Responses to Metabolic-Gastrointestinal
and Liver Alterations
1. Understanding the GI System
Assessment:
a. Health History
Current health Status
● Pain
● Heartburn
● Nausea
● Vomiting
● Altered bowel habits
Previous Health Status
● Ulcer
● gallbladder disease
● inflammatory bowel
● Disease
● GI bleeding
Family History
● Ulcerative colitis
● Colon cancer
● Stomach ulcers
● Diabetes
● Alcoholism
● Crohn’s Disease
Lifestyle Pattern
● Occupation
● Home life
● Financial status
● Stress level
● Recent life
● Changes
Physical Examination
1. Assessing the mouth
2. Assessing the abdomen
● Before inspecting the
abdomen, mentally divide it
into 4 quadrants
● Auscultation provides
information about bowel
motility and the underlying
vessels and organs
● Use abdominal percussion to
determine the size and
location of abdominal organs
and detect excessive
accumulation of fluid and air.
● Begin percussion in the right
lower quadrant and proceed
clockwise covering all four
quadrants
● Use direct or indirect
percussion
● Abdominal palpation includes
light and deep touch to
determine the size, shape,
position and tenderness of
major abdominal organs and
to detect masses and fluid
accumulation
Eliciting Abdominal Pain
● Rebound tenderness
● Iliopsoas sign
● Obturator sign
3. Assessing the liver
● Percussing the liver allows you to
estimate the size
● Hepatomegaly is commonly
associated with hepatitis and other
liver disease
● Percussing the liver
4. Assessing the rectum
● Perform a rectal examination
○ First inspect the perianal
area
○ ask the patient to strain, this
may reveal internal
hemorrhoids, polyps or
fissure
● Palpate the rectum
 - Inborn errors of metabolism (End stage
Diagnostic Tests liver disease, PPU)
● Esophagogastrodoudenoscopy - Those who have “taning”
(EGD) - Inability of therapies that offer long-term
survival
● Colonoscopy
- Those who do not have
● Endoscopy
contraindications/comorbidities (cardio-
pulmonary disease)
Laboratory Tests - Those who don’t have cancer
● Liver-Spleen Scan - Those who don’t have AIDS/STD’s
● MRI - No experience or history of chronic
● Fecal Analysis alcoholism/ drug addiction
● Percutaneous Liver Biopsy
● Peritoneal Fluid Analysis LeVeen Shunt Insertion (PVS-
Peritoneovenous shunt)
- From peritoneum connecting between
TREATMENTS:
the peritoneum cavity and the systemic
Drug therapy:
venous circulation
 Ammonia detoxicants
- Ascitic fluid is drain from abdominal
- Lactulose
cavity into the superior vena cava
- This device is use to control ascites
 Antacids
using LeVeen tube
- Aluminum hydroxide
- Magnesium hydroxide
Complications:
- Calcium carbonate
- Leakage of the ascitic fluid from the
incision
 Antidiuretic hormone
- Wound infection
- Vasopressin
- Subcutaneous bleeding (continuous
bleeding, patient may develop DIC or
 Antiemetics Disseminated intravascular coagulation-
- Dolasetron which is common in OB)
- Metoclopramide
Gastrointestinal Intubation
 Histamine-2 Receptor Antagonists  Nasoenteric
- Famotidine - Insertion of tube from mouth to small
- Ranitidine intestine
 Nasogastric
 Proton pump Inhibitors - Mouth to stomach
- Lansoprazole
- Omeprazole - How to measure: tip of nose, to tip of
pinna, to xiphoid process)
SURGERY: - Small intestine (Alkaline) = determine by
Liver Transplantation checking the pH, when still acid and the
- Life threatening liver problem litmus paper turns to red- acid; when
- Those who do not respond to any blue= alkaline (meaning the tube is in
treatments the duodenum)
Patients’ candidate to have liver transplantation: - Washing/ aspirating stomach contents=
- Congenital biliary abnormalities GASTRIC LAVAGE
- Chronic hepatitis - Feeding (GASTRIC GAVAGE)
 2. Minnesota esophagogastric tamponade
TYPES OF NG TUBES: tube
1. Levin tube
- One entry port
- For feeding or aspirating

2. Salem sump tube

- Used in ICU and CCU
- Has y-connector (pig tail)
- Allows atmospheric air to enter the
stomach
- Yung blue kay like pigtail which allows
atmospheric air to enter pt’s stomach.
So the tip of salem sump tube is just
float or nasa gitna so there is no
potential na makainjure sya stomach
- -
MULTILUMEN ESOPHAGEAL TUBE
PLACEMENT
- Has many entry-ports
- For emergency
- One entry port is for inflating the balloon
- There are a lot of entry port wherein ang
isang entry port kay sa inflating balloon
para pag may ruptured varices sa end
part of esophagus to be used as
esophageal tamponade
- 4 lumen/ entry ports
2 balloons for: gastric balloon
inflammation (elongated balloon- for
esophageal balloon; the other balloon is
for gastric balloon)
- 1 lumen= pressure monitoring port
- 1 lumen= gastric balloon inflammation
- 1 lumen= gastric aspiration lumen part
- 1 lumen= esophageal aspiration lumen
- 1 lumen= esophageal balloon pressure
monitoring port
- 1 lumen= esophageal balloon-inflation
lumen

1. Linton tube
3. Sengstaken-blakemore tube
- 3 entry ports
- Lower part of tube has balloon (for
compression when there is bleeding
- 1 port= gastric balloon inflation
- 1 port= for esophageal aspiration
- 1 port= gastric aspiration

- 3 entry ports
- Prevent bleeding
- Monitor patient for any signs and
symptoms of bleeding
- 1 lumen= gastric inflation
- 1 lumen= esophageal inflation
- 1 lumen= gastric aspiration
Complication:
- Necrosis of tissue (has frequency of
inflating and deflating given by the
physician)
NASOENTERIC DECOMPRESSION TUBE
- Use to aspirate intestinal contents for
analysis or to correct intestinal
obstruction
- Catheter is directly inserted into the
central venous line (superior vena cava_
via subclavian vein
2. Peripheral parenteral nutrition
- Inserted in periphery
- Full calorie needs
- To minimize risk of infection and
complication

1. Miller- Abbott Tube

COMMON GI DISORDERS:

1. Acute GI bleeding
2. Acute pancreatitis
3. Bowel infarction
4. Liver cirrhosis
5. Hepatic failure and encephalopathy
6. Intra-abdominal hypertension
- Has 2 entry port (one for suction; the
other is for bag inflation)

2. Dennis sump tube

NUTRITIONAL SUPPORT
Enteral (by mouth)
- Via NGT, nasoenteric tube or
gastrostomy tube

Parenteral nutrition
- Food is given via IV
- Expensive, high caloric intake
- Monitor blood sugar kasi pwede mag
shoot up ang sugar; be alter of
hyperglycemia

Types:
1. Total parenteral nutrition
- Lipids, amino acids
RESPONSES TO ALTRED PERCEPTION
Anatomy and Physiology
Function of Nervous System
- Provide rapid communication and integration
between various organs, as well as with the
outside environment.
- It detects changes within the body and in its
surroundings, and responds accordingly.
- Fast communication is achieved by means of
electrical signals known as nerve impulses,
which are generated and carried by specialized
cells, called neurons
Major Components of the Nervous System
 Brain
- Enclosed and protected in the cranium
- Central processing center
- it receives information, makes decision
and coordinates the body response
 Spinal cord
- Enclose in the spinal column
- Functions as a communication gateway
between the brain and the trunk and
the limbs
 Nerves
- Cordlike structures that conduct
information, similar to electricity-
conducting wires
- Composed of axons of neurons, the
cell bodies of which are clustered in
know-like structures called ganglia
- Ganglia commonly serve as relay
centers, where neurons synapse and
transmit information to each other
CNS : brain and spinal cord
PNS: nerves and ganglia
Sensory Nerve Fibers
- Carry sensory information from sensory
receptors to CNS
Motor Nerves
- Conduct instructions from the CNS to effector
organs like muscle and glands
Mixed Nerve
- Both sensory and motor
2 MAJOR GROUPS OF NERVES
1. Cranial nerves
- 12 pairs of nerves
- From base of the brain and relay
information between the brain and the
head and neck regions
- CN X (vagus): internal organs
2. Spinal nerves
- 31 pairs arise from segments of the
spinal cord and innervate the trunk and
limbs
- Communicate with the brain via spinal
cord
- Mixed nerves
PERIPHERAL NS
 Somatic
- Includes sensory nerves from the skin,
muscles, bones and joints and motor
nerves that innervate skeletal muscles
- Control voluntary muscular contractions
as well as involuntary somatic reflexes
 Visceral
- Includes sensory division that detects
changes in the viscera like the organs
in the thoracic and abdominal cavities
and motor division that controls cardiac
muscle, smooth muscle of internal
organs and glands
- It produces, for example faster heart
rate and breathing rate during physical
exercise, and slower cardiorespiratory
rate during sleep
Autonomic NS, acting independently of the body’s
consciousness and voluntary control
Neurologic Assessment
 Health History
- Patients current state of health
- Ask reason of hospitalization; chief
complaint
- Common complaint: headache, any
motor disturbance like weakness in
upper/ lower extremities or presence
paresis/ paralysis, complaints of
 seizure, sensory deviation or any
altered LOC
- Previous health status
- Head injury r/t accidents, history of
major illnesses, surgeries , allergies
- Lifestyle
- Smoking, drug addiction, education
level, occupation, hobbies
- Family’s health
- Family history of disease like cardiac,
renal disease, hypertension, cancer,
mental disease etc.
 Physical Examination
- Mental Status
- 3 Parameters : Assess LOC, speech,
cognitive functions
- LOC
- 4 levels: alert, obtunded/lethargic,
stuporous, coma
1. Alert- oriented, follow command,
immediately responds, completely
and appropriately responds to any
stimuli (verbal/pain)
2. Obtunded/lethargy – drowsy but
delayed response to verbal
stimuli, sleep again
3. Stuporous – respond to pain
stimuli, need vigorous stimuli for
patient to respond
4. Comatose- totally no response
- Tool used GSC- Glasgow coma scale
 Eye opening response (4)
 Spontaneous, eye
opening to speech,
pain, none
 Verbal response (5)
 Oriented
 Confused
 Inappropriate
words
 Incomprehensible
words
 None
 Motor response (6)
 Immediately when
asked
 Localizes
 Withdraw
 Abnormal flexion
(decerebrate,
decorticate)
 Abnormal
extension
 None
- Speech
- Slurred speech
- Cognitive Functions
- Consider educational level
- Test memory: remote and recent
- Assess orientation
- Attention span
- Cranial Nerve Functions
- 12 cranial nerves
 Olfactory
 Optic
 Oculomotor
 Trochlear
 Trigeminal
 Abducens
 Facial
 Acoustic/vestibulocochlear
 Glossopharyngeal
 Vagus
 Spinal Accessory
 Hypoglossal
- Checking brain stem function
o Oculocephalic reflex
 Doll’s eye – eye goes to the
side where the head is
turned, or no movement of
eyes.
 NORMAL: eyes move to the
opposite side.
 Indicates: deep coma, severe
brain stem damage
- Oculovestibular reflex
 Instilling of ice or cold water
in the ear
 Normal: eye movement is
goes to the instilled ear
 Before checking, assess that
there is no ear infection and
tympanic membrane is intact
because to prevent infection
and additional injury to the
patient’s ear
  If the patient is conscious  Lifting of the
there is nystagmus(kadali) testicles : indicates
 Comatose, brain stem intact L1, L2
lesions – no movement
- Pupils sizes
- PERRLA
 Pupils are Equal, Round,
Reactive to Light and
Accommodation
- Sensory Function
- Check or assess the ability or function
of sensory receptors to detect stimuli
- Test 5 sensations
 Pain
 Light touch
 Vibration
 Position
- Motor Functions
Deep Tendon
- Aid in evaluating in different structures
0 – absent
in the neuro like cerebral cortex,
corticospinal tracts, muscles, 1+ - present reflex but nawawala
cerebellum, and nasal ganglia 2+ - normal
- Assess the muscular parts like 3+ - increased reflexes
resistance of muscle to passive 4+ - hyperactive
stretching, arm muscle movement, leg Superficial reflexes
movement, weakness of the periphery  Abdomen - 0 or 1+
- Test balance: Romberg’s Test
Diagnostic Tests
- Reflexes
 Imaging Studies
- Assess the deep tendon reflex and
o Computed Tomography Scan
superficial reflexes to assess the
o Magnetic Resonance Imaging
integrity of the sensory receptor organs
o Positron Emission Tomography Scan
- Testing the Deep tendon reflex
 This provides the colorimetric
 Biceps
information about the brain’s
 Triceps
metabolic activity
 Brachioradialis
o Skull and Spinal X-rays
 Pattelar
 Achilles tendon reflex  Angiography
- Superficial reflexes o Uses radio optic contrast medium
 Pharyngeal reflex  Check if the patient is allergic
 Gag reflex to iodine or shellfish
 Abdominal reflex o Cerebral angiography
 Test the thoracic o Digital subtraction angiography
spinal segments  Highlights the cerebral blood
(T8,9,10) vessel
 Cremasteric Reflex  Uses fluoroscopy
 Test the lumbar  Computer aided
area (L1,L2)  Uses dye to see if there are
blood clots, emboli,
 Tongue blade to
aneurysm
scratch the inner
 Electrophysiologic studies
part of the thigh
o Electroencephalography (EEG)
  Records the brain’s electrical  For cerebral edema
activity o Diuretics
 Used to diagnosed patients o Thrombolytics
with seizure activity, brain  Surgery
injury, intracranial lesion or o Craniotomy
any masses, tumors, TIA, to  Surgery commonly involves
rule out if patient is brain opening the skull and expose
dead. the brain
o Evoked Potential Studies (EPS)  Indicated for ventricular
 Used to measure the nervous shunting, excising tumors or
system electrical response to abscess, aneurysm for
visual, auditory or sensory aneurysm tapping
stimulus  Patient are at risk for
 Other Tests infections, hemorrhage,
o Lumbar Puncture respiratory compromise and
 Common in spinal anesthesia increased ICP
 2 positions:  Signs and Symptoms for
 Fetal position (llie increased ICP:
down)  Vomiting
 Knees are flexed  Nausea
(sitting)  Headache
 Used for CS  Increased BP
 Aspirate of CSF (increase- systolic;
 Indicated to detect blood in decrease –
the CSF or for CSF analysis, diastolic)
used to inject dye for any  Widening pulse
radiologic studies pressure
 Contraindicated to patients  Change of mental
with lumbar deformity and for status
patients with infection in the o Restlessn
puncture site ess
 Used in caution for patients o Confusio
with increased ICP
n
o Transcranial Doppler Studies
o Seizure
 Visualize the blood flow in
 Shall breathing
the cerebral arteries
 If not managed pt
 Provides the information for
will go to coma
the presence, quality, and
o Cerebral aneurysm repair
nature of blood flow in the
brain  Clipping of aneurysm
 Other Treatments
o Barbiturate Coma
Treatments  Conventional treatment
 Medication Therapy  Injecting high IV dose of
o Analgesics short acting barbiturate
o Anticonvulsants  Pentobarbital
o Anticoagulants and antiplatelets  Reduce the patient’s
o Barbiturates metabolic rate and cerebral
o Benzodiazepines blood flow
 ULTIMATE GOAL: relieve
o Calcium channel blockers
increased ICP and protect
o Corticosteroids
cerebral tissue
  Risky 2. Jacksonian seizure
 Last resort 3. Sensory seizure
INCREASED ICP 4. Complex partial seizure
- Increased ICP is defined as a 5. Secondarily generalized partial seizure
sustained elevation in pressure above 6. Generalized seizure
20mmHg 7. Absence seizure/petit mal seizure
- ICP<15mmHg – Intracranial 8. Myoclonic seizure
hypertension 9. Clonic seizure
 Acute 10. Tonic seizure
 Chronic 11. Generalized clonic-tonic seizure
12. Atonic seizure
Levels ICP in mmHg
Normal 5-15
Mild 16-20
Moderate 21-30
Severe 31-40
Very Severe 41 & Above

 Cerebrospinal fluid drainage

o Insertion of tube or catheter to drain if
there is presence of infection in the
CSF or hydrocephalus
o Goal is to the reduced ICP to desired
level and maintain
o Fluid is drawn from the lateral ventricle
 Procedure is ventriculostomy
 Plasmapheresis
o Blood from the patient flows in the cell
from formed elements
o Separates plasma and plasma will be
filtered to remove toxins, O2 antibodies

Common Disorders
 Acute Spinal Cord Injury
 Arteriovenous malformation
o Arteries are dilated and tangled
o Usually in cerebral blood vessels
 Cerebral aneurysm
 Encephalitis
 Guillain-Barre Syndrome
o Muscle weakness
o Peripheral nerves are demyelinated
o Autoimmune and progressive
 Head injury
o Contusion
o Concussion
 Meningitis
 Stroke
 Seizure

Types of Seizure
1. Partial seizure