GASTRO INTESTINAL

TRACT
DISORDERS
 Gastro-esophageal
reflux (GERD)

Backflow of gastric contents into

the esophagus
Usually due to incompetent
lower esophageal sphincter ,
pyloric stenosis or motility
disorder
Symptoms may mimic ANGINA
or MI
   
 ASSESSMENT
 Heartburn
 Dyspepsia
 Regurgitation
 Epigastric pain
 Difficulty swallowing
 Ptyalism
 Diagnostic test
 Endoscopy or barium 
swallow
 Gastric pH analysis
 NURSING
INTERVENTIONS
1. Instruct the patient to AVOID stimulus that
increases stomach pressure and decreases
GES pressure
2. Instruct to avoid spices, coffee, tobacco and
carbonated drinks
3. Instruct to eat LOW-FAT, HIGH-FIBER diet
4. Avoid foods and drinks TWO hours before
bedtime
 NURSING
INTERVENTIONS

5. Elevate the head of the bed with an

approximately 8-inch block
6. Administer prescribed H2-blockers,
PPI and prokinetic meds like cisapride
and metochlopromide
7. Advise proper weight reduction
BARRET’S ESOPHAGUS

Result from long standing

untreated GERD
Identified as a precancerous
condition and if untreated can result
in adenocarcinoma of the esophagus
Common among middle aged
white men, woman, and African
Americans
 DIGESTIVE DISORDERS
Pathophysiology

Untreated
GERD

Barret’s
esophagus

Adenocarcinoma
of the esophagus

   
BARRET’S ESOPHAGUS
Clinical Manifestation
Frequent heart burn
Complain symptom same as GERD,
peptic ulcer or esophageal stricture
Diagnostic finding
Esophagogastroduodenoscopy
(EGD) is performed
Biopsy are taken
BARRET’S ESOPHAGUS
Assessment
It reveals an esophageal
lining that is red rather than
pink

Management
EGD in six to twelve
months
Medical management is
similar that of GERD
HIATAL HERNIA
HIATAL HERNIA
 Protrusion of the stomach into the diaphragm 
thru an opening
 Two types­ Sliding hiatal hernia(most 
common) and Axial hiatal hernia

ASSESSMENT
 Heartburn
 Regurgitation
 Dysphagia
 50%; without symptoms

   
DIAGNOSTIC TEST
 Barium swallow and fluoroscopy.

NURSING INTERVENTIONS
 Provide small frequent feedings
 AVOID reclining for 1 hour after eating
 Elevate the head of the head on 8 –inch block
 Provide pre­op and post­op care

   
 Hiatal hernia Hiatal hernia – X-
ray

   
 Sliding Hiatal Hernia
 Protrusion of the esophagastric junction into the 
thoracic cavity and back into the abdominal cavity 
in relation to position changes.

Causes:
 Muscle weakness in  the esophageal hiatus:
 Aging process 
 Congenital muscle weakness
 Obesity
 Trauma
 Surgery
 
 Prolonged increases in intra­abdominal pressure
 
 Sliding Hiatal Hernia

   
Paraesophageal / Rolling Hernias
 The gastric junction remains below the diaphragm, but 
the fundus of the stomach and the greater curvature rolls 
into the thorax next to the esophagus
 Cause:  anatomic defect.

   
Management
 Medications
 Antacids
 Antiemetics
 Histamine Receptor Antagonist
 Gastric Acid Secretion Inhibitor

 AVOID; These drugs lowers the LES (lower 
esophageal sphincter) pressure:
 Anticholinergics
 Xanthine derivatives
 Ca­channel blockers
 Diazepam
   
Nursing Interventions
 Relieve Pain
 Modify diet
 High CHON diet to enhance LES pressure
 Small frequent feedings (4­6)
 Eat slowly and chew food properly
 Avoid: fatty foods, Cola beverages, Coffee, Chocolate, Alcohol; all these 
Foods and beverages decrease LES pressure
 Assume upright position before and after eating (1­2hours.)
 Do not eat at least 3 hours before bedtime to prevent  nighttime reflux
 No evening snacks.
 Promote lifestyle changes
 Elevate head of bed 6­12 inches for sleep.
 Avoid factors that increase the intra­abdominal pressure.
 Use of constrictive clothing 
 Straining
 Heavy lining
 Bending, stooping
 Coughing

   
   
Surgery
 Nissen Fundoplication (gastri wrap­around)
 Pre­op Care
 Teach on DBCT exercise, incentive spirometry to prevent postop respiratory 
complications.
 Inform on possible post –op contraptions:
 Chest tube
 NGT
 Postop Care
 Facilitate airway clearance
 Semi­Fowler’s Position
 Reinforce DBCT exercises, incentive spirometry, chest physiotheraphy.
 Facilitate swallowing
 A large NGT is inserted to prevent the fundoplication from being made too tightly.
 Drainage from NG tube returns to yellowish green within first 8­12 hours post­op.
 Oral fluids after peristalsis returns; near normal diet within 6 weeks.
 Small frequent meals.
 Maintain upright position.
 Avoid gas forming foods.
 Frequent position changes and early ambulation to clear air from the GI tract.
 Report for persistent Dysphagia and gas pain.

   
 DIGESTIVE DISORDERS
GASTRITIS
Inflammation of the gastric or stomach mucosa.
Common GI problem

Signs & Symptoms

A. Acute Gastritis
- Abdominal discomfort
- Headache
- Lassitude
- Nausea
- Anorexia
- Vomiting
  - Hiccupping  
 DIGESTIVE DISORDERS
B. Chronic Gastritis
- Anorexia
- Heartburn after eating
- Belching
- A sour taste in the mouth
- Nausea and vomiting

   
 Acute Gastritis Chronic Gastritis

   
 DIGESTIVE DISORDERS
Pathophysiology
Gastric mucous
↓
Edematous and hyperemic
↓
Superficial erosion
↓
Secretes gastric juice
↓
Contains little acid but more mucus
↓
Superficial erosion
    ↓
Hemorrhage
 DIGESTIVE DISORDERS
Treatment
1.Naso gastric intubation
2.Analgesics agents
3.Sedatives
4.Antacids
5.Intravenous fluids
6.Fiberoptic endoscopy
7.Gastrojejunostomy or gastric resection (Pyloric
obstruction)
8.Antibiotics
9.Proton Pump Inhibitors
10.Bismuth salt
   
 DIGESTIVE DISORDERS
Nursing Intervention
1.Reducing anxiety
2.Promoting optimal nutrition
3.Promoting fluid balance
4.Relieving pain
5.Teaching patient self-care

   
 Peptic Ulcer Disease
These are circumscribed lesions in the
mucosal membranes of the stomach and
duodenum
Commonly referred with respect to the
location  if in the stomach, gastric ulcer
and if in the duodenum, duodenal ulcer
The precise cause is not known, but
there are implicated factors that can lead to
its development:
Duodenal vs Gastric Ulcer
 DIGESTIVE DISORDERS
Pathophysiology
Emotional Cigarette Genetic
Psychogenic Drugs Caffeine Alcohol Smoking Factors

Imbalance between Acid secretion and mucosal barrier

Autodigestion

Erosion
Painless

Ulceration Pain

N/V

   
Bleeding
 Gastric Ulcers
Ulceration of the mucosal lining of
the stomach; most commonly found in
the antrum
Gastric secretions and stomach
emptying rate are usually normal
Also characterized by reflux into the
stomach of bile containing duodenal
contents
Occurs more often in men, in
unskilled laborers, and in lower
socioeconomic groups; peak age 40 – 55
years (older age group)
Caused by smoking, alcohol abuse,
emotional tension, and drugs
(salicylates, steroids)
 Assessment findings
1. Pain located in the upper left epigastrium, with
possible radiation to the back; usually occurs 1 – 2
hours after meals, rarely at night. The pain is
described as burning, aching, gnawing discomfort.
The pain is NOT relived by eating.
2. Weight loss, vomiting, bleeding episodes,
epigastric tenderness, and pyrosis.
3. Complications associate with peptic ulcer:
Bleeding, Perforation, Pyloric obstruction and
intractable pain. A chronic complication seen in
gastric ulcer is gastric cancer.
 Laboratory:
Hgb and Hct decreased (if anemic)
Endoscopy reveals ulceration;
BIOPSY is usually done to detect H.
pylori infection and to rule out
MALIGNANCY!
Gastric analysis: normal gastric
acidity in gastric ulcer (increased in
duodenal ulcer)
Upper GI series: presence of ulcer
confirmed
 Nursing interventions
1. Administer medications as ordered.
Watch out for side – effects of
cimetidine like dizziness, rash, mild
diarrhea, muscle pain and
gynecomastia in males.
2. Provide nursing care for the client
with ulcer surgery.
3. Prepare the client for diagnostic
procedure for barium swallow and
EGD
4. Provide client teaching and discharge
planning concerning
Nursing interventions
A. Medication regimen
1) Take medications at prescribed
times. Antacids are taken ONE hour
AFTER meals.
2) Have antacids available at all
times.
3) Recognize situations that would
increase the need for antacids.
4) Avoid ulcerogenic drugs
(salicylates, steroids).
5) Know proper dosage, action, and
side effects.
 Nursing interventions
B. Proper diet
1) Bland diet consisting of six small
meals/ day. Small frequent meals are NOT
necessary as long as the medications are taken
BEFORE meals.
2) Eat meals slowly.
3) Avoid acid-producing substances
(caffeine, alcohol, highly seasoned foods, milk
and creams).
4) Avoid stressful situations at mealtime.
5) Plan for rest periods after meals.
6) Avoid late bedtime snacks.
Nursing interventions
C. Avoidance of stress-producing
situations and development of
stress-reduction methods
(relaxation techniques, exercises,
biofeedback).
 Duodenal Ulcers
 Most commonly found in the first 2 cm of the
duodenum
 Occur more frequently than gastric ulcers
 Characterized by gastric hyperacidity and a
significant increased rate of gastric emptying
 Occur more often in younger men; more
women affected after menopause; peak age: 35
– 45 years (younger than gastric ulcer group)
 Caused by smoking, alcohol abuse,
psychologic stress
 An acute duodenal ulcer is seen in two views on
upper endoscopy in the panels below.

   
 Assessment findings
Pain located in mid – epigastrium and described
as burning, cramping; usually occurs 2 – 4
hours after meals and is relieved by food.
Usually not accompanied by nausea and
vomiting
Diagnostic tests: same as for gastric ulcer.
Nursing interventions: same as for gastric ulcers.
Medical management: same as for gastric ulcers
 Ulcer Surgery
Types
Vagotomy: severing of part of the vagus
nerve innervating the stomach to decrease
gastric acid secretion
Antrectomy: removal of the antrum of
the stomach to eliminate the gastric phase of
digestion
Pyloroplasty: enlargement of the pyloric
sphincter with acceleration of gastric
emptying
 Ulcer Surgery
Gastroduodenostomy (Billroth I): removal of
the lower portion of the stomach with anastomosis
of the remaining portion of the duodenum
Gastrojejunostomy (Billroth II): removal of
the antrum and distal portion of the stomach and
duodenum with anastomosis of the remaining
portion of the stomach to the jejunum
Gastrectomy: removal of 60% - 80% of the
stomach
Esophagojejunostomy (total gastrectomy):
removal of the entire stomach with a loop of
jejunum anastomosed to the esophagus
   
Summary of Nursing Management of the
Patient undergoing Gastric Surgery
 Pre – op Care
 Teach deep breathing exercises 
(high abdominal incision causes 
respiratory complications).
 Provide nutritional support  TPN
 Inform about post­op measures and 
tubes to anticipate
Nasogastric tube
TPN until peristalsis returns
Summary of Nursing Management of the
Patient undergoing Gastric Surgery
Post-op Care
 Promote patent airway and 
ventilation
 Semi­Fowler’s position
 Reinforce Deep Breathing and 
Coughing exercise, incentive 
spirometry
 Administer analgesic before 
activities
 Splint incision before patient coughs
 Encourage early ambulation
Summary of Nursing Management of the
Patient undergoing Gastric Surgery
Promote adequate nutrition
 NPO until peristalsis returns
 Measure NG drainage accurately 
(reddish for the first 12 hrs.)
 Monitor for sign of leakage of 
anastomosis, e.g. dyspnea, pain, fever, 
when oral fluids are initiated
 Small, frequent feedings
 Monitor for early satiety and 
regurgitation
 Eat less food at a slower pace
 Monitor weight regularly
Summary of Nursing Management of the
Patient undergoing Gastric Surgery

 Prevent potential complications
 Bleeding – first 24 hours, 4th to 7th
day post-op due to non-healing
 Monitor NG drainage for blood
 Avoid unnecessary irrigation or repositioning of the 
NGT
 Monitor for signs of peritonitis:
 Severe abdominal pain, rigidity fever
Dumping Syndrome
DUMPING SYNDROME
A group of unpleasant vasomotor
and G.I. symptoms caused by rapid
emptying of gastric content into the
jejunum.
Abrupt emptying of stomach
contents into the intestine
Common complication of some
types of gastric surgery
Pathophysiology
Pathophysiology
 Nursing Interventions
Eat in a recumbent or semi  recumbent
position
Lie down after a meal
Small, frequent feedings
Moderate fat, high protein diet.
 Fats slow down gastric motility, proteins
increase colloidal osmotic pressure and prevents
shifting of plasma
Limit carbohydrates, no simple sugars
Give fluids few hours after meals or in
between meals
Avoid very hot and cold foods and beverages
 The client is scheduled to have an upper 
gastrointestinal tract series. Which of the 
following treatments should the nurse 
anticipate after the examination?
A. Administering a laxative.
B. Placing the client on a clear liquid diet.
C. Giving the client a tapwater enema.
D. Starting an intravenous infusion.

   
 The client is scheduled to have an upper 
gastrointestinal tract series. Which of the 
following treatments should the nurse 
anticipate after the examination?
A. Administering a laxative.
B. Placing the client on a clear liquid diet.
C. Giving the client a tapwater enema.
D. Starting an intravenous infusion.

   
 A client who has been diagnosed with gastroesophageal 
reflux disease (GERD) complains of heartburn. To decrease 
the heartburn, the nurse should instruct the client to 
eliminate which of the following items from the diet?
A. Lean beef.
B. Air­popped popcorn.
C. Hot chocolate.
D. Raw vegetables.

   
 A client who has been diagnosed with gastroesophageal 
reflux disease (GERD) complains of heartburn. To decrease 
the heartburn, the nurse should instruct the client to 
eliminate which of the following items from the diet?
A. Lean beef.
B. Air­popped popcorn.
C. Hot chocolate.
D. Raw vegetables.

   
 The client with (GERD) complains of a 
chronic cough. The nurse understands that in 
a client with GERD this symptom may be 
indicative of which of the following 
conditions?
A. Development of laryngeal cancer.
B. Irritation of the esophagus.
C. Esophageal scar tissue formation.
D. Aspiration of gastric contents.

   
 The client with (GERD) complains of a 
chronic cough. The nurse understands that in 
a client with GERD this symptom may be 
indicative of which of the following 
conditions?
A. Development of laryngeal cancer.
B. Irritation of the esophagus.
C. Esophageal scar tissue formation.
D. Aspiration of gastric contents.

   
 The client attends two sessions with the dietitian to learn 
about diet modifications to minimize gastroesophageal 
reflux. The teaching would be considered successful if the 
client says that she will decrease her intake of which of the 
following food?
A. Fats.
B. High­sodium foods.
C. Carbohydrates.
D. High­calcium foods.

   
 The client attends two sessions with the dietitian to learn 
about diet modifications to minimize gastroesophageal 
reflux. The teaching would be considered successful if the 
client says that she will decrease her intake of which of the 
following food?
A. Fats.
B. High­sodium foods.
C. Carbohydrates.
D. High­calcium foods.

   
 Which of the following dietary measures 
would be useful in preventing esophageal 
reflux?
A. Eating small, frequent meals.
B.  Increasing fluid intake.
C. Avoiding air swallowing with meals.
D. Adding a bedtime snack to the dietary plan.

   
 Which of the following dietary measures 
would be useful in preventing esophageal 
reflux?
A. Eating small, frequent meals.
B.  Increasing fluid intake.
C. Avoiding air swallowing with meals.
D. Adding a bedtime snack to the dietary plan.

   
 A client with peptic ulcer disease tells the nurse that he has 
black stools, which he has not reported to his physician. 
Based on this information, which nursing diagnosis would 
be appropriate for this client?
A. Ineffective Coping related to fear of diagnosis of chronic 
illness.
B. Deficient Knowledge related to unfamiliarity with 
significant signs and symptoms.
C. Constipation related to decreased gastric motility.
D. Imbalanced Nutrition: Less Than Body Requirements 
related to gastric bleeding.
   
 A client with peptic ulcer disease tells the nurse that he has 
black stools, which he has not reported to his physician. 
Based on this information, which nursing diagnosis would 
be appropriate for this client?
A. Ineffective Coping related to fear of diagnosis of chronic 
illness.
B. Deficient Knowledge related to unfamiliarity with 
significant signs and symptoms.
C. Constipation related to decreased gastric motility.
D. Imbalanced Nutrition: Less Than Body Requirements 
related to gastric bleeding.
   
 The client asks the nurse what causes a 
peptic ulcer to develop. The nurse responds 
that recent research indicates that many 
peptic ulcers are the result of which of the 
following?
A. Work­related stress.
B. Helicobacter pylori infection.
C. Diets high in fat.
D. A genetic defect in the gastric mucosa.

   
 The client asks the nurse what causes a 
peptic ulcer to develop. The nurse responds 
that recent research indicates that many 
peptic ulcers are the result of which of the 
following?
A. Work­related stress.
B. Helicobacter pylori infection.
C. Diets high in fat.
D. A genetic defect in the gastric mucosa.

   
 A client with a peptic ulcer reports epigastric pain that 
frequently awakens her during the night, a feeling of 
fullness in the abdomen, and a feeling of anxiety about her 
health. Based on this information, which nursing diagnosis 
would be most appropriate? 
A. Imbalanced Nutrition: Less than Body Requirements 
related to anorexia.
B. Disturbed Sleep Pattern related to epigastric pain.
C. Ineffective Coping related to exacerbation of duodenal 
ulcer.
D. Activity Intolerance related to abdominal pain.
   
 A client with a peptic ulcer reports epigastric pain that 
frequently awakens her during the night, a feeling of 
fullness in the abdomen, and a feeling of anxiety about her 
health. Based on this information, which nursing diagnosis 
would be most appropriate? 
A. Imbalanced Nutrition: Less than Body Requirements 
related to anorexia.
B. Disturbed Sleep Pattern related to epigastric pain.
C. Ineffective Coping related to exacerbation of duodenal 
ulcer.
D. Activity Intolerance related to abdominal pain.
   
 The nurse is preparing to teach a client with a peptic 
ulcer about the diet that should be followed after 
discharge. The nurse should explain that the diet 
will most likely consist of which of the following?
A. Bland foods.
B. High­protein foods.
C. Any foods that are tolerated.
D. Large amounts of milk.

   
 The nurse is preparing to teach a client with a peptic 
ulcer about the diet that should be followed after 
discharge. The nurse should explain that the diet 
will most likely consist of which of the following?
A. Bland foods.
B. High­protein foods.
C. Any foods that are tolerated.
D. Large amounts of milk.

   
 The nurse finds a client who has been diagnosed 
with a peptic ulcer surrounded by papers from his 
briefcase and arguing on the telephone with a 
coworker. The nurse’s response to observing these 
actions should be based on knowledge that:
A. Involvement with his job will keep the client from 
becoming bored. 
B. A relaxed environment will promote ulcer healing.
C. Not keeping up with his job will increase the client’s 
stress level.
D. Setting limits on the client’s behavior is an important 
nursing responsibility.

   
 The nurse finds a client who has been diagnosed 
with a peptic ulcer surrounded by papers from his 
briefcase and arguing on the telephone with a 
coworker. The nurse’s response to observing these 
actions should be based on knowledge that:
A. Involvement with his job will keep the client from 
becoming bored. 
B. A relaxed environment will promote ulcer healing.
C. Not keeping up with his job will increase the client’s 
stress level.
D. Setting limits on the client’s behavior is an important 
nursing responsibility.

   
 A client with a peptic ulcer has been instructed to 
avoid intense physical activity and stress. Which 
activity should the client incorporate into the home 
care plan?
A. Conduct physical activity in the morning so that he can 
rest in the afternoon.
B. Have the family agree to perform the necessary yard 
work at home.
C. Give up jogging and substitute a less demanding hobby.
D. Incorporate periods of physical and mental rest in his 
daily schedule.

   
 A client with a peptic ulcer has been instructed to 
avoid intense physical activity and stress. Which 
activity should the client incorporate into the home 
care plan?
A. Conduct physical activity in the morning so that he can 
rest in the afternoon.
B. Have the family agree to perform the necessary yard 
work at home.
C. Give up jogging and substitute a less demanding hobby.
D. Incorporate periods of physical and mental rest in his 
daily schedule.

   
 A client is to take one daily dose of ranitidine, (Zantac) at 
home to treat her peptic ulcer. The nurse knows that the 
client understands proper drug administration of ranitidine 
when she says that she will take the drug at which of the 
following times?
A. Before meals.
B. With meals.
C. At bedtime.
D. When pain occurs.

   
 A client is to take one daily dose of ranitidine, (Zantac) at 
home to treat her peptic ulcer. The nurse knows that the 
client understands proper drug administration of ranitidine 
when she says that she will take the drug at which of the 
following times?
A. Before meals.
B. With meals.
C. At bedtime.
D. When pain occurs.

   
 A client has been taking aluminum hydroxide (Amphojel) 
30 mL six times per day at home to treat his peptic ulcer. He 
tells the nurse that he has been unable to have a bowel 
movement for 3 days.  Based on this information, the nurse 
would determine that which of the following is the most 
likely cause of the client’s constipation?
A. The client has not been including enough fiber in his diet.
B. The client needs to increase his daily exercise.
C. The client is experiencing a side effect of the aluminum 
hydroxide.
D. The client has developed a gastrointestinal obstruction.

   
 A client has been taking aluminum hydroxide (Amphojel) 
30 mL six times per day at home to treat his peptic ulcer. He 
tells the nurse that he has been unable to have a bowel 
movement for 3 days.  Based on this information, the nurse 
would determine that which of the following is the most 
likely cause of the client’s constipation?
A. The client has not been including enough fiber in his diet.
B. The client needs to increase his daily exercise.
C. The client is experiencing a side effect of the aluminum 
hydroxide.
D. The client has developed a gastrointestinal obstruction.

   
   
 Intestinal Obstruction
 Mechanical intestinal obstruction:  physical 
blockage of the passage of intestinal contents with 
subsequent distention by fluid and gas caused by:
 Adhesion
Hernias
Volvulus
Intussusceptions
Inflammatory bowel disease
Foreign bodies
Strictures
Neoplasmas
  Fecal impaction  
   
 Intestinal Obstruction
 Paralytic ileus (neurogenic or adynamic ileus):         
     interference with the nerve supply to the 
intestine resulting in decreased or absent peristalsis 
caused by:
 abdominal surgery
 peritonitis
 pancreatic toxic conditions
 shock
 spinal cord injuries
 electrolyte imbalances (especially hypokalemia)

   
 Intestinal Obstruction
 Vascular obstructions: interference with the 
blood supply to the portion of the intestine, 
resulting in ischemia and gangrene of the 
bowel caused by:
 an embolus
 atherosclerosis

   
 Assessment findings
 Small intestine: non­ fecal vomiting; 
colicky intermittent abdominal pain
 Large intestine: cramplike abdominal pain, 
occasional fecal vomitus; client will be 
unable to pass stools or flatus.
 Abdominal distention
 Abdominal rigidity
 High­ pitch bowel sounds above the level of the 
obstruction
 Decreased or absent bowel sound distal to 
obstruction
   
 Small Bowel Large Bo we l

 Abdominal discomfort or 
 Intermittent lower abdominal 
pain possibly accompanied 
by visible peristaltic waves  cramping
in upper and middle   Lower abdominal cramping
abdomen  Minimal  or no vomiting 
 Upper or epigastric  (may contain fecal material)
abdominal distention
  Obstipation or ribbon like 
 Nausea and early, profuse 
vomiting stool
 Obstipation  No major F and E imbalance
 Severe F and E imbalances  Metabolic Acidosis
 Metabolic alkalosis

   
 Diagnostic tests
 Flat­plate (x­ray) of the abdomen reveals the 
presence of the gas and fluid (air – fluid levels)
 Hct increased
 Serum sodium, potassium, chloride decreased
 BUN increased (from dehydration and loss of 
plasma volume)

   
 Nursing Interventions
Monitor fluid and electrolyte balance, 
prevent further imbalance, keep client NPO 
and administer IV fluids as ordered.
Accurately measure drainage from NG/ 
intestinal tube.
Place client in fowler’s position to alleviate 
pressure on diaphragm and encourage nasal 
breathing to minimize swallowing of air and 
further abdominal distention.

   
 Nursing Interventions
 Institute comfort measures associated with 
NG intubation and intestinal decompression.
 Prevent complications.
 Measure abdominal girth daily to assess for 
increasing abdominal distention.
 Assess for signs and symptoms of peritonitis.
Monitor urinary output.

   
 The physician orders intestinal decompression with 
a Cantor tube for the client. The primary purpose of 
a nasoenteric tube such as a Cantor tube is to 
accomplish which of the following?
A. Remove fluid and gas from the intestine.
B. Prevent fluid accumulation in the stomach.
C. Break up the obstruction.
D. Provide an alternative route for drug administration.

   
 The physician orders intestinal decompression with 
a Cantor tube for the client. The primary purpose of 
a nasoenteric tube such as a Cantor tube is to 
accomplish which of the following?
A. Remove fluid and gas from the intestine.
B. Prevent fluid accumulation in the stomach.
C. Break up the obstruction.
D. Provide an alternative route for drug administration.

   
 After insertion of a nasoenteric tube, the 
nurse should place the client in which 
position?
A. Supine.
B. Right side­lying.
C. Semi­Fowler’s.
D. Upright in a bedside chair.

   
 After insertion of a nasoenteric tube, the 
nurse should place the client in which 
position?
A. Supine.
B. Right side­lying.
C. Semi­Fowler’s.
D. Upright in a bedside chair.

   
 Which of the following nursing diagnoses 
would be most appropriate for a client with 
an intestinal obstruction?
A. Impaired Swallowing related to NPO status.
B. Urinary Retention related to deficient fluid 
volume.
C. Deficient Fluid Volume related to nausea and 
vomiting.
D. Chronic Pain related to abdominal distention.
   
 Which of the following nursing diagnoses 
would be most appropriate for a client with 
an intestinal obstruction?
A. Impaired Swallowing related to NPO status.
B. Urinary Retention related to deficient fluid 
volume.
C. Deficient Fluid Volume related to nausea and 
vomiting.
D. Chronic Pain related to abdominal distention.
   
   
 Ulcerative
Colitis
Is a recurrent ulcerative and inflammatory
disease of the mucosal and submucosal layer of the
colon and rectum.
Is a serious disease, accompanied by systemic
complications and a high mortality rate.
The incidence of the disease is highest in
Caucasians and people of Jewish heritage.
Ulcerative Colitis
Signs and Symptoms:
Predominant Symptoms
 diarrhea, abdominal pain, rectal bleeding
Pallor; if bleeding is severe
Anorexia
Weight Loss
Dehydration
Cramping
Anemia
Skin Lesions
Rebound tenderness in right lower quadrant
Joint Abnormalities
 PATHOPHYSIOLOGY
ulcerations

bleeding

Mucosa becomes edematous and inflamed

Abscesses form

Infiltrates is seen in the mucosa and submucosa with clumps of neutrophils (crypt abscess)

Begins in the rectum

Proximally to involve the entire colon

Macular Hypertrophy / fat deposits

Bowel narrows, shortens and thickens

 Gross appearance – UC
 The most intense
inflammation begins at the
lower right in the sigmoid
colon and extends upward and
around to the ascending colon.
 At the lower left is the
ileocecal valve with a portion of
terminal ileum that is not
involved.
 Inflammation with ulcerative
colitis tends to be continuous
along the mucosal surface and
tends to begin in the rectum.
   
 Treatment

Diet and Fluid intake

Oral fluids, low-residue diets; supplemental
vitamin therapy; and iron replacement
IV Therapy
Smoking Cessation
Avoiding foods that exacerbate symptoms,
such as milk and cold foods
Parental Nutrition (PN) may be provided as
indicated
 Treatment

Pharmacologic therapy
Sedative, antidiarrheal, and antiperistaltic
medications
Sulfasalazine (Azulfidine) – Which are effective
for mild or moderate inflammation.
Given with a glass of water to prevent stone
precipitation
Antibiotics for secondary infections
Adrenocortico tropic hormone (ACTH) and
certicosteroids (↓ bleeding)
Aminosalicylates (Topical and oral)
Immunomodulator agent (eg. IMURAN)
 Treatment
Surgical management
Total colectomy with ileostomy – An opening
into the ileum or small intestine (usually by
means of an ileal stoma on the abdominal wall) is
commonly performed after a total colectomy
(i.e. Excision of the entire colon).
Total Colectomy with continent ileostomy –
Involves the removal of the entire colon and
creation of the continent ileal reservoir (i.e. Cock
pouch)
Total Colectomy with ileonal anastomosis –
Surgical procedures that eliminates the need for a
permanent ileostomy. It establishes an ileal
reservoir and anal sphincter control of elimination
is retained.
 The client with 
ILEOSTOMY
 Provide explanation of pre­operative and post­
operative procedures
 Oral antibiotics  to ↓ intestinal bacteria thus 
↓potential for peritonitis and wound infection post­op
 Maintain fluid and electrolyte imbalance
 Self – care activities; minimize odor formation
 WOF: obstruction as evidenced by sudden decrease in 
drainage or onset of severe abdominal pain, vomiting

   
Nursing Interventions

1. Maintaining Normal Elimination

 Determine if there is a relationship
between diarrhea and certain foods, activities,
or emotional stress
 Encourage bed rest to decrease peristalsis
2. Relieving Pain
 Administer anticholinergic medications 30
mins. before a meal to decrease intestinal
motility
 Give Analgesic agents as prescribed
Nursing Interventions

3. Maintaining Fluid balance

 Record I and 0 including wound / fistula
drainage
 Monitor weight daily
 Assess for signs of fluids volume deficit
 Encourage oral intake
Nursing Interventions

4. Promoting Nutritional measures

 Use PN when symptoms are severe
 Test for glucose daily
 Give feeding high in protein and low in
fat and reside after PN therapy
 Provide small frequent, low residue
feedings if oral foods are tolerated

5. Promoting rest
 Recommend intermittent rest periods
during the day
Encourage activity within limits
Nursing Interventions
6. Reducing Anxiety
 Establish report by being attentive and
displaying a calm confidence manner
 Tailor information about impending
surgery to patients level of understanding and
desire for detail

7. Promoting coping skills

 Provide understanding and emotional
support to patient who feels isolated helpless and
out of control
 Use stress-reduction measures: relaxation
techniques breathing exercises and biofeedback
Crohn’s Disease
 “REGIONAL ENTERITIS”

 Is an inflammatory disease of the GIT affecting

usually the small intestine

 Commonly occurs in adolescents and young

adults
Signs and Symptoms:
- Anorexia, n/v
- Weight Loss
- Anemia
- Fever
- Abdominal distention
- Diarrhea (bloody)
- Colicky abdominal pain
 Pathophysiology
Edema and thickening of the
transmucosa

Ulcers begin to appear on infammed mucosa

(lesions are discontinuous and separated by normal tissue)

Formation of fistulas, fissures & abscesses (extends into the peritoneum)

GRANULOMAS

Bowel wall thickens and become

fibrotic

Intestinal lumen narrows

Diseased bowel loops

(sometimes adhere to other loops)
 Gross appearance – CD
• This portion of terminal ileum
demonstrates the gross findings with
Crohn's disease.
• Though any portion of the
gastrointestinal tract may be involved
with Crohn's disease, the small
intestine--and the terminal ileum in
particular--is most likely to be
involved.
• The middle portion of bowel seen
here has a thickened wall and the
mucosa has lost the regular folds.
• The serosal surface demonstrates
reddish indurated adipose tissue that
creeps over the surface.
• Serosal inflammation leads to
adhesions.
• The areas of inflammation tend to
  be  discontinuous throughout the
bowel.
 Nursing
Interventions
 Maintain NPO during the active phase

 Monitor for complications like severe

bleeding , dehydration, electrolyte imbalance

 Monitor bowel sounds, stool and blood

studies

 Restrict activities
 Nursing

Interventions
Administer IVF, electrolytes and TPN if
prescribed

 Instruct the patient to AVOID gas-forming

foods,milk products and foods such as whole
grains, nuts, raw fruits and vegetables, pepper,
alcohol and caffeine

 Diet progression  clear fluid to low residue,

high protein diet

 Administer drugs  anti-inflammatory,

antibiotics, steroids, bulk-forming agents and
vitamin/iron supplements
 Crohn’s Disease Ulcerative Colitis

Transmural Mucous ulceration

Ileum/ascending colon Rectum/ lower colon
Cause Unknown Unknown
Jewish Familial
Environmental Jewish
Emotional stress
Age 20-30 years 15-40 years
40-60 years
Bleeding ; stool with pus and mucus Severe; stool with blood, pus and mucus
Perianal involvement Severe Mild
Fistulas Common Rare
Rectal involvement 20% 100%
Diarrhea 5-6 soft stool/ day 20-30 watery stool/ day
Abdominal pain + +
Weight loss + +
Intervention TPN Diet
Steriods TPN
Azulfidine (Sulfasalazine) Steriods
Ileostomy Azulfidine (Sulafasalazine)
  Colectomy   Ileostomy/
Proctocolectomy
 A client who had ulcerative colitis for the past 5 years is 
admitted to the hospital with an exacerbation of the disease. 
Which of the following factors was most likely of greatest 
significance in causing an exacerbation of ulcerative colitis?
A. A demanding and stressful job.
B. Changing to a modified vegetarian diet.
C. Beginning a weight­training program.
D. Walking 2 miles everyday.

   
 A client who had ulcerative colitis for the past 5 years is 
admitted to the hospital with an exacerbation of the disease. 
Which of the following factors was most likely of greatest 
significance in causing an exacerbation of ulcerative colitis?
A. A demanding and stressful job.
B. Changing to a modified vegetarian diet.
C. Beginning a weight­training program.
D. Walking 2 miles everyday.

   
 Which goal for the client’s care should take 
priority during the first days of 
hospitalization for an exacerbation of 
ulcerative colitis?
A. Promoting self­care and independence.
B. Managing   diarrhea.
C. Maintaining adequate nutrition.
D. Promoting rest and comfort.

   
 Which goal for the client’s care should take 
priority during the first days of 
hospitalization for an exacerbation of 
ulcerative colitis?
A. Promoting self­care and independence.
B. Managing   diarrhea.
C. Maintaining adequate nutrition.
D. Promoting rest and comfort.

   
 The client with ulcerative colitis is following 
orders for bed rest with bathroom privileges. 
Which would be the primary rationale for 
this activity restriction? 
A. To conserve energy.
B. To reduce intestinal peristalsis.
C. To promote rest and comfort.
D. To prevent injury.

   
 The client with ulcerative colitis is following 
orders for bed rest with bathroom privileges. 
Which would be the primary rationale for 
this activity restriction? 
A. To conserve energy.
B. To reduce intestinal peristalsis.
C. To promote rest and comfort.
D. To prevent injury.

   
 A client who has ulcerative colitis says to the nurse, 
“I can’t take this anymore! I’m constantly in pain, 
and I can’t leave my room because I need to stay by 
the toilet. I don’t know how to deal with this.” 
Based on these comments, an appropriate nursing 
diagnosis for this client would be
A. Impaired Physical Mobility related to fatigue.
B. Disturbed Thought Processes related to pain.
C. Social Isolation related to chronic fatigue.
D. Ineffective Coping related to chronic abdominal pain.
   
 A client who has ulcerative colitis says to the nurse, 
“I can’t take this anymore! I’m constantly in pain, 
and I can’t leave my room because I need to stay by 
the toilet. I don’t know how to deal with this.” 
Based on these comments, an appropriate nursing 
diagnosis for this client would be
A. Impaired Physical Mobility related to fatigue.
B. Disturbed Thought Processes related to pain.
C. Social Isolation related to chronic fatigue.
D. Ineffective Coping related to chronic abdominal pain.
   
 A client newly diagnosed with ulcerative colitis has been 
placed on steroids. He states that he has heard that taking 
steroids can be dangerous and asks the nurse why steroids 
are prescribed. Which of the following statements by the 
nurse provides the client with accurate information about the 
use of steroid therapy in the treatment of ulcerative colitis?
A. “Ulcerative colitis can be cured by the use of steroids.”
B. “Steroids are used in severe flare­ups because they can 
decrease the incidence of bleeding.”
C. “Long­term use of steroids will prolong periods of 
remission.”
D. “The side effects of steroids outweigh their benefit to 
clients with ulcerative colitis.”

   
 A client newly diagnosed with ulcerative colitis has been 
placed on steroids. He states that he has heard that taking 
steroids can be dangerous and asks the nurse why steroids 
are prescribed. Which of the following statements by the 
nurse provides the client with accurate information about the 
use of steroid therapy in the treatment of ulcerative colitis?
A. “Ulcerative colitis can be cured by the use of steroids.”
B. “Steroids are used in severe flare­ups because they can 
decrease the incidence of bleeding.”
C. “Long­term use of steroids will prolong periods of 
remission.”
D. “The side effects of steroids outweigh their benefit to 
clients with ulcerative colitis.”

   
 A client who has ulcerative colitis has persistent diarrhea. 
He is thin and has lost 12 pounds since the exacerbation of 
his ulcerative colitis. The nurse should anticipate that the 
physician will order which of the following treatment 
approaches to help the client meet his nutritional needs?
A. Initiate continuous enteral feedings.
B. Encourage a high­calorie, high­protein diet.
C. Implement total parenteral nutrition.
D. Provide six small meals a day.

   
 A client who has ulcerative colitis has persistent diarrhea. 
He is thin and has lost 12 pounds since the exacerbation of 
his ulcerative colitis. The nurse should anticipate that the 
physician will order which of the following treatment 
approaches to help the client meet his nutritional needs?
A. Initiate continuous enteral feedings.
B. Encourage a high­calorie, high­protein diet.
C. Implement total parenteral nutrition.
D. Provide six small meals a day.

   
 The physician prescribes sulfasalazine 
(Azulfidine) for the client with ulcerative 
colitis to continue taking at home. What 
instructions should the nurse give the client 
about taking this medication? 
A. Avoid taking it with food.
B. Take the total dose at bedtime.
C. Take it with a full glass (240 mL) of water.
D. Stop taking it if urine turns orange yellow.

   
 The physician prescribes sulfasalazine 
(Azulfidine) for the client with ulcerative 
colitis to continue taking at home. What 
instructions should the nurse give the client 
about taking this medication? 
A. Avoid taking it with food.
B. Take the total dose at bedtime.
C. Take it with a full glass (240 mL) of water.
D. Stop taking it if urine turns orange yellow.

   
 Which of the following diets would be most 
appropriate for the client with ulcerative 
colitis?
A. High calorie, low protein.
B. High protein, low residue.
C. Low fat, high fiber.
D. Low sodium, high carbohydrate.

   
 Which of the following diets would be most 
appropriate for the client with ulcerative 
colitis?
A. High calorie, low protein.
B. High protein, low residue.
C. Low fat, high fiber.
D. Low sodium, high carbohydrate.

   
 Which of the following would be a priority 
focus of care for a client experiencing an 
exacerbation of his Crohn’s disease?
A. Encouraging regular ambulation.
B. Promoting bowel rest.
C. Maintaining current weight.
D. Decreasing episodes of rectal bleeding.

   
 Which of the following would be a priority 
focus of care for a client experiencing an 
exacerbation of his Crohn’s disease?
A. Encouraging regular ambulation.
B. Promoting bowel rest.
C. Maintaining current weight.
D. Decreasing episodes of rectal bleeding.

   
 A client ulcerative colitis symptoms have 
been present for longer than 1 week. The 
nurse recognizes that the client should be 
assessed carefully for signs of which of the 
following complications?
A. Heart failure.
B. Deep vein thrombosis.
C. Hypokalemia.
D. Hypocalcemia.

   
 A client ulcerative colitis symptoms have 
been present for longer than 1 week. The 
nurse recognizes that the client should be 
assessed carefully for signs of which of the 
following complications?
A. Heart failure.
B. Deep vein thrombosis.
C. Hypokalemia.
D. Hypocalcemia.

   
 A client is scheduled for an ileostomy. Which of the 
following interventions would be most helpful in preparing 
the client psychologically for the surgery?
A. Include family members in preoperative teaching 
sessions.
B. Encourage the client to ask questions about managing an 
ileostomy.
C. Provide a brief, thorough explanation of all preoperative 
and postoperative procedures.
D. Invite a member of the ostomy association to visit the 
client.
   
 A client is scheduled for an ileostomy. Which of the 
following interventions would be most helpful in preparing 
the client psychologically for the surgery?
A. Include family members in preoperative teaching 
sessions.
B. Encourage the client to ask questions about managing an 
ileostomy.
C. Provide a brief, thorough explanation of all preoperative 
and postoperative procedures.
D. Invite a member of the ostomy association to visit the 
client.
   
 A client who is scheduled for an ileostomy has an order for 
oral neomycin to be administered before surgery. The nurse 
understands that the rationale for administering oral 
neomycin before surgery is to 
A. Prevent postoperative bladder infection.
B. Reduce the number of intestinal bacteria.
C. Decrease the potential for postoperative hypostatic 
pneumonia.
D. Increase the body’s immunologic response to the 
stressors of surgery.

   
 A client who is scheduled for an ileostomy has an order for 
oral neomycin to be administered before surgery. The nurse 
understands that the rationale for administering oral 
neomycin before surgery is to 
A. Prevent postoperative bladder infection.
B. Reduce the number of intestinal bacteria.
C. Decrease the potential for postoperative hypostatic 
pneumonia.
D. Increase the body’s immunologic response to the 
stressors of surgery.

   
 Of the following outcomes for client care 
after an ileostomy, which has the highest 
priority?
A. Providing relief from constipation.
B. Assisting the client with self­care activities.
C. Maintaining fluid and electrolyte balance.
D. Minimizing odor formation.

   
 Of the following outcomes for client care 
after an ileostomy, which has the highest 
priority?
A. Providing relief from constipation.
B. Assisting the client with self­care activities.
C. Maintaining fluid and electrolyte balance.
D. Minimizing odor formation.

   
 The client asks the nurse, “Is it really possible to lead a 
normal life with an ileostomy?” Which action by the nurse 
would be the most effective to address this question?
A. Have the client talk with a member of the clergy about 
these concerns.
B. Tell the client to worry about those concerns after 
surgery.
C. Arrange for a person with an ostomy to visit the client 
preoperatively.
D. Notify the surgeon of the client’s question.

   
 The client asks the nurse, “Is it really possible to lead a 
normal life with an ileostomy?” Which action by the nurse 
would be the most effective to address this question?
A. Have the client talk with a member of the clergy about 
these concerns.
B. Tell the client to worry about those concerns after 
surgery.
C. Arrange for a person with an ostomy to visit the client 
preoperatively.
D. Notify the surgeon of the client’s question.

   
 The nurse should instruct the client with an 
ileostomy to report which of the following 
symptoms immediately?
A. Passage of liquid stool from the stoma.
B. Occasional presence of undigested food in the 
effluent.
C. Absence of drainage from the ileostomy for 6 or 
more hours.
D. Temperature of 99.8F (37.7C).
   
 The nurse should instruct the client with an 
ileostomy to report which of the following 
symptoms immediately?
A. Passage of liquid stool from the stoma.
B. Occasional presence of undigested food in the 
effluent.
C. Absence of drainage from the ileostomy for 6 or 
more hours.
D. Temperature of 99.8F (37.7C).
   
   
 DIGESTIVE DISORDERS
APPENDICITIS
Infectious and inflammatory process of the appendix
creating acute abdominal pain and nausea.

Signs & Symptoms

Vague epigastric or peri-umbilical pain which
progress to right lower quadrant pain
Low-grade fever
Nausea
Vomiting
Loss of appetite
Local tenderness when pressure is applied
   
 This is the normal appearance of the appendix against the
background of the cecum.

   
This appendix was removed surgically. The patient presented with abdominal pain
that initially was generalized, but then localized to the right lower quadrant, and
physical examination disclosed 4+ rebound tenderness in the right lower quadrant.
The WBC count was elevated at 11,500. Seen here is acute appendicitis with
yellow to tan exudate and hyperemia, including the periappendiceal
   
fat superiorly, rather than a smooth, glistening pale tan serosal surface.
 DIGESTIVE DISORDERS
Pain gradually becomes localized in RLQ / Mc
Burney’s point (halfway between the umbilicus
and the anterior spine of the ileum)
• Pain is initially intermittent then
become steady and severe over a short
period.

Rebound tenderness (Blumberg sign)

 Psoas sign (lateral position with right hip
flexion)
 Rovsing’s sign (right quadrant pain when the
left is palpated)
 Obturator sign (pain on external rotation of the
   
right thigh)
 McBurney's point is located one third of the
distance along a line from the front of the right
pelvic bone and the belly button.

   
Pathophysiology
DIGESTIVE DISORDERS
Inflammation
↓
↑ Intraluminal pressure
↓
∗ Lymphoid Swelling
∗ ↓ Venous drainage
∗ Thrombosis
∗ Bacterial invasion
↓
Abscess
↓
Gangrene
↓
Perforation (24-36hrs)
↓
   
Peritonitis
 DIGESTIVE DISORDERS
Treatment
1. Antibiotics
2. Analgesics given post – op
3. Appendectomy
4. General or spinal anesthetic with a low abdominal
incision or by laparoscopy

Goals:
 Bed rest
• NPO
• Relieve pain (cold application over the abdomen NEVER heat)
• Avoid factors that increase peristalsis, thereby rupture:
 Heat application over the abdomen
 Laxative
   Enema  
 REVIEW QUESTIONS

 4 items

   
 In a client with acute appendicitis, the nurse 
should anticipate which of the following 
treatments?
A. Administration of enemas to clean bowel.
B. Insertion of a nasogastric tube.
C. Placement of client on NPO status.
D. Administration of heat to the abdomen.

   
 In a client with acute appendicitis, the nurse 
should anticipate which of the following 
treatments?
A. Administration of enemas to clean bowel.
B. Insertion of a nasogastric tube.
C. Placement of client on NPO status.
D. Administration of heat to the abdomen.

   
 A client with acute appendicitis develops a 
fever, tachycardia, and hypotension. Based 
on these assessment findings, the nurse 
suspects which of the following 
complications?
A. Deficient fluid volume.
B. Intestinal obstruction.
C. Bowel ischemia.
D. Peritonitis.

   
 A client with acute appendicitis develops a 
fever, tachycardia, and hypotension. Based 
on these assessment findings, the nurse 
suspects which of the following 
complications?
A. Deficient fluid volume.
B. Intestinal obstruction.
C. Bowel ischemia.
D. Peritonitis.

   
 Postoperative nursing care for a client after 
an appendectomy would include which of the 
following interventions?
A. Administering sitz baths four times a day.
B. Noting the first bowel movement after surgery.
C. Limiting the client’s activity to bathroom 
privileges.
D. Measuring abdominal girth every 2 hours.

   
 Postoperative nursing care for a client after 
an appendectomy would include which of the 
following interventions?
A. Administering sitz baths four times a day.
B. Noting the first bowel movement after surgery.
C. Limiting the client’s activity to bathroom 
privileges.
D. Measuring abdominal girth every 2 hours.

   
 A client who had an appendectomy for a perforated 
appendix returns from surgery with a drain inserted 
in the incisional site. The nurse understands that the 
purpose of the drain is to accomplish which of the 
following?
A. Provide access for wound irrigation.
B. Promote drainage of wound exudates.
C. Minimize development of scar tissue.
D. Decrease postoperative discomfort.

   
 A client who had an appendectomy for a perforated 
appendix returns from surgery with a drain inserted 
in the incisional site. The nurse understands that the 
purpose of the drain is to accomplish which of the 
following?
A. Provide access for wound irrigation.
B. Promote drainage of wound exudates.
C. Minimize development of scar tissue.
D. Decrease postoperative discomfort.

   
   
 Peritonitis
 Local or generalized inflammation of part or all 
of the parietal and visceral surfaces of the 
abdominal cavity.
 Initial response: edema, vascular congestion, 
hypermotility of the bowel and outpouring 
plasma­like fluid from the extracellular, vascular 
and interstitial compartments into the peritoneal 
space.
 Later response: abdominal distention leading to 
respiratory compromise, hypovolemia results in 
decreased urinary output.

   
 Peritonitis
 Intestinal motility gradually decrease and 
progresses to paralytic ileus.
 Caused by trauma (blunt or penetrating), 
inflammation (ulcerative colitis, 
diverticulitis), volvulus, interstitial 
ischemia, or intestinal obstruction.

   
 Causes
Ruptured appendix
Perforated peptic ulcer
Diverticulitis
Pelvic inflammatory disease
Urinary tract infection or trauma
Bowel obstruction
Bacteria invasion

   
 Pathophysiolo
gy
Inflammatio
n
Fluid shift
into
abdominal
Adhesio cavity (300-
ns 500 ml.)
Abscess  Peristalsis

Intestinal Bowel distended with gas

Obstructio & fluid
n

Hypovolemia
Electrolyte
imbalance
Dehydration
Shock
   
 Medical Management
NPO with fluid replacement.
Drug therapy: antibiotics to combat 
infection
Surgery
 Laparatomy: opening made through the 
abdominal wall into the peritoneal cavity to 
determine the cause of peritonitis.
 Depending on cause, bowel resection may be 
necessary.

   
 Assessment findings
Severe abdominal pain, rebound tenderness, muscle 
ridigity, absent bowel sounds, abdominal distention 
(particularly if large bowel obstruction).
Anorexia, nausea and vomiting
Swallow respirations; decreased urinary output; 
weak,rapid pulse; elevated temperature.
Signs of shock
Tachycardia
Tachypnea
Oliguria
Restlessness
Weakness pallor
Diaphoresis
   
 Assessment findings
 Diagnostic tests
 WBC elevated WBC (20,000/cu. mm or 
higher)
 Hct elevated (if hemoconcentration)

   
 Nursing Interventions
Assess respiratory status for possible distress.
Assess characteristics of abdominal pain and 
changes overtime.
Administer medications as ordered.
Perform frequent abdominal assessment.
Monitor and maintain fluid and electrolyte balance; 
monitor for sings of septic shock.
Maintain patency of NG or intestinal tubes.
Provide routine pre­and post­op care if surgery 
ordered.

   
 Collaborative Management
Monitor VS, I and O.
NGT is inserted to relieve abdominal distention
Bed rest in semi­fowler’s position
Encourage deep breathing exercises
Insertion of drainage tube
Fluid, electrolytes and colloids replacement
Antibiotics
TPN solutions

   
 DIGESTIVE DISORDERS

HEMORRHOIDS

Dilated blood vessels beneath the

lining of the anal canal

Dilated portions of veins in the anal canal

   
 DIGESTIVE DISORDERS
Signs and Symptoms
Constipation in an effort to prevent pain or
bleeding associated with defecation
Anal pain
Rectal bleeding
Anal itchiness
Mucous secretion from the anus
Sensation of incomplete evacuation of the rectum
Intestinal hemorrhoids may prolapsed
Bright red bleeding
Edema (caused by thrombus)
Ischemia of the area
  Necrosis  
 Pathophysiology

Shearing of the mucosa during

defecation
↓
↑ P during pregnancy or straining , Sliding of the
structures in the anal wall
↓
Inflammation & edema of the anus
↓
Thrombosis of the hemorrhoid
↓
Ischemia
↓
Necrosis
   
 DIGESTIVE DISORDERS
Treatment
Surgery
 Hemorrhoidectomy
 Sclerotherapy (5 % phenol in oil)
 Cryosurgery
 Rubber band ligation
Preop care
Low residue diet to reduce the bulk of stool
Stool softeners
Postop care
Promotion of comfort
Analgesics as prescribed
   
Excision
• For the patient with small, external hemorrhoids, where there is severe
pain, clot formation, and danger of infection, simple excision of the clot may be
all that is necessary.
• This means that after the hemorrhoidal area has been anethesized, a small
incisioin is made in the skin directly over the blood clot.
• The clot is then gently squeezed out with thumb and forefinger.
   
Injection
• This works best for small, internal hemorrhoids that are not prolapsed and where
intermittent bleeding is the only symptom.
• A special solutions is injected into the tissue surrounding the hemorrhoid.
• This solution causes the blood in the swollen veins to clot; the clot eventually
dissolves and pain and bleeding soon disappear.
   
 Banding
• If the hemorrhoids are too large to respond satisfactorily to
injection, and if they are not permanently prolapsed, the banding
technique offers a safe, effective, and painless alternative to surgery.
• In this procedure, rubber bands are placed around the base of
the hemorrhoidal mass.
• In about seven days, the hemorrhoid dries up and sloughs off.

   
 Hemorrhoidectomy
The only method for complete cure of large, permanently protruding
hemorrhoids is surgical removal. This is especially true if other
measures have failed to relieve symptoms. In this operation, all of the
hemorrhoidal tissue is removed from beneath the skin and mucous
membrane. The incision is then closed with sutures. The patient can
usually leave the hospital in six or seven days. Final healing takes three
to four week
   
 DIGESTIVE DISORDERS
Promotion of comfort
Analgesics as prescribed
Side lying position
Hot sitz bath 12-24 hrs. Postop
Promotion of elimination
Stool softener as prescribed
Encourage the client to defecate as soon as the
urge occurs
Analgesic before initial defecation
Enema as prescribed, using a small-bore
rectal tube

   
 DIGESTIVE DISORDERS
Nursing Intervention
High fiber diet
Bulk laxatives
Provide good personal hygiene
Increase Fluid intake
Warm compress, sitz bath
Analgesic ointments
Suppositories
Patient teaching

   
 REVIEW QUESTIONS

 4 items

   
 A 36­year­old female client has been 
diagnosed with hemorrhoids. Which of the 
following factors in the client’s history 
would most likely be a primary cause of her 
hemorrhoids?
A. Her age.
B. Three vaginal delivery pregnancies.
C. Her job as a schoolteacher.
D. Varicosities in her legs.

   
 A 36­year­old female client has been 
diagnosed with hemorrhoids. Which of the 
following factors in the client’s history 
would most likely be a primary cause of her 
hemorrhoids?
A. Her age.
B. Three vaginal delivery pregnancies.
C. Her job as a schoolteacher.
D. Varicosities in her legs.

   
 Which position would be ideal for the client 
in the early postoperative period after a 
hemorrhoidectomy?
A. High Fowler’s 
B. Supine.
C. Side­lying.
D. Trendelenburg’s.

   
 Which position would be ideal for the client 
in the early postoperative period after a 
hemorrhoidectomy?
A. High Fowler’s 
B. Supine.
C. Side­lying.
D. Trendelenburg’s.

   
 The nurse instructs the client who has had a 
hemorrhoidectomy not to use sitz baths until 
at least 12 hours postoperatively to avoid 
inducing which of the following 
complications?
A. Hemorrhage.
B. Rectal spasm.
C. Urinary retention.
D. Constipation.

   
 The nurse instructs the client who has had a 
hemorrhoidectomy not to use sitz baths until 
at least 12 hours postoperatively to avoid 
inducing which of the following 
complications?
A. Hemorrhage.
B. Rectal spasm.
C. Urinary retention.
D. Constipation.

   
 The nurse teaches the client who has had rectal 
surgery the proper timing for sitz baths. The nurse 
knows that the client has understood the teaching 
when the client states that it is most important to 
take a sitz bath
A. First thing each morning.
B. As needed for discomfort.
C. After a bowel movement.
D. At bedtime.

   
 The nurse teaches the client who has had rectal 
surgery the proper timing for sitz baths. The nurse 
knows that the client has understood the teaching 
when the client states that it is most important to 
take a sitz bath
A. First thing each morning.
B. As needed for discomfort.
C. After a bowel movement.
D. At bedtime.

   
   
 CHOLECYSTITIS
burn, severe PATHOPHYSIOLOGY
trauma, surgical
   Acute inflammation of the gall 
procedure
Inflammation of the walls of the
bladder. gallbladder

  An empyema of the gall bladder  Edema & thickening of gallbladder

can be caused by calculus, acalculus mucosa

  ↓ blood supply to liver/ gall bladder

 Clinical Manifestation
•         Rigidity of the upper abdomen
•         N&V   ischemia

  
Nursing Interventions necrosis

•         relieve pain
•         improve respiratory status
•         improve nutritional status
•         promote skin care & biliary 
drainage
•         monitoring & managing 
complication
            bleeding  
          loss of appetite 
 CHOLELITHIASIS
• Presence of calculi in the gallbladder
• Increasing prevalence after age 40
• “Silent”, usually detected incidentally during surgery or evaluation for unrelated problems
• 3 F’s (Fat, Female, Forty)
Clinical Manifestations
Distended gall bladder
Fever
Biliary colic with excruciating RUQ pain radiating to the back or right shoulder
Nausea and vomiting (hours after heavy meal)
Restlessness, Jaundice ↓ bile acid synthesis, ↑ cholesterol
synthesis
Dark brown colored urine
Grayish/clay-colored stool Bile becomes supersaturated w/
cholesterol
Precipitation of
PATHOPHYSIOLOGY unconjugated bile Cholesterol stones form
pigment Gall stone

↓ bile transport to
Inflammatory changes in
duodenum =
gallbladder
clay-colored stool

Obstruction of bile passage

↑ bile absorption
by blood =
jaundice Congestion/distension of gall
  dark colored urine  
bladder
 Assessment Findings

 Most patients are asymptomatic
 When symptomatic  RUQ and epigastric pain
 Fever and Leukocytosis in cholecystitis
 CHARCOT TRIAD (fever, jaundice, RUQ pain)
 Intolerance to fatty foods (nausea, vomiting, 
sensation of fullness)

   
   
 Gross appearance of gallbladder after sectioning longitudinally.
Notice thickness of gallbladder wall, abundant stones

   
 • Obesity increases the risk for cholelithiasis.
• Note the mix gallstones with a prominent
component of yellowish cholesterol seen here in an
opened gallbladder removed at surgery.

   
 Treatment

 Reduce the incidence of acute episodes of gall

bladder pain and cholecyctitis by supportive and
dietary management

 Non surgical approaches including lithotripsy

and dissolution of gall stones

 Provide temporary solutions to the problems

associated with gall stones.

 Cholecystectomy – removal of the gall bladder

 CHOLECYSTECTOMY
Pre­op Care
 IV fluids to replace fluid electrolyte 
losses due to vomiting
 Vitamin K injection, especially if the 
prothrombin time is prolonged

   
 CHOLECYSTECTOMY
Post­op Care 
 Position: Low or Semi Fowlers to 
promote lung expansion
 Deep breathing and coughing exercises 
to avoid atelectasis
 Encourage early ambulation post­op
 Diet: Low fat diet for 2 – 3 months

   
 CHOLEDOCHOSTOMY
If with CBD exploration: T – tube 
 Purpose: to drain the bile
 Drainage:
 Brownish red for the first 24 hours 
(combination of bile and blood)
 300 – 500 mL of bile drainage for the 
first 24 hours
 Drainage bottle should be placed in bed 
at the level of incision; this is to drain the 
  excess bile, not all the bile
 
   
   
 Treatment
 Laparoscopic cholecystectomy
 Removal of the gall bladder through a small
incision through the umbilicus.

 Choledochotomy
 Opening of the gallbladder to remove stones

 Ursodeoxycholic acid(UDCA) and

Chenodeoxycholic acid (CDCA)
 Dissolve small gallstones composed of
cholesterol
 Acts by inhibiting the synthesis and secretion of
cholesterol, thereby desaturating the bile.
    203
   
macky 204
    205
Nursing Interventions

 Relieving pain
 MEPERIDINE HCL (drug of choice)
 Do not administer morphine sulfate, this may
cause spasm of the sphincter
 Improving respiratory status
 remind patient to expand lungs fully to prevent
atelectasis, promote early ambulation
 monitor elderly and obese patients
 Improving nutritional status
 advise patient at time of discharge to maintain a
nutritious diet and avoid excessive fats:
Nursing Interventions
Promoting skin care and biliary drainage
 connect tubes to drainage receptacle and
secure tubing to avoid kinking
 place drainage bag in patient’s pocket when
ambulating
 observe for indications of infections, leakage
of bile or obstruction of bile drainage.
 observe for jaundice
 change dressing frequently, using ointment
 keep careful record of intake and output
 measure bile colleted every 24 hours
 document
 REVIEW QUESTIONS

 5 items

   
 A client is admitted to the hospital with a diagnosis of 
cholecystitis. The client is complaining of severe abdominal 
pain and extreme nausea and has vomited several times. 
Based on this data, which nursing diagnosis  would have the 
highest priority for intervention at this time?
A. Anxiety related to severe abdominal discomfort.
B. Deficient Fluid Volume related to vomiting.
C. Pain related to gallbladder inflammation.
D. Imbalanced Nutrition: Less Than Body Requirements 
related to vomiting.

   
 A client is admitted to the hospital with a diagnosis of 
cholecystitis. The client is complaining of severe abdominal 
pain and extreme nausea and has vomited several times. 
Based on this data, which nursing diagnosis  would have the 
highest priority for intervention at this time?
A. Anxiety related to severe abdominal discomfort.
B. Deficient Fluid Volume related to vomiting.
C. Pain related to gallbladder inflammation.
D. Imbalanced Nutrition: Less Than Body Requirements 
related to vomiting.

   
 A client with cholecystitis is complaining of 
severe right upper quadrant pain. Which of 
the following medications would the nurse 
anticipate administering to relieve the 
client’s pain?
A. Meperidine (Demerol).
B. Acetaminophen with codeine.
C. Promethazine (Phenergan).
D. Morphine sulfate.

   
 A client with cholecystitis is complaining of 
severe right upper quadrant pain. Which of 
the following medications would the nurse 
anticipate administering to relieve the 
client’s pain?
A. Meperidine (Demerol).
B. Acetaminophen with codeine.
C. Promethazine (Phenergan).
D. Morphine sulfate.

   
 If a gallstone becomes lodged in the common 
bile duct, the nurse should anticipate that the 
client’s stools would most likely become 
what color?
A. Green.
B. Gray.
C. Black.
D. Brown.

   
 If a gallstone becomes lodged in the common 
bile duct, the nurse should anticipate that the 
client’s stools would most likely become 
what color?
A. Green.
B. Gray.
C. Black.
D. Brown.

   
 Which of the following discharge 
instructions would be appropriate for a client 
who has had a laparoscopic 
cholecystectomy?
A. Avoid showering for 48 hours after surgery.
B. Return to work within 1 week.
C. Change the dressing daily until the incision 
heals.
D. Use acetaminophen (Tylenol) to control any 
fever.
   
 Which of the following discharge 
instructions would be appropriate for a client 
who has had a laparoscopic 
cholecystectomy?
A. Avoid showering for 48 hours after surgery.
B. Return to work within 1 week.
C. Change the dressing daily until the incision 
heals.
D. Use acetaminophen (Tylenol) to control any 
fever.
   
 How much bile would the nurse expect the 
T­tube to drain during the first 24 hours after 
a choledocholithotomy?
A. 50 to 100 mL.
B. 150 to 250mL.
C. 300 to 500 mL.
D. 550 to 700 mL.

   
 How much bile would the nurse expect the 
T­tube to drain during the first 24 hours after 
a choledocholithotomy?
A. 50 to 100 mL.
B. 150 to 250mL.
C. 300 to 500 mL.
D. 550 to 700 mL.

   
   
 DIGESTIVE DISORDERS

DIVERTICULAR DISEASE
• Sac like outpouching or herniation of
the lining of the bowel that protrudes through
a weak portion of the muscle layer.
• Commonly in the colon

   
   
 diverticula

   
 DIGESTIVE DISORDERS
Signs & Symptoms
Diverticulosis
Exist when multiple diverticula are present without
inflammation or symptoms
Common in 60 years old and above
Diverticulitis
Narrowing of large bowel with fibrotic structure
Chronic constipation with episodes of diarrhea
Occult bleeding
Weakness, fatigue and anorexia
Tenderness, palpable mass, fever
Abdominal pain, rigid board like abdomen (due to
development of abscess or perforation)

   
 DIGESTIVE DISORDERS
Pathophysiology
Mucosa and submucosal layers

Increase intraluminal pressure, low volume

in colon, decrease muscle strength

Herniated through muscular wall

Diverticulum

Bowel contents accumulate and

decompose

Inflammation and infection

Obstructed and irritated colon

   
 DIGESTIVE DISORDERS
Treatment
high fiber diet to prevent constipation
clear liquids until inflammation subsides
low fat diet
antibiotics for 7-10 days
laxatives
antispasmodics for spastic pain, taken before
meals an at bed time
stool softeners, warm oil enemas
surgery is necessary if perforation, peritonitis,
abscess formation, hemorrhage or obstruction
occurs, recurrence of diverticula is common.
   
 DIGESTIVE DISORDERS
Nursing Intervention
maintain normal elimination pattern
increase fluid intake to 2L/day
soft food but high fiber content
exercise program to improve abdominal
muscle tone
encourage daily intake of laxatives
relieve pain
analgesics as ordered
monitor and record pain (location and
duration)
monitor and manage potential complications
   
 REVIEW QUESTIONS

 5 items

   
 Which of the following laboratory findings 
would the nurse expect to find in a client 
with diverticulitis?
A. Elevated red blood cell count.
B. Decreased platelet count.
C. Elevated white blood cell count.
D. Elevated serum blood urea nitrogen 
concentration.

   
 Which of the following laboratory findings 
would the nurse expect to find in a client 
with diverticulitis?
A. Elevated red blood cell count.
B. Decreased platelet count.
C. Elevated white blood cell count.
D. Elevated serum blood urea nitrogen 
concentration.

   
 The nurse is aware that the diagnostic test 
typically ordered for acute diverticulitis do 
not include a barium enema
A. Can perforate an intestinal abscess.
B. Would greatly increase the client’s pain.
C. Is of minimal diagnostic value in diverticulitis.
D. Is too lengthly a procedure for the client to 
tolerate.

   
 The nurse is aware that the diagnostic test 
typically ordered for acute diverticulitis do 
not include a barium enema
A. Can perforate an intestinal abscess.
B. Would greatly increase the client’s pain.
C. Is of minimal diagnostic value in diverticulitis.
D. Is too lengthly a procedure for the client to 
tolerate.

   
 Which of the following measures should the 
client with diverticulitis be taught to 
integrate into his daily routine at home?
A. Using enemas to relieve constipation.
B. Decreasing fluid intake to increase the formed 
consistency of the stool.
C. Eating a high­fiber diet when symptomatic with 
diverticulitis.
D. Refraining from straining and lifting activities.
   
 Which of the following measures should the 
client with diverticulitis be taught to 
integrate into his daily routine at home?
A. Using enemas to relieve constipation.
B. Decreasing fluid intake to increase the formed 
consistency of the stool.
C. Eating a high­fiber diet when symptomatic with 
diverticulitis.
D. Refraining from straining and lifting activities.
   
 Which of the following signs would be 
indicative of peritonitis in a client with 
diverticulitis?
a. Hyperactive bowel sounds.
b. Rigid abdominal wall.
c. Explosive diarrhea.
d. Excessive flatulence.

   
 Which of the following signs would be 
indicative of peritonitis in a client with 
diverticulitis?
a. Hyperactive bowel sounds.
b. Rigid abdominal wall.
c. Explosive diarrhea.
d. Excessive flatulence.

   
 Which of the following medications would 
the nurse anticipate administering to a client 
with diverticular disease? 
A. Psyllium hydrophilic mucilloid (Metamucil).
B. Diphenoxylate with atropine sulfate (Lomotil).
C. Diazepam (Valium).
D. Aluminum hydroxide (Amphojel).

   
 Which of the following medications would 
the nurse anticipate administering to a client 
with diverticular disease? 
A. Psyllium hydrophilic mucilloid (Metamucil).
B. Diphenoxylate with atropine sulfate (Lomotil).
C. Diazepam (Valium).
D. Aluminum hydroxide (Amphojel).

   
   
 Acute Pancreatitis
Characterized by edema and
inflammation confined to the pancreas.

Signs & symptoms

Abdominal pain LUQ; may start at the
epigastrium, radiate to the back, flanks
Jaundice
Fever
Nausea & vomiting
Dehydration
Mental confusion
Dyspnea
Tachypnea
Hypotension
   
Absent or decrease bowel sounds
 Criteria on admission to 
hospital
 Age > 55 years old
 WBC  16,000/mm3
 Serum glucose > 200mg/dL (> 11.1 
mmol/L)
 Serum LDH > 350 u/mL 
 AST > 200 u/mL

   
 Pathophysiology
Damage to
pancreatic cells

Inflammation

Edema of the pancreas

and pancreatic duct

Obstruction to the flow

of pancreatic enzyme

Activation of pancreatic
enzymes inside the
pancreas

Auto digestion of the

pancreas

Fatty
Hemorrhage Ulceration Infection
necrosis
   
 DIAGNOSTIC TEST
 Serum AMYLASE and Lipase are increased
 Serum Calcium is decreased
 Calcium combine with fatty acid released by 
lipolysis  soaps
 CT Scan
 Shows enlargement of the pancreas
 Serum Glucose
 Is increased, due to damage to Islet of Langerhans 
causing inadequate insulin secretion

   
 MEDICAL 
MANAGEMENT
 Drug Therapy
Analgesics (DEMEROL) to relieve pain
Smooth muscle relaxant (PAPAVERINE)to relieve pain
Anticholinergics (ATROPINE) to decrease pancreatic 
stimulation
 Diet modification
 NPO usually for a few days to promote GIT rest
 Peritoneal lavage

   
 Nursing Interventions
 Administer analgesics, antacids, anti cholinergic 
as ordered
 Withhold food/fluid and eliminate odor of food 
from environment to ↓pancreatic stimulation
 Maintain nasogastric tube and assess drainage
 Institute non­pharmacologic measures to decrease 
pain (knee chest, fetal position)
 Small frequent feedings instead of three large 
ones (↑CHO, ↑CHON, ↓Fat)

   
 Nursing Interventions

 TPN to provide nutritional supplement during 
acute phase when NPO is instituted
 Calcium supplements to manage hypocalcemia
 Vitamin D to promote calcium absorption
 Insulin to manage hyperglycemia
 Eliminate ALCOHOL totally!

   
 REVIEW QUESTIONS

 8 items

   
 The initial diagnosis of pancreatitis is 
confirmed if the client’s blood work shows a 
significant elevation in which of the 
following serum values?
A. Amylase.
B. Glucose.
C. Potassium.
D. Trypsin.

   
 The initial diagnosis of pancreatitis is 
confirmed if the client’s blood work shows a 
significant elevation in which of the 
following serum values?
A. Amylase.
B. Glucose.
C. Potassium.
D. Trypsin.

   
 The client who has been hospitalized with pancreatitis does 
not drink alcohol because of her religious convictions. She 
becomes upset when the physician persists in asking her 
about alcohol intake. The nurse should explain that the 
reason for these questions is that
A. There is a strong link between alcohol use and acute 
pancreatitis.
B. Alcohol intake can interfere with the tests used to 
diagnose pancreatitis.
C. Alcoholism is a major health problem, and all clients are 
questioned about alcohol intake.
D. The physician must obtain the pertinent facts, regardless 
of religious beliefs.

   
 The client who has been hospitalized with pancreatitis does 
not drink alcohol because of her religious convictions. She 
becomes upset when the physician persists in asking her 
about alcohol intake. The nurse should explain that the 
reason for these questions is that
A. There is a strong link between alcohol use and acute 
pancreatitis.
B. Alcohol intake can interfere with the tests used to 
diagnose pancreatitis.
C. Alcoholism is a major health problem, and all clients are 
questioned about alcohol intake.
D. The physician must obtain the pertinent facts, regardless 
of religious beliefs.

   
 Which of the following signs and symptoms 
would the nurse expect to see in a client with 
acute pancreatitis? 
A. Diarrhea.
B. Jaundice.
C. Hypertension
D. .Ascites 

   
 Which of the following signs and symptoms 
would the nurse expect to see in a client with 
acute pancreatitis? 
A. Diarrhea.
B. Jaundice.
C. Hypertension
D. .Ascites 

   
 The nurse evaluates the client’s most recent 
laboratory data. Which laboratory finding 
would be consistent with a diagnosis of acute 
pancreatitis?
A. Hyperglycemia.
B. Leukopenia.
C. Thrombocytopenia. 
D. Hyperkalemia.

   
 The nurse evaluates the client’s most recent 
laboratory data. Which laboratory finding 
would be consistent with a diagnosis of acute 
pancreatitis?
A. Hyperglycemia.
B. Leukopenia.
C. Thrombocytopenia. 
D. Hyperkalemia.

   
 The initial treatment plan for a client with 
pancreatitis most likely would focus on 
which of the following as a priority?
A. Resting the gastrointestinal tract.
B. Ensuring adequate nutrition.
C. Maintaining fluid and electrolyte balance.
D. Preventing the development of an infection.

   
 The initial treatment plan for a client with 
pancreatitis most likely would focus on 
which of the following as a priority?
A. Resting the gastrointestinal tract.
B. Ensuring adequate nutrition.
C. Maintaining fluid and electrolyte balance.
D. Preventing the development of an infection.

   
 The nurse notes that a client with acute pancreatitis 
occasionally experiences muscle twitching and 
jerking. How should the nurse interpret the 
significance of these symptoms?
A. The client may be developing hypocalcemia.
B. The client is experiencing a reaction to meperidine 
(Demerol).
C. The client has a nutritional imbalance.
D. The client needs a muscle relaxant to help him rest.

   
 The nurse notes that a client with acute pancreatitis 
occasionally experiences muscle twitching and 
jerking. How should the nurse interpret the 
significance of these symptoms?
A. The client may be developing hypocalcemia.
B. The client is experiencing a reaction to meperidine 
(Demerol).
C. The client has a nutritional imbalance.
D. The client needs a muscle relaxant to help him rest.

   
 Which of the following would most likely be 
a major nursing diagnosis for a client with 
acute pancreatitis?
A. Ineffective Airway Clearance.
B. Excess Fluid Volume.
C. Impaired Swallowing.
D. Imbalanced Nutrition: Less Than Body 
Requirements.

   
 Which of the following would most likely be 
a major nursing diagnosis for a client with 
acute pancreatitis?
A. Ineffective Airway Clearance.
B. Excess Fluid Volume.
C. Impaired Swallowing.
D. Imbalanced Nutrition: Less Than Body 
Requirements.

   
 The client with chronic pancreatitis should 
be monitored closely for the development of 
which of the following disorders?
A. Cholelithiasis.
B. Hepatitis.
C. Irritable bowel syndrome.
D. Diabetes mellitus.

   
 The client with chronic pancreatitis should 
be monitored closely for the development of 
which of the following disorders?
A. Cholelithiasis.
B. Hepatitis.
C. Irritable bowel syndrome.
D. Diabetes mellitus.

   
   
 Liver Cirrhosis
    Is a chronic disease of the liver in which liver 
tissue is replaced by connective tissue, resulting 
in the loss of liver function. 
   Cirrhosis is caused by damage from toxins 
(including alcohol), metabolic problems, chronic 
viral hepatitis or other causes. 
   Cirrhosis is irreversible but treatment of the 
causative disease will slow or even halt the 
damage.  

   
 Types
o Laennec’s cirrhosis: associated with
alcohol abuse and malnutrition; characterized
by an accumulation of fat in the liver cells,
progressing to widespread scar formation
o Postnecrotic cirrhosis: results in severe
inflammation with massive necrosis as a
complication of viral hepatitis.
o Cardiac cirrhosis: occurs as a
consequence of right-sided heat failure;
manifested by hepatomegaly with some fibrosis
o Biliary cirrhosis: associated with biliary
obstruction, usually in the common bile duct;
results in chronic impairment of bile excretion

   
 PATHOPHYSIOLOGY
Alcohol abuse, malnutrition, infection, drugs, biliary, obstruction

Destruction of hepatocytes

Fibrosis / scarring

Obstruction of blood flow, Increase pressure in the venous and sinusoidal

Channel, Fatty infiltration fibrosis / scarring

Portal hypertension

   
 Assessment
Findings
 Anorexia, N/V, changes in bowel patterns (altered 
ability of the liver to metabolized CHO, CHONS, 
and fats)
 Hepatomegaly (early/initially), atrophy of the liver 
(later, as fibrosis replaces the liver parenchyma)
 Jaundice, pruritus, tea colored urine (due to ↑ serum 
bilirubin in the blood)
 Fever (response to tissue injury)
 Bleeding tendencies (liver unable to store vitamin K)

   
 Assessment
Findings
 Splenomegaly (due to ↑ back pressure of the blood)
 Spider angioma (red spots on the upper body)
 Palmar erythema
 Portal obstruction and ascites (due to increasing 
pressure, low level of serum albumin)
 Esophageal varices
 Infection

   
   
   
 Hepatic Encephalopathy
 Due to ↑increased AMMONIA levels
 The liver cannot convert ammonia by 
products of protein metabolism into 
Urea.
 This will accumulate and cause the 
hepatic coma. 
 The initial manifestations are 
BEHAVIORAL changes and MENTAL 
changes.
   
 Hepatic Encephalopathy

Other findings in advanced stages are:
 Asterixis  flapping tremors of the hands
 Constructional Apraxia  deterioration of 
handwriting and inability to draw a simple 
star figures 
 Confusion / disorientation
 Delirium / hallucination
 Fetor hepaticus­ disagreeable odor from the 
mouth.

   
 Summary of Collaborative 
Management
 Rest. To reduce metabolic demands of the liver.
 Diet
HIGH calorie, HIGH carbohydrates, LOW 
protein that is restricted to complete protein 
only, moderate fats.
 Skin care
 Avoid trauma/injury
 Prevent infection

   
 Manage Ascites
 Monitor weight, intake and output, 
abdominal girth
 Restrict sodium and fluid intake
 Administer diuretics as ordered
 Administer albumin / IV as 
ordered assist in paracentesis

   
 Manage Esophageal varices
 Avoid the following to prevent rupture 
of the varices:
 Shouting, yelling, screaming
 Straining at stool
 Bending, stooping
 Hot, spicy foods.
 Lifting heavy objects

   
   
   
   
 If bleeding esophageal 
varices occur:
 Place in semi­Fowler’s position to prevent aspiration
 Suction the mouth
 Administer vasopressin as ordered. This produce  
vasoconstriction of splanchnic arterial bed.
 Gastric lavage with tap water (room temperature 
saline) as ordered.
 Sclerotherapy
 Balloon tamponade with the use of Sengstaken –  
Blakemore tube
 Variceal band ligation

   
 Decrease Ammonia 
formation
 Restrict protein in the diet
 Duphalac (lactulose) to lower pH in the colon and 
reduce formation of alkaline ammonia. It also 
increases peristalsis so, excretion of ammonia via 
feces is enhanced.
 Neomycin sulfate to reduce colonic bacteria 
which are responsible for ammonia formation.
 Tap water or NSS enema to remove digested 
blood from the colon . Blood is protein and will 
produce ammonia.

   
 Summary of Collaborative 
Management
 Avoid sedatives and paracetamol. These 
are hepatotoxic agents.
 Avoid ASA. This causes bleeding. 
Eliminate alcohol.

   
 Nursing Interventions
Provide sufficient rest and comfort.
 Provide bed rest with bathroom privileges.
 Encourage gradual, progressive, increasing activity with 
planned rest periods.
 Institute measures to relieve pruritus.
Do not use soaps and detergents.
Bath with tepid water followed by application of an 
emollient lotion.
Provide cool, light, nonrestrictive clothing.
Keep nails short to avoid skin excoriation from 
scratching.
Apply cool, moist compresses to pruritic areas.
   
 Nursing Interventions
Promote nutritional intake
 Encourage small frequent feedings.
 Promote a high calorie, low to moderate protein, high 
carbohydrate, low fat diet, with supplemental vitamin 
therapy (vitamins A, B­complex, C, D, K and folic acid)
Prevent infection
 Prevent skin breakdown by frequent turning and skin 
care.
 Provide reverse isolation for clients with severe 
leucopenia; put special attention to hand washing­
technique.
 Monitor WBC.
   
 Health teachings
Provide client teaching and discharge planning concerning
 Avoidance of agents that may be hepatotoxic ( sedatives, 
opiates, or OTC drugs detoxified by the liver).
 How to assess for weight gain and increase abdominal 
girth.
 Avoidance of person with upper respiratory infections.
 Recognition and reporting of signs of recurring illness 
(liver tenderness, increased jaundice, increased fatigue, 
anorexia).
 Avoidance of all alcohol.
 Avoidance of straining at stool, vigorous blowing of nose 
and coughing to decrease the incidence of bleeding.
   
 REVIEW QUESTIONS

 8 items

   
 The nurse is assessing a client who is in the 
early stages of cirrhosis of the liver. Which 
sign would the nurse anticipate finding?
A. Peripheral edema.
B. Ascites.
C. Anorexia.
D. Jaundice.

   
 The nurse is assessing a client who is in the 
early stages of cirrhosis of the liver. Which 
sign would the nurse anticipate finding?
A. Peripheral edema.
B. Ascites.
C. Anorexia.
D. Jaundice.

   
 A client with cirrhosis begins to develop ascites. 
Spironolactone (Aldactone) is prescribed to treat 
the ascites. The nurse should monitor the client 
closely for which of the following drug related side 
effects?
A. Constipation.
B. Hyperkalemia.
C. Irregular pulse.
D. Dysuria.

   
 A client with cirrhosis begins to develop ascites. 
Spironolactone (Aldactone) is prescribed to treat 
the ascites. The nurse should monitor the client 
closely for which of the following drug related side 
effects?
A. Constipation.
B. Hyperkalemia.
C. Irregular pulse.
D. Dysuria.

   
 What diet should be implemented for a client 
who is in the early stages of cirrhosis?
A. High calorie, high carbohydrate.
B. High protein, low fat.
C. Low fat, low protein.
D. High carbohydrate, low sodium.

   
 What diet should be implemented for a client 
who is in the early stages of cirrhosis?
A. High calorie, high carbohydrate.
B. High protein, low fat.
C. Low fat, low protein.
D. High carbohydrate, low sodium.

   
 A client with cirrhosis complains that his skin 
always feels itchy and that he “scratches himself 
raw” while he sleeps. The nurse should recognize 
that the itching is the result of which abnormality 
associated with cirrhosis?
A. Folic acid deficiency.
B. Prolonged prothrombin time.
C. Increased bilirubin levels.
D. Hypokalemia.

   
 A client with cirrhosis complains that his skin 
always feels itchy and that he “scratches himself 
raw” while he sleeps. The nurse should recognize 
that the itching is the result of which abnormality 
associated with cirrhosis?
A. Folic acid deficiency.
B. Prolonged prothrombin time.
C. Increased bilirubin levels.
D. Hypokalemia.

   
 The client with cirrhosis has developed 
ascites. The nurse should recognize that the 
pathologic basis for the development of 
ascites in clients with cirrhosis is portal 
hypertension and
A. an excess serum sodium level.
B. an increased metabolism of aldosterone.
C. a decreased flow of hepatic lymph.
D. a decreased serum albumin level.

   
 The client with cirrhosis has developed 
ascites. The nurse should recognize that the 
pathologic basis for the development of 
ascites in clients with cirrhosis is portal 
hypertension and
A. an excess serum sodium level.
B. an increased metabolism of aldosterone.
C. a decreased flow of hepatic lymph.
D. a decreased serum albumin level.

   
 A client with cirrhosis vomits bright red blood and 
the physician suspects bleeding esophageal varices. 
The physician decides to insert a Sengstaken­Blake 
more tube. The nurse should explain to the client 
that the tube acts by
A. providing a large diameter for effective gastric lavage.
B. applying direct pressure to gastric bleeding sites.
C. blocking blood flow to the stomach and esophagus.
D. applying direct pressure to the esophagus.

   
 A client with cirrhosis vomits bright red blood and 
the physician suspects bleeding esophageal varices. 
The physician decides to insert a Sengstaken­Blake 
more tube. The nurse should explain to the client 
that the tube acts by
A. providing a large diameter for effective gastric lavage.
B. applying direct pressure to gastric bleeding sites.
C. blocking blood flow to the stomach and esophagus.
D. applying direct pressure to the esophagus.

   
 The physician orders oral neomycin as well 
as a neomycin enema for a client with 
cirrhosis. The nurse understands that the 
purpose of this therapy is to
A. reduce abdominal pressure.
B. prevent straining during defecation.
C. block ammonia formation.
D. reduce bleeding within the intestine.

   
 The physician orders oral neomycin as well 
as a neomycin enema for a client with 
cirrhosis. The nurse understands that the 
purpose of this therapy is to
A. reduce abdominal pressure.
B. prevent straining during defecation.
C. block ammonia formation.
D. reduce bleeding within the intestine.

   
 The nurse monitors a client with cirrhosis for 
the development of hepatic encephalopathy. 
Which of the following would be an 
indication that hepatic encephalopathyis 
developing?
A. Decreased mental status.
B. Elevated blood pressure.
C. Decreased urinary output. 
D. Labored respirations.

   
 The nurse monitors a client with cirrhosis for 
the development of hepatic encephalopathy. 
Which of the following would be an 
indication that hepatic encephalopathyis 
developing?
A. Decreased mental status.
B. Elevated blood pressure.
C. Decreased urinary output. 
D. Labored respirations.

   
End