Git Handouts

CARE OF THE CLIENTS WITH GASTROINTESTINAL DISORDERS Handouts for ISU-Ilagan Student Nurse
 The GIT is composed of two general parts (23 – 26 foot long)

 The main GIT starts from the mouthEsophagusStomachSmall
IntestineLarge Intestine
The Accessory Organs are the:

1. Salivary glands
2. Liver
3. Gallbladder
4. Pancreas
The GIT ANATOMY
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
Functions:
 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 squamous epithelium
 Posterior to the trachea and heart

Functions:
 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!
Functions:
CHARLES Z. ARIOLA JR, MSN, LPT, RN. 1

 The functions of the stomach are generally to digest the food

(proteins) and to propel the digested materials into the SI for
final digestion
 The Glands and cells in the stomach secrete digestive
enzymes:
Stomach:
1. Parietal cells- HCl acid and Intrinsic factor
2. Chief cells- pepsin digestion of PROTEINS!
3. Antral G-cells- gastrin
4. Argentaffin cells- serotonin
5. Mucus neck cells- mucus
The Small intestine

 Grossly divided into the Duodenum, Jejunum and Ileum
 The ileum is the longest part (about 12 feet)
 Longest segment of the GI tract 7000cm
 Area for secretion and absorption
 Ileo-cecal valve controls passage of intestinal contents in the large
intestines
Functions:
 The intestinal glands secrete digestive enzymes that finalize
the digestion of all foodstuff
 Enzymes for carbohydrates disaccharidases
 Enzymes for proteins dipeptidases and aminopeptidases
 Enzyme for lipids intestinal lipase
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
Functions:
 Absorbs water
 Eliminates wastes
 Bacteria in the colon synthesize Vitamin K
 Appendix participates in the immune system
The Gastrointestinal System Physiology

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
Functions of the Digestive System

1. To breakdown food particles into the molecular form for digestion.
2. To absorb into the bloodstream the small molecules produced by
digestion
3. To eliminate undigested and unabsorbed foodstuffs and other waste
products from the body
 Process of digestion begins with this act
 Saliva is excreted from 3 pairs of glands
 Parotid
 submaxillary
 sublingual
 1.5 liters of saliva is secreted daily
 Saliva contains enzyme Ptyalin or salivary amylase
 Contains mucus and water which helps to lubricate the food
facilitating swallowing
 As food is swallowed the epiglottis covers the trachea
 Esophageal sphinter relaxes to permit bolus of food to enter the
stomach
Gastric Function
 Stomach mixes and stores foods with secretion
 Secretes gastric acid, HCL 2.4L per day
 Also secretes Pepsin and Intrinsic factor
 Function of gastric secretion is to breakdown food and destroy
most ingested bacteria
 Chyme, food mixed with gastric secretions
 Pyloric sphincter
Small intestines function

 Digestive process continues in the duodenum.
 Accessory digestive organs, pancreas, liver and gall bladder
 Digestive enzymes
a. Trypsin – digest proteins
b. Amylase – digest starch

c. lipase – digest fats
 Bile – emulsifies fats
 Carbohydrates
 disaccharrides – sucrose, maltose and galactose
 monosacharides – glucose and fructose
 major role is absorption
 duodenum – iron and calcium
 jejunum – fats, protein, carbohydrate, Na, chloride
 ileum - Vit B12 and bile salts
Colonic Function
 4 hrs after eating residual waste passes through the ileo-cecal valve
 Bacteria assist in completing the breakdown of waste material
 12 hours after a meal
 Feces 75% water, 25% solid
 Indole and skatole
 bile
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
Functions:
 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
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
Functions:
 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
Functions:
 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!
THE NURSING PROCESS IN GIT DISORDERS
Assessment
Health history Nursing History
PE
Laboratory procedures
Clinical history and manifestations
Elicit information regarding:
- pain, indigestion
- intestinal gas, nausea and vomiting
- hematemesis
- changes in bowel habits and characteristics
- current medication intake
- tobacco and alcohol use
The ABDOMINAL examination
The sequence to follow is:
Inspection
Auscultation
Percussion
Palpation
Physical Assessment
Assessment of the mouth, abdomen and rectum

 Lie the patient supine with knee flexed
 Inspect for previous scars, shape
Bowel Sounds
- normoactive – BS q 5 to 20 secs
- hypoactive – 1-2 sounds in 2 minutes

- hyperactive – 5-6 sounds in < 30secs
- absent – no sound in >3-5 mins
Laboratory Procedures
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
Occult Blood Testing

- Instruct the patient to adhere to a 3-day meatless diet
- No intake of NSAIDS, aspirin and anti-coagulant
- Screening test for colonic cancer
Breath Test
Urea breath test

- detect the presence of Helicobacter Pylori
Hydrogen breath test
- evaluate carbohydrate absorption
Upper GIT study: Barium Swallow

 examines the upper GI tract
 Barium sulfate is usually used as contrast
 Detect or exclude anatomic or functional derangement of the upper
GI organ or sphincter
 Aids in the diagnosis of ulcers, varices, tumors, regional enteritis and
malabsorption syndrome
Upper GIT study: barium swallow
Pre-test: NPO post-midnight, low residue diet

Post-test: Laxative is ordered, increase pt fluid intake, instruct that
stools will turn white, monitor for obstruction
Lower GIT study: barium enema

- Examines the lower GI tract
- Barium is instilled rectally

Pre-test: Clear liquid diet and laxatives, NPO post-midnight, cleansing
enema prior to the test
Post-test: Laxative is ordered, increase patient fluid intake, instruct that

stools will turn white, monitor for obstruction
- Detects the presence of tumors, polyps and other lesions of the
small intestines
- Demonstrate any abnormal anatomy or malfunction of the bowel.
Gastric Analysis
- Aspiration of gastric juice to measure pH, appearance, volume and
contents
- Pre-test: NPO 8 hours, avoidance of stimulants, drugs and
smoking
- Post-test: resume normal activities
- Yields information about the secretory activity of the gastric
mucosa
- Presence or degree of gastric retention in patients thought to have
pyloric or duodenal obstruction
- Useful for diagnosis of Zollinger Ellison Syndrome
EGD(esophagogastroduodenoscopy)
- Visualization of the upper GIT by endoscope
- Pre-test: ensure consent, NPO 8 hours, pre-medications like
atropine and anxiolytics
- Pretest: NPO
- Intra-test: position : LEFT lateral to facilitate salivary drainage
and easy access
- Post-test: NPO until gag reflex returns, place patient in SIMS
position until he awakens, monitor for complications, saline
gargles for mild oral discomfort
Lower GI- scopy

- Use of endoscope to visualize the anus, rectum, sigmoid and colon
- Evaluate rectal bleeding, acute or chronic diarrhea, change in
bowel patterns, ulcerations, polyps, tumors
- Pre-test: consent, NPO 8 hours, cleansing enema until return is
clear
- 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
Paracentesis
- Removal of peritoneal fluid for analysis
- 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
Liver Biopsy
Pretest
- Consent
- NPO
- Check for the bleeding parameters
Intratest:
- Position: Semi fowler’s LEFT lateral to expose right side of
abdomen
Post-test:
- position on RIGHT lateral with pillow underneath, monitor VS and
complications like bleeding, perforation. Instruct to avoid lifting
objects for 1 week
COMMON GIT SYMPTOMS AND MANAGEMENT

- CONSTIPATION
- DIARRHEA
- DUMPING SYNDROME
1. 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
2. DIARRHEA
- Abnormal fluidity of the stool
- Multiple causes
- Gastrointestinal Diseases
- Hyperthyroidism
- Food poisoning
Nursing Interventions
1. Increase fluid intake- ORESOL is the most important treatment!
2. Determine and manage the cause
3. Anti-diarrheal drugs
3. 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
PATHOPHYSIOLOGY:
- Foods high in CHO and electrolytes must be diluted in the jejunum
before absorption takes place.
- The rapid influx of stomach contents will cause distention of the

jejunum early symptoms
- The hypertonic chyme will draw fluid from the blood vessels to
dilute the high concentrations of CHO and electrolytes
- Later, there is increased blood glucose stimulating the increased

secretion of insulin
- Then, blood glucose will fall causing reactive hypoglycemia
DUMPING SYNDROME
ASSESSMENT FINDINGS: early symptoms
1. Nausea and Vomiting
2. Abdominal fullness
3. Abdominal cramping
4. Palpitation
5. Diaphoresis
ASSESSMENT FINDINGS: LATE symptoms:

6. Drowsiness
7. Weakness and Dizziness
8. Hypoglycemia
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
4. Instruct to LIE DOWN after meals
5. Administer anti-spasmodic medications to delay gastric emptying
GIT SYMPTOMS AND MANAGEMENT
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
ASSESSMENT
- Severe pallor
- Fatigue
- Weight loss
- Smooth BEEFY-red tongue
- Mild jaundice
- Paresthesia of extremities
- Balance disturbance
NURSING INTERVENTION
- Lifetime injection of Vitamin B 12 weekly initially, then MONTHLY
DISORDERS OF THE GASTROINTESTINAL SYSTEM
UPPER GI SYSTEM (ESOPHAGUS)
1. HIATAL HERNIA
- Protrusion of the esophagus into the diaphragm thru an opening
- Occurs more often in women
- Two types- Sliding hiatal hernia
- ( most common) and Axial hiatal hernia
ASSESSMENT Findings in Hiatal hernia

1. Heartburn
2. Regurgitation
3. Dysphagia
4. 50%- without symptoms
DIAGNOSTIC TEST
Barium swallow and fluoroscopy
1. Provide small frequent feedings
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
2. 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
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
1. Variceal ligation
2. Shunt procedures
CONDITIONS OF THE STOMACH
1. Gastro-Esophageal Reflux
 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 ( for GERD)

 Heartburn
 Dyspepsia
 Regurgitation
 Epigastric pain
 Difficulty swallowing
 Ptyalism
 Odynophagia or dysphagia
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
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
5. Elevate the head of the bed with an approximately 8-inch block
Conditions of the Stomach
6. Administer prescribed H2-blockers, PPI and prokinetic meds like
cisapride, metochlopromide
7. Advise proper weight reduction
Barret’s Esophagus
 Result from long standing untreated GERD
 Precancerous condition that can lead to adenocarcinoma of the
esophagus
 More common in middle aged men
 Heartburn and symptoms of peptic ulcer and esophageal strictures

Diverticulum
 Outpouching of mucosa and submucosa that protrude through a
weak portion of the musculature
 Zenker’s diverticulum, most common and frequent in men older than
60 years old
 Dysphagia, fulness in the neck, belching, regurgitation of undigested
food gurgling noises after eating
 Diverticulum becomes filled with food and regurgitate when assuming

a recumbent position causing coughing
 Halitosis and sour taste is common
Cancer Of The Esophagus

 >3x more common in men
 Occurs in the fifth decade of life
 Chronic irritation, ingestion of alcohol and tobacco use
 GERD and Barret’s Esophagus
 Usually squamous cell epidermoid type
Clinical Manifestation
 Dysphagia
 Mass in the throat
 Regurgitation of undigested foods
 Foul breath and hiccups
2. GASTRITIS
- Inflammation of the gastric mucosa
- May be Acute or Chronic
Etiology: Acute- bacteria, irritating foods, NSAIDS, alcohol, bile and
radiation
Chronic- Ulceration, bacteria, Autoimmune disease, diet, alcohol, smoking
PATHOPHYSIOLOGY OF Gastritis
Insults cause gastric mucosal damage inflammation, hyperemia and
edema superficial erosions  decreased gastric secretions, ulcerations
and bleeding
ASSESSMENT (Acute)
Dyspepsia
Headache
Anorexia
Nausea/Vomiting
ASSESSMENT (Chronic)
Pyrosis
Singultus
Sour taste in the mouth
Dyspepsia
N/V/anorexia
Pernicious anemia
DIAGNOSTIC PROCEDURE
- EGD- to visualize the gastric mucosa for inflammation
- Low levels of HCl
- Biopsy to establish correct diagnosis whether acute or chronic
1. Give BLAND diet
2. Monitor for signs of complications like bleeding, obstruction and
pernicious anemia
3. Instruct to avoid spicy foods, irritating foods, alcohol and caffeine
4. Administer prescribed medications- H2 blockers, antibiotics, mucosal
protectants
5. Inform the need for Vitamin B12 injection if deficiency is present
3. 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
PATHOPHYSIOLOGY
- Disturbance in acid secretion and mucosal protection
- Increased acidity or decreased mucosal resistance erosion and
ulceration
4. 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
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!
 Nausea
 Vomiting is more common

 Hematemesis
 Weight loss
DIAGNOSTIC PROCEDURES
1. EGD to visualize the ulceration
2. Urea breath test for H. pylori infection
3. Biopsy- to rule out gastric cancer
1. Give BLAND diet, small frequent meals during the active phase of the
disease
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
NURSING INTERVENTIONS FOR BLEEDING

1. Maintain on NPO
2. Administer IVF and medications
3. Monitor hydration status, hematocrit and hemoglobin
Conditions of the Stomach
4. Assist with SALINE lavage
5. Insert NGT for decompression and lavage
6. Prepare to administer blood transfusion
7. Prepare to give VASOPRESSIN to induce vasoconstriction to reduce
bleeding
8. Prepare patient for SURGERY if warranted
SURGICAL PROCEDURES FOR PUD

- Total gastrectomy, vagotomy, gastric resection, Billroth I and II,
pyloroplasty
Post-operative Nursing management
1. Monitor VS
2. Post-op position: FOWLER’S
3. NPO until peristalsis returns
4. Monitor for bowel sounds
5. Monitor for complications of surgery
6. Monitor I and O, IVF
7. Maintain NGT
8. Diet progress: clear liquid full liquid six bland meals
9. Manage DUMPING SYNDROME
DUODENAL ULCER
- Ulceration of duodenal mucosa and submucosa
- Usually due to increased gastric acidity
- Condition of the Duodenum
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
1. Same as for gastric ulceration
2. Patient teaching-avoid alcohol, smoking, caffeine and carbonated
drinks
Take NSAIDS with meals
Adhere to medication regimen
CONDITIONS OF THE SMALL INTESTINE
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
1. Fever
2. Abdominal distention
3. Diarrhea
4. Colicky abdominal pain
5. Anorexia/N/V
6. Weight loss
7. Anemia
CONDITIONS OF THE LARGE INTESTINE
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
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 CHRON’S DISEASES and

ULCERATIVE COLITIS
1. Maintain NPO during the active phase
2. Monitor for complications like severe bleeding, dehydration, electrolyte
imbalance
3. Monitor bowel sounds, stool and blood studies
4. Restrict activities= rest and comfort
5. Administer IVF, electrolytes and TPN if prescribed
Monitor complications of diarrhea
6. 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
7. Diet progression- clear liquid LOW residue, high protein diet
8. 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
PATHOPHYSIOLOGY
Obstruction of lumen increased pressure decreased blood supply
bacterial proliferation and mucosal inflammation ischemia necrosis
rupture
ASSESSMENT
1. Abdominal pain: begins in the umbilicus then localizes in the RLQ (Mc
Burney’s point)
2. Anorexia
4. Fever
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
1. Preoperative care
- NPO
- Consent
- Monitor for perforation and signs of shock
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
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
- POSITION post-op: RIGHT side-lying, SEMI- FOWLER’S to decrease
tension on incision, and legs flexed to promote drainage
Administer prescribed pain medications
HEMORRHOIDS
- Abnormal dilation and weakness of the veins of the anal canal
- Variously classified as Internal or External, Prolapsed, Thrombosed
and Reducible
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. Skin tags
DIAGNOSTIC TEST
1. Anoscopy
2. Digital rectal examination
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
4. Administer stool softener as prescribed
Post-operative care for hemorrhoidectomy

1. Position: Prone or Side-lying
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
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
PATHOPHYSIOLOGY
- Increased intraluminal pressure, LOW volume in the lumen and
Decreased muscle strength in the colon wall herniation of the
colonic mucosa
ASSESSMENT
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
1. Maintain NPO during acute phase
2. Provide bed rest
3. Administer antibiotics, analgesics like meperidine (morphine is not used)
and anti-spasmodics
4. Monitor for potential complications like perforation, hemorrhage and
fistula
5. Increase fluid intake
6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts
to avoid trapping
7. introduce soft, high fiber foods ONLY after the inflammation subsides
8. Instruct to avoid activities that increase intra-abdominal pressure
CONDITION OF 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
ETIOLOGY:
Post-infection, Alcohol, Cardiac diseases, Schisostoma, Biliary
obstruction
ASSESSMENT FINDINGS
1. Anorexia and weight loss
2. Jaundice
3. Fatigue
4. Early morning nausea and vomiting
5. RUQ abdominal pain
6. Ascites
7. Signs of Portal hypertension
1. Monitor VS, I and O, Abdominal girth, weight, LOC and Bleeding
2. Promote rest. Elevated the head of the bed to minimize dyspnea
3. Provide Moderate to LOW-protein (1 g/kg/day) and LOW-sodium diet
4. Provide supplemental vitamins (especially K) and minerals
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
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
Conditions of the Accessory organs
The Gallbladder
Cholecystitis
- Inflammation of the gallbladder
- Can be acute or chronic
- Acute cholecystitis usually is due to gallbladder stonES
- 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
Pathophysiology
- 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
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
4. WBC count increased
5. Oral cholecystography cannot visualize the gallbladder
6. ERCP: revels inflamed gallbladder with gallstone
1. Maintain NPO in the active phase
2. Maintain NGT decompression
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
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
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
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
Etiology and predisposing factors

- Alcoholism
- Hypercalcemia
- Trauma
- Hyperlipidemia
- Biliary tract disease - cholelithiasis
- Bacterial disease
- PUD
- Mumps
PATHOPHYSIOLOGY of acute pancreatitis

- Self-digestion of the pancreas by its own digestive enzymes
principally TRYPSIN
- Spasm, edema or block in the Ampulla of Vater reflux of
proteolytic enzymes auto digestion of the pancreas
inflammation
- Autodigestion of pancreatic tissue
- Hemorrhage, Necrosis and Inflammation
- KININ ACTIVATION will result to increased permeability
- Loss of Protein-rich fluid into the peritoneum
- HYPOVOLEMIA
ASSESSMENT findings
1. Abdominal pain- acute onset, occurring after a heavy meal or alcohol
intake
2. Abdominal guarding
3. Bruising on the flanks and umbilicus
4. N/V, jaundice
5. Hypotension and hypovolemia
6. 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
1. Assist in pain management. Usually, Demerol is given. Morphine is
AVOIDED
2. Assist in correction of Fluid and Blood loss
3. Place patient on NPO to inhibit pancreatic stimulation
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
ENDOCRINE
DISEASES
Hormones – chemical receptors that regulate organ function in concert with

nervous system.
Negative feedback mechanism
The ANATOMY of the Endocrine System

The endocrine system is composed of ductless glands that release their
hormones directly into the bloodstream
The Hypothalamus controls most of the endocrinal activity of the pituitary
gland

The pituitary gland controls most of the activities of the other endocrine
glands

The Pituitary Gland
Is divided into two parts- the anterior or adenohypophysis and the
posterior or the neurohypophysis
The PHYSIOLOGY of the Endocrine System: Anterior Pituitary

Secretes the following hormones:
1. Growth hormone
2. Prolactin
3. Gonadotrophins- LH and FSH
4. Stimulating hormones and trophic hormones
ACTH
TSH
MSH
The PHYSIOLOGY of the Endocrine System: Posterior Pituitary

Stores and releases
1. OXYTOCIN
2. ADH/Vasopressin

The THYROID gland
Located in the anterior neck lateral to the trachea
Contains two lobes connected by the isthmus
Microscopically composed of thyroid follicles where the hormones are
produced and stored
The PHYSIOLOGY of the Endocrine System: Thyroid

Produces the thyroid hormones by the thyroid follicles:
1. Tri-iodothyronine or T3
2. Tetra-iodothyronine or thyroxine or T4
The Parafollicular cells secrete CALCITONIN
The PARAthyroid glands

Located at the back of the thyroid glands
Four in number
Secretes PARATHYROID hormone (PTH) that controls calcium and
phosphorus levels
PTH is stimulated by a DECREASED Calcium level

The Adrenal Glands
Located above the kidneys
Composed of two parts- the outer Adrenal Cortex and the inner Adrenal
medulla
T
he PHYSIOLOGY of the Endocrine System: Adrenal Cortex
Secretes three types of STEROID hormones
1. Glucocorticoids- like Cortisol, cortisone and corticosterone
2. Mineralocorticoids- like Aldosterone
3. Sex hormones- like estrogen and testosterone
The PHYSIOLOGY of the Endocrine System: Adrenal Medulla
Essentially a part of the SYMPATHETIC autonomic system
Secretes Adrenergic Hormones:
1. Epinephrine
2. Nor-epinephrine

The Pancreas
This retroperitoneal organ has both endocrine and exocrine functions
The endocrine function resides in the ISLETS of Langerhans
The islets have three types of cells- alpha, beta and delta cells
The PHYSIOLOGY of the Endocrine System: The Pancreas

The ALPHA cells secrete GLUCAGON
The BETA cells secrete INSULIN
The DELTA cells secrete SOMATOSTATIN

Hormone Levels Assay
These are blood examinations for the levels of individual hormones

Hormone Levels Assay
Measurements can also be done after stimulation and suppression of the
secretions- Stimulation and Suppression tests

Hormone Levels of T3/T4
Usually done to diagnose hypo/hyperthyroidism

If T3 is elevated, T4 is elevated and TSH is depressed Primary
HYPERthyroidism

If T3 is depressed,T4 is depressed and TSH is elevated Primary
HYPOthyoidism

Radio-Active iodine uptake (RAI)
This is a thyroid function test to measure the absorption of the injected
iodine isotope by the thyroid tissue

Radio-Active iodine uptake (RAI)
Increased uptake may indicate HYPERfunctioning gland
Decreased uptake my indicate HYPOfunctioning gland

Thyroid Scan
Performed to identify nodules or growth in the thyroid gland
RAI is used

Thyroid Scan
Pretest- Check for pregnancy, Thyroid medication may be withheld
temporarily, advise NPO
Post-test- Ensure proper disposal of body wastes
BMR
It measures the oxygen consumption under basal conditions of overnight
fast and rest from mental and physical exertion.
it can be estimated from the oxygen consumed over a timed interval by
analysis of samples of expired air
The test indirectly measures metabolic energy expenditure or heat
production.
Results are expressed as the percentage of deviation from normal after

appropriate corrections have been made for age, sex, and body surface
area.
Low values are suggestive of hypothyroidism, and high values reflect
thyrotoxicosis.

FASTING BLOOD GLUCOSE
Aids in the diagnosis of Diabetes
Pre-test: NPO for 8 hours
Normal FBS- 80-109 mg/dL
DM- 126 mg/dL and above

GLUCOSE tolerance test
Aids in the diagnosis of DM
Pre-test: Provide high-carbohydrate foods x 3 days, instruct to avoid
caffeine, alcohol and smoking, NPO 10 hours prior to test

GLUCOSE tolerance test
Post-test: avoid strenuous activity for 8 hours
Normal OGTT- 1 and 2 hours post-prandial- glucose is less than 200 mg/dL

Glycosylated Hemoglobin A 1-C
Blood glucose bound to RBC hemoglobin
Reflects how well blood glucose is controlled for the past 3 months
FASTING is NOT required!

Glycosylated Hemoglobin A 1-C
Normal level- expressed as percentage of total hemoglobin
N- 4-7%
Good control- 7.5%or less
Fair control- 7.5 % to 8.9%
Poor control- 9% and above
DISORDERS OF THE ENDOCRINE GLAND

Disorders are generally grouped into:
1. HYPER- when the gland secretes excessive hormones
2. HYPO- when the gland does not secrete enough hormones
DISORDERS OF THE ENDOCRINE GLAND

Hyper and Hypo can be classified as PRIMARY when the Gland itself is the
problem or SECONDARY when the pituitary or the hypothalamus is causing
the problem
Disorders of the
PITUITARY GLAND
DISORDERS OF the PITUITARY GLAND
HYPOPITUITARISM
Hyposecretion of the anterior pituitary gland
CAUSES: Congenital, Post-partal necrosis, infection and tumor

HYPOPITUITARISM
PATHOPHYSIOLOGY:
Depends on the major hormone/s depleted
Panhypopituitarism (simmond’s disease)

 total absence of all pituitary secretions
 Postpartum pituitary necrosis (Sheehan’s syndrome occur in women
with severe blood loss, hypotension at the time of delivery.
 Complication of radiation therapy to the head and neck area
 Total destruction of the pituitary gland by means of trauma, tumor or
vascular lesions.
Pituitary Tumors
1. Eosinophilic tumors – Gigantism or acromegally
2. Basophilic tumors – Cushing syndrome
3. Chromophobic tumors – 90%
Diagnostics
 Physical examination and history
 CT scan
 MRI
 Hormone levels determination
Surgical management
Hypophysectomy
- removal of pituitary tumor used to treat Cushing syndrome
- palliative measures to relieve bone pain from malignant metastasis of
breat and prostate Ca

Hypopituitarism: ASSESSMENT Findings
1. Retarded physical growth due to decreased GH dwarfism
2. Low intellectual development
3. poor development of secondary sexual characteristics

1. Provide emotional support to the family
2. Encourage client and family to express feelings
3. Administer prescribed hormonal replacement therapy

HYPERPITUITARISM
The hyper-secretion of the gland
 ACROMEGALY
CAUSES: tumor, congenital disorder
PATHOPHYSIOLOGY
Depends on the hormone/s that is/are increased

ASSESSMENT FINDINGS for Hyper-pituitarism
1. Increased growth Gigantism or Acromegaly
2. large and thick hands and feet
3. Visual disturbances
4. Hypertension, hyperglycemia
5. Organomegaly

1. Provide emotional support to clients and family
2. Provide frequent skin care
3. Prepare patient for surgery- removal of pituitary gland

Post-operative care
1. Monitor VS, LOC and neurologic status
2. Place patient on Semi-Fowler’s
Post-operative care
3. Monitor for Increased ICP, bleeding, CSF leakage
4. Instruct patient to AVOID sneezing, coughing and nose-blowing
5. Monitor development of DI- measure I and O
6. Administer prescribed medications- antibiotics, analgesics and steroids
DISORDERS OF the PITUITARY GLAND: Posterior gland

DIABETES INSIPIDUS
A hypo-secretion of ADH
CAUSES: Conditions that increase ICP, Surgical removal of post pit. tumor

PATHOPHYSIOLOGY
 Decreased ADH failure of tubular re-absorption of water
increased urine volume
ASSESSMENT findings
1. Polyuria of more than 4 liters of urine/day
2. Polydipsia
3. Signs of Dehydration
4. Muscle pain and weakness
5. Postural hypotension and tachycardia
Diagnostic test
Fluid deprivation test – 8-12 hrs or 3-5% wt loss. Inability to increase
specific gravity and osmolality
DIAGNOSTIC TEST
1. Urinary Specific gravity very low, 1.006 or less
2. Serum Sodium levels high
Medical management
Objectives
1. To replace ADH
2. Ensure adequate fluid replacement
3. identify and correct the underlying intracranial pathology
1.Monitor VS, neurologic status and cardiovascular status
2. Monitor Intake and Output
3. Monitor urine specific gravity
4. Provide adequate fluids
5. Administer Chlorpropamide or Clofibrate as prescribed to increase the
action of ADH if decreased
Hypolipidemic effect, diuretic effect
6. Administer VASOPRESIN. Desmopressin or Lypressin are given
intranasal. Pitressin is given IM
Longer duration and fewer side effects

SIADH
Hyper-secretion of ADH abnormally
CAUSES: tumor, paraneoplastic syndromes, head injury, infections

SIADH
PATHOPHYSIOLOGY
Increased ADH water re-absorption water intoxication, hypervolemia

DIAGNOSTIC TEST for SIADH

1. Urine specific gravity is increased (concentrated)
2. Hyponatremia
3. CBC shows hemodilution

ASSESSMENT findings
1. Signs of Hypervolemia
2. Mental status changes
3. Abnormal weight gain
4. Hypertension
5. Anorexia, Nausea and Vomiting
6. HYPOnatremia

1. Monitor VS and neurologic status
2. Provide safe environment
3. Restrict fluid intake (less than 500cc/day)
4. Monitor I and O and daily weight
5. Administer Diuretics and IVF carefully
6. Administer prescribed Demeclocycline to inhibit action of ADH in the
kidney
Disorders of the
ADRENAL GLAND
Functions as part of ANS
Secretes adrenaline and cathecolamines
Epinephrine, increase blood circulation to vital organs, fight or flight
response
Catecholamines, release free fatty acids increase BMR and elevate blood
glucose levels
Adrenocortical Insufficiency
(addison’s disease)
adrenal cortex function is inadequate to meet the patient’s need for
cortical hormones
Tuberculosis and histoplasmosis, steroid use
DISORDERS OF the ADRENAL GLAND

Hypo-secretion: ADDISON’S Disease
Decreased secretion of adrenal cortex hormones, especially glucocorticoids
and mineralocorticoids
CAUSE: tumor, idopathic, surgery
These hormones are essential for life, if not treated patient will die.

PATHOPHYSIOLOGY
Decreased Glucocorticoids decreased resistance to stress

PATHOPHYSIOLOGY
Decreased mineralocorticoids decreased retention of sodium and water
Hypovolemia

ASSESSMENT Findings for Addison’s disease
1. Weight loss
2. GI disturbances
3. Muscle weakness, lethargy and fatigue
4. Hyponatremia
5. Hyperkalemia
6. Hypoglycemia
7. dehydration and hypovolemia
8. Increased skin pigmentation
9. leukocytosis
Addisonian Crisis
Cyanosis, classic signs of circulatory shock, pallor, apprehension, rapid and
weak pulse, rapid respirations and low blood pressure
Medical management
1. combating circulatory shock
2. Restore blood circulation
3. Administering fluids and corticosteroids

1. Monitor VS especially BP
2. Monitor weight and I and O
3. Monitor blood glucose level and K
4. Administer hormonal agents as prescribed
5. Observe for ADDISONIAN crisis
6. Educate the client regarding lifelong treatment, avoidance of strenuous
activities, stress and seeking prompt consult during illness
7. Provide a high-protein, high carbohydrate and increased sodium intake

ADDISONIAN crisis
A life-threatening disorders caused by acute severe adrenal insufficiency
CAUSES: Severe stress, infection, trauma or surgery

ADDISONIAN crisis
PATHOPHYSIOLOGY
Overwhelming stimuli mobilize body defense decreased stress
hormones inadequate coping

ASSESSMENT Findings for Addisonian Crisis= “severe lahat”
1. Severe headache
2. Severe pain
3. Severe weakness
4. Severe hypotension
5. Signs of Shock

1. Administer IV glucocorticoids, usually hydrocortisone
2. Monitor VS frequently
3. Monitor I and O, neurological status, electrolyte imbalances and blood
glucose
4. Administer IVF
5. Maintain bed rest
6. Administer prescribed antibiotics

Hyper-secretion: CUSHING’S DISEASE
A condition resulting from the hyper-secretion of glucocorticoids from the
adrenal cortex
CAUSES: Pituitary tumor, adrenal tumor, abuse of steroids, bronchogenic
Ca
PATHOPHYSIOLOGY
Increased Glucocorticoids exaggerated effects of the hormone
Common in women 20-40 y/o
Virilization, appearance of musculine traits an d recession of feminine
traits, hirsutism, breast atrophy, menses cease, enlarge clitoris, voice
deepens


ASSESSMENT FINDINGS for Cushing
1. Generalized muscle weakness and wasting
2. Truncal obesity
3. Moon-face, oily skin
4. Buffalo hump
5. Easy bruisability
6. Reddish-purplish striae on the abdomen and thighs
7. Hirsutism and acne
8. Hypertension
9. Hyperglycemia
10. Osteoporosis
11. Amenorrhea
DIAGNOSTIC TESTS
1. Serum cortisol level
2. Serum glucose and electrolytes
Dexamethasone suppression test
Medical management
Surgical removal by transphenoidal hypophysectomy, 90% success rate

1. Monitor I and O , weight and VS
2. Monitor laboratory values- glucose, Na, K and Ca
3. Provide meticulous skin care
4. Administer prescribed medications like aminogluthetimide to inhibit
adrenal hyperfunctioning
5. Prepare client for surgical management- pituitary surgery and
adrenalectomy
6. Protect patient from infection
7. Improve body image
8. Provide a LOW carbohydrate, LOW sodium and HIGH protein diet

Hyper-secretion: CONN’S DISEASE
Hyper-secretion of Aldosterone from the adrenal cortex
CAUSES: pituitary tumor, adrenal tumor

Hypersecretion: CONN’S DISEASE
PATHOPHYSIOLOGY
Increased Aldosterone exaggerated effects

ASSESSMENT findings in CONN’S disease
1. Symptoms of HYPOkalemia
2. Hypertension
3. Hypernatremia
4. Headache, N/V
5. Visual changes
6. Muscles weakness, fatigue and nocturia

DIAGNOSTIC TEST
1. Urine gravity- low (due to polyuria)
2. Serum Sodium- high
3. Serum Potassium- very low
4. Increased urinary Aldosterone

1. Monitor VS, I and O and urine sp gravity
2. Monitor serum K and Na
3. Provide Potassium rich foods and supplements
4. Administer prescribed diuretic- Spironolactone
5. Maintain sodium-restricted diet
6. Prepare patient for possible surgical interventions

Hyper-secretion: Pheochromocytoma
Increased secretion of epinephrine and nor-epinephrine by the adrenal
medulla
CAUSE: tumor
Benign and originates from chromaffin cells
men=women 40-50 y/o
PATHOPHYSIOLOGY
Increased Adrenergic hormones exaggerated sympathetic effects

ASSESSMENT Findings in Pheochromocytoma
1. Hypertension
2. Severe headache
3. Palpitations
4. Tachycardia
5. Profuse sweating and Flushing
6. Weight loss, tremors
7. Hyperglycemia and glycosuria

1. Monitor VS especially BP
2. Monitor for HYPERTENSIVE crisis
3. Avoid stimulation that can cause increased BP
4. Administer Anti-hypertensive agents like alpha-adrenergic blockers-
Phenoxybenzamine
5. Prepare Phentolamine for hypertensive crisis
6. Monitor blood glucose and urine glucose
7. Promote adequate rest and sleep periods
8. provide HIGH calorie foods and Vitamins/mineral supplements
9. Prepare patient for possible surgery
Disorders of the
THYROID GLAND
Thyroid Function
Thyroid hormone
- T3
- T4
Secretion is controlled by TSH (Thyrotropin)
control the cellular metabolic activity
T4 – weak hormone, maintains body metabolism in a steady state(4.5-
11.5ng/dl)
T3 – 5x as potent as T3, more rapid metabolic function (70-220ng/dl)
Function
 Accelerates metabolic processes by increasing the level of specific
enzymes that contributes to oxygen consumption
 Influence cell replication and important in brain development
 Necessary for normal growth
 Role of Iodine
 Essential to thyroid function for synthesis of its hormones
 Ingested in diet and absorbed in the blood
Assessment and diagnostic findings

 Inspection for swelling and assymetry
 Palpated for size, symmetry, tenderness
 Auscultation of audible vibration or bruit
Thyroid function Test

TSH has a sensitivity and specificity of greater than 95% (.4 – 6.15
mU/ml)
FT4 correlate with metabolic status and are elevated in Hyperthyroidism
and decrease in Hypothyroidism.
Fine needle aspiration biopsy

- safe and accurate method of detecting malignancy

Thyroid scan
- location, size, shape and anatomic function of thyroid gland
- “Hot’, “Cold”
DISORDERS OF the THYROID GLAND
HYPOsecretion: HYPOTHYROIDISM
A hypothyroid state characterized by decreased secretions of T3 and T4
Definition
a. Thyroid gland produces insufficient amount of thyroid hormone
b. Myxedema: characteristic accumulation of nonpitting edema in
connective tissues throughout body; water retention in mucoprotein
deposits in interstitial spaces
c. More common females aged 30 – 60
Pathophysiology
a. Primary (more common)
1. Defect in thyroid gland
2. Congenital defects
3. Post treatment of hyperthyroidism
4. Thyroiditis
5. Iodine deficiency
b. Secondary
1. Deficiency in TSH (pituitary gland)
2. Peripheral resistance to thyroid hormones
Causes
Chronic lymphocytic thyroiditis
 Atrophy of gland with aging
 Therapy for hyperthyroidism
- radioactive iodine, thyroidectomy
 Medications, lithium, iodine, antithyroid
 Radiation to head and neck
 Iodine deficiency and excess

HYPOsecretion: HYPOTHYROIDISM
PATHOPHYSIOLOGY
Decreased T3 and T4 decreased basal metabolism
Signs and Symptoms:

Slow onset over months to years
a. Metabolism: slowed
1. Intolerance to cold
2. Sleepiness
3. Fatigue, weakness
b. Cardiovascular
1. Bradycardia, alterations in blood pressure
2. Tendency for development of congestive heart failure, myocardial
infarction
c. Gastrointestinal
1. Enlarged tongue, anorexia, vomiting
2. Constipation
d. Neuromuscular: Apathy, slow movement and thinking

e. Other
1. Goiter: thyroid gland enlarges in attempt to produce more hormone
2. Edema in hands, feet, face; dry skin and hair

ASSESSMENT findings for Hypothyroidism
1. Lethargy and fatigue
2. Weakness and paresthesia
3. COLD intolerance
4. Weight gain
5. Bradycardia, constipation
8. Forgetfulness and memory loss
9. Slowness of movement
10. Menstrual irregularities and cardiac irregularities
11. Dry hair and skin, loss of body hair
12. Generalized puffiness and edema around the eyes and face
Specific Conditions
a. Iodine Deficiency
1. Dietary foods grown in iodine poor soil
2. Use of non-iodized salt
3. Medications, such as lithium carbonate, amiodarone (Cordarone)
Hashimoto’s Thyroiditis
1. Autoimmune disorder
2. Antibodies produced against thyroid tissue
Myxedematous coma
1. Life-threatening complication of long-standing and untreated
hypothyroidism
2. Hyponatremia, hypoglycemia, acidosis
3. Precipitated by stressors, failure to take thyroid replacement meds
4. Treatment includes restoring balance throughout systems and
increasing thyroid hormone levels
Diagnostic Tests
a. Serum thyroid antibodies (TA): antibodies in Hashimoto’s Thyroiditis

b. TSH test: (from pituitary) elevated with primary hypothyroidism
c. T3 and T4: decreased for diagnosis of hypothyroidism
d. T3 uptake test; decreased with hypothyroidism
RAI uptake test
1. Oral or intravenous dose of radioactive iodine (131I or 123I) given to
client
2. Thyroid scanned after 24 hours
3. Uptake decreased with hypothyroidism
4. Size and shape of gland revealed
f. Serum cholesterol is elevated
1. Monitor VS especially HR
2. Administer hormone replacement: usually Levothyroxine( Synthroid)-
should be taken on an empty stomach
3. Instruct patient to eat LOW calorie, LOW cholesterol and LOW fat diet
4. Manage constipation appropriately
5. Provide a WARM environment
6. Avoid sedatives and narcotics because of increased sensitivity to these
medications
7. Instruct patient to report chest pain promptly
Nursing Diagnoses
a. Decreased Cardiac Output
b. Constipation
c. Risk for Impaired Skin Integrity: due to over all edema high risk for
skin breakdown: preventative interventions
HYPERfunctioning: HYPERTHYROIDISM
Called GRAVE’S DISEASE
A hyperthyroid state characterized by increased circulating T3 and T4
Pathophysiology
a. Autoimmune reactions (Grave’s disease)
b. Excess secretion of TSH from pituitary gland
c. Neoplasms (toxic multinodular goiter)
d. Thyroiditis
e. Excessive intake of thyroid medications
Women >8x more than men
Second and forth decade
Signs and symptoms

Metabolism
1. Hypermetabolism
2. Increased appetite with weight loss

3. Heat intolerance, increased sweating
Cardiovascular
1. Systolic hypertension
2. Tachycardia, atrial fibrillation
3. Dysrhythmias, palpitations
4. Possibly angina, congestive heart failure
Gastrointestinal
1. Increased peristalsis with diarrhea
2. Hyperactive bowel sounds
Neuromuscular
1. Nervousness, restlessness
2. Insomnia
3. Fine tremor
4. Emotional lability (mood swings)
Other
1. Fine hair
2. Smooth and warm skin

ASSESSMENT Findings for Hyperthyroidism
1. Weight loss
2. HEAT intolerance
3. Hypertension
4. Tachycardia and palpitations
5. Exopthalmos
6. Diarrhea
7. Warm skin
8. Diaphoresis
9. Smooth and soft skin
Oligomenorrhea to amenorrhea
10. Fine tremors and nervousness
11. Irritability, mood swings, personality changes and agitation
Graves’ disease
1. Most common cause of hyperthyroidism
2. Antibody against TSH receptor site
3. Cause unknown, but hereditary link
4. More common in females aged 20 – 40
Signs and symptoms

a. Signs of hyperthyroidism plus
b. Enlarged thyroid gland (goiter)
c. Proptosis (forward displacement of eyes) causing blurred vision,

diplopia, lacrimation, photophobia
d. Exophthalmos (forward protrusion of eyes) causing corneal dryness,
irritation, ulceration
e. Changes in menstruation
Toxic Multinodular Goiter

1. Nodules in thyroid tissue secrete excessive thyroid hormone
2. Usually female in 60 – 70’s, has had goiter for a number of years
Thyroiditis
1. Viral infection of thyroid
2. May become chronic and lead to hypothyroidism
Diagnostic findings
Thyroid gland is enlarged
Thrill often can be palpated and bruit is heard over the thyroid arteries
a. Serum thyroid antibodies (TA): antibodies in Graves’ disease
b. TSH test: (from pituitary) suppressed with primary hyperthyroidism
c. T3 and T4: elevated for diagnosis of hyperthyroidism, thyroiditis
d. T3 uptake test; elevated with hyperthyroidism
e. RAI uptake test

Oral or intravenous dose of radioactive iodine (131I) given to client
Thyroid scan after 24 hours
Size and shape of gland revealed
Uptake is increased with Grave’s disease
Thyroid suppression test

1. RAI and T4 measured and then remeasured after client takes thyroid
hormone
2. No suppression with hyperthyroid
Medications
1. Antithyroid medications: block synthesis of thyroid hormones
a. Propylthiouracil (PTU)
b. Methimazole (Tapazole)
2. Beta-adrenergic blockers: control symptoms (tachycardia, tremor,
etc.)
a. Propanolol (Inderal)
b. Atenolol (Tenormin); for those with cardiac or asthma problems
Radioactive Iodine Therapy

1. Process:
a. Iodine is taken up by thyroid
b. Concentrates in the thyroid gland and destroys cells
c. Less hormone is produced
d. Dose given orally

e. Results occur in 6 to 8 weeks
2. Not to be given to pregnant women
3. Client often hypothyroid after treatment
Surgery
1. Subtotal thyroidectomy: only part of thyroid
2. removed
2. Total thyroidectomy to treat cancer of thyroid: client will need life-
long thyroid replacement
3. Prior to surgery: get client into euthyroid state
4. Iodine (Potassium Iodide) given prior to surgery to decrease size and
vascularity of thyroid

1. Provide adequate rest periods in a quiet room
2. Administer anti-thyroid medications that block hormone synthesis-
Methimazole and PTU
3. Provide a HIGH-calorie diet, HIGH protein
4. Manage diarrhea
5. Provide a cool and quiet environment
6. Avoid giving stimulants
7. Administer PROPRANOLOL for tachycardia
8. Administer IODIONE preparation- Lugol’s solution and SSKI to inhibit the
release of T3 and T4
9. Prepare clients for Radioactive iodine therapy
10. Prepare patient for thyroidectomy
11. Manage thyroid storm appropriately
Nursing Diagnoses
a.Risk for Decreased Cardiac Output
b. Disturbed Sensory Perception: Visual
1. Interventions to protect eye from corneal irritation and to maintain
moisture
2. Lubricants and taping eyes shut at night
c. Imbalanced Nutrition-Less than body requirements: Diet high in
protein and calories
d. Disturbed Body Image: Exophthalmos may continue post treatment

Thyroid storm
An acute LIFE-threatening condition characterized by excessive thyroid
hormone
CAUSE: Manipulation of the thyroid during surgery causing the release of

excessive hormones in the blood

ASSESSMENT Findings for Thyroid Storm
1. HIGH fever
2. Tachycardia and Tachypnea
3. Systolic HYPERtension
4. Delirium and coma
5. Severe vomiting and diarrhea
6. Restlessness, Agitation, confusion and Seizures

1. Maintain PATENT airway and adequate ventilation
2. Administer anti-thyroid medications such as Lugol’s solution,
Propranolol, and Glucocorticoids
3. Monitor VS
4. Monitor Cardiac rhythms
5. Administer PARACETAMOL ( not Aspirin) for FEVER
6. Manage Seizures as required.
7. Provide a quiet environment

THYROIDECTOMY
Removal of the thyroid gland
PRE-OPERATIVE CARE - Thyroidectomy
1. Obtain VS and weight
2. Assess for Electrolyte levels, glucose levels and T3/T4 levels
PRE-OPERATIVE CARE - Thyroidectomy
3. Provide pre-operative teaching like coughing and deep breathing, early
ambulation and support of the neck when moving
4. Administer prescribed medications

POST-OPERATIVE CARE - Thyroidectomy
1. Position patient: Semi-Fowler’s, neck on neutral position
2. Monitor for respiratory distress- apparatus at bedside- tracheostomy
set, O2 tank and suction machine!
3. Check for edema and bleeding by noting the dressing anteriorly and at
the back of the neck
4. LIMIT client talking
5. Assess for HOARSENESS
Expected to be present only initially, limit excess vocalization
If persistent, may indicate damage to laryngeal nerve!
6. Monitor for Laryngeal Nerve damage – Respiratory distress, Dysphonia,
voice changes, Dysphagia and restlessness
7. Monitor for signs of HYPOCALCEMIA and tetany due to trauma of the

parathyroid
8. Prepare Calcium gluconate
9. Monitor for thyroid storm
DISORDERS OF the PARATHYROID GLAND

Hypo-functioning: HYPOPARATHYROIDISM
Hypo-secretion of parathyroid hormone
CAUSES: tumor, removal of the gland during thyroid surgery
Pathophysiology
a. Often due to damage or removal of parathyroid glands during
thyroidectomy
b. Hypocalcemia, elevated blood phosphate levels, decreased activation
of Vitamin D in intestines

Hypo-functioning: HYPOPARATHYROIDISM
PATHOPHYSIOLOGY
Decreased PTH deranged calcium metabolism

ASSESSMENT Findings for HypoParaThyroidism
1. Signs of HYPOCALCEMIA
2. Numbness and tingling sensation on the face
3. Muscle cramps
4. (+) Trosseau’s and (+) Chvostek’s signs
5. Bronchospasms, laryngospasms, and dysphagia
6. Cardiac dysrhythmias
7. Hypotension
8. Anxiety, irritability ands depression

1. Monitor VS and signs of HYPOcalcemia
2. Initiate seizure precautions and management
3. Place a tracheostomy set. O2 tank and suction at the bedside
4. Prepare CALCIUM gluconate
5. Provide a HIGH-calcium and LOW phosphate diet
6. Advise client to eat Vitamin D rich foods
7. Administer Phosphate binding drugs

Hyper-functioning:
HYPERPARATHYROIDISM
Hyper-secretion of the gland
CAUSE: Tumor
Pathophysiology
a. Often due to damage or removal of parathyroid glands during
thyroidectomy
b. Hypocalcemia, elevated blood phosphate levels, decreased activation
of Vitamin D in intestines

Hyper-functioning:
HYPERPARATHYROIDISM
PATHOPHYSIOLOGY
Increase PTH increased CALCIUM levels in the body

ASSESSMENT Findings for Hyperparathyroidism
1. Fatigue and muscle weakness/pain
2. Skeletal pain and tenderness
3. Fractures\
4. Anorexia/N/V epigastric pain
5. Constipation
6. Hypertension
7. Cardiac Dysrhythmias
8. Renal Stones

1. Monitor VS, Cardiac rhythm, I and O
2. Monitor for signs of renal stones, skeletal fractures. Strain all urine.
3. Provide adequate fluids- force fluids
4. Administer prescribed Furosemide to lower calcium levels
5. Administer NORMAL saline
6. Administer calcium chelators
7. Administer CALCITONIN
8. Prepare the patient for surgery
Client with Cancer of Thyroid

1. Types
a. Papillary thyroid carcinoma
1. More common in female in 40’s
2. Usually single nodule
3. Risks: exposure of area to xray, nuclear fallout, family history
b. Follicular thyroid cancer: more common in female in 50’s
Diagnosis
a. Palpable firm nontender nodule in thyroid
b. Usually no elevation in thyroid hormones
c. Thyroid scans, needle biopsy of nodule
Treatment
a. Subtotal or total thyroidectomy

b. Radioactive iodine therapy with 131I
c. Client will need continued medical followup; thyroid replacement
d. 95% survival rate without metastasis
Selected Endocrine
PHARMACOLOGY
Endocrine Medications
Anti-diuretic hormones
Enhance re-absorption of water in the kidneys
Used in DI
1. Desmopressin and Lypressin intranasally
2. Pitressin IM
Endocrine Medications
Anti-diuretic hormones
SIDE-effects
Flushing and headache
Water intoxication
Thyroid Medications
Thyroid hormones
Levothyroxine (Synthroid) and Liothyroxine (Cytomel)
Replace hormonal deficit in the treatment of
HYPOTHYROIDSM
Thyroid Medications
Thyroid hormones
Side-effects
2. Signs of increased metabolism= tachycardia, hypertension
Thyroid Medications
Thyroid hormones
Nursing responsibility
1. Monitor weight, VS
2. Instruct client to take daily medication the same time each morning
WITHOUT FOOD
3. Advise to report palpitation, tachycardia, and chest pain
4. Instruct to avoid foods that inhibit thyroid secretions like cabbage,
spinach and radishes
ANTI-Thyroid Medications
ANTI-THYROID medications
Inhibit the synthesis of thyroid hormones
1. Methimazole (Tapazole)
2. PTU (prophylthiouracil)
3. Iodine solution- SSKI and Lugol’s solution
Side-effects
N/V
Diarrhea
AGRANULOCYTOSIS
Most important to monitor
Nursing responsibilities
1. Monitor VS, T3 and T4, weight
2. The medications WITH MEALS to avoid gastric upset
3. Instruct to report SORE THROAT or unexplained FEVER
4. Monitor for signs of hypothyroidism. Instruct not to stop abrupt
medication
Lugol’s Solution
Used to decrease the vascularity of the thyroid
T3 and T4 production diminishes
Given per orem, can be diluted with juice
Use straw
STEROIDS
Replaces the steroids in the body
Cortisol, cortisone, betamethasone, and hydrocortisone
STEROIDS
Side-effects
HYPERglycemia
Increased susceptibility to infection
Hypokalemia
Edema
STEROIDS
Side-effects
If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension,
cataract, mood changes, hirsutism, and fragile skin
STEROIDS
1. Monitor VS, electrolytes, glucose
2. Monitor weight edema and I/O
STEROIDS
3. Protect patient from infection
4. Handle patient gently
5. Instruct to take meds WITH MEALS to prevent gastric ulcer
formation
STEROIDS
6. Caution the patient NOT to abruptly stop the drug
7. Drug is tapered to allow the adrenal gland to secrete endogenous
hormones
Quick Review
Hypothyroidism
Hyposecretion of thyroid hormones
Common causes: Iodine deficiency, Hashimotos
Manifestations: related to hypo-metabolic state: constipation, weight gain,
cold intolerance, poor appetite, mental slowness
Nursing Management:
Provide warm environment
LOW calorie diet, HIGH fiber
Avoid sedatives
Drugs: Hormone replacement
Hyperthyroidism
Hyper-secretion of thyroid hormones
Common cause: Graves, Toxic goiter
Manifestation: increased metabolism: weight loss, diarrhea, heat
intolerance, hypertension
Nursing Management:
Adequate rest and sleep
Cool environment
HIGH calorie foods
Eye care
Drugs: anti-thyroid: PTU and methimazole, propranolol
Care of patients after thyroidectomy

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CARE OF THE CLIENTS WITH GASTROINTESTINAL DISORDERS Handouts for ISU-Ilagan Student Nurse

 The GIT is composed of two general parts (23 – 26 foot long)

The Accessory Organs are the:

The GIT ANATOMY

CHARLES Z. ARIOLA JR, MSN, LPT, RN. 1

 The functions of the stomach are generally to digest the food

The Small intestine

The Large intestine

 Approximately 5 feet long, with parts:

The Gastrointestinal System Physiology

Functions of the Digestive System

Small intestines function

b. Amylase – digest starch

CHARLES Z. ARIOLA JR, MSN, LPT, RN. 4

THE NURSING PROCESS IN GIT DISORDERS

Assessment of the mouth, abdomen and rectum

- hypoactive – 1-2 sounds in 2 minutes

COMMON LABORATORY PROCEDURES

Occult Blood Testing

Urea breath test

Upper GIT study: Barium Swallow

Upper GIT study: barium swallow

Pre-test: NPO post-midnight, low residue diet

COMMON LABORATORY PROCEDURES

Lower GIT study: barium enema

- Barium is instilled rectally

Post-test: Laxative is ordered, increase patient fluid intake, instruct that

COMMON LABORATORY PROCEDURES

Lower GI- scopy

- Examination of the gallbladder to detect stones, its ability to

COMMON GIT SYMPTOMS AND MANAGEMENT

4. Administer prescribed laxatives, stool softeners

- The rapid influx of stomach contents will cause distention of the

- Later, there is increased blood glucose stimulating the increased

- Then, blood glucose will fall causing reactive hypoglycemia

ASSESSMENT FINDINGS: LATE symptoms:

GIT SYMPTOMS AND MANAGEMENT

DISORDERS OF THE GASTROINTESTINAL SYSTEM

UPPER GI SYSTEM (ESOPHAGUS)

ASSESSMENT Findings in Hiatal hernia

4. 50%- without symptoms

ASSESSMENT findings for EV

ASSESSMENT findings for EV

CONDITIONS OF THE STOMACH

ASSESSMENT ( for GERD)

CHARLES Z. ARIOLA JR, MSN, LPT, RN. 12

 Diverticulum becomes filled with food and regurgitate when assuming

Cancer Of The Esophagus

3. PEPTIC ULCER DISEASE

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

ASSESSMENT (Gastric Ulcer)

 Vomiting is more common

NURSING INTERVENTIONS FOR BLEEDING

SURGICAL PROCEDURES FOR PUD

- Condition of the Duodenum

DUODENAL ULCER ASSESSMENT

CONDITIONS OF THE SMALL INTESTINE