METABOLISM All the chemical reactions necessary to maintain life Occurs in all living cells at different rates The

The liver is the most versatile and metabolically active

HELPERS IN METABOLIC REACTIONS ENZYMES a catalyst protein that is not altered in the process of metabolism Selective: enzyme substrate specificity CO ENZYMES small organic molecules that facilitate enzyme functions HORMONES stimulates or inhibits metabolism THYROXINE glucose uptake, glucose catabolism for energy, protein synthesis, lipolysis CORTISOL lipolysis, gluconeogenesis, protein catabolism (adrenal cortex) TESTOSTERONE protein synthesis
T3T4 = increases metabolic process

TWO PHASES OF METABOLISM ANABOLISM (up) o o reactions where small molecules are put together to build larger ones utilizes energy in the process Reactions in which large molecules are broken down to smaller ones Energy is released in the form of heat or is captured in another chemical bond ENERGY INPUT = ENERGY OUTPUT Input is provided by Kcalories provided for indigested food Output o o o Basal metabolism life maintenance (65%) Physical activity Thermic effect of food processing

CATABOLISM (down) o o

DIGESTIVE PROCESS 1. Ingestion 2. Digestion 3. Secretion

4. Absorption 5. Excretion CATEGORIES of NUTRIENTS 1. Carbohydrates Primary sources: plant, sugars, and starches (grain and root vegetables) Energy value : 4kCal per gram; excess is converted to glycogen or fat Recommended daily intake: 125 175gm (mostly complex) body function: converted to glucose for cellular function deficiency: over time tissue wasting since protein and fats are broken down and metabolic acidosis could result CARBOHYDRATE METABOLISM: o o GIT digestion and absorption Liver metabolism basal state releases glucose to maintain an average concentration of 80mg/dL o o o 2. Proteins 3. Fats Saturated fats: animal products, coconuts Unsaturated fats: seeds, nuts, vegetable oils Cholesterol: meats, milk products, egg yolks Energy value: 9kCal per gram Recommended daily intake 30% or less of daily caloric intake Primary sources animal products and plant sources (20 essential AA) Energy value: 4kcal per gram Recommended daily intake: MALE 56gm; FEMALE 45gm Body function: building body tissues, enzymes, hemoglobin, clotting factors, hormone and neurotransmitter precursors 0.5 1.5gm/kg BW/ day individual body requirement 0.8gm/ kg to replace degraded proteins Additional needed with growth, pregnancy, tissue repair and healing (1.5 2gms/kg BW/ day) Feedback glycogenesis (>100mg/dL) Glycogenolysis breakdown of glycogen to glucose Gluconeogenesis formation f glucose from non CHO sources; CNS protective mechanism

Body function: o fatty acids are essential for body cell membranes for some substances including hormones o concentrated source of cell fuel

deficiency: excessive weight loss and skin lesions precursors of phospholipids and glycolipids for myelin sheath and cell membranes major fuel in muscle and CNS in fasting, preferred by cardiac muscles ad liver as source of energy CHOLYMICRONS end products of lipid digestion LIPOLYSIS breakdown of stored fats into glycerol and fatty acids BETA OXIDATION breakdown of fatty acids to acetyl CoA converted to ketone bodies

4. VITAMINS Essential organic compounds facilitate bodys use nutrients Fat soluble: A,D,E,K which are produced or stored in body and can reach toxic levels o o o o Vit. A needed for vision, skin and mucous membrane integrity Vit. D needed for calcium homeostasis Vit. E antioxidant Vit. K needed for clotting proteins by the liver; synthesized by bacteria in large bowel Water soluble: B vitamins and C which are excreted and seldom reach toxic levels o Vit. B1(Thiamine) needed for function of heart, muscles, nerves o o o o o o o o 5. MINERALS Vit. B2 (Riboflavin) needed for utilize other nutrients Vit. B6(Pyridoxine) needed for protein metabolism Vit. B12(Cyanocobalamin) essential for RBC formation Vit. C(Ascorbic Acid) antioxidant; needed for healing wounds Niacin (Nicotinamide) needed for CHO and fat metabolism Biotin needed for catabolism of fatty acids and CHO Patothenic needed for steroid, heme synthesis Folic Acid(Folacin) needed for formation of RB, health of nervous system

Necessary for maintenance of bodys structures and functioning Major minerals needed include: calcium, phosphorus, potassium, sulfur, sodium, chloride, magnesium Trace elements (necessary in small amounts) include: iron (RBC formation), iodine (for metabolism), copper, zinc (absorption of Vit. C), selenium

HEALTH HISTORY Problems with swallowing, heartburn, nausea (stimulated by CTZ in the medulla), vomiting, regurgitation Indigestion, frequency and characteristics of bowel movements, change in bowel habits Changes in appetite , weight loss or gain, food intolerance Abdominal pain, excessive belching (burping) History of surgery, use of prosthesis (colostomy has problem in LI) History of diseases related to metabolism ( hyperthyroidism, DM) Previous surgery ( Billroths operation) Use of prosthesis Excessive perspiration, energy level palpiatations Changes in vital signs Throat tightness Jaundice (may be due to inability of liver to conjugate), skin and hair changes Changes in general appearance posture Changes in sensorium, general vitality Dietary intake and patterns ( do the 24 hour diet recall) Mental (due to encephalopathy secondary to hepatic disorder) and emotional status ANTHROPOMETRIC MEASURE Desired Body Weight DBW for Filipinos = (height in cm 100) x 0.1 Standard computations of DBW Men (5ft = 106lbs)

For every inch above 5ft: +6lbs For every inch below 5ft: 6lbs (add 10% for big frame or subtract 10% for small frame) Women (5ft = 100 lbs) For every inch above 5ft: +5lbs For every inch below 5ft: 5lbs (add 10% for big frame or subtract 10% for small frame) ANALYSIS Underweight weight of 10% below DBW Overweight weight of 10 20% above DBW Severely obese 40% above DBW Body Frame Size Ratio = Analysis Small Frame Medium Frame Large Frame 9.6 10.4 9.6 10.4 10.1 Height in cm Male 11 10.1 11 Female Wrist Circumference

Body Mass Index BMI = Weight in kg (Height in meter) 2 BMI = Weight in (lbs) x 705 (Height in inches) 2 Analysis of obtained result: <18.5 underweight 18.5 24.9 normal 25 29.9 overweight > 30 obese

Mid Upper arm circumference (MAC) Determines muscle wasting Determines fat content of SQ tissues Used to indicate cholesterol levels Estimates body fat using a double fold Waist indicator of fat distribution Ideally <35 for women and <40 for men 0 .8 for women 0.9 for men Triceps skin fold (TSF)

Waist measurement -

Waist Hip ratio -

HEALTH ASSESSMENT a. INSPECTION Lips/ mucous membranes, teeth symmetry, color, size, moisture, texture, missing teeth Oral cavity appearance of tongue, pharynx, uvula, gag reflex Abdomen color, shape, contour, enlargement, movements, umbilical location b. AUSCULTATION Done before percussion so as not to alter the bowel sounds Abdomen check for bowel sounds (5 30clicks/min), arterial bruits and friction rubs Assess on RLQ where ileoceccal valve is located

c. PERCUSSION Abdomen to determine sizes of organs, gas patterns, R mid clavicular 7th ICS for liver; posterior L axillary line for spleen; fluid levels or contents Liver normally 6 10 cm; large in males than in females 4 8 cm in the sterna line; 7 12 cm in R mid clavicular line Spleen normally tynpany or resonance is heard on site when not enlarged. My be dull at posterior L axillary line 10th ICS Shifting dullness and fluid wave test when theres ascites d. PALPATION

Palpate the tender areas last Lips and mucosa moisture, firmness of gums, movement of texture of tongue Abdomen light palpation (1cm) to check for tenderness, tension or muscle guarding Deep palpation (1.5 2 cm) for tenderness and masses

PATHOLOGIC SIGNS OF ABDOMINAL DISORDERS Iliopsoas Muscle Test (appendicitis) The patient in supine position raises his R leg straight up and off the table. Examiners hand are on the upper thigh pressing down while the patient opposes the force Test is (+) if the patient experiences abdominal pain

Obturator Muscle Test (appendicitis) With patient in supine position, ask him to flex his R leg at the hip and knee at 90 angle. Holding the leg above the knee, grasp the ankle and rotate the leg laterally and medially (+) peritonitis (appendix ruptured); abdominal rigidity

MvBurneys Sign With your fingertips firmly palpate the RLQ, then release the pressure very quickly

Rovsings Sign Pain upon pressure in RLQ (rebound tenderness)

Murphy Sign Pain upon pressure in RUQ ; pain upon inspiration; involves the gallbladder

Grey Turners Sign Bruising at the flank area (posterior)

Due to bleeding of pancreas (pancreatitis) Enzymes are produced that digest the pancreas itself

Cullens Sign

Bruising around the umbilicus (anterior)

LABORATORY and DIAGNOSTIC EXAMINATIONS 1. Ultrasonography UTZ KUB checks for renal failure; should have full bladder Full abdomen on NPO

2. Magnetic Resonance Imaging Metals are removed

3. Computed Tomography MIO is not necessary

4. Esophageal Function Studies Test for esophageal sphincter pressure normally should be higher than the pressure in the stomach Test for swallowing pattern normally is not propulsive or asynchronus wave Test for acid reflux normally after instillation of diluted HCl acid int eh stomach, esophageal pH will not drop Esophageal Manometer test measures the motility and function of the esophagus and esophageal sphincter. A tube is usually inserted through the nose and passed into the esophagus. The pressure of the sphincter muscle is recorded and also the contraction waves of swallowing are recorded. The manometry test is a tool used to help evaluate swallowing disorders Acid Clearing Test acid in the esophagus should be cleared in less than 10 swallows Bernstein Test discomfort that occurs with the instillation of a diluted HCl acid will indicate esophagitis or ulcerated esophageal lesion 5. Gastric Analysis Used to evaluate the completeness of a vagotomy, confirm hypersecretion or achlorhydria (absence of HCl), estimate acid secretory capacity, assay for intrinsic factor

6. EGD (Esophagogastroduodenoscopy) Direct visualization of a body system or part by means of a lighted flexible tubes More accurate than radiologic exam Can be used to dilate esophageal strictures, remove foreign bodies, inject on varices, and cure lesions with a laser beam or heat probe 7. Proctosigmoidoscopy Visualization of the large intestine, sigmoid, rectum and anus with the use of endoscope (flexible 24inches) or a sigmoidoscope (rigid metal scope 10inches) 8. Oral Cholecystography X r visualization of the biliary tree and gallbladder with the use of dye This is contraindicated in iodine dye allergy or in the early months of pregnancy Monitors gallbladder emptying Assess for allergies with seafoods

9. Upper and Lower GIT series Upper A series of x rays of the esophagus, stomach, and duodenum during and after drinking a barium solution (BARIUM SWALLOW) Lower x ray visualization of the lower intestine and rectum (BARIUM ENEMA) Barium swallow o Useful in detecting strictures, hernias, diverticula, varices, ulcers, tumors, and motility disorders o Not performed with suspected GIT perforation since it will cause severe inflammatory reactions. Diatrazoate Meglumine is used instead of barium o Contraindicated in intestinal obstruction
Strictures constricted like atresia Hernia out pouching of the tissues

10. Percutaneous Transhepatic Cholangiogram Needle is inserted to the skin though flouroscopic guidance, contrast medium is injected to the biliary nodule and then withdrawn to visualize the outline thru flouroscopy

11. ERCP (Endoscopic Retrograde Cholangio Pancreatography) On NPO Endoscopic cannulation of the ampulla of Vater and retrograde injection radiographic dyes into the biliary tract Aid in the detection of strictures, intraductal stones, malignant tumors, and pancreatic disorders 12. Stool Examinations Occult blood test or Guaiac Test Stool culture Fecal fat levels check the gallbladder function Fecal urobilinogen

13. Serum Liver Function Tests Bilirubin formed from the breakdown of hemoglobin by the reticuloendothelial system and conjugated in the liver NV: Total Direct 0.1 1.2 mg/dL 0.1 0.3 mg/dL

Indirect 0.1 1 mg/dL SGPT/ ALT (Serum Glutamic Pyruvic Transaminase or Alanine Amino Transferase) o Liver enzyme used to diagnose hepatocellular destruction. It is also found in small amounts in the heart, kidney and skeletal muscle SGOT/ AST (Serum Glutamic Oxoacetic Transaminase) o Enzyme mainly found in the heart and liver with moderate amount in skeletal muscles, kidneys and pancreas Alkaline Phosphatase (42 136 U/L) o Enzyme mainly produced in the liver and bone Measure of albumin and globulin; an indirect indicator of liver function and disease 14. Coagulation studies Clotting time (7 15 mins) now replaced with ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) Serum Protein (6 8 g/dL) o

Bleeding time ( 1 9 mins) the length of time required for bleeding to cease Prothrombin time (11 15 secs) useful for testing for impaired liver synthesis of Factors II, VII, X APTT (35 45 secs) to check for detects in Factors (I, II, V, VIII, IX, XI, and XII). Screens for hemophilia A & B, not to detect minor clotting defects

15. Pancreatic Function Test (SERUM AMYLASE) NV: 60 160 U/dL Increased in acute and chronic pancreatitis, obstruction of pancreatic duct, acute alcoholic intoxication and DM Decreased in advanced chronic necrosis of the liver and chronic alcoholism

16. Lipid Profile Cholesterol o o o o Total cholesterol HDL LDL TC/HDL ration 400 800mg/dL >35 45 mg/dL < 130 mg/dL 20:1 NV:

Triglyceride formed by esterification of glycerol and free fatty acids 40 190 mg/dL

17. Urine/ Kidney Function Test Glycosuria seen in DM; bilirubinuria observed inhepatocellualr disease or hepatic biliary obstruction Ketonuria appears after increased fat metabolism, low CHO diet intake, anorexia, prolonged vomiting and fasting Creatinine by product of muscle catabolism from creatinine phosphate NV: 0.7 1.4 mg/dL Uric acid by product of protein metabolism

18. Other electrolytes Calcium NV: 4.3 5.3 mEq/L

Phosphate NV: Potassium NV:

1.7 2.6 mEq/L 3.5 5 mEq/L

Magnesium NV: 1.3 2.1 mEq/L Sodium NV: 136 148 mEq/L

NURSING DIAGNOSES FOR CLIENTS with GIT DISORDERS Nutrition, alteration in: less than body requirements related to o o o o Inability to ingest Malabsorption Anorexia Increased cellular metabolism

Nutrition, alteration in: more than body requirements related to excess ingestion Oral mucous membranes, alterations in related to chemical and microbiological irritants Activity intolerance, potential: related unavailability of cellular nutrients Self concept, disturbance in: body image related to o o Excess body weight Excessive weight loss Mechanical obstruction Inadequate dietary roughage Inadequate fluid intake Inactivity Local inflammatory process Anxiety Food intolerance

Bowel elimination, alteration in: constipation related to o o o o

Bowel elimination, alteration in: diarrhea related to o o o

PHARMACOLOGY for GIT DISTURBANCES 1. ANTI EMETICS Acts by: Diminishing the sensitivity of the chemoreceptor trigger zone (CTZ) to irritants Decreasing labyrinthine excitability

2. ANOREXIANTS Description: Used to suppress the appetite Act at the hypothalamic appetite center to suppress the desire for food; they generally produce CNS stimulation 3. ANTACIDS and MUCOSAL HEALING AGENTS Description: Used to neutralize the gastric acid Act by providing a protective coating on the stomach lining and lowering the gastric acid level which allows more rapid movement of stomach contents into the duodenum Guidelines: Give after meals (1 3 Monitor stools Contain high Na+

Misoprostol S/E: menstrual discomfort hours) induce absorption ADR: Caution: pregnancy test NOTE: give 30mins before meals

4. GIT ANTICHOLINERGICS Description: S/E: NOTE: Blurred vision, dryness of the mouth, urinary retention, constipation give 30mins before meals Inhibits vagal stimulation Acts by inhibiting smooth muscle contraction in the GIT Leads to decreased acid production

5. GIT ANTIHISTAMINES Description: Used to inhibit acid secretion Act as the hydrogen receptor Effective in the short term therapy of peptic ulcer

6. H2 BLOCKERS Block H2 receptors and histamine release Decrease acid production Examples:

o o

Ranitidine cimetidine Never administer with antacids (GIVE AT LEAST 3 HOURS AFTER) Administer with/before meals

Guidelines: o o

7. PROTON PUMP INHIBITORS Description: Inhibits the final step of acid secretion by blocking the actions of the gastric parietal cells and proton pump This is accomplished by blocking ATPase enzyme that is important for the secretion of gastric acid Examples: o o Esomeprazole Omeprazole

8. ANTIDIARRHEALS Description: Used to alleviate diarrhea Act by various mechanisms to promote the formation of formed stools

9. CATHARTIC LAXATIVES Description: Used to alleviate or prevent constipation Act by various mechanisms to promote evacuation of a normal stool

10. INTESTINAL ANTIBIOTIC Clarithromycin, tetracycline, amoxicillin, neomycin

11. PANCREATIC ENZYMES Description: Use to promote the digestion of proteins, fats, and starches Acts as replacements for natural endogenous pancreatic enzymes (proteae, lipase, amylase) 12. ANTIDIURETIC HORMONE

Description: Used to treat diabetes insipidus Acts to: o o Promote water reabsorption by the distal renal tubules Cause vasoconstriction and increased muscle tone of the bladder, GIT, uterus, and blood vessels GENERAL NURSING PROCEDURES Enemas Irrigation of NGT Paracentesis Ileostomy Colostomy Gastric gavage Hyperalimentation (TPN)

NURSING RESPONSIBILITIES for COMMON DIAGNOSTIC EXAMS 1. Upper GIT series Before: After: Give laxative Assess stools NPO Barium is given X- rays will be taken

2. Endoscopy Before: After: Consent NPO Sedation Antocholinergic Local anesthetic Position: left lateral decubitus position

Position: Sims NPO Monitor bradycardia

3. Gastric analysis To measure secretions of HCl and pepsin Gastric contents will be aspirated and analyzed Not to eat dark colored foods

4. Stool exam for Guaiac Test No chocolate colored foods 72hours prior Avoid: cocoa, red meat, and vit.C