases
the stomach as it mixes food during
(↑acidity) this results to release of Secretin
digestion
hormone → w/c inhibit gastric acid secretion
4. Serosa or adventitia – a serous
and slows gastric motility and gastric
membrane covered with an outer layer
emptying
of squamous epithelial cells

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 SMALL INTESTINE GASTROINTESTINAL TRACT

- 2.5 cm. (1 inch) wide and 6 meters (20 DEFECATION REFLEX

feet) long – fills most of the abdomen
feces enter the rectum and cause distention
3 PARTS: of wall of the rectum > send impulses to the
sacral segment of the spinal cord – then back
a.) duodenum – First (10 inches) of small to the colon, sigmoid and rectum > initiate
intestine which connects to the stomach relaxation of the internal anal sphincter >
relaxation or contraction of external anal
- Receives chyme from the stomach through
sphincter (voluntary control)
the pyloric sphincter
THE GIT PHYSIOLOGY
- Fluids from the pancreas and gall bladder via
the common bile duct SYMPATHETIC
- Manufactures intestinal juice ▪ Generally INHIBITORY!
- Susceptible to inflammatory processes ▪ Decreased gastric secretions
▪ Decreased GIT motility
- Neutralizes the acidic chyme from the ▪ But: Increased sphincteric tone and
stomach constriction of blood vessels
b.) jejunum – middle portion (8 feet long) PARASYMPATHETIC
- Absorption of Magnesium, Calcium, Iron
▪ Generally EXCITATORY!
c.) ileum – with connects to the large intestine ▪ Increased gastric secretions
(12 feet long) ▪ Increased gastric motility
▪ But: Decreased sphincteric tone and
- Chyme moves slowly towards the ileocecal dilation of blood vessels
valve (3 - 10 hours)
PANCREATIC INTESTINAL JUICE ENZYMES
1. Amylase digests starch to Maltose
LARGE INTESTINE 2. Maltase reduces maltose to
monosaccharides glucose
1. The large intestine is about 5 feet long
3. Lactase splits lactose into galactose
2. The large intestine absorbs water and
and glucose
eliminates wastes
4. Sucrase reduces sucrose to fructose
3. Intestinal bacteria play a vital role in the
and glucose
synthesis of some B vitamins and
5. Nucleoses split nucleic acids to
vitamin K.
nucleotides
4. 3 parts:
6. Enterokinase activates trypsinogen to
a.) cecum – which connects to the small trypsin
intestines

b.) colon – 4 parts (ascending, transverse, SECRETION AND DIGESTION

descending, sigmoid colon)
major portion of digestion occurs in the
c.) rectum – 17-20 cm. (7-8 inches) long, 🡪 anal small intestines by the action of pancreatic
canal and intestinal secretions (enzymes) and bile

5. The ileocecal valve prevents contents a.) Carbohydrate digestion

of large intestine from entering ileum
start in the mouth → Ptyalin –
6. The anal sphincters guard the anal
breakdown polysaccharides to disaccharides
canal
intestinal enzymes (maltase, lactase,
sucrase) → breakdown disaccharides to

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monosaccharides (glucose, galactose b. the hepatic ducts deliver bile to the
fructose) duodenum via the common bile duct

b.) Protein digestion c. the common bile duct opens into the
duodenum, with the pancreatic duct at the
- start in the stomach → pepsin – breakdown
ampulla of Vater
of proteins to polypeptides
d. the sphincter prevents the reflux of
- small intestines → trypsin – breakdown of
intestinal contents into the common bile
polypeptides into peptides and amino acids
duct and pancreatic duct.
c.) Fat digestion
Detoxifies ammonia into urea
- fats require emulsification into small
J. GALLBLADDER
droplets before it can be broken down into
glycerol and fatty acids 1. The gallbladder stores and
Bile – from liver; emulsify fats so that it could be concentrates bile
broken down 2. The gallbladder contracts to force bile
into the duodenum during the
pancreatic lipase → breakdown fats into digestion of fats
glycerol and fatty acids 3. The cystic duct joins the hepatic duct
to form the common bile duct
4. The sphincter of oddi guards the
PERITONEUM entrance into the duodenum
5. The presence of fatty materials in the
1. The peritoneum lines the abdominal duodenum stimulates the liberation of
cavity cholecystokinin, which causes
2. The peritoneum forms the mesentery contraction of the gallbladder and
that supports the intestines and blood relaxation of the sphincter of oddi
supply.

LIVER
PANCREAS
1. the liver is the largest gland in the body,
EXOCRINE GLAND
weighing 3 to 4 lbs.
2. The liver contains Kupffer’s cells, which a. the pancreas secretes sodium
remove bacteria in the portal venous bicarbonate to neutralize the acidity of the
blood. stomach contents that enter the duodenum.
3. The liver removes excess glucose and
amino acids from the portal blood b. Pancreatic juices contain enzymes
4. The liver synthesizes glucose, amino for digesting carbohydrates, fats, and
acids and fats proteins.
5. The liver aids in the digestion of fats,
ENDOCRINE GLAND
carbohydrates and proteins
6. The liver stores and filters blood (200 to a. the islets of Langerhans secrete
400 ml of blood stored) insulin.
7. The liver stores vitamins A, D and B and
iron. b. insulin secreted into the bloodstream
8. The liver secretes bile to emulsify fats and is important for carbohydrate metabolism
(500 to 1000 ml of bile a day) c. the pancreas secretes glucagon to
9. Hepatic duct raise blood glucose levels
a. the hepatic duct delivers bile to the d. the pancreas secretes somatostatin
gallbladder via the cystic duct to exert a hypoglycemic effect

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 GASTROINTESTINAL TRACT ASSESSMENT OF THE GIT

ABSORPTION NURSING HISTORY: SUBJECTIVE DATA

▪ the intestinal wall has many folds which 1. General Data

are covered by fingerlike projections
a. presence of dental prosthesis, comfort
called (villi) → increase the absorptive
of usage
area of the small intestines b. difficulty eating or digesting food
▪ in the center of the villi are capillaries, c. nausea or vomiting
veins, small arteries for absorption of d. weight loss
nutrients into the blood vessel system e. pain – may be caused by distention or
▪ 90% of absorption occurs within the small sudden contraction of any part of the
intestines by active transport or diffusion GIT
▪ amino acids, monosaccharides, Na+,
- specify the area, describe the pain
Ca++ are transported by active transport
w/ the expenditure or use of energy 2. Specific data if symptoms are present
▪ other nutrients, fatty acids and H2O –
a. situations or events that effect
diffuse passively across the cell symptoms
membrane b. onset, possible cause, location,
▪ reabsorption of H2O, electrolytes and duration, character of symptoms
bile occurs mainly in the ascending c. relationship of specific foods, smoking
colon or alcohol to severity of symptoms
d. how the symptoms were managed
before seeking medical help
GIT role in Fluid and Electrolytes Balance 3. Normal pattern of bowel elimination
▪ GIT secretions contain electrolytes a. frequency and character of stool
▪ severe fluid and electrolyte imbalance b. use of laxatives, enemas
may occur with excessive losses of
gastrointestinal fluids 4. Recent changes in normal patterns

Ex. 1.) Na+ and K+ deficits: vomiting, a. changes in character of stool

diarrhea, gastric suctioning, intestinal fistula (constipation, diarrhea, or alternating
constipation and diarrhea)
2.) Ca++ & Mg++ deficits: malnutrition, mal- b. changes in color of stool
absorption, intestinal fistula
melena - black tarry stool (upper GI
3.) Metabolic alkalosis: loss of gastric acid bleeding)
by suctioning or persistent vomiting
hematochezia – fresh blood in the stool
4.) Metabolic acidosis: loss of bicarbonate- (lower GI bleeding)
rich intestinal secretions by severe diarrhea or
fistula c. drugs /medications being taken
d. measures taken to relieve symptoms

B. PHYSICAL EXAMINATION: OBJECTIVE DATA

Other functions of the GIT
a.) Mouth and Pharynx
▪ the GIT supports bacterial growth and
has a role in antibody formation 1. lips – color, moisture, swelling, cracks or
▪ intestinal bacteria synthesize Vit. K → lesions
required for production of clotting 2. teeth – completeness (20 in children, 32
factors II (Prothrombin), VII, IX, X in adults), caries, loose teeth, absence
of teeth → impair adequate chewing

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 3. gums – color, redness, swelling, ▪ Normoactive
bleeding, pain (gingivitis) ▪ Hypoactive – 1 or 2 sounds in 2 mins.
4. mucosa – color (light pink) ▪ Absent – no sounds in 3-5 mins.
▪ examine for moisture, white spots → peritonitis, paralytic ileus,
or patches, areas of bleeding, or ▪ Hyperactive
ulcers → diarrhea, gastroenteritis, early
▪ white patches – due to candidiasis intestinal obstruction
(oral thrush)
▪ white plaques w/in red patches 3. PERCUSSION
may be malignant lesions ▪ done to confirm the size of various
5. tongue – color, mobility, symmetry, organs
ulcerations / lesions or nodules
▪ to determine presence of excessive
6. pharynx – observe the uvula, soft amounts of air or fluid
palate, tonsils, posterior pharynx ▪ Normal – tympany
▪ signs of inflammation (redness, ▪ dullness or flatness – area of liver and
edema, ulceration, thick yellowish spleen, solid structure
secretions), assess also for
symmetry of uvula and palate – tumor

b.) Abdomen 4. PALPATION

- assess for the presence or absence of ▪ to determine size of liver, spleen, uterus,
tenderness, organ enlargement, kidneys – if enlarged
masses, spasm or rigidity of the ▪ determine presence and chac. of
abdominal muscles, fluid or air in the abdominal masses
▪ determine degree of tenderness and
abdominal cavity muscle rigidity (rebound or direct)
Anatomic Location of Organs c.) Rectum
RUQ – liver, gallbladder, duodenum, right ▪ perineal skin and perianal skin
kidney, hepatic flexure of colon ▪ assess for presence of pruritus, fissures,
external hemorrhoids, rectal prolapse
RLQ - cecum, appendix, right ovary and
fallopian tube COMMON LABORATORY PROCEDURES:
LUQ – stomach, spleen, left kidney, pancreas, NURSING RESPONSIBILITIES AND IMPLICATIONS
splenic flexure of colon
3 PHASES OF DIAGNOSTIC TESTING
LLQ – sigmoid colon, left ovary and tube
Pretest
1. INSPECTION
- Client preparation
▪ assess the skin for color, texture, scars,
Intra-test
striae, engorged veins, visible peristalsis
(intestinal obstruction), visible pulsations - specimen collection and VS monitoring
(abdominal aorta), visible masses (hernia)
Post-test
▪ assess contour (flat, protuberant,
globular) - Monitoring and follow-up nursing care
▪ abdominal distension, measure
abdominal girth or circumference at the RELATED NURSING DIAGNOSES
level of umbilicus or 2-5 cm. below
▪ Anxiety
2. AUSCULTATION ▪ Fear
▪ Impaired physical mobility
▪ presence or absence of peristalsis or ▪ Deficient knowledge
bowel sounds
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 STOOL EXAMS ▪ Stool for Lipids
- ↑fat diet, no alcohol(3days)
▪ Stool Analysis
- 72-hour stool specimen
▪ Occult Blood → GUAIAC test
▪ Steatorrhea B. HYDROGEN BREATH TEST
▪ Ova/Parasites
▪ Bacteria 1. It is used to evaluate carbohydrate
▪ Viruses absorption.

General Nursing consideration for stool 2. A radioactive substance is ingested, and

collection after a certain time period, exhaled gases are
measured.
Pretest: Determine purpose/s, obtain gloves,
3.the test measures the amount of hydrogen
container and tongue blade
produced in the colon, absorbed in the blood,
Intratest: and then exhaled in the breath.

▪ Instruct to defecate in clean bed pan 4. This test is used as a diagnostic test for short
▪ Void before collection bowel syndrome, lactose intolerance, and
▪ Do not discard tissue in bedpan bacterial overgrowth of the intestine (blind
▪ Obtain 2.5 (1 inch) formed stool loop syndrome, Crohn’s disease, distal ilea
▪ 15-30 ml of liquid stool disease).

Post-test: prompt delivery NURSING CONSIDERATIONS:

FECAL ANALYSIS ▪ The patient should be NPO 12 hours
Fecal Occult Blood Test (FOBT) before the procedure.
▪ The patient should not smoke after
- Detects GI bleeding midnight before the test.
- ↑Fiber diet 48-72 hours ▪ Antibiotics and laxative/enemas should
not be used for 1 week before the test.
A. HEMOCCULT GUAIAC TESTS:
These products may alter the laboratory
NURSING AND PATIENT CARE CONSIDERATION: results.

Common practices are the following; for 3 Laboratory Test

days before the test and during the stool
CEA (Carcinoembryonic antigen)
collection period:
▪ (+) colon cancer and other forms of
1. Diet should have a high fiber content.
cancer
2. Avoid red meat in the diet. ▪ ↑ CEA - recurrence or spread of tumor
▪ ↓ effectiveness of therapy
▪ Avoid food with a high peroxide content, ▪ A blood sample is withdrawn or sent to
such as turnips, cauliflower, broccoli, laboratory
horseradish, and melon. ▪ Avoid Heparin
▪ Avoid enemas or laxatives before the
stool specimen collection. EXFOLIATIVE CYTOLOGY
▪ Avoid iron preparations, iodides,
bromides, aspirin, no steroidal anti- ▪ Detect malignant cells
inflammatory drugs (NSAIDs), or vitamin ▪ Liquid diet
C supplements greater than 250 mg/day ▪ UGI: NGT insertion – saline lavage
▪ LGI: laxative, enema, proctoscope
FECAL ANALYSIS
GASTRIC ANALYSIS
▪ Stool for Ova and Parasites
▪ Stool Culture ▪ Gastric analysis requires the passage of a
nasogastric tube into the stomach to
aspirate gastric contents for the analysis
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 of acidity (pH), appearance and volume; 2. As the barium passes through the GI tract,
the entire gastric content are aspirated fluoroscopy outlines the GI mucus and organs.
and then specimens are collected every
3. Spot films record significant findings.
15 minutes for 1 hour.
▪ Histamine or pentagastrin may be 4. Double-contrast studies administer barium
administered subcutaneously to stimulate first followed by a radio lucent substance,
gastric secretions and may produce a such as air, to produce a thin layer of barium
flushed feeling. to coat the mucosa.
▪ Esophageal reflux of gastric acid may be
performed by ambulatory pH monitoring; ▪ This allows for better visualization of any
a probe is placed just above the lower type of lesion.
esophageal sphincter, is connected to an NURSING AND PATIENT CARE
external recording device, and provides CONSIDERATIONS
a computer analysis and graphic display
of results. 1. Explain procedure to patient.
▪ to quantify gastric acidity Normal 1-5 mEq
2. Instruct patient to maintain low-residue diet
/L
for 2 to 3 days before test and a clear liquid
▪ NPO for 12 hours
dinner the night before the procedure.
▪ an NGT is inserted and gastric contents
are aspirated, connected to suction 3. Emphasize NPO after midnight before the
▪ gastric content collected every 15 test.
minutes to 1 hour
▪ Result: 4. Encourage patient to avoid smoking,
▪ ↓HCL: Gastric Ca & Pernicious Anemia alcohol, caffeine before the test.
▪ ↑HCL: Zollinger-Ellison Syndrome & 5. Explain that the health care provider may
Doudenal Ulcer prescribe all narcotics and anticholinergics to
*check pH be held 24 hours before the test.

Nursing Intervention 6. Tell the patient that he or she will be

instructed at various times throughout the
▪ Fasting for 8 to 12 hours is required before procedure to drink the barium (480 to 600 mL).
the test.
▪ Avoid tobacco and chewing gum for 6 7. Explain that a cathartic will be prescribed
hours before the test. after the procedure.
▪ Medication that stimulate gastric 8. Instruct the patient that stool will be light in
secretions are withheld for 24 to 48 hours. color for the next 2 to 3 days from the barium.
Post-procedure 9. Instruct patient to notify health care
▪ Client may resume normal activities. provider if he or she has not passed the barium
▪ Refrigerate gastric samples if not tested in 2 to 3 days
within 4 hours. 10. Note that water-soluble iodinated contrast
agent (such as Gastrografin) may be used for
a patient with a suspected perforation or
GI TRACT VISUALIZATION colonic obstruction.
RADIOLOGY AND IMAGING STUDIES

UPPER GASTROINTESTINAL SERIES AND SMALL

BOWEL SERIES (Barium swallow)

1. Upper GI series and small-bowel series are

fluoroscopic x-ray examinations of the
esophagus, stomach, and small intestine after
the patient ingests barium sulfate.
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 GIT Visualization 4. An enema or cathartic may be ordered
after the barium enema.
Barium Swallow- UGIS
5. Inform the patient that barium may cause
Pretest: written consent, NPO the night light-colored stools for several days after the
Intratest: administer barium orally, then procedure.
followed by X-ray

Post-test: Laxative for constipation, increased

fluids, assess for intestinal obstruction, warn
that stool is light colored!

BARIUM ENEMA (Lower GI series)

1. Fluoroscopic x-ray examination visualizing

the entire large intestine is administered after
the patient is given an enema of barium
sulfate.

2. Can visualize structural changes, such as

tumors, polyps, diverticula, fistulas,
obstructions, and ulcerative colitis. Barium Enema- LGIS
3. Air may be introduced after the barium to Pretest: Informed consent, NPO the night,
provide a double-contrast study. Enema the morning
NURSING AND PATIENT CARE Intratest: Position on LEFT side, administer
CONSIDERATIONS enema, then X-ray follow

1. Explain to the patient: Post-test: Cleansing enema, Laxative for

constipation, assess for intestinal obstruction
A. What the x-ray procedure involves.
ULTRASONOGRAPHY
B. That proper preparation provides a
more accurate view of the tract and that 1. A noninvasive test focuses high-frequency
preparations may vary. sound waves over an abdominal organ to
C. That it is important to retain the obtain an image of the structure.
barium so all surfaces of the tract are coated 2. Ultrasound can detect small abdominal
with opaque solution. masses, fluid-filled cysts, gallstones, dilated
2. Instruct the patient on the objective of bile ducts, ascites, and vascular abnormalities.
having the large intestine as clear of fecal 3. Ultrasound with Doppler may be ordered for
material as possible: vascular assessment.
A. The patient may be given a low-
NURSING AND PATIENT CARE
residue, low-fat diet, 1 to 3 days before the
CONSIDERATIONS
examination.
1. If indicated, prepare the patient before the
B. The day before the examination,
procedure with a special diet, laxative, or
intake may be limited to clear liquids (no drinks
other medication to cleanse the bowel and
with red dye).
decrease gas.
C. The day before the examination, an
2. Abdominal ultrasound usually requires the
oral laxative, suppository, and/or cleansing
patient to be NPO for at least 6 hours before
enema may be prescribed
the procedure.
3. The patient will be NPO after midnight the
day of procedure.
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3. Change position of patient, as indicated, for depending on which portion of the GI tract is
better visualization of certain organs. to be viewed.

COMPUTED TOMOGRAPHY (CT) SCAN Endoscopes contain multipurpose

channels that allow for air insufflation,
1. This is an x-ray technique that provides irrigation, fluid aspiration, and the passage of
excellent anatomic definition and is used to special instruments. These instruments include
detect tumors, cysts, and abscesses. biopsy forceps, cytology brushes, needles,
2. The CT can also detect dilated bile ducts, wire baskets, laser probes, and electrocautery
pancreatic inflammation, and some snares.
gallstones. Endoscopic functions other than
3. It identifies changes in intestinal wall visualization include biopsy or cytology of
thickness and mesenteric abnormalities. lesions, removal of foreign objects or polyps,
control of internal bleeding, and opening of
4. Ultrasound and CT can be used to perform strictures.
guided needle aspiration of fluid or cells from
lesions anywhere in the abdomen. The fluid or
cells are then sent for laboratory tests (such as
cytology or culture).

NURSING AND PATIENT CARE

CONSIDERATIONS

1. Instruct the patient that fasting for 4 hours

before the procedure and an enema or
cathartic may be necessary. This is to cleanse
the bowel for better visualization.

2. Ask the patient if she is pregnant. If yes, do

not proceed with scan and notify health care ESOPHAGOGASTRODUODENOSCOPY (EGD)
provider.
1. This allows for visualization of the esophagus,
3. Ask if there are known allergies to iodine or stomach, and duodenum.
contrast media. A contrast medium may be
2. EGD can be used to diagnose acute or
given intravenously (IV) to provide better
chronic upper GI bleeding, esophageal or
visualization of body parts. If allergic, notify the
gastric varices, polyps, malignancy, and
technician and health care provider
gastroesophageal reflux.
immediately.
3. Instruments passed through the scope can
4. Instruct the patient to report symptoms of
be used to perform a biopsy or cytologic
itching or shortness of breath if receiving
study, remove polyps or foreign bodies,
contrast media, and observe patient closely.
control bleeding, or open strictures.
ENDOSCOPIC PROCEDURES
NURSING AND PATIENT CARE
Endoscopy is the use of a flexible tube CONSIDERATIONS
(the fiberoptic endoscope) to visualize the GI
1. Explain the following to the patient:
tract and to perform certain diagnostic and
therapeutic procedures. Images are A. The type of procedure to be
produced through a video screen or performed on the patient. As an outpatient,
telescopic eyepiece. The tip of the endoscope advise that someone must accompany the
moves in four directions, allowing for wide- patient to drive home due to the patient
angle visualization. The endoscope can be being sedated.
inserted through the rectum or mouth,

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 B. NPO for 8 to 12 hours before the 5. Monitor vital signs every 30 minutes for 3 to 4
procedure to prevent aspiration and allow for hours, and keep the side rails up until the
complete visualization of the stomach. patient is fully alert.

C. Remove dentures and partial plates 6. Monitor the patient for abdominal or chest
to facilitate passing the scope and preventing pain, cervical pain, dyspnea, fever,
injury. hematemesis, melena, dysphagia,
lightheadedness, or a firm distended
2. Inform the health care provider of any
abdomen. These may indicate complications.
known allergies and current medications.
Medications may be held until the test is 7. Instruct the patient on the above listed signs
completed. and symptoms, and advise to report
immediately should any occur, even after
3. Obtain prior x-rays, and send with the
discharge.
patient.
8. Possible complications include perforation
4. Describe what will occur during and after
of the esophagus or stomach, pulmonary
the procedure:
aspiration, hemorrhage, respiratory
A. The throat will be anesthetized with a depression or arrest, infection, cardiac
spray or gargle. arrhythmias or arrest.

B. An IV sedative will be administered.

C. The patient will be positioned on the

left side with a towel or basin at the mouth to
catch secretions.

D. A plastic mouthpiece will be used to

help relax the jaw and protect the
endoscope. Emphasize that this will not
interfere with breathing.

E. The patient may be asked to swallow

once in a while as the endoscope is being
advanced. The patient should not swallow,
talk, or move tongue. Secretions should drain
from the side of the mouth, and the mouth
may be suctioned.

F. Air is inserted during the procedure to

permit better visualization of the GI tract. Most
of the air is removed at the end of the
procedure. The patient may feel bloated,
burp, or pass flatus from remaining air. ESOPHAGOGASTROSCOPY
G. Keep patient NPO according to
Pretest: Informed consent, NPO for 8 hours,
protocol until patient is alert and gag reflex
warn that gag reflex is abolished
has returned.
Intratest: Position on LEFT side during scope
H. May resume regular diet after gag
insertion
reflex returns and tolerating fluids.
Post-test: NPO until gag returns. Monitor for
I. May experience a sore throat for 24
complications
to 36 hours after the procedure. When the gag
reflex has returned, throat lozenges or warm
saline gargles may be prescribed for comfort.

12
 PROCTOSIGMOIDOSCOPY AND 3. Explain to the patient that a feeling of
COLONOSCOPY fullness will occur when water is introduced
into the GI tract. This eliminates air space and
1.Proctosigmoidoscopy(rectosigmoidoscopy) provides for high resolution.
is the visualization of the anal canal, rectum,
and sigmoid colon through a fiberoptic 4. Observe the patient for a change in vital
sigmoidoscope. signs, bleeding, pain, vomiting, abdominal
distention or rigidity.
2. Colonoscopy is the visualization of the entire
large intestine, sigmoid colon, rectum, and 5. Ensure that patients who have had
anal canal. endoscopic procedures requiring sedation
have a caregiver to drive home after the
3. Sigmoidoscopy or colonoscopy can be procedure.
used to diagnose malignancy, polyps,
inflammation, or strictures.

4. Colonoscopy is used for surveillance in

patients with a history of chronic ulcerative
colitis, previous colon cancer, or colon polyps.

5. Lower GI endoscopy can be used to

perform biopsy, remove foreign objects, or
obtain specimen for culture or cytology.

6. Colonoscopy, a more extensive procedure

than proctosigmoidoscopy, requires several
days of bowel preparation and use of
conscious sedation during the procedure. The
bowel preparation includes approximately 1
gallon or less iso-osmolar electrolyte solution
to consume over a 3- to 4-hour period the day
before the procedure, clear liquid diet the day
before the procedure, and an oral laxative
the night before the procedure. Protocols
may vary.

ANOSCOPY, PROCTOSCOPY,
PROCTOSIGMOIDOSCOPY, COLONOSCOPY

Pretest: Consent, NPO, and enema

administration the morning

Intratest: Position on the LEFT side during scope

insertion

Post-test: Monitor for complications

NURSING CARE:
CHOLECYSTOGRAPHY
1. Verify the patient’s compliance with the
pretest bowel preparation the day before the Performed to detect gallstones and to assess
procedure, usually an oral laxative (such as the ability of the gallbladder to fill,
magnesium citrate) and a clear liquid diet. concentrate its contents, contract and
empty.
2. The patient must be NPO after midnight.

13
 NURSING INTERVENTION

▪ Assess allergies to iodine or seafood. ENDOSCOPIC RETROGRADE

▪ Contrast agents such as iopanoic acid CHOLOANGIOPANCREATOGRAPHY (ERCP)
(telepaque), iodipamide meglumine
▪ Examination of the hepato-biliary system is
(cholografin), or sodium ipodate
performed via a flexible endoscope
(oragrafin) may be administered to 10 to
inserted into the esophagus to the
12 hours (evening before) before the test.
descending duodenum; multiple positions
▪ Client is NPO after the contrast agent is
are required during the procedure to pass
administered
the endoscope.
▪ Instruct the client that if a rash, itching,
▪ If medication is administered before the
hives or difficulty in breathing occurs after
procedure, the client is closely monitored
taking the contrast agent, to report to the
for signs of respiratory and central nervous
emergency room
system depression, hypotension, over
Post-procedure: sedation, and vomiting.

▪ Inform the client that dysuria is common NURSING INTERVENTION

because the contrast agent is excreted in
the urine ▪ A client is NPO for several hours before the
▪ A normal diet may be resumed (a fatty procedure.
meal may enhance excretion of the ▪ Sedation is administered before the
contrast agent) procedure.

IV CHOLECYSTOGRAM Post procedure

▪ Monitor vital signs

X-ray visualization of the gallbladder
▪ Monitor for the return of gag reflex
after administration of contrast media
▪ Monitor for signs of perforation or infection
intravenously

Pre-test: Allergy to iodine and sea-foods ENDOSCOPIC RETROGRADE

CHOLANGIOPANCREATOGRAPHY
Intra-test: ensure patent IV line
▪ Examination where a flexible endoscope is
Post-test: increase fluid intake to flush out the inserted into the mouth and via the
dye, Assess for delayed hypersensitivity common bile duct and pancreatic duct to
reaction to the dye like chills and N/V visualize the structures
▪ Iodinated dye can also be injected after for
ORAL CHOLECYSTOGRAM
the x-ray procedure
▪ X-ray visualization of the gallbladder after
Pre-test: consent, NPO for 12 hours, Allergy to
administration of contrast media
sea-foods, Atropine sulfate
▪ Done 10 hours after ingestion of contrast
tablets Intra-test: Gag reflex is abolished, Position on
▪ Done to determine the patency of biliary LEFT side
duct
Post-test: NPO until gag reflex returns, Position
side lying and monitor for perforation and
hemorrhage

14
 PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAM

Under fluoroscopy, the bile duct is entered

percutaneously and injected with a dye to
observe filling of hepatic and biliary ducts

LIVER BIOPSY

A needle is inserted through the abdominal

wall to the liver to obtain tissue sample for
biopsy and microscopic examination.
PARACENTESIS
NURSING INTERVENTION
Transabdominal removal of fluid from the
▪ Obtained informed consent
peritoneal cavity for analysis.
▪ Assess results of coagulation test
NURSING INTERVENTION (prothrombin time, partial thromboplastin
time, platelet count.).
▪ Obtain informed consent ▪ Administer a sedative as prescribe.
▪ Have the client void before the start of the ▪ Note that the client is placed in the supine
procedure to empty bladder and to move or left lateral position during the procedure
bladder out of the way of the paracentesis to expose the right side of the upper
needle. abdomen.
▪ Measure abdominal girth, weight, baseline
vital signs. Post-procedure
▪ Note that the client is position upright on ▪ Assess vital signs
the edge of the bed with the back ▪ Assess biopsy site for bleeding.
supported and the feet resting on a stool ▪ Monitor for peritonitis.
(Fowler’s position is used to the client ▪ Maintain bed rest for several hours.
confined to bed.) ▪ Place the client on the right side with a
Post-procedure pillow under the costal margin to decrease
the risk of hemorrhage, and instruct the
▪ Monitor vital signs client to avoid coughing and straining.
▪ Measure fluid collected, describe, and ▪ Instruct the client to avoid heavy lifting and
record. strenuous activities for 1 week.
▪ Label fluid samples and send it to the
laboratory for analysis. Risk Factors
▪ Apply a dry sterile dressing to the insertion ▪ Family history of gastrointestinal disorders
site; monitor site for bleeding. ▪ Chronic laxative use
▪ Measure abdominal girth and weight. ▪ Tobacco use
▪ Monitor for hypovolemia, electrolyte loss, ▪ Chronic alcohol use
mental status changes or ▪ Chronic high stress levels
encephalopathy. ▪ Allergic reaction to food or medication
▪ Monitor for hematuria caused by bladder ▪ Chronic use of aspirin or non-steroidal anti-
trauma. inflammatory drugs
▪ Instruct the client to notify physician if the
urine becomes bloody, pink or red.
15
▪ Long-term gastrointestinal conditions such ▪ Dressing changes every 48-72 hrs with
as ulcerative colitis that may predispose to antibiotic ointment to catheter insertion
colorectal cancer ▪ Medication is never administered in a TPN
▪ Previous abdominal surgery or trauma line
which can lead to adhesions ▪ Observe for complications
▪ Neurological disorders that can impair ▪ Infection
movement particularly with chewing and ▪ Venous thrombosis
swallowing ▪ Hyperglycemia
▪ Cardiac, respiratory, and endocrine
disorders that may lead to constipation
▪ Diabetes mellitus, which may predispose to
oral candidal infections

ALTERNATIVE FEEDING:

1. Enteral hyperalimentation- delivery of

nutrients directly to the GI tract.

a. Short- term- esophagostomy;

nasogastric tube

b. Long- term- gastrostomy; jejunostomy

INDICATIONS OF NGT:

A. Gavage- to deliver nutrients; for

feeding purposes
B. Lavage- to irrigate the stomach
C. Decompression- to remove stomach
contents or air

2. Hyperalimentation (total parenteral

nutrition)- method of giving highly
concentrated solutions intravenously to
maintain a patient’s nutritional balance when
oral or enteral nutrition is not possible

NURSING MANAGEMENTS:

▪ Filter is used in the IV tubing to trap

bacteria
▪ Solution and administration equipment
should be changed every 24 hours
16
 STOMATITIS
Figure 3: Many cases
▪ Refers to the inflammation of the oral
have irregular red
mucosa, which presents with ulcers that
macules without obvious
can cause pain and difficulty drinking
white peripheral
and eating.
lines. Here the patient
▪ Can be present on the inner lips and
also has a mild white
cheeks, on the gums, or on the tongue.
coated tongue, a
▪ Caused by infection, irritants, trauma or
common comorbid
allergic reaction or systemic or skin
feature of geographic
diseases.
tongue.
▪ Most commonly, it is due to: Xerostomia/
dry mouth.
▪ It is the inflammation of the mouth that is Figure 4: The
frequently caused by chemotherapy erythematous macules
agents are much more obvious
▪ Cells of the mouth can become when combined with
damaged leading to erosion, ulceration, white coated tongue or,
inflammation, and secondary infections. as here, with a mild white
▪ Eating and drinking can be painful, and hairy
nutritional problems may occur tongue. Occasional
▪ Herpes stomatitis – cold sore macules are outlines with
▪ Aphthous stomatitis – cancker sore irregular white lines, a
pathognomonic feature
CLINICAL MANIFESTATIONS

▪ Dry, painful mouth, open ulcerations, Figure 5: Geographic

predisposing the client to infection tongue occurs even in
▪ Commonly found on the children and infants.
▪ buccal mucosa,
▪ soft palate
▪ oropharyngeal mucosa
▪ lateral and ventral areas of the TREATMENTS
tongue ▪ Meticulous oral hygiene
▪ If candidiasis, white plaque like lesions ▪ Frequent use of a mild saline mouthwash
on the tongue; when wiped away, red ▪ Avoiding extremes of hot, cold, or very
sore tissue appears spicy food and liquids
▪ In extreme cases, a swish-and-spit of kaolin
and pectin, diphenhydramine hcl, and
Figure 2: Serpiginous lidocaine may provide relief before
white lines may be quite mealtime
pronounced and often
surround erythematous PHARMACOLOGICAL MANAGEMENT
areas of papillae loss or
Antibiotics –
edematous papillae.
- tetracycline syrup
- minocycline (swish and swallow)
Antifungals – ASSESSMENT
- nystatin oral suspension (swish and ▪ history of difficulty in swallowing
swallow) ▪ assess for gag reflex
▪ ask the pt to swallow and observe
Antiviral –
movement of the larynx
- Intravenous acyclovir for
immunocompromised clients NURSING MANAGEMENT

Anti-inflammatory agents and immune Pts. with pharyngeal weakness:

modulators ▪ can tolerate solids more easily than liquids
▪ teach “double-swallow” technique
Symptomatic topical agents
▪ helps minimize the possibility of aspiration
- gargle or mouthwash ▪ closely supervise the pt during feeding,
suction equip. shld. be ready
▪ elevate head of bed during feeding or
ESOPHAGEAL DISORDERS position on the unaffected side

DYSPHAGIA - to ensure better control

ACHALASIA ▪ if the ability to swallow is absent 🡪 NGT

ESOPHAGEAL STRICTURES Pts. With esophageal weakness:

GERD → HERNIA ▪ small-frequent feedings are advised to pts

▪ elevate head of bed
DYSPHAGIA
ACHALASIA
problem in ingesting necessary nutrients
because of difficulty in swallowing ▪ also called cardio spasm or aperistalsis
▪ there is absence of peristalsis in the
CAUSES: esophagus and in which the esophageal
sphincter fails to relax after swallowing
1) pharyngeal muscle weakness
▪ cause is unknown
▪ disease or trauma of glossopharyngeal ▪ little or no food enters the stomach
nerves
S/SX:
▪ neuromuscular disorders (poliomyelitis,
multiple sclerosis, myasthenia gravis ▪ gradual onset of dysphagia for both fluids
2) esophageal disorders and solids
▪ loss of weight
▪ obstruction caused by enlarged ▪ substernal chest pain
thyroid, tumors, strictures 🡪 narrowed ▪ regurgitation of esophageal contents onto
opening pillow at night
▪ absence of peristalsis of the esophagus
DIAGNOSTIC TESTS:
PATHOPHYSIOLOGY
Barium swallow, esophagoscopy
Weak pharyngeal/esophageal muscles →
difficulty moving the food from the oropharynx MEDICAL MGT:
into the esophagus → immediate
regurgitation of fluids into the nasal passages Medications – Nitrates, Nifedipine
→ aspiration of feedings may occur from Forceful dilation of the LES by pneumatic
failure of the glottis to close dilators → a balloon is inserted and inflated for
1 min., 2-3 times

18
 NSG. INTERVENTIONS: ▪ obesity
▪ surgical removal lower esophagus due to
▪ encourage pt. to drink fluids with meals cancer
and use the valsalva maneuver (bearing ▪ ascites
down with a closed glottis) while ▪ hiatal hernia → major cause
swallowing → to help push the food
▪ advise soft diet PATHOPHYSIOLOGY
▪ elevate head during sleeping to prevent
Lower esophageal sphincter (LES) – muscle at
regurgitation
the junction between esophagus and
▪ after esophageal surgery, monitor for signs
stomach
of esophageal perforation as evidenced
by chest pain, shock, dyspnea and fever When food enters the pharynx and
esophagus → LES relaxes to permit or allow
ESOPHAGEAL STRICTURES food to enter into the stomach
narrowing of the lumen of the esophagus LES is usually contracted to prevent reflux
of gastric material back to the esophagus
CAUSES: ↓ LES pressure → reflux can occur
▪ caused by anticholinergics, caffeine,
▪ ingestion of corrosive substances (alkaline alcohol, smoking, when the person is
or acid) lying down
▪ reflux esophagitis - prolonged NGT
S/SX:
- irritation of the esophageal walls lead to
formation of a stricture that → the esophageal ▪ heartburn (pyrosis)
lumen and leads to dysphagia ▪ burning sensation below the sternum
that may be referred or radiate to the
- food may collect and partially or totally
back or neck if severe
obstruct the esophagus
▪ frequently accompanied by a sour
- fluids are easier to swallow than solids regurgitation of gastric contents into the
mouth but is not accompanied by nausea
INTERVENTIONS:
Hiatal hernia – may be diagnosed by x-ray,
▪ gradual dilation by mechanical dilators or upper gastrointestinal series (UGIS)
balloons
▪ rubber or metal mechanical dilators of MEDICAL MGT.
increasing sizes are passed through the
▪ Liquid antacids (ex. Maalox) – 30 ml taken
area of strictures, producing mild
1 hr. and 3 hrs. after meals and at bedtime
discomfort
or whenever heartburn occurs → to
▪ the balloon is inflated to create pressure
decrease gastric acidity
▪ dilation procedure is done every 3-4 wks
▪ Medications that increase LES contraction
for 4-6 months
▪ Urecholine, Metoclopramide HCL
▪ monitor pt for signs of esophageal
(reglan, plasil)
perforation
▪ Cimetidine, Ranitidine, Famotidine
GASTROESOPHAGEAL REFLUX DISEASE (GERD) (histamine H2 receptor blockers)
▪ Surgery for hiatal hernia
refers to a group of conditions that cause ▪ Ex. Posterior gastropexy – returning the
reflux of gastric and duodenal contents back stomach to the abdomen and suturing it in
to the esophagus place
▪ Nissen fundoplication – wrapping the
CAUSES:
fundus of the stomach around the lower
▪ idiopathic incompetent lower esophageal part of the esophagus to restore sphincter
sphincter (LES) competence and prevent reflux
▪ pregnancy
19
 NSG. INTERVENTION TYPES of HERNIA

Patient teaching for GERD: Sliding hernia (most common)

1. high-protein, low-fat diet Rolling hernia

2. avoidance of foods containing caffeine
(coffee, tea, colas), theobromine
(chocolate) and alcohol
3. small, frequent meals
4. Encourage the client to eat slowly and
avoid drinking fluids with meals to limit the
volume in the stomach
5. Encourage the client to sit up for at least 1
hour after eating.
6. avoidance of:
a. smoking
b. supine position for 2-3 hrs after eating
c. bending over
d. lifting heavy objects and wearing tight
belts or girdles after eating
7. sleeping with the head slightly elevated →
to prevent regurgitation while pt is sleeping
8. WEIGHT REDUCTION

HIATAL HERNIA

refers to protrusion of part of the stomach, B. CLINICAL FINDINGS:

through the diaphragmatic hiatus into the
thoracic cavity → caused by obesity, trauma, 1. Subjective: substernal burning pain or
weakening of muscles fullness after eating; dyspepsia in the
recumbent position; nocturnal dyspnea.
A. ETIOLOGY
2. Objective: GI series and endoscopy show
▪ congenital weakness of the diaphragm protrusion of the stomach through the
▪ injury diaphragm; regurgitation
▪ pregnancy
▪ obesity. C. THERAPEUTIC INTERVENTIONS:

- Function of the cardiac sphincter is lost, 1. Small, frequent, bland feedings.

gastric juices enter the esophagus causing 2. Pharmacologic management: antacids,
inflammation. antisecretory agents, antiemetics, especially
those that promote gastric emptying

3. Surgical repair (done infrequently)

Fundoplication

20
 NURSING CARE: ASSESSMENT FINDINGS:

1. Teach the client and family about the ▪ Abdominal cramping

dietary regimen. ▪ Epigastric discomfort
2. Encourage attempts at weight loss. ▪ Hematemesis
3. Avoid constricting clothing and heavy ▪ Indigestion
lifting.
4. Encourage the client to sit up for at least 1 DIAGNOSTIC EVALUATION:
hour after eating.
1. Fecal occult blood test can detect occult
5. Encourage the client to eat slowly and
blood in vomitus and stools if the client has
avoid drinking fluids with meals to limit the
gastric bleeding.
volume in the stomach.
2. Blood studies show low Hgb level and Hct
GASTRITIS when significant bleeding has occurred.
3. Upper GI endoscopy with biopsy confirms
GASTRITIS is an inflammation of the gastric the diagnosis when performed within 24hrs
mucosa (the stomach lining). It may be acute of bleeding.
or chronic. 4. Upper GI series may be performed to
exclude serious lesions.
Acute gastritis produces mucosal reddening,
edema, hemorrhage, and erosion. TREATMENT:
Chronic gastritis is common among elderly ▪ Blood transfusion
people and people with pernicious anemia. ▪ I.V. fluid therapy
In chronic atrophic gastritis, all stomach ▪ NG lavage to control bleeding
mucosal layers are inflamed. ▪ Oxygen therapy, if necessary
▪ Partial or total gastrectomy (rare)
POSSIBLE CAUSES:
▪ Vagotomy and pyloroplasty (limited
ACUTE GASTRITIS success when conservative treatments
have failed)
▪ Chronic ingestion of irritating foods, spicy
foods or alcohol IMPLEMENTATION:
▪ Drugs, such as aspirin and other
nonsteroidal anti-inflammatory drugs 1. If the client is vomiting, give antiemetics
(NSAIDs) (in large doses), cytotoxic agents, and I.V. fluids to prevent dehydration and
caffeine, corticosteroids, antimetabolites, electrolyte imbalance.
2. Monitor fluid intake and output and
phenylbutazone, and indomethacin
electrolyte levels.
▪ Ingestion of poisons, especially
3. Provide a bland diet to prevent
dichlorodiphenyltrichloroethane (DDT), recurrence.
ammonia, mercury, carbon tetrachloride, 4. Offer smaller, more frequent meals to
and corrosive substances reduce irritating gastric secretions.
▪ Endotoxins released from infecting Eliminate foods that cause gastric upset.
bacteria, such as staphylococci, 5. If surgery is necessary, prepare the client
Escherichia coli, and salmonella, viruses preoperatively and provide appropriate
(gastroenteritis) postoperative care to decrease
preoperative anxiety and prevent
CHRONIC GASTRITIS: intraoperative and postoperative
complications.
▪ Alcohol ingestion
6. Administer antacids and other prescribed
▪ Cigarette smoke
medications
▪ Environmental irritants 7. Urge the client to take prophylactic
▪ Peptic ulcer disease medications as prescribed to prevent
▪ Benign or malignant ulcers recurring symptoms.
▪ Autoimmune disease 8. Provide emotional support.

21
 PEPTIC ULCER DISEASE (PUD) Doudenal

A. ETIOLOGY: ▪ Burning pain in mid epigastric area 2 to 4

hours after eating
1. Ulcerations of the gastrointestinal mucus ▪ Melena
and underlying tissues caused by gastric ▪ Pain that often is relieved by eating
secretions that have a low pH (acid)
C. THERAPEUTIC INTERVENTIONS:
2. Causes include conditions that increase
the secretion of hydrochloric acid by the 1. Bland foods, and restriction of irritating
gastric mucosa or that decrease the tissue’s substances.
resistance to the acid. 2. Antibiotic therapy if microorganism is
identified; tetracycline, metronidazole, and
a. infection of the gastric and / or bismuth
duodenal mucusa by Campylobacter pylori 3. Histamine H2 receptor antagonists or
or Helicobacter pylori. proton pump inhibitors, antacids
b. Zollinger – Ellison syndrome: tumors 4. Sedatives, tranquilizers, anticholinergics,
secreting gastrin, which will stimulate the and analgesics
production of excessive hydrochloric acid. 5. Antiemetics
6. A nasogastric tube for decompression,
c. certain drugs such as aspirin, steroids, installation of vasoconstrictors, and/or
and indomethacin will decrease tissue saline lavages when hemorrhage occurs.
resistance.
SURGICAL INTERVENTION:
d. smoking
3. Peptic ulcers may be present in the a. Vagotomy-surgical division of the vagus
esophagus, stomach, or duodenum (most nerve to eliminate the vagal impulses that
common site ). stimulate hcl acid secretion in the
stomach.
4. Complication include pyloric or duodenal
obstruction, hemorrhage and or perforation. b. Billroth I: removal of the lower portion of the
stomach and attachment of the
remaining portion to the duodenum.
(GASTRODUODENOSTOMY)
c. Billroth II: removal of the antrum and distal
portion of the stomach and subsequent
anastomosis of remaining section to the
jejunum. (GASTROJEJUNOSTOMY)
d. Antrectomy: removal of the antral portion
of the stomach.
e. Gastrectomy: removal of 60%-80% of the
stomach.
f. Esophagojejunostomy (total gastrectomy):
removal of the entire stomach with a
loop of jejunum anastomosed to the
esophagus.
B. ASSESSMENT GASTRIC AND DUODENAL
ULCERS g. Common complications of total or partial
gastric resection:
Gastric ▪ Dumping syndrome
▪ Gnawing sharp pain in or left of the mid ▪ Hemorrhage
epigastric region 1 to 2 hours after eating ▪ Pneumonia
▪ Hematemesis ▪ Pernicious anemia
▪ Nausea and vomiting

22
 NURSING CARE:

1. Allow ample time for the client to express

feelings and concerns.
2. Administer and assess effects of sedatives,
antacids, anticholinergics, H2 receptor
antagonists, antibiotics, and dietary
modifications.
3.Encourage hydration to reduce
anticholinergic side effects and dilute the
hydrochloric acid in the stomach.
4. Instruct client to:
a. Eat small to medium-sized meals 1. Eat smaller meals at more frequent intervals
because this helps prevent gastric / adherence to six, small, dry, meals per day.
distention; encourage between-meal
2. Avoid high-carbohydrate intake and
snacks to achieve adequate calories
concentrated sweets.
when necessary.
b. Avoid foods that increase gastric acid 3. Consume liquids only between meals or
secretion or irrigate gastric mucosa. refraining from taking fluids during meals but
c. Avoid foods that cause distress; varies rather 2 hours after meals.
for individuals but common offenders
are the gas producers (legumes, 4. Lie down or rest after eating or on a
carbonated beverages, vegetables). recumbent position for ½ hour after meals.
d. eats meals in pleasant, relaxing
DUMPING SYNDROME
surrounding to reduce acid secretions.
e. administers calcium and iron ▪ Dumping syndrome is rapid emptying of
supplements as ordered if client's
the gastric contents into the small
medication increases gastric ph.
intestine.
5. Refrain from administering drugs such as ▪ Dumping syndrome occurs following
salicylates, NSAIDS, steroids, and ACTH. gastric reaction.
6. Observe for complications such as gastric
hemorrhage, perforation and drug toxicity. ASSESSMENT

7. Provide postoperative care after gastric ▪ Symptoms occurring 30 minutes after

resection: eating.
▪ Nausea and vomiting
a. monitor vital signs; assess the dressing
for drainage. ▪ Feeling of abdominal fullness and
b. maintains a patent nasogastric tube to abdominal cramping
suction to prevent stress on the suture ▪ Diarrhea
lines. ▪ Palpitation and tachycardia
c. observes the color and amount of ▪ Perspiration
nasogastric drainage; excessive
▪ Weakness and dizziness
bleeding or the presence of bright red
blood after 12 hours should be reported ▪ Borborigmy
immediately
CLIENT EDUCATION

▪ Eat high-protein, high-fat, low

carbohydrate diet.
▪ Eat small meals and avoid consuming
fluids with meals.
▪ Avoid sugar and salt.
▪ Lie down after meal.
23
▪ Take antispasmodic medications as RISK FACTORS
prescribe to delay gastric emptying.
▪ Men > Women
APPENDICITIS ▪ 10-30 years old
▪ History of constipation
Appendicitis is inflammation of the appendix
▪ Low fiber diet
When the appendix becomes inflamed or
infected, rupture may occur within a matter of
hours, leading to peritonitis and sepsis.

▪ an inflammatory lesion of the vermiform

appendix, located near the ileocecal
valve
▪ can be caused by occlusion of the
lumen of the appendix by hardened
feces (fecaliths), by foreign objects, or
by kinking of the appendix may impair
circulation and lower resistance to
organisms such as bacilli or
streptococci
▪ Abdominal pain, localized tenderness,
▪ a small part of the appendix may be and fever
edematous or necrotic or entire ▪ Initially, generalized pain around the
appendix may be involved 🡪 abscess umbilicus, then localized pain in the right
formation 🡪 may lead to rupture and lower quadrant
peritonitis ▪ Changes in behavior, anorexia, or
vomiting (common early signs)
ASSESSMENT ▪ White blood cell (WBC) count of 15,000 to
20,000/ul
▪ Pain in the periumbilical area that ▪ Constipation or diarrhea
descends to the right lower quadrant. ▪ Possible perforation (indicated by sudden
pain relief) or peritonitis (indicated by
▪ Abdominal pain that is most intense at
increased pain, rigid abdomen, obvious
Mcburney’s point.
guarding of the abdomen, high fever, and
▪ Rebound tenderness and abdominal elevated WBC count) if untreated
rigidity.
▪ Low-grade fever. MEDICAL DIAGNOSIS AND TREATMENT
▪ Elevated white blood cell count.
▪ Surgical removal of the appendix
▪ Anorexia, nausea, and vomiting.
▪ Management of peritonitis, shock,
▪ Client in side-lying position, with abdominal
dehydration, and infection
guarding and legs flexed.
▪ Chest x-ray to differentiate appendicitis
▪ Constipation or diarrhea.
from pneumonia (pneumonia may cause
referred pain in the right lower quadrant
and thus may be misdiagnosed as
appendicitis)
▪ Barium GI series and ultra-sonography to
differentiate appendicitis from other
abdominal problems

NURSING CARE

▪ Don’t administer enemas or laxatives or

apply heat to the abdomen
24
▪ When the appendix is not perforated, ▪ cessation of peristalsis occurs due to
perform the same postoperative care as severe peritoneal infection and lead to
for any abdominal surgery acute intestinal obstruction
▪ When the appendix is perforated (and
Penrose drains are in place), place the SIGNS AND SYMPTOMS
child in semi-Fowler’s position or on his right ▪ abdominal pain and tenderness (local or
side after surgery diffuse, often rebound) abdominal rigidity
(board-like abdomen)
NURSING MANAGEMENT
▪ nausea, vomiting
A. Preoperative Care ▪ high fever, high leukocytosis
▪ weakness, diaphoresis, pallor,
▪ bed rest
tachycardia, shock
▪ placed pt on NPO – in preparation for
▪ later signs: paralytic ileus, abdominal
surgery
distention
▪ intravenous fluids – to maintain F/E
balance MEDICAL MGT.
▪ ice bag may help relieve pain, no heat is
applied because this may ↑ circulation Surgery –
and congestion to the appendix and lead ▪ depending on underlying cause ,
to rupture peritoneal lavage
B. Post-operative care Post-operative medical mgt.
▪ general post-op care 1) NGT insertion
▪ Flat on bed 6-8 hours
▪ Monitor sensation in the lower extremities 2) IV fluids and electrolytes
▪ food permitted when peristalsis returns 3) antibiotics
▪ Ambulation after 24 hours
▪ Avoid lifting heavy objects/increasing 4) maintain drains
abdominal pressure
NSG. MGT.
▪ Resume all normal activities after 2-4 weeks
▪ bed rest in semi-fowler’s position
PERITONITIS
▪ give mouth care
▪ is an inflammation of the peritoneum ▪ maintain F/E replacement
caused by trauma or by rupture of an ▪ encourage deep breathing exercises
organ containing bacteria, which are then ▪ use measures to reduce the pts anxiety
introduced into the abdominal cavity
DIVERTICULAR DISEASE
▪ ex. of organisms – E-coli, streptococci,
staphylococci, gonococci Diverticular disease has 2 clinical forms:
▪ can also be caused by rupture of the DIVERTICULOSIS and DIVERTICULITIS.
fallopian tube in ectopic pregnancy, Diverticulosis occurs when the intestinal
perforation of a gastric ulcer, traumatic mucosa protrudes through the muscular wall.
rupture of the spleen or liver The common sites for diverticula are in the
▪ inflammation causes adhesions, abscess descending and sigmoid colon, but they may
formation develop anywhere from the proximal end of
▪ peritoneum → there is redness, edema the pharynx to the anus.
and production of large amounts of fluid
Diverticulitis is an inflammation of the
containing electrolytes and proteins →
diverticula that may lead to infection,
hypovolemia, electrolyte imbalance,
hemorrhage, or obstruction.
dehydration → hypovolemic shock

25
 POSSIBLE CAUSES: ▪ Bland diet, stool softeners, and occasional
doses of mineral oil for diverticulosis with
▪ Age (most common in people over age pain, mild GI distress, constipation, or
40) difficult defecation.
▪ Chronic constipation, more common in ▪ Bland diet (for diverticulosis after pain
obese individuals subsides) or liquid diet (for mild diverticulitis
▪ Congenital weakening of the intestinal or diverticulosis before pain subsides); low-
wall fiber diet indicated following the liquid
▪ Low intake of roughage and fiber diet; when the client is asymptomatic, low-
▪ Straining during defecation fat, high-fiber diet recommended.
▪ Stress ▪ Temporary colostomy possible for
▪ Men affected more than women perforation, peritonitis, obstruction, or
fistula that accompanies diverticulitis.
ASSESSMENT FINDINGS:
IMPLEMENTATION:
▪ Anorexia
▪ Stool with blood and mucus 1. Asses abdominal distention and bowel
▪ Change in bowel habits sounds to determine baseline and detect
▪ Constipation and diarrhea changes in the client’s condition.
▪ Fever 2. Monitor and record vital signs, intake and
▪ Flatulence output, and laboratory studies to assess
▪ Intermittent left lower quadrant pain or fluid status.
midabdominal pain that radiates to the 3. Monitor stools for occult blood to detect
back bleeding.
▪ Nausea 4. Maintain the client’s diet to improve
▪ Rectal bleeding nutritional status and promote healing.
5. Maintain position, patency, and low
DIAGNOSTIC EVALUATION:
suction of NG tube to prevent nausea and
▪ Barium enema (contraindicated in clients vomiting
with acute diverticulitis) shows 6. Keep the client in semi-Fowler’s position to
inflammation, narrow lumen of the bowel, promote comfort and GI emptying.
and diverticula. 7. Prepare the client for surgery, if necessary
▪ Hematologic study shows increased WBC (administer cleansing enemas, osmotic
count and ESR. purgative, and oral and parenteral
▪ Sigmoidoscopy (contraindicated in clients antibiotics), to avoid wound
with acute diverticulitis) shows a thickened contamination from bowel contents
wall in the diverticula. during surgery.
▪ Computed tomography scan shows 8. Provide postoperative care (watch for
abscesses or thickening of the bowel. signs of infection; perform meticulous
wound care; watch for signs of
TREATMENT: postoperative bleeding; assist with turning,
coughing, and deep breathing; teach
▪ Generally, no treatment for asymptomatic
ostomy self-care) to promote healing and
diverticulosis
prevent complications.
▪ Colon resection (for diverticulitis refractory
9. Administer TPN to improve nutritional status
to medical treatment)
when the client can’t receive nutrition
▪ High residue diet with no seeds for
through the GI tract.
diverticulosis
10. Administer medications as prescribed to
▪ Low residue diet with diverticulitis
maintain or improve the client’s condition.

26
11. Review key teaching topics with the client ▪ Fever
to ensure adequate knowledge about his ▪ Flatulence
condition and treatment, including: ▪ Nausea
▪ decreasing constipation ▪ Pain in the lower right quadrant
▪ following dietary recommendations ▪ Weight loss
and restrictions ▪ 3-4 semisoft stools / day with mucus and
▪ avoiding corn, nuts, and fruits and pus.
vegetables with seeds
▪ monitoring stools for bleeding DIAGNOSTIC EVALUATION:

1. Abdominal x-ray shows congested,

CROHN’s DISEASE (Regional Enteritis)
thickened, fibrosed, and narrowed
CROHN’s DISEASE is a chronic inflammatory intestinal wall.
disease of the small intestine, usually affecting 2. Barium enema shows lesions (granulomas)
the terminal ileum. It also sometimes affects in the terminal ileum.
the large intestine, usually in the ascending 3. Fecal occult blood test is positive.
colon. It’s slowly progressive with 4. Proctosigmoidoscopy shows ulceration.
exacerbations and remissions. 5. Upper GI series shows a classic string sign:
segments of stricture separated by normal
POSSIBLE CAUSES: bowel.
▪ Emotional upsets 6. A CBC usually shows a decreased Hgb
▪ Fried foods level and Hct; WBC may be elevated.
▪ Milk and milk products 7. Low albumin and protein levels reflect
▪ Unknown poor absorption of protein.
▪ Abdominal cramps and spasms after 8. Erythrocyte sedimentation rate (ESR) is
meals elevated due to inflammation.
▪ Chronic diarrhea / steatorrhea
TREATMENT:
▪ Fever
▪ Flatulence DRUG THERAPY OPTIONS:
▪ Nausea
1. Analgesic: meperidine (Demerol),
▪ Pain in the lower right quadrant
morphine
▪ Weight loss
2. Antianemic: ferrous sulfate (Feosol), ferrous
▪ 3-4 semisoft stools / day with mucus and
gluconate (Fergon)
pus.
3. Antibiotic: sulfasalazine (Azulfidine),
metronidazole (Flagyl)
4. Anticholinergic: propantheline (Pro-
Banthine), dicyclomine (Bentyl)
5. Antidiarrheal: diphenoxylate (Lomotil)
6. Antiemetic: prochlorperazine
(Compazine)
7. Anti-inflammatory: olsalazine (Dipentum)
8. Corticosteroid: prednisone (Deltasone)
9. Immunosupressant: mercaptopurine
(Purinethol), azathioprine (Imuran)
10. Potassium supplement: potassium chloride
(K-Lor) administered with food, potassium
gluconate (Kaon)
▪ Abdominal cramps and spasms after meals
▪ Chronic diarrhea / steatorrhea

27
 IMPLEMENTATION: POSSIBLE CAUSES:

▪ Bedrest, weigh daily ▪ Genetics

▪ NPO in acute stage, TPN as ordered. ▪ Idiopathic
▪ High CHON, calorie, bland, low residue ▪ Allergies
diet. ▪ Autoimmune disease
▪ Avoid gas-producers, irritating food, and ▪ Emotional stress
milk products. ▪ Viral and bacterial infections
▪ Offer small frequent feedings.
▪ Vitamin replacement ADEK. ASSESSMENT FINDINGS:
▪ IVF, I/O, tepid fluids up to 3L/day. ▪ Abdominal cramping, distention, and
▪ Perianal care with lubricants and tenderness
ointments. ▪ Anorexia
▪ Hot sitz baths, monitor stools. ▪ Bloody, purulent, mucoid, watery stools
▪ Emotional support esp. family members. (15 to 20 per day)
▪ Administer medications, as prescribed, to ▪ Dehydration
maintain or improve the client’s condition. ▪ Fever
▪ Maintain the client’s diet; withhold food ▪ Hyperactive bowel sounds
and fluid as necessary to minimize GI ▪ Nausea and vomiting
discomfort. ▪ Weakness
▪ Minimize stress and encourage ▪ Weight loss
verbalization of feelings to allay the client’s
anxiety. DIAGNOSTIC EVALUATION:
▪ If surgery is necessary, provide
1. Barium enema shows ulcerations.
postoperative care (monitor vital signs;
2. Blood chemistry shows decreased
monitor dressings for drainage; monitor
potassium level and increased osmolality.
ileostomy drainage and perform ileostomy
3. Hematology shows decreased Hgb level
care as needed; assess incision for signs of
and Hct.
infection; assist with turning, coughing, and
4. Intestinal biopsy helps to differentiate
deep breathing; get the client out of bed
between ulcerative colitis and regional
on the 1st postoperative day if stable) to
enteritis.
promote healing and prevent
5. Stool specimen is positive for blood and
complications.
mucus.
ULCERATIVE COLITIS 6. Urine chemistry displays increased urine
specific gravity.
ULCERATIVE COLITIS is a major health
problem and a potentially debilitating TREATMENT:
disease. It’s a type of inflammatory bowel
Colectomy or ileostomy
disease that produces lesions primarily
confined to the large bowel, with ulcerations IMPLEMENTATION:
of the large bowel’s mucosa and submucosa.
Healing of lesions causes scarring and ▪ Assess GI status and fluid balance to
strictures, leading to bowel obstruction, and determine deficient fluid volume.
ulcers may perforate, causing hemorrhage ▪ Monitor and record vital signs, intake and
and peritonitis. Ulcerative colitis usually output, laboratory studies, daily weight,
develops in people between ages 18-35 and urine specific gravity, calorie count, and
occurs more commonly in women than in fecal occult blood to determine deficient
men. fluid volume.

28
▪ Monitor the number, amount, and ▪ Started 5-7 days post-op in the bathroom
character of stools to determine status of preferably
nutrient absorption. ▪ Equipment: irrigating solution, catheter
▪ Maintain the client’s diet; withhold food with stoma tip, irrigating sleeve
and fluid as necessary to prevent nausea ▪ Tepid water used 18-24 in above stoma
and vomiting. (shoulder height)
▪ Administer I.V. fluids and TPN to maintain ▪ 500-1000ml irrigated slowly
hydration and improve nutritional status. ▪ Done same time everyday / as preferred
▪ Maintain position, patency, and low ▪ Return flow expected within 15-45 mins
suction of NG tube to prevent nausea and
vomiting. INTESTINAL OBSTRUCTIONS
▪ Keep the client in semi-Fowler’s position to
promote comfort.
▪ Administer medications, as prescribed, to
maintain or improve the client’s condition.
▪ Provide skin, mouth, nares, and perianal
care to promote comfort and prevent skin
breakdown.

OSTOMY CARE

▪ Referral to enterostomal therapist.

▪ Encourage verbalization of
fears/concerns.
▪ Teach character of drainage: ileostomy –
liquid 4-6x/day, transverse colostomy –
mushy OD, descending/sigmoid – soft
formed q 2-3 days
▪ Skin care – nystatin, karaya powder,
soap/H2O pat dry
▪ Odor control – deodorant drops, bismuth
tabs, mouthwash solutions, spinach,
parsley added to ostomy bag.
▪ Odor – avoid gas-formers (cabbage,
beans, broccoli, cauliflower, corn, onions,
eggs, fish, condiments.
▪ Diet – ileostomy (clear liquids, strained HEMORRHOIDS
fruits/veggies progress to regular diet, Na/K A. GENERAL INFORMATION:
rich food, avoid fried, seasoned food, nuts,
raisins, raw fruits) ▪ Congestion and dilation of the veins of the
▪ colostomy – clear liquid, solid low-residue rectum and anus; usually result from
1st 6 weeks impairment of flow of blood through the
▪ Ileostomy drainage q 4-6 hrs emptied, venous plexus.
pouch 5-7 days max ▪ May be internal (above the anal sphincter)
or external (outside anal sphincter).
OSTOMY IRRIGATION ▪ Most commonly occur between ages 20-
50.
▪ Only colostomies are irrigated; ileostomy
▪ Predisposing conditions include
no need
occupations requiring long periods of
▪ Purposes – stimulate emptying of colon to
standing; increased intra-abdominal
avoid use of appliance
29
 pressure caused by prolonged a. Assist client to side-lying or prone position,
constipation, pregnancy, heavy lifting, provide flotation pad when sitting.
obesity, straining at defecation; portal
b. Administer analgesics as ordered
hypertension.
4. Promote elimination: administer stool
SIGNS AND SYMPTOMS softeners as ordered and, if possible,
▪ Anal pain administer analgesics before first post-op
▪ Rectal bleeding bowel movement.
▪ Itchiness 5. Provide client teaching and discharge
▪ Constipation planning concerning
▪ Mucous secretion from anus
a. Dietary modification (low-residue, soft
B. MEDICAL MANAGEMENT: progress to high fiber/fresh fruits, force fluids
2.5-3L/day)
1. Stool softeners, local anesthetics, or anti-
inflammatory creams. b. Defecate when urge is felt
2. Diet modification: high fiber, adequate
c. Use of stool softeners as needed until
liquids. (6-8 glasses/day)
healing occurs.
3. Hemorrhoidectomy: surgical excision of
hemorrhoids indicated when there is d. Sitz baths after each bowel movement.
prolapse, severe pain, and excessive
e. Perineal care with antiseptic solutions.
bleeding.
4. Slerosis, rubber-band ligation. f. Recognition and reporting immediately
to physician of the following signs and
C. ASSESSMENT FINDINGS:
symptoms:
1. Bleeding with defecation, hard stools with 1. Rectal bleeding
streaks of blood.
2. Pain with defecation, sitting, or walking. 2. Continued pain on defecation
3. Protrusion of external hemorrhoids upon 3. Puslike drainage from rectal area
inspection.
4. Diagnostic tests HEPATIC CIRRHOSIS

a. Proctoscopy reveals presence of internal A. ETIOLOGY AND PATHOPHYSIOLOGY

hemorrhoids
1. Irreversible fibrosis and degeneration of the
b. Hgb and Hct decreased if bleeding liver
excessive, prolonged.
2. Several types of cirrhosis; Laënnec’s
D. NURSING INTERVENTIONS: PREOPERATIVE (alcoholic cirrhosis, nutritional cirrhosis) most
common
1. Prepare the client for hemorrhoidectomy.
2. In addition to routine pre-op care, provide 3. Incidence higher in alcoholics, who are
laxatives/enemas to promote cleansing of often malnourished, and in those who have
the bowel. had hepatitis

4. As liver failure progresses, there is increased

E. NURSING INTERVENTIONS: POSTOPERATIVE
secretion of aldosterone, decreased
1. Provide routine post-op care. absorption and utilization of the fat-soluble
2. Assess for rectal bleeding; inspect rectal vitamins (A, D, E, K), and ineffective
area/dressings every 2-3hours and report detoxification of protein wastes
significant increases in bloody drainage.
3. Promote comfort.
30
5. Hepatic coma (hepatic encephalopathy) 6. Converts =Hyperammonemia
may result from high blood ammonia levels ammonia to urea
when the liver is unable to convert the 7. Stores Vit and =Deficiencies of Vit
ammonia to urea minerals and min
8. Metabolizes = Gynecomastia,
Goals: Eliminate cause, Rest, Nutritional/Fluid
estrogen testes atrophy
support, liver transplant

C. THERAPEUTIC INTERVENTIONS:
Subjective: anorexia; nausea; weakness;
fatigue; abdominal discomfort; pruritus 1. Rest
Objective: 2. Restriction of alcohol, hepatotoxic drugs.
3. Vitamin therapy: especially the fat soluble
▪ Weight loss; ascites; esophageal varices vitamins A, D, E and K and vitamin B
resulting from portal hypertension; (thiamine chloride and nicotinic acid); zinc
hemorrhoids; edema of extremities;
and calcium supplements
hematemesis; hemorrhage resulting from
4. Diuretics to control ascites and edema
decreased formation of prothrombin;
5. Neomycin and lactulose may be
jaundice; delirium caused by rising blood
prescribed for elevated blood ammonia
ammonia levels
▪ Elevated liver enzymes (aspartate levels (2-4 soft stools)
aminotransferase (AST), alanine 6. Paracentesis if respiratory distress occurs as
aminotransferase (ALT), alkaline a result of ascites
phosphatase (ALP), gamma-glutamyl ▪ Rest- wt, I/O, position, O2
transferase (GGT) ▪ Nutrition – early-CHON, B complex, Vit
▪ Decreased serum albumin; elevated
serum bilirubin ACK, small freq, NGT/TPN, Aquasol ADE
▪ Late – adeq CHON – encephalopathy
LIVER PHYSIOLOGY AND PATHOPHYSIOLOGY
– (-) nitrogen balance mm wasting
Normal Function Abnormality in
▪ Skin care- SQ edema, immobility,
function
1. Stores glycogen = Hypoglycemia jaundice, infxn, position, lotion
2. Synthesizes = Hypoproteinemia ▪ Bleeding- pad rails, pressure injection
proteins
site, melena, v/s, stool softeners
3. Synthesizes =Decreased
globulins Antibody formation ▪ Teaching- Alco Anon, low Na
4. Synthesizes = Bleeding
7. Surgical intervention to decrease portal
Clotting factors tendencies
hypertension: a portacaval shunt
5. Secreting bile = Jaundice and
pruritus 8. Esophageal varices management
31
Sengstaken-Blakemore tube: 5. Alcohol contraindicated to avoid
irritation and malnutrition

b. Hepatic coma

1. Protein: reduced according to

tolerance; 15-30g

2. High calorie (1500-2000g) to prevent

catabolism and liberation of nitrogen

3. Fluid carefully controlled according to

output

NURSING CARE:
Varices Sengstaken - Blakemore tube for
bleeding esophageal varices to apply direct ▪ Abdominal girth measurements for
pressure to the varices; vasopressin may be baseline data relative to ascites.
administered IV to control GI bleeding; ▪ Skin for presence of jaundice, dryness,
plasminogen inhibitors to limit fibrinolysis petechiae, ecchymoses, spider angiomas,
and palmar erythema
9. Provide care when a Sengstaken -
▪ Signs of hepatic coma such as confusion,
Blakemore tube is in place
flapping of extremities
a. Maintain traction once the tube is ▪ Observe for bleeding
passed and the gastric balloon is inflated to ▪ Provide special skin care and keep nails
ensure proper placement, elevate bed 30-45 trimmed because pruritus is associated
degrees with jaundice
▪ Maintain the client in a semi-Fowler’s
b. Maintain the esophageal balloon at
position to prevent ascites from causing
inflated level (30-35mm Hg) up to 48 hrs
dyspnea
c. Deflate gastric balloon for a few minutes ▪ Monitor intake and output, abdominal
at specific intervals if ordered to prevent girth, and daily weight to assess fluid
necrosis balance
▪ Assist with paracentesis
d. Gastric lavage as ordered
a. Have client void before procedure
e. Suction orally as necessary because the
client is unable to swallow saliva b. Assist to a sitting or high-Fowler’s
position
10. Dietary modification:
c. Observe for shock
a. Cirrhosis:
d. Maintain pressure dressing over needle
1. Protein as tolerated (80-100g); with
insertion site
increasing liver damage, protein metabolism
is hindered e. Bedrest for 24 hrs post.

2. High carbohydrate, moderate fat; CHOLELITHIASIS / CHOLECYSTITIS

provides for energy; vitamin, mineral, and
electrolyte supplements A. ETIOLOGY AND PATHOPHYSIOLOGY:

3. Low sodium (500-1000mg daily); helps 1. Inflammation of the gallbladder; usually

control increasing ascites caused by the presence of stones
(cholelithiasis), which are composed of
4. Soft foods if esophageal varices are cholesterol, bile pigments, and calcium.
present; prevents danger of rupture and 2. Diseased gallbladder is unable to contract
bleeding in response to fatty foods entering the

32
 duodenum because of obstruction by 2. Objective:
calculi or edema.
a. Vomiting; elevated temperature and WBC;
3. When the common bile duct is completely
jaundice may be present
obstructed, the bile is unable to pass into
the duodenum and is absorbed into the b. Diagnostic tests
blood.
4. Incidence is highest in obese women in the - Serum bilirubin is elevated
fourth decade. - Ultrasonography determines the presence
of gallstones;

-Endoscopic retrograde
cholangiopancreatography (ERCP) reveals
presence of gallstones

CONDITION OF THE GALLBLADDER

DIAGNOSTIC PROCEDURES

1. Ultrasonography- can detect the stones

2. Abdominal X-ray
PREDISPOSING FACTORS 3. Cholecystography
“F” 4. WBC count increased
▪ Female 5. Oral cholecystography cannot visualize the
▪ Fat gallbladder
▪ Forty
▪ Fertile 6. ERCP: revels inflamed gallbladder with
▪ Fair gallstone

Pathophysiology C. THERAPEUTIC INTERVENTIONS:

Supersaturated bile, Biliary stasis Medical management

↓ - Nasogastric suctioning to reduce nausea

and eliminate vomiting
Stone formation
- Narcotics to decrease pain
↓
- Antispasmodics and anticholinergics to
Blockage of Gallbladder reduce spasms and contractions of the
gallbladder
↓
- Antibiotic therapy if infection is suspected
Inflammation, Mucosal Damage and WBC
infiltration NURSING INTERVENTIONS

1. Maintain NPO in the active phase

1.Subjective:
2. Maintain NGT decompression
indigestion after
eating fatty or fried 3. Administer prescribed medications to
foods; pain, usually in relieve pain. Usually Demerol (MEPERIDINE)
the right upper
- Codeine and Morphine may cause spasm of
quadrant of the
the Sphincter → increased pain. Morphine
abdomen, which
cause MOREPAIN
may radiate to the
back, nausea.
33
4. Instruct patient to AVOID HIGH- fat diet and between 6 months and 2 years, and the
GAS-forming foods success rate is only about 30 %

5. Assist in surgical and non-surgical measures 1. Secure the drainage bag; avoid kinking of
the tube
6. Surgical procedures- Cholecystectomy,
Choledochotomy, laparoscopy 2. Measure drainage at least every shift;
drainage during the first day may reach 500 to
PHARMACOLOGIC THERAPY 1000 ml and then gradually decline
▪ Analgesic- Meperidine 3. Apply ordered protective ointments around
▪ Chenodeoxycholic acid= to dissolve tube to prevent excoriation
the gallstones
▪ Antacids 4. When the tube is removed, usually in 7 days,
▪ Anti-emetics observe stool for normal brown color, which
indicates bile is again entering the duodenum
POST-OPERATIVE NURSING INTERVENTIONS
T-tube tract removal – threaded catheter with
1. Monitor for surgical complications basket

2. Post-operative position after recovery from ERCP removal – cut papilla of sphincter of
anesthesia- LOW FOWLER’s Oddi enlarge opening, threaded cath with
basket
3. Encourage early ambulation

4. Administer medication before coughing

and deep breathing exercises

5. Advise client to splint the abdomen to

prevent discomfort during coughing

6. Administer analgesics, antiemetics,

antacids

7. Care of the biliary drainageor T-tube

drainage
▪ Extracorporeal shockwave lithotripsy
8. Fat restriction is only limited to 4-6 weeks. ▪ Endoscopic sphincterotomy/retrograde
Normal diet is resumed cholangio-pancreatography
TREATMENT OF STONES: ▪ Percutaneous transhepatic dissolution
▪ Nasal biliary dissolution
CHOLESTEROL DISSOLVENT:
SHOCKWAVE LITHOTRIPSY
Moctanin is administered through a nasal
biliary catheter to dissolve stones left in the bile ▪ It is designed for a client with a small
duct after cholecystectomy. Dissolution may number of stones and mild to moderate
take 1 to 3 weeks. Observe the client for symptoms.
anorexia, nausea, vomiting, and abdominal ▪ The client sits in a tank of water or holds a
pain. water filled cushion against the
appropriate place on the abdomen.
ORAL BILE ACIDS: ▪ Shock waves are sent through the water
until the stones disintegrate (1 to 2 hours).
Chenodiol (chenix) and ursodiol (actigall) are ▪ The client is on cardiac monitor throughout
administered to dissolve small stones. Side the procedure, because shock waves
effects include diarrhea (especially with must be coordinated with cardiac rhythm
chenodiol), elevation of hepatic enzymes, to prevent arrhythmias.
gastritis, and gastric ulcers. Dissolution takes

34
▪ After the procedure, observe the client for f. Nausea and vomiting
hematuria, hematoma, nausea, and g. Tachycardia, shock, hypotension
biliary colic. h. Dyspnea
i. Low grade fever
ERCP j. Elevated serum amylase / lipase / glucose
k. Grey Turner’s, Cullens’s sign
▪ It uses an endoscope to remove stones
l. Chronic steatorrhea
from the common bile duct.
m. Jaundice
▪ After the procedure, monitor the client for
n. Hyperglycemia
bleeding, pain, and fever.
▪ Promote bed rest for 6 to 8 hours, and give CONDITION OF THE PANCREAS
the client nothing by mouth until the gag
reflex returns. PATHOPHYSIOLOGY of acute pancreatitis

PANCREATITIS ▪ Self-digestion of the pancreas by its own

digestive enzymes principally TRYPSIN
PANCREATITIS is the inflammation of the ▪ Spasm, edema or block in the Ampulla of
pancreas. Vater → reflux of proteolytic enzymes →
auto digestion of the pancreas →
In acute pancreatitis, pancreatic enzymes
inflammation
are activated in the pancreas rather than the
▪ Autodigestion of pancreatic tissue
duodenum, resulting in tissue damage and
autodigestion of the pancreas. ↓
In chronic pancreatitis, chronic inflammation Hemorrhage, Necrosis and Inflammation
results in fibrosis and calcification of the
pancreas, obstruction of the ducts, and ↓
destruction of the secreting acinar cells. KININ ACTIVATION will result to increased
permeability
POSSIBLE CAUSES:
↓
1. Alcoholism - chronic
Loss of Protein-rich fluid into the peritoneum
2. Bacterial or viral infection
HYPOVOLEMIA
3. Biliary tract disease - acute
NURSING INTERVENTIONS
4. Blunt trauma to the pancreas or abdomen

5. Drugs: steroids, thiazide diuretics, oral 1. Assist in pain management. Usually,

contraceptives Demerol is given. Morphine is AVOIDED

6. Duodenal ulcer 2. Assist in correction of Fluid and Blood loss

7. Hyperlipidemia 3. Place patient on NPO to inhibit pancreatic

stimulation
ASSESSMENT FINDINGS:
4. NGT insertion to decompress distention and
a. Abrupt onset of pain in the epigastric / LUQ remove gastric secretions
area that radiates to the shoulder, 5. Maintain on bed rest
substernal area, back, and flank
b. Abdominal tenderness and distention 7. Position patient in SEMI-FOWLERs to
c. Aching, burning, stabbing, pressing pain decrease pressure on the diaphragm
d. Knee-chest position, fetal position, or
8. Deep breathing and coughing exercises
leaning forward for comfort d/t abdominal
pain 9. Provide parenteral nutrition
e. Mental confusion, hypocalcemia – mm
10. Introduce oral feedings gradually- HIGH
irritability
carbo, LOW FAT
35
11. Maintain skin integrity QUICK SUMMARY

12. Manage shock and other complications PEPTIC ULCER

TREATMENT: PANCREATITIS ▪ Ulceration of mucosa; In the stomach or

1. NPO, TPN, Bland, low-fat, high-protein diet duodenum

of small, frequent meals with restricted ▪ Outstanding Symptom: PAIN

intake of caffeine, alcohol, and gas- ▪ Nursing Goal: Allow ulcer to heal, prevent

forming foods complication

2. Bed rest ▪ Rest: physical and Mental

3. I.V. fluids (vigorous replacement of fluids ▪ Eliminate certain foods

and electrolytes) BT: packed RBC, FWB ▪ Medications: antacid, H2 blockers, Proton

4. Surgical intervention to treat the Pump inhibitors, antibiotics, mucosal

underlying cause, if appropriate protectants

5. Maintain position, patency, and low ▪ Surgery: Vagotomy, Billroth 1 and 2

suction of NG tube to prevent nausea

LIVER CIRRHOSIS
and vomiting.
6. Monitor I/O, wt OD, abd girth, electrolytes. ▪ Destruction of liver with replacement by
7. Monitor blood glucose levels. scars
8. Meds: meperidine, H2 blockers, ▪ Common causes: alcoholism, post-
anticholinergics, antacids, Ca gluconate, hepatitic
pancreatic enzyme replacements ▪ Manifestations related to liver
(Viokase, Pancreatin, Pancrease) derangements
▪ Pain – meperidine, NG sxn, oral care, ▪ Jaundice, Ascites, splenomegaly,
bedrest bleeding, enceph
▪ Nutrition – IVF, BT, wt, I/O, abd. Girth ▪ Nursing goal: Control manifestations and
▪ Respi – position, cough, deep breath maximize liver function
▪ Teaching – biliary dse, alcohol ▪ Encourage rest
▪ Goals: control pain, rest pancreas, ▪ Avoid hepatotoxic drugs
support nutrition/hydration ▪ Diet: HIGH calorie, Restricted protein, LOW
9. Keep the client in semi-Fowler’s position (if Na
his blood pressure allows) to promote ▪ Weigh client and measure abdominal girth
comfort and lung expansion. daily
10. Keep the client in bed and turn him every ▪ Provide skin care for jaundice and edema
2hrs, or utilize a specialty rotation bed ▪ Assess for bleeding: esophageal, rectal,
to prevent pressure ulcers. cutaneous
11. Provide a quiet, restful environment to ▪ DRUGS: Antacids, Diuretics, Albumin,
conserve energy and decrease Neomycin and Lactulose
metabolic demands.

36
 CHOLECYSTITIS

▪ Inflammation of the gallbladder

commonly caused by cholelithiasis
(Female, Fat, Forty, Fertile, Fair)
▪ Manifestations: Fat intolerance, RUQ pain,
Nausea and vomiting, Jaundice, Murphy’s
sign
▪ Nursing Goal: Relieve symptoms and assist
in stone removal
▪ Administer MEPERIDINE, avoid morphine
▪ Maintain Fluid and electrolyte balance
▪ Maintain a Low-fat diet
▪ Semi-fowler’s position
▪ Assist in surgery
▪ Care of the T-tube

Pancreatitis

▪ Inflammation of the pancreas brought

about by the digestion of the organ by the
enzyme it produces
▪ Common causes: Alcoholism, stone
▪ Manifestations: Extreme upper abdominal
pain radiating into the back, vomiting,
nausea, Abdominal distention,
Steatorrhea and weight loss
▪ Laboratory: ELEVATED lipase and amylase
▪ Nursing Goal: relieve symptoms, maintain
blood volume and GIT rest
▪ NPO
▪ Provide IVF and Parenteral nutrition
▪ Drugs: MEPERIDINE, never morphine,
Antacids, anticholinergics
▪ After Acute phase: LOW fat diet, avoid
alcohol, fat and vitamin replacements

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