Signs of Appendicitis cont’d

 Obturator Muscle Test- With patient in supine position, ask him to flex his right leg at the hip and knee
at 90 degree angle. Holding the leg above the knee, grasp the ankle and rotate the leg laterally and
medially
 McBurney’s Sign/Blumberg’s sign- pain upon release of fingers palpating the RLQ
 Rovsing’s Sign-pain upon pressure in RLQ
 Murphy’s Sign-pain upon pressure in RUQ

 Grey Turner’s Sign- bruising at the flank

area

 Cullen’s Sign-bruising around the umbilicus

Laboratory and Diagnostic Imaging

 Ultrasonography
 Magnetic resonance Imaging
 Scintigraphy (with metaiodobenzylguanidine (MIBG)
 Computer tomography

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 waves.
 Test for acid reflux- normally after instillation of diluted HCL acid in the stomach, esophageal pH will
not drop
 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.

Gastric Analysis
 Used to evaluate the completeness of a vagotomy, confirm hypersecretion or achlorhydria, estimate
acid secretory capacity, assay for intrinsic factor
 Precautions in clients with heart failure, HPN

EGD- Esophagogastroduodenoscopy
 Direct visualization of a body system or part by means of a lighted, flexible tube/
 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

Proctosigmoidoscopy
 The visualization of the large intestine, sigmoid, rectum and anus with the use of an endoscope
(flexible-24 inches) or a sigmoidoscope (rigid, metal scope-10 inches)
 Bowel prep

2. Endoscopy- direct visualization (esophagoscopy, gastroscopy, esophagogastroduodenoscopy)

Before procedure:
 Consent
 NPO
 Sedation
 Anticholinergics
 Local anesthetic
 Position: left lateral decubitus position

After procedure:
 Position: Sims
 NPO
 Monitor for bradycardia

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 is 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 Meglumime is use instead of barium
o MIBG or Gastrographin may be used if pt has GIT perforations.
o Contraindicated in intestinal obstruction

Upper Gastrointestinal Series

Before procedure:
 NPO
 Barium’s given
 X-rays will be taken
 Hold opioids/anticholinergics 24 hours before

After procedure:
 Gives laxatives
 Assess stools(2-3 days)
Oral Cholecystography
 X-ray visualization of the biliary tree and gall bladder with the use of a dye.
This is contraindicated in iodine dye allergy or in the early months of pregnancy; jaundice or liver
dysfunction
Bilevac (High fat substance) will be given during the test

Percutaneous Transhepatic Cholangiogram (PTC)

 Needle is inserted to the skin through fluoroscopic guidance, contrast medium is injected to the biliary
nodule and then withdrawn to visualize the outline through fluoroscopy
 Obturator Muscle Test- With patient in supine position, ask him to flex his right leg at the hip and knee
at 90 degree angle. Holding the leg above the knee, grasp the ankle and rotate the leg laterally and
medially

ERCP Endoscopic Retrograde Cholangio-Pancreatography

 Endoscopic cannulation of the ampulla of Vater and retrograde injection of radiographic dyes into the
biliary tract
 Aid in the detection of strictures, intraductal stones, malignant tumors, and pancreatic disorders

Stool Examinations
 Occult Blood test(Hemoccult/guaiac test)
 Stool culture
 Fecal fat levels
 Fecal urobilinogen

Stool exam for occult blood Guaiac test

 No chocolate colored foods 42 hours prior to the test
 Avoid: cocoa, red meat, oral iron, iodine, colchicine
 Vit. C, turnips, beets, horseradish, melons

Serum Liver Function Tests

 Bilirubin-formed from the breakdown of hemoglobin by the reticuloendothelial system and conjugated
in the liver
o NV: Total-0.1-1.2 mg/dl
o Direct-0.1-0.3 mg/dl
o Indirect-0.1-1 mg/dl
 SGPT/ALT (Serum Glutamic Pyruvic Transaminase/Alanine Amino Transferase – liver enzyme used to
diagnose hepatocellular destruction. It is also found in small amounts in the heart, kidney and skeletal
muscle
 SGOT (Serum Glutamic Oxaloacetic Transaminase) - Enzyme found mainly in the heart and liver with
moderate amounts in skeletal muscles, kidneys and pancreas
o NV: 8-38 U/L
 Alkaline Phosphatase – an enzyme mainly produce din the liver and bone
o NV: 42-136 U/L
 Serum Protein – measure of albumin and globulin; an indirect indicator of liver function and disease
o NV: 6-8 g/dl
Coagulation Studies
 Clotting Time – NV: 7-15 mins
 Bleeding Time – the length of time required for bleeding to cease. NV: 1-9 mins
 Prothrombin Time – useful in testing for impaired lvier synthesis of Factors II, VII, X.
o NV: 11-15 sec
o Used to assess effectiveness of anticoagulant therapy, Vit. K deficiency or liver dysfunction
 APTT – to check for defects in Factors (I, II, V, VIII, IX, XI, XII). Screens for hemophilia A & B. May not
detect minor clothing defects
o NV: 35-45 seconds

Pancreatic Function Test

 Serum Amylase – NV: 60-160 U/DL
o Increased in acute and chronic pancreatitis, obstruction of pancreatic duct, acute alcoholic
intoxication and DM
o Decreased in advanced chronic necrosis of the liver and chronic alcoholism

Lipid Profile
 Cholesterol
o Total cholesterol ----------- 400-800 mg/dl
o HDL ---------------------------- >35-40 mg/dl
o LDL ----------------------------- <130 mg/dl
o TC/HDL ratio ---------------- 20:1
 Triglycerides – formed by esterification of glycerol and free fatty acids
o NV: 40-190 mg/dl

Urine/Kidney Function Tests

 Glycosuria seen in DM:
 Bilirubinemia observed in hepatocellular disease or hepatic-biliary obstruction
 Ketonuria appear after increased fat catabolism, low CHO intake, anorexia, prolonged vomiting and
fasting
 Creatinine – by product of muscle catabolism from creatinine phosphate
o NV: 0.7-1.4 mg/dl
 Uric Acid – a by-product of protein metabolism – NV: 1-5.8 mg/dl

Other Electrolytes
- Calcium NV: 4.5-5.3 mEq/L
- Phosphate NV: 1.7-2.6 mEq/L
- Potassium NV: 3.5-5 mEq/L
- Magnesium NV: 1.3-2.1 mEq/L
- Sodium NV: 136-148 mEq/L

ASSESSMENT FOR ENDOCRINE FUNCTION

 Thyroid gland – may not be visible
o Exophthalmos, lid lag, periorbital edema, or generalized facial edema, skin texture
o Thyroid auscultation – presence of bruit
o Normally lobes are smooth, small, and centrally located, painless, and rise freely with
swallowing: check solitary nodules
Thyroid Function Tests
 Thyroid scan – by a scintillation camera or a scintiscanner after administration of radioisotope of
iodine or technetium
o Areas of hyperactivity – gray or black regions “hot spots” / Hypoactivity – white or gray regions
o Normally color of uptake of the radioisotope is uniform
 Thyroid Ultrasonography
 Thyroid Biopsy
 T4 – Serum Thyroxine (5-12 ug/dL)
o Increased with hyperthyroidism and decreased with hypothyroidism
 T3 – Triiodothyronine (120-195 ug/dL)
o Rises in tandem with T4 but when alone is specific to toxic goiter and Grave’s disease
o TSH – Thyroid stimulating hormone (<10uU/dL)

Parathyroid Glands
 Serum calcium and phosphorus: CT Scan
 (metaiodobenzylguanidine)

Adrenal Glands
 Adrenal – arteriography/angiography detects benign and malignant tumors using a radioisotope
 Adrenal venography – detects tumors indicating Cushing’s syndrome – cortisol levels are high;
pheochromocytoma when catecholamine levels are high
 Scintigraph – scanning of the adrenals with the help of MIBG

Pituitary Function Tests

 Serum studies of hormones
 Roentgenograms of hand and wrist to determine bone age
o Retarded age found in hypopituitarism, GH deficiency and hypothyroidism, gonadal dysgenesis
o Accelerated age in excess estrogens and androgens, hyperthyroidism

Blood Sugar Tests

 Fasting – NV: 100-110 mg/dl
 2Hr. Post Prandial Blood Sugar
o NV: 65-140 mg/dl
 Random – NV not more than 140 mg/dl
 Oral Glucose Tolerance Test – Normal blood sugar levels after 30 mins., 1hr, and 2hrs interval
 Glycosylated hemoglobin test – increased in high glucose levels. True test of blood sugar months
before the test
 Glycosylated Hemoglobin (HbA1c)
o 7.5% & blow – Good
o 7.6% - 8.9% - Fair
o 9% and above – Poor

Pharmacology for Gastrointestinal Disturbances

 Antiemetics
o Acts by
 Diminishing the sensitivity of the chemoreceptor trigger zone (CTZ) to irritants or
 Decreasing labyrinthine excitability
 Anorexiants
o Description
1. Used to suppress the appetite
2. Act at the hypothalamic appetite center to suppress the desire for food; they generally produce
CNS stimulation

 Antacids and Mucosal Healing Agents

o Description
1. Used to neutralize gastric acid
2. 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
o Guidelines for Antacids
 Given after meals (1-3 hours pc)
 Monitor stool
 Caution for constipation or diarrhea

Aluminum containing – diarrhea (amphogel)

Magnesium containing – constipation (Maalox, Riopan)

Misoprostol (Prostaglandin analogue)

S/E: menstrual discomfort
ADR: induce abortion
Caution: Pregnancy test

(note: give 30 mins. Before meals)

 Gastrointestinal Anticholinergics
Description
1. Inhibits vagal stimulation
2. Act by inhibiting smooth muscle contraction in the GI Tract
3. Leads to decreased acid production
S/E: blurred vision, dryness of the mouth, urinary retention, constipation
(note: give 30 mins. before meals)

 Gastrointestinal Antihistamines
Description
1. Used to inhibit gastric acid secretion
2. Act as the Hydrogen receptor blockers of the stomach parietal cells
3. Effective in the short-term therapy of peptic ulcer

H2 blockers
Description
1. Blocks H2 receptors and histamine release
2. Decreases acid production
3. Examples: Ranitidine, Cimetidine
Guidelines:
Never administer with antacids
Administer with meals/before meals
 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: Esomeprazole, omeprazole

 Antidiarrheals
Description:
1. Used to alleviate diarrhea
2. Act by various mechanisms to promote the formation of formed stools

 Cathartics Laxatives
Description
1. Used to alleviate or prevent constipation
2. Act by various mechanisms to promote evacuation of a normal stool

 Intestinal Antibiotics (Clarithromycin, tetracylines, amoxicillin, neomycin)

 Pancreatic Enzymes
Description
1. Used to promote the digestion of proteins, fats and starches
2. Acts as a replacement for natural endogenous pancreatic enzymes (protease, lipase, amylase)

 Antidiuretic Hormone
Description
1. Used in the treatment of diabetes insipidus
2. Acts to
a. Promote water reabsorption by the distal renal tubules
b. Cause vasoconstriction and increases muscle tone of the bladder, GI tract, uterus and blood
vessels.

General Nursing Procedures

o Enemas
o Irrigation of nasogastric tube
o Paracentesis
o Ileostomy
o Colostomy
o Gastric gavage (nasogastric tube, or percutaneous endoscopic gastrostomy tube)
o Hyperalimentation (Total Parenteral Nutrition)

Enemas-Generally used only in acute situations, short term basis

1. Local irritation to bowel, e.g. tap water,
2. Soap suds: drawing fluid into bowel, e.g. phosphate enemas (Fleet)
3. Softening fecal mass, e.g. oil retention
Considerations:
o Monitor fluid and electrolyte levels
o Prevent infection and complications
o Care to prevent tissue and mucosal injury

Nursing Diagnoses for Clients with GIT Disturbances

 Nutrition, alteration in: less than body requirements related to
1. Inability to ingest
2. Malabsorption
3. Anorexia
4. Increased cellular metabolism
Nutrition, alteration in: more than body requirements related to excess ingestion

 Oral mucous membranes, alteration in related to chemical and microbiological irritants.

 Activity intolerance, potential: related to unavailability of cellular nutrients
 Self-concept, disturbance in: body image related to
1. Excess body weight
2. Excessive weight loss

 Bowel elimination, alteration in: constipation related to:

1. Mechanical obstruction
2. Inadequate dietary roughage
3. Inadequate fluid intake
4. Inactivity
 Bowel elimination, alteration in: diarrhea related to:
1. Local inflammatory process
2. Anxiety
3. Food intolerance

Nursing Diagnosis for Clients with GIT Disturbances

o Activity intolerance related to decreased metabolic rate
o Sleep pattern disturbance related to increased metabolic rate
o Coping, ineffective individual related to chronic nature of disability
o Fluid volume, alteration in: excess related to electrolyte imbalance
o Fluid volume deficit, actual related to increased urinary output
o Nutrition, alteration in: less than body requirements related to imbalance between expenditure and
carbohydrate utilization
o Sensory-perceptual alteration related to metabolic alteration
o Noncompliance related to inability to accept chronic disease

BMI -wt in kg/(ht((ht)

o Overweight- BMI > or equal to 25
o Obesity- BMI>or equal to 30
o Underweight-less than 18.5
o Normal 18.5-24.9
 ‘Pear’ shape ‘Apple’ shape

 Less visceral  More

fat visceral fat
 Lower risk of  Higher risk
weight- of weight-
related related
health health
problems problems

Malnutrition
Undernutrition
 Marasmus-deficiencies in CHON and calories are approximately equal in severity/deficiency of all
nutrients.
PCM-Protein Calorie and Malnutrition

Kwashiorkor – severe protein deficiency

Underweight Conditions
 BMI < 18.5 associated with disease, medical
treatments
 Loss of visceral protein stores lead to negative
nitrogen balance
 Adverse to health if compromised by stress,
injury or infection

Therapeutic Management of Underweight Clients

 Increase calories & reestablish regular meal
pattern
 Increase intake of high nutrition density food
(highest level of Kcals)
 Megestrol Acetate (Megace_) & Dronabinol
(Marinol) as appetite stimulants are used in clients with HIV-AIDS cancer.

 Etiology on Under nutrition

1. Children – coming of another sibling
2. Poor Diet
3. Inability to assimilate food ingestion
4. Physical stress
5. Abnormal Nutrient losses
PATHOPHYSIOLOGY OF MALNUTRITION
(Deficient Dietary Amino Acids)
 KWASHIORKOR
1. Lack of plasma proteins (albumin) – edema
2. Increase of extracellular H20 & loss of K+
3. No production of lipoproteins – fatty liver & hepatomegaly
4. Pancreatic atrophy & fibrosis – leads to malabsorption
5. Reduced bone density & impaired renal function
6. Lack of antibodies & lymphocytes-infection
7. Melanin and keratin lack- hair & skin discoloration
8. Lack of hemoglobin & erythopoetin anemia
9. General body weakness

________________________________________________________________________________________
Under nutrition of all nutrients
 MARASMUS

1. Caloric intake is too low to support protein synthesis for growth or the storage of fat.
2. Muscle wasting & anemia
3. Fat wasting & increase in serum triglyceride & phospholipid levels
4. Vitamin A deficiency & blindness
5. Generalized body weakness

COMPARISON OF MARASMUS – KWASHIORKOR

Marasmus Kawahiorkor
 Wasted appearance  Edema (CHON <3g/dL)
 Stunted growth  Desquamation of skin
 Loss of subcutaneous fat  Discolored hair
 Relatively normal skin, hair, liver  Enlarged abdomen
function & affect.  Weight loss, muscle wasting
 Extreme apathy

Nursing Diagnoses
 Imbalanced Nutrition
 Risk for infection
 Risk for Fluid Volume Deficit
 Risk for Impaired Skin Integrity
 Altered thought processes
 Activity intolerance
 Altered body image
  Therapeutic Management
1. Enteral Nutrition via mouth or tube (polymeric formulas or elemental formulas, specialized diets).
2. Total parenteral nutrition (a solution of amino acids, glucose, minerals, trace elements & vitamins.)

Enteral Nutrition
 Tube feedings used to meet caloric & protein requirements in clients unable to consume adequate
food.
 Used for clients with difficulty swallowing, unresponsiveness, oral/neck trauma/surgery, anorexia,
serious illness
 Feeding Solutions
1. Standard is 1 calorie per ml with 14% protein; 60% carbohydrates, 25-30% fat with added
vitamins & minerals to meet recommended daily intake

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE

 Parenteral Nutrition
a. Total Parental Nutrition (TPN) also called hyperalimentation is intravenous administration of
nutrient emulsions
b. Usually administered through a central vein, sometimes with triple lumen catheter; lesser
concentrations may be given through peripheral vein
 c. Used with clients who have undergone major surgery, trauma, or as seriously malnourished.

 Medications: Supplemental vitamin & minerals

 Fluid & Dietary Management:

a. Correction of imbalances, particularly potassium, magnesium, calcium
b. Gradual re-introduction of protein & calories; vitamins & minerals
c. Fat and lactose introduced lastly
d. Gradual refeeding to prevent further electrolyte imbalances, malabsorption & diarrhea.

CLIENT WITH OBESITY

- Upper body obesity (central, truncal, “apple”, intra-abdominal)
- Lower body obesity (peripheral, “pear”, hips & thighs)
- Waist-hip ratio (> 1 males; 0.8 females)
- Risk factors for obesity
1. Heredity
2. Physical inactivity
3. Environmental influences
4. Psychologic factors

Complications
- Impaired hepatic function – FA from visceral fat go directly to the liver.
- Impaired circulatory function – atherosclerosis & arteriosclerosis
- Drug treatment is only suggested with BMI > 30 or BMI >27 with co-morbidities in conjunction
with diet & exercise therapies.

Treatments
 Dietary Management
- Low calories & fat with adequate nutrients, minerals & fiber
- Regular meals with small servings
- Gradual weight loss of no more than 1 – 2 pounds per week.
- Usually 1000-1500 calories per day
- Best diet plan contains modifications without severe restrictions, low fat, well-balanced
nutrition & improved eating habits.

 Behavior Modification

 Exercise
 30 minutes of aerobic exercise 3-5x/wk

 Medications examples
- Amphetamines, antidepressants, Sibutramine (Meridia), Orlistat (Xenical), Phenylpropanolamine,
Bulk-forming products
- Anorexia medications are contraindicated during pregnancy, lactation & clients with cardiac, live &
kidney problems
- Amphetamines & antidepressants cause toxicity & dependency
 Surgery
 Procedures: vertical banded gastroplasty and roux-en-Y gastric bypass, Reduce stomach capacity

 Maintaining Weight Loss

a. Majority of dieters regain weight within 2 year period
b. Long-term weight loss is lifelong commitment

 Nursing Diagnoses
a. Imbalanced Nutrition: More than Body Requirements
b. Activity Intolerance
c. Ineffective Therapeutic Regimen Management
d. Chronic Low Self-Esteem: Referral for counseling as appropriate