IX.

GASTROINTESTINAL
A. Pancreatitis:
1. Pathophysiology:
a. The pancreas has two separate
functions:
1) Endocrine- INSULIN
2) Exocrine- DIGESTIVE enzymes
b. Two types of pancreatitis:
1) Acute: #1 cause = ALCOHOL
#2 cause = gallbladder disease
2) Chronic: #1 cause =
PANCREATITIS
2. S/S:
a. Pain- Does the pain increase or
decrease with eating? INCREASE
b. Abdominal distention/ascites
(losing protein rich fluids like
enzymes and blood
into the abdomen) ascites
c. Abdominal mass- swollen
PANCREAS
d. Rigid board-like abdomen
(guarded)
What does it mean? PERITONITIS
e. Bruising around umbilical area
CULLEN sign; flank area GREY
TURNERS sign.
f. Fever (inflammation)
g. N/V
h. Jaundice
i. Hypotension = BLEEDING or
ASCITIS
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3. Dx:
a. Serum lipase and amylase
INCREASE
b. WBCs INCREASE
c. Blood sugar INCREASE
d. ALT, AST-liver enzymes
INCREASE
e. PT, PTT PROLONGED.
(BLEEDING)
f. Serum bilirubin INCREASE
g. H/H (Hemoglobin & Hematocrit)
UP or DOWN
Why down BLEEDING , up
DEHYDRATED.
***Please note that all normal ranges
for blood test depend on the lab
performing the test.
The values listed in this book are only
to be used as a reference.
4. Tx:
a. Goal: Control pain
1) Decrease gastric secretions (KEEP
NPO, NGT to suction, bed rest)
Want the stomach empty and dry
2) Pain Medications:
PCA narcotics morphine
sulfate(Morphine), hydromorphone
(Dilaudid)

Fentanyl patches
3) Steroids, why? DECREASE
INFLAMMATION
4) Anticholinergics, why? DRY UP
THE STOMACH ACIDS
Benzotropine
(Cogentin)Diphenoxylate/Atropine
(Lonox)
5) Pantoprazole (Protonix) (proton
pump inhibitor)
6) Ranitidine HCI (Zantac),
Famotidine (Pepcid) (H2 receptor
antagonist)
7) Antacids
8) Maintain fluid and electrolyte
balance
9) Maintain nutritional status ease
into a diet
10) Insulin WHY?
PANCREAS IS SICK
STEROIDS MAKE IT GO UP
GETTING A TPN
Normal Lab Values
AST=8-40 U/L
ALT= 10-30 U/L
Normal Lab
Values
Hemoglobin:
Male: 14-18 g/dl
Female: 12-16
g/dl
Hematocrit:
Male: 40-54%
Female: 38-47%
Normal Lab Values
Amylase: 45-200 U/L (dye)
Lipase: 0-110 U/L
*TESTING STRATEGY*
Pancreas client = Keep stomach empty
and dry.
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11) Daily weights
12) Eliminate alcohol
13) Refer to AA if this is the cause.
B. Cirrhosis:
Liver DETOXIFYING the body.
Helps your blood to CLOT
The liver helps to metabolize
(break down) DRUGS, DECREASE
THE DOSE. NEVER GIVE
ASPIRIN.
The liver synthesizes ALBUMIN
1. Pathophysiology:
Liver cells are destroyed and are
replaced with connective/scar tissue
alters the
CIRCULATION within the liver the
BP in the liver goes UP, this is called
portal HYPERTENTION
2. S/S:
a. FIRM, nodular liver

b. Abdominal pain liver capsule has

stretched
c. Chronic dyspepsia (GI upset)
d. Change in BOWEL habits
e. Ascites
f. Splenomegaly
g. DECREASED serum albumin
HOLD ON THE FLUID IN THE
VASCULAR SPACE
h. INCREASED ALT & AST
LIVER ENZYMES
i. Anemia
j. Can progress to hepatic
encephalopathy/coma
*TESTING STRATEGY*
If your liver is sick your
#1 concern = Bleeding.
*TESTING STRATEGY*
Never give Tylenol to liver people.
*TESTING STRATEGY*
When spleen is enlarged the immune
system is involved.
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3. Dx:
a. Ultrasound
b. CT, MRI
c. Liver biopsy
Clotting studies pre- PT and PTT
Vital signs pre-procedure
How do you position this client?
SUPINE WITH RIGHT ARM
BEHIND THE HEAD
Exhale and hold DIAPHRAM
Why? To get the DIAPHRAM out of
the way.
Post: Lie on RIGHT side
Vital signs, worried about
HEMORRHAGE.
4. Tx:
a. Antacids, vitamins, diuretics
b. No more ALCOHOL (dont need
more damage)
c. I & O and daily WEIGHT (Any
time you have ascites you have a fluid
volume problem)
d. Rest
e. Prevent bleeding (bleeding
precautions)
f. Measure abdominal girth, why?
ASCITIS
g. Paracentesis:
Removal of fluid from the
PERITONAL cavity (ascites)
Have client void
Position SITTING UP/FOWLERS
Vital signs
h. Monitor jaundice good SKIN
care, CUT FINGERNAILS.
i. Avoid NARCOTICS - liver cant
metabolize drugs well when its sick
*TESTING STRATEGY*

Anytime you are pulling

fluids throw them into
shock.
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j. Diet:
Decrease protein
Low Na diet
C. Hepatic Coma:
1. Pathophysiology:
a. When you eat protein, it transforms
into AMMONIA, and the liver
converts it to urea. Urea can be
excreted through the kidneys without
difficulty.
b. When the liver becomes impaired
then it cant make this conversion, so
what
chemical builds up in the blood?
AMMONIA
c. What does this chemical do to the
LOC? AMMONIA
2. S/S:
a. Minor mental changes/motor
problems
b. Difficult to AWAKE.
c. Asterixis- FLAPPING FINGERS
d. HANDWRITING changes
e. Reflexes will decreases.
f. EEG SLOWS DOWN.
g. What is Fetor? Breath smells like
AMMONIA.VERY STONG BREATH
SMELL.
h. Anything that increases the
ammonia level will aggravate the
problem.
i. Liver people tend to be GI bleeders.
3. Tx:
a. Lactulose (Lactulax, Duphalac)
(decrease serum ammonia)
b. Cleaning enemas
c. Decrease PROTEIN in the diet
d. Monitor serum ammonia
Lets Get Normal Straight First!
Protein Breaks down to
ammonia The Liver converts
ammonia to urea Kidneys excrete
the urea
*TESTING STRATEGY*
If you give liver client narcotics its
the same thing
as double dosing them.
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D. Bleeding Esophageal Varices
1. Pathophysiology:
a. High BP in the liver (PORTAL
HTN) forces collateral circulation to
form.
This circulation forms in 3 different
places stomach, esophagus, rectum
b. When you see an alcoholic client
that is GI bleeding it is usually
esophageal

varices.
Usually no problem until
RUPTURES.
2. Tx:
a. Replace BLOOD
b. VS
c. CVP
d. Oxygen (any time someone is
ANEMIC, Oxygen is needed)
e. Octreotide (Sandostatin) lowers
BP in the liver.
f. Sengstaken Blakemore Tube
What is the purpose? To hold
PRESSURE on bleeding varices
g. Cleansing enema to get rid of
h. Lactulose (Neo-Fradin) (decrease
ammonia)
i. Saline lavage to get blood out of
STOMACH
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E. Peptic Ulcers:
1. Pathophysiology:
a. Common cause of GI BLEEDING
b. Can be in the esophagus, stomach,
duodenum
c. Mainly in males or females?
MALES, BUT INCREASING IN
FEMALES
d. Erosion is present
2. S/S:
a. Burning PAIN usually on the midepigastric area/back
b. Heartburn (dyspepsia)
3. Dx:
a. Gastroscopy (EGD, endoscopy):
1) NPO pre
2) Sedated
3) NPO until what returns? GAG
REFLEX
4) Watch for perforation by watching
for PERFORATION, bleeding, or
SWALLOWING.
b. Upper GI:
1) Looks at the esophagus and
stomach with dye
2) NPO past midnight
3) No smoking, chewing gum, or
mints. Remove the nicotine patch, too.
Smoking INCREASE stomach
SECRETIONS which will affect
the test.
Smoking INCREASE stomach
SECRETIONS
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4. Tx:
a. Medications:
1) Antacids: Liquids or tablets?
LIQUIDS (to ____________stomach)
Take when stomach is empty and at
bedtime when stomach is empty

acid can get on ulcer take antacid to

protect ulcer.
2) Proton Pump Inhibitors: (decrease
acid secretions)
Omeprazole (Prilosec),
Lansoprazole (Prevacid),
Pantoprazole
(Protonix), Esomeprazole
(Nexium)
3) H2 antagonist: Ranitidine
(Zantac), Famotidine (Pepcid)
GI Cocktail (donnatel, viscous
lidocaine, Mylanta II)
Antibiotics for H. Pylori:
Clarithromycin (Biaxin),
Amoxicillin
(Amoxil), Tetracycline
(Panmycin), Metronidazole
(Flagyl)
Sucrafata (Carafate): forms a
barrier over wound so acid cant get
on the
ulcer
b. Client Teaching:
Decrease STRESS
Stop SMOKING
Eat what you can tolerate; avoid
temperature extremes and extra spicy
foods;
avoid CAFFEINE (irritant).
Need to be followed for one year
5. Classifications:
a. Gastric ulcers: laboring person;
malnourished, pain is usually half
hour to 1 hour
after meals; food doesnt help, but
VOMITTING does; vomit blood
b. Duodenal ulcers: executives; wellnourished; night time pain is common
and 2-3
hours after meals; FOOD helps; blood
in stools
F. Hiatal Hernia:
1. Pathophysiology:
a. This is when the hole in the
diaphragm is too large so the
STOMACH moves up
into the thoracic cavity.
b. Other causes of hiatal hernia:
congenital abnormalities, trauma, and
SURGET
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2. S/S:
a. Heartburn
b. FULLNESS after eating
c. Regurgitation
d. Dysphagia (difficulty
SWALLOWING)
3. Tx:
a. Small frequent meals

b. Sit up 1 hour after eating Keep the

stomach in down position.
c. Elevate HOB
d. Surgery
e. Teach life style changes and healthy
diet
G. Dumping Syndrome:
1. Pathophysiology:
The stomach empties too quickly
and the client experiences many
uncomfortable
to severe side effects usually
secondary to gastric bypass,
gastrectomy, or gall
bladder disease.
2. S/S:
a. Fullness
b. Palpitations
c. Faintness
3. Tx:
d. Weakness
e. Cramping
f. Diarrhea
a. Semi-recumbent with meals
b. Lie down after meals
c. No FLUIDS with meals (drink in
between meals)
d. Decrease CARBS (carbs empty
fast)
*TESTING STRATEGY*
Lay on left side to keep food in the
stomach.
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H. Ulcerative Colitis and Crohns
Disease:
1. Pathophsiology:
a. Ulcerative Colitis ulcerative
inflammatory bowel disease
Just in the large intestine
b. Crohns Disease also called
Regional Enteritis; inflammation and
erosion of
the ILEUM *can be found anywhere
2. S/S:
a. Diarrhea
b. Rectal bleeding
c. Weight loss
f. Dehydration
g. Blood in stools
h. Anemia
d. Vomiting
i. Rebound tenderness
e. Cramping j. Fever
What is rebound tenderness? Push
in let go HURTS
What does it mean? Peritoneal
INFLAMMATION
3. Dx:
a. CT
b. Colonoscopy
CLEAR liquid diet for 12-24 hours.

NPO 6-8 hours pre

Avoid NSAIDs
Laxatives or enemas until CLEAR
Go-LYTELY
Sedated for procedure
Post op watch for ANTI-EMETIC.
We are going to assume the
WORST!
c. Barium Enema
BE or lower GI
Done if colonoscopy was
incomplete
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4. Tx:
a. Diet:
High fiber or low fiber? LOW
FIBER
Trying to limit motility to help save
fluid.
Avoid cold foods or hot foods and
smoking
All of these can INCREASE motility.
b. Medications:
Anti-diarrheals
Only given with mildly symptomatic
ulcerative colitis clients; does not
work well in severe cases.
Antibiotics
Steroids (decrease
INFLAMMATION)
c. Surgery:
1) Ulcerative Colitis:
Total Colectomy (ilesostomy
formed)
Kocks ileostomy or a J Pouch (no
external bag)
A Kocks Pouch has a nipple valve
that opens and closes to
EMPTY intestines
The J Pouch procedure removes the
colon and attaches the ileum into
the rectum.
2) Crohns: (try not to do surgery)
May remove only the ILEUM area.
The client may end up with an
ileostomy or a colostomy. It just
depends
on the area affected.
d. Post op Care:
1) Ileostomy Care:
Its going to drain LIQUID all the
time.
Avoid foods hard to digest; rough
foods INCREASE motility.
Gatorade in the summer
At risk for kidney stones (always a
little DEHYDRATED)
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2) Colostomy Care:

What happens as waste moves

through the colon?
Water and nutrients are being
absorbed and the STOOL is
forming.
Colostomy ascending and
transverse semi LIQUID stools
Colostomy descending or
sigmoid semi formed or FORMED.
Which one do you irrigate?
SIGMOID & DECENDING
Why regulate? FOR
REGULARITY OF STOOLS
When is the best time to irrigate?
Same TIME everyday
After a MEAL
The further down the colon the
stoma is, the more formed the stool
will be
because WATER is being drawn out.
The stool is more normal.
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I. Appendicitis:
1. Pathophysiology:
Related to a LOW fiber diet
2. S/S:
Generalized pain initially
Eventually localizes in the right lower
quadrant (McBurneys POINT)
Rebound tenderness
Nausea and vomiting
Get good history (abdominal pain
1st then N & V)
Anorexia
3. Dx:
WBC INCREASE
Ultrasound
CT
Do not do enemas because you are
worried about what? RUPTURE
4. Tx:
Surgery
Most done via laparoscope unless
perforated.
After any major abdominal surgery,
what is the position of choice?
SITTING ON THE RIGHT SIDE
*TESTING STRATEGY*
#1 thing to worry about is
rupture.
*TESTING STRATEGY*
Positioning is very important to learn
as a brand new nurse.
*TESTING STRATEGY*
Never want pressure on a suture line.
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J. Hyperalimentation (total parental
nutrition) (TPN):
1. Nursing Considerations:

Keep refrigerated; warm for

administration; let sit out for a few
minutes prior to
hanging.
Central line needed
Filter needed
Nothing else should go through this
line (dedicated line)
Discontinued gradually to avoid
HYPOGLYCEMIA
Daily WEIGHTS
May have to start taking INSULIN
Accu-checks q6 hours
Check URINE (for GLUCOSE &
KETONES)
Do not mix ahead- mixture changes
everyday according to electrolytes.
Can only be hung 24 hours
Change tubing with each new bag.
IV bag may be covered with dark
bag to prevent chemical breakdown.
Needs to be on a pump

Home TPN-emphasize hand

washing
Most frequent complication
INFECTION
*TESTING STRATEGY*
Protein cant leak through the
glomerulus unless there is kidney
damage.
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2. Assisting the MD insert a central
line:
Have saline available for flush; do
not start fluids until positive
confirmation of
placement (CXR). (3) 10cc syringe
Position? TRENDELENBURG to
distend veins.
If air gets in the line what position
do you put the client in?
LEFT SIDE TREDELENBURG
When you are changing the tubing,
how can you avoid getting air in the
line?
Clamp it off

Valsalva
Take a deep BREATH and
HUMMMMMM
Why is an x-ray done postinsertion?
Check for PLACEMENT
Make sure your client does not have a
PNEUMOTHORAX.
NCLEX Critical Thinking
Exercise:
A nurse is assisting a physician
inserting a central line, for a client
diagnosed with sepsis. After
inserting the central line. Which of the
following options would be most
appropriate?
1. Start the ordered antibiotics.
2. Allow the physician to start the
antibiotics as ordered.
3. Check for blood return and if
present start the antibiotics ordered.
4. Administer the stat antibiotics after
you have confirmation of placement of
the central line.