Diagnostic Tests

LESSON 1: ANEURYSM ● Chest X-ray

● Computed Tomography Angiography
Aneurysm (CTA)
- is a localized sac or dilation formed at ● Transesophageal Echocardiography
a weak point in the wall of the artery
Medical Management
CHARACTERISTICS of ARTERIAL ● Control Blood Pressure
ANEURYSM ● Correcting Risk Factors

Pharmacologic
● Beta blockers
● Metoprolol
● Carvedilol
● Angiotensin Receptor Blockers
(ARBs)
● Valsartan [Diovan]
● Irbesartan [Avapro])

Surgical Management
● Endovascular Grafts Placed
Percutaneously
● Thoracic endografts

B. ABDOMINAL AORTIC ANEURYSM

(AAA)
- occurring in the aorta running through
the abdomen
1. AORTIC ANEURYSM
Etiologic Classification Of Arterial
Aneurysms
● Congenital
● Mechanical (hemodynamic)
● Traumatic (pseudoaneurysms)
● Inflammatory (noninfectious)
● Infectious (mycotic)
● Pregnancy-related degenerative
● Anastomotic (post-arteriotomy) and
graft aneurysms

A. THORACIC AORTIC ANEURYSM (TAA)

- occurring in a part of the aorta running Clinical Manifestations
through the chest ● Patients with (AAA) feel their heart
- the walls of aorta become weak and beating in their abdomen when lying
the part of aorta nearer to the heart down
enlarges ● Client's awareness of a pulsating
mass in the abdomen, with or without
Clinical Manifestations pain, followed by abdominal pain and
● Back, neck or substernal pain back
● Dyspnea, stridor or brassy cough if ● Aortic calcification noted on x-ray
pressing on trachea ● Mild to severe mid-Claudication
● Hoarseness (ischemic pain with exercise, relieved
● Aphonia by rest)
● Edema of the face and neck ● Complication: peripheral emboli to
● Distended neck vein lower extremities
● Dysphagia ● Rupture and hemorrhage abdominal
or lumbar back pain

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 ● Cool, cyanotic extremities if iliac
arteries are involved
Assessment
● A pulsatile mass in the middle and
upper abdomen.
● A systolic bruit may be heard over the
mass.
Diagnostic Findings
● Duplex ultrasonography
● Computed Tomography Angiogram
Gerontologic Considerations
● Occurs between 60 and 90
Pharmacologic Therapy
● Antihypertensive agents
● Diuretics
● Beta blockers
● ACE inhibitors
● ARBs
Endovascular and Surgical Management
● When an abdominal aortic aneurysm
measured at least 5.5 cm (2 in) wide
or was enlarging, the standard
treatment had been open surgical
repair of the aneurysm by resecting
the vessel and sewing a bypass graft
in place.
Nursing Management
● Anticipating a rupture
● patient may have cardiovascular,
cerebral, pulmonary, and renal
impairment
● Asses all organ systems
● Vital signs and Doppler assessment
every 15 minutes
● Assess for bleeding, pulsation,
swelling, pain, and hematoma
formation
● Skin changes of the lower extremity,
lumbar area, or buttocks
2. DISSECTING AORTA
- Occasionally, in an aorta diseased by
arteriosclerosis, a tear develops in the
intima or the media degenerates,
resulting in a dissection
Clinical Manifestations
● Sudden onset of symptoms
● Severe and persistent pain
● The pain is in the anterior chest or
back and extends to the shoulders,
epigastric area, or abdomen
● Increased BP
Diagnostics Findings
● Arteriography
● Multidetector-Computed Tomography
Angiography (MDCTA)
● TEE
● duplex ultrasonography
● MRA
Arterial Embolism and Arterial
Thrombosis
● Acute vascular occlusion may be
caused by an embolus or acute
thrombosis.
● Acute arterial occlusions may result
from iatrogenic injury, which can occur
during insertion of invasive catheters
such as those used for arteriography,
PTA or stent placement, or an
intra-aortic balloon pump, or it may
occur as a result of IV drug abuse.
Clinical Manifestations
The six Ps
1. Pain
2. Pallor
3. Pulselessness
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 4. Paresthesia PRESSURE HIGHER HIGHER
5. Poikilothermia (coldness) (HYPERTENS
6. Paralysis ION) STAGE
2
Diagnostic Findings
● transthoracic echocardiogram (TTE) HYPERTENSI HIGHER and/or HIGHER THAN
VE CRISIS THAN 180 120
● chest x-ray (consult your
● electrocardiography (ECG) doctor
● Noninvasive duplex immediately)
● Doppler ultrasonography
Medical management TWO CLASSES:
● Heparin therapy 1. HYPERTENSIVE EMERGENCY
-An initial IV bolus of 60 U/kg body weight is 2. HYPERTENSIVE URGENCY
given, followed by a continuous infusion of 12
U/kg/h until the patient undergoes Urgency vs. Emergency
endovascular treatment or surgery. ➢ Urgency- severely elevated BP with
no current evidence of secondary
Endovascular Management organ damage, although if left
untreated, target organ injury may
result imminently
→ Decrease BP Soon
➢ Emergency- severely elevated BP
with evidence of target organ injury
→ Decrease BP Immediately
➢ Target organs - CNS, heart, kidney,
eye

HYPERTENSIVE EMERGENCY
● is a situation in which blood pressures
Nursing management are extremely elevated and must be
● Patient remains on bed rest lowered immediately (not necessarily
● Vital signs are taken initially every 15 to less than 140/90 mm Hg) to halt or
minutes prevent damage to the target organs
● Collaborates with the primary provider (Chobanian et al., 2003; Rodriguez et
al., 2010).
LESSON 2: HYPERTENSIVE CRISIS ● Conditions associated with a
hypertensive emergency include
Hypertensive Crisis hypertension of pregnancy, acute
➢ A hypertensive crisis is a sudden, myocardial infarction, dissecting aortic
severe increase in blood pressure. aneurysm, and intracranial
➢ The blood pressure reading is 180/120 hemorrhage.
millimeters of mercury (mm Hg) or ● Assessment will reveal actual or
greater. developing clinical dysfunction of the
➢ A hypertensive crisis is a medical target organ.
emergency. It can lead to a heart ● Hypertensive emergencies are acute,
attack, stroke or other life-threatening life threatening blood pressure
health problems. elevations that require prompt
BLOOD SYSTOLIC mm Hg SYSTOLIC mm treatment in an intensive care setting
PRESSURE (upper number) Hg (upper
because of the serious target organ
CATEGORY number)
damage that may occur.
NORMAL LESS and LESS THAN 80 ● The therapeutic goals are reduction of
THAN 120
the mean blood pressure by 20% to
ELEVATED 120-129 and LESS THAN 80 25% within the first hour of treatment,
a further reduction to a goal pressure
HIGH BLOOD 130-139 or 80-89
PRESSURE of about 160/100 mm Hg over a period
(HYPERTENS of up to 6 hours, and then a more
ION) STAGE1
gradual reduction in pressure over a
HIGH BLOOD 140 OR or 90 OR period of days.

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 ● Extremely close hemodynamic
Pharmacology monitoring of the patient's blood
● The medications of choice in pressure and cardiovascular status is
hypertensive emergencies are those required during treatment of
that have an immediate effect. hypertensive emergencies and
Intravenous vasodilators: urgencies.
❖ sodium nitroprusside (Nitropress), ● The exact frequency of monitoring is a
❖ nicardipine hydrochloride (Cardene), matter of clinical judgment and varies
❖ clevidipine (Cleviprex), with the patient's condition.
❖ fenoldopam mesylate (Corlopam), ● Taking vital signs every 5 minutes is
❖ enalaprilat, appropriate if the blood pressure is
❖ nitroglycerin changing rapidly; taking vital signs at
● These medications have immediate 15- or 30- minute intervals in a more
actions that are short-lived (minutes to stable situation may be sufficient.
4 hours), and they are therefore used ● A precipitous drop in blood pressure
for initial treatment. can occur that would require
immediate action to restore blood
Other Medical Management: pressure to an acceptable level.
● Experts also recommend assessing
the individual’s fluid volume status. Summary: Management
● If there is volume depletion secondary Hypertensive urgency and Hypertensive
to natriuresis caused by the elevated Emergency
blood pressure, then volume Hypertensive Hypertensive
replacement with normal saline can Urgency Emergency
prevent large sudden drops in blood
pressure when antihypertensive Managed by using oral Managed by using IV
medications are administered antihypertensive antihypertensive agents
agents
(Rodriguez et al., 2010).
Treatment is initiated Reducing the mean
HYPERTENSIVE URGENCY with very low doses of arterial pressure by 10%
- Describes a situation in which blood oral agents using during the first hour and
pressure is very elevated but there is incremental doses as an additional 15% within
no evidence of impending or needed and avoiding the next 2 to 3 hours
large starting doses has been recommended
progressive target organ damage that may result in
(Chobanian et al., 2003). excessive blood
● Elevated blood pressures pressure reduction
associated with severe
headaches, nosebleeds, or The initial goal is to Specific agents
reduce blood pressure (according to 1" choice)
anxiety are classified as
to 160/110 mm Hg over - Sodium
urgencies. several hours to days. Nitroprusside
● In these situations, oral agents - Fenoldopam (D,
can be administered with the Mean arterial pressure receptor agonist)
goal of normalizing blood (MAP) should be - Nitroglycerin
pressure within 24 to 48 hours reduced by no more - Enalaprilat IV
(Rodriguez et al., 2010). than 25% within the (active metabolite
first 24 hours of enalapril)
- Hydralazine
Pharmacology Specific agents - Nicardipine
● Oral doses of fast-acting agents are (according to 1" choice - Esmolol
recommended for the treatment of - Labetalol (IV)
- ACE inhibitors - Phentolamine
hypertensive urgencies.
- Calcium channel
Beta-adrenergic blockers (i.e., blocker
labetalol [Trandate]), (Nicardipine)
ACE inhibitors (i.e., captopril - Labetalol (Oral)
[Capoten]) - Clonidine
- Nifedipine
Alpha 2-agonists (i.e., clonidine
[Catapres])
Nursing Management Discharge/Follow-Up Plans

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● A normal blood pressure should not
be the discharge goal of patients
admitted with hypertensive
emergencies. Aiming for a diastolic
blood pressure of 100-110 at
discharge may be reasonable.
● Patient education is critical in helping
to prevent future hypertensive crises
and in managing blood pressure in
general
● Stressing compliance with diet, weight
reduction if necessary, avoidance of
illicit drugs and other substances (ie.,
sympathomimetics). and adherence to
antihypertensive therapy is important.
● Scheduling a 2-week follow up with a
primary care physician should be
coordinated at the time of discharge.
Patients should be instructed to call
their doctor or return to seek medical
attention if any acute symptoms return
or appear.

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LESSON 3: ARRHYTHMIA Inherent Rates
Arrhythmias are disorders of the heart ➢ SA: 60-100
rhythm. ➢ AV JUNCTION: 40-60
➢ VENTRICULAR: 20-40

ASSESSMENT
1. ECG
-24h Holter monitor
2. Echocardiogram
-Stress test
3. Coronary angiography
4. Electrophysiology study

BASIC RHYTHM STRIP INTERPRETATION

1. Determine the rate.

2. Rhythm regular/ irregular?
3. Find the P wave
4. Determine the PR interval
5. Find the QRS
6. Any ectopic beats?
7. Find the T wave.

DETERMINE HEART RATE

PR INTERVAL
represents time from the beginning of atrial
depolarization to the beginning of ventricular
depolarization, measured from the beginning
of the p wave to the beginning of the qrs
complex (o.12-o.20)

QRS COMPLEX
represents the length of time for
depolarization of the ventricular muscle and
is measured from the beginning of the qrs
complex to the end of the s wave, should
measure between 0.06-0.10 seconds in NORMAL SINUS RHYTHM
duration

ST SEGMENT
represents the total length of time for
ventricular muscle to be depolarized and
repolarized, measured from the beginning of
the qrs complex to the end of the t wave,
normal range is 0.32- 0.42

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RAPID ECTOPIC RHYTHM
SINUS/ ATRIAL DYSRHYTHMIA
TREATMENT
• Ca-channel blockers (Diltiazem)
• B-blockers (Propranolol)
SINUS BRADYCARDIA
TREATMENT
● treat the underlying cause
● atropine
● isuprel
● artificial pacing
● prevent further vagal stimulation
● withhold the B-blocker
● Rate is dependent on the basic
NURSING MANAGEMENT
rhythm. If the basic rhythm is sinus,
the rate is constant between 60-100
bpm
● P wave is followed by a QRS complex
● P-R interval is greater than 0.12 sec.
and constant from beat to beat
● QRS Complex duration is 0.12 sec. or
less. Every QRS complex is preceded
by a P wave
● Rhythm is regular
● Rate is above 300 (300-600) per
minute with a chaotic rhythm.
● P wave are non-identifiable, only
fibrillatory waves
● P-R interval not measurable
● QRS Complex duration is 0.1 sec. or
less
● Rhythm is irregularly irregular, i.e.
irregular with no specific pattern
● Rate: 250-400 bpm.
● P-wave “saw-tooth” appearance, are
known as F or flutter waves
● P-R Interval is not measurable
● QRS Complex duration is 0.1 sec. or
less ∙
● Rhythm may be regular or irregular
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 ➔ Monitor V/S
➔ Assess skin, lung & heart sounds,
peripheral pulses
➔ Monitor laboratory studies
➔ Give antidysrhythmic & sedative
medications as ordered
➔ Maintain quiet environment
➔ Administer O2 as prescribed
➔ Elimination of tobacco, alcohol,
caffeine & other stimulants

MEDICAL MANAGEMENT
➔ Medications
➔ IV Fluids LESSON 4: INTRODUCTION TO GI
➔ Bed rest DIAGNOSTICS
➔ O2 therapy
➔ Transcutaneous & transvenous pacing
➔ Vagal stimulation
➔ Electrical & Chemical Cardioversion
➔ Radiofrequency Ablation

STOMACH
- Cardia - Fundus - Body - Pylorus

Chief Cells
The gastric chief cell (also known as a
zymogenic cell or peptic cell) is a cell in the
stomach that releases pepsinogen (Inactive
form) and chymosin.

G-cells secrete gastrin – Gastrin stimulates

parietal cell to secrete hydrochloric acid.
Parietal Cell – Secrete Hydrochloric Acid
Mucin Cell – Secrete mucus to help protect
the stomach cell from hydrochloric acid.

Phases of Gastric Secretion

1. Cephalic Phase – Triggered by sight,
smell because of the food presence.
Stimulates the vagus nerve.
2. Gastric Phase – Stimulates by stretch
receptors to release gastric Acid.
3. Intestinal Phase – triggered by the
release of food containing digestive
proteins released in the proximal small
intestine.

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 PHYSICAL ASSESSMENT
Inspection:
Oral Cavity
- Lips, Gums, Tongue

7S:
● Symmetrical and movement with
LIVER respiration.
● Largest accessory organ in the GI ● Scar
● Metabolizes food, drugs and other by ● Striae
products to Amino acids and lipids ● Stoma
● Produces Bile – to emulsify fats. ● Shape of the umbilicus
● Shape of the flank (full, straight)
PANCREAS ● Skin lesions
Exocrine and Endocrine gland
● Exocrine – Amylase – CHO- Trypsin Striae
and Chymotrypsin – CHON - Lipase – - Silvery white linear marked about
Fats 1-6cm in pregnant and obese
● Endocrine – Insulin – Absorb glucose individuals.
-Glucagon – Control blood sugar - Striae in Cushing’s Syndrome is
usually purple or blue in color.

Shape of Umbilicus

PHYSICAL ASSESSMENT
History:
➔ Abdominal pain
➔ Dyspepsia
➔ Nausea
➔ Vomiting
➔ Diarrhea Shape of Flank
➔ Constipation
➔ Fecal incontinence
➔ Jaundice
➔ Previous GI disease 4P:
● Prominent
veins
● Pulsation visible
● Peristalsis visible
● Pigmentation

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Prominent veins
Caput Medusa
● It is the appearance of distended and
engorged superficial epigastric veins,
which are seen radiating from the
umbilicus across the abdomen.
● Contour: Flat to round
● Symmetry: symmetric; note for
bulging, masses or asymmetry
● Umbilicus: midline, inverted and no
discoloration
● Skin: smooth and even in color

Contour: Xiphoid to symphysis pubis

Pulsation Visible
Aortic Aneurysm
● It is a balloon-like bulge in the aorta,
the large artery that carries blood from Abdominal Bulge
the heart through the chest and torso. ● When the patient is in supine position,
the flank is bulging.
Peristalsis visible ● Possible causes:
Intestinal obstruction - Hernias
- Lipomas
- Hematomas
- Undescended Testicles
- Tumors

Auscultation:
Pyloric stenosis Bell: bruit sound
● is a narrowing of the opening from the Diaphragm: Bowel Sound
stomach to the first part of the small N: 5 – 30 times per min
intestine. Peristalsis - Downward movement of the
Pigmentation intestine.
Grey Turner sign An occasional borborygmus (loud
● Is a discoloration of the left flank prolonged gurgle) may be heard.
associated with acute hemorrhagic Bowel sound:
pancreatitis ● Normoactive -
Cullen sign ● Hypoactive – less than 5 times/min
● a hemorrhagic discoloration of the ● Hyperactive – loud, high pitched
umbilical area due to intraperitoneal ● Absent – listen for at least 5 mins
hemorrhage from any cause; one of
the more frequent causes is acute Percussion:
hemorrhagic panniculitis. ● Dullness: Organ like liver, Fluid,
1D: Feces
● Distention ● Tympanic: Gas
○ Flat
○ Fluid-filled Palpation:
○ Fetus (Pregnant) ● Light: swelling
○ Flatus (Air-filled) ● Deep: masses
○ Fecal
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Rectal Inspection and Palpation
● anal canal is approximately 2.5 to 4
cm (1 to 1.6 inches) in length
● the internal and external sphincter
● inspection for lumps, rashes,
inflammation, excoriation,
● tears, scars, pilonidal dimpling, and
tufts of hair at the pilonidal area
● pilonidal cyst, perianal abscess, or
anorectal fistula or
● fissure, rectal prolapse, polyps, and
internal hemorrhoids.
DIAGNOSTIC EXAMINATION
Stool Tests
● Inspecting the specimen for
consistency, color, and occult (not
visible) blood.
● Additional studies: fecal urobilinogen,
fecal fat, nitrogen, Clostridium difficile,
fecal leukocytes, calculation of stool
osmolar gap, parasites, pathogens,
food residues, and other substances,
require laboratory evaluation.
● Stool samples are usually collected on
a random basis unless a quantitative
study is to be performed.
● Quantitative 24- to 72-hour collections
must be kept refrigerated until
transported to the laboratory.
Fecal occult blood testing (FOBT)
● Guaiac Test
● One of the most commonly performed
stool tests.
● It can be useful in initial screening for
several disorders, although it is used
most frequently in early cancer
detection programs.
● It should not be performed when there
is hemorrhoidal bleeding.
● Patients were advised to avoid
ingesting red meats, aspirin,
nonsteroidal anti-inflammatory drugs,
turnips, and horseradish for 72 hours
prior to the study because it was
thought that these were associated
with false-positive results
● Patients were advised to avoid
ingesting vitamin C from supplements
or foods as it was believed that this
was associated with false-negative
results.
● Increase Fiber intake
Fecal Immunological Test (FIT)
● Use monoclonal or polyclonal
antibodies to detect the globin protein
in human hemoglobin.
● An antibody that binds to a blood
protein called hemoglobin is used to
detect any blood
● Only one fecal stool sample is
required
● Dietary restrictions are not required
prior to submission of the stool
specimen.
Stool DNA Testing
● relatively new means to detect certain
DNA related to colon cancer.
● The stool DNA test does not require
any dietary or medication restrictions
and can detect neoplasia anywhere in
the colon.
Non-Invasive Breath Test
● Hydrogen breath test was developed
to evaluate carbohydrate absorption,
in addition to aiding in the diagnosis of
bacterial overgrowth in the intestine
and short bowel syndrome.
Hydrogen Breath Test: Instruction
● Eating a low carbohydrate diet for a
couple of days.
● Avoid foods that may produce gas in
the intestinal tract which could cause
inaccurate test results.
● Breath tests can be done any time
before a colonoscopy prep, but not for
four (4) weeks after a colonoscopy
prep, or any test that requires a bowel
prep.
● Patients will drink a solution of lactose,
fructose, sucrose, or glucose in water.
● After drinking the solution, pt will be
asked to breathe into a plastic bag.
● Breath samples are obtained every 15
minutes for adults, and every 30
minutes for children.
● The breath sample will be analyzed for
hydrogen content to determine if you
are able to properly break down the
lactose or sucrose, or if you have
bacterial overgrowth.
Urea Breath Test
● Urea breath tests detect the presence
of Helicobacter pylori.
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 ● The bacteria that can live in the
mucosal lining of the stomach and
cause peptic ulcer disease.
Urea Breath Test: instruction
• Four weeks before the test, do not take
any antibiotics or Pepto-Bismol® (oral
bismuth subsalicylate).
• Two weeks before the test do not take any
over-the-counter or prescription proton pump
inhibitors, such as omeprazole (Prilosec®),
lansoprazole (Prevacid®), pantoprazole
(Protonix®), rabeprazole (AcipHex®) or
esomeprazole (Nexium®), dexlansoprazole
(Dexilant®).
● Food and drinks: One hour before the
test, do not eat or drink anything (including
water).
How to collect breath:
After the procedure
● Breath samples are sent to the
laboratory where they are tested.
● May resume normal activities.
● No restrictions.
Abdominal Ultrasonography
● A noninvasive diagnostic technique in
which high frequency sound waves
are passed into internal body
structures, and the ultrasonic echoes
are recorded on an oscilloscope as
they strike tissues of different
densities.
● It is particularly useful in the detection
of an enlarged gallbladder or
pancreas, the presence of gallstones,
an enlarged ovary, an ectopic
pregnancy, or appendicitis.
● It is used to look at organs and blood
vessels in the abdomen:
- Liver
- Gallbladder
- Spleen
- Pancreas
- Kidneys
- Inferior vena cava
- Aorta
Abdominal Ultrasonography: Nursing
Intervention
● Avoid food and drinks (fast) for eight
to 12 hours before an abdominal
ultrasound.
● Before the abdominal ultrasound,
patient will change into a hospital
gown and to remove any jewelry.
● After the procedure, patient will be
able to return to normal activities
immediately.
● If gallbladder studies are being
performed, the patient should eat a
fat-free meal the evening before the
test.
● If barium studies are to be performed,
they should be scheduled after
ultrasonography.
● Patients who receive moderate
sedation are observed for about 1
hour to assess for level of
consciousness, orientation, and ability
to ambulate.
Fluoroscopy
Upper Gastrointestinal Tract Study
● An upper GI fluoroscopy delineates
the entire GI tract after the introduction
of a contrast agent.
● A radiopaque liquid (e.g., barium
sulfate) is commonly used
○ Thin barium, diatrizoate sodium
(Hypaque) and at times water
are used due to their low
associated risks.
● AKA Barium Swallow
● The GI series enables the examiner to
detect or exclude anatomic or
functional disorders of the upper GI
organs or sphincters.
● It also aids in the diagnosis of ulcers,
varices, tumors, regional enteritis, and
malabsorption syndromes.
Upper Gastrointestinal Tract Study
● Fluoroscopic examination next
extends to the stomach as its lumen
fills with barium, allowing observation
of stomach motility, thickness of the
gastric wall, the mucosal pattern,
patency of the pyloric valve, and the
anatomy of the duodenum.
● Multiple x-ray images are obtained
during the procedure, and additional
images may be taken at intervals for
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 up to 24 hours to evaluate the rate of
gastric emptying.
Upper Gastrointestinal Tract Study: Nursing
Intervention
● Instruct regarding dietary changes
prior to the study should include a
clear liquid diet, with nothing by mouth
(NPO) from midnight the night before
the study.
● Do not smoke or chew gum during the
NPO period because these can
increase gastric secretions and
salivation.
● Bowel cleansing preparatory agent:
Polyethylene glycol (PEG)-based
solutions
● Oral medications are withheld on the
morning of the study and resumed that
evening, but each patient’s medication
regimen should be evaluated on an
individual basis.
● When a patient with insulin dependent
diabetes is NPO, their insulin
requirements will need to be adjusted
accordingly.
● Follow-up care is provided after the
upper GI procedure to ensure that the
patient has eliminated most of the
ingested barium.
● Fluids may be increased to facilitate
evacuation of stool and barium.
Minimally Invasive:
Blood study
CBC – Comprehensive Metabolic Panel
● to conduct a broad assessment of
various aspects of physical well-being.
● It can detect a range of abnormalities
in blood sugar, nutrient balance, and
liver and kidney health.
● Glucose, Calcium, Sodium,
Potassium, Bicarbonate, Chloride,
Blood urea nitrogen (BUN),
Creatinine, Albumin, Total protein,
Alkaline phosphatase (ALP), Alanine
aminotransferase (ALT), Aspartate
aminotransferase (AST), Bilirubin
Serum Blood Study
Prothrombin time/Partial thromboplastin
time
- is a test used to help diagnose
bleeding or clotting disorders.
- A PT measures the number of
seconds it takes for a clot to form in
- the sample of blood after substances
(reagents) are added.
Triglycerides - measures the amount of
triglycerides in your blood.
Amylase - measures the amount of amylase
in your blood or urine. Amylase is an
enzyme, or special protein, that helps you
digest food.
Lipase - measures the level of a protein
called lipase in your blood. Lipase helps your
body absorb fats. When your pancreas is
inflamed or injured, it releases more lipase
than usual.
Liver function tests - are blood tests used
to help diagnose and monitor liver disease or
damage. The tests measure the levels of
certain enzymes and proteins in your blood.
● Alanine transaminase (ALT). ALT is
an enzyme found in the liver that helps
convert proteins into energy for the
liver cells. When the liver is damaged,
ALT is released into the bloodstream
and levels increase.
● Aspartate transaminase (AST). AST
is an enzyme that helps metabolize
amino acids. Like ALT, AST is
normally present in blood at low
levels. An increase in AST levels may
indicate liver damage, disease or
muscle damage.
● Alkaline phosphatase (ALP). ALP is
an enzyme found in the liver and bone
and is important for breaking down
proteins. Higher-than-normal levels of
ALP may indicate liver damage or
disease, such as a blocked bile duct,
or certain bone diseases.
● Albumin and total protein. Albumin
is one of several proteins made in the
liver. Your body needs these proteins
to fight infections and to perform other
functions. Lower-than-normal levels of
albumin and total protein may indicate
liver damage or disease.
● Bilirubin. Bilirubin is a substance
produced during the normal
breakdown of red blood cells. Bilirubin
passes through the liver and is
excreted in stool. Elevated levels of
bilirubin (jaundice) might indicate liver
damage or disease or certain types of
anemia.
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 ● Gamma-glutamyltransferase (GGT).
GGT is an enzyme in the blood.
Higher- than-normal levels may
indicate liver or bile duct damage.
● L-lactate dehydrogenase (LD). LD is
an enzyme found in the liver. Elevated
levels may indicate liver damage but
can be elevated in many other
disorders.
● Prothrombin time (PT). PT is the
time it takes your blood to clot.
Increased PT may indicate liver
damage but can also be elevated if
you're taking certain blood-thinning
drugs, such as warfarin.
Carcinoembryonic Antigen (CEA)
- Is a protein that is normally not
detected in the blood of a healthy
person.
- When detected it indicates that cancer
is present, although not what type of
cancer is present.
- Primary providers can use CEA
results to determine the stage and
extent of the disease and the patient’s
prognosis for cancer, especially GI
and, in particular, colorectal cancer.
Cancer Antigen (CA) 19–9
- CA 19-9 is also a protein that exists on
the surface of certain cells and is shed
by tumor cells, making it useful as a
tumor marker to follow the course of
the cancer.
- CA 19-9 levels are elevated in most
patients with advanced pancreatic
cancer, but they may also be elevated
in other conditions such as colorectal,
stomach, and bile duct cancers.
- Elevated levels may also be found in
noncancer conditions.
Alpha Fetoprotein
- is a protein produced primarily by the
liver in a developing baby (fetus).
- AFP is produced whenever liver cells
are regenerating. With chronic liver
diseases, such as hepatitis and
cirrhosis, AFP may be chronically
elevated.
- Increased amounts of AFP are found
in many people with the most common
type of liver cancer called
hepatocellular carcinoma and in a rare
type of liver cancer: hepatoblastoma
Minimally Invasive: Fluoroscopy
Lower Gastrointestinal Tract Study
- Visualization of the lower GI tract is
obtained after rectal installation of
barium.
- The barium enema can be used to
detect the presence of polyps, tumors,
or other lesions of the large intestine
and demonstrate any anatomic
abnormalities or malfunctioning of the
bowel.
- Each portion of the colon may be
readily observed.
- The procedure usually takes about 15
to 30 minutes, during which time x-ray
images are obtained.
- To determine the cause of signs and
symptoms, such as the following:
● Abdominal pain
● Rectal bleeding
● Changes in bowel habits
● Unexplained weight loss
● Chronic diarrhea
● Persistent constipation
● Abnormal growths (polyps) as part of
colorectal cancer screening
● Inflammatory bowel disease
- Contraindicated:
● Active inflammatory disease of the
colon
● Signs of perforation or obstruction: a
water-soluble contrast study may be
performed.
● Active GI bleeding
Minimally Invasive: Nursing Intervention
Lower Gastrointestinal Tract Study
- Bowel Preparation: emptying and
cleansing the lower bowel.
● A low-residue diet 1 to 2 days before
the test, a clear liquid diet and a
laxative the evening before, NPO after
midnight
● Cleansing enemas until returns are
clear the following morning.
● Fleet Enema
14
 ● Makes sure that barium enemas are
scheduled before any upper GI
studies.
● wear a hospital gown and remove
eyewear, jewelry or removable dental
devices.
● lying on side
● lubricated enema tube will be inserted
into the rectum. A barium bag will be
connected to the tube to deliver the
barium solution into the colon.
- Instruct to hold the enema tube in
place. To relax, take long, deep
breaths.
- Patient may be asked to turn and hold
various positions on the exam table.
- A number of X-rays of the colon will
likely be taken from various angles.
- A barium enema exam typically takes
about 30 to 60 minutes.
- Post procedure:
● increasing fluid intake
● evaluating bowel movements for
evacuation of barium
● noting increased number of bowel
movements, because barium has high
osmolarity
● may draw fluid into the bowel, thus
increasing the intraluminal contents
and resulting in greater output.
Minimally Invasive: Hepatobiliary
Iminodiacetic Acid (HIDA)
- Scan is an imaging procedure used to
diagnose problems of the liver,
gallbladder and bile ducts.
- AKA cholescintigraphy or hepatobiliary
scintigraphy
- A HIDA scan is most often done to
evaluate your gallbladder.
- It's also used to look at the
bile-excreting function of your liver and
to track the flow of bile from your liver
into your small intestine.
● Gallbladder inflammation
(cholecystitis)
● Bile duct obstruction
● Congenital abnormalities in the bile
ducts, such as biliary atresia
● Postoperative complications, such as
bile leaks and fistulas
● Assessment of liver transplant
- Risk:
➔ Allergic reaction to medications
containing radioactive tracers used for
the scan
➔ Bruising at the injection site
➔ Radiation exposure, which is small
➔ Pregnant or breastfeeding.
- Preparation: Before
➢ Fasting for four hours before HIDA
scan.
➢ Ask about any medication a patient is
taking, including vitamins and herbal
supplements.
➢ Remove jewelry and accessories
➢ Patient should wear a hospital gown
during the exam
- Preparation: After
➢ In most cases, you can go about your
day after your scan.
➢ Drink plenty of water to help flush
radioactive material out of the body.
Minimally Invasive: Blood Glucose
Monitoring
- It is the immediate measurement of
blood glucose using blood sample
from a fingerstick or heel stick.
- AKA Hemogluco test (HGT) or
Capillary blood glucose (CBG)
- Normal: Adult – 80 – 120mg/dl
- Hypoglycemia:
➢ Newborn: <30mg/dl
➢ Children: <50mg/dl
15
DIAGNOSTIC EXAMINATION: Invasive: Endoscopic Retrograde
Invasive: Endoscopic ultrasonography Cholangio-pancreatography (ERCP)
(EUS)

- A specialized enteroscopic procedure

that aids in the diagnosis of GI
disorders by providing direct imaging
of a target area.
- Uses the endoscope in combination
- A small high-frequency ultrasonic
with x-rays to view the bile ducts,
transducer is mounted at the tip of the
pancreatic ducts, and gallbladder.
fiberoptic scope, which displays
- ERCP is helpful in evaluating
images that are of higher-quality
jaundice, pancreatitis, pancreatic
resolution and definition than regular
tumors, common bile duct stones, and
ultrasound imaging.
biliary tract disease.
- may be used to evaluate submucosal
- Before:
lesions, specifically their location and
depth of penetration.
- EUS may aid in the evaluation of
diseases and changes in the bowel
wall due to ulcerative colitis.
- Nursing Intervention: Same with
abdominal Ultrasound

Invasive: Esophago-gastroduodenoscopy
(EGD)
➔ Assess allergies to intravenous (IV)
contrast dyes.
➔ Not eat, drink or smoke for at least six
hours before the procedure.
- During:
➔ Anesthetic spray to numb the throat.
➔ Inserts the endoscope
➔ Injects a special dye through the
➔ catheter.
➔ Therapeutic Purposes:
- It allows direct visualization of the
◆ Break up and remove stones.
esophageal, gastric, and duodenal
◆ Place stents to open blocked or
mucosa through a lighted endoscope.
narrowed ducts.
- It is valuable when esophageal,
➔ Diagnostic Purposes:
gastric, or duodenal disorders or
◆ Checks for signs of blockage or
inflammatory, neoplastic, or infectious
problems.
processes are suspected.
◆ Remove tumors or tissue
- views the GI tract through a viewing
samples
lens and can obtain images through
◆ to biopsy.
the scope to document findings.
- After:
- Electronic video endoscopes also are
➔ Assess Gag Reflex
available that attach directly to a video
➔ Instruct to eat soft foods for a day or
processor, converting the electronic
two until the soreness subsides.
signals into pictures that are projected
➔ Patient may experience some bloating
on a screen.
and nausea.
➔ Patient may return to work and normal
activities the next day.

16
Invasive: Nursing Interventions

● Screen for colon and rectal cancer

- NPO for 8 hours prior to the ● Detect and evaluate inflammatory and
examination. ulcerative bowel disease
- Patient is given a local anesthetic ● Locate the source of lower GI bleeding
gargle or spray. and perform hemostasis by
- Midazolam (Versed), a sedative that coagulation
provides moderate sedation with loss ● Determine the cause of lower GI
of the gag reflex and relieves anxiety disorders, especially when barium and
during the procedure. proctosigmoidoscopy results are
- Atropine may be given to reduce inconclusive
secretions ● Assist diagnose colonic strictures and
- Glucagon may be given to relax benign or malignant lesions
smooth muscle. ● Evaluate the colon postoperatively for
- The patient is positioned in the left recurrence of polyps and malignant
lateral position to facilitate clearance lesions
of pulmonary secretions and provide ● Investigate iron-deficiency anemia of
smooth entry of the scope. unknown origin
- After the procedure: ● Remove colon polyps
● Assessment includes level of ● Remove foreign objects and
consciousness, vital signs, oxygen sclerosing strictures by laser
saturation, pain level, and monitoring Contraindicated for:
for signs of perforation - Pregnant women near term
● Temporary loss of the gag reflex is - Patients with bleeding disorders
expected; wait until the patient’s gag - Patients who had a recent acute
reflex has returned. myocardial infarction or abdominal
● Patients who were sedated for the surgery
procedure must remain in bed until - Patients with ischemic bowel disease,
fully alert. acute
- diverticulitis, peritonitis, fulminant
Invasive: Fiberoptic Colonoscopy granulomatous colitis, perforated
- direct visualization of the bowel was viscus, or fulminant ulcerative colitis:
the only means to evaluate the colon. For these cases or for screening
- These scopes have the same purposes, virtual colonoscopy may
capabilities as those used for EGD but help visualize polyps before they
are larger in diameter and longer. become concerns.
- It is most frequently used for cancer Before procedure:
screening and for surveillance in - Secure an informed consent.
patients with previous colon cancer or - Obtain a medical history of the patient.
polyps. - Provide information about the
- Tissue biopsies can be obtained as procedure.
needed, and polyps can be removed - Ensure that the patient has complied
and evaluated. with the bowel preparation.
- Establish an IV line.
- Provide reassurance.
- Explain to the patient that air may be
introduced through the colonoscope.
- Instruct the patient to empty bladder
prior to the procedure.
17
 - Instruct the patient to remove all
metallic objects from the area to be
examined.
- Instruct the patient to cooperate and
follow directions.
During the procedure:
- Assist with patient positioning as
necessary.
- Administer medications as ordered.
- Instruct the patient to bear down.
- Change the position of the patient.
- Encourage the patient to take slow,
deep breaths.
Invasive: Percutaneous Transhepatic
Cholangiography (PTC)
- An x-ray procedure that involves the
injection of a contrast material directly
into the bile ducts inside the liver to
produce pictures of the bile ducts.
- Rarely used for diagnostic purposes
alone due to the multitude of other
less invasive and reliable imaging
studies.
- After the procedure:
● Observe the patient closely for signs
of bowel perforation.
● Obtain and record the patient’s vital
signs.
● Instruct patient to resume a normal
diet, fluids, and activity as advised by
the health care provider.
● Provide privacy while the patient rest
after the procedure.
● Monitor for any rectal bleeding.
● Encourage increased fluid intake.
Invasive: Percutaneous Transhepatic
Cholangiography (PTC)
This procedure can be carried out even in the
presence of liver dysfunction and jaundice.
It is useful for:
1. distinguishing jaundice caused by liver
disease (hepatocellular jaundice) from that
caused by biliary obstruction
2. investigating the GI symptoms of a patient
whose gallbladder has been removed
3. locating stones within the bile ducts
4. diagnosing cancer involving the biliary
system
Preparation:
- Fasting: 4 to 8 hour
- Sterile procedure is performed
- Patient also receives local anesthesia
- Coagulation parameters and platelet count
should be normal
- Broad-spectrum antibiotics are given
During:
- A flexible needle is inserted into the liver
from the right side in the midclavicular line
immediately beneath the right costal
margin
- Successful entry of a duct is noted when
bile is aspirated or on injection of a
contrast agent.
- Ultrasound can be used to guide puncture
of the duct.
- Bile is aspirated, and samples are sent for
bacteriology and cytology
- A water-soluble contrast agent is injected
to fill the biliary system.
- The fluoroscopy table is tilted, and the
patient is repositioned to allow x-rays to be
taken in multiple projections.
- Before the needle is removed, as much
dye and bile as possible are aspirated to
anticipate subsequent leakage into the
needle tract and eventually into the
peritoneal cavity, thus minimizing the risk
of bile peritonitis.
After:
- Closely observe the patient for symptoms
of bleeding, peritonitis, and sepsis.
- Assesses the patient for pain and
indications of these complications and
reports them promptly to the primary
provider
- Takes measures to reassure the patient
and ensures patient comfort.
- Antibiotic agents are often prescribed to
minimize the risk of sepsis and septic
shock.
18
Liver Biopsy - apply pressure to site with sterile dressing
after procedure
- put patient on R side with pillow or special
sandbag in costal area for a minimum of 2
hours
- tell patient to stay (flat) in bed 12-14hours
- NPO for about 2 hours and then resume
meal
- avoid coughing, lifting, or straining for
1–2-week post procedure

CT scan
- Removal of a small amount of liver tissue,
MRI
usually through needle aspiration.
Technetium-labeled RBC scintigraphy – an
- It permits examination of liver cells.
imaging test that can help detect the origin of
- The most common indication is to evaluate
gastrointestinal bleeding.
diffuse disorders of the parenchyma and to
diagnose space-occupying lesions.
- Gold Standard for Liver Cancer
- Percutaneously with ultrasound guidance LESSON 5. MANAGEMENT OF PATIENTS
- Transvenously through the right internal WITH INTESTINAL AND RECTAL
jugular vein to right hepatic vein under DISORDERS
fluoroscopic control.
- Laparoscopic Liver Biopsy ABNORMALITIES OF FECAL
ELIMINATION
Complication: CONSTIPATION
- Peritonitis - caused by blood or bile leak ● Abnormal infrequency or irregularity of
after liver biopsy. defecation;
- Bleeding ● Abnormal hardening of stools that makes
- Infection their passage difficult and sometimes
- Accidental injury to nearby organ painful;
- Hematoma in the neck ● A decrease in stool volume, or retention of
- Temporary problem with facial nerves stool in the rectum for a prolonged period;
- Temporary voice problem ● Sense of incomplete evacuation after
- Puncture of the lung defecation.
● Complications: Hypertension, fecal
Preparation: impaction, hemorrhoids, fissures,
- Patient must sign consent form megacolon; (+) Valsalva maneuver
- NPO 4-6 hours before procedure ● Management: Education (gastrocolic
- Pre-procedure V/S reflex), bowel habit training, increased
- Check labs, especially prothrombin times fiber and fluid intake, and judicious use of
- Have pt empty bladder immediately before laxatives (avoid laxative abuse)
procedure
Bulk Forming
- Place patient in supine position with pillow
underneath back on far-right side of bed- Psyllium hydrophilic Polysaccharides and
exposing the right side(hypochondriac mucilloid (Metamucil) cellulose derivatives mix
region). Head should be turned to the left with intestinal fluids,
and right arm extended above head Methylcellulose swell, and stimulate
(Citrucel) peristalsis.
- Local anesthetic agent instilled into biopsy
area per MD Saline agent
- Before the procedure instruct patient
practice breathing in the following way: Magnesium hydroxide Nonabsorbable
inhale, exhale, inhale, exhale completely (Milk of Magnesia) magnesium ions alter
stool consistency by
and hold breath until MD inserts and
drawing water into the
removes needle intestines by osmosis;
peristalsis is stimulated.
After: Action occurs within 2 h.
- Monitor V/S
19
Lubricant
Mineral oil Nonabsorbable
Glycerin suppository hydrocarbons soften
fecal matter by
lubricating the intestinal
mucosa; the passage of
stool is facilitated. Action
occurs within 6-8 h for
mineral oil and within 30
minutes for glycerin
suppository.
Stimulant
Bisacodyl (Dulcolax) Irritates the colonic
epithelium by stimulating
Senna (Senokot) sensory nerve endings
and increasing mucosal
secretions. Action
occurs within 6-8 h.
Fecal Softener
Docusate (Colace) Hydrates the stool by its
surfactant action on the
colonic epithelium
(increases the wetting
efficiency of intestinal
water); aqueous and
fatty substances are
mixed. Does not exert a
laxative action
Osmotic Agent
stimulant laxatives (eg, bisacodyl) because
they can weaken colonic function.
DIARRHEA
● An increased frequency of bowel
movements (more than three per day);
● An increased amount of stool (more than
200g/day); and
● Altered consistency (ie, increased liquidity)
of stool.
● Acute diarrhea: 1 or 2 days;
● Chronic diarrhea: more than 2 to 3 weeks
Types of Diarrhea
● Secretory: high-volume diarrhea; caused
by increased production and secretion of
water and electrolytes by the intestinal
mucosa into the intestinal lumen.
● Osmotic: occurs when water is pulled into
the intestines by the osmotic pressure of
unabsorbed particles, slowing the
reabsorption of water.
● Malabsorptive: inhibiting effective
absorption of nutrients manifested by
markers of malnutrition that include
hypoalbuminemia;
● Exudative: caused by changes in mucosal
integrity, epithelial loss, or tissue
destruction by radiation or chemotherapy

Polyethylene glycol Cleanses colon rapidly Complications of Diarrhea

and electrolytes and induces diarrhea.
(Colyte)
HEALTH PROMOTION
Preventing Constipation
● Emphasize the importance of responding
to the urge to defecate.
● Teach how to establish a bowel routine,
and explain that having a regular time for
defecation (eg, best time is after a meal)
may aid in initiating the reflex.
● Provide dietary information; suggest eating
high-residue, high-fiber foods, (eg, fruits,
vegetables) adding bran daily (must be
introduced gradually), and increasing fluid
intake (unless contraindicated).
● Explain how an exercise regimen,
increased ambulation, and abdominal
muscle toning will increase muscle
strength and help propel colon contents.
● Describe abdominal toning exercises
(contracting abdominal muscles 4 times
daily and leg-to-chest lifts 10 to 20 times
each day).
● Explain that the normal position (semi
squatting) maximizes use of abdominal
muscles and force of gravity.
● Avoid overuse or long-term use of
● Potential for cardiac dysrhythmias;
● Loss of bicarbonate;
● Report the ff: Urine output <0.5mL/kg/hr or
2 to 3 consecutive hours, muscle
weakness, paresthesia, hypotension,
anorexia, and drowsiness
● Chronic diarrhea: Irritant dermatitis
Management of Diarrhea
● Eliminating or treating underlying cause;
● Drug of Choice: Loperamide [Imodium]
● Pharmacologic: Antibiotics,
anti-inflammatory agents and
antidiarrheals (eg, loperamide [Imodium],
diphenoxylate [Lomotil])
During an episode of acute diarrhea:
● Bed rest, intake of liquids and foods low in
bulk until the acute attack subsides;
● Recommend a bland diet of semisolid and
solid foods (if able to tolerate food intake);
● Avoid caffeine, carbonated beverages, and
very hot and very cold foods;
● Restrict milk products, fat, whole-grain
products, fresh fruits, and vegetables for
several days
20

IRRITABLE BOWEL SYNDROME
● Clinical Manifestations: IBS-D, IBD-C,
IBS-A
● Assessment & Diagnosis:
➢ Recurrent abdominal pain at least 3
days a month for the past 3 months
with two or more of the ff:
1. Improvement with defecation;
2. Change in freq. of stool;
3. Change in appearance of stool.
Management of Irritable Bowel Syndrome
● Goals of Treatment: Relieving abdominal
pain, controlling the diarrhea or
constipation, and reducing stress.
● For IBS-C: Lubiprostone, a chloride
channel regulator in the gut
● For IBS-D: alosteron (Lotronex)
● Probiotics (Lactobacillus, Bifidobacterium),
complementary medicine
ACUTE INFLAMMATORY INTESTINAL
DISORDERS
APPENDICITIS
● Appendicitis: inflammation of the
appendix;
● Most common cause of acute surgical
abdomen; most common reason for
emergency abdominal surgery;
● Age: Commonly occurs between the ages
of 10 and 30 years; although may occur at
any age
Clinical Manifestation
● Initial: Vague epigastric or periumbilical
pain (ie, visceral pain that is dull and
poorly localized); progresses to
● Right lower quadrant pain (ie, parietal pain
that is sharp, discrete, and well localized);
● Usually accompanied by a low-grade fever
and nausea and sometimes by vomiting,
loss of appetite
● Local tenderness at McBurney’s point;
● Rebound tenderness (ie, production or
intensification of pain when pressure is
released) may be present;
Rovsing’s sign
● Deep palpation of the left iliac fossa
causes pain in the right iliac fossa;
Psoas sign
● Also known as the Ilio-psoas sign. Passive
extension of the right hip may cause pain
in the right iliac fossa;
Obturators sign or Copes sign
● Flexion and internal rotation of the right hip
causes pain
ASSESSMENT AND DIAGNOSTIC
FINDINGS
● History and Physical Exam: Patient is
usually younger;
● CBC: Reveals elevated WBC,
neutrophils
● Imaging studies (esp. CT Scan if
diagnosis is uncertain): Right lower
quadrant density or localized
distention of the bowel
● Pregnancy test (for women): To R/O
ectopic pregnancy, before radiologic
studies are done;
● Urinalysis: To R/O urinary tract
infection
● Diagnostic laparoscopy: To R/O acute
appendicitis in equivocal cases
MEDICAL MANAGEMENT
● Appendectomy (ie, surgical removal
of the appendix) is performed as soon
as possible to decrease the risk of
perforation.
● If perforation of the appendix
(abscess formation) occurs, the
patient may be initially treated with
antibiotics; place a drain in the
abscess
21
NURSING MANAGEMENT:
PRE-OPERATIVE MANAGEMENT
● IV infusion to replace fluid loss and
promote adequate renal function and
antibiotic therapy to prevent infection.
● If there is evidence or likelihood of
paralytic ileus, a nasogastric tube is
inserted.
● An enema is not administered
because it can lead to perforation.
NURSING MANAGEMENT:
POST-OPERATIVE MANAGEMENT
● After surgery, the nurse places the
patient in a high- Fowler’s position.
● An opioid, usually morphine sulfate, is
prescribed to relieve pain.
● Food is provided as desired and
tolerated on the day of surgery when
normal bowel sounds are present.
● When tolerated, oral fluids are
administered.
DIVERTICULAR DISEASES
- Diverticulum is a saclike herniation of the
lining of the bowel that extends through a
defect in the muscle layer;
- Diverticulosis exists when multiple
diverticula are present without inflammation
or symptoms;
- Diverticulitis results when food and bacteria
retained in a diverticulum produce infection
and inflammation that can impede drainage
and lead to perforation or abscess formation.
DIVERTICULAR DISEASES
Cause: Mucosa and submucosal layers of
the colon
herniate through the muscular wall because
of:
• High intraluminal pressure;
• Low volume in the colon (ie, fiber-deficient
contents);
• Decreased muscle strength in the colon
wall (ie,
muscular hypertrophy from hardened fecal
masses).
ASSESSMENT AND DIAGNOSTIC
FINDINGS
• Diagnostic Test of Choice: CT with contrast
agent if the suspected diagnosis is
diverticulitis;
it can also reveal abscesses;
• Colonoscopy, permits visualization of the
extent of diverticular disease and allows the
physician to biopsy tissue to rule out other
diseases;
• (x) Barium enema: If with (/) peritoneal
irritation
• Abdominal x-rays may demonstrate free air
under the diaphragm if a perforation has
occurred from diverticulitis.
• Other laboratory tests: Complete blood cell
count, revealing an elevated white blood cell
count, and elevated erythrocyte
sedimentation rate (ESR).
MEDICAL MANAGEMENT
• Can be treated on an outpatient basis with
diet and
Medication;
• When symptoms occur, rest, analgesics,
and antispasmodics are recommended;
• Diet: Clear liquid diet (initially) then
high-fiber, low-fat diet
• Hospitalization for acute diverticulitis
• Broad-spectrum antibiotics are prescribed
for 7 to 10 days.
• An opioid (eg, meperidine [Demerol]) is
prescribed for pain relief; (x) Morphine;
• Antispasmodics such as propantheline
bromide and oxyphencyclimine (Daricon)
may be prescribed.
22
SURGICAL MANAGEMENT ● Crohn’s disease is a subacute and
• One-stage resection, in which the inflamed chronic inflammation of the GI tract
area is removed and a primary end-to-end wall that extends through all layers (ie,
anastomosis is completed; transmural lesion).

• Multiple-stage procedures for complications CROHN’S DISEASE CLINICAL

such as obstruction or perforation (eg, MANIFESTATIONS
Hartmann’s procedure). ● Onset: Insidious;
● Prominent right lower quadrant
abdominal pain and diarrhea
unrelieved by diarrhea;

INFLAMMATORY BOWEL DISEASES

● Ulcerative colitis is a recurrent
ulcerative and inflammatory disease of
the mucosal and submucosal layers of
the colon and rectum.
● Affects the superficial mucosa of the
colon and is characterized by multiple
ulcerations, diffuse inflammations, and
desquamation or shedding of the
colonic epithelium.

ASSESSMENT AND DIAGNOSTIC

FINDING
● Most conclusive diagnostic aid:
Barium Study of upper GI tract, shows
a “string sign” on an x-ray film of the
terminal ileum (indicating constriction
of a segment of intestine);
● Confirm Diagnosis: Endoscopy,
colonoscopy, intestinal biopsies, CT
scan, barium enema

INFLAMMATORY BOWEL DISEASES
● Inflammatory bowel disease (IBD)
refers to two chronic inflammatory GI
disorders: Crohn’s disease (ie,
regional enteritis) and ulcerative
colitis.
INTESTINAL OBSTRUCTION
- Exists when blockage prevents the
normal flow of intestinal contents
through the intestinal tract.
Two Types of Processes:
1. Mechanical Obstruction: Obstruction
caused from pressure on the intestinal
wall e.g., intussusception, polypoid
tumors, stenosis, strictures,
adhesions, hernias, and abscesses.
23
 2. Functional Obstruction: Intestinal
musculature cannot propel the
contents along the bowel e.g.,
muscular dystrophy, endocrine
disorders (e.g., DM), etc.
MECHANICAL CAUSES OF INTESTINAL
OBSTRUCTION

Cause Course of Results

Events

Adhesions Loops of intestine After surgery,

become adherent adhesions
to areas that heal produce a SMALL BOWEL OBSTRUCTION:
slowly or scar after kinking of an CLINICAL MANIFESTATIONS
abdominal intestinal loop.
surgery; occurs ● Initial: Crampy pain; wavelike, colicky
most commonly in ● Vomiting; passing of blood, mucus (no
the small intestine. fecal matter, flatus); reverse
peristalsis;
Intussuscepti One part of the The intestinal
ons intestine slips into lumen becomes ● Signs of dehydration: intense thirst,
another part narrowed and drowsiness, parched tongue and
located below it blood supply mucous membranes; hypovolemic
(like a telescope becomes
shock if uncorrected
shortening); it strangulated.
occurs more
commonly in SMALL BOWEL OBSTRUCTION:
infants than ASSESSMENT & DX FINDINGS
adults.
● Based on symptoms and imaging
Volvulus Bowel twists and Intestinal lumen studies
turns on itself and becomes ● Imaging Studies: Abdominal x- ray,
occludes the blood obstructed. Gas CT- scan (abn. Quantities of gas, fluid,
supply. and fluid
accumulate in or both)
the trapped ● Laboratory Studies: Dehydration, Loss
bowel. of plasma volume, possible infection
Hernia Protrusion of Intestinal flow
intestine through a may be SMALL BOWEL OBSTRUCTION:
weakened area in completely MEDICAL MANAGEMENT
the abdominal obstructed. ● Decompression of bowel thru NGT;
muscle or wall. Blood flow to the
● Monitoring for bowel ischemia
area may be
obstructed as (mandatory);
well. ● Surgical intervention (if possibility of
strangulation and tissue necrosis is
Tumor A tumor that exists Intestinal lumen
within the wall of becomes suspected)
the intestine partially
extends into the obstructed; if the SMALL BOWEL OBSTRUCTION:
intestinal lumen, tumor is not NURSING MANAGEMENT
or a tumor outside removed,
the intestine complete ● Maintaining the function of nasogastric
causes pressure obstruction tube;
on the wall of the results. ● Assessing and measuring the
intestine. Most nasogastric Output;
common type is
colorectal ● Assessing for fluid and electrolyte
adenocarcinoma. imbalance
● Monitoring nutritional status; and
● Assessing improvement (eg, return of
normal bowel sounds, decreased
abdominal distention, etc.)

24
 LESSON 6:
LARGE BOWEL OBSTRUCTION METABOLIC-GASTROINTESTINAL
● Clinical Manifestations: Differs AND LIVER ALTERATIONS
clinically from small bowel obstruction
d/t relatively slower occurrence of ACUTE GASTROINTESTINAL BLEEDING
symptoms Gastrointestinal Bleeding
● PA & Dx Findings: Abdominal x- ray ● also known as gastrointestinal
and abdominal CT or MRI: Distended hemorrhage, is all forms of bleeding in
colon and pinpoint sight of obstruction; the gastrointestinal tract, from the
● Barium studies are contraindicated mouth to the rectum.
● When there is significant blood loss
Medical Management: over a short time, symptoms may
● Restoration of intravascular volume; include vomiting red blood, vomiting
● Correction of electrolyte abnormalities; black blood, bloody stool, or black
and stool.
● Nasogastric aspiration and
decompression CLASSIFIED INTO
➔ Upper Gastrointestinal Bleeding
Surgical Management: ➔ Lower Gastrointestinal Bleeding
● Colonoscopy (to untwist and
decompress bowel); UPPER GASTROINTESTINAL BLEEDING
● Cecostomy (surgical opening of ❖ Gastritis - inflammation of the gastric
cecum for pxs urgently in need of or stomach mucosa.
relief from obstruction);
● Rectal tube placement (decompress ❖ Acute Gastritis - may be classified as
area lower in the bowel) erosive or nonerosive, based upon
● Colonic stent (as palliative intervention pathologic manifestations present in
or as bridge for definitive surgery); the gastric mucosa.
● Surgical resection, colostomy,
ileostomy ❖ Chronic Gastritis - is often classified
according to the underlying causative
mechanism, which most often includes
an infection with H. pylori.

ACUTE GASTRITIS
Erosive Form: caused by local irritants such
as aspirin and other nonsteroidal
anti-inflammatory drugs (NSAIDs) (e.g.,
ibuprofen); alcohol consumption; and
gastric radiation therapy.

Nonerosive form: caused by an infection with

Helicobacter pylori (H. pylori).

A more severe form of acute gastritis is

caused by the ingestion of strong acid or
alkali, which may cause the mucosa to
become gangrenous or to perforate. Scarring
can occur, resulting in pyloric stenosis
(narrowing or tightening) or obstruction.

Stress-related gastritis – due to illness,

traumatic injuries, burn, infection, major
surgeries.

25
CHRONIC GASTRITIS
Chronic H. pylori gastritis is implicated in the Assessment and Diagnostic Findings:
development of peptic ulcers, gastric ● Endoscopy and histologic examination
adenocarcinoma (cancer), and gastric ● A complete blood count (CBC)
mucosa-associated lymphoid tissue ● H. pylori Test: Urea Breath Test
lymphoma.
Medical Management
Chronic gastritis may also be caused by a ● Refrain from alcohol and food until
chemical gastric injury (gastropathy) as the symptoms subside.
result of long-term drug therapy (e.g., aspirin ● A nonirritating diet
and other NSAIDs) or reflux of duodenal ● Nasogastric (NG) intubation
contents into the stomach, which most often
occurs after gastric surgery Pharmacologic
● Antacids
Autoimmune disorders such as Hashimoto ● Histamine-2 receptor antagonists (H2
thyroiditis, Addison disease, and Graves’ blockers) (e.g., famotidine [Pepcid],
disease are also associated with the Ranitidine [Zantac])
development of chronic gastritis ● Proton pump inhibitors (e.g.,
omeprazole [Prilosec], lansoprazole
Upper Gastrointestinal Bleeding [Prevacid]), and IV fluids
Surgical Management
Gastrojejunostomy
➢ a surgical procedure that creates an
anastomosis between the stomach
and the jejunum. It can be performed
in either a hand- sewn or a stapled
fashion, either open or
laparoscopically.
➢ To treat gastric outlet obstruction, also
called pyloric obstruction

Management: Chronic gastritis

Manifestation: Acute Gastritis
● Chronic gastritis is managed by
➔ Epigastric pain or discomfort
modifying the patient’s diet, promoting
➔ Dyspepsia (indigestion)
rest, reducing stress, recommending
➔ Anorexia
avoidance of alcohol and NSAIDs, and
➔ Hiccups
initiating medications that may include
➔ Nausea and vomiting
antacids, H2 blockers, or proton pump
➔ Erosive gastritis may cause bleeding:
inhibitors.
-Hematemesis
● H. pylori may be treated with selected
-Melena (black, tarry stools)
drug combinations which typically
-Hematochezia (bright red, bloody
include a proton pump inhibitor,
stools)
antibiotics, and sometimes bismuth
salts
Manifestation: Chronic Gastritis
➔ Fatigue
NURSING MANAGEMENT
➔ Pyrosis after eating
➔ Reducing Anxiety
➔ Belching, a sour taste in the mouth
➔ Promoting Optimal Nutrition
➔ Early satiety
➔ Promoting Fluid Balance
➔ Anorexia
➔ Relieving Pain
➔ Nausea and vomiting.
➔ Mild epigastric discomfort or report
intolerance to spicy or fatty foods or
PEPTIC ULCER DISEASE
slight pain that is relieved by eating
may be referred to as a gastric,
duodenal, or esophageal ulcer,
Complication: Chronic Gastritis
depending on its location.
- Pernicious anemia – malabsorption of
Vitamin B12
26
 an excavation (hollowed-out area) Gastric ulcer Duodenal ulcer
that forms in the mucosa of the
stomach, in the pylorus (the opening Age Between the Between age
age groups groups of 20-50.
between the stomach and duodenum),
50-60.
in the duodenum or in the esophagus.
Male: Almost equal. 2:1
Peptic ulcers are more likely to occur Female
in the duodenum than in the stomach. Ratio

Pain Felt over the Felt above the

Chronic gastric ulcers tend to occur in umbilicus and umbilicus and
the lesser curvature of the left to midline. right to the
stomach,near the pylorus. midline.

Radiation of No radiation. May radiate to

Esophageal ulcers occur as a result of Pain the back.
the backward flow of HCl from the
Nature of Periodical. Periodical
stomach into the esophagus
Pain
(gastroesophageal reflux disease
[GERD]). Weight Loss Present due to No weight loss as
Risk Factors: reduced intake. the patient feels
better with eating
❖ 65 years and older and hence goes
❖ Familial tendency: Type O on eating.
❖ NSAID use
Hemorrhages Hematemesis Black or bloody
❖ H. pylori infections
(blood vomiting) stools (malena)
❖ Smoking may be present may be present
❖ Alcohol Consumption
❖ Zollinger–Ellison syndrome (ZES). Gastric Sensation of Bloated feeling of
symptoms feeling fullness, intestinal gas.
● is a rare condition in which indigestion,
benign or malignant tumors heartburn, gas
form in the pancreas and trouble or
duodenum that secrete belching.
excessive amounts of the Malignancy Chances are Chances are
hormone gastric Common. Rare.

Aggravating Immediately 1-2 hours after

factors after food food, when the
stomach gets
empty, middle of
the night or sleep.

Ameliorating Vomiting or After taking food.

factors alkali foods.

Clinical Manifestations
Peptic Ulcer Disease: Classification Gastric ulcer versus Duodenal ulcers
1. Gastric ulcer. tend to occur in the
Gastric ulcer Duodenal ulcer
lesser curvature of the stomach, near
the pylorus. Normal/hypo-secretion of Hyper-secretion
2. Duodenal ulcer. Peptic ulcers are gastric acid
more likely to occur in the duodenum
Pain 1-2 hrs pc meals Pain 2-4 hrs pc
than in the stomach.
meals
3. Esophageal ulcer. Esophageal ulcer
occur as a result of the backward flow Food aggravates pain Food may relieve
of HCl from the stomach into the pain
Esophagus.
Vomiting common Vomiting not
common
Upper Gastrointestinal Bleeding
More likely to Less likely to
27
hemorrhage manifests as hemorrhage, but if H. pylori Triple therapy Efficacy of
hematemesis occurs, likely to infection with a PPI bid, therapy is
manifest as melena plus approximately
clarithromycin 85% qid dosing
500 mg bid, plus may decrease
Assessment and Diagnostic Findings amoxicillin 1000 adherence to the
- PE: may reveal pain, epigastric mg bid (or regimen
metronidazole
tenderness, or abdominal distention. 500 mg bid) for
- Upper endoscopy: the preferred 10-14 days.
diagnostic procedure because it
allows direct visualization of Quadruple
therapy with
inflammatory changes, ulcers, and bismuth
lesions. subsalicylate 525
- Biopsy of the gastric mucosa and any mg qid, plus
suspicious lesions can be obtained. tetracycline 500
mg qid, plus
- H. pylori infection metronidazole
- Serologic testing for antibodies 250 mg qid, plus
- Stool antigen test a PPI daily for
- Urea breath test 10-14 days

Prophylacti Peptic ulcer Prevents

Medical Management c therapy healing doses of recurrent
● Antibiotics Therapy to eradicate H. for NSAID PPIs (above) ulceration in
ulcers approximately
pylori
Misoprostol 80-90% of
● Methods to manage gastric acidity: 100-200 mcg qid patients; qid
○ medications, lifestyle changes, dosing may
and surgical intervention. decrease
adherence to the
regimen
Pharmacologic Management
H₂, histamine-2; bid, two times a day; PPIs, proton
Indications Drug Regimen Nursing
pump inhibitors; qid, four times a day; NSAID,
Considerations
nonsteroidal anti-inflammatory drug
Ulcer H2 receptor Should be used
healing antagonists: for 6-8 weeks for Other Management
complete peptic
Ranitidine 150 ulcer healing; Smoking Cessation
mg bid or 300 mg patients who are - Smoking decreases the secretion of
at bedtime at high risk bicarbonate from the pancreas into the
require a duodenum, resulting in increased
Cimetidine 400 maintenance
mg bid or 800 mg dose for 1 year acidity of the duodenum.
at bedtime Dietary Modification
Famotidine 20 - Avoid consumption of alcohol, coffee
mg bid or 40 mg (including decaffeinated coffee, which
at bedtime
also stimulates acid secretion), and
Nizatidine 150 other caffeinated beverages.
mg bid or 300 mg
at bedtime Surgical Operations for Peptic Ulcer
PPIs: Should be used Disease
Omeprazole 20 for 4-8 weeks for Operation Description Adverse Effects
mg daily complete peptic
ulcer healing: Vagotomy Severing of the Some patients
Lansoprazole 30 patients who are vagus nerve. experience
mg daily at high risk Decreases problems with
require a gastric acid by feeling of
Rabeprazole 20 maintenance diminishing fullness, dumping
mg daily dose for 1 year cholinergic syndrome,
stimulation to the diarrhea, and
Pantoprazole 40 parietal cells, gastritis.
mg daily making them less
responsive to
Esomeprazole 40 gastrin. May be
mg daily performed via an

28
 open surgical gastrin) as well diarrhea.
approach or as a small portion
laparoscopy. May of the duodenum
be performed to and pylorus. The
reduce gastric remaining
acid secretion. A segment is
drainage type of anastomosed to
procedure (see the duodenum.
pyloroplasty) is May be
usually performed performed in
to assist with conjunction with a
gastric emptying truncal vagotomy.
(because there is
total denerva- Billroth II Removal of lower Patients
tion of the (gastrojejun portion (antrum) frequently have
stomach). ostomy) of stomach with associated dump-
anastomosis to ing syndrome,
Severs the right jejunum. Dotted anemia, weight
and left vagus lines show loss, and
nerves as they Some patients portion removed malabsorption.
Trunchal enter the experience (antrectomy). A
vagotomy stomach at the problems with duodenal stump
distal part of the feeling of remains and is
esophagus; most fullness, dumping oversewn.
commonly used syndrome,
Upper Gastrointestinal Bleeding
to decrease acid diarrhea, or
secretions. constipation. Surgical Management
● Billroth II gastrojejunostomy
Complications
Severs vagal
● Dumping syndrome
innervation to the Fewer associated
stomach but adverse effects ● Gastrojejunocolic fistula
Selective maintains than with truncal ● Increased risk of gastric
vagotomy innervation to the vagotomy. adenocarcinoma, 15-20 yrs
rest of the
post-surgery
abdominal
organs.
No associated
Denervates dumping
acid-secreting syndrome
parietal cells but
Proximal preserves vagal
(parietal innervation to the
cell) gastric gastric antrum
vagotomy and pylorus.
without
drainage

Pyloroplasty Longitudinal See adverse

incision is made effects
into the pylorus associated with
and transversely truncal and
sutured closed to selective
enlarge the outlet vagotomies, as
and relax the appropriate ● Total Gastrectomy
muscle; usually - Esophagojejunostomy
accompanies
Complications
truncal and
selective ● Dumping syndrome
vagotomies. ● Pernicious Anemia

Antrectomy Removal of the

Dumping syndrome
Billroth 1 lower portion of Patients may 3D’s –
(gastroduod the antrum of the have problems 1. Dizziness
enostomy) stomach (which with feeling of 2. Diarrhea
contains the cells fullness, dumping
that secrete syndrome, and
3. Diaphoresis

29

Preventing Dumping Syndrome
The following strategies may help prevent
some of the uncomfortable signs and
symptoms of dumping syndrome related
to tube feeding:
● Slow the formula instillation rate to
provide time for carbohydrates and
electrolytes to be diluted.
● Administer feedings at room
temperature, because temperature
extremes stimulate peristalsis.
● Administer feeding by continuous drip
(if tolerated) rather than by bolus, to
prevent sudden distention of the
intestine.
● Advise the patient to remain in
semi-Fowler position for 1 hour after
the feeding; this position prolongs
intestinal transit time by decreasing
the effect of gravity.
● Instill the minimal amount of water
needed to flush the tubing before and
after a feeding, because fluid given
with a feeding increases intestinal
transit time.
Nursing Management
Nasogastric tube or NG tube
- is used in patients suffering from
dysphagia due to their inability to meet
nutritional needs despite food
modifications and because of the
possibility of aspiration.
- is a procedure in which a thin, plastic
tube is inserted into the nostril, toward
the esophagus, and down into the
stomach.
Indications
● Gastric decompression. The
nasogastric tube is connected to
suction to facilitate decompression by
removing stomach contents.
● Aspiration of gastric fluid content.
Either for lavage or obtaining a
specimen for analysis.
● Feeding and administration of
medication. Introducing a passage into
the GI tract will enable a feeding and
administration of various medications.
● Prevention of vomiting and aspiration.
In trauma settings, NG tubes can be
used to aid in the prevention of
vomiting and aspiration, as well as for
assessment of GI bleeding.
Nursing Considerations
● Provide oral and skin care.
● Verify NG tube placement.
● Wear gloves.
● Face and eye protection
Risks and Complications
● Aspiration.
● Discomfort.
● Trauma.
● Wrong placement.
Nursing Management
● A gastrostomy is a procedure in
which an opening is created into the
stomach either for the purpose of
administering nutrition, fluids, and
medications via a feeding tube, or for
gastric decompression in patients with
gastroparesis, gastroesophageal
reflux disease, or intestinal obstruction
● A jejunostomy is a surgically placed
opening into the jejunum for the
purpose of administering nutrition,
fluids, and medications.
30
Nursing Management
Nursing Nursing Interventions
Diagnosis
Acute pain Relieving Pain and Improving
Nutrition
● Administer prescribed
Imbalanced
medications.
nutrition ● Avoid aspirin, which is an
anticoagulant, and other
NSAIDS as well alcohol
and foods and beverages
that contain acid-
enhancing caffeine
(colas, tea, coffee,
chocolate), along with
decaffeinated coffee,
● Encourage patient to eat
regularly spaced meals in
a relaxed atmosphere;
obtain regular weights
and encourage dietary
modifications.
● Encourage relaxation
techniques to help
manage stress and pain..
Anxiety Reducing Anxiety
● Assess what patient
wants to know about the
disease, and evaluate
level of anxiety;
encourage patient to
express fears openly and
without criticism.
● Explain diagnostic tests
and administering
medications on schedule.
● Interact in a relaxing
manner, help in
identifying stressors, and
explain effective coping
techniques and relaxation
methods.
● Encourage family to
participate in care, and
give emotional support.
Deficient
knowledge
Upper Gastrointestinal Bleeding Nursing
Management
Monitoring and Managing Complications
If hemorrhage is a concern:
● Assess for faintness or dizziness and
nausea, test stool for occult or gross
blood; monitor vital signs frequently
(tachycardia, hypotension, and
tachypnea).
● Insert an indwelling urinary catheter
and monitor intake and output; insert
and maintain an IV line for infusing
fluid and blood.
● Monitor laboratory values (hemoglobin
and hematocrit).
● Insert and maintain a nasogastric tube
and monitor drainage; provide lavage
as ordered.
● Monitor oxygen saturation and
administering oxygen therapy.
● Place the patient in the recumbent
position with the legs elevated to
prevent hypotension, or place the
patient on the left side to prevent
aspiration from vomiting.
● Treat hypovolemic shock as indicated.
● cause and severity of the hemorrhage
must be identified quickly and the
blood loss treated to prevent
hemorrhagic shock.
Upper Gastrointestinal Bleeding
Nursing Management
If perforation and penetration are
concerns:
● Note and report symptoms of
penetration (back and epigastric pain
not relieved by medications that were
effective in the past).
● Note and report symptoms of
perforation (sudden abdominal pain,
referred pain to shoulders, vomiting
and collapse, extremely tender and
rigid abdomen, hypotension and
tachycardia, or other signs of shock).
METABOLIC-GASTROINTESTINAL AND
LIVER ALTERATIONS
MALABSORPTION SYNDROME
- Condition that diffusely affect the small
intestine and reduce its absorption
function.
Causes may include:
● Diseases affecting the intestine itself,
such as celiac disease.
● Absence or low levels of certain
digestive enzymes.
● Diseases of the pancreas, such as
chronic pancreatitis or cystic fibrosis.
● Diseases caused by parasites, such
as giardiasis or worms.
● Changes in the bacteria normally
found in the intestinal tract.
● Surgery, such as removal of the
gallbladder, that alters or reduces the
length of the intestinal tract.
31
 ● Human immunodeficiency virus (HIV)
Celiac Sprue
- AKA Celiac Disease;
Gluten-Sensitive Enteropathy
- A serious autoimmune condition that
is characterized by the presence of an
immune response that is triggered by
ingesting gluten.
- The damage is noted on the villi of the
small intestine.
- It can develop in any age.
- Etiology: Unknown
- Autoimmune attacks Gliadin
- Inflammation in the lining of the
small intestine that will lead to
damage and reduced or
inability to absorb nutrients.
Celiac Sprue
Risk Factors:
● Familial History
● Other Autoimmune disease: DM
type 1 and thyroid disease
● Autoimmune related conditions like
down syndrome
● Having microscopic colitis
Complication:
● Iron deficiency anemia
● B12 and Folate Deficiency Anemia
● Osteoporosis
● Vitamin K Malabsorption
● Malnutrition
● Lactose intolerance
● Megaloblastic Anemia
Assessment and Diagnostic Finding
- Serology testing looks for antibodies in
your blood. Elevated levels of certain
antibody proteins indicate an immune
reaction to gluten.
- the immunoglobulin A (IgA)
- anti-tissue transglutaminase
(tTG)
- which is 90% sensitive
and 95% specific to
celiac disease.
- Genetic testing for human leukocyte
antigens (HLA-DQ2 and HLA-DQ8)
can be used to rule out celiac disease.
- Endoscopic Biopsy - take a small
tissue sample (biopsy) to analyze for
damage to the villi.
Medical Management
➢ Celiac disease is a chronic,
noncurable, lifelong disease.
➢ Symptom management - targeted
treatment.
➢ The treatment is to refrain from
exposure to gluten in
➢ foods and other products.
Chapter 47-5 Patient Education
The nurse instructs the patient to avoid
consuming the following:
● Food that contain gluten-containing
grains, including wheat, barley, bran,
durum, spelt, faro, khorasan, rye,
seitan, bulgur, graham, semolina,
farina, emmer, and triticale; these
generally include:
○ Cakes, pastries, cookies
○ Breads, pastas, rolls, pizza,
crackers
● Brewer’s yeast; this generally includes
beer, ale, and porter
● Malt, malt extract, and malt flavoring
● Modified food starch made from wheat
(commonly and carefully read the
labels before consuming the following:
○ Candies
○ Caramel-colored foods
○ Oat products not specifically
labeled as produced gluten-free
facilities
○ Processed lunch meats and
“shaped” foods (e.g., cheese
sticks)
○ Salad dressings, condiments,
soy sauce, seasonings
32
 ○ Soft drinks Bile remaining in the gallbladder initiates a
● Some foods are specifically labeled as chemical reaction; autolysis and edema
“gluten free.” occur.
↓
Nursing Management Blood vessels in the gallbladder compressed,
● Provides patient and family education compromising its vascular supply.
regarding adherence to a gluten-free
diet and how to avoid other gluten Causes
products. ● Gallbladder stone
● Products that are not foods can also ● Bacteria
contain gluten gels. ● Alterations in fluids and electrolytes
● Patients must understand how to Bile stasis
carefully read labels on both foods
and nonfood products to determine if Cholelithiasis
they contain gluten. - Calculi formation of the solid
constituents of the bile usually from
METABOLIC-GASTROINTESTINAL AND cholesterol, bilirubin and calcium.
LIVER ALTERATIONS
Risk Factors: (4F’s)
DISORDER OF THE GALLBLADDER - Female
➔ These disorders include inflammation - Forty
of the biliary system and carcinoma - Fat
that obstructs the biliary tree. - Fertile
➔ Gallbladder disease with stones is the
most common disorder of the biliary
system.
➔ Not all occurrences of cholecystitis are
related to stones (calculi) in the
gallbladder (cholelithiasis) or stones in
the common bile duct
(choledocholithiasis).

Cholecystitis
- Inflammation of the gallbladder which
can be acute or chronic.
CLINICAL MANIFESTATIONS:
● Pain and Biliary Colic
Sign and Symptoms:
● Jaundice
- Pain and Tenderness
● Changes in Urine and Stool Color
- Rigidity of the upper right abdomen
● Vitamin deficiency
- Nausea and Vomiting
- Palpable Gallbladder
- Leukocytosis
- Fever and Sepsis

Classification
● Calculous cholecystitis - a gallbladder
stone obstructs bile outflow.
● Acalculous cholecystitis - describes
acute inflammation in the absence of
obstruction by gallstones.

Pathophysiology ASSESSMENT AND DIAGNOSTIC

FINDINGS
Calculous cholecystitis occurs when a ➔ Abdominal X-Ray
gallbladder stone obstructs the bile outflow. ➔ Ultrasonography
↓ ➔ Radionuclide Imaging or
Cholescintigraphy

33
 ➔ Endoscopic Retrograde Cholesterol levels Elevated in biliary
Cholangiopancreatography (ERCP) obstruction; decreased in
parenchymal liver
disease

MEDICAL MANAGEMENT
● NUTRITIONAL AND SUPPORTIVE
THERAPY
● Pharmacologic Therapy- UDCA &
CDCA

NONSURGICAL REMOVAL OF
GALLSTONES
Table 50-1 Studies Used in the Diagnosis of
● Dissolving Gallstones
Biliary Tract and Pancreatic Disease
● Stone Removal by Instrumentation
Studies Diagnostic Uses

Magnetic resonance Visualizes the biliary tree

cholangiopancreatogr and capable of detecting
aphy biliary tract obstruction

Cholecystogram, Visualizes gallbladder

cholangiogram and bile duct

Celiac axis Visualize ;iver and

arteriography pancreas

Laparoscopy Visualize anterior surface

of liver, gallbladder, and
mesentery through a
trocar

Ultrasonography Show size of the

abdominal organs and
presence of masses

Helical computed Detect neoplasms; MEDICAL MANAGEMENT

tomography and diagnose cysts,
magnetic resonance pseudocysts, abscess, INTRACORPOREAL
imaging and hematomas; LITHOTRIPSY
determine severity of Extracorporeal Shock Wave
pancreatitis based on the
Lithotripsy
presence of necrosis
and/or peripancreatic
fluid collections SURGICAL MANAGEMENT

Endoscopic retrograde Visualize biliary ● Laparoscopic Cholecystectomy

cholangiopancreatogr structures and pancreas
aphy via endoscopy

Endoscopic Identify small tumors and

ultrasound facilitate fine-needle
aspiration biopsy of
tumors or lymph nodes
for diagnosis

Serum alkaline In absence of bone

phosphatase disease, to measure
biliary tract obstruction

Gamma-glutamyl, Markers for biliary stasis;

gamma-glutamyl also elevated in alcohol
transpeptidase lactate abuse
dehydrogenase

34

SURGICAL MANAGEMENT
● Cholecystectomy
● Small-Incision Cholecystectomy
● Choledochostomy
● Surgical Cholecystostomy
● Percutaneous Cholecystostomy
Chapter 50-2 Patient Education
Managing Self-Care After Laparoscopic
Cholecystectomy
The Nurse instructs the patient about pain
management, activity and exercise, wound
care, nutrition, and follow-up care as
described below.
Managing Pain
● You may experience pain or
discomfort from the gas used to inflate
your abdominal area during surgery.
Sitting upright in bed or a chair,
walking, or using a heating pad may
ease the discpmfort.
● Take analgesic medications as
needed and as prescribed. Report to
your surgeon if pain is unrelieved even
with analgesic use.
Resuming Activity
● Begin light exercise (walking)
immediately.
● Take a shower or bath after 1 or 2
days.
● Drive a car after 3 or 4 days.
● Avoid lifting objects exceeding 5
pounds after surgery, usually for 1
week.
● Resume secual activity when desired.
Check for the Wound
● Check ouncture site daily for signs of
infection.
● Wash puncture site with mild soap and
water.
● Allow special adhesive strips on the
puncture site to fall off. Do not pull
them off.
Resuming eating
● Resume your normal diet.
● If you had fat intolerance before
surgery, gradually add fat back into
your diet in small increments.
Managing Follow-Up Care
● Make an appointment with your
surgeon for 7-10 days after discharge.
● Call your surgeon if you experience
any signs or symptoms of infection at
or around the puncture site: redness,
tenderness, swelling, heat, or
drainage.
● Call your surgeon if you experience a
fever of 37.7 °C (100 °F) or more for 2
consecutive days.
● Call your surgeon if you have
developed nausea, vomiting, or
abdominal pain.
METABOLIC-GASTROINTESTINAL AND
LIVER ALTERATIONS
DISORDER OF THE PANCREAS
Pancreatitis
➔ Inflammation of the pancreas.
➔ Commonly described as autodigestion
of the pancreas.
Acute pancreatitis does not usually lead to
chronic pancreatitis unless complications
develop.
Chronic pancreatitis is an inflammatory
disorder characterized by progressive
destruction of the pancreas. can be
characterized by acute episodes.
Pancreatitis Pathophysiology
Gallstones enter the common bile duct and
lodge at the ampulla of Vater.
↓
The gallstones obstruct the flow of the
pancreatic juice or causing reflux of bile from
35
 the common bile duct into the pancreatic
duct.
↓
The powerful enzymes within the pancreas
are activated.

Causes
● Alcohol abuse. (80%)
● Bacterial or viral infection.
● Duodenitis.
Pancreaticoduodenal - The pancreas,
● Medications.
stomach, and bowel are joined back together
after a pancreaticoduodenectomy.
Clinical Manifestations
● Severe abdominal pain.
● Board-like abdomen.
● Ecchymosis.
● Nausea and vomiting.
● Hypotension.

Nursing Management
● Acute pain
● Imbalanced nutrition: less than body
requirements
● Ineffective breathing pattern

Assessment and Diagnostic Findings

Nursing Management Intervention:
● Serum amylase and lipase levels
● Relieve pain and discomfort. The
● CBC
current recommendation for pain
○ Increase WBC
management in this population is
○ Hematocrit and hemoglobin
parenteral opioids including morphine,
levels
hydromorphone, or fentanyl via
● Elevated Serum Bilirubin Levels
patient-controlled analgesia or bolus.
● X-ray studies of the Abdomen and
● Improve breathing pattern. The nurse
Chest
maintains the patient in a
● Ultrasound studies
semi-Fowler’s position and
● Contrast-Enhanced CT scans
encourages frequent position
● Magnetic Resonance Imaging (MRI)
changes.
scans
● Improve nutritional status. Between
acute attacks, the patient receives a
Medical Management
diet that is high in protein and low in
● Pain management.
fat. The patient should avoid heavy
● Adequate administration of analgesia
meals and alcoholic beverages.
(morphine, fentanyl, or
● Maintain skin integrity. The nurse
hydromorphone)
carries out wound care as prescribed
● Intensive care.
and takes precautions to protect intact
● Respiratory care.
skin from contact with drainage.
● Biliary drainage.

Pancreatitis: Surgical Management

Pancreaticojejunostomy - to create an
artificial passage connecting the pancreas to
the second part of the small bowel.

36
METABOLIC-GASTROINTESTINAL AND
LIVER ALTERATIONS
DISORDER OF THE LIVER
Cirrhosis is a chronic disease characterized
by replacement of normal liver tissue with
diffuse fibrosis that disrupts the structure and
function of the liver.

Types of Cirrhosis:
1. Alcoholic cirrhosis – Laennec’s
2. Post-necrotic cirrhosis
3. Biliary cirrhosis
4. Cardiac cirrhosis Clinical Manifestations
● Early Signs
● Body Malaise
● RUQ discomfort
● GI disturbance
● Anorexia
● Indigestion
● Bowel Habit Change (Diarrhea or
Constipation)
● Liver is unable to detoxify
○ Metabolic acidosis
○ Bleeding: Fail to synthesize clotting
factors
○ Edema/Ascites: Fail to synthesize
protein
○ Diuretics, Albumin, Limit OFI
Cirrhosis: Pathophysiology
Causes: Complications
● Excessive alcohol consumption. ● Portal hypertension - Portal hypertension
● Injury. is an increase in the pressure within the
● Hepatitis. portal vein.
● Right-sided heart failure. ● The increase in pressure is caused by a
blockage in the blood flow through the
liver.
● Portal hypertension – Management
● Portosystemic Shunt
- is a tract created within the liver using
x-ray guidance to connect two veins
within the liver.
- The shunt is kept open by the
placement of a small, tubular metal
device commonly called a stent.

37

● Esophageal Varices - are dilated
tortuous veins in submucosa of the lower
esophagus.
● Apply Pressure by the use of
Sengstaken – Blakemore
Esophagogastric Balloon Tamponade
Tubes
- Sengstaken – Blakemore
- is a tube used in emergency medicine to
stop bleeding in your stomach or
esophagus.
- Nsg Responsibility
● Scissor at bedside
● Balloon at 30-35mmHg
Cirrhosis Complications
● Hepatomegaly and Splenomegaly
● Hepatorenal Syndrome
● Hepatic encephalopathy
● Gastrointestinal Varices
● Caput medusae
● Spider angioma
Assessment and Diagnostic Findings
● Liver Scan
● Liver Biopsy
● Cholecystography and Cholangiography
● Splenoportal Venography
● CBC, S. Alb., S. Globulin, S. alkaline
phosphatase, AST, ALT, GGT,
Cholinesterase, T.Bilirubin, D.Bil., In.Bil.,
and PT
Medical Management
● Rest
● Vit ADEK
● Diuretics
● Neomycin and Lactulose
● Paracentesis
● No alcohol and Hepatotoxic Drugs
Nursing Management
Diet
- Low Protein, High Carbs., Moderate
Fats
- Low Sodium
- Soft foods
- Alcohol is contraindicated
Promoting Rest
- Position bed for maximal respiratory
efficiency; provide oxygen if needed.
- Initiate efforts to prevent respiratory,
circulatory, and vascular disturbances.
- Encourage patient to increase activity
gradually and plan rest with activity and
mild exercise.
Providing Skin Care
- Change patient’s position frequently.
- Avoid using irritating soaps and
adhesive tape.
- Provide lotion to soothe irritated skin;
take measures to prevent patient from
scratching the skin.
Reducing Risk of Injury
- Use padded side rails if patient
becomes agitated or restless.
- Orient to time, place, and procedures to
minimize agitation.
- Instruct patient to ask for assistance to
get out of bed.
- Carefully evaluate any injury because of
the possibility of internal bleeding.
- Provide safety measures to prevent
injury or cuts (electric razor, soft
toothbrush).
38
 - Apply pressure to venipuncture sites to
minimize bleeding.
Monitoring and Managing Complications.
- Monitor for bleeding and hemorrhage.
- Monitor the patient’s mental status
closely and report changes so that
treatment of encephalopathy can be
initiated promptly.
- Carefully monitor serum electrolyte
levels are and correct if abnormal.
- Administer oxygen if oxygen
desaturation occurs; monitor for fever or
abdominal pain, which may signal the
onset of bacterial peritonitis or other
infection.
- Assess cardiovascular and respiratory
status; administer diuretics, implement
fluid restrictions, and enhance patient
positioning, if needed.
- Monitor intake and output, daily weight
changes, changes in abdominal girth,
and edema formation. Monitor for
nocturia and, later, for oliguria, because
these states indicate increasing severity
of liver dysfunction.
LIVER TRANSPLANTATION
Liver Transplant
- Used to treat life-threatening ESLD for
which no other form of treatment is
available.
- total removal of the diseased liver and
replacement with a healthy liver
- success depends on successful
immunosuppression.
Immunosuppressant:
- Immunosuppressant used to prevent
organ rejection after a kidney, liver, or
heart transplant.
● Cyclosporine (Neoral)
● Tacrolimus (Prograf)
● Corticosteroids
● Azathioprine (Imuran)
● Mycophenolate mofetil (CellCept)
● Sirolimus (formerly known as rapamycin
● [Rapamune])
● Everolimus [Afinitor]
● Antithymocyte globulin (Thymoglobulin)
● Basiliximab (Simulect)
● Daclizumab (Zenapax).
Complication:
● Bleeding
● Infection
● Rejection
● LDLT (Donor)
Nursing Management
1. Patient and family preparations
2. Awareness on the risk and benefits
3. Time to wait for available donor
4. Living Donor Liver Transplant
5. After transplant concerns
- Immunosuppression
- Adherence to medications
DISORDER OF THE ANORECTUM
HEMORRHOIDS
- dilated portions of veins in the anal
canal.
Two types:
● Internal hemorrhoids – those above
the internal sphincter.
● External hemorrhoids – those
appearing outside the external
sphincter.
Classified by degree of prolapse:
- First degree — do not prolapse and
protrude into anal canal
- Second degree — prolapse outside the
anal canal during defecation but reduce
spontaneously
39
- Third degree — prolapsed to the extent
that they require manual reduction
- Fourth degree — prolapsed to the extent
that they may not be reduced
- Diet: High Fiber; Adequate liquids (6-8
glasses/day)
- Warm compress
- Sclerotherapy involves injecting a
sclerosing agent
- Rubber band ligation procedure
- Surgery: Hemorrhoidectomy

Nursing Management:
- Enemas
- Laxatives

Post-operative:
- Assess Rectal Bleeding
- Promote comfort
- Stool softener
- Increase fiber and increase OFI
- No Sitz bath 12-48 hrs post–op.

DISORDER OF THE ESOPHAGUS

Hiatal Hernia
- the opening in the diaphragm through
which the esophagus passes becomes
enlarged, and part of the upper stomach
moves up into the lower portion of the
thorax.
Manifestation: - May result from congenital weakness of
- Itching and pain the diaphragm or injury. Pregnancy, or
- Bright red bleeding with defecation obesity.

External hemorrhoids Types of Hiatal Hernia

- Severe pain ● Sliding
- Inflammation ● Paraesophageal
- Edema

Internal hemorrhoids
- Not usually painful
- Bleed or prolapse when they become
enlarged.

Predisposing Factors
- Age: 20-50yrs old
- Prolonged standing
- Intra-abdominal pressure
- Pregnancy
- Heavy Lifting
- Obesity
- Straining at defecation
- Portal hypertension

Diagnostic Exam:
- Proctoscopy
- CBC: Hgb/Hct

Medical Management
- Stool Softener
- Anti-inflammatory cream

40
1. Sliding
- Sliding, or type I, hiatal hernia
occurs when the upper
stomach and the
gastroesophageal junction are
displaced upward and slide in
and out of the thorax.
- About 95% of patients with
esophageal hiatal hernia has a
sliding hernia.

● Paraesophageal
- Types II, III, or IV

Clinical Manifestation:
● Many patients are asymptomatic
● Pyrosis – Substernal burning pain
2. Paraesophageal ● Regurgitation
- Hernia occurs when all or part of the ● Dysphagia
stomach pushes through the ● Intermittent epigastric pain or fullness
diaphragm beside the esophagus. after eating
- further classified as types II, III, or IV,
depending on the extent of herniation. Diagnostic Findings:
- X-ray studies
- Barium swallow
- Esophagogastroduodenoscopy (EGD)
- Esophageal manometry
- Chest CT scan

Management:
- Small Frequent Feedings: Bland diet
- Sit upright for 1hr after meals
- Elevate the head of the bed on 4- to 8-inch

Pharmacologic:
- Antacids: Neutralizing Acidity
- Magnesium hydroxide
- Aluminum Hydroxide
- Proton Pump Inhibitors
41
- Omeprazole ➢Vomiting
- Nexium (Esomeprazole) ➢Abdominal pain
- H2 Inhibitors ➢ACETONE breath
- Ranitidine ➢Hyperventilation
➢KUSSMAUL Respirations
Surgical Management:
- Herniorrhaphy (Surgical Hernia Repair) Assessment and Diagnostic Findings
- indicated in patients who are symptomatic, ➢Blood glucose levels may vary between
although the primary reason for the surgery 300 and 800 mg/dL (16.6 and 44.4 mmol/L).
is typically to relieve GERD symptoms and ➢Evidence of ketoacidosis is reflected in low
not repair the hernia. serum bicarbonate (0 to 15 mEq/L) and low
pH (6.8 to 7.3) values.
Lesson 7: DKA, HHS, GERD ➢low partial pressure of carbon dioxide
(PCO2 10 to 30 mm Hg)
DIABETIC KETOACIDOSIS ➢Sodium and potassium concentrations may
be low, normal, or high, depending on the
➢ DKA is a potentially life threatening amount of water loss (dehydration).
complication in patients with -IDDM -Type 2 ➢Increased levels of creatinine, blood urea
DM nitrogen (BUN), and hematocrit
➢ DKA is a medical emergency, without
treatment it can lead to death. Management
➢ DKA was 1st described in 1886 until correcting dehydration, electrolyte loss, and
introduction of insulin therapy in 1920,it was acidosis
fatal.
A. REHYDRATION
DEFINITION ❖ IV fluid replacement 0.9% sodium
> Defined as the presence of main clinical chloride
features : ❖ Fluid volume status monitoring
(PLASMA expanders
1. Hyperglycemia
2. Dehydration and electrolyte loss B. RESTORING ELECTROLYTES
3. Acidosis ❖ Monitor Potassium levels
❖ Frequent (every 2 to 4 hours initially)
ECGs and laboratory measurements
of potassium are necessary during the
first 8 hours of treatment.
❖ Potassium replacement is withheld
only if hyperkalemia is present or if the
patient is not urinating.

Quality and Safety Nursing Alert!

Because a patient's serum potassium level
may drop quickly as a result of rehydration
and insulin treatment, potassium
replacement must begin once potassium
levels drop to normal in the patient with DKA.
CLINICAL MANIFESTATIONS
➔ Polyuria C. REVERSING ACIDOSIS
➔ Polydipsia (increased thirst) IV infusion of insulin ( Regular insulin)
➔ Fatigue Ex: 100 units mix w/ 500ml 0.9% NS
➔ Blurred vision 1 unit=5ml
➔ Weakness 5 units/hr = 25ml per hr
➔ Headache
Quality and Safety Nursing Alert
GASTROINTESTINAL SYMPTOMS: When hanging the insulin drip, the nurse
➢Anorexia must flush the insulin solution through the
➢Nausea entire IV infusion set and discard the first 50

42
mL of fluid. Insulin molecules adhere to the
inner surface of plastic IV infusion sets;
therefore, the initial fluid may contain a
decreased concentration of insulin.
HYPERGLYCEMIC HYPEROSMOLAR
SYNDROME
Other names:
➔ Hyperosmolar Hyperglycemic
nonketotic syndrome (HHNK)
➔ Hyperosmolar coma
➔ Non-ketotic Hyperosmolar coma
➔ Hyperosmolar nonketotic syndrome
➔ Hyperosmolar Hyperglycemic
nonketotic coma
➔ Nonketotic Hyperglycemic
Hyperosmolar coma
DEFINITION
● Is a life-threatening emergency
resulting from a lack of effective
insulin, or severe insulin resistance,
causing extreme hyperglycemia.
● HHS is precipitated by a stressor such
as trauma, injury, or infection that
increases insulin demand.
● Serum glucose: > 600 mg/Dl
Pathophysiology:
there is enough insulin to prevent
acidosis and the formation of ketone
bodies at the cellular level, but there is
not enough insulin to facilitate the
transportation of all the glucose into
the cells
glucose molecules accumulate in the
bloodstream,
❖ Potassium
❖ sodium
❖ phosphate
Patients may lose up to 25% of their
total body water. Fluids are pulled
from individual body cells by
increasing serum hyper osmolality and
extracellular fluid loss, causing
intracellular dehydration and body cell
shrinkage.
The patient with HHNKC has severe
hyperglycemia and azotemia without
ketoacidosis.
Both diffuse and focal central nervous
system deficits may occur.
These may include:
❖ hallucinations,
❖ aphasia,
❖ nystagmus,
❖ hemianopsia, hemiplegia,
❖ hemi sensory deficits, and focal
or grand mal seizures.
❖ Coma may arise.
As extracellular volume decreases
Blood viscosity increases
➢Thromboemboli (increased blood
viscosity, enhanced platelet
aggregation and adhesiveness, and
possibly patient’s immobility).
➢ increased Cardiac workload
➢ Renal blood flow is decreased.
➢ Stroke
Mortality rate of HHS = 10% - 50%, which is
higher than that of DKA (1.2%-9%)
The cardinal symptoms: polyuria and
polydipsia
CLINICAL MANIFESTATION:
● Hypotension
● Profound dehydration
● Tachycardia
● Seizures, hemiparesis
➔ Neurologic deficits may be mistaken
for senility: progression of
pathophysiologic processes with
resultant hypovolemic shock and
multiple organ failure.
➔ As shock progresses, lactic acidosis
may arise due to poor perfusion.
Assessment and Diagnostic Findings
● Blood glucose
● Serum electrolytes
● BUN
● CBC
● ABG
Management
● fluid replacement,
● correction of electrolyte imbalances,
● insulin administration.
NURSING DIAGNOSIS
● Risk for deficient fluid volume related
to polyuria and dehydration
● Risk for electrolyte imbalance related
to fluid loss or shifts
● Deficient knowledge about diabetes
self-care skills or information
● Anxiety related to loss of control, fear
of inability to manage 3925 diabetes,
misinformation related to diabetes,
fear of diabetes complications
43
 fatigue
Guidelines to Follow During Periods of
Illness (“Sick Day Rules”) Respiratory Deep, rapid Same as DKA
Kussmaul's
The nurse instructs the patient to: respirations
● Take insulin or oral antidiabetic agents
Cardiovascular Tachycardia,
as usual. Test blood glucose and urine hypotension,
ketones every 3 to 4 hours. ECG changes
● Report elevated glucose levels as
Metabolic/Gl/en Polyuria, Polyuria,
specified or urine ketones to your docrine polyphagia, polyphagia,
primary provider. polydipsia, fruity polydipsia, fatigue,
"acetone" breath, generalized
● Take supplemental doses of regular abdominal pain, weakness, nausea,
insulin every 3 to 4 hours, if needed, if weight loss, vomiting
you take insulin. Substitute soft foods fatigue,
generalized
(e.g., 1/3 cup regular gelatin, 1 cup weakness,
cream soup, 1⁄2 cup custard, 3 nausea, vomiting
squares graham crackers) six to eight
Integumentary Dry, flushed skin; Same as DKA
times a day if you cannot follow your poor turgor; dry
usual meal plan. mucous
membranes
● Take liquids (e.g., 1⁄2 cup regular cola
or orange juice, 1⁄2 cup broth, 1 cup VS monitoring BP low (more BP is low (more
sports drink [Gatorade]) every 1⁄2 to 1 than 20% below than 20% below
normal), HR more normal). HR more
hour to prevent dehydration and to than 100 bpm, than 100 bpm, CVP
provide calories, if vomiting, diarrhea, CVP less than 2 less than 2 mm Hg
mm Hg (less than (less than 5 cm
or fever persists. 5 cm H₂O). H₂O), temperature
● Report nausea, vomiting, and diarrhea temperature possibly elevated
to your primary provider, because normal
extreme fluid loss may be dangerous. Diagnostic Values reflect Values reflect
● Be aware that if you are unable to tests/laboratory dehydration/meta dehydration
retain oral fluids, you may require values bolic acidosis secondary to
(ketosis) hyperglycemia,
hospitalization to avoid diabetic secondary to osmotic diuresis,
ketoacidosis and possibly coma. hyperglycemia, and possible lactic
abnormal acidosis from
lipolysis, and hypoperfusion; fluid
Clinical Findings: Comparison of DKA & osmotic diuresis; loss 9 L or more.
HHS fluid loss 6.5 L Anion gap:
or more. Anion normal
DKA HHS gap: more than
10
Type of Usually type 1 Usually type 2
diabetes Hgb/Hct Elevated Same as DKA

Signs, Symptoms are a Same as DKA; also Serum Elevated Same as DKA
symptoms/physi result mainly of possible seizures BUN/creatinine
cal assessment hyperglycemia, and tremors
intracellular Serum Initially elevated, Same as DKA
hypoglycemia, electrolytes then decreased
hypotension or 250-800 mg/dL (+
impending ketones)
hypovolemic
shock, and Serum glucose 250-800 mg/dL (+ 400-1800 mg/dL
fluid-electrolyte ketones) (-ketones)
imbalance with
possible Serum ketones Elevated Normal; rarely
acid-base slightly elevated
imbalance
ABGS pH 6.8-7.3, HCO, pH 7.3-7.5, HCO,
Neurologic Altered LOC Shallow, rapid 12-20 mEq/L, 20-26 mEq/L.
(confusion, (tachypneic) CO₂ CO, 30-40 mEq/L
lethargy. breathing 15-25 mEq/L
irritability, coma),
stroke like Serum 300-350 mOsm/L More than 350
symptoms osmolality mOsm/L
(unilateral/bilatera
l weakness, Urine Positive/positive Positive/negative
paralysis, glucose/aceton
numbness, e
paresthesia),

44
Onset Hours to days More than 1 day BUN and Elevated Elevated
creatinine levels
History/risk Undiagnosed Undiagnosed DM;
factors for DM, infections, infections, Mortality rate 1%-5% 10%-20%
development of acute especially
crisis pancreatitis, gram-negative
uremia, insulin acromegaly,
resistance Cushing's
COLLABORATIVE
syndrome;
Medications: thyrotoxicosis; PROBLEMS/POTENTIAL
digitalis acute pancreatitis, COMPLICATIONS
intoxication: hyperalimentation;
omission/reductio pancreatic ● Fluid overload, pulmonary edema, and
n of insulin carcinoma; cranial heart failure
dosage; failure to trauma/ subdural ● Hypokalemia
increase insulin hematoma; uremia,
to compensate hemodialysis, ● Hyperglycemia and ketoacidosis
for stress of peritoneal dialysis; ● Hypoglycemia
infections; injury, burns, heat stroke:
emotional pneumonia: Ml,
● Cerebral edema
problems, or stroke
surgery NURSING INTERVENTIONS
Medications: loop
and thiazide Maintaining Fluid and Electrolyte Balance
diuretics (ie., ● Intake and output are measured. IV
hydrochlorothiazide fluids and electrolytes
, chlorthalidone,
furosemide), ● are given as prescribed, and oral fluid
diazoxide; intake is encouraged when it is
glucocorticoids (ie.,
hydrocortisone,
permitted.
dexamethasone), ● Laboratory values of serum
propranolol electrolytes (especially sodium and
(Inderal); phenytoin
(Dilantin), sodium potassium) are monitored.
bicarbonate ● Vital signs are monitored hourly for
signs of dehydration (tachycardia,
Mortality 10% or less 10%-25%
orthostatic hypotension) along with
Comparison of Diabetic Ketoacidosis and
assessment of breath sounds, level of
Hyperglycemic Hyperosmolar Syndrome consciousness, presence of edema,
and cardiac status (ECG rhythm
Characteristics DKA HHS
strips).
Patients most Can occur in Can occur in type I
commonly type 1 or type 2 or type 2 diabetes;
affected diabetes; more more common in Increasing Knowledge about Diabetes
common in type 2 2 diabetes, Management
type 1 diabetes especially older ● carefully assess the patient’s
patients with type 2
diabetes understanding of and adherence to
the diabetes management plan
Precipitating event Omission of Physiologic stress
insulin; (infection, surgery,
● Discuss early manifestations of DKA
physiologic stroke, MI) or HHS.
stress ● provide education about basic skills
(infection,
surgery, stroke, again to patients who may not be able
MI) to recall the instructions
Onset Rapid (<24 Slower (over
● Discuss prevention of future
hours) several days) recurrence and readmissions for
treatment of these complications.
Blood glucose Usually >250 Usually >600
levels mg/dl. (>13.9 mg/dL. (>33.3 ● educate the patient about the need for
mmol/l.) mmol/L) maintaining blood glucose at a normal
level and learning about diabetes
Arterial pH level <7.3 Normal
management and basic skills.
Serum and urine Present Absent
ketones
Decreasing Anxiety
Serum osmolality 300-350 >350 mOsm/L ● Imagery
mOsm/L ● Distraction
Plasma <15 mEq/L Normal ● Optimistic self-recitation
bicarbonate level ● Music

45
MONITORING AND MANAGING
POTENTIAL COMPLICATIONS

Fluid Overload
● measuring vital signs
● Central venous pressure monitoring
and hemodynamic monitoring
● Physical examination
● Monitor I &O

Hypokalemia:
● replacement of potassium
● monitoring of the cardiac rate, cardiac
rhythm, ECG, and serum potassium

Cerebral Edema:
● gradual reduction in the blood glucose
level
● monitoring of the blood glucose level, MANAGEMENT
serum electrolyte levels, fluid intake, Avoid situations that decrease LES pressure
urine output, mental status, and or cause esophageal irritation:
neurologic signs. 1. Eat LF diet
● Precautions are taken to minimize 2. Avoid caffeine, tobacco, beer, milk,
activities that could increase foods containing peppermint or
intracranial pressure. spearmint, carbonated drinks
3. avoid eating or drinking 2 hours before
GASTROESOPHAGEAL REFLUX bedtime;
DISEASE (GERD) 4. maintain normal body weight;
5. avoid tight-fitting clothes;
● Excessive reflux may occur because 6. elevate the head of the bed by at least
of an incompetent lower esophageal 30 degrees
sphincter, pyloric stenosis, or a motility
disorder. Pharmacologic Management of GERD
● Incidence of GERD seems to increase Key Examples Actions/Class Key Nursing
with aging. Considerations

Antacids/Acid Neutralize acid Potential risk of

CLINICAL MANIFESTATIONS neutralizing agents Therapeutic and gastric acid
● Pyrosis (burning sensation in the ● Calcium Pharmacologic suppression is the
carbonate class: Antacid loss of protective
esophagus) (Tums) flora and an
● Dyspepsia (indigestion) ● Aluminum increased risk of
hydroxide, infection,
● Regurgitation magnesium, especially
● Dysphagia or odynophagia hydroxide, Clostridium
● Hypersalivation and difficile
simethicone
● Esophagitis (Maalox)

Histamine-2 (H) Decrease Potential risk of

ASSESSMENT & DIAGNOSTIC FINDINGS
receptor gastric acid gastric acid
To evaluate damage to esophageal mucosa: antagonists production suppression is the
● Endoscopy ● Famotidine Therapeutic loss of protective
(Pepcid) class: flora and an
● Barium Swallow ● Ranitidine Antiulcer drugs increased risk of
(Zantac) infection,
To evaluate degree of acid reflux: ● Cimetidine Pharmacologic especially
(Tagamet) class: Clostridium
● Ambulatory 12-hour to 36-hour pH H2-receptor difficile
monitoring antagonists
For direct
injection (IVP),
To measure bile reflux patterns: dilute 2 mL (20
● Bilirubin monitoring (Bilitec) mg) with

46
 compatible doses of antacid
solution to a total Pharmacologic by 30 minutes
volume of either 5 class:
or 10 mL; Gl protectants
administer over at
least 2 minutes

Monitor for SURGICAL MANAGEMENT

QT-interval
Nissen Fundoplication
prolongation in
patients with ● Wrapping of a portion of the gastric
kidney injury fundus around the sphincter area of
Prokinetic agents Accelerate May cause tardive the esophagus
● Metocloprami gastric emptying dyskinesia
de (Reglan) Therapeutic
class: Gl Typically used
stimulants short term

Pharmacologic
class:
Dopamine
antagonist

Proton pump Decrease Potential risk of

inhibitors (PPIs) gastric acid gastric acid
● Pantoprazole production suppression is the
(Protonix) Therapeutic loss of protective
● Omeprazole class: flora and an
(Prilosec) Antiulcer increased risk of Barrett's Esophagus
● Esomeprazole drugs infection, ● A condition in which the lining of
(Nexium) especially
● Lansoprazole Clostridium
the esophageal mucosa is altered;
(Prevacid) Pharmacologic difficile ● Typically occurs in association with
● Rabeprazole class: GERD (long-standing, untreated);
(Aciphex) Proton pump For a 2-minute
● Dexlansopraz inhibitors infusion (IVP), ● Cause: Reflux changing the cells
ole (Dexilant) give the lining the lower esophagus
reconstituted vials
● Signs & Symptoms: Similar with
(4 mg/mL) over at
least 2 minutes GERD; may also complain
symptoms r/t PUD, esophageal
May increase the stricture, or both
risk of hip
fractures and
interfere with
some vitamin and
mineral absorption
(B12, iron,
magnesium)

Interact with
commonly
prescribed
medications such
as diuretics and
clopidogrel

Assessment:
Reflux inhibitors: Stimulates Primary use is for
Esophagogastroduodenoscopy (EGD)
● Bethanechol parasympathetic urinary retention
chloride Therapeutic ● Expected finding: Esophageal lining
(Urecholine) class: Do not use with that is red rather than pink.
Cholinergic possible Gl
obstruction or
peptic ulcer Biopsies
Pharmacologic ● Expected finding: High-grade
class:
Cholinergic dysplasia (HGD), Columnar epithelium
replacing squamous epithelium.
Surface Preserve Give on an empty
Agents/Alginate-b mucosal barrier stomach hour MANAGEMENT
ased barriers Therapeutic before or 2 hours Individualized; Monitoring
● Sucralfate class: after meals
Antiulcer ● Follow-up Endoscopy (within 6mon)
drugs Separate from ● Intensive surveillance biopsies

47
 large quantities of food overload the
SURGICAL MANAGEMENT stomach and promote gastric reflux;
● Endoscopic resection ● Avoid any activities that increase pain
● Radiofrequency ablation and to remain upright for 1 to 4 hours
after each meal to prevent reflux;
Nursing Diagnosis ● Head of the bed should be placed on
Based on the assessment data, the nursing 4- to 8- inch (10- to 20-cm) blocks;
diagnoses may include the following: ● Eating before bedtime is discouraged.
● Imbalanced nutrition, less than body ● Advise that excessive use of
requirements, related to difficulty over-the-counter antacids can cause
swallowing rebound acidity
● Risk for aspiration related to difficulty ● H2 antagonists are administered as
swallowing or to tube feeding prescribed to decrease gastric acid
● Acute pain related to difficulty irritation.
swallowing, ingestion of an abrasive
agent, tumor, or frequent episodes of
gastric reflux
● Deficient knowledge about the
esophageal disorder, diagnostic
studies, medical management,
surgical intervention, and rehabilitation

NURSING MANAGEMENT

Encouraging Adequate Nutritional Intake

● A baseline weight is obtained, and
daily weights are recorded.
● The patient's intake of nutrients is
assessed.
● Encourage the patient to eat slowly
and to chew all food thoroughly so that
it can pass easily into the stomach.
● Small, frequent feedings of
nonirritating foods are recommended
to promote digestion and to prevent
tissue irritation.
● Sometimes liquid swallowed with food
helps the food pass through the
esophagus, but usually liquids should
be consumed between meals.
● Food should be prepared in an
appealing manner to help stimulate
the appetite.
● Irritants such as tobacco and alcohol
should be avoided

Decreasing Risk of Aspiration

● Keep patient in at least a
semi-Fowler's position to decrease the
risk of aspiration;
● Instruct in the use of oral suction to
decrease the risk of aspiration further.

Relieving Pain
● Small, frequent feedings (six to eight
per day) are recommended because

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