GASTROINTESTINAL (METABOLIC)

Disorders

ANATOMY and PHYSIOLOGY

Liver
● largest gland of the body (illustration )
● lobes divide into lobules by blood vessels
and fibrous material
● ducts - hepatic duct from liver; cystic duct
from gallbladder; common bile duct formed
by hepatic duct and cystic duct and drains
into duodenum

FUNCTIONS
● 1.Metabolism of fat, carbohydrates and
protein
● converts glucose to glycogen for storage
● converts glycogen to glucose and releases
into blood
● forms glucose from fats or proteins
● breaks down fatty acids into ketones
● stores fat

● synthesizes triglycerides, phospholipids,

cholesterol, and choline (B complex factor)
● synthesizes various proteins
● converts amino acid to ammonia
● converts ammonia to urea

FUNCTIONS
● Secretes bile, which is important in
emulsifying of fats
● Detoxifies substances such as drugs,
hormones
● Metabolizes vitamins
GASTROINTESTINAL (METABOLIC) ● Endoscopy
Disorders ● Esophagogastroduodenoscopy
● Complete blood count (CBC)
PEPTIC ULCER DISEASES ● Test stool for occult blood (Fecal occult
blood test)

COMPLICATIONS
Hemorrhage
● Medical Management:
● Treat with tap water lavage to control
Pathophysiology bleeding
● Administer Intra-arterial vasopressin
● Disruption/ Erosion of the mucosal layer/ ● Administer Intravenous fluids and blood
gastric lining replacement
● Acid diffuses back into mucosa
● Most common site: junction of fundus and Perforation
pylorus ● finding: severe abdominal pain
● Normal gastric acid secretion Peritonitis
● finding: board-like abdomen
Signs and symptoms ● Paralytic ileus (obstruction): scarring may
● Pain obstruct pylorus
● Burning or gas, worse with food
● Pain in left upper epigastric area Medical MANAGEMENT
● Nausea ● NPO (nothing by mouth)
● Vomiting ● Nasogastric tube insertion for lavage
● Bleeding; hematemesis ● Antibiotics: Drug of Choice: Clarithromycin
(Biaxin)
DUODENAL ULCERS ● Metronidazole (Flagyl)
Etiology/Risk factors ● H2 receptor antagonists:
● Excessive production of hydrochloric acid ● Cimetidine (Tagamet); Ranitidine
● More rapid gastric emptying hydrochloride (Zantac); Famotidine (Pepcid);
● Familial tendency Nizatidine (Axid)
● Stress
● More frequent in people with type O blood Medical management
● More common in men ages 25 to 50 ● Anticholinergics:Dicyclomine hydrochloride
(Bentyl)
Pathophysiology: ● Antacids: Aluminum hydroxide (Amphogel);
Aluminum-magnesium combinations
● Located 0.5 to 2 cm below pylorus (Maalox, Mylanta, Gelusil); Calcium
● Arteriosclerotic changes in adjacent blood carbonate (Tums)
vessels ● Cytoprotective:Sucralfate (Carafate)
● Vagus nerve stimulation causes tissues to ● Proton pump inhibitors: Omeprazole
release gastrin, which increases secretion of (Prilosec), Lansoprazole (Prevacid), and
hydrochloric acid Anxiolytics
● Blood transfusion
Signs and symptoms
● Pain Surgical MANAGEMENT
● Heartburn occur during night or when ● Vagotomy: eliminates stimulation of gastric
stomach is empty cells
● Pain relieved by food intake ● Pyloroplasty: widening pylorus to improve
● Melena (tarry stool; black with digested gastric emptying
blood) ● Subtotal gastrectomy
● Billroth I (gastroduodenostomy)
DIAGNOSTIC STUDIES ● Billroth II (gastrojejunostomy)
 ● Total gastrectomy
Signs and symptoms
Post-op Complications ● Bloody diarrhea ranging from two to three
Dumping syndrome per day to ten to 20 per day
● from rapid emptying of the stomach. ● stools may also contain pus and mucus
● more common with Billroth II ● abdominal (tenderness and cramping) pain
● subsides after several months ● Fever
● decrease with slow eating, low-carbohydrate, ● weight loss
high-protein and fat diet ● Anemia
● avoid liquids with meals ● Tachycardia
● dehydration
Signs and Symptoms: ● impaired absorption of fat-soluble vitamins
● Tachycardia such as E, K
● Palpitations ● systemic manifestations:
● Syncope ● skin lesions - erythema nodosum
● diaphoresis, diarrhea, nausea, abdominal ● joint inflammation
distention ● inflammation of the eyes - uveitis
● Pernicious anemia secondary to loss of ● liver disease
intrinsic factor
Diagnostics
Nursing Interventions ● Sigmoidoscopy
● Pain relief ● Colonoscopy
● Assess for bleeding ● Barium enema
● Discuss lifestyle changes: stop smoking, ● Complete blood count (CBC)
decrease stress
● Health teaching - medications, diet Medical MANAGEMENT
● Assess for post-operative complications- ● fluid, electrolyte, and blood replacement
infection, bleeding,respiratory complications ● steroids
● Maintain patency of NG tube ● immunosuppressives
● Observe drainage for signs of bleeding ● anti-infectives:
(drainage should be dark red after 24 hours) ● Sulfasalazine (Azulfidine) is the primary drug
● Mouth care of choice
● anticholinergics
DISORDERS OF INTESTINE ● Antidiarrheals
● Dietary restrictions - high calorie and high
INFLAMMATORY BOWEL DISEASES protein

ULCERATIVE COLITIS Surgical management

● Affects young people ages 15 to 40

Pathophysiology
● ulceration and inflammation entire length of
colon
● involves mucosa and submucosa
● begins in rectum and extends to distal colon
● abscess and ulcers lead to bleeding and
diarrhea
● colon cannot absorb, so fluids and COMPLICATIONS
electrolytes go out of balance ● Increased risk of colon cancer
● protein is lost in stools ● Fluid and electrolyte imbalances
● scarring produces narrowing, thickening, and
shortening of colon NURSING INTERVENTIONS
● remissions and exacerbations ● Manage pain
 ● Manage diarrhea ● loperamide (Imodium) drug of choice
● Teach weight loss and nutrition ● balloon dilation of strictures
● Teach coping ● surgery will not cure Crohn's disease; may
● Remedy knowledge deficit limit damage
● Reduce anxiety ● colectomy with ileostomy
● subtotal colectomy with ileostomy or
CROHN’S DISEASE ileorectal anastomosis
Definition/Etiology:
NURSING INTERVENTIONS
● young people 15 to 30 years old After surgery, monitor for:
● inflammation of segments of bowel, ● diarrhea
especially ileum, jejunum, and colon, with ● fluid balance and nutrition
areas of normal bowel between inflamed ● skin integrity
bowel - cobblestone appearance ● coping and self-care
● inflammation involves all layers of bowel wall ● sexuality
- transmural ● medications
● ulceration, fissures, fistula, and abscess
formation DIVERTICULAR DISEASE
● bowel wall thickens and narrows, producing ● Outpouching of the intestinal mucosa
strictures ● Definition/Etiology
● slowly progressive ● Most common in sigmoid colon
● Constipation
● Low fiber diet
Signs and symptoms ● Obesity
● Diarrhea with steatorrhea (fats not ● Colon wall thickens with increased pressure
processed) in bowel
● Abdominal pain - right lower quadrant ● Stool and bacteria retained in diverticulum
● Fatigue become inflamed and small perforations
● Weight loss occur
● Dehydration ● Inflammation of surrounding tissue
● Fever
● Systemic manifestations: Signs and symptoms
● arthritis, clubbing of fingers ● Frequently asymptomatic
● skin inflammations ● Crampy, lower, left abdominal pain
● nephrolithiasis ● Alternating constipation and diarrhea
● Low grade fever, chills, anorexia, nausea
COMPLICATIONS ● leukocytosis
● obstruction from strictures
● fistula formation
● bowel may perforate and infect: peritonitis DIAGNOSIS
● Barium enema
MEDICAL MANAGEMENT ● Complete blood count
● Rest ● Urinalysis
● nutritional support ● Stool for occult blood
● hyperalimentation ● Colonoscopy
● diet high in calories and protein, low in
roughage and fat Medical MANAGEMENT
● steroids as anti-inflammatories ● Diverticulosis (outpouching)
● immunosuppressives ● high fiber diet
● anti-infectives: sulfasalazine (Azulfidine) ● bulk laxatives
primary drug of choice ● stool softeners
MEDICAL MANAGEMENT ● anticholinergics
● Anticholinergics
● antidiarrheals Medical MANAGEMENT
 ● Diverticulitis (inflammation)
● NPO
● rest bowel
● antibiotics
Surgical MANAGEMENT
● Bowel resection
● Temporary colostomy
COMPLICATIONS
● Abscess formation
● Perforation with peritonitis
● Fistula
● Bowel obstruction
NURSING INTERVENTIONS
● Teach appropriate diet
● Avoid straining, coughing, lifting
● Avoid increased abdominal pressure
CONSTIPATION
Definition/etiology
● Change in normal
characterized by decreased frequency
● stool is hard, dry, difficult to pass
● stool is retained in rectum
Etiology/Risk factors
● insufficient dietary fiber
● insufficient fluid intake
● medications, especially opiates
Etiology/ Risk Factors
● lack of activity
● ignoring urge to defecate
● chronic laxative abuse
● lack of privacy/psychological factors
● pregnancy
● neuromuscular impairment
● hypothyroidism
Signs and symptoms
● hard, dry stool
● abdominal distention
● decreased frequency of usual patterns
● straining
● nausea/anorexia
● palpable mass
● hemorrhoids
● fecal impaction with diarrhea
COMPLICATIONS
● Obstruction/perforation
● Cardiovascular alterations
MEDICAL MANAGEMENT
● Cathartics
● saline laxatives
● milk of magnesia
● stimulant laxatives
● bisacodyl (Dulcolax)
● bulk-forming laxatives
● psyllium (Metamucil)
● lubricant-emollient
● mineral oil
● stool softeners
● docusate sodium (Colace)
● enemas
● cleansing - saline, soap solution
● softening - oil retention
NURSING INTERVENTIONS
● Teach nutrition: increased fiber, and
increased fluids
● Teach: obey urge to defecate
● Provide privacy and comfort
● Increase activity
bowel habits
DIARRHEA
Definition / Etiology
Loose stools due to:
● fecal impaction
● ulcerative colitis
● intestinal infections
● increased fiber
● medications
SIGNS AND SYMPTOMS
● Loose watery stools
COMPLICATIONS
● Dehydration
● Electrolyte imbalance
MEDICAL MANAGEMENT
● Mild diarrhea
● Oral fluids to replace lost fluid
● Moderate diarrhea
● Drugs that decrease motility (Lomotil,
Imodium)
● Severe diarrhea
● due to infection
● Antimicrobials
● fluid replacement
Nursing Interventions
● Monitor for fluid and electrolyte imbalance
● Prevent skin excoriation
 ● Teach client about foods that may affect ● For patients with nasogastric or
bowel elimination, e.g., fruits, vegetables nasointestinal tubes, provide oral care.
● Insert nasogastric tubes: Salem sump
BOWEL OBSTRUCTION (double lumen), Levin (single lumen)
Definition / Etiology: ● Nasointestinal tubes
● Mechanical: ● cantor tube - single lumen, mercury filled
● Adhesions weight on tip
● Hernias ● miller-Abbott - double lumen with mercury
● Neoplasms weighted tip
● Volvulus ● advance two inches per hour
● Intussusception ● Maintain fluid and electrolyte balance.
● Nonmechanical:
● Paralytic ileus COLON CANCER
● Occlusion of vascular supply Definition/etiology
● Distended abdomen from accumulation of ● May develop from adenomatous polyps
fluid, gas, intestinal contents Risk factors
● Fluid shifts due to increased venous ● Low residue diet, high-fat diet, refined foods
pressure with hypotension and hypovolemic Pathophysiology
shock ● Adenocarcinoma is the most common type
● Bacterial proliferate ● Most common locations are sigmoid rectum
and ascending colon
SIGNS AND SYMPTOMS ● Often metastasizes to the liver
● Abdominal pain ● Classification (staging) systems: TNM or
● Abdominal distention (more with large bowel Duke's
obstruction) Signs and Symptoms
● Nausea/Vomiting (more with small bowel ● rectal bleeding
obstruction) ● change in bowel habits
● Hypoxia ● constipation, diarrhea
● Metabolic acidosis ● change in shape of stool
● Bowel necrosis from impaired circulation ● anorexia and weight loss
● abdominal pain, palpable mass
COMPLICATIONS DIAGNOSTICS
● Perforation and peritonitis ● Colonoscopy
● Shock ● Sigmoidoscopy
● Strangulation of bowel ● Digital examination
● Stool for occult blood
Diagnostics ● Barium enema
● Upper-GI and lower-GI series ● CT scan
● Abdominal X ray ● Carcinoembryonic antigen (CEA)
● Air in bowel ● Alkaline phosphatase and AST (aspartate
● Blood Studies aminotransferase)
● CBC
● BUN Complications
● Obstruction
Medical MANAGEMENT Management
● Decompress the abdomen ● radiation
● Nasointestinal tube ● chemotherapy
● Surgical bowel resection ● treatment of choice is surgery - bowel
resection, colostomy
Nursing Interventions ● right hemicolectomy - involves ascending
● Manage pain, but avoid morphine or colon
codeine. ● left hemicolectomy - involves descending
● Slows bowel motion colon
● Measure abdominal girth
 ● abdominal-perineal resection: removal of ● infected blood, semen, vaginal secretions or
sigmoid colon and rectum with formation of a saliva must enter the body
colostomy
Nursing Interventions PATHOPHYSIOLOGY
● Manage pain ● Hepatitis B has three distinct antigens
● Monitor for complications ● HBsAg - surface antigen
● wound infection ● HBcAg - core antigen
● atelectasis ● HBeAg - e antigen
● thrombophlebitis ● damage to the hepatocytes causes
● Maintain fluid and electrolyte balance inflammation and necrosis
● Care of ostomy ● liver function decreased in proportion to
damage
LIVER DISEASES ● healing takes three - four months
HEPATITIS
Definition/etiology Signs and symptoms
● Acute inflammatory disease of the liver ● jaundice if liver fails to conjugate bilirubin or
caused by viral, bacterial, or toxic ingestion excrete it
Pathophysiology ● clay-colored stools from lack of urobilin
● Inflammation of liver ● urine is dark from urobilin excreted in urine
● Enlargement of Kupffer cells rather than stool
● Bile stasis ● urine foams when shaken
● Regeneration of cells with no residual ● pruritus from bile salts excreted through skin
damage ● right upper quadrant pain from edema and
inflammation of liver
TYPES ● anorexia, nausea, vomiting, malaise, weight
Hepatitis A loss
● transmitted from infected food, water, milk, ● prolonged bleeding from impaired absorption
shellfish of vitamin K
● fecal-oral route of infection common in poor ● anemia from decreased RBC lifespan
sanitation/overcrowding
● higher incidence in fall and winter Diagnostics – Serologic Markers
● new vaccine available ● HBsAg - hepatitis B surface antigen
● anti-Hbc - antibodies to B core
Hepatitis B antigens
● blood-borne and sexually transmitted may ● elevated alanine aminotransferase
become a carrier (ALT previously SGPT)
● elevated bilirubin
Hepatitis C ● elevated aspartate
● transmitted parenterally (post-transfusion aminotransferase (AST; previously
hepatitis) and possibly fecal-oral route may SGOT)
become a carrier ● elevated alkaline phosphatase
Hepatitis D ● prolonged prothrombin
● blood borne coexists with hepatitis B
Hepatitis E Management
● water borne contaminated food or water; ● symptomatic treatment of pain
rare in the United States ● antiemetics as needed

HEPATITIS B 3 STAGES
Risk factors/infection route Pre-icteric (pre-jaundice) or prodromal stage
● homosexuality ● when general flu-like symptoms occur
● iv drug use Icteric stage
● health professionals ● during which jaundice occurs (not all patients
● hemodialysis with hepatitis develop jaundice)
● transmission routes Post-icteric (post-jaundice)
 ● or recovery stage: ● Impaired aldosterone metabolism resulting in
patient continues to have fatigue and malaise edema
● Impaired estrogen metabolism:
Nursing Interventions gynecomastia, menstrual changes, changes
● Fatigue - provide rest periods; may require in distribution of body hair, vascular changes
bed rest initially - spider angiomas, palmar erythema
● Maintain skin integrity ● Impaired metabolism of protein,
● Client will tolerate less activity carbohydrate, and fat
● Nutrition needs: ● produces less plasma protein, resulting in
● increase carbohydrates and proteins; edema and ascites
decrease fat ● produces less of proteins needed for clotting
● avoid alcohol (fibrinogen and prothrombin)
● eat frequent, small meals ● absorbs less vitamin K, resulting in
● Remedy knowledge deficit prolonged bleeding
● Arrange for home care needs ● liver fails to convert glycogen to glucose,
● Teach infection control resulting in hypoglycemia
● use disposable utensils and dishes or keep
separate from others DIAGNOSTICS
● good handwashing ● Liver function studies
● do not share razors, toothbrush, etc. ● ALT
● AST
CIRRHOSIS ● Alkaline phosphatase
Definition/etiology ● Prothrombin time
● Irreversible, chronic, progressive ● CBC
degeneration of the liver, with fibrosis and ● Decreased cholesterol because liver
areas of nodular regeneration synthesis impaired
Types ● Elevated serum bilirubin and urine bilirubin
● Laennec's cirrhosis-related to alcohol abuse ● ERCP to examine bile duct
● Post-necrotic - associated with viral hepatitis ● CT scan of liver
or exposure to hepatotoxin ● Liver biopsy
● Biliary cirrhosis-associated with inflammation
or obstruction of gallbladder or bile duct Medical MANAGEMENT
● Cardiac cirrhosis -associated with congestive ● Steroids for post-necrotic cirrhosis
heart failure ● Replace B vitamins and fat-soluble vitamins
● Diet
PATHOPHYSIOLOGY ● increased carbohydrates
● Nodular liver with fibrosis and scar ● protein may be restricted, depending on
tissue amount of damage and symptoms
● Destroys hepatocytes and kills ● no alcohol
tissue (necrosis)
● Necrosis, nodules, and scar tissue NURSING INTERVENTIONS
obstruct flow of blood, lymph, and ● Monitor for bleeding
bile ● Alteration in nutrition
● Impaired bilirubin metabolism ● 2,000-3,000 calories daily
Signs and symptoms ● Low fat
● Weakness, fatigue, weight loss, ● Provide rest periods; client will not tolerate
hepatomegaly strenuous activities
● Right upper quadrant pain ● Remedy any knowledge deficit about
● Jaundice, pruritus, steatorrhea (decreased cirrhosis and its therapies
absorption of fat and fat-soluble vitamins) ● Changes in LOC
● Clay-colored stools ● confusion
● Increased bilirubin in urine, producing dark ● avoid sedation
colored urine ● Impaired skin integrity, from edema and
Signs and symptoms pruritus
 ● Monitor fluid balance ● Nitroglycerin- will decrease myocardial
● Measure abdominal girth daily effects
● Weigh daily ● Beta-adrenergic neuron-blocking agents -
● Measure I & O may decrease risk of recurrent bleeding by
COMPLICATIONS decreasing pressure in portal system
● Portal hypertension ● Cathartics- to remove blood from GI tract
● Ascites and decrease absorption of ammonia
● Hepatic encephalopathy
PORTAL HYPERTENSION SURGICAL INTERVENTION
Definition/etiology ● Splenorenal shunt- Shunt to decrease blood
● Increased pressure in the portal flow to liver and therefore pressure
Pathophysiology: > mesocaval shunt
● Normal blood flow is altered. > portacaval shunt
● Producing an increased resistance to flow ● TIPS (transjugular intrahepatic
through the liver. portosytsemic shunt) - shunt placed
● Congestion in the portal system dilates between hepatic and portal vein
veins, especially in esophagus and rectum.
Nursing Intervention
SIGNS AND SYMPTOMS ● Monitor for signs of/ bleeding
● Prominent abdominal-wall veins (caput ● Avoid intake of alcohol, irritating or rough
medusa) food
● hemorrhoids ● Avoid increased pressure in abdomen
● enlarged spleen ● If bleeding occurs - administer transfusions,
● anemia from increased destruction of RBCs fresh frozen plasma, vitamin K
● esophageal varices and GI b ● Monitor for infection

Diagnostics ASCITES
● Endoscopy Definition/etiology
Medical MANAGEMENT ● accumulation of fluid in the peritoneum
● Sclerotherapy - injection of a sclerosing Pathophysiology
agent into varices ● Portal hypertension causes increased
● Balloon tamponade - Sengstaken- plasma and lymphatic hydrostatic pressure
Blakemore tube is inserted into the stomach in portal system
● gastric balloon is inflated and presses on ● Hypoalbuminemia causes decreased colloid
lower esophagus while allowing suctioning osmotic pressure
● esophageal balloon places pressure on ● Hyperaldosteronism due to liver's inability to
varices metabolize aldosterone causes body to
● Pressure is released as ordered to prevent retain sodium and water
necrosis
● Traction for increased pressure added by Signs and symptoms
attaching tube to football helmet ● Abdominal distention
● Assess for bleeding and signs of shock ● Protruding umbilicus
● Assess for respiratory distress - aspiration or ● Dull sound on percussion of abdomen, fluid
displacement of tube, suction PRN wave
● Keep head of bed elevated ● Bulging flank
● Dyspnea
MEDICATIONS
Vasopressin diagnostics
● constricts veins and decreases portal blood ● Abdominal x-ray
flow ● CT scan
● given IV or into superior mesenteric artery ● Ultrasound
● side effects include hypothermia, myocardial
ischemia, acute renal failure MEDICAL MANAGEMENT
● Diuretics
 ● Spironolactone (Aldactone)-aldosterone
antagonist, spares potassium ACUTE PANCREATITIS
● IV albumin ● Definition/etiology
● Diet: Low in sodium ● Inflammation of the pancreas
● Paracentesis to remove fluid ● Alcohol ingestion
● Peritoneal venous shunt-allows drainage of ● Gall stones
fluid from the peritoneum to superior vena ● Drug ingestion
cava ● Viral infections
● Trauma

Nursing Interventions PATHOPHYSIOLOGY

● Measure I & O ● Autodigestion from premature activation of
● Weigh patient daily pancreatic enzymes
● Abdominal girth ● Proteases and lipases, normally active in
● Monitor hydration status: Skin turgor small intestine, are activated in the pancreas
● Restrict fluids ● Phospholipase A digests adipose and
● Monitor for ineffective breathing patterns parenchymal tissues
● Position patient to semi-Fowler's position ● Elastase digests elastic fibers of blood
● Monitor for impaired skin integrity vessels, producing bleeding
● Remedy knowledge deficit ● Amylase digests carbohydrates
● Inflammation response occurs from enzyme
HEPATIC ENCEPHALOPATHY release
● Mental dysfunction associated with severe
liver disease. Signs and symptoms
● ● Left upper quadrant abdominal pain
● Definition/etiology ● pain worsens after eating and when lying flat
● impaired ammonia metabolism in liver ● nausea and vomiting
poisons brain tissue ● fever, agitation, confusion
● ammonia produced in bowel from action of ● hypovolemia and shock
bacteria on protein ● hemorrhage into retroperitoneal space may
produce ecchymosis in flank or around
Signs and symptoms umbilicus
● Changes in LOC from confusion to coma ● tachypnea, pulmonary infiltrates, atelectasis
● Changes in sleep pattern from circulating enzymes
● Memory loss
● Asterixis - flapping tremor DIAGNOSTICS
● Impaired handwriting ● Liver Function test (Serum amylase, serum
● Hyperventilation with respiratory alkalosis lipase, and urinary amylase): Elevated
● Fetor hepaticus - musty, sweet odor to enzymes
breath ● CBC: Elevated WBCs, decreased
hemoglobin and hematocrit
Medical MANAGEMENT ● LDH and AST (SGOT)
● Neomycin sulfate (Mycifradin)-inhibits action ● HGT: hyperglycemia
of intestinal bacteria ● Serum Calcium
● Lactulose (Cephulac)-absorbs ammonia and ● hypocalcemia
produces evacuation of the bowel ● Chest x- ray
● Diet: low protein diet ● CT scan
● Diagnostics: Serum ammonia level ● Abdominal Ultrasound
Nursing Interventions ● ERCP
● Maintain safety.
● Tremor, confusion can lead to injury. COMPLICATIONS
● Monitor intake and output. ● Respiratory problems: Atelectasis and
● Ascites and low intake decrease fluid volume Pneumonia from the immobility imposed by
● Diarrhea from medications. pain
 ● Tetany: from decreased calcium levels
● Abscess or pseudocyst
Medical Management
● Pain relief: Meperidine (Demerol)
● Fluid maintenance to prevent shock
● Insulin for hyperglycemia
● Calcium replacement
● Decrease stimulation of pancreas: NPO-TPN
(nothing by mouth; total parenteral nutrition),
NG tube, anticholinergics and h2-receptor
antagonists
NURSING INTERVENTIONS
● Monitor onset and progress of pain
● Monitor alteration in breathing patterns
● Monitor nutritional status
● Oral care when NPO
● If eating is allowed, diet high in proteins and
carbohydrates and low in fat
● Monitor fluid and electrolyte balances
CHOLECYSTITIS
● Definition/etiology
● Inflammation of the gallbladder
● usually due to gallstones (Cholelithiasis)
● Bile is blocked, and infects tissue
● More common in women, especially those
over 40 and those who use birth control pills
● Types
● Cholesterol - most common
● Pigment - unconjugated bilirubin
PATHOPHYSIOLOGY
● Common bile duct is obstructed by a
gallstone
● Bile cannot be excreted, some is reabsorbed
● Remaining bile distends and inflames gall
bladder
● May scar gallbladder, resulting in less storing
of the bile from the liver
● Can perforate gall bladder
● Endoscopic retrograde cholangiography
(ERCP)
● Endoscopic retrograde catheterization of the
gallbladder (ERCG)
● Ultrasound
Medical MANAGEMENT
● Rest
● Diet: Low-fat
● Removal of stone in common duct by
endoscopy
● To dissolve cholesterol stones
> Chenodeoxycholic acid (Chenodiol)-side
effects are diarrhea and hepatotoxicity and >
Ursodeoxycholic acid (UDCA)
Medical MANAGEMENT
● Control pain - Meperidine (Demerol) is drug
of choice
● Replace vitamin K if bleeding time is
prolonged
● Extracorporeal shock wave lithotripsy
(ESWL) - may have hematuria after
procedure, but not longer than 24 hours
● Choledocholithotomy - to remove or break
up stones
● Laparoscopic laser cholecystectomy
● Cholecystectomy
NURSING INTERVENTIONS
● Monitor vital signs
● Monitor pain and medicate as needed
● Teach client - dietary restriction of fatty foods

Signs and symptoms

● Colicky pain in right upper quadrant with
possible radiation to right shoulder and back
● Indigestion after eating fatty foods
● Nausea and vomiting
● Jaundice (if the liver is involved or inflamed
or the common duct obstructed)
● Low grade fever

DIAGNOSTICS
GASTROINTESTINAL (METABOLIC)
Disorders

ANATOMY and PHYSIOLOGY

● ________ largest gland of the body
(illustration)
● lobes divide into lobules by
_______________ and _______________
● ducts-_____________from liver; cystic duct
from______________; common bile duct
formedby____________and____________a
nd drains into ______________.

FUNCTIONS
Metabolism of fat, carbohydrates and protein
● converts glucose to _________ for storage
● converts __________ to glucose and
releases into blood
● forms ______________ from fats or proteins
● breaks down fatty acids into ___________
● synthesizes ____________, phospholipids,
_______________, and _______ (B
complex factor)
● synthesizes various proteins
● converts amino acid to __________
● converts ammonia to ________
● Secretes _______, which is important in
emulsifying of fats
● Detoxifies substances such as drugs,
hormones
● Metabolizes ____________-
 GASTROINTESTINAL (METABOLIC) Pathophysiology:
Disorders
PEPTIC ULCER DISEASES ● Located 0.5 to 2 cm below pylorus
● ____________ changes in adjacent blood
vessels
● _________________ causes tissues to
release _________, which
___________secretion of hydrochloric acid

Signs and symptoms

● Pain
Pathophysiology ● Heartburn occur _____________or when
stomach is ____________
● _________________of the mucosal layer/ ● Pain relieved by _____________
gastric lining ● Melena-
● Acid diffuses back into ________ ● Endoscopy
● Most common site: _______________ and ● Complete blood count (CBC)
______________ ● Test stool for ____________(Fecal occult
● Normal gastric acid secretion blood test)

Signs and symptoms COMPLICATIONS

Medical Management:
DUODENAL ULCERS ● Treat with tap water __________ to control
Etiology/Risk factors bleeding
● Administer Intra-___________l vasopressin
● Excessive production of ● Administer Intravenous fluids and blood
_____________________ replacement
● More ____________ gastric emptying ● _________
● Familial tendency _________________ ● finding: severe abdominal pain
● More frequent in people with type _______ ● Peritonitis
blood ● finding: _________________
● More common in men ages ___ to ____ ● ________________(obstruction):scarring
years old. may obstruct pylorus

Medical MANAGEMENT
● NPO (nothing by mouth)
● Nasogastric tube insertion for lavage
● Antibiotics: Drug of Choice:
___________________ and Metronidazole
(Flagyl)
 ● ______________antagonists: Cimetidine
(Tagamet); Ranitidine hydrochloride DISORDERS OF INTESTINE
(Zantac); Famotidine (Pepcid); and
Nizatidine (Axid) INFLAMMATORY BOWEL DISEASES
● ____________________: Dicyclomine _________________
hydrochloride (Bentyl) ● Affects young people ages __________
● Pathophysiology: ulceration and
● ____________________: Aluminum inflammation entire length of colon, involves
hydroxide (Amphogel); Aluminum- __________and____________begins in
magnesium combinations (Maalox, Mylanta, __________and extends to
Gelusil); and Calcium carbonate (Tums) ______________
● abscess and ulcers lead to bleeding and
● ______________________:Sucralfate diarrhea
(Carafate) ● colon cannot absorb, so fluids and
● _______________________: Omeprazole electrolytes go out of balance
(Prilosec) and Lansoprazole (Prevacid) ● __________ is lost in stools
● _________________________ ● scarring produces narrowing, thickening, and
● Blood transfusion shortening of colon
● remissions and exacerbations
surgical MANAGEMENT
● Vagotomy: _________________ Signs and symptoms
● _______________________: widening ● Bloody diarrhea ranging from two to three
pylorus to improve gastric emptying per day to ____ to _____ per day
● Subtotal gastrectomy ● stools may also contain _____ and
● ______________ (gastroduodenostomy) ________
● Billroth II (________________) ● abdominal (tenderness and cramping) pain
● Total gastrectomy ● Fever
● ____________
Post-op Complications ● Anemia
● _____________________ ● Tachycardia
● from rapid emptying of the stomach. ● dehydration
● more common with _______________ ● impaired absorption of __________ vitamins
● subsides after several months such as E, K
● Decrease with ______________, ● systemic manifestations: skin lesions -
__________ high-protein and ________ _____________, joint inflammation ,
● avoid liquids with meals inflammation of the eyes - uveitis and liver
● Signs and Symptoms: Tachycardia, disease
___________, Syncope, diaphoresis,
__________, nausea, and __________. Diagnostics
● Pernicious anemia secondary to loss of
______________________ Medical MANAGEMENT
● fluid, electrolyte, and blood replacement
Nursing Interventions ● steroids
● Pain relief ● immunosuppressives
● Assess for bleeding ● ______________: ___________ (Azulfidine)
● Discuss life-style changes: ____________, primary drug of choice
___________ ● anticholinergics
● Health teaching - medications, diet ● Antidiarrheals
● Assess for post-operative complications - ● Dietary restrictions - _____________
infection, bleeding, respiratory complications
● Maintain patency of NG tube
● Observe drainage for signs of __________ Surgical management
(drainage should be dark red after 24 hours)
● Mouth care
 ● steroids as anti-inflammatories
● immunosuppressives
● anti-infectives: _________________-
primary drug of choice
● ________________
● _________________
● _______________drug of choice
● balloon dilation of strictures
● surgery will not cure Crohn's disease; may
limit damage: colectomy with ileostomy and
subtotal colectomy with ileostomy or
ileorectal anastomosis
COMPLICATIONS
NURSING INTERVENTIONS
NURSING INTERVENTIONS After surgery,
● Monitor for:
CROHN’S DISEASE
● Definition/Etiology: DIVERTICULAR DISEASE
● young people _______ to _____ years old ● Outpouching of the ___________________
● inflammation of segments of bowel, ● Definition/Etiology
especially ___________, jejunum, and ● Most common in _____________________
________, with areas of normal bowel ● Constipation
between inflamed bowel - ____________ ● _______________ diet
● inflammation involves all layers of bowel ● ______________
wall- ________ ● Colon wall thickens with increased pressure
● ulceration, fissures, fistula, and abscess in bowel
formation ● Stool and bacteria retained in diverticulum
● bowel wall __________and ___________, become inflamed and small perforations
producing ___________ occur
● slowly progressive ● Inflammation of surrounding tissue

Signs and symptoms Signs and symptoms

● Diarrhea with ______________ ● Frequently asymptomatic
(fats not processed) ● Crampy, lower, left abdominal pain
● Abdominal pain - _______ ● Alternating constipation and diarrhea
● Fatigue ● Low grade fever, chills, anorexia, nausea
● Weight loss ● leukocytosis
● Dehydration
● Fever DIAGNOSIS
● Systemic manifestations: ● _______________
_____________,__________,____ ● Complete blood count
_____________and ___________. ● Urinalysis
● ________________
COMPLICATIONS ● Colonoscopy
● obstruction from strictures
● fistula formation Medical MANAGEMENT
● bowel may perforate and infect: peritonitis ● Diverticulosis (outpouching): Diverticulitis
(inflammation), NPO, rest bowel and
MEDICAL MANAGEMENT antibiotics
● Rest
● nutritional support Surgical MANAGEMENT
● hyperalimentation
● diet high in __________ and ____________, COMPLICATIONS
low in ______________ and ___________
NURSING INTERVENTIONS
● Teach appropriate diet
● Avoid straining, coughing, lifting: _________
Definition/etiology
● Change in normal bowel
characterized
____________________stool
__________, ________, difficult to pass
● stool is retained in _________-
Etiology/Risk factors
● insufficient _______________
● insufficient _______________
● medications, especially ______________
CONSTIPATION
Etiology/ Risk Factors..cont.
● lack of activity
● ignoring urge to defecate
● chronic laxative abuse
● lack of privacy/psychological factors
● pregnancy
● neuromuscular impairment
● hypothyroidism
● ______________ - saline, soap solution
● softening - ________________-
NURSING INTERVENTIONS
● Teach nutrition:
habits ● ___________________________
by ● Teach: obey urge to defecate
is ● Provide privacy and comfort
● __________________
DIARRHEA
Definition / Etiology
● Loose stools due to:
● fecal impaction
● ___________________
● intestinal infections
● increased fiber
● ____________________
SIGNS AND SYMPTOMS
● ________________

Signs and sypmtoms COMPLICATIONS

● hard, dry stool ● ________________
● _________________ ● Electrolyte imbalance
● decreased frequency of usual patterns
● ________________ MEDICAL MANAGEMENT
● nausea/anorexia ● _______________
● ___________________ ● Oral fluids to replace lost fluid
● hemorrhoids
● _________________ with diarrhea ● ________________
● Drugs that decrease motility (Lomotil,
COMPLICATIONS Imodium)

MEDICAL MANAGEMENT ● ________________

● ____________ ● due to infection
● saline laxatives ● Antimicrobials
● milk of magnesia ● fluid replacement

● stimulant laxatives Nursing Interventions

● ________________ ● Monitor for fluid and electrolyte imbalance
● Prevent _______________
● ___________________ ● Teach client about foods that may affect
● psyllium (Metamucil) bowel elimination, e.g., fruits, vegetables

● lubricant-emollient BOWEL OBSTRUCTION

● mineral oil ● Definition / Etiology:

● ___________________ ● ______________:
● docusate sodium (Colace) ● Adhesions
● Hernias
● enemas ● Neoplasms
 ● Volvulus Pathophysiology
● Intussusception ● ______________ is the most common type
● Most common locations are __________and
● Nonmechanical: ascending colon
● ___________________ ● Often metastasizes to the liver
● ___________________ ● Classification (staging) systems:
_________________
● Distended abdomen from accumulation of ● NCER
fluid, gas, intestinal contents
Signs and Symptoms
● Fluid shifts due to increased venous ● rectal bleeding
pressure with hypotension and hypovolemic ● change in bowel habits
shock ● ______________, _____________
● change in shape of stool
● Bacterial proliferate ● ____________ and weight loss
SIGNS AND SYPTOMS ● abdominal pain, palpable mass

COMPLICATIONS DIAGNOSTICS
● Colonoscopy
Diagnostics ● ___________________
● Upper-GI and lower-GI series ● Digital examination
● Abdominal X ray ● Stool for ____________________
● Air in bowel ● Barium enema
● Blood Studies ● CT scan
● _______________________
Medical MANAGEMENT ● Alkaline phosphatase and AST (aspartate
● Decompress the abdomen aminotransferase)
● Nasointestinal tube
● Surgical bowel resection Complications
● Obstruction
Nursing Interventions
● Manage pain, but avoid _____________ or Management
_______________. _____________________
● Slows bowel motion ● chemotherapy
● Measure ______________ ● treatment of choice is __________ - bowel
● For patients with nasogastric or resection, colostomy
nasointestinal tubes, provide oral care. ● right hemicolectomy -
● Insert nasogastric tubes: Salem sump ______________________
(double lumen), Levin (single lumen) ● _________________- involves descending
● Nasointestinal tubes colon
● _______________- single lumen, mercury ● ___________________: removal of sigmoid
filled weight on tip colon and rectum with formation of a
● miller-Abbott - double lumen with mercury colostomy
weighted tip
● advance two inches per hour Nursing Interventions
● Maintain fluid and electrolyte balance. ● Manage pain
● Monitor for complications
COLON CADefinition/etiology ● ___________
● May develop from adenomatous polyps ● ___________
● ____________
Risk factors ● Maintain fluid and electrolyte balance
● _________________, _____________, ● Care of ostomy
refined foods
LIVER DISEASES
 ● HBeAg - _________________
HEPATITIS ● damage to the hepatocytes causes
inflammation and necrosis
● Definition/etiology ● liver function ____________in proportion to
damage
● Pathophysiology ● healing takes ___________months
● Inflammation of liver
● Enlargement of _____________ Signs and symptoms
● Bile stasis ● ______________ if liver fails to conjugate
● Regeneration of cells with no residual bilirubin or excrete it
damage ● clay-colored stools from lack of
______________
TYPES ● urine is dark from urobilin excreted in urine
● _____________ rather than stool
● transmitted from infected food, water, milk, ● urine foams when shaken
shellfish ● ___________ from bile salts excreted
● ___________ route of infection common in through skin
poor sanitation/overcrowding ● __________________________from edema
● higher incidence in _______and _______ and inflammation of liver
● new vaccine available ● anorexia, nausea, vomiting, malaise, weight
loss
● Hepatitis B ● ___________________ bleeding from
● ___________ and sexually transmitted impaired absorption of vitamin K
● may become a carrier ● anemia from decreased RBC lifespan

● ___________ Diagnostics –
● transmitted parenterally (post-transfusion Serologic Markers
hepatitis) and possibly fecal-oral route ● HBsAg - hepatitis B surface antigen
● may become a carrier ● anti-Hbc - antibodies to B core antigens
● elevated alanine aminotransferase (ALT
● Hepatitis D previously SGPT)
● ___________________ ● elevated bilirubin
● coexists with ___________________ ● elevated aspartate aminotransferase (AST;
previously SGOT)
● Hepatitis E ● elevated alkaline phosphatase
● _________________ ● prolonged prothrombin time
● contaminated food or water; rare in the
United States Management

HEPATITIS B 3 STAGES
● Pre-icteric (pre-jaundice) or prodromal
Risk factors/infection route stage
● _______________ ● when general
● iv drug use ____________________occur
● ____________________
● hemodialysis ● __________________
● transmission routes ● during which jaundice occurs (not all patients
● infected blood, semen, vaginal secretions or with hepatitis develop jaundice)
saliva must enter the body
● Post-icteric (post-jaundice)
PATHOPHYSIOLOGY ● or ____________________:
● Hepatitis B has three distinct antigens ● patient continues to have fatigue and
● HBsAg - _______________ malaise
● HBcAg - ________________ ●
Nursing Interventions ● Increased bilirubin in urine, producing dark
● Fatigue colored urine
● ___________________
● ______________________ ● Impaired aldosterone metabolism resulting in
● Maintain skin integrity edema
● Client will tolerate less activity ● Impaired estrogen metabolism:
● Nutrition needs: gynecomastia, menstrual changes, changes
● increase _____________ and in distribution of body hair, vascular changes
____________; decrease _______ - ____________________, palmar erythema
● avoid alcohol
● _____________, small meals ● Impaired metabolism of protein,
carbohydrate, and fat
● Remedy knowledge deficit produces less plasma protein, resulting in
● Arrange for home care needs ____________ and ______________
● Teach infection control produces less of ____________ needed for clotting
1. (fibrinogen and prothrombin)
2. absorbs less vitamin ______, resulting in prolonged
3. bleeding
liver fails to convert glycogen to __________,
CIRRHOSIS resulting in ______________
● Definition/etiology
● Irreversible, chronic, progressive DIAGNOSTICS
degeneration of the liver, with fibrosis and ● Liver function studies
areas of nodular regeneration ● 1.
● ● 2.
● Types ● 3.
● _________________- related to alcohol ● Prothrombin time
abuse ● CBC
● ● Decreased cholesterol because liver
● Post-necrotic - associated with viral hepatitis synthesis impaired
or exposure to _____________ ● Elevated ___________and _____________
● ● ERCP to examine bile duct
● _____________________- associated with ● CT scan of liver
inflammation or obstruction of gallbladder or ● Liver biopsy
bile duct
● Medical MANAGEMENT
● Cardiac cirrhosis - associated with ● Steroids -
__________________ ● Replace B vitamins and fat-soluble vitamins
● Diet
PATHOPHYSIOLOGY ● increased _____________
● Nodular liver with fibrosis and scar tissue ● protein may be restricted, depending on
● Destroys hepatocytes and kills tissue amount of damage and symptoms
(necrosis) ● ____________
● Necrosis, nodules, and scar tissue obstruct
flow of blood, lymph, and bile NURSING INTERVENTIONS
● Impaired bilirubin metabolism ● Monitor for bleeding
● Alteration in nutrition
Signs and symptoms ● ___________ calories daily
● Weakness, fatigue, weight loss, ● _____________
hepatomegaly ● Provide rest periods; client will not tolerate
● _______________________ strenuous activities
● Jaundice, pruritus, steatorrhea (decreased ● Remedy any knowledge deficit about
absorption of fat and fat-soluble vitamins) cirrhosis and its therapies
● _______________- ● Changes in LOC
 ● _____________ ● _________________
● _______________
● Impaired skin integrity, from edema and MEDICATIONS
pruritus ● _______________
● Monitor fluid balance ● constricts veins and decreases portal blood
● Measure abdominal girth daily flow
● Weigh daily ● given IV or into superior mesenteric artery
● Measure I & O ● side effects include

COMPLICATIONS ● Nitroglycerin

PORTAL HYPERTENSION ● ___________________________

● may decrease risk of recurrent bleeding by
Definition/etiology decreasing pressure in portal system
● _______________________
● Cathartics
Pathophysiology:
● Normal blood flow is altered. SURGICAL INTERVENTION
● Producing an increased resistance to flow ● Splenorenal shunt
through the liver. ● Shunt to decrease blood flow to liver and
● Congestion in the portal system dilates therefore pressure
veins, especially in _______________ and ● mesocaval shunt
_______________. ● portacaval shunt
● TIPS -
SIGNS AND SYMPTOMS ● shunt placed between hepatic and portal
● Prominent abdominal-wall veins vein
(__________________)
● hemorrhoids Nursing Intervention
● enlarged spleen
● ____________from increased destruction of ASCITES
RBCs
● esophageal varices and GI bleeding ● Definition/etiology
● accumulation of fluid in the ______________
Diagnostics
● Pathophysiology
Medical MANAGEMENT ● Portal hypertension causes increased
plasma and _____________________ in
● Sclerotherapy portal system
● Hypoalbuminemia causes decreased
● Balloon tamponade ___________________
● _____________________is inserted into the ● Hyperaldosteronism due to liver's inability to
stomach metabolize aldosterone causes body to
● gastric balloon is inflated and presses on retain _________and water
lower esophagus while allowing suctioning
● esophageal balloon places pressure on Signs and symptoms
varices
diagnostics
● Pressure is released as ordered to prevent
necrosis MEDICAL MANAGEMENT
● Traction for increased pressure added by ● ____________
attaching tube to football helmet ● Spironolactone (Aldactone) - aldosterone
● Assess for bleeding and signs of shock antagonist, spares potassium
● Assess for respiratory distress - aspiration or ● IV albumin
displacement of tube, suction PRN ● Diet:
 ● _________________ ● Proteases and lipases, normally active in
● ______________- to remove fluid small intestine, are activated in the
● Peritoneal venous shunt _______________
● Phospholipase A digests adipose and
Nursing Interventions parenchymal tissues
● ______________ digests elastic fibers of
HEPATIC ENCEPHALOPATHY blood vessels, producing bleeding
● ___________________ digests
Definition/etiology carbohydrates
● Impaired _________ metabolism in liver ● Inflammation response occurs from
poisons brain tissue _________________ release
● ammonia produced in bowel from action of
bacteria on protein Signs and symptoms
● ___________________
Signs and symptoms ● pain worsens after ____________ and when
● Changes in LOC from confusion to coma lying flat
● Changes in sleep pattern ● nausea and vomiting
● Memory loss ● fever, agitation, confusion
● Asterixis - ● hypovolemia and shock
● Impaired handwriting ● hemorrhage into retroperitoneal space may
● ________________- with respiratory produce ecchymosis in flank or around
alkalosis umbilicus
● Fetor hepaticus -
DIAGNOSTICS
Medical MANAGEMENT ● _______________(Serum amylase, serum
● __________________(Mycifradin) lipase, and urinary amylase)
● inhibits action of intestinal bacteria ● Elevated enzymes
● CBC
● Lactulose (Cephulac) ● Elevated ________, ___________
hemoglobin and hematocrit
● LDH and AST (SGOT)
● Diet: _____________________ ● HGT
● ● _________________
● Diagnostics ● Serum Calcium
● __________________ ● __________________
● Chest x- ray
Nursing Interventions
● Maintain safety. COMPLICATIONS
● Monitor intake and output. ● Respiratory problems
● Ascites and low intake decrease fluid volume ● Atelectasis
● Diarrhea from medications ● Pneumonia from the immobility imposed by
pain
ACUTE PANCREATITIS ● ____________
● Definition/etiology ● from decreased calcium levels
● Inflammation of the pancreas ● Abscess or pseudocyst
● __________________
● ______________ Medical MANAGEMENT
● Drug ingestion ● Pain relief : ______________(Demerol)
● Viral infections ● Fluid maintenance to prevent shock
● Trauma ● Insulin for _______________
● Calcium replacement
PATHOPHYSIOLOGY ● Decrease stimulation of pancreas
● Autodigestion from premature activation of ● .
________________ ● .
 ● anticholinergics
● h2-receptor antagonists
● Laparoscopic laser cholecystectomy
NURSING INTERVENTIONS ● Cholecystectomy
● Monitor onset and progress of pain
● Monitor alteration in breathing patterns NURSING INTERVENTIONS
● Monitor nutritional status
● Oral care when NPO
● If eating is allowed, diet high in proteins and
carbohydrates and low in fat
● Monitor fluid and electrolyte balances

CHOLECYSTITIS
Definition/etiology
● Inflammation of the gallbladder
● usually due to gallstones (Cholelithiasis)
● Bile is blocked, and infects tissue
● More common in _______, especially those
over 40 and those who use birth control pills

Types
● ________________ - most common
● Pigment - __________________

PATHOPHYSIOLOGY
● Common bile duct is obstructed by a
_____________
● Bile cannot be excreted, some is reabsorbed
● Remaining bile distends and inflames gall
bladder
● May scar gallbladder, resulting in less storing
of the bile from the liver
● Can perforate gall bladder

Signs and symptoms

● Colicky pain in _____________with possible
radiation to right shoulder and back
● Indigestion after eating _______ foods
● Nausea and vomiting
● Jaundice (if the liver is involved or inflamed
or the common duct obstructed)
● Low grade fever

DIAGNOSTICS

Medical MANAGEMENT
● Control pain - Meperidine (Demerol) is drug
of choice
● Replace vitamin K if bleeding time is
prolonged
● ____________________________
● may have hematuria after procedure, but not
longer than 24 hours
● Choledocholithotomy