MEDICAL SURGICAL NURSING

GASTROINTESTINAL SYSTEM
The GIT System: Anatomy and Physiology • Abdominal
The GI system is composed of two general o Inspection, Auscultation, Percussion &
parts Palpation
GI TRACT o Position: Lie supine & knee flexed
Mouth- Esophagus- Stomach- SI- LI (4 quadrants & 9 regions)
ACCESSORY ORGANS: o Note: skin changes, nodule, lesions,
• Salivary glands scarring, discoloration, inflammation,
• Liver bruising & striae
• Gallbladder o Contour and symmetry (expected is
• Pancreas flat, rounded & scaphoid)
GASTROINTESTINAL ASSESSMENT • Auscultation
• Laboratory Procedures o Normal bowel sounds: irregularly
• Health History range from 5-30 per minute and it is
• Abdominal pain heard every 5-20 seconds
• Dyspepsia o Hypoactive: 1 or 2 sounds in 2 minutes
• Gas o Hyperactive: 5 to 6 sounds in less than
30 seconds
• Nausea and vomiting
o Absent: no sound in 3 to 5 minutes
• Diarrhea
o Bruits sounds, Friction rub &
• Constipation
Borborygmi (stomach growling)
• Fecal incontinence,
• Percussion
• Jaundice
o Use for the size & density of the
• Previous GI disease
abdominal organs and to detect
• Past health, Family, and Social History presence of air-filled, fluid- filled or solid
• Oral care (lesions, thrush) masses.
• Dental visit o Tympani- presence of air in the
• Food discomfort stomach and small intestine
• Sore throat or bloody sputum o Dullness- heard over organs & solid
• Use of alcohol & tobacco masses.
• Past and current medication use & previous • Rectal Inspection and Palpation
diagnosis, treatment, and surgery o Position: knee chest, left lateral with
• Current nutritional status, lab test hip and knee flexed, or standing with
• Changes in eating and appetite hips flexed and upper body supported
• Psychosocial, spiritual, or cultural factors by the examination table.
PHYSICAL ASSESSMENT o What to look for?
• Oral Cavity ✓ Fistula
o Inspection and Palpation ✓ Fissures
o NO DENTURES ✓ Rectal prolapse
• Lips ✓ Polyps
o Inspection ✓ Hemorrhoids
o Locate and Inspect Stensen duct General Nursing Intervention for GI diagnostic
• Gums evaluation
o Inspection • Establishing nursing diagnoses
o Odor, Hard palate • Providing needed information about the test
• Tongue and the activities required for the patient.
o Inspection • Providing instruction and post procedure care
o Tonsil, Uvula & soft palate and activity restrictions
o Frenelum • Providing health information and procedural
education to patient and significant others.
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
• Informing the primary provider of known
medical conditions or abnormal laboratory
values
• Assessing for adequate hydration before,
during and immediately after the procedure.
COMMON LABORATORY PROCEDURES
• FECALYSIS
o Examination of stool consistency, color
and the presence of occult blood.
o FOBT
o FIT- use monoclonal antibodies to
detect the globin protein in human hgb
o Stool DNA to test colon cancer
• SERUM LABORATORY STUDIES
o CBC
o Prothrombin Time
o Triglycerides
o Liver function test, amylase & Lipase
o CEA
o CA
o Alpha-fetoprotein
• BREATH TEST
o To evaluate carbohydrate absorption
o Bacterial overgrowth in the intestine
and short bowel syndrome
o Urea breath test- presence of H-Pylori
• ABDOMINAL ULTRASOUND
o Enlarge gall bladder or pancreas,
presence of gallstone on enlarge ovary,
ectopic pregnancy and appendicitis.
o Endoscopic Ultrasonography (EUS)-
provide direct imaging of a target area.
o The patient is instructed to fast for 8-12
hours before the test
✓ Fat free meal ( Gallbladder)
✓ If barium is to be performed, it should
be done after Ultrasound.
• GENETIC TESTING
o For people who are at risk for certain
GIT disorder.
• IMAGING STUDIES
o X-ray
o CT scan
o MRI
o PET
o Scintigraphy (radionuclide imaging)
o Virtual colonoscopy
◼ contrast is totally eliminated.
• UPPER GIT STUDY
o Upper GI fluoroscopy- contrast agent
(barium sulfate), thin sulfate barium,
diatrizoate sodium and water- low
associated risk
o Detects ulcer, varices, tumors, regional
enteritis and malabsorption syndrome
o Double contrast-administration of
thick barium suspension (esophagus &
stomach)
o Enteroclysis – very detailed, use
barium and methylcellulose (partial
small bowel obstruction and
diverticula).
• PREPARATIONS PRIOR TO THE TEST
o Clear liquid diet with NPO from
midnight the night before the study.
o No smoking & Chewing gum during
NPO (increase gastric secretion &
salivation)
o Bowel cleansing – using Polyethylene
glycol (most effective cleanser agent)
o Oral meds are withheld on the morning
of the study & resume evening.
o Insulin requirements will be adjusted
accordingly if client is with DM
• LOWER GIT STUDY
• Lower GIT study: barium enema
o Examines the lower GI tract
o Barium sulfate is usually used as
contrast.
o Detects polyps, Tumor, or other lesions of
Large intestine
o It takes 15-30 minutes, during which time x-
ray images is obtained.
• Double Contrast Study
o Also called air – contrast barium enema
(instillation of thick barium followed by the
instillation of air.
o It detects small lesions
o The patient feels some cramping or
discomfort during the test
• Water Soluble Contrast Study
o Water Soluble iodinated contrast agent
o ex. Diatrizoic Acid/ Gastrografin
o Test for Active Inflammatory disease,
fistulas or perforation.
o Check for allergy to iodine
o Patient may experience diarrhea until
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
• NURSING INTERVENTION
• Preparation of patient
✓ Emptying & Cleansing of lower bowel
✓ Low residue diet 1-2 days before the test
✓ Clear liquid and laxative evening before the
test
✓ NPO after midnight
✓ Cleansing enema until the return is clear
the following morning.
✓ Enema- CONTRAINDICATED- active
inflammatory disease.
✓ Barium Enema is CONTRAINDICATED in
patient with sign of obstruction and
perforation. (They can use water soluble
contrast study)
✓ Laxative and enema is
CONTRAINDICATED for active GI
bleeding
• COMPUTED TOMOGRAPHY
• It provides cross sectional images of
abdominal organs and structures.
• It is viewed in computer monitor.
• Valuable tool for detecting many
inflammatory conditions in the colon
(appendicitis, diverticulitis, regional
enteritis, ulcerative colitis, disease of liver,
pancreas, spleen, kidney and pelvic
organs.
• It can be performed with or without oral or
IV contrast
• NURSING INTERVENTION
✓ Check for allergy (corticosteroids &
antihistamine)
✓ Current serum creatinine level
✓ Pregnancy status (Contrast)
✓ Kidney protective measure (IV sodium
bicarbonate 1 hour before and 6 hours
after IV contrast and oral N- acetylcysteine
(Mucomyst) before and after the study (free
radical scavenger)
• MRI
o Supplemental for US and CT scan
o It uses magnetic fields and radio-waves
to produce image.
o Abdominal soft tissue, blood vessels,
fistula, abscesses, neoplasms and
other source of bleeding.
o Use oral contrast agent
o No METAL
• NURSING INTERVENTION
✓ Prior the test
✓ NPO 6-8 hours before the test
✓ Removal or jewelry/ metal
✓ It takes 60-90 min (the technician may ask
deep breath at specific interval)
✓ CLAUSTROPHOBIA
✓ Noise- knocking sound (headset or listen to
music or wear blindfold)
• PET
o It produces images of the body by detecting
the radiation emitted from radioactive
substances. It is injected into the body IV
and are usually tagged with radioactive
isotopes of oxygen, nitrogen, carbon or
fluorine. The scanner essentially “captures”
where the radio active substances are in
the body, transmit information to a scanner
and produces a scan with “hot spots” for
evaluation by radiologist or oncologist.
• Scintigraphy
o Radionuclide testing –relies on the use of
radio- active isotopes (ex. Iodine, indium,
technetium)
o Reveal displaced anatomic structure,
changes in organ size and presence of
neoplasm or lesions like cyst or abscesses
o also used to measure the uptake of tagged
RBC and leukocytes
o Abnormal concentration of blood cells are
then detected at 24 and 48 hours interval.
o Tagged cells are useful in determining the
source of internal bleeding when all other
studies have returned a negative result.
• Gastrointestinal Motility Studies
o Radionuclide testing also used to assess
gastric emptying and colonic transit time.
During gastric emptying studies, the liquid
and solid components of a meal ( typically
scrambled eggs) are tagged with
radionuclide markers. After ingestion of the
meal, the patient is positioned under
scintiscanner, which measure the rate of
passage of the radioactive substance from
the stomach.
o Useful in diagnosing disorders of gastric
motility, diabetic gastroparesis and
dumping syndrome.
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
• COLONIC TRANSIT STUDIES
o Used to evaluate colonic motility and
obstructive defecation syndrome.
o The amount of time that it takes for the
radioactive material to move through the
colon indicates colonic motility.
ENDOSCOPIC PROCEDURE
• EGD (esophagogastroduodenoscopy)
o Visualization of the upper GIT by insertion
of lighted fiberscope
• Endoscopic Retrograde
Cholangiopancreatography (ERCP)- it uses
endoscope in combination with x-rays to view
the bile ducts, pancreatic ducts and gall
bladder
• Upper GI Fibroscopy- therapeutic endoscopy
can be used to remove common bile duct
stones, dilate strictures, and treat gastric
bleeding and esophageal varices.
• NURSING INTERVENTION
✓ Prior to examination:
✓ NPO for 8 hours
✓ Before the introduction of the endoscope,
the patient is given a local anesthetic
gargle or spray.
✓ Midazolam (Versed)- a sedative to relieve
anxiety
✓ Atropine to reduce secretion
✓ Glucagon to relax smooth muscle
✓ Patient is position left lateral to facilitate
clearance of pulmonary secretions and
provide smooth entry of the scope.
COMMON LABORATORY PROCEDURES
LOWER GI- SCOPY
✓ Use of endoscope to visualize the large
intestine
NURSING INTERVENTION
✓ Warm tap water or fleet enema until the
return is clear
✓ No sedation required
✓ During procedure, monitor V/S, skin color
and Temp, pain tolerance and vagal
response.
✓ After procedure: WOF bleeding, intestinal
perforation. (fever, rectal drainage,
abdominal distention and pain)
COMMON LABORATORY PROCEDURES
GASTRIC ANALYSIS
• Yields information about the secretory activity
of the gastric mucosa and the presence or
degree of gastric retention in patient thought to
have pyloric or duodenal obstruction.
• Aspiration of gastric juice to measure pH,
appearance, volume and contents
• Useful in diagnosing Zollinger-Ellison
syndrome or atrophic gastritis.
NURSING INTERVENTION
✓ NPO 8-12 hours before the procedure
✓ Medication that affects gastric secretions
are withheld for 24 – 48 hours before the
test
✓ No smoking on the morning of the test
because it increases gastric secretion.
COMMON LABORATORY PROCEDURES
CHOLECYSTOGRAPHY
• Injection of a dye and an x-ray examination to
visualize the gallbladder
COMMON LABORATORY PROCEDURES
PARACENTESIS
• Removal of peritoneal fluid for analysis
COMMON LABORATORY PROCEDURES
LIVER BIOPSY
• Invasive procedure where needle is inserted
into the liver to remove a small piece of tissue
for study
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
COMMON GIT SYMPTOMS AND UPPER GI SYSTEM
MANAGEMENT CONDITION OF THE ESOPHAGUS
DUMPING SYNDROME HIATAL HERNIA
• A condition of rapid emptying of the gastric • Protrusion of the esophagus into the
contents into the small intestine usually after a diaphragm may be caused by congenital
gastric surgery weakening of the muscle in the diaphragm
• Symptoms occur 10-30 minutes after eating around the esophagogastric opening.
ASSESSMENT FINDINGS: early symptoms • More common in women
1. Nausea and Vomiting, early satiety TYPES
2. Abdominal fullness, diarrhea • Sliding Esophageal Hernia
3. Abdominal cramping, pain • Paraesophageal Hernia
4. Diaphoresis and tachycardia – Initial Sign ASSESSMENT FINDINGS IN HIATAL HERNIA
(Resolve after 1 hour or with defecation) 1. Heartburn - PS
LATER SIGN 2. Regurgitation
1. Hypoglycemia (2-3 hrs after eating) 3. Dysphagia
2. Burning epigastric pain increase after meal 4. Intermittent epigastric pain
(Bile reflux) 5. Fullness after eating
DS NURSING INTERVENTIONS LARGE HIATAL HERNIA CAN HAVE:
1. Advise patient to eat LOW-carbohydrate HIGH- • Intolerance in food
fat and HIGH-protein diet • Nausea and vomiting
2. Instruct to eat SMALL frequent meals, include ANY TYPE CAN HAVE:
MORE dry items. • Hemorrhage
3. Instruct to AVOID consuming FLUIDS with • Obstruction
meals • Strangulation
4. Instruct to LIE DOWN after meals DIAGNOSTIC TEST
MEDICATION FOR BILE REFLUX
• X-ray
• Sucralfate (Carafate)
• Barium swallow
• Cholestyramine (Questran)- prevent
• EGD
reabsorption of bile (stool)
• CT Scan
NURSING INTERVENTIONS
GIT SYMPTOMS AND MANAGEMENT
1. Provide small frequent feedings
PERNICIOUS ANEMIA
2. AVOID supine position for 1 hour after eating
• Results from Deficiency of vitamin B12 due to
3. Elevate the head of the bed on 4-8 inch block
autoimmune destruction of the parietal cells,
4. Avoid activities that increases intra-abdominal
lack of INTRINSIC FACTOR or total removal
pressure
of the stomach
SURGERY
PERNICIOUS ANEMIA ASSESSMENT
• Surgical Hernia Repair (to manage the GERD
• Severe pallor
symptoms)
• Fatigue
• Laparoscopy with open transabdominal or
• Weight loss transthoracic approach ( bleeding, adhesion or
• SMOOTH BEEFY-RED TONGUE injury in spleen)
• Paresthesia of extremities • After surgery: Liquid to solid diet slowly
NURSING INTERVENTION FOR PERNICIOUS • WOF post-op belching , vomiting, gagging,
ANEMIA abdominal distention and epigastric chest pain
• Lifetime injection of Vitamin B 12 weekly (Surgical revision)
initially, then MONTHLY
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
CONDITION OF THE ESOPHAGUS DEVIRTICULUM
ESOPHAGEAL VARICES Esophageal diverticulum- is an outpouching of
• Dilation and tortuosity of the submucosal veins mucosa and submucosa that protrudes through
in the distal esophagus the weak portion of the musculature of the
• ETIOLOGY: commonly caused by PORTAL esophagus.
hypertension secondary to liver cirrhosis.
(elevated pressure in the veins that drains in SITE:
the portal system. • Pharyngoesophageal- upper
• This is an Emergency condition! • Midesophageal - middle
ASSESSMENT FINDINGS FOR EV • Epiphrenic - lower
1. Hematemesis • Zenker diverticulum - most common type,
2. Melena caused by dysfunctional sphincter that fail to
3. Signs of shock if bleeding is severe open
4. Ascites • Midesophageal diverticula – uncommon
DIAGNOSTIC PROCEDURE • Epiphrenic diverticula – larger diverticula due
• Endoscopy/Esophagoscopy to malfunction of lower esophageal sphincter
• US or motor disorder of esophagus.
• CT scan • Intramural diverticulosis – numerous small
LABORATORY TEST diverticula associated with a stricture in the
• Liver Function Test (AST) Bilirubin, Alkaline upper esophagus.
Phosphatase and serum protein CLINICAL MANIFESTATION
• Splenoportography, hepatoportography, celiac • Dysphagia – primary symptoms
angiography • Fullness in the neck
NURSING INTERVENTIONS FOR EV • Belching
1. Monitor VS strictly. Note for signs of shock • Regurgitation
2. Prepare for blood transfusion, IV fluids, volume • Gurgling noise after eating
expander • Coughing
3. Assist with Sengstaken-Blakemore tube • Halitosis – decomposition of food retained in
4. Assist in iced saline irrigation diverticula
NOTE: DIAGNOSTIC EXAM
• Non surgical tx of bleeding EV is preferable • Barium Swallow – nature and location
because of high mortality rate of emergency • Manometric – motor disorder
surgery to control bleeding and because of
• Esophagoscopy is CONTRAINDICATED
having Liver cirrhosis.
because of danger in perforation
PHARMACOLOGIC MNGT.
• Blind insertion of NG tube should be avoided
• Sandostatin Octreotide- Control bleeding
MANAGEMENT
• Vasopressin (Petressin)- decrease portal SURGERY
pressure
• Diverticulectomy
• Beta-blocker- (Propranolol, nadolol) decrease
• Myotomy of cricopharyngeal muscle- to relieve
portal pressure and use to prevent first
spasticity
bleeding episode. And should not be use in
• Endoscopic Stapler Diverticulectomy – reduce
acute bleeding. (Prophylaxis only)
risk of fistula and does not require NGT
NURSING MANAGEMENT
1. Observe for leakage and developing fistula
2. Food and fluids are withheld until x-ray studies
shows no leakage
3. Diet: start with liquid to tolerated
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
GASTROESOPHAGEAL REFLUX DISEASE BARRET ESOPHAGUS
• Backflow of gastric or doudenal contents into • Lining of the esophagus is altered, in
the esophagus association with GERD.
• Usually due to incompetent lower esophageal • The cells changes from squamous to columnar
sphincter , pyloric stenosis, hiatal hernia or lined epithelium, which resembles the
motility disorder intestines.
ASSOCIATED CONDITION • BE is the only known precursor to
• Tobacco use ESOPHAGEAL CARCINOMA
• Coffee drinking CLINICAL MANIFESTATION
• Alcohol consumption • Symptoms of GERD
• Gastric infection with H Pylori • Symptoms related PUD
ASSESSMENT ( for GERD) • DX Exam
✓ Heartburn • EGD – (Red rather than Pink)
✓ Dyspepsia • Biopsy – high grade dysplasia (abnormal
✓ Regurgitation changes in the cell)
✓ Epigastric pain MANAGEMENT
✓ Difficulty swallowing • Surveillance with biopsy
✓ Hypersalivation • PPI
✓ esophagitis • Endoscopic resection
DIAGNOSTIC TEST • Radiofrequency ablation (kills surrounding
• EGD cells and tissue)
• Barium Swallow • Metal stent
• Bilitec (measure bile reflux)
• Esophageal PH monitoring ACHALASIA
NURSING INTERVENTIONS • ABSENT OR INEFFECTIVE peristalsis of the
1. Instruct the patient to AVOID stimulus that distal esophagus accompanied by failure of the
increases stomach pressure and decreases esophageal sphincter to relax in response to
GES pressure swallowing.
2. Instruct to avoid spices, coffee, milk, beer, CLINICAL MANIFESTATION
peppermint, tobacco and carbonated drinks ✓ Dysphagia (solid and liquid)
3. Instruct to eat LOW-FAT, HIGH-FIBER diet ✓ Regurgitation
1. 4.Avoid foods and drinks TWO hours before ✓ Non- cardiac chest or epigastric pain
bedtime ✓ Heartburn (Pyrosis)
4. Elevate the head of the bed with an ✓ Aspiration of gastric content ( secondary
approximately 30 degree/ 8-inch block complication)
5. Avoid increasing weight; tight-fitting clothes DIAGNOSTIC EXAM
MEDICATION • X-Ray
• Antacid/H2 blocker- if reflux persist • Barium swallow
• Proton-pump inhibitors-decrease release of • CT-scan of the chest
gastric acid • Endoscopy
SURGERY • Manometry (Confirmatory test)- a process in
• Open or Laparoscopic Nissen Fundoplication which peristalsis, contraction amplitudes and
(wrapping of a portion of the gastric fundus esophageal pressure is being measured.
around the sphincter area of the esophagus. MANAGEMENT
• Eat slowly and to drink fluid with meals.
• Nitrates and Calcium channel blocker- to
decrease esophageal pressure and improve
◼ swallowing.
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
• Botox (Botulinum toxin)- inhibit contraction of NURSING INTERVENTIONS
smooth muscle. 1. Give BLAND diet
• Pneumatic Dilation – to stretch the narrowed 2. Monitor for signs of complications like
area of the esophagus. bleeding, obstruction and pernicious anemia
SURGERY 3. Instruct to avoid spicy foods, irritating foods,
• ESOPHAGOMYOTOMY- cutting esophageal alcohol and caffeine
muscle fibers. (perform laparoscopic) 4. Administer prescribed medications- H2
• ENDOSCOPIC MYOTOMY (Per Oral blockers, antibiotics, mucosal protectants
Endoscopic Myotomy – POEM) 5. Inform the need for Vitamin B12 injection if
deficiency is present
GASTRITIS
• Inflammation of the gastric mucosa PEPTIC ULCER DISEASE
• May be Acute or Chronic • An ulceration of the gastric and duodenal lining
• Erosive or Non-erosive • May be referred as to location as Gastric ulcer
• Etiology: Acute- bacteria (non-erosive), in the stomach, or Duodenal ulcer in the
irritating foods, NSAIDS, alcohol, bile and duodenum
radiation (erosive) GASTRIC ULCER
• Etiology: Chronic- Ulceration, bacteria, • Risk factors: Stress, smoking, NSAIDS abuse,
Autoimmune disease, diet, alcohol, smoking Alcohol, Helicobacter pylori infection, and
ASSESSMENT (ACUTE) History of gastritis
✓ Dyspepsia • Incidence is high in older adults
✓ Epigastric pain • Acid secretion is NORMAL
✓ Anorexia ASSESSMENT (GASTRIC ULCER)
✓ hiccup 1. Epigastric pain
✓ Melena ✓ Characteristic: Gnawing, sharp pain in the
✓ hematochezia mid-epigastrium 1-2 hours AFTER eating,
ASSESSMENT (CHRONIC) often NOT RELIEVED by food intake,
✓ Pyrosis sometimes AGGRAVATING the pain!
✓ Belching, sour taste (mouth) 2. Nausea
✓ N/V/anorexia 3. Vomiting (more common)
✓ Pernicious anemia 4. Hematemesis
DIAGNOSTIC PROCEDURE 5. Weight loss
• EGD DIAGNOSTIC PROCEDURES
• Biopsy • EGD to visualize the ulceration
• CBC • Gastric analysis
MEDICAL MANAGEMENT • Upper GI series
• Supportive (IV & Medication) NURSING INTERVENTIONS
• Gastrojejunostomy 1. Give BLAND diet, small frequent meals and
CHRONIC GASTRITIS avoid acid-producing substances
• Modification of diet 2. Administer prescribed medications- H2
blockers, PPI, mucosal barrier protectants and
• Rest, reduction of stress, no alcohol &
antacids
medication.
3. Monitor for complications of bleeding,
• For H. Pylori (Antibiotic & Bismuth Salt)
perforation and intractable pain
4. Provide teaching about stress reduction and
relaxation techniques
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
DUODENAL ULCER CONDITIONS OF THE LARGE INTESTINE
• Ulceration of duodenal mucosa and ULCERATIVE COLITIS
submucosa • Ulcerative and inflammatory condition of the
• Usually due to increased gastric acidity GIT usually affecting the large intestine
DUODENAL ULCER ASSESSMENT • The colon becomes edematous and develops
1. PAIN Characteristic: bleeding ulcerations
Burning pain in the mid-epigastrium 2- • Cause: Unknown, contributing factors include
4 HOURS after eating or during the allergies, autoimmune reaction
night, RELIEVED by food intake ASSESSMENT FINDINGS FOR UC
DIAGNOSTIC TESTS ✓ Anorexia
• EGD ✓ Weight loss
NURSING INTERVENTIONS ✓ Fever
1. Same as for gastric ulceration ✓ SEVERE diarrhea with Rectal bleeding
2. Patient teaching-avoid alcohol, smoking, ✓ Anemia
caffeine and carbonated drinks ✓ Dehydration
3. Take NSAIDS with meals ✓ Abdominal pain and cramping
4. Adhere to medication regimen NURSING INTERVENTIONS for CD and UC
1. Maintain NPO during the active phase
2. Monitor for complications like severe bleeding,
dehydration, electrolyte imbalance
3. Monitor bowel sounds, stool and blood studies
4. Restrict activities
5. Administer IVF, electrolytes and TPN if
prescribed
6. Instruct the patient to AVOID gas-forming
foods, MILK products and foods such as whole
grains, nuts, RAW fruits and vegetables
SURGICAL PROCEDURES FOR PUD especially SPINACH, pepper, alcohol and
• Total gastrectomy, vagotomy, gastric caffeine
resection, Billroth I and II, 7. Diet progression- clear liquid→ LOW residue,
esophagogastrojejunostomy high protein diet
8. Administer drugs- anti-inflammatory,
CONDITIONS OF THE SMALL INTESTINE antibiotics, steroids, bulk-forming agents and
CROHN’S DISEASE vitamin/iron supplements
• Also called Regional Enteritis
• An inflammatory disease of the GIT affecting CONDITIONS OF THE LARGE INTESTINE
usually the small intestine APPENDICITIS
• Cause: Unknown, contributing factors include • Inflammation of the vermiform appendix
allergies, autoimmune reaction • ETIOLOGY: usually fecalith, lymphoid
ASSESSMENT findings for CD hyperplasia, foreign body and helminthic
✓ Fever obstruction
✓ Abdominal distention PATHOPHYSIOLOGY
✓ Diarrhea • Obstruction of lumen increased pressure
✓ Colicky abdominal pain decreased blood supply bacterial
✓ Anorexia/N/V proliferation and mucosal inflammation
✓ Weight loss ischemia necrosis rupture
✓ Anemia
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
ASSESSMENT FINDINGS FOR APPENDICITIS • Second Degree- prolapse outside the anal
✓ Abdominal pain: begins in the umbilicus then canal during defecation but reduce
localizes in the RLQ (Mc Burney’s point) spontaneously.
✓ Anorexia • Third Degree – prolapse to the extent that they
✓ Nausea and Vomiting require manual reduction.
✓ Fever • Fourth Degree- prolapse to the extent that they
✓ Rebound tenderness and abdominal rigidity (if may not be reduced.
perforated) EXTERNAL HEMORRHOIDS
✓ Constipation or diarrhea • These dilated veins lie below the internal anal
DIAGNOSTIC TESTS sphincter
1. CBC- reveals increased WBC count • Usually, the condition is PAINFUL
2. Ultrasound ASSESSMENT FINDINGS FOR HEMORRHOIDS
3. Abdominal X-ray ✓ Internal hemorrhoids- cannot be seen on the
NURSING INTERVENTIONS peri-anal area
1. Preoperative care ✓ External hemorrhoids- can be seen
• NPO ✓ Bright red bleeding with each defecation
• Consent ✓ Rectal/ perianal pain
• Monitor for perforation and signs of shock ✓ Rectal itching
• POSITION of Comfort: RIGHT SIDELYING DIAGNOSTIC TEST
in a low FOWLER’S 1. Anoscopy
• Avoid Laxatives, enemas & HEAT 2. Digital rectal examination
APPLICATION NURSING INTERVENTIONS
2. Post-operative care 1. Advise patient to apply cold packs to the
• Monitor VS and signs of surgical anal/rectal area followed by a SITZ bath
complications 2. Apply astringent like witch hazel soaks
• Maintain NPO until bowel function returns 3. Encourage HIGH-fiber diet and fluids
• POSITION post-op: RIGHT side-lying, 4. Administer stool softener as prescribed
semi- fowler’s to decrease tension on 5. Good personal hygiene
incision, and legs flexed to promote • Reduce Engorgement
drainage • Warm compress
• Administer prescribed pain medications • Sits baths
• Analgesic ointments
HEMORRHOIDS • Suppositories
• Abnormal dilation and weakness of the veins of • Astringents
the anal canal • Gel Foam
• Variously classified as Internal or External Post-operative care for hemorrhoidectomy
PATHOPHYSIOLOGY 1. Position: Prone or Side-lying
• Increased pressure in the hemorrhoidal tissue 2. Maintain dressing over the surgical site
due to straining, pregnancy, obesity, heavy 3. Monitor for bleeding
lifting, etc→ dilatation of veins 4. Administer analgesics and stool softeners
INTERNAL HEMORRHOIDS 5. Advise the use of SITZ bath 3-4 times a day
• These dilated veins lie above the internal anal
sphincter DIVERTICULOSIS AND DIVERTICULITIS
• Usually, the condition is PAINLESS DIVERTICULOSIS
DEGREE OF PROLAPSE • Abnormal out-pouching of the intestinal
• First Degree- do not prolapse and protrude into mucosa occurring in any part of the LI most
anal canal commonly in the sigmoid
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
Diverticulitis ANAL FISSURE
• Inflammation of the diverticulosis • Is a longitudinal tear or ulceration in the lining
DIVERTICULOSIS AND DIVERTICULITIS of the canal usually just distal to the denate
Etiology: line.
✓ Stress • Caused by trauma (passing of large firm stool)
✓ Congenital weakening of the muscular fibers of • Childbirth
the intestine • Anal sex
✓ Dietary deficiency of fiber • Sign & Symptoms
ASSESSMENT findings for D/D • Painful defecation
✓ Left lower Quadrant pain • Burning
✓ Bowel irregularities • Bleeding (bright red blood after bowel
✓ Rectal bleeding movement)
✓ nausea and vomiting MANAGEMENT
✓ Fever
• Fiber supplement
DIAGNOSTIC STUDIES
• Stool softener
• If no active inflammation, COLONOSCOPY
• Bulk agent, increase OFI
and Barium Enema
• Sits bath
• CT scan is the procedure of choice!
• Medication
• Abdominal X-ray
• Nitroglycerine ointment
NURSING INTERVENTIONS
• Ca Channel blocker
1. Maintain NPO during acute phase
• Botox
2. Provide bed rest
3. Administer antibiotics, analgesics like • This agents works by increasing blood supply
meperidine (morphine is not used) and anti- and relaxing anal sphincter.
spasmodics
4. Monitor for potential complications like Conditions of the GIT accessory organ
perforation and hemorrhage CONDITION OF THE LIVER
5. Increase fluid intake LIVER CIRRHOSIS
6. Avoid gas-forming foods or HIGH-roughage • A chronic, progressive disease characterized
foods containing seeds, nuts to avoid trapping by a diffuse damage to the hepatic cells
7. introduce soft, high fiber foods ONLY after the • The liver heals with scarring, fibrosis and
inflammation subsides nodular regeneration
8. Instruct to avoid activities that increase intra- • Etiology: post-infection, alcohol, cardiac
abdominal pressure diseases, biliary obstruction
ASSESSMENT FINDINGS
ANAL FISTULA ✓ Anorexia and weight loss
• A tiny tubular, fibrous tract that extends into the ✓ Jaundice
anal canal from an opening located beside the ✓ Fatigue
anus in the perianal skin. Result from abscess. ✓ Easy bruising
• With purulent drainage ✓ RUQ abdominal pain
• Stool leakage ✓ Changes in mood, alertness and mental ability
✓ Signs of Portal hypertension
• Passage of flatus or stool in vagina or bladder
NURSING INTERVENTIONS
• Systemic infection (untreated)
1. Monitor VS, I and O, Abdominal girth, weight,
SURGERY
LOC and Bleeding
• Fistulectomy – excision of the fistulous tract
2. Promote rest. Elevated the head of the bed to
minimize dyspnea.
3. Provide Moderate to LOW-protein (1 g/kg/day)
and LOW-sodium diet
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
4. Provide supplemental vitamins (especially K)
and minerals
5. Administer prescribed
6. Diuretics= to reduce ascites and edema
7. Lactulose= to reduce NH4 in the bowel
8. Antacids and Neomycin= to kill bacterial flora
that cause NH production
9. Avoid hepatotoxic drugs
✓ Paracetamol
✓ Anti-tubercular drugs
10. Reduce the risk of injury
✓ Side rails reorientation
✓ Assistance in ambulation
✓ Use of electric razor and soft-bristled
toothbrush
11. Keep equipments ready including
Sengstaken-Blakemore tube, IV fluids,
Medications to treat hemorrhage
THE GALLBLADDER
CHOLECYSTITIS
• Inflammation of the gallbladder
• Can be acute or chronic
• Acute cholecystitis usually is due to gallbladder
stones
• Chronic cholecystitis is usually due to long
standing gall bladder inflammation
• Formation of GALLSTONES in the biliary
apparatus
PATHOPHYSIOLOGY
• There are two major types of gallstones: those
composed pre- dominantly of pigment and
those composed primarily of cholesterol.
Pigment stones probably form when
unconjugated pigments in the bile precipitate to
form stones
• Cholesterol, a normal constituent of bile, is
insoluble in water. Its solubility depends on bile
acids and lecithin (phospholipids) in bile. In
gallstone-prone patients, there is decreased
bile acid synthesis and increased cholesterol
synthesis in the liver, resulting in bile
supersaturated with cholesterol, which
precipitates out of the bile to form stones.
PREDISPOSING FACTORS
• Female
• Fat
• Forty
• Fertile and Fair
ASSESSMENT FINDINGS FOR
CHOLECYSTITIS
✓ Indigestion, belching and flatulence
✓ Fatty food intolerance, steatorrhea
✓ Epigastric pain that radiates to the scapula or
localized at the RUQ after heavy meal
✓ Mass at the RUQ
✓ Murphy’s sign
✓ Jaundice, pruritus, dark amber urine
DIAGNOSTIC PROCEDURES
• Ultrasonography
• Radionuclide Imaging
• Or Cholescintigraphy
• Cholecystography
• Endoscopic retrograde
• cholangiopancreatography (ERCP) permits
direct visualization of structures that could
once be seen only during laparotomy.
NURSING INTERVENTIONS
1. Maintain NPO in the active phase
2. Maintain NGT decompression
3. Administer prescribed medications to relieve
pain. Usually Demerol (MEPERIDINE)
• Codeine and Morphine may cause
spasm of the Sphincter→ increased pain.
Morphine cause MOREPAIN
4. Instruct patient to AVOID HIGH- fat diet and
GAS-forming foods
5. Surgical procedures- Cholecystectomy,
Choledochotomy, laparoscopy
POST-OPERATIVE NURSING INTERVENTIONS
1. Monitor for surgical complications
2. Position client in semi-fowlers or side lying.
3. Encourage early ambulation
4. Administer medication before coughing and
deep breathing exercises
5. Advise client to splint the abdomen to prevent
discomfort during coughing
THE PANCREAS: EXOCRINE FUNCTION
PANCREATITIS
• Inflammation of the pancreas
• Can be acute or chronic
• Etiology and predisposing factors
• Alcoholism
• Hypercalcemia
• Trauma
• Hyperlipidemia
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
PATHOPHYSIOLOGY OF ACUTE 8. Introduce oral feedings gradually- HIGH carbo,
PANCREATITIS LOW FAT
• Self-digestion of the pancreas by its own
digestive enzymes principally TRYPSIN • Situation: Ms Annie is a 50 y/o executive
• Gallstones enter the common bile duct and who has come to the emergency room w/ a
lodge at the ampulla of Vater, obstructing chief complain of “vomiting” of 2 days
the flow of pancreatic juice or causing a re- duration.
flux of bile from the common bile duct into Ms annie vomited blood several times. The
the pancreatic duct, thus activating the vomiting of blood is knows as
powerful enzymes within the pancreas. a) Melena
Normally, these remain in an inactive form b) Hyperemesis
until the pancreatic secretions reach the c) Hematemesis
lumen of the duodenum. Activation of the d) Dyspepsia
enzymes can lead to vasodilation,
increased vascular permeability, necrosis, In taking Ms. Anne’s medical history, the nurse
erosion, and hemorrhage should also determine if Mrs. Anderson had
ASSESSMENT FINDINGS any
✓ Abdominal pain and tenderness and back pain a) Melena
result from irritation and edema of the in- b) Hyperemia
flamed pancreas that stimulate the nerve c) Hematemesis
endings. d) Hematinemia
✓ Abdominal guarding
✓ A rigid or board-like abdomen Ms. Annie complains of gnawing stomach pain.
✓ Ecchymosis (bruising) in the flank or around It is important to determine if this pain
the umbilicus may indicate severe pancreatitis. a) Occurs while eating
✓ N/V, jaundice b) Is relieved by food
✓ Hypotension and hypovolemia c) Occurs upon awakening
✓ HYPERGLYCEMIA, HYPOCALCEMIA d) Is relieved by coffee
✓ Signs of shock
Ms. Annie reports having difficulty in
DIAGNOSTIC TESTS swallowing. The appropraite term to charted
• Serum amylase and serum lipase would be
• CT scan/Ultrasound a) Anorexia
• WBC b) Dyspepsia
• Serum calcium decreased c) Dysphagia
diagnostic laparotomy) d) Eructation

NURSING INTERVENTIONS The term pyrosis refers to

1. Assist in pain management. Usually, Demerol a) Fever
is given. Morphine is AVOIDED b) Esophageal burning
2. NGT insertion to decompress distention and c) Excessive vomiting
remove gastric secretions d) Air swallowing
3. Place patient on NPO to inhibit pancreatic
stimulation
4. Maintain on bed rest
5. Position patient in SEMI-FOWLER’s or knee
chest position to decrease pressure on the
diaphragm
6. Avoid caffeine products and alcohol
7. Provide parenteral nutrition
 MEDICAL SURGICAL NURSING
GASTROINTESTINAL SYSTEM
Subsequently Ms. Annie is admitted to the hospital
with a tentative diagnosis of peptic ulcer, the
physician orders a GI series.
To prepare Ms. Annie for the GI series, the
nurse must
a) Give enema until clear
b) Keep the patient NPO after midnight
c) Insert a levine tube
d) Administer a laxative at bedtime

The GI series confirms the diagnosis of peptic

ulcer and Ms. Annie is out on a controlled diet.
Which of the following foods are permitted on
a liberal diet?
a) Beer and wine
b) Tacos
c) Coffee and Cola beverages
d) Raw fruits and vegetables