Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

MEDICAL AND SURGICAL NURSING

Gastrointestinal System
Lecturer: Mark Fredderick R. Abejo RN,MAN
______________________________________________________________________________________________

OVERVIEW OF THE STRUCTURE AND FUNCTION OF

THE GASTROINTESTINAL TRACT
I.

MS

II. MIDDLE ALIMENTARY CANAL (Absorption)

A. 2nd half of duodenum
B. Jejunum
C. Ileum
D. 1st half of ascending colon

UPPER ALIMENTARY CANAL (Digestion)

A. Mouth initial phase of digestion
B. Pharynx
C. Esophagus
D. Stomach complete digestion
E. First half of duodenum digestion
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Abejo

Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

III. LOWER ALIMENTARY CANAL (Elimination)

A. 2nd half of ascending colon
B. Transverse colon
C. Descending colon
D. Sigmoid colon
E. Rectum
IV. ACCESSORY ORGANS
A. Salivary glands produces 1.2-1.5 L of saliva per day
1. Parotid below and in front the ear
2. Sublingual
3. Submandibular
B. Vermiform appendix
C. Liver largest gland, occupies most of R hypochondriac
region
1. Glisons capsule covers liver, transparent, brown
2. Liver lobules functional site
D. Gall bladder
E. Pancreas

I.

II. APPENDECITIS Inflammation of the vermiform appendix

(located at the R. iliac region, produces WBC during fetal life)

Small intestines initial phase of absorption

Large intestines absorption of vitamin K and complete phase
of absorption
Tears: lacrimal gland lacrimal duct lacrimal sac
punctae nasolacrimal gland
PAROTITIS (Endemic mumps) inflammation of the parotid
gland

A.

B.

C.

MS

3.
4.
5.

Better to have mumps at an early stage,

preferably before puberty may lead to
sterility
Provide a general liquid to soft diet
Apply cold compress or ice pack at affected site
Prevent complications

Cervicitis, oophoritis, vaginitis

Meningitis

Orchitis sterility

ETIOLOGIC AGENT
1. Paramyxovirus virus
SIGNS AND SYMPTOMS
1. Swollen parotid gland
2. Earache / otalgia
3. Dysphagia
4. Fever, chills, anorexia, generalized body malaise
NURSING MANAGEMENT
1. Strict isolation
2. Meds as ordered

Antipyretics

Antibiotics to prevent secondary infection

GENTIAN VIOLET HAS NO COOLING
EFFECT! Cooling effect may be caused
by vinegar!
2

A.

PREDISPOSING FACTORS
1. Microbial invasion
2. FECALITHS undigested food particles (tomato,
guava seeds)
3. intestinal obstruction

B.

SIGNS AND SYMPTOMS

1. (+) Rebound tenderness
2. Low grade fever, anorexia, nausea and vomiting
3. Pain at r iliac region
4. Diarrhea/constipation
5. Tachycardia d/t pain

C.

DIAGNOSTICS
1. CBC mild leukocytosis
2. PE (+) rebound tenderness
3. Urinalysis (+) acetone)

D.

NURSING MANAGEMENT PRE-OP

1. Secure informed consent
2. Routinary nursing care

NPO

Skin preparation

Avoid enema may lead to rupture

3. Administer medications as ordered

antipyretics

antibiotics

Abejo

Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

NO ANALGESICS! May mask pain which

indicates impending rupture
4. Monitor IO VS and Bowel sounds
5. Avoid heat application rupture
6. Maintain patent IV line
E.

A.

PREDISPOSING FACTORS
1. Alcoholism
2. Malnutrition
3. Viruses
4. Toxicity

Carbon tetrachloride
5. Use of hepatotoxic agent

B.

SIGNS AND SYMPTOMS

1. Early

Weakness and fatigue

Anorexia

Nausea and vomiting

Tea-colored urine, clay-colored stool

Decreased sexual urge

Amenorrhea

Dyspepsia indigestion

Hepatomegaly

Jaundice

Urticaria/pruritus

Loss of pubic/axillary hair

NURSING MANAGEMENT POST-OP

1. If (+) penrose drain (indicates rupture) place
patient on affected site for drainage
2. If (-), position is based on pt. comfort
3. Administer medications as ordered

Analgesics

Antibiotics

Antipyretics PRN
4. Maintain patent IV line
5. Monitor VS IO and bowel sounds (N=borborygmi)

Complications: PERITONITIS AND SEPTICEMIA

MC BURNEYS POINT incision site for appendectomy

III. LIVER CIRRHOSIS (Laennecs cirrhosis) loss of

architectural design of liver leading to fat necrosis and
scarring; can lead to liver cancer

2.

MS

Late signs

Hematologic changes
Anemia
Leucopenia
Bleeding tendencies

Endocrine changes
Spider angiomas/ telangiectasis
Caput medusae (Varicose veins radiating
from the umbilicus)
Palmar erythema
Gynecomastia

GIT changes
Ascites
Bleeding esophageal varices d/t portal
HPN

Neuro changes
Hepatic encephalopathy
Early Asterixis (flapping hand
tremors)
Abejo

Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
Late

headache,
dizziness,
confusion, irritability, fetor hepaticus,
(ammonia-like breath), decreased
LOC hepatic coma
C.

DIAGNOSTICS
1. Liver enzymes

SGPT (ALT) elevated

SGOT (AST) elevated

2. Serum cholesterol

Ammonia elevated
3. Indirect bilirubin / Unconjugated bilirubin elevated
4. CBC low
5. PTT prolonged
6. Hepatic UTZ fat necrosis of liver lobules

D.

NURSING MANAGEMENT
1. Enforce CBR
2. Monitor strictly VS and IO
3. Weigh pt daily and assess for pitting edema
4. Measure abdominal girth and notify physician
5. Restrict Na and fluids
6. Diet high in CHO, moderate in fat, decreased
CHON, increased vitamins and minerals
7. Meticulous skin care
8. Prevent complications

Ascites
Administer medications as ordered
Loop diuretics (Furosemide)
Assist in abdominal paracentesis
(empty the bladder pre-op)

Bleeding esophageal varices

Administer meds as ordered
Vitamin K
Pitressin (to conserve fluids)
Institute NGT decompression by gastric
lavage (ice/cold saline solution)
Assist in mechanical decompression
insertion of sengstaken-blakemore catheter
( 3-lumen catheter) decompress
esophageal veins prevents bleeding

Hepatic Encephalopathy
Assist in mechanical ventilation
Monitor VS, NVS
Maintain side rails
Administer medications as ordered
Lactulose for ammonia excretion

A.

PREDISPOSING FACTORS (na di hamak naman na

wala nito si Rico Yan)
1. Chronic alcoholism
2. Hepatobiliary disorders
3. Drugs:

Thiazide diuretics - Etacrynic acid Ano daw?

OCPs

Pentamide HCl (Pentam) for AIDS

4. Metabolic disturbances

Hyperlipidemia

Hyperparathyroidism
5. Obesity
6. Diet: high in saturated fats

B.

S/Sx
1. Severe abdominal pain radiating from the back (left
upper quadrant), chest and flank area accompanied
by DOB and aggravated by eating (so dapat naka
TPN to, uhm, usually an infusion vamine glucose or
lipofundin, kung may pera ang patient eh di
Nutripak; remember to keep all lines securely taped
to prevent embolism)
2. Shallow respirations
3. Tachycardia and palpitations, hypertension
4. Anorexia, N&V, dyspepsia
5. Decreased bowel sounds
6. (+) Cullens sign ecchymoses around umbilicus
and (+) Grey-turners spots ecchymoses at the
flank area; both are indications of hemorrhage

C.

DIAGNOSTICS
1. Serum amylase (very toxic to the body) and lipase
elevated
2. Serum Ca low (hypocalcemia)

PANCREAS
Both an endocrine (islets of Langerhans) and exocrine gland
(Acinar cells)

D.

NURSING MANAGEMENT
1. Administer meds as ordered

Narcotic analgesics
Meperidine HCl (Demerol) Respiratory
Depression
DO NOT GIVE MORPHINE can
cause spasm of the sphincter of Oddi

Smooth muscle relaxation

Papanarine HCl

Vasodilators
NTG

Antacids (Maalox)

H2 receptor antagonist

IV. PANCREATITIS an acute or chronic inflammation of the

pancreas leading to pancreatic edema, necrosis and
hemorrhage d/t autodigestion; idiopathic; TRYPSIN kills
pancreas

MS

Abejo

Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

2.

3.

4.
5.

6.

V.

Ranitidine (Zantac)
Decrease pancreatic stimulation

Calcium gluconate

Phosphate binders
Amphogel
Withhold food and fluids (need to rest the GIT)

Nursing goal: rest the Git

Upon d/c: high CHO and CHON, low fat

Assist in TPN or hyperalimentation

Complications of TPN
Infection (so maintain strict asepsis)
Air embolism
Hyperglycemia
Hyponatremia
Instruct pt to assume comfortable position

Fetal position (knee-chest position)

Prevent complications

Chronic hemorrhagic pancreatitis

Shock

Septicemia
Stress management

DBE, biofeedback

A.

PREDISPOSING FACTORS
1. High risk group: women
2. Obesity
3. Post-menopausal women
therapy
4. Diet high in saturated fats
5. Sedentary lifestyle
6. Neoplasm
7. Obstruction

undergoing

estrogen

B.

SIGNS AND SYMPTOMS

1. Severe abdominal pain (RUQ) radiating from the
back and chest that usually occurs at night
2. Fatty intolerance (pain after ingestion of high fat
meals) characterized by: Anorexia, nausea and
vomiting
3. Tea-colored urine and steatorrhea

C.

DIAGNOSTICS
1. Gallbladder series (Oral cholecystogram) confirm
presence of gallstones
2. Serum lipase elevated
3. Indirect bilirubin elevated
4. Alkaline phosphatase elevated
5. Transaminases elevated

D.

NURSING MGT
1. Narcotic analgesics

Meperidine HCl (Demerol)

2. Anticholinergic agents

Atropine sulfate
3. Anti-emetics

Metoclopramide (Plasil)

Phenergan
4. Diet low in fat, high CHON and CHO
5. Meticulous skin care
6. Assist in surgery: Cholecystectomy

Post-op: maintain patency of tube drain (t-tube)

Monitor for infections

CHOLECYSTITIS/CHOLELITHIASIS inflammation of
the gallbladder with gallstone formation

STOMACH

J-shaped structure

Widest section of alimentary canal especially p.c.

A.

B.

C.

MS

Parts
1. Antrum
2. Fundus
3. Pylorus
Valves - prevents reflux
1. cardiac between esophagus and stomach
2. pyloric stomach and duodenum

projectile vomiting

olive shaped belly

Cells
1. Chief cells or zymogenic cells

Gastric amylase digests CHO

Gastric lipase digests fats

Pepsin proteins

Rennin milk and milk products

2. Parietal/augentaffin/oxyntic cells

Produces intrinsic factors reabsorption of B12

(cyanocobalamin) maturation of RBCs
Abejo

Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
10. Microbial invasion (Helicobacter pylori)

Metronidazole
SE: photosensitivity

Etampicillin

3.

Produces HCl acid with pH of 1-2 aids in

digestion
Endocrine cells

Secretes gastrin stimulates HCl Acid secretion

C.

D.

FUNCTIONS
1. Mechanical and chemical digestion
2. Storage of food

CHO and CHON 1-2 hours

Fats 2-3 hours

V.

PEPTIC ULCER DISEASE erosion/excoriation of

submucosa/mucosal lining d/t

Hypersecretion of acid pepsin

Decreased resistance of mucosal barrier to HCl

acid secretion (neutralizes acidity)

TYPES
1. Severity

Acute ulcers submucosal

Chronic ulcers deeper underlying tissues; (+)

scar formation
2. Location

Stress (Critically-ill patients)

Curlings ulcer
Burns and trauma hypovolemia
GIT ischemia decreased resistance
of mucosal barrier to HCl acid
secretion
Cushings ulcer
Head trauma
CVA/Stroke increased vagal
stimulation hyperacidity
ulceration

Gastric

Duodenal

Differences
Location
Pain

Gastric Ulcer
Antrum
30 mins-1hour p.c.

Pain location
Pain
character

Epigastrium
Gaseous and burning, not
relieved by food and
antacids
Normal

Gastric acid
secretion
Weight
Hemorrhage
Complication
s
High risk

MS

A.

INCIDENCE RATE
1. Men
2. Aggressive

B.

PREDISPOSING FACTORS
1. Heredity
2. Emotional stress
3. Smoking vasoconstriction gastric ischemia
4. Alcoholism release of histamine parietal cells
to secrete gastrin
5. Irregular diet
6. Rapid eating
7. Ulcerogenic drugs

Aspirin

Ibuprofen

Indomethacin (SE:corneal cloudiness)

Steroids

NSAIDs
8. Foods or beverages rich in caffeine
9. Gastrin producing tumors

Gastrinoma Zollinger-Ellisons Syndrome

6

Loss
Hematemesis
Hemorrhage,
cancer
60 y.o above

stomach

Duodenal Ulcer (90%)

Duodenal bulb
2-3 hours p.c.
12mn-3am pain
Mid-epigastrium
Cramping and burping,
relieved by food and
antacids
Increased
Gain
Melena
Perforation
20 y.o above

D.

DIAGNOSTICS
1. Endoscopy
2. (+) Stool occult blood
3. Gastric analysis reveals

Normal gastric acid secretion if gastric

Increased gastric acid secretion if duodenal

4. Upper GI series confirms ulceration

E.

NURSING MANAGEMENT (Diet, Drugs, Surgery)

1. Bland diet non-irritating, non-spicy

Avoid beverages and foods high in caffeine or

milk and milk containing products
2. Admin meds as ordered

Antacids
ACA aluminum containing antacids
Aluminum OH gel (Ampho gel)
SE: constipation, hyperphosphatemia,
hypoparathyroidism
MAD magnesium containing antacids
Milk of magnesia
SE: diarrhea
Mg + Al preparations (Maalox) less SE

H2 receptor antagonists

Abejo

Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN

3.

Cimetidine (Tagamet) antagonizes oral

anti-coagulant, more SEs
Ranitidine (Zantac) most common,
fewer SE
Famotidine (Pepsid)
Give antacids and Cimetidine ONE
HOUR APART decreased antacid
absorption and vise versa
Instruct client to avoid smoking because it
decreases effectiveness of drug

Cytoprotective agents
Sucralfate (Carafate) provides a pastelike substance that coats the mucosal
lining
Cytotec (Misoprostol) causes severe
spasm (abortifacient) uterine cramping
bleeding

Anticholinergic/Anti-spasmodic agents
Atropine
Propanthelene sulfate (Probanthene)

Sedatives, tranquilizers
Assist in surgical procedure: subtotal gastrectomy

Billroth I (removal of 1/3 of stomach)

Gastroduodenostomy gastric stump to
the duodenum
F.

MS

Billroth II
Gastrojejunostomy gastric stump to
jejunum
Removal of to of the stomach,
duodenal valve and anastomosis of gastric
stump to jejunum
Complic: DUMPING SYNDROME

Vagotomy (severe vagus nerve) and

pyloroplasty for drainage
Decrease vagal stimulation decrease
HCl acid secretion prevent hemorrhage

NURSING MANAGEMENT POST OP

1. Monitor NGT output that includes:

Immediately after post-op bright red

32-46 hours greenish in color

48h dark red because of influence of HCl

acid
2. Administer medications as ordered

Antimicrobials

Narcotic analgesics

Anti-emetics
3. Maintain a patent IV line
4. Monitor VS, IO, Bowel Sounds
5. Prevent complication

Hemorrhage shock

Paralytic Ileus most common type of

complication in all abdominal surgery

Peritonitis

Septicemia

Hypokalemia

Pernicious anemia

DUMPING SYNDROME (Billroth II) rapid

emptying of hypertonic food solutions; chyme
food and HCl acid from stomach to jejunum
with resultant hypovolemia dizziness,
diaphoresis, palpitation, tachycardia, diarrhea,
weakness
Nursing management for dumping
syndrome:
Provide fluids BEFORE meals
Avoid fluids/chilled solutions
Provide a small frequent feeding or 6
equal divided feeding
Diet low in CHO and sugar moderate
CHON and fats
Instruct pt to lie flat on bed 15-30
minutes after each feeding

Abejo

Medical and Surgical Nursing

Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
VI. DIVERTICULUM outpouching of the intestinal mucosa
particularly the sigmoid colon; DIVERTICULOSIS
multiple diverticulum; DIVERTICULITIS inflammation of
diverticula

MS

A.

PREDISPOSING FACTORS
1. High risk: female
2. Congenital weakness of muscular fibers of intestines
3. Obesity
4. Stress
5. Diet: decrease in roughage

B.

SIGNS AND SYMPTOMS

1. Intermittent pain at LLQ and tenderness at the
rectosigmoid area
2. Alternate bouts of diarrhea/constipation with blood
and mucosa
3. Decreased hematocrit/hemoglobin amnesia

C.

DIAGNOSTICS
1. Barium Enema reveals inflammatory process
2. Decreased hematocrit/hemoglobin (d/t diarrhea)

D.

NURSING MANAGEMENT
1. Administer medications as ordered.

Bulk laxatives

Anti-cholinergics
Atropine Sulfate
Propanthelene Bromide

Antibiotics for infection

2. Provide dietary intake:

Diverticulosis high roughage/fiber with no

seeds

Diverticulitis low fiber diet

3. Assist in surgical procedure

Bowel resection: removal of diseased portion

of the bowel and creation of colostomy.
8

Abejo