Medical Surgical Nursing

The GASTRO-INTESTINAL System

Nurse Licensure Examination Review
By: JOHN MARK B. POCSIDIO, RN, USRN, MSN

FUNCTION OF GIT SYSTEM:

 To break down food particles into the molecular form for digestion.
 To absorb into the bloodstream the small molecules produced by
digestion.
 To eliminate undigested and unabsorbed foodstuffs and other waste
products from the body.

The GIT is composed of two general parts

The main GIT starts from the mouthEsophagus Stomach SI LI
The accessory organs are the
Salivary glands
Liver
Gallbladder
Pancreas

The Mouth
 Contains the lips, cheeks, palate, tongue, teeth, salivary glands,
masticatory/facial muscles and bones
 Anteriorly bounded by the lips
 Posteriorly bounded by the oropharynx

The Mouth
 Important for the mechanical digestion of food
 The saliva contains SALIVARY AMYLASE or PTYALIN that starts the
INITIAL digestion of carbohydrates

The Esophagus
 A hollow collapsible tube
 Length- 10 inches
 Made up of stratified squamos epithelium
 The upper third contains skeletal muscles
 The middle third contains mixed skeletal and smooth muscles
 The lower third contains smooth muscles and the esophago-gastric/
cardiac sphincter is found here
 Functions to carry or propel foods from the oropharynx to the
stomach

The stomach
 J-shaped organ in the epigastrium
 Contains four parts- the fundus, the cardia, the body and the pylorus
 The cardiac sphincter prevents the reflux of the contents into the
esophagus
  The pyloric sphincter regulates the rate of gastric emptying into the
duodenum
 Capacity is 1,500 ml!

PARTS OF A STOMACH:
 Cardia (holding area for food in the top of stomach)
 Fundus (upper left part of stomach)
 Body (holding area for food and the main area of stomach)
 Antrum (lower stomach, where food mixes with gastric juices and chyme is
formed

FUNCTION OF THE STOMACH:

 Serving as a temporary storage area for food.
 Beginning digestion.
 Breakdown of food into chyme, a semifluid substance
 Moving the gastric contents into the small intestine.

Stomach:
1. Parietal cells- HCl acid and Intrinsic factor
2. Chief cells- pepsin digestion of PROTEINS!
3. Antral G-cells- gastrin ( stimulates gastric secretion & motility)
4. Argentaffin cells- serotonin (enhances intestinal motility)
5. Mucus neck cells- mucus

GI HORMONES & FUNCTIONS

GASTRIN ( Produced in pyloric antrum &duodenal mucosa)----- stimulates
secretion of gastric acid& pepsinogen, increases gastric blood flow, stimulates
gastric smooth muscle contraction.
GASTRIC INHIBITORY PEPTIDES ( produced in duodenal & jejunal mucosa)---
inhibits gastric secretion & motility.
SECRETIN (produced in duodenal & jejunal mucosa)- stimulates secretion of bile
and alkaline pancreatic fluid.
CHOLECYSTOKININ ( produced in duodenal & jejunal mucosa)– stimulates
gallbladder contraction and secretion of enzyme-rich pancreatic fluid), slows down
gastric emptying.

The Small intestine

 Grossly divided into the Duodenum, Jejunum and Ileum
 The duodenum contains the two openings for the bile and pancreatic
ducts
 The ileum is the longest part (about 12 feet)

FUNCTION OF THE SMALL INTESTINE:

 Finalized digestion of all food stuff
 Absorbing food molecules through its wall into the circulatory
system , which delivers them to body cells.
 Secreting hormones that help control secretion of bile , pancreatic
fluid, & intestinal fluid.
The Large intestine
Approximately 5 feet long, with parts:
1. The cecum widest diameter, prone to rupture
2. The appendix
3. The ascending colon
4. The transverse colon
5. The descending colon
6. The sigmoid most mobile, prone to twisting
7. The rectum- holds fecal material until urge to defecate occurs
8. Anus- opening through which stool leaves the body, anal sphincter
provides closure of anus.

LARGE INTESTINES
FUNCTION OF THE LARGE INTESTINE:
 Absorbs water
 Eliminates wastes
 Bacteria in the colon synthesize Vitamin K
 Appendix participates in the immune system
SYMPATHETIC
Generally INHIBITORY!
Decreased gastric secretions
Decreased GIT motility

But: Increased sphincteric tone and constriction of blood vessels

PARASYMPATHETIC
Generally EXCITATORY!
Increased gastric secretions
Increased gastric motility
But: Decreased sphincteric tone and dilation of blood vessels

The Liver
 The largest internal organ
 Located in the right upper quadrant
 Contains two lobes- the right and the left
 The hepatic ducts join together with the cystic duct to become the
common bile duct

FUNCTION OF THE LIVER:

 Functions to store excess glucose, fats and amino acids
 Also stores the fat soluble vitamins- A, D and the water soluble-
Vitamin B12
 Produces the BILE for normal fat digestion
 The Von Kupffer cells remove bacteria in the portal blood
 Detoxifies ammonia into urea & eliminated to the urine.

The gallbladder
 Located below the liver
  The cystic duct joins the hepatic duct to become the bile duct
 The common bile duct joins the pancreatic duct in the sphincter of
Oddi in the first part of the duodenum

FUNCTION OF THE GALLBLADDER:

 Stores and concentrates bile
 Contracts during the digestion of fats to deliver the bile
 Cholecystokinin is released by the duodenal cells, causing the
contraction of the gallbladder and relaxation of the sphincter of
Oddi

The pancreas
 A retroperitoneal gland
 Functions as an endocrine and exocrine gland
 The pancreatic duct (major) joins the common bile duct in the
sphincter of Oddi

FUNCTION OF THE PANCREAS:

 The exocrine function of the pancreas is the secretion of digestive
enzymes for carbohydrates, fats and proteins
 Pancreatic amylase carbohydrates
 Pancreatic lipase (steapsin) fats
 Trypsin, Chymotrypsin and Peptidases proteins
 Bicarbonate to neutralize the acidic chyme. Stimulated by
SECRETIN!

Gastrointestinal Assessment
Laboratory Procedures
The ABDOMINAL examination
The sequence to follow is:
Inspection
Auscultation
Percussion
Palpation

COMMON LABORATORY PROCEDURES

FECALYSIS
Examination of stool consistency, color and the presence of occult blood.
Special tests for fat, nitrogen, parasites, ova, pathogens and others
FECALYSIS: Occult Blood Testing
Instruct the patient to adhere to a 3-day meatless diet
No intake of NSAIDS, aspirin and anti-coagulant, vit c, iron
Screening test for colonic cancer

Upper GIT study: barium swallow

 Examines the upper GI tract
 Barium sulfate is usually used as contrast
Upper GIT study: barium swallow
Examines the esophagus & stomach
Pre-test: NPO post-midnight
Post-test: Laxative is ordered (constipation), instruct that stools will
turn white, monitor for obstruction
Lower GIT study: barium enema
 Examines the lower GI tract, large colon
 Pre-test: Clear liquid diet and laxatives, NPO post-midnight,
cleansing enema prior to the test
 Lower GIT study: barium enema
 Post-test: Laxative is ordered, increase patient fluid intake, instruct
that stools will turn white, monitor for obstruction -(inform MD if
bowel movement doe not occur in 2days.)

Gastric analysis
 Aspiration of gastric juice to measure pH, appearance, volume and
contents
 HOW?
 Insertion of nasogastric tube to examine fasting gastric contents for
acidity & volume.

o CONT
 PRETEST:
 KEEP NPO 6-8 HOURS PRETEST
 ADVICE CLIENT ABOUT NO SMOKING, ANTICHOLINERGIC MEDICATION,
ANTACIDS FOR 24 HOURS BEFORE THE TEST.
 INFORM CLIENT THAT TUBE WILL BE INSERTED INTO THE STOMACH
VIA THE NOSE, & INSTRUCT TO EXPECTORATE SALIVA TO PREVENT
BUFFERING OF SECRETIONS.
 POSTTEST:
 PROVIDE FREQUENT MOUTH CARE.

EGD
(esophagogastroduodenoscopy
 Visualization of the upper GIT by endoscope
 Pre-test: ensure consent, NPO 8 hours, pre-medications like atropine
and anxiolytics
 Intra-test: position : RIGHT lateral to facilitate salivary drainage and
easy access
 Post-test:
 NPO until the gag reflex return
 Sims position until the client awakens.
 Monitor for signs of perforation (bleeding, pain, unusual difficulty
swallowing , elevated temp.
 Maintain bedrest for the sedated client until alert.
 Lozenges, saline gargles, or oral analgesics can relieve minor sore throat ,
after the gag reflex returns.
Lower GI- scopy
 Use of endoscope to visualize the anus, rectum, sigmoid and colon
 Pre-test: consent, clear liquid diet at noon before the test, NPO 8
hours, cleansing enema until return is clear

 Lower GI- scopy

 Intra-test: position is LEFT lateral, right leg is bent and placed
anteriorly
 Post-test: bed rest, monitor for complications like bleeding and
perforation

Cholecystography
 Examination of the gallbladder to detect stones, its ability to
concentrate, store and release the bile
 Pre-test: ensure consent, ask allergies to iodine, seafood and dyes;
contrast medium is administered the night prior, NPO after contrast
administration

 Post-test: Advise that dysuria is common as the dye is excreted in

the urine, resume normal activities.
 A normal diet may be resumed( fatty meal may enhance excretion of
the contrast agent.)

Paracentesis
Removal of peritoneal fluid for analysis & for the relief of difficulty of
breathing ( ascitis)
Paracentesis

Pre-test: ensure consent, instruct to VOID and empty bladder, measure

abdominal girth
Intra-test: Upright on the edge of the bed, back supported and feet
resting on a foot stool
POSTPROCEDURE:
1. MONITOR THE VS
2. MEASURE ABDOMINAL GIRTH & WEIGHT
3. MONITOR FOR HYPOVOLEMIA, ELECTROLYTE LOSS, MENTAL STAUS
CHANGES & ENCEPHALOPATHY
4. MONITOR FOR HEMATURIA CAUSED BY BLADDER TRAUMA.
5. EVALUATE EFFECTIVENESS BY: ABDOMINAL GIRTH, WEIGHT,
RESPIRATORY RATE.

Liver biopsy
Pretest
Consent
NPO
Check for the bleeding parameters (platelet count, PT, PTT)
Intratest
Position: Semi fowler’s LEFT lateral to expose right side of
abdomen or supine.
Post-test: position on RIGHT lateral with pillow underneath, monitor VS
and complications like bleeding, perforation. Instruct to avoid lifting
objects for 1 week

CONSTIPATION
An abnormal infrequency and irregularity of defecation
Multiple causations

Pathophysiology
Interference with three functions of the colon
1. Mucosal transport
2. Myoelectric activity
3. Process of defecation

NURSING INTERVENTIONS
1. Assist physician in treating the underlying cause of constipation
2. Encourage to eat HIGH fiber diet to increase the bulk
3. Increase fluid intake
4. Administer prescribed laxatives, stool softeners
5. Assist in relieving stress

DIARRHEA

Abnormal fluidity of the stool

excessively frequent passage of stools
Multiple causes
Gastrointestinal Diseases
Hyperthyroidism
Food poisoning
Drugs
Food intolerance
Infectious organisms

Nursing Interventions
1. Increase fluid intake- ORESOL is the most important treatment!
( water is not sufficient)
 2. Determine and manage the cause (antibiotics if bacteria is the
cause)
3. Anti-diarrheal drugs ( not initially used if bacteria is the cause)
4. Avoid carbonated, caffeinated, and high-sugar drinks (osmotic pull)–
increases diarrhea ---NCLEX

CONT.
5. Diet should progress, as tolerated. As the symptoms begin to subside,
bland foods (cream soups, crackers, toast, rice, yogurt, custards) can be introduced
into the diet. Spicy foods, dairy products, vegetables, fruits, high-sugar foods, and
alcohol should be avoided for the first 2 to 3 days
6. Check VS, Monitor for shock due to dehydration.

DUMPING SYNDROME
 A condition of rapid emptying of the gastric contents into the small
intestine usually after a gastric surgery
 Symptoms occur 30 minutes after eating

ASSESSMENT FINDINGS: early symptoms

1. Nausea and Vomiting
2. Abdominal fullness
3. Abdominal cramping
4. Palpitation
5. Diaphoresis
6. Drowsiness
7. Weakness and Dizziness
8. Hypoglycemia

DS NURSING INTERVENTIONS
1. Advise patient to eat LOW-carbohydrate HIGH-fat and HIGH-protein
diet
2. Instruct to eat SMALL frequent meals, include MORE dry items.
3. Instruct to AVOID consuming FLUIDS with meals
DS NURSING INTERVENTIONS
4. Instruct to LIE DOWN after meals what side???
5. Administer anti-spasmodic medications to delay gastric emptying

PERNICIOUS ANEMIA
 Results from Deficiency of vitamin B12 due to autoimmune
destruction of the parietal cells, lack of INTRINSIC FACTOR or total
removal of the stomach
 PERNICIOUS ANEMIA ASSESSMENT
Severe pallor
Fatigue
Weight loss
SMOOTH BEEFY-RED TONGUE
Mild jaundice
Paresthesia of extremities
Balance disturbance

Diagnostic test:
Schillings test: measures the absorption of radioactive vitB12 both before & after
parenteral administration of intrinsic factor.
Fasting client is given radioactive vit B12 by mouth & non radioactive vit
B12 IM to saturate tissue binding sites & to permit some excretion of radioactive
vitamin B12 in the urine if it is absorbed.
24 hour urine collection is obtained.
8%-40% is excreted in 24 hours is normal.
More than 40% indicates pernicious anemia.

NURSING INTERVENTION for Pernicious Anemia

Lifetime injection of Vitamin B 12 weekly initially, then MONTHLY
Cont.
Check up twice a year is recommended. Why? Prone to gastric cancer ------NCLEX
ALERT

STOMATITIS
Stomatitis is an inflammation of the mucous membranes of the mouth,
involving the cheeks, gums, tongue, lips, and roof or floor of the mouth,
and affecting all age groups. The two primary types of stomatitis are
aphthous (also called a canker sore) and herpes simplex virus type 1 (also
called a cold sore).
Stomatitis
CAUSES
 TRAUMA TO MUCOUS MEMBRANES
 IRRITATION
 HERPES SIMPLEX VIRUS

Signs and symptoms

 PAIN
 ULCERATIONS, LESIONS
 SWOLLEN LYMPH NODES
TREATMENT:
1. Practice good oral hygiene.
2. Appropriate dental care. ( soft bristled toothbrush, toothettes, poorly
fitting dentures should be corrected.)
3. Avoid irritating beverages & spicy foods. Avoid hot food & drinks. No to
tortilla chips & nuts.
4. Topical anesthetics can be used to decrease pain. ( lidocaine
mouthwash.)
5. Oral meds may be prescribed: acyclovir ( herpes), tetracycline,
corticosteriods, Nystatin ( fungal)

ACHALASIA
 SIGNS & SYMPTOMS:
Difficulty swallowing solids and liquids (Main symptom)
Feeling of food sticking in the lower esophagus.
Chest pain.
Weight loss.
Regurgitation of undigested food
Halitosis
DIAGNOSTICS
ENDOSCOPY
BARIUM SWALLOW
MANOMETRY ( confirmatory)
INTERVENTION:
Having client eat slowly and chew food completely to aid passage through a
narrowed LES
Having client drink fluids with meals to help prevent a feeling of food sticking to
the throat.
Explaining that warm food and liquids may be swallowed easier than cold
ones.
Elevating the head of the bed 6 to 12 inches to decrease reflux at night.
Using medications such as nitrates, such as nitroglycerin; or calciumchannel
blockers, such as nifedipine (Procardia); to help to relax the sphincter and make
food passage easier.
CONT….
Using balloon dilation of the narrowed esophagus.
Using a botulinum toxin (Botox) injection instead of balloon dilation; Botox is
injected into the lower esophageal sphincter muscle to provide symptom relief.
Using surgery (esophagomyotomy), cutting LES muscle fibers to decrease
obstruction, if other treatments are unsuccessful.

HIATAL HERNIA
 Portion of your stomach herniates to the weakened esophageal
hiatus of your diaphragm.
 Two types- Sliding hiatal hernia
( most common) and Axial hiatal hernia

CAUSES
MALFORMATIONS
MUSCLE WEAKNESS OF THE ESOPHAGEAL HIATUS
ESOPHAGEAL SHORTENING
OBESITY

ASSESSMENT Findings in Hiatal hernia

1. Heartburn
2. Regurgitation
3. Dysphagia
4. 50%- without symptoms

DIAGNOSTIC TEST
Barium swallow and fluoroscopy
NURSING INTERVENTIONS
1. Provide small frequent feedings (bland)
2. AVOID supine position for 1 hour after eating
3. Elevate the head of the bed on 8-inch block
4. Provide pre-op and post-op care
5. Avoid carbonated beverages & anticholinergic drugs.- CBQ
6. Avoid heavy lifting- CBQ
7. Avoid tight constricted clothing.- CBQ
8. Importance of treating persistent cough.
9. Adherence to weight reduction plan.

Esophageal Varices
 Dilation and tortuosity of the submucosal veins in the distal
esophagus
 ETIOLOGY: commonly caused by PORTAL hypertension secondary to
liver cirrhosis
 This is an Emergency condition!
ASSESSMENT findings for EV
1. Hematemesis
2. Melena
3. Ascites
4. jaundice
5.hepatomegaly/splenomegaly

ASSESSMENT findings for EV

Signs of Shock- tachycardia, hypotension, tachypnea, cold clammy skin,
narrowed pulse pressure

DIAGNOSTIC PROCEDURE
Esophagoscopy

NURSING INTERVENTIONS FOR EV

1. Monitor VS strictly. Note for signs of shock
2. Monitor for LOC
3. Maintain NPO
4. Monitor blood studies
5. Administer O2
6. prepare for blood transfusion
7. prepare to administer Vasopressin and Nitroglycerin
8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon
tamponade
9. Prepare to assist in surgical management:
Endoscopic sclerotherapy
Variceal ligation
Shunt procedures
 Gastro Esophageal Reflux Disease (GERD)
GASTRIC REFLUX
Conditions of the Stomach
ASSESSMENT ( for GERD)
Heartburn
Dyspepsia
Regurgitation
Epigastric pain
Difficulty swallowing
Ptyalism

Diagnostic test
Endoscopy or barium swallow
Gastric ambulatory pH analysis
Note for the pH of the esophagus, usually done for 24 hours
The pH probe is located 5 inches above the lower esophageal
sphincter
The machine registers the different pH of the refluxed material into
the esophagus

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- CBQ
5. Elevate the head of the bed with an approximately 8-inch block- CBQ
6. Administer prescribed H2-blockers, PPI and prokinetic meds like
cisapride, metochlopromide
7. Advise proper weight reduction

PEPTIC ULCER DISEASE

 An ulceration of the gastric and duodenal lining
 May be referred as to location as Gastric ulcer in the stomach, or
Duodenal ulcer in the duodenum
 Most common Peptic ulceration: anterior part of the upper
duodenum

GASTRIC ULCER
Ulceration of the gastric mucosa, submucosa and rarely the muscularis

Risk factors: Stress, smoking, NSAIDS abuse, Alcohol, Helicobacter pylori

infection, type A personality and History of gastritis
Incidence is high in older adults
Acid secretion is NORMAL
H.PYLORI
 Conditions of the Stomach

ASSESSMENT (Gastric Ulcer)

Epigastric pain
Characteristic: Gnawing, sharp pain in the mid-epigastrium 1-2
hours AFTER eating, often NOT RELIEVED by food intake, sometimes
AGGRAVATING the pain!
Conditions of the Stomach

ASSESSMENT (Gastric Ulcer)

Nausea
Vomiting is more common
Hematemesis
Weight loss
DIAGNOSTIC PROCEDURES
1. EGD to visualize the ulceration
2. Urea breath test for H. pylori infection
Avoid antibiotics for 1 month
Avoid sucralfate, omeprazole 1 week before the test -CBQ
3. Biopsy- to rule out gastric cancer

NURSING INTERVENTIONS
1. Give DAT / BLANDdiet, small frequent meals during the active phase of
the disease-CBQ
2. Administer prescribed medications- H2 blockers, PPI, mucosal barrier
protectants and antacids
3. Monitor for complications of bleeding, perforation and intractable
pain
4. provide teaching about stress reduction and relaxation techniques
5. Avoid acid producing substances ( caffeine, alcohol, highly seasoned
foods, spicy foods ( irritant).)
6. Plan for rest periods after mealtime.

DUODENAL ULCER
Ulceration of duodenal mucosa and submucosa
Usually due to increased gastric acidity
DUODENAL ULCER ASSESSMENT
PAIN characteristic:
Burning pain in the mid-epigastrium 2-4 HOURS after eating or
during the night, RELIEVED by food intake

DIAGNOSTIC TESTS
EGD and Biopsy
Condition of the Duodenum
NURSING INTERVENTIONS
1. Same as for gastric ulceration
2. Patient teaching-avoid alcohol, smoking, caffeine and carbonated
drinks
Take NSAIDS with meals
Adhere to medication regimen
CROHN’S DISEASE
 Also called Regional Enteritis
 An inflammatory disease of the GIT affecting usually the small
intestine
 ETIOLOGY: unknown
 The terminal ileum thickens, with scarring, ulcerations, abscess
formation and narrowing of the lumen

ASSESSMENT findings for CD

1. Fever
2. Abdominal distention
3. Diarrhea
4. Colicky abdominal pain
5. Anorexia/N/V
6. Weight loss
7. Anemia
CROHNS DISEASE OF THE ILEUM

ULCERATIVE COLITIS
 Ulcerative and inflammatory condition of the GIT usually affecting the large
intestine
 The colon becomes edematous and develops bleeding ulcerations
 Scarring develops overtime with impaired water absorption and loss of
elasticity

ASSESSMENT findings for UC

1. Anorexia
2. Weight loss
3. Fever
4. SEVERE diarrhea with Rectal bleeding
5. Anemia
6. Dehydration
7. Abdominal pain and cramping
NURSING INTERVENTIONS for CD and UC
1. Maintain NPO during the active phase
2. Monitor for complications like severe bleeding, dehydration, electrolyte
imbalance
3. Weigh daily, record the number & characteristics of stools daily.
4. Monitor bowel sounds, stool and blood studies
5. Restrict activities, promote rest, good perineal care with frequent
washing & adequate drying after each bowel movement.
6. Administer IVF, electrolytes and TPN if prescribed
7. Instruct the patient to AVOID gas-forming foods, MILK products and
foods such as whole grains, nuts, RAW fruits and vegetables especially
SPINACH, pepper, alcohol and caffeine-----LOCAL ALERT!!
8. Diet progression- clear liquid LOW residue, high protein diet
9. Administer drugs- anti-inflammatory, antibiotics, steroids, bulk-forming
agents and vitamin/iron supplements

APPENDICITIS

 Inflammation of the vermiform appendix

 ETIOLOGY: usually fecalith, lymphoid hyperplasia, foreign body and
helminthic obstruction
APPENDICITIS
PATHOPHYSIOLOGY
Obstruction of lumen increased pressure decreased blood supply
bacterial proliferation and mucosal inflammation ischemia necrosis
rupture
ASSESSMENT FINDINGS for Appendicitis
1. Abdominal pain: begins in the umbilicus then localizes in the RLQ (Mc
Burney’s point)
2. Right side lying with left hip flex ( psoas sign)
3. Rovsing sign-palpation on the LLQ can paradoxically have pain on RLQ
4. Fever, anorexia, N/V
5. Rebound tenderness and abdominal rigidity (if perforated)
6. Constipation or diarrhea

DIAGNOSTIC TESTS
1. CBC- reveals increased WBC count
2. Ultrasound
3. Abdominal X-ray
NURSING INTERVENTIONS
1. Preoperative care
NPO
Consent
Monitor for perforation and signs of shock

NURSING INTERVENTIONS
1. Preoperative care
Monitor bowel sounds, fever and hydration status
POSITION of Comfort: RIGHT SIDELYING in a low FOWLER’S
Avoid Laxatives, enemas & HEAT APPLICATION –LOCAL ALERT!!!
CONDITIONS OF THE LARGE INTESTINE
2. Post-operative care
Monitor VS and signs of surgical complications
Maintain NPO until bowel function returns
If rupture occurred, expect drains and IV antibiotics
CONDITIONS OF THE LARGE INTESTINE
2. Post-operative care
POSITION post-op: RIGHT side-lying, semi- fowler’s to decrease tension
on incision, and legs flexed to promote drainage
Administer prescribed pain medications
BOARD EXAM QUESTION…
IF APPENDIX RUPTURES. HOW WOULD YOU POSITION YOUR PATIENT?------SEMI-
FOWLERS----CGFNS ALERT!!!

HEMORRHOIDS
 Congestion & dilation of the veins of the rectum & anus; usually result
from impairment of flow of blood through the venous plexus.
 May be internal ( above the anal sphincter) or external ( outside the anal
sphincter)
 Most commonly occur between ages 20-50

Predisposing factors:
Occupation that requires prolonged standing
Increased intra-abdominal pressure or caused by prolonged constipation such as:
pregnancy, heavy lifting, obesity, straining at defecation, portal
hypertension
Hemorrhoids
PATHOPHYSIOLOGY
Increased pressure in the hemorrhoidal tissue due to straining,
pregnancy, etc dilatation of veins

 Internal hemorrhoids
 These dilated veins lie above the internal anal sphincter
 Usually, the condition is PAINLESS
 External hemorrhoids
 These dilated veins lie below the internal anal sphincter
 Usually, the condition is PAINFUL

ASSESSMENT findings for Hemorrhoids

1. Internal hemorrhoids- cannot be seen on the peri-anal area
2. External hemorrhoids- can be seen
3. Bright red bleeding with each defecation
4. Rectal/ perianal pain
5. Rectal itching
6. Constipation

DIAGNOSTIC TEST
1. Anoscopy
2. Digital rectal examination

NURSING INTERVENTIONS
1. Advise patient to apply cold packs to the anal/rectal area followed by a
SITZ bath
2. Apply astringent like witch hazel soaks
 3. Encourage HIGH-fiber diet and fluids (no to nuts, coffee, spicy foods)—
IRRITATING!!!--- CGFNS!
4. Administer stool softener as prescribed

Post-operative care for hemorrhoidectomy

1. Position: Prone or Side-lying --LOCAL ALERT!!!!
2. Maintain dressing over the surgical site
3. Monitor for bleeding
4. Administer analgesics and stool softeners
5. Advise the use of SITZ bath 3-4 times a day
6. limit sitting to short periods of time

DIVERTICULOSIS AND DIVERTICULITIS

 Diverticulosis
 Abnormal out-pouching of the intestinal mucosa occurring in any
part of the LI most commonly in the sigmoid
 Diverticulitis
 Inflammation of the diverticulosis
ASSESSMENT findings for D/D
1. Left lower Quadrant pain
2. Flatulence
3. Bleeding per rectum
4. nausea and vomiting
5. Fever
6. Palpable, tender rectal mass
DIAGNOSTIC STUDIES
1. If no active inflammation, COLONOSCOPY and Barium Enema
2. CT scan is the procedure of choice!
3. Abdominal X-ray

NURSING INTERVENTIONS
BED REST DURING ACUTE PHASE
NPO/ CLEAR LIQUIDS DURING ACUTE PHASE
AVOID LIFTING, STRAINING, COUGHING, BENDING--- to avoid increased
intra-abdominal pressure
AVOID GAS FORMING FOODS, HIGH ROUGHAGE FOODS, SEEDS, NUTS
AVOID HIGH FIBER DURING INFLAMMATION
AVOID BARIUM ENEMA!!!
AVOID MORPHINE!!!! GIVE DEMEROL FOR PAIN
NO TO LAXATIVE!!!!!!!

The liver
 Liver Cirrhosis
 A chronic, progressive disease characterized by a diffuse damage to
the hepatic cells
 The liver heals with scarring, fibrosis and nodular regeneration
Liver Cirrhosis
ETIOLOGY:
Post-infection, Alcohol, Cardiac diseases, Schisostoma, Biliary
obstruction

Types:

Laennec’s Cirrhosis
most common
alcoholic cirrhosis
scar tissue surrounds the portal areas
chronic disease
Postnecrotic Cirrhosis
a sequelae of viral hepatitis
Biliary Cirrhosis
due to chronic biliary obstruction and infection
Cardiac Cirrhosis
due to right-sided heart failure

Pathogenesis:

repeated destruction of hepatic cell

→ scar tissue formation (fibrotic) → regeneration of liver cell follows → another

destruction will occur → cycle (scarring and regeneration) will be repeated until
hepatocytes becomes fibrotic and liver function is compromised
Liver physiology and Pathophysiology
ASSESSMENT FINDINGS
1. Anorexia and weight loss
2. Jaundice
3. Fatigue
ASSESSMENT FINDINGS
4. Early morning nausea and vomiting
5. RUQ abdominal pain
6. Ascites
7. Signs of Portal hypertension

NURSING INTERVENTIONS
1. Monitor VS, I and O, Abdominal girth, weight, LOC and Bleeding
2. Promote rest. Elevated the head of the bed to minimize dyspnea
NURSING INTERVENTIONS
3. Provide Moderate to LOW-protein (1 g/kg/day) and LOW-sodium diet– to
prevent hep enceph
4. Provide supplemental vitamins (especially K) and minerals

Asterixis
Effects of Constructional Apraxia
CONDITION OF THE LIVER
NURSING INTERVENTIONS
5. Administer prescribed
Diuretics= to reduce ascites and edema
Lactulose= to reduce NH4 in the bowel
Antacids and Neomycin= to kill bacterial flora that cause NH production
NURSING INTERVENTIONS
6. Avoid hepatotoxic drugs
Paracetamol
Anti-tubercular drugs
7. Reduce the risk of injury
Side rails reorientation
Assistance in ambulation
Use of electric razor and soft-bristled toothbrush
8. Keep equipments ready including Sengstaken-Blakemore tube, IV
fluids, Medications to treat hemorrhage
The Gallbladder
CONDITION OF THE GALLBLADDER
Cholecystitis
Inflammation of the gallbladder
Can be acute or chronic
Cholecystitis

Acute cholecystitis usually is due to gallbladder stones

Cholecystitis
Chronic cholecystitis is usually due to long standing gall bladder
inflammation

Cholelithiasis
Formation of GALLSTONES in the biliary apparatus
Predisposing FACTORS
“F”
Female
Fat
Forty
Fertile
Fair

Supersaturated bile, Biliary stasis

Stone formation

Blockage of Gallbladder

Inflammation, Mucosal Damage and WBC infiltration

ASSESSMENT findings for cholecystitis
1. Indigestion, belching and flatulence
2. Fatty food intolerance, steatorrhea
ASSESSMENT findings for cholecystitis
3. Epigastric pain that radiates to the scapula or localized at the RUQ
4. Mass at the RUQ
5. Murphy’s sign
6. Jaundice
7. dark orange and foamy urine

DIAGNOSTIC PROCEDURES
1. Ultrasonography- can detect the stones
2. Abdominal X-ray
3. Cholecystography
DIAGNOSTIC PROCEDURES
4. WBC count increased
5. Oral cholecystography cannot visualize the gallbladder
6. ERCP: revels inflamed gallbladder with gallstone

NURSING INTERVENTIONS
1. Maintain NPO in the active phase
2. Maintain NGT decompression
NURSING INTERVENTIONS
3. Administer prescribed medications to relieve pain. Usually Demerol
(MEPERIDINE)
Codeine and Morphine may cause spasm of the Sphincter increased
pain. Morphine cause MOREPAIN
4. Instruct patient to AVOID HIGH- fat diet and GAS-forming foods
5. Assist in surgical and non-surgical measures
6. Surgical procedures- Cholecystectomy, Choledochotomy, laparoscopy

CONDITION OF THE GALLBLADDER

PHARMACOLOGIC THERAPY
Analgesic- Meperidine
Chenodeoxycholic acid= to dissolve the gallstones
Antacids
Anti-emetics

Post-operative nursing interventions

1. Monitor for surgical complications
2. Post-operative position after recovery from anesthesia- LOW FOWLER’s
Post-operative nursing interventions
3. Encourage early ambulation
4. Administer medication before coughing and deep breathing exercises
5. Advise client to splint the abdomen to prevent discomfort during
coughing
Post-operative nursing interventions
6. Administer analgesics, antiemetics, antacids
7. Care of the biliary drainageor T-tube drainage
8. Fat restriction is only limited to 4-6 weeks. Normal diet is resumed

Pancreatitis
Inflammation of the pancreas
Can be acute or chronic
Pancreatitis
Etiology and predisposing factors
Alcoholism
Hypercalcemia
Trauma
Hyperlipidemia

Etiology and predisposing factors

Biliary tract disease - cholelithiasis
Bacterial disease
PUD
Mumps

ASSESSMENT findings
1. Abdominal pain- acute onset, occurring after a heavy meal or alcohol
intake
2. Abdominal guarding

ASSESSMENT findings
3. Bruising on the umbilicus (cullen sign), Bruising on the flanks ( grey
turners spots)---CGFNS!!!
4. N/V, jaundice
5. Hypotension and hypovolemia
6. HYPERGLYCEMIA, HYPOCALCEMIA
7. Signs of shock

DIAGNOSTIC TESTS
1. Serum amylase and serum lipase
2. Ultrasound
3. WBC
4. Serum calcium
5. CT scan
6. Hemoglobin and hematocrit

NURSING INTERVENTIONS
1. Assist in pain management. Usually, Demerol is given. Morphine is
AVOIDED CGFNS ALERT!!
2. Assist in correction of Fluid and Blood loss
NURSING INTERVENTIONS
3. Place patient on NPO to inhibit pancreatic stimulation ( NO ICE CHIPS &
HARD CANDIES)---NCLEX!
4. NGT insertion to decompress distention and remove gastric secretions
5. Maintain on bed rest
7. Position patient in SEMI-FOWLER’s to decrease pressure on the
diaphragm
8. Deep breathing and coughing exercises
9. Provide parenteral nutrition
10. Introduce oral feedings gradually- HIGH carbo, LOW FAT
11. Maintain skin integrity
12. Manage shock and other complications