NCM 116 Lecture - Prelim PDF

MEDICAL SURGICAL NURSING (PRELIM) NCM 116 LECTURE
- Intestinal Cells
NURSING CARE OF CLIENTS WITH DIGESTIVE - Parietal cells - produces and secretes
PROBLEMS gastric juice HCL acid (pH1) and Intrinsic
Factors (Vit. B12 binding protein)
- Mucous Neck Cells - production of sticky
mucus and clings to mucosa as protection
from HCL and digestive enzymes.
- Chief cells - production of protein digesting
enzymes (Pepsin)
SMALL INTESTINE
● Chemical digestion
● Absorption of nutrients, vitamins, electrolytes
● Parts:
○ Duodenum
○ Pancreatic Duct
■ Pancreas - secretes pancreatic enzymes
■ Trypsin - breakdown protein
■ Amylase - starch
■ Lipase - fats
■ Alkaline in pH because of high concentration
of bicarbonate, alkaline pH help neutralize
acid
○ Ampulla of Vater
○ Common Bile Duct
■ Gallbladder - stores and secretes bile
● Emulsify fats
● Absorbs fats and fat soluble Vits
GASTROINTESTINAL TRACT (ADEK)
MOUTH ■ Liver - Produces Bile
● Ingestion and mastication ● Yellow to green fluid containing bile
salts, bile pigments (Bilirubin),
PHARYNX cholesterol
● Passageway for air, food, fluids ○ Jejunum
○ Ileum
EPIGLOTTIS ■ Ileocecal valve
● Flap the open and closes to prevent food or fluids
2 TYPES OF CONTRACTIONS
enter the trachea
1. Peristalsis
ESOPHAGUS
- propels contents toward the colon
● Secretes mucus, passageway and facilitates 2. Segmentation
movement of food - produces mixing waves that move contents
back and forth in churning motion
STOMACH
● Temporary storage
LARGE INTESTINE
● Break down food by churning & churning to turn it
into CHYME consistency (heavy cream) ● Water and Na Ion absorption temporary storage of
● Parts: fecal matter; Elimination.
○ Lower Esophageal or Cardioesophageal sphincter ● Parts:
○ Fundus ○ Ileocecal Valve
○ Cecum
○ Body
○ Appendix
○ Pylorus ○ Colon
○ Pyloric Sphincter - Ascending
○ On the gastric lining: - Transverse
- Descending
- Gastric Pits ○ Sigmoid
- Gastric Glands ○ Rectum
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○ Anal canal, internal and external sphincter - Intestinal gas

❖ BELCHING – expulsion of gas
Components Of Large Intestine: from stomach to mouth.
● Bacteria, assist in completing the breakdown of the ❖ FLATULENCE – expulsion of gas
waste materials (undigested / unabsorbed proteins from the rectum.
and bile salts) - Nausea & Vomiting
● 2 types of colonic secretions: - Change in bowel habits and stool
1. Bicarbonate solution – to neutralize. characteristics.
2. Mucus – protects the colonic mucosa.
● ONSET – when it is started?
Peristalsis: ● LOCATION – Where? Radiating?
● Slow and weak – move the colonic components. ● DURATION – How long it last? Recurring?
● Intermittent and strong propel contents for ● SEVERITY – mild, mod, severe? Pain scale.
considerable distance.
TYPES OF ABDOMINAL PAIN
WASTE PRODUCT OF DIGESTION
1. Visceral Pain
● FECES consist of: ● Caused by distension hollow organs or stretching
o Undigested food of solid organs
o Inorganic materials ● Description: Crampy, Achy, Dull, Burning, Colicky,
o Water Poorly Localized.
o Bacteria ● Onset: Gradual
● Brown color – results from the breakdown of bile
by the intestinal bacteria. 2. Parietal Pain
● Fecal odor is chemically formed by the intestinal ● Caused by inflammation or irritation of parietal
bacteria. peritoneum e.g. appendicitis, peritonitis
● Description: Sharp, stabbing pain, Steady and
ACCESSORY DIGESTIVE ORGANS
severe, Tenderness, Guarding, Rigidity, Rebound,
Well Localized.
Teeth
● Onset: Sudden
Salivary glands
● Secretes 1.5L of saliva a day to lubricate and
REFERRED ABDOMINAL PAIN:
facilitate swallowing.
- Pain occurs, travels or refers from the primary site and
● Contains mucus, water, enzyme, ptyalin or
becomes highly localized at DISTANT SITES
salivary amylase to break down starches.
- Parotid
- Submandibular
- Sublingual
Pancreas
Liver / Gallbladder
● Metabolism of CHON, CHO, and FATS
● Secretes bile
● Detoxifies various substances (drug and
hormones)
● Vitamin metabolism – stores vit. A, B, K, and B12
HEALTH HISTORY
● Collection of subjective data PAST HEALTH HISTORY

● Nursing health history ● Any gastrointestinal disorder or conditions in the past?
1. Present health concern ● Had any infections?
2. Past health history ● Had any abdominal surgery or trauma?
3. Family history ● Taking any prescribed or OTC medications?
4. Lifestyle and health pattern
PRESENT HEALTH HISTORY FAMILY HISTORY

➔ To help elicit information about the current symptoms: ● Any history of GIT diseases or disorders in the family?
Use COLDSPA mnemonic as your guide.
● CHARACTER – Describe the sign or symptom
e.g. LIFESTYLE AND HEALTH PRACTICES
- Abdominal pain ● Alcohol consumption and cigarette smoking
- Dyspnea ● Coffee and food preferences and consumption
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● Activities, exercises, stress level REGIONS AND QUADRANTS OF ABDOMEN
Key Points For Assessment:

● Explain each aspect of the examination to ease
anxiety level and obtain cooperation.
● Provide privacy.
● Position on supine with knee flexed
● Sequence of the abdominal assessment; not to alter
● Patterns of bowel sounds.
- Inspection
- Auscultation
- Percussion (use diaphragm of the stethoscope)
- Palpation
● Void first (distended bladder interfere accurate
examination)
ORGANS PER QUADRANT
● Observe verbal and non – verbal cues.
INSPECTION
OBSERVE COLORATION OF SKIN

● Redness, Pale, Yellowish, Bruises, Hematoma
- Inspect for stretch marks/scars (ask the source of
scar, measure the length, document the location
and appearance of scar
● Nonhealing, redness, inflamed, keloids

- Assess for lesions and rashes
● Changes in mole size, color, border symmetry,

wounds CONDITIONS PER REGION
- Inspect the umbilicus
● Purple or bluish discoloration around umbilicus

(Cullen’s Signs)
- Indicate intra-abdominal bleeding, deviated,
everted
INSPECT ABDOMINAL CONTOUR

● Distended or generalized protuberant from
obesity, air or fluid accumulation, scaphoid
(sunken) seen with severe weight loss
- Assess abdominal symmetry
● from organ enlargement, large masses, bulging of

abdominal wall from hernia, bowel obstruction
- Inspect abdominal movement when breathing
● Diminished abdominal respiration

- Observe aortic pulsation
● Exaggerated pulsation with abdominal aortic

aneurysm
- Observe for peristaltic waves
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NATURE OF VOMITUS ● Electrolyte imbalances

● Hormonal abnormalities
● Mechanical bowel obstruction, ileus
● Drugs (laxative abuse, anticholinergic agents,
opiates)
● Loss of innervation (Hirschsprung's disease)
● Neuromuscular (paralysis, spinal cord injury or
sacral lesion, multiple sclerosis)
● Anorectal disorders (hemorrhoids, fecal impaction,
cancer, abscess, fissures)
DISORDER OF THE MOUTH

STOMATITIS
➔ Inflammation of the oral cavity
➔ Types:
1. Primary
DIARRHEA - APHTHOUS STOMATITIS or canker sores
- Most common type
Causes:
- Benign and non-contagious
● Infectious agents (Escherichia coli, Salmonella, 2. Secondary
Shigella,Campylobacter, Glardia, Amoeba, Clostridium - Candidiasis or oral thrush
difficile, Cyclospora, Cryptosporidium, Rotavirus) - May be due to overgrowth of normal flora
● Food poisoning
● Drugs (antibiotics, magnesium)
● Fecal impaction Etiology:
● Bowel disease (irritable bowel syndrome, ulcerative ● Infection e.g. herpes zoster or cytomegalovirus,
colitis) syphilis etc.
● Malabsorption syndromes (lactose Intolerance, Celiac ● Allergy to coffee, potatoes, cheese, nuts, citrus fruits
sprue, fat malabsorption) ● Vitamin deficiency eg. Vitamin B folate, zinc and iron
● Short bowel syndrome ● Systemic disease e g. HIV chronic renal failure,
inflammatory bowel disease
● Irritants eg. tobacco and alcohol
Characteristics Of Stool:
● Chemotherapy and Radiation
1. Appearance ● Trauma
● Tarry black (melena) - Upper GI bleed
● Bright red blood - Lower GI bleed
● Blood streaking on surface of stool or on toilet
paper - Lower rectal or anal bleeding
2. Other characteristics with specific problem

● Bulky, greasy, foamy, foul smelling, gray with
silvery sheen-steatorrhea (fatty stool)
● Light gray "clay colored" (due to absence of bile
pigment, acholic)-biliary obstruction
● Mucus or pus visible-chronic ulcerative colitis
● Small, dry, rocky-hard masses-constipation ● CANKER SORES- whitish gray center and
obstruction erythematous ring
● Marble-sized stool/ pellets-spastic colon syndrome ● Whitish plaque-like lesion, appears red and sore when
wipe away - COMMON IF WITH CANDIDIASIS
● Dysphagia
DYSPHAGIA (DIFFICULTY IN SWALLOWING)
● Dry or hot sensation on area of lesions
➔ onset ( acute or gradual), intermittent, continuous ● Elevation of temperature - RARE
● Pain
CONSTIPATION
➔ frequency, consistency, color, blood/mucus,size. Laboratory Assessment
Change in bowel habits, diet. ● COMPLETE BLOOD COUNT- may reveal
➔ CAUSES: INFECTION.
● Inadequate fluid intake psychological factors
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● CYTOLOGIC CULTURE and GRAM STAIN and causes undesirable symptoms such as pain and
TESTING - to identify the CAUSATIVE respiratory distress
MICROORGANISM
Nursing Care:
● Provide ORAL CARE EVERY 2 HOURS and twice
at night
● Use SOFT-BRISTLED TOOTHBRUSH OR FOAM
SWABS to stimulate gums and clean the oral cavity
● Use SODIUM BICARBONATE solution (baking
soda), WARM SALINE or Chlorhexidine 2%
aqueous mouth wash in rinsing the mouth Avoid
COMMERCIAL MOUTHWASHES
● Provide SOFT, BLAND and NON ACIDIC foods
● Apply TOPICAL ANALGESICS or ANESTHETICS
as prescribed
● Administer prescribed medication
Drug Therapy
TYPE OF DRUG CONSIDERATIONS

STOMATITIS
General Tetracycline USUAL DOSE - 250mg/10ml for

Syrup 10 days
INSTRUCTION: rinse for 2 mins
then swallow
Herpes Acyclovir USUAL DOSE - 5mg/kg for 1

Simplex (Zovirax) hour IV q 8hr
INSTRUCTION: make sure
client has no renal problem
Fungal Nystatin USUAL DOSE - 600,000 units

(Mycostatin) QID oral suspension
Anti-Inflammatory Agents And Immune Modulators Cause:

● Triamcinolone in Benzocaine ● INAPPROPRIATE RELAXATION of lower esophageal
● Dexamethasone sphincter or inability of the LES to close fully
● Amlexanox
● Amlexanox Predisposing Factors:
● Thalidomide ● Ingestion of LARGE INTESTINE
● Condition associated with DECREASED GASTRIC
Symptomatic Topical Agents For Pain EMPTYING
● Benzocaine ● Recumbent or SUPINE positioning after eating.
● Camphor phenol ● Insertion of nasogastric tube (NGT)
● 15 ml 2 % viscous Lidocaine gargle of mouthwash ● INCREASED INTRAABDOMINAL and
every 3 hours ( maximum of 8 doses per day) INTRAGASTRIC PRESSURE e.g. pregnancy, wearing
of tight belts, obesity, bending over, ascites
DISORDER OF THE GASTROINTESTINAL SYSTEM

(DISORDERS OF THE ESOPHAGUS) Factors That Relax Lower Esophageal Sphincter
● Fatty foods, Chocolates
● Caffeinated beverages
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
● Citrus fruits, tomatoes and tomato products
● BACKWARD FLOW (reflux) of gastrointestinal ● Alcohol
contents into the esophagus ● Nicotine in cigarette smoke
● MOST COMMON upper GI disorder ● High levels of estrogen and progesterone
● common in PEOPLE OVER AGE 45 ● Medication e.g calcium channel blockers
● Considered a disease process when acid is excessive (calcibloc,anticholinergic drugs ( AS04)
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ANTACIDS
● GENERIC NAME: Aluminum or Magnesium
Hydroxide
● BRAND NAMES: Maalox, Mylanta
INDICATION: management of heartburn

ACTION: elevates gastric pH and deactivates pepsin
SIDE EFFECTS: constipation and diarrhea
CLIENT INSTRUCTIONS: take the antacid 1 hour before
and 2-3 hours after meals.
Subjective Data: HISTAMINE RECEPTOR ANTAGONISTS

● HEARTBURN - suggest reflux. Drug Names:
● DYSPHAGIA - suggest narrowing of lumen. ● famotidine (Pepcid)
● ranitidine (Zantac)
Objective Data: ● cimetidine (Tagamet)
● Dyspepsia - MOST COMMON SYMPTOM; occurs ● nizatidine (Axid)
30-60 minutes after meals and with reclining position.
● Regurgitation- with sour or bitter taste INDICATION: management of heartburn
● Hypersalivation ACTION: suppresses secretion of gastric acid by blocking
● Dysphagia the histamine receptor sites
● Odynophagia- sharp substernal pain on swallowing DRUG INTERACTION: CIMETIDINE may have significant
● Eructation (belching)
interactions with WARFARIN, THEOPHYLLINE,
● Pyrosis- burning sensation in the esophagus.
PHENYTOIN, NIFEDIPINE and PROPRANOLOL
● Chronic cough
● Aspiration pneumonia
● Respiratory Distress PROTON PUMP INHIBITORS
Drug Names:
Diagnostic Tests ● omeprazole (Priolosec)
● 24-hour ambulatory esophageal pH monitoring-most ● lansoprazole (Prevacid)
accurate method allows for observation of the ● rabeprazole (Aciphex)
frequency of reflux episodes and their associated ● pantoprazole (Protonix)
symptoms ● esomeprazole (Nexium)
● Upper endoscopy
● Esophageal manometry (measures the rhythmic INDICATION: management of heartburn
muscle contractions ACTION: inhibits gastric acid secretion by blocking
● (peristalsis) that occur in esophagus when swallowing) enzymes associated with the 30-60 minutes before meals
final stage of acid production
Diet Therapy CLIENT INSTRUCTIONS: should be taken 30-60 minutes
● Avoid CAFFEINATED AND CARBONATED foods. before meals
● Avoid SPICY and ACIDIC FOODS
● SMALL FREQUENT FEEDINGS (4-6 small meals) Other Drugs:
● Avoid food 3 hours before going to bed. METOCLOPRAMIDE (Plasil) (GI stimulant) antiemetic
● Standing, Sitting or High Fowler’s position after eating
● ACTION- increase rate of gastric emptying and
relaxation of the pyloric sphincter
Lifestyle Changes ● ADVERSE EFFECTS- fatigue, anxiety, ataxia and
● ELEVATED HEAD OF THE BED 6-8 inches for sleep hallucinations
● DO NOT LIE DOWN 3-4 hours after eating.
● Avoid NICOTINE and ALCOHOL SURGICAL MANAGEMENT
● LOSE WEIGHT- if the patient is obese.
● Avoid CONSTRICTIVE CLOTHING, STRAINING or
LAPAROSCOPIC NISSEN FUNDOPLICATION (LNF)
BENDING OVER.
● WRAPPING AND ANCHORING fundus around the
lower esophageal sphincter
Drug Therapy
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Nursing Care After Surgery:

● Elevate the head of the bed at least 30 degrees to
lower the diaphragm and facilitate lung expansion.
● Facilitate insertion of NGT to prevent excessive
tightening of the fundoplication.
ENTERYX PROCEDURE
● Monitor drainage of NGT (should be normal yellowish
green within the first 8 hours after surgery) ● PURPOSE: to tighten the lower esophageal sphincter
● Check placement every 4-8 hours Avoid alcohol, ● INJECTION OF SOFT, SPONGY PERMANENT
caffeinated and carbonated foods. IMPLANT made of liquid polymeric material into the
● Monitor for dysphagia (sign that fundoplication is too LES muscle
tight).
● Monitor for gas bloat syndrome. Patient Care After Endoscopic Therapies
● Administer simethicone 80 mg QID for excessive gas ● Maintain on CLEAR LIQUIDS for 24 hours
as per doctor’s order. ● After the DAY 1-shift to SOFT DIET such as custard,
pureed vegetables, mashed potatoes
ENDOSCOPIC THERAPIES ● Avoid NSAIDs and ASPIRIN for 10 days Give LIQUID
MEDICATIONS as much as possible
● Avoid NGT INSERTION for at least 1 month.
STRETTA PROCEDURE
● Watch out for CHEST or ABDOMINAL PAIN,
● PURPOSE- to inhibit the activity of the vagus nerve.
BLEEDING, DYSPHAGIA, SHORTNESS OF
● use of radiofrequency energy through needles to
BREATH, NAUSEA of VOMITING.
induce THERMAL BURN in the gastroesophageal
junction; tiny lesions occur initially and as it heals, it
tightens the tissues and increase muscle mass at the HIATAL HERNIA
LES ➔ opening in the diaphragm through which the
● Lasts 45 minutes; recovery time is 1-2 days. esophagus passess becomes enlarged and part of the
upper stomach moves up into the lower portion of the
thorax
Procedure:
➔ Occurs more often in women than in men
- Outpatient endoscopic procedure
- 45 minutes, conscious sedation
- Delivery of temperature-controlled radiofrequency 2 TYPES OF HIATAL HERNIAS
energy ● TYPE 1 - Sliding occurs when the upper stomach and
- Significant reduction in GERD symptoms the gastroesophageal junction are displaced upward
- Significant reduction in esophageal acid exposure and slide in and out of the thorax
- Low incidence of side-effects as compared to ● Para esophageal occurs when all of the part of the
anti-reflux surgery stomach pushes through the diaphragm beside the
● Note: Based upon peer-reviewed literature esophagus
evaluating each procedure separately (not
compared prospectively) Clinical Manifestations
● Pyrosis
● Regurgitation
● Dysphagia
● Intermittent epigastric pain
● Fullness after eating
● Large hiatal hernia Intolerance to food, nausea and
vomiting
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Assessment And Diagnostic Findings Pathophysiology

● X ray
● Barium enema
● Esophagogastroduodenoscopy
● Esophageal manometry
● Chest CT scan
Management
● Frequent small frequent feeding
● Not to recline 1 hr. after eating Elevate head of the
bed 4-8 inches.
● Surgical Hernia repair for patient with gastric outlet
obstruction or suspected strangulation: Post operative
report immediately belching, vomiting, gagging,
abdominal distention and epigastric chest pain.
DISORDER OF THE STOMACH AND SMALL INTESTINE

(DISTURBANCES IN DIGESTION)
GASTRITIS
➔ inflammation of the stomach mucosa
ILLUSTRATION OF MALDIGESTION IN CHRONIC
Classification: GASTRITIS
● Acute - includes erosive gastritis and stress ulcers
● Chronic - includes non- erosive gastritis.
Types Of Chronic Gastritis

● TYPE A - inflammation of the glands in the fundus and
body
● TYPE B -
inflammation of the
glands from fundus
to antrum
● Atrophic - diffuse ACUTE GASTRITIS CHRONIC GASTRITIS
inflammation and
destruction of ● Rapid onset of ● Vague epigastric pain
deeply located epigastric pain ● Pain relieved by food
glands. ● Pain not relieved by ● Anorexia
food ● Nausea and vomiting
● Anorexia ● Intolerance of fatty or
Etiology:
● Nausea and vomiting spicy food
ACUTE GASTRITIS CHRONIC GASTRITIS ● Dyspepsia ● Pernicious anemia
● Gastric hemorrhage
● local irritants ( drug, ● May occur due to bile ● Hematemesis
alcohol, corrosive acid reflux (complication Diagnostic Test
substances ) of gastrojejunal surgery
➔ Esophagogastroduodenoscopy with biopsy
● Bacterial invasions by or peptic ulcer disease)
salmonella, E.Coli and ● Chronic use of irritants
H.pylori Drug Therapy
● H2 Receptor Antagonists
● Antacids
● Proton Pump Inhibitors
● Vitamin B12 (if there is pernicious anemia)
● Triple therapy (if there us H. Pylori in bipsy)
○ 1 Bismuth subsalicylates or proton pump inhibitor
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(omeprazole)
○ 1 Antibiotic (metranidazole)
○ 1 Antibiotic (tetracycline, clarithromycin,
amoxicillin)
● DRUGS TO AVOID- aspirin, ibuprofen.
● Instruct client to limit intake of goods and spices that
cause distress e.g. tea, cola, chocolate, mustard,
pepper, and hot spices.
● Instruct client to avoid alcohol and tobacco.
● Give soft, bland diet and smaller, more frequent
meals.
Stress Reduction
● Progressive muscle relaxation
● Cutaneous stimulation
● Guided imagery
● Distraction
Surgical Management
● partial / total gastrectomy
● Pyloroplasty- surgery to widen the opening in the Pathophysiology
lower part of the stomach (pylorus) so that the
stomach contents can empty into the small intestine.
● Vagotomy- surgical procedure that involves resection
of the vagus nerve to reduce acidity of the stomach.
PARAMETER GASTRIC ULCER DUODENAL ULCER

PEPTIC ULCER DISEASE
Age Usually 50 years or Usually 50 years or
● Ulceration of the gastric mucosa, duodenum and
older older
rarely the lower esophagus and jejunum
● Types Gender Male/female ratio Male/female ratio 1:1
○ Gastric ulcer 1:1
○ Duodenal ulcers
○ Stress ulcers (Curling’s Ulcer or Cushing's Ulcer)- Blood Group No differentiation Most often type O
result of critical illness and severe physical or
emotional stress General May be Usually well nourished
Nourishment malnourished
❖ Curling’s Ulcer- due to hypovolemic shock Stomach acid Normal secretion or Hypersecretion
❖ Major surgery- sepsis, severe burns, and hypoxia production hyposecretion
❖ Cushing's Ulcer- aftermath of cerebral trauma which
cause stimulation of vagus and increase Hcl Clinical course Healing and Healing and
recurrence recurrence
production
Pain Occurs 30-60 Occurs 1.5- 3 hours
minutes after meal; after a meal; at night
at night rarely 1-2 am
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DRUG THERAPY
PARAMETER GASTRIC ULCER DUODENAL ULCER
Triple Therapy (most successful region)
Pain Accentuated by Relived by ingestion of ● Bismuth compound or proton-pump inhibitor
ingestion of food food (omeprazole)
● Metronidazole
Response to Healing with the Healing with
● Tetracycline or clarithromycin and amoxicillin
Treatment appropriate therapy appropriate therapy
Hemorrhage Hematemesis more Melena more common Hyposecretory Drugs

common than than hematemesis
● Histamine Receptor Antagonists
melena
● Proton Pump Inhibitors
Malignant Perhaps in less than Rare ● Prostaglandin Analogues
change 10% ○ Misoprostol (cytotec)
○ Lower gastric secretion and higher resistance of
Recurrence Tends to heal and 60% recurrence in the mucosa to injury
recurs often in the same year ○ CONTRAINDICATION: pregnancy
same location
Mucosal Barrier Fortifiers

Predisposing Factors ● SUCRALFATE (CARAFATE)
● Stress ● Action: forms a seal over the ulcer, protecting if from
● Irregular hurried meals irritation
● Smoking and alcoholism ● Instruction: take 1 hour before meals and at bedtime
● caffeinated , fatty, spicy, acidic foods ● Side effect: constipation
● Ulcerogenic medications- Aspirin, NSAIDs, Steroids
● GI disorders- Gastritis, Zollinger- Ellison Syndrome Diet Therapy
● Type A personality
● Bland diet
● Type O blood
● Small frequent feedings (6 small meals/day)
● Avoid caffeine-containing foods (coffee, tea, or cola)
Complications ● Avoid tobacco and alcohol
● Hemorrhage
● Perforation Management For Hypervolemia
● Pyloric obstruction
● Monitor vital signs intake and output
● Intractable Disease
● Monitor serum electrolytes to determine need for
replacement.
ASSESSMENT: ● Administer isotonic solutions (NSS or lactated
History Ringer’s).
● Alcohol and tobacco use ● Perform blood transfusion as prescribed to expand
● Use of corticosteroids, aspirin, and NSAIDs blood volume.
● If there is active bleeding, administer Fresh Frozen
Plasma.
Clinical Manifestation
● Monitor the following:
● Epigastric tenderness
○ Signs of SHOCK (hypotension, chills, palpitations,
● Rigid, board like abdomen with rebound tenderness
diaphoresis, weak thready pulse)
● Diminishing hyperactive bowel sounds
○ Occult blood
● Dyspepsia
○ Hematocrit, hemoglobin and coagulation studies
● Vomiting
● Perform GASTRIC DECOMPRESSION OR LAVAGE.
● AVOID NSAIDs to minimize GI bleeding.
Diagnostic Tests ● Vasopressin (Pitressin) a vasoconstricting drug.
● Low hemoglobin and hematocrit
● Positive occult blood test ENDOSCOPIC THERAPY
● Barium examination
● Goal: Promote blood clot formation
● Esophagogastroduodenoscopy (most accurate)
● Methods of Endoscopic Therapy
● Elevated immunoglobulin G antibodies (suggest
○ Thermal Contact- heater probe or multi
H.Pylori Infection)
electrocoagulation
● Fecalysis
○ Inject bleeding site with diluted epinephrine
○ Laser therapy
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○ Mechanical clip
EARLY SIGNS (WITHIN 30 LATE SIGNS (90 MINUTES-
MINUTES AFTER FEEDING) 3 HOURS AFTER FEEDING)
Client Preparation
● Administer SEDATIVES e.g. midazolam and ● Vertigo ● Dizziness
● Tachycardia ● Light- headedness
meperidine. ● Syncope ● Palpitations
● Place on NPO 6 hours prior to the procedure. ● Pallor ● Diaphoresis
● Desire to lie down ● Confusion
Care After Procedure
● Resume diet once gag reflex is present Management For Dumping Syndrome
● Small frequent feeding.
Management For Perforation ● Do not take fluids with meals.
● Replace lost fluids, blood, and electrolytes ● Advise a high- protein, high- fat, low to moderate
● Administer antibiotics carbohydrate diet.
● Place on NPO ● Administer pectin to prevent syndrome.
● Gastric lavage or decompression
● Monitor for signs of septic shock (fever, pain, GASTROENTERITIS
tachycardia, lethargy, or anxiety) ● Inflammation of the mucous membranes of the
stomach and the intestinal tract.
Surgical Management For Obstruction ● CLASSIC MANIFESTATION- increase in the
● Gastroduodenostomy (Billroth I) frequency and water content of the stools or vomiting.
● Gastrojejunostomy (Billroth II)
● Partial Gastrectomy Types
● Pyloroplasty enlargement of the pyloric sphincter ● VIRAL- caused by Norwalk virus or rotavirus.
● BACTERIAL- caused by E. coli, campylobacter
Client Preparation enteritis or shigellosis.
● Insert NGT connected to suction to remove secretions
and empty the stomach. Pathophysiology
Assessment
● Nausea and vomiting (first 2 days of illness)
● Diarrhea
● Myalgia
● Headache
● Malaise
● Abdominal tenderness
Signs of Dehydration
Post- Operative Care
● Poor skin turgor
● Monitor placement, patency, and drainage of NGT ● Dry mucous membranes
● Monitor for Dumping Syndrome ● Hypotension
● Oliguria
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Management
● FLUID REPLACEMENT
○ Monitor vital signs, I and O and weight (1kg weight
loss is equivalent to 1L loss).
○ Administer HYPOTONIC IV FLUIDS
○ (0.45% NaCI)
○ Oral Rehydration Salts (Oresol)
○ If with HYPOKALEMIA- incorporate potassium
supplements
○ Observe standards precautions
● DIET THERAPY Pathophysiology
○ IF NOT ACTIVELY VOMITING- clear liquids with
electrolytes.
○ IF VOMITING- NO
○ IF TREATED- crackers, toast, and jelly.
○ IF IMPROVING- bland diet.
○ AVOID caffeine.
● DRUG THERAPY
○ Racecadotril (Hidrasec) and LOPERAMIDE
(IMODIUM)- to inhibit peristalsis.
○ BISMUTH SUBSALICYLATES (PEPTO-
Clinical Manifested
BISMUL)- to reduce watery volume of stool
(suppresses H. Pylori and assist in healing of
mucosal lesions).
○ ANTIBIOTICS
➢ NORFLOXACIN OR CIPROFLOXACIN
➢ If caused by bacteria
➢ TRIMETHOPRIM- SULFAMETHOXAZOLE
(BACTRIM)
DISORDER OF THE LOWER GI TRACT (DISORDERS

OF THE GASTROINTESTINAL SYSTEM Drug Therapy
● Salicylate Compounds
INFLAMMATORY BOWEL DISEASES ○ Drug name- Sulfasalazine (Azulfidine).
ULCERATIVE COLITIS ○ Indication- Management of ulcerative colitis.
● Chronic inflammatory process affecting the mucosa ○ Action- inhibits prostaglandin synthesis to reduce
and submucosa of the SIGMOID COLON and inflammation.
RECTUM. ○ Adverse effects- leukopenia and anemia.
○ Client Instruction
➢ Take the drug with a full glass of water
CROHN’S DISEASE (REGIONAL ENTERITIS)
➢ Take the drug after meals to prevent GI
● Subacute or chronic inflammatory bowel disease discomfort.
affecting segmental areas along the ENTIRE WALL ● Oral or Intravenous Corticosteroids
OF THE GI TRACT; most commonly noted within the ○ Drug name- Prednisone
TERMINAL ILEUM. ○ Indication- to reduce inflammation
○ Adverse Effects- hyperglycemia, osteoporosis,
peptic ulcer disease, increased risk for infection
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● Immunosuppressive Drugs Post-operative Care

○ Should be given in combination with steroids to be ● Monitor color, odor, consistency of ileostomy output
effective. (effluent).
○ Drug name- cyclosporine, mercaptopurine. ● Instruct client to report any foul or unpleasant odor (it
○ Indication- to reduce inflammation. may indicate intestinal blockage or infection).
○ Adverse Effects- thrombocytopenia, leukopenia, ● Instruct the client to wear a pouch system at all times.
anemia, renal failure, infection, headache, ● Apply a skin barrier to prevent irritation and injury to
stomatitis, hepatotoxicity. the skin.
● Anti- Diarrheal Drugs
○ Diphenoxylate HCI and loperamide (imodium)
TOTAL PROCTOCOLECTOMY WITH CONTINENT
● Infliximab (Remicade)
ILEOSTOMY
○ Given for refractory disease or for toxic
megacolon an immunoglobulin G that neutralizes ● Alternative to traditional ileostomy with external pouch.
activity of tumor necrosis factor. ● Creation of an internal reservoir called a Kock’s
ileostomy or ileal reservoir to be drained periodically.
Diet Therapy
Post-operative Care
● If the client has severe symptoms:
○ NPO ● Monitor character and quality of effluent.
○ Total Parenteral Nutrition (TPN) ● Teach the client to drain stoma when sensation of
● Avoid: fullness is felt.
○ Whole- wheat grains ● Apply a small dressing to keep stoma moist.
○ Nuts
○ Fresh fruit and vegetables lactose containing TOTAL COLECTOMY WITH ILEOANAL ANASTOMOSIS
foods caffeinated beverages ● Removal of the colon and rectum with anastomosis of
○ Pepper the ileum and the anal canal.
○ Alcohol smoking
DISCHARGE INSTRUCTION FOR CLIENTS WITH
Surgical Management ILEOSTOMY
● Indications for Surgery
○ Bowel perforation Skin Care
○ Toxic megacolon
● Use pectin- based skin barrier to protect skin from
○ Hemorrhage
irritation.
○ Colon cancer
● Use skin sealants and ostomy skin creams.
○ Failure of conventional treatment
● Monitor skin for irritation.
TOTAL PROCTOCOLECTOMY WITH PERMANENT

Pouch Care
ILEOSTOMY
● Empty pouch when it is ⅓ full
➔ Terminal ileum is pulled through the abdominal wall
● Change pouch at intervals such as before meals,
and forms a stoma or ostomy.
before bedtime, before walking in the morning, 2-4
hours after meals.
Diet
● Chew food thoroughly
● Be cautious in taking high-fiber and high-cellulose
foods such as popcorn, peanuts, coconut, string
beans, shrimp and lobster, rice, skinned vegetables
(tomatoes, corn and peas)
Medications
● Avoid taking enteric- coated and capsule medications
Pre-operative Care
● Do not take laxative or enema.
● Administer oral or parenteral antibiotics such as ● Contact physician of no stool ‘has passed in 6-12
neomycin sulfate (Mycifradin) as bowel antiseptic. hours.
● Administer laxative or edema.
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DANGER SIGNS! distention.

● Drastic increase or decrease in effluent. ● Instruct with meals because it can result to distention.
● Stomal swelling, abdominal cramping, distention, and ● Instruct on lifestyle changes (regular exercise,
absence of drainage. adequate rest periods, stress management).
● Anticholinergics and Ca channel blocker.
Interventions for Danger Signs
● Remove pouch. DIVERTICULOSIS AND DIVERTICULITIS
● Lie down and assume knee-chest position. TWO FORMS OF DIVERTICULAR DISEASE
● Begin abdominal massage.
● Apply moist towels to the abdomen. 1. DIVERTICULOSIS
● Drink hot tea. ● asymptomatic multiple out-pouching of the
● Contact the health care provider. intestinal mucos.
IRRITABLE BOWEL SYNDROME 2.) WITHOUT INFLAMMATION DIVERTICULITIS

● Also known as SPASTIC BOWEL OR MUCUS ● Symptomatic multiple out-pouching of the
COLITIS intestinal mucosa WITH INFLAMMATION; causes
● Different from ulcerative colitis because there is no retention of hardened stool: 20% of patients with
inflammation or ulceration present. diverticulosis results to diverticulitis.
Risk Factors Incidence

● Emotional stress or anxiety, depression ● More common in older adults
● Diverticulitis ● More prevalent in men
● Intolerance to gastric stimulants such as caffeine or
spicy foods or lactose
Predisposing Factors
● Diet high in fats
● Smoking and alcohol ● Diet low in fiber
● CAUSE: UNKNOWN ● Diet high in refined carbohydrates
● INCIDENCE: Common among women, Caucasians
and Jewish population. Complications
● Bowel perforation and peritonitis
Pathophysiology and Clinical Manifestations ● Bowel obstruction
● Hemorrhage
● Shock
Pathophysiology
Diagnostic Test
● Contrast studies
● Barium enema
● Colonoscopy Assessment:
● Manometry and electromyography- to study
● Acute onset of crampy abdominal pain in the left lower
intraluminal pressure changes that generated
quadrant
spasticity.
● Abdominal distention
● Low-grade fever
Nursing Interventions ● Chronic constipation with intervals of diarrhea
● Administer anti-diarrheals antispasmodics, ● Occult bleeding
bulk-forming laxatives as ordered. ● Nausea and vomiting
● Encourage high-fiber diet and avoid fatty and gas ● Leukocytosis
forming foods (carbonated beverages, cauliflower or
beans). Diagnostic Test:
● Instruct client to avoid and tobacco.
● Barium enema and colonoscopy (contraindicated if
● Encourage to increase oral fluids intake but shoould
there is diverticulitis due to the danger of perforation)
not be taken with meals because it can result to
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● Complete blood count - increase ESR and WBC ● Decreased or absent bowel sounds
● Urinalysis
● CT Scan - procedure of choice & can reveal abscess. Diagnostic Test
● WBC Count
Nursing Interventions: - Leukocytosis: WBC above 10,000/mm3
● Instruct client to eat high fiber foods - Perforation: suggested if WBC is above
● Encourage to increase fluids. ● 20.000/mm3
● Administer bulk laxatives and anticholinergics ● Increase neutrophils.
asprescribed. ● Ultrasound may reveal enlarged appendix by at least
● Encourage client to lose weight and avoid activities 6mm.
that increase intra-abdominal pressure such as ● Pregnancy Test for female to rule out ectopic
straining at stool (Valsalva maneuver), vomiting, lifting, pregnancy.
bending, lifting or ● Urinalysis to rule out UTI or renal calculi.
● tight clothing. ● CT Scan
- Ordered if symptoms are recurrent or prolonged
Surgical Management - May reveal presence of fecalith
● Neuro-Spec imaging uses a technetium labeled
● Colon resection with temporary colostomy
anti-CD 15 monoclonal antibody that selectively binds
to neutrophils at the at injection site.
APPENDICITIS ● Uses gamma camera.
● Inflammation of the vermiform appendix ● Diagnosis within 1 hour.
● More common in males 10-30 years of age
Management
Etiology ● Maintain patient on NO for possible admission.
● Obstruction by fecal impaction, kinking of the ● Administer IV fluids as prescribed to prevent fluids and
appendix, electrolytes imbalance.
● parasites or infections. ● Maintain patient in semi-Fowler's position to prevent
● Low fiber diet ● upward spread of infection.
● High intake of refined carbohydrates ● DO NOT GIVE LAXATIVE NOR
● ENEMA to prevent perforation of the appendix.
Pathophysiology ● DO NOT APPLY LOCAL HEAT to prevent
inflammation
● and perforation.
● Instead apply COLD compress
Surgical Management
LAPAROSCOPY
● A small incision in the umbilicus is made and a small
endoscope is used to visualize the appendix.
● If diagnosis is not definitive.
LAPAROTOMY
● An open approach in which large abdominal incision is
Assessment: made.
● Acute abdominal pain at RLQ or
● McBurney's point (halfway between the umbilicus and APPENDECTOMY
the anterior iliac crest) ● Removal of the inflamed appendix
● Anorexia, nausea and vomiting ● Guided with laparoscopy.
● Rigid and guarded abdomen ● Done with spinal anesthesia.
● Blumberg sign (rebound tenderness)
● Rovsign sign upon palpation LLQ pain in the RLQ Nursing Care for Appendectomy
increases.
● Maintain client flat on bed for 6-8 hours.
● Fever (temperature of 38-38.5 °C)
● Monitor for return of sensation in the lower extremities.
● Psoas or Copes psoas or Obraztsova’s
● Maintain on NPO until peristalsis returns.
● Sign (lateral position with right hip flexion)
● Instruct client to ambulate after 24 hours. Tell the
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client that he can resume normal activities within 2-4 - WBC: 500/ml
weeks. - RBC: 50,000/ml
● Gram stain: (+ bacteria
PERITONITIS - Culture reveals: E. coli, klebsiella, proteus,
pseudomonas. If untreated can result to septic
● Inflammation of the peritoneum, the serous membrane
shock and death
lining the abdominal cavity and covering the viscera.
Management
2 Types of Peritonitis
● Administration of the following as prescribed.
1. PRIMARY
- IV fluids to replace lost fluids (isotonic)
- acute bacterial infection resulting from
- Broad spectrum antibiotics
contamination of the peritoneum through the
- Oxygen if there is dyspnea due to ascites
vascular system.
● Analgesics (meperidine or morphine)
- May occur from tuberculosis, cirrhosis, and
- Antiemetics (metoclopramide)
ascites.
● Monitor daily weight, intake and output to monitor fluid
status.
2. SECONDARY ● Side lying with knees flexed to lessen pain.
- Bacterial invasion resulting from acute bacterial ● NGT insertion to decompress the stomach and
abdominal disorder. intestine.
- May occur from gangrenous bowel, visceral ● Maintain client on NPO.
perforation, bile leakage, blunt or penetrating.
Trauma (gunshot wound).
Surgical Management
● Abdominal surgery guided by exploratory laparotomy.
Pathophysiology ● Appendectomy if there is appendicitis.
● Colon resection with or without colostomy if there is
bowel perforation.
Nursing Care After Surgery

● Maintain patient in SEMI-FOWLER'S POSITION to
promote drainage of peritoneal contents and allow
adequate lung expansion.
● Perform PERITONEAL IRRIGATION as prescribed
● Check for presence of abdominal distention or pain
(suggestive of irrigate retention)
Clinical Manifestation
● Assess incision, dressing and drains.
● RIGID, BOARDLIKE ABDOMEN (CLASSIC SIGN) ● Instruct client to AVOID LIFTING for at least 6 weeks.
● Abdominal pain diffuse and becomes localized near
the site of inflammation.
● Distended abdomen' Complications
● Nausea, anorexia, and vomiting ● Sepsis- major cause of death
● Diminishing bowel sounds ● Wound evisceration and dehiscence.
● Inability to pass flatus or feces.
● Rebound tenderness in the abdomen. HEMORRHOIDS
● High fever ● Dilated and painful veins in the rectum, anal canal,
● Dehydration inside or outside the anal sphincter.
● Oliguria
● Hiccup’s
Classifications
● Internal- hemorrhoids ABOVE the anal sphincter.
Diagnostic Assessment
● External- hemorrhoids BELOW the anal sphincter.
● ELEVATED WBC: 20,000/MM?
● Hgb and Hct may be low.
● Altered levels of K+, Na +. CI -
● Abdominal x-ray may show free air and fluid in the
peritoneum.
● CT Scan or ultrasound - changes in abdominal organs
● Peritoneal Lavage may reveal the following:
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Risk Factors Pre- operative Care

● Familial tendency ● Advise low residue diet.
● Straining at stool ● Administer stool softeners.
● Prolonged sitting or standing
● Pregnancy, prolonged labor Nursing Care After Hemorrhoidectomy
● Obesity
● Watch out for bleeding.
● Portal hypertension
● Place the client in PRONE OR SIDE-LYING
● Anal intercourse
POSITION
● Colon malignancy
● Administer analgesics as prescribed.
● Administer stool softeners.
Pathophysiology ● Offer warm Sitz baths 3-4 times a day.
DISORDER INVOLVING THE ACCESSORY

ORGANS DISORDERS OF THE GASTROINTESTINAL
SYSTEM
Assessment
● Bleeding with defecation of hard stool and pain - due
to stretching and irritation of mucosa.
● External hemorrhoids- extreme pain due to thrombosis
and edema; appear reddish blue lump.
● Internal hemorrhoids- not usually painful, until it
bleeds & prolapse when enlarged; some protrude
during defecation and retracts after defecation.
Diagnostic Test
● Digital rectal examination
● Sigmoidoscopy
● Colonoscopy rules out colorectal CA
Nursing Interventions
● Instruct client on the importance of HIGH-FIBER DIET
and INCREASED FLUID INTAKE.
● Instruct client to take STOOL SOFTENERS and use
CHOLELITHIASIS AND CHOLECYSTITIS
ointments such as dibucaine, anti-inflammatory, or
astringents medication that causes contraction or ● CHOLELITHIASIS- STONE FORMATION in the
constriction of tissues). gallbladder and accessory ducts.
● Apply ICE PACKS for several hours followed by warm ● CHOLEDOCHOLITHIASIS- stone formed at the
packs. Common Bile Duct.
● CHOLECYSTITIS- INFLAMMATION of the
gallbladder.
Surgical Management
Risk Factor:
● HEMORRHOIDECTOMY- removal of hemorrhoid-
● Female gender
Internal and external packing secured by a T-binder.
● Fat (Obesity)
● Cryosurgery - application of extreme low temperature
● Fair (Caucasian)
to destroy or remove diseased tissue (prolonged
● Forty (age)
wound healing)
● Fertile (multigravida; use of contraceptive pills)
● Rubber band ligation- internal hemorrhoids
(anoscope & small rubber band).
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Pathophysiology Purposes Of Oral Cholecystography

1. To defect gallstones
2. Assess the ability of the gallbladder to fill, concentrate
and store a dye like, iodine - based radiopaque
contrast medium.
● Administer MEPERIDINE HCL (drug of choice) as
prescribed for pain relief.
● AVOID ADMINISTERING MORPHINE!!!
- it may cause spasm of the sphincter of Oddi
S/sx: ● Use BAKING SODA or CALAMINE-CONTAINING
LOTIONS for pruritus.
● Encourage LOW-FAT DIET
● Administer BILE SALTS such as Chenodeoxycholic
acid (chenodiol)or Ursodioxycholic acid (UDCA)
ursodiol.
- Used to dissolve gallstones.
Surgical Management:
➔ Cholecystectomy
Preoperative Nursing Care:

● Administer IV fluids to replace electrolytes.
Diagnostic Test
● Administer vitamin K injection, especially if
prothrombin time is prolonged as per doctor's order.
ULTRASONOGRAPHY
● Dx.procedure of choice. Accurate, can be used even if Postoperative Nursing Care:
pt liver dysfunction and jaundice. 95% stone detection
● Place patient in SEMI-FOWLER'S POSITION to
promote lung expansion
ENDOSCOPIC RETROGRADE ● NGT DECOMPRESSION to prevent gastric distention.
CHOLANGIOPANCREATOGRAPHY (ERCP) ● LOW-FAT DIET for 2-3 months
● Visualization of gallbladder, cystic duct, common ● Encourage ambulation after 24 hours.
hepatic duct, and common bile duct. ● Encourage to resume normal activities within 2-3
days.
IV CHOLANGIOGRAM ● Monitor T-Tube if common bile duct exploration was
done.
● Radiographic image of the bile ducts that is obtained
by cholangiography.
● Prolonged Prothrombin time T - TUBE INSERTION
● CBC – leukocyte Purpose:
➔ to DRAIN BILE
CHOLECYSTOGRAPHY
● (gall bladder imaging) Drainage Characteristics:
● It should be BROWNISH RED for the first 24 hours.
Types Of Cholecystography: ● It should be 300-500 ML for the first 24 hours.
1. ORAL - done 10 HOURS after administration of
contrast medium Nursing Responsibilities:
2. INTRAVENOUS - done 10 MINUTES after ● Place drainage bottle or Jackson Pratt AT THE
administration of contrast medium. LEVEL OF THE INCISION.
ORAL CHOLECYSTOGRAPHY PANCREAS

➔ radiographic examination of the gallbladder. ● Large, elongated accessory organ of digestion.
● secretes bicarbonate and pancreatic enzymes aiding
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in the process of digestion (exocrine function-amylase ● Fecal fat determinations

lipase, trypsin) ● Blood and urine glucose
● contains the islets of Langerhans composed of beta
cells secreting insulin and alpha cells secreting Nursing Interventions
glucagon.
● Administer MEPERIDINE HCL (DEMEROL) as
ordered
PANCREATITIS ● AVOID MORPHINE SULFATE!!!
➔ Inflammation of the pancreas ● Place client on NPO DURING ACUTE PHASE
➔ CAUSE is unknown; linked with autodigestion. ● bland, LOW-FAT DIET, LOW CHON, HIGH CHO;
avoid alcohol.
Types Of Pancreatitis: ● NGT DECOMPRESSION insertion to remove gastrin
and prevent further stimulation of the pancreas.
1. Acute - vary from mild, self-limiting disorder to severe,
● Administer CALCIUM SUPPLEMENTS (WITH
fatal and does not respond to any treatment.
● VITAMIN D) if there is hypocalcemia.
- edema and inflammation confined to the
● Administer INSULIN as ordered if there is
pancreas
hyperglycemia.
2. Chronic -continuous and prolong with fibrosis
Surgical Management
Risk Factor:
➔ Pancreatectomy
● Alcohol abuse
● surgical removal of part or all of the part of
● MEDICATIONS
pancreas.
● Antihypertensives, diuretics, antimicrobials.
● immunosuppressives, oral contraceptives
● GI DISORDERS: Biliary obstruction and intestinal LIVER CIRRHOSIS
diseases ● Irreversible chronic inflammatory disease
characterized by massive degeneration and
Pathophysiology destruction of hepatocytes resulting in a disorganized
lobular pattern of regeneration.
Types/Causes:
1) LAENNEC'S- caused by ALCOHOLISM or
hepatotoxic drugs.
2) POST-NECROTIC- caused by viral HEPATITIS or
industrial hepatotoxins.
3) BILIARY - caused by BILIARY PROBLEMS
4) CARDIAC - caused by CONGESTIVE HEART
FAILURE (CHF)
HEPATITIS
Types:
● Hepatitis A (HAV): Infectious H.
● Hepatitis B (HBV): Serum H.
● Hepatitis C (HCV): non-A, non-B / Post-transfusion H.
● Hepatitis D 9HDV): Delta H.
Pathophysiology:
Other Manifestation
● Grey Turner's Spot or sign Bluish flank discoloration
● Cullen sign
● Bluish periumbilical discoloration.
Diagnostic Test
● Elevated serum and urinary amylase, serum lipase,
serum bilirubin, alkaline phosphatase, and
sedimentation rate
● White blood cell count
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PORTAL HYPERTENSION Diagnostic Test

● Normal portal vein pressures range from 5-10 mm Hg. ● LIVER BIOPSY (definitive test)
● Refers to elevated pressures in the portal venous ● Abdominal x-ray
system. ● Ct scan
● Venous pressure more than 5 mm Hg greater than the ● Endoscopy
inferior vena cava pressure is defined as portal ● Elevated Aspartate Aminotransferase (AST)SGOT)
hypertension. 4.8-19U/L, Alanine
● Aminotransferase (ALT)(SGT) 2.4-17 U/L, bilirubin
TB0-0.9mg/dL
● Prolonged prothrombin time (PT) (N) 11-16 seconds.
● Decreased serum albumin.
● CBC reveals anemia.
● Serum ammonia = Normal: 150-250mg/dL, 10-80
ug/dl.
Preparing A Patient For Ultrasound Of The Liver

● Place patient on NPO 8-12 hours
● before the procedure
● Administer laxative a night before the test.
● Maintain adequate hydration.
Preparing A Patient For Liver Biopsy

● Place patient on NPO 2-4 hours before the test
● ADMINISTER VITAMIN K
● Monitor prothrombin time.
● Position patient in LEFT LATERAL POSITION with
pillow under right shoulder.
● Instruct to HOLD BREATH 5-10 seconds during
needle insertion.
Nursing Care After Liver Biopsy

● Turn the patient to sides q4 hours.
● Place on bed rest for 24 hours
● Monitor for signs of bleeding.
PATHOGENESIS OF EDEMA IN LIVER CIRRHOSIS
● Place client on BED REST with bathroom privileges
● Offer LOW-PROTEIN, HIGH
● CARBOHYDRATES and vitamins (ADEK, B-complex)
● RESTRICT AMOUNT OF ORAL FLUIDS and
eliminate alcohol intake
● Provide meticulous skin care.
● Monitor weight, intake and output and
● ABDOMINAL GIRTH
● Assist in paracentesis if necessary.
Assessment: ● Monitor for bleeding of esophageal varices.
● Perform tap water or NSS enema as per doctor's
order.
● Avoid giving aspirin (causes bleeding) and sedatives
(hepatotoxic).
Medication For Patient With Cirrhosis

1) ANTACID - to prevent GI bleeding.
2) SPIRONOLACTONE - (Potassium-sparing diuretic) -
diuretic of choice to manage ascites; does not cause
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hypokalemia.
3) FUROSEMIDE - diuretic given if a patient has
hyperkalemia after prolonged use of spironolactone.
4) VITAMIN K - prevents bleeding tendencies.
5) INTRAVENOUS ALBUMIN - to manage ascites and
edema.
6) DUPHALAC (Lactulose) reduces levels of ammonia.
7) NEOMYCIN SULFATE - reduce colonic bacteria
responsible for ammonia formation.
Prevention Of Bleeding Of Esophageal Varices

● Avoid Valsalva maneuver.
● Avoid bending or stooping.
● Avoid hot spicy foods.
● Avoid lifting heavy objects.
Interventions For Bleeding Of Esophageal Varices

● Place patient in SEMI-FOWLER'S
● POSITION to prevent aspiration.
● Suction the mouth.
● Perform gastric lavage with tap water.
● Insert SENGSTAKEN-BLAKEMORE TUBE
● Administer: IV fluids, blood transfusion as ordered
● Administer VASOPRESSIN to constrict splanchnic
arteries.
Preparing A Patient For Paracentesis

● Ask to empty the bladder to prevent puncture.
● Check serum protein studies.
● Place patient in sitting or upright position
Nursing Care After Paracentesis

● Check urine output.
● Watch out for board-like abdomen (sign of
PERITONITIS)
● Monitor for signs of hypovolemic shock.
21
THE ENDOCRINE SYSTEM
ANTERIOR PITUITARY GLAND DYSFUNCTION
POSTERIOR PITUITARY GLAND DYSFUNCTION
22
(ANTERIOR) HYPERPITUITARISM (+BASOPHILIC OR EOSINOPHILIC TUMOR)
23
POSTERIOR PITUITARY GLAND
(ANTERIOR) HYPOPITUITARISM (+CHROMOPHOBIC TUMOR)
24
POSTERIOR PITUITARY GLAND (HYPOPITUITARISM)
OTHER ORGANS / GLANDS INVOLVED IN ENDOCRINE SYSTEM:
25
REVIEW OF NORMAL STRUCTURES AND FUNCTIONS ● Thyrotropic Hormones (TSH)

● Adrenocorticotropic Hormone (ACTH)
ENDOCRINE SYSTEM ● Melanocyte-Stimulating Hormone (MSH)
➔ is made of hormones secreting glands that helps
maintain and regulate vital functions such as: Posterior Pituitary (Neurohypophysis) secretes:
● Response to stress and injury ● Antidiuretic Hormone (ADH)
● Growth and development ● Oxytocin
● Reproduction
● Ionic homeostasis THE THYROID AND PARATHYROID
● Energy metabolism
➔ Thyroid gland is located in the neck in close
approximation to the first part of the trachea. In humans,
Major Organs the thyroid gland has a “butterfly” shape
● Pituitary ➔ Close examination of a thyroid gland will reveal one or
● Thyroid and Parathyroid in the neck more small, light-colored nodules on or protruding from
● Adrenals its surface - these are parathyroid glands (meaning
● Pancreas “beside the thyroid”)
● Ovaries or Testes
The Thyroid secretes:
THE PITUITARY GLAND ● Thyroxine (T4)
➔ The Pituitary Gland, also known as the hypophysis, and ● Triiodothyronine (T3)
master gland ● Thyrocalcitonin
Two Parts The Parathyroid secretes:

1. Anterior Pituitary (Adenohypophysis) ● Parathormone (PTH)
2. Posterior Pituitary (Neurohypophysis)
THE ADRENAL GLANDS
Anterior Pituitary (Adenohypophysis) secretes: ➔ The two adrenal glands are located immediately anterior
● Growth Hormones (GH) or Somatotropin to the kidneys
● Prolactin (Mammotropic, Lactotropic, Luteotrophic)
● Gonadotropic Hormones (LH and FSH)
26
Two Regions Ovaries

● Adrenal Medulla (inner) - which is a source of the ➔ Two groups of female sex hormones are produced in
catecholamines epinephrine and norepinephrine the ovaries, the estrogens and progesterone
● Adrenal Cortex (outer) - which secretes several ➔ These steroid hormones contribute to the development
classes of steroid hormones, glucocorticoids and and function of the female reproductive organs and sex
mineralocorticoids characteristics
The Adrenal Cortex At the onset of puberty, estrogens promotes:

● Glucocorticoids ● The development of the breast
● Mineralocorticoids ● Distribution of fat evidenced in the hips, legs, and breast
● Androgens ● Maturation of reproductive organs such as the uterus
and vagina
The Adrenal Medulla ● Repair endometrium after menstruation
● Epinephrine (adrenaline)
● Norepinephrine (noradrenaline) Progesterone causes:
● The uterine lining thickens in preparation for pregnancy.
THE PANCREAS
➔ An elongated organ nestled next ro the first part of the Regulation of Hormones
small intestine. The endocrine pancreas refers to ➔ The secretion of many hormones is initiated by a
those cells within the pancreas that synthesize and negative-feedback system
secrete hormones
➔ The endocrine portion of the pancreas take the form of
many small cluster of cells called Islets of Langerhans
Pancreatic Secretions
● Endocrine - insulin and glucagon - secreted to blood
● Exocrine - digestive enzymes (acinar cells), aqueous
NaHCO3 solution (duct cells) - secreted to the
duodenum collectively as pancreatic juice
NURSING CARE OF PATIENTS WITH DISTURBANCES IN
Three major cell types: ENDOCRINE FUNCTIONS
● Alpha Cells (A Cells) - secrete the hormone glucagon
● Beta Cells (B Cells) - produce insulin and cells DISORDERS OF THE PITUITARY GLAND
● Delta Cells (D Cells) - secretes the hormone
somatostatin, which is also produced by a number of
HYPERPITUITARISM
other endocrine cells in the body.
➔ oversecretion of one or more of the hormones secreted
by the pituitary gland caused by a secreting pituitary
THE OVARIES AND TESTES tumor, typically a benign adenoma.
➔ The gonads, the primary reproductive organs, are the
testes in the male and the ovaries in the female. These Three Major Types of Pituitary Tumors
organs are responsible for producing the sperm and A. Eosinophilic Tumor
ova, but they also secrete hormones and are ● Enlargement involves all tissues and organs
considered to be endocrine glands. (gigantism)
● Many of these patient suffer from headaches and
Testes visual disturbances because the tumors exert
pressure on the optic nerves
➔ Males sex hormones, as a group are called androgens
➔ The principal androgen is testosterone, which is B. Basophilic Tumor
secreted by the testes. ● Give rise to Cushing’s Syndrome with features
largely attributable to hyperadrenalism, including
This steroid hormone is responsible for: masculinization and amenorrhea in females,
● The growth and development of the male reproductive truncal obesity, hypertension, osteoporosis and
structures polycythemia
● Increased skeletal and muscular growth
● Enlargement of the larynx accompanied by voice C. Chromophobic Tumor
changes ● Represent 90% of pituitary tumors
● Growth and distribution of body hair ● Produce no hormones but destroy the pituitary
● Increased male sexual drive gland causing hypopituitarism
● Patient with this disease are often obese and
27
somnolent and exhibit fine, scanty hair, dry, soft

skin, a pasty complexion and small bo0nes
● They also experience headache, loss of libido and
visual defects progressing to blindness
● Other signs and symptoms include polyuria,
polyphagia, lowering of the basal metabolic rate
and a subnormal body temperature.
Signs and Symptoms of Hyperpituitarism
Systemic
● Excessive or abnormal growth patterns
● Abnormal milk secretion (galactorrhea)
● Overstimulation of one or more of the target glands
resulting in the release of excessive thyroid, sex, or
Adrenocortical hormones
Local
● Blindness due to pressure in the optic nerve
● Headaches
● Somnolence (state of being drowsy)
Intervention
Diagnostic Evaluation Drug:
1. Radiologic ● Bromocriptine (Parlodel) lower GH level and prolactin
2. Laboratory testing level
● A sensitive and specific immunologic staining ● Octreotide and Lanreotide (Somatostatin Analog) used
method that helps determine the nature of the preoperatively to improve patient condition and shrink
hormones synthesized and secreted by pituitary the tumor
tumors. ● Hypophysectomy treatment of choice
● Plasma levels of GH, LTH, FSH, and LSH
3. Metrizamide - accentuated CT scan Hypophysectomy
● Partial or complete removal of pituitary gland
GIGANTISM ● Indications:
➔ which is an overgrowth of the long bones, develops in ○ Pituitary tumors
children before the age at which the epiphyses of the ○ Diabetic retinopathy
bones close. ○ Metastatic cancer of breast or prostate
Individuals suffering from gigantism may grow as tall as 8 or ● Surgical approaches:
9 feet. ○ Craniotomy - transfrontal
○ Transsphenoidal - incision via inner aspect of
ACROMEGALY upper lip and gingiva
➔ is an adult disease that develops following closure of
the epiphyses of the long bones. Nursing Interventions after Transsphenoidal
➔ Marks by both increases in bone thickness and Hypophysectomy:
hypertrophy of the soft tissues. ● Keep head elevated to promote venous drainage for 2
weeks
● Maintain nasal pack as per doctor’s order
● Provide good oral care
● Avoid blowing of nose and other activities that increase
ICP
● Report output greater than 900 ml / 2hrs
CUSHING’S DISEASE
➔ Oversecretion of ACTH by a basophilic tumor, which in
turn results in oversecretion of adrenocortical hormones
SEXUAL DISTURBANCE
➔ Excess secretion of gonadotropic hormones from
pituitary tumors produces sexual precocity in children
➔ Excess Prolactin secretion causes amenorrhea or
galactorrhea (excessive flow of milk) in women.
28
Nursing Interventions the long term nature of the disease and impact on daily
● Help the client accept the altered body image that is life
irreversible ● Provide adequate rest periods
● Assist family to understand what the client is
experiencing Types Of Dwarfism
● Help the client recognize that medical supervision will ● Disproportionate Dwarfism - some average size parts
be required for life of the body and some shorter than normal parts of the
● Help the client understand the basis for the change in body
sexual functioning ● Proportionate Dwarfism - the individual is smaller than
● Assist the client in expressing feelings the average all over
● Care for the client following a hypophysectomy:
○ Protect from stress situations DIABETES INSIPIDUS (ADH DEFICIENCY)
○ Protect from infection ➔ Disorder of the posterior lobe of the pituitary gland
○ Follow and maintain an established schedule for characterized by a deficiency of ADH (vasopressin).
hormone replacement
● Follow a nursing care for the client undergoing Causes of ADH insufficiency
intracranial surgery: 1. Vasopressin deficiency (ADH deficiency) due to
○ Perform neurologic assessments ● Abnormalities in the hypothalamus and primary
○ Measure specific gravity of urine, and check daily gland from familial or idiopathic causes primarily
weight to identify complication of DI diabetes Insipidus
○ Check nasal drainage for glucose to determine ● Destruction of the gland by tumors in the
presence of CSF hypothalamo pituitary region, trauma, infectious
○ Encourage deep breathing but not coughing process, vascular accidents or metastatic tumors
○ Institute measures to prevent constipation from breast or lung (secondary diabetes Insipidus).
● Medications such as phenytoin (Dilantin),
HYPOPITUITARISM alcohol, and lithium carbonate
➔ Deficiency of one or more of the hormones produced by
the anterior lobe of the pituitary 2. Nephrogenic" diabetes Insipidus
➔ When both the anterior and posterior lobes fail to ● Owing to an inherited defect, the kidney tubules
secrete hormones, the condition is called cannot reabsorb water.
PANHYPOPITUITARISM ● This condition also may develop secondary to
potassium depletion or pyelonephritis.
Causes:
● Hypophysectomy Assessment
● Non-secreting pituitary tumors Major Manifestations
● Pituitary dwarfism ● Polyuria –urine output greater than 250 ml per hour
● Postpartum pituitary necrosis ● Polydipsia- drinks 2L-20L of fluid daily and craves for
● Functional disorders cold water
● Urine specific gravity of 1.001 to 1.005
Specific Disorders resulting to Hypopituitarism
● Dwarfism Diagnostic Exams
● Secondary Adrenocortical insufficiency 1. Water deprivation test - is carried out by withholding
● Myxedema (severe hypothyroidism) fluids for 8-12 hours or until 3%-5% of the body weight
● Sexual and reproductive disorders is lost
● the patient is weighed frequently during the test
Intervention ● plasma and osmolality studies are performed at
● Removal the beginning and end of the test
● Permanent replacement of the hormones secreted by ● the inability to increase the specific gravity and
the target organ osmolality of the urine is characteristic of diabetes
● Medication insipidus
○ Corticosteroids for correction of secondary 2. Does not respond to ADH injection (only for
Adrenocortical insufficiency Nephrogenic D. I.)
○ Thyroid hormone for treatment of Myxedema 3. Plasma level of ADH
○ Sex hormone to correct hypogonadism
Intervention
DWARFISM 1. Desmopressin ( DDAVP) is a synthetic vasopressin
given intranasally, insufflated through the nose. Largely
Nursing Intervention: replaced vasopressin for long term treatment of persons
● Monitor effects of hormone replacement with severe D. I.
● Discuss the importance of adhering medical regimen on 2. Surgical resection of tumor
a long term basis 3. Vasopressin injection (aqueous Pitressin) or
● Allow client ample time to verbalize feelings regarding vasopressin tannate (Pitressin Tannate).
29
● Pitressin typically alleviates polyuria, and usually ➔ The thyroid gland needs iodine in order to synthesize
polydipsia for 24 - 72 hours. and secrete its hormones.
4. Chlorpropamide (diabinese) and thiazide are used in
mild forms GOITER
Types of Goiter
Nursing Management
● Physical assessment and continue monitoring of F and 1. Endemic (iodine Deficient ) Goiter
E imbalance status: I and O, daily weight, skin turgor, ● is principally caused by nutritional iodine
electrolyte levels deficiency.
● Replace fluid by mouth or parenterally ● It is twice as prevalent in women as in men.
● Monitor response to ADH replacement ● Commonly developed in adolescents, pregnant
● Teach clients on long term vasopressin therapy the women and nursing mothers residing in iodine
need for daily weight records, recognition of polyuria. deficient regions.
● Advised wearing of medical identification bracelet 2. Sporadic Goiter
● is not restricted to any geographic area.
SIADH (SYNDROME OF INAPPROPRIATE ANTIDIURETIC
HORMONE) Causes:
➔ Excessive ADH secretion from the pituitary gland ● Genetic defects resulting in faulty iodine metabolism
➔ Opposite of diabetes Insipidus. ● Ingestion of large amounts of nutritional goitrogens (e.g.
➔ Patient cannot excrete a dilute urine cabbage, soybeans, peanuts, peaches, peas,
➔ Retain fluids strawberries, spinach, and radishes)
➔ Develop sodium deficiency ● Ingestion of medicinal goitrogens, e.g. thiouracil
(propylthiouracil), thiocarbamides (aminothiazole,
Cause: trauma, stroke, malignancies of lungs, medications, tolbutamide) and iodine in large doses.
stress
Diagnosis and Assessment
Clinical Manifestations
● Headache ● the goiter grows large enough to distort the appearance
● nausea / vomiting of the neck
● muscle cramps ● they may also experience respiratory distress and
● restlessness difficulty swallowing if the goiter is very large.
● lethargy
● confusion Medical Management
● decreased reflexes Pharmaceutical Management
● seizure
● strong iodine solution (Lugol’s solution) or saturated
● coma
solution of potassium iodine (SSKI drops).
● Death
● Thyroid hormone replacement with sodium
levothyroxine (Synthroid), Desiccated thyroid (thyroid
Medical Management
USP) and sodium liothyronine (Cytomel),
● Eliminating underlying cause
● When administering thyroid preparations, assess the
● Establish Airway
individual carefully for symptoms of thyrotoxicosis,
● Restricting fluid intake as per doctor’s order
(tachycardia, increased appetite, diarrhea, sweating,
● Mannitol (hypertonic solution)
agitation, tremors, palpitation)
● Lasix / Bumex (loop diuretic)
● Corticosteroids
● Positioning Surgical Management
● Subtotal thyroidectomy
Nursing Management
● Close monitoring of fluid and intake, daily weight, urine HYPERTHYROIDISM (THYROTOXICOSIS; OVERACTIVE
and blood chemistries and neurologic status. THYROID)
● Monitoring and regulating IVF accurately
➔ Excessive synthesis and secretion of endogenous or
● Administer medications as per doctor’s
exogenous thyroid hormones by the thyroid
order.Assessment of patients for side effects of
treatment of SIADH
● Assess for pain, anxiety, and depression; and provide Causes, Incidence, and Risk Factors
interventions to improve pain management and coping ● Graves disease
ability. ● Toxic multinodular goiter
● Monitor signs and symptoms of complications ● Toxic adenoma
● Thyroiditis
DISORDERS OF THE THYROID GLAND ● Tumors of the testes or ovaries
➔ Thyroid Enlargement (Simple Goiter, Non-toxic Goiter, ● Inflammation (irritation and swelling) of the thyroid due
Nodular Goiter) to viral infections or other causes
30
● Ingestion of excessive amounts of thyroid hormone choice through a straw

● Ingestion of excessive iodine ● Assess client for signs of hypothyroidism
● Radioactive iodine Therapy
Symptoms ● Thyroidectomy (If the thyroid must be removed with
radiation or surgery, replacement thyroid hormones
● Weight loss
must be taken for the rest of the person's life)
● Polyphagia
● Beta-blockers (propranolol and atenolol)
● Diaphoresis
● Nervousness
● Restlessness Complications of Thyroidectomy
● Heat intolerance ● rapid heart rate, congestive heart failure, and atrial
● Increased sweating fibrillation.
● Fatigue ● thyroid crisis or "storm"
● Insomnia ● Fever
● Frequent bowel movements ● decreased mental alertness
● Menstrual irregularities in women ● abdominal pain may occur
● increases the risk for osteoporosis
Assessment
● increased heart rate Nursing Interventions
● Systolic blood pressure may be elevated ● Monitor V/S, I&O
● thyroid enlargement or goiter. ● Provide cool, quiet environment
● Provide adequate rest; promote normal thought
Laboratory Exams processes (minimize sleep disruption); use safety
measures to reduce risk of trauma or fall
● Serum TSH is usually decreased
● Provide high caloric, protein, CHO, vitamin diet without
● T3 and free T4 are usually elevated
stimulants, extra fluids; restrict stimulants (tea, coffee,
● Triglycerides
alcohol)
● T3RU
● IVF therapy as prescribed
● Radioactive iodine uptake
● Weigh client daily
● Glucose test
● Provide eye protection: ophthalmic medicine
● Cholesterol test
● Provide emotional support
● Antithyroglobulin antibody
● Be alert for complications: corneal abrasion, heart
Thyroid Scan disease, thyroid storm
● Measures the affinity of the thyroid gland for radioactive ● Maintain skin integrity
iodine( Normal 15-40%) ● Explain procedures to client and encourage
● Preparation verbalization of feelings
● No diagnostic test with contrast medium for the past 3 ● Thyroidectomy: Preoperative care
mos. ● administer prescribed antithyroid drugs to achieve
● No foods or drugs with iodine for 2weeks prior to test euthyroid state
● Discontinue contraceptive pills ● teach coughing, DBE, and use of hands to support neck
● NPO6-8hrs if 131 is used and to avoid strain on suture lines
● IV No fasting
Pre-Operative
Treatment ● Achieve euthyroid state by Lugol’s Administration and
● Antithyroid medications (Thyroid Inhibitors) any antithyroid drug as per doctor’s order
● Examples: Iodine (Lugol’s Solution), Methimazole ● Takes 2-3 weeks to decrease the vascularity of the
(Tapazole), PTU (Propylthiouracil) thyroid and prevent postoperative hemorrhage
● Major S/E:
○ Agranulocytosis (decreased WBC)
Postoperative care
○ Skin disturbances (hypersensitivity)
○ N/V (irritation of gastric mucosa) ● semi-fowler’s position without pillows
○ Decreased metabolism ● Limit head movement
○ Iodine: bitter taste; stains teeth (local oral effect on ● Avoid tension on suture line
B teeth and mucosa ● check dressing esp. back of neck
● observe for respiratory distress caused by tracheal
edema
Nursing Interventions ● be alert for signs of hemorrhage
● Report the occurrence of any S/E to the physician , ● instruct patient: talking limited, note any hoarseness –
especially sore throat and fever. may indicate injury in laryngeal nerve
● Avoid crowded places and potentially infectious ● observe for signs of tetany: Chvostek’s sign,
situations Trousseau’s sign
● Administer liquid iodine prep dilute in beverage of ● calcium gluconate IV at bedside
31
● Have tracheostomy set and suction machine ready at usually all elevated
bedside
● observe for signs of thyroid storm (high fever, The three major forms of therapy
tachycardia, irritability, delirium, coma)
1. Antithyroid medication e.g, Propylthiouracil and
● gradual increase ROM of neck
Methimazole
2. Radioiodine e.g. 131 Iodine (1311) therapy
GRAVE’S DISEASE (TOXIC DIFFUSE GOITER, 3. Surgery
EXOPHTHALMIC GOITER)
➔ It is predominantly a disorder of females. Nursing Intervention
➔ It affects women four times as often as it does men,
● Provide an environment that is restful both mentally and
especially young women between the ages of 20 and
physically.
40.
● Explain to significant others that any bizarre, difficult
behavior is likely to be temporary and should steadily
Causes improve with intervention.
● Over functioning of the entire gland ● Maintain a quiet, understanding manner when caring.
● Single or multiple functioning adenomas of thyroid ● Accept their irritation and emotional outburst as normal
cancer expressions of the disease.
● Over treatment of myxedema with thyroid hormone ● Incorporate occupational therapy into care planning
● Provide a well-balanced diet
Hallmarks of Graves' disease ● Provide cool environment
● Hyperthyroidism
● Thyroid gland enlargement Thyroid Storm
● Exophthalmos (abnormal protrusion of the eyes). ● Uncontrolled and potentially life-threatening
● Dermopathy ) skin lesions hyperthyroidism due to sudden and excessive release
of thyroid hormone into the bloodstream
Etiology
● Graves' disease is an autoimmune disorder. Precipitating factors
● have circulating autoantibodies that react against ● Stress
thyroglobulin. ● Infection
● thyroid-stimulating immunoglobulins (TSI) are present in ● Unprepared thyroid surgery
the serum of 80 to 90 percent of hyperthyroid
individuals. Clinical manifestations
● Assessment and Diagnosis
● hyperpyrexia, diarrhea, dehydration, extreme
● extremely agitated and irritable, with a hand tremor at
tachycardia, arrhythmias, extreme irritation, delirium,
rest.
coma, shock and death if not adequately treated
● Weight loss occurs owing to the quickened metabolism.
● the person's bodily processes literally "speed up”
Management
Signs & Symptoms ● Drug therapy: antithyroid drugs Propylthoiuracil(PTU),
Hydrocortisone, sedatives, cardiac drugs, oxygen
● loose bowel movements
administration, Iodine to lower output of T4
● heat intolerance
● Immediate management of hyperthermia, tachycardia
● profuse diaphoresis
and prevention of vascular collapse
● Tachycardia
● Tremors
● skin become warm and smooth Nursing intervention
● hair appears thin and soft. ● Administer IV therapy as ordered
● emotions are adversely may be cyclic, ranging from mild
euphoria to extreme fatigue and depression, again HYPOTHYROIDISM
followed by episodes of over activity
➔ The thyroid gland fails to produce enough thyroid
hormones.
Assessment ● Myxedema - Adult hypothyroidism
● Graves' disease is diagnosed on the basis of ● Cretinism – Hypothyroidism in infants and
○ the person's often striking physical appearance children
(enlarged neck, protruding eyes, agitated
expression) Causes:
○ the symptoms of agitation, restlessness, and
weight loss; and ● Hashimoto's thyroiditis (the most common, an
○ The serum thyroid hormone levels, 24 hour autoimmune disease) - Chronic progressive disease of
thyroid gland caused by infiltration of lymphocytes
radio-iodine uptake, and T3 resin uptake are
32
● progressive destruction of the parenchyma and Nursing Care:

hypothyroidism if untreated ● Take the medication as scheduled at the same each day
● Medications : lithium, iodine compounds, antithyroid ● Take radial pulse; notify physician if greater than 100
medications beats/min
● Radiation to the neck and head ● Monitor V/S to detect changes in CV status and ability
● congenital defects to respond to stress
● surgical removal of the thyroid gland ● Monitor ECG tracings to detect arrhythmias
● inflammatory conditions. ● Provide warm environment and prevent chilling
● Administer fluids and all prescribed drugs with caution
Risk factors ● WOF and teach patients signs of complications
● age over 50 years A. Angina pectoris
● female gender B. Cardiac failure: dyspnea, palpitations
● Obesity C. Myxedema coma: weakness, syncope, slow pulse
● thyroid surgery rate, subnormal temperature, slow respirations,
● exposure of the neck to X-ray or radiation treatments lethargy
● Adequate hydration and roughage in diet (high fiber)
● Control of dietary intake to limit calories and reduce
Symptoms weight
● Low calorie,high protein, increase fiber and fluids
Early symptoms Late symptoms
● Patient teaching on continued HRT through life; regular
medical check-up; energy conservation techniques and
● weakness ● slow speech
the need to increase activity gradually; how and when to
● fatigue ● dry flaky skin
take medications
● cold intolerance ● thickening of the skin
● constipation ● puffy face, hands and feet
● weight gain (unintentional) ● decreased taste and smell Complications:
● depression ● thinning of eyebrows ● Myxedema coma, the most severe form of
● joint or muscle pain ● hoarseness hypothyroidism
● thin, brittle fingernails ● abnormal menstrual ● Symptoms and signs of myxedema coma include:
● thin and brittle hair periods - unresponsiveness
● paleness - decreased breathing
- Low blood pressure
- low blood sugar
Note: Patient with Hypothyroidism are Hypersensitive to - below normal temperature.
narcotics and barbiturates
Other complications:
Laboratory Examinations: ● heart disease
● T4 test (low) ● increased risk of infection
● serum TSH (high in primary hypothyroidism, low or ● Infertility
low-normal in secondary hypothyroidism) ● miscarriage.
● increased cholesterol levels
● increased liver enzymes
● increased serum prolactin HYPERPARATHYROIDISM
● low serum sodium ➔ is excessive production of parathyroid hormone by the
● complete blood count (CBC) that shows anemia parathyroid glands
Treatment Types of Hyperparathyroidism

● Replace the deficient thyroid hormone (Synthetic 1. Primary hyperparathyroidism
levothyroxine) ● Parathyroid hormone is produced without regard
○ Examples: Levothyroxine sodium (Synthroid), to the calcium levels.
Liothyronine sodium (Cytomel), Liothrix (Euthroid, ● It is caused by enlargement of one or more of the
Thyrolar) parathyroid glands.
● Administration of high dose glucocorticoids every 8 to
12 hrs for 24 hrs. followed by low dose therapy as per 2. Secondary hyperparathyroidism
doctor’s advised ● when the body produces extra parathyroid
hormone because the calcium levels are too low.
Major S/E:
● Increased metabolism 3. Tertiary hyperparathyroidism
● Hyperactivity ● If the parathyroid glands continue to produce too
● Cardiac stimulation much parathyroid hormone even though the
calcium level is back to normal
33
Symptoms: Complications:
● Fatigue Complications that result from excess calcium deposits within
● Back pain the body
● Joint pain ● Skeletal damage
● Fractures of long bones ● Urinary tract infection due to kidney stones and
● Decreased height obstruction
● Increased urine output ● Peptic ulcer disease
● Increased thirst ● pancreatitis
● Upper abdominal pain ● Pseudogout
● Loss of appetite
● Nausea
HYPOPARATHYROIDISM
● Muscular weakness
● Muscle pain ➔ is having insufficient parathyroid hormone, which
● Depression causes abnormal low blood levels of calcium and
● Personality changes phosphorus.
● Stupor and possibly coma
● Itching of the skin Causes:
● Blurred vision (because of cataracts) ● Lack of PTH.
● Bone pain or tenderness ● Blood calcium levels fall, and phosphorus levels rise.
● Injury to the parathyroid glands during head and neck
Laboratory Examination: surgery.
● Serum calcium is increased. ● Side effect of radioactive iodine treatment for
● Serum phosphorus is decreased. hyperthyroidism
● Serum alkaline phosphatase may be increased. ● PTH secretion also may be impaired when blood levels
● Intact parathyroid hormone (PTH) in the blood is of magnesium are low
increased. ● When blood pH is too high, a condition called metabolic
● Bone X-ray shows bone reabsorption or fractures. alkalosis.
● Imaging of the kidneys or ureters may show
calcification or obstruction. Symptoms:
● Reduced bone mineral density on bone densitometry ● Tingling lips, hands, and feet
(DEXA) ● Muscle cramps
● Urinary calcium may be increased. ● Pain in the face, legs, and feet
● Abdominal pain
Treatment: ● Dry hair
Treatment depends upon the severity and cause of the ● Brittle nails
condition. ● Dry, scaly skin
● Cataracts
● In primary hyperparathyroidism, if the calcium level is
● Weakened tooth enamel in children
very high or symptoms are present, surgery may be
● Muscle spasms called tetany (can lead to spasms of the
necessary to take out the gland that is overproducing
larynx, causing breathing difficulties)
the hormone.
● Convulsions (seizures)
● Secondary hyperparathyroidism is treated by restoring
the calcium back into the normal range, usually by
giving calcium and vitamin D alone or in combination, Laboratory Examinations:
depending on the underlying disorder. ● Low serum calcium level
● High serum phosphorus level
Nursing Interventions: ● Low serum parathyroid hormone level
● Low serum magnesium level (possible)
● Strain the urine, observing for stones
● Abnormal heart rhythms on ECG
● Encourage fluid intake, especially fluids such as
● Urine calcium
cranberry juice to acidify the urine
● Assist the client in ambulating to help prevent
demineralization Treatment:
● I/O monitoring ● Goal to increase serum Ca level to 9 to 10 mg/dl and
● Combat constipation eliminate the symptoms
● Limit intake of foods high in calcium especially milk / ● Ca Chloride or Ca gluconate given IV for emergency
dairy products treatment
- Calciferol (vit D) to help raise serum calcium levels
- Parathormone injections
- High calcium diet
- Aluminum hydroxide to decrease absorption of
phosphorus from the GI tract
34
Nursing Interventions: ● Changes in the blood pressure or heart rate

● Observe for respiratory distress and have emergency
equipment available to perform a tracheostomy
● Maintain seizure precautions
● Monitor serum Ca and phosphate levels
● Check V/S frequently
● Provide a calm environment free of harsh stimuli
● Provide a drug and dietary instruction including
elimination of milk, cheese and egg yolks because of
high phosphorus content
ADDISON'S DISEASE
➔ adrenal hormone deficiency caused by damage to the
outer layer of the adrenal gland (adrenal cortex).
Alternative Names: Assessment and Laboratory Examinations:

● Adrenocortical hypofunction ● Blood pressure is low.
● Chronic adrenocortical insufficiency ● Cortisol level is low.
● Adrenal insufficiency ● Serum sodium is low.
● increased potassium.
● An abdominal x-ray may show adrenal calcification.
Causes: ● An abdominal CT scan may show adrenal calcification,
Damage to the adrenal cortex caused by the following: enlargement or atrophy.
● autoimmune disease
● infections such as tuberculosis, HIV, or fungal Medical Management:
infections
● Immediate treatment for combating circulatory shock
Hemorrhage, blood loss
● Restoring blood circulation
● Tumors
● Administering fluids and corticosteroids
● Use of blood-thinning drugs (anticoagulants) ,
● Monitoring V/S
anticonvulsants and rifampicin
● Placing pt in a recumbent position with legs elevated
● Hydrocortisone (Solu-Cortef) via IV D5NSS
Risk factors: ● Vasopressor amines maybe required if hypotension
● Type I diabetes persist
● Hypoparathyroidism
● Hypopituitarism Nursing Interventions:
● Pernicious anemia
● Monitor V/S, be alert for elevation of temperature (infxn,
● Testicular dysfunction
DHN), alterations in PR and rhythm and alterations in
● Graves' disease
BP
● Chronic thyroiditis
● Observe for signs of Na and K imbalance
● Candidiasis
● MIO and weigh daily
● Dermatitis herpetiformis – eruption of itching papules,
● Administer steroids as ordered
vesicles and lesions resembling hives typically in
● Administer steroids with antacid to limit ulcerogenic
clusters
factor of the drug
● Vitiligo – skin disorder manifested by smooth white
● Put the client in a private room to prevent contact with
spots to various parts of the body
clients having infectious diseases
● Myasthenia gravis – progressive weakness of
● Limit the number of visitors
voluntary muscles
CUSHING'S SYNDROME EXCESSIVE CORTICOSTEROID

Symptoms:
➔ Additional symptoms that may be associated with this
● Extreme weakness
disease
● Fatigue
● weight gain (unintentional)
● emaciation
● Buffalo hump
● Nausea and vomiting
● skin spots, red
● Chronic diarrhea
● skin blushing/flushing
● Loss of appetite
● muscle atrophy or thin extremities
● Darkening of the skin - patchy skin color
● fatigue
- Unnaturally dark color in some locations
● bone pain or tenderness
- Paleness may also occur
● high blood pressure
● Mouth lesions on the inside of a cheek
● Slow, sluggish, lethargic movement
35
Assessment and Laboratory Examination: Assessment:

● Serum cortisol, urinary cortisol and low dose ● Polyphagia
dexamethasone suppression test ● Polydipsia
● cranial MRI or cranial CT scan may show pituitary tumor ● Polyuria
● abdominal CT may show adrenal mass ● Hyperglycemia
● glucose test is elevated ● Weight Loss
● potassium test may be low ● Blurred Vision
● Increase serum Na ● Slow Wound Healing
● white blood cell count may be elevated ● Vaginal Infections
● Weakness & Paresthesias
Treatment: ● Signs Of Inadequate Feet Circulation
● Cushing's syndrome caused by drug therapy with
corticosteroids, the drug must be slowly decreased APPROACH TO DIABETES MELLITUS:
under medical supervision. ● nutritional therapy
● Cushing's disease is caused by a tumor, surgery to ● low glycemic index
remove the tumor is recommended. ● exercise
(HYPOPHYSECTOMY) ● oral hypoglycemic agents/insulin
● Radiation is needed as well. ● education`
● Hydrocortisone (cortisol) replacement therapy is needed ● Monitoring
after surgery, and sometimes forever.
EXERCISE GUIDE DIABETIC FITNESS:
Nursing Interventions: ● Frequency - 3x a week
● Monitor vital signs, MIO, daily weight, blood glucose and ● Intensity - 60-80% of Maximal Heart Rate
electrolytes ● Time - AEROBIC ACTIVITY 20-30mins. With 5-10mins.
● Protect the client from exposure to infections WARM-UP
● Minimize stress in the environment by limiting visitors
and explaining procedures carefully Oral Hypoglycemic Agents:
● Instruct client regarding diet and supplementation;
● Sulfonylureas
encourage diet rich in nutrient dense foods such as
- Chlorpropamide (Diabinase)
fruits and vegetables, whole grains and legumes to
- Tolbutamide (Orinase)
improve and maintain nutritional status and prevent any
- Glimepinide (Solosa)
possible drug-induced nutrient deficiencies
- Acetohexamide (Dymelor)
● Prandial Glucose Regulator
Other management: - Repaglinide (Novonorm)
● Increased protein and potassium but decrease calories - Rosiglitazone (Avandia)
and sodium ● Non-sulfonylureas
● Medication: - Metformin (Glucophage)
● Aminoglutethimide (Cytadren) - Precose (Acarbose)
● Mitotane (Lysodren) - Rosiglitazone (Avandia)
● Ketoconazole (Nizoral)
● Trilostane (Modastane) Major S/E of Antidiabetics
● Surgery: adrenalectomy ● Irritability
● Confusion
DIABETES MELLITUS ● Tachycardia
➔ A group of metabolic diseases characterized by ● Tremor
increased levels of glucose in the blood resulting from ● Moist skin
defects in insulin secretion , insulin action or both ( ● Headache
American Diabetes Association 2016). ● Hunger
● Oral hypoglycemics
○ Skin rash
Major Types:
○ Jaundice
1. INSULIN-DEPENDENT DIABETES - formerly called ○ Pruritus
juvenile type; has rapid onset and requires insulin ○ Allergic reactions
administration
2. NON-INSULIN DEPENDENT DIABETES - formerly Nursing care for patients taking antidiabetics
called adult onset type, often can be controlled with diet ● Assess clients for signs of hypoglycemia
3. GESTATIONAL DIABETES - occurs during pregnancy ● Instruct client to
usually during 2nd and 3rd Trimester ● use proper medication procedure
● Comply with dietary program
● avoid alcohol
36
● Be prepared for hypoglycemic incidents (rapid acting Management for DKA

glucose solution, hard candy, orange juice) ● Treating hyperglycemia
● Correcting dehydration thru rehydration, electrolytes
Insulin Administration loss and acidosis
● Administer all form of insulin subcutaneously
● Use only regular insulin for IV administration HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC
● When mixing insulin, draw regular insulin into the COMA
syringe first ● A metabolic disorder of type 2 resulting from a relative
● Rotate sites of administration deficiency initiated by an illness that raises the demand
for insulin.
Major Complications of Diabetes Mellitus ● Management same with DKA
● HYPOGLYCEMIA ● Kussmaul respirations- Deep, rapid respiration
● DIABETIC KETOACIDOSIS (DKA) characteristic of diabetic acidosis or other conditions
● HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC causing acidosis.
SYNDROME (HHNS)
Causes of Hypoglycemia
● Too much insulin
● Excessive intake of antidiabetic agents
● Unusually high levels of exercise
● Insulin potentiating drugs
Signs of Hypoglycemia
● Sweating
● Tremor
● Tachycardia
● Palpitations
● Nervousness
● Hunger
Simple Carbohydrate to Treat Hypoglycemia

● 3 or 4 commercially prepared glucose tablets- CHILD:
2-3 GLUCOSE TABS Chronic Complications of DM
● 4-6 ounces of fruit juice or regular soda- CHILD: ½ CUP ● Peripheral Neuropathies- Result from thickening of
OR 120 ML OF ORANGE JUICE OR vessel walls that supply peripheral nerves causing
SUGAR-SWEETENED JUICE alteration in sensory perception.
● 6-10 Life Savers or hard candy- CHILD: 3-4 HARD ● Retinopathy- Microangiopathy of the retina leading to
CANDIES OR 1 CANDY BAR retinal microvascular occlusion, eventually leading to
● 2-3 teaspoons of sugar or honey- CHILD: 1 SMALL blindness.
BOX OF RAISINS ● Nephropathy- Thickening of glomerular basement
● 10-15 g of simple carbohydrate membrane resulting in hardening and thickening of the
glomeruli.
DIABETIC KETOACIDOSIS ● Macrovascular disease- Atherosclerosis
Assessment
● 3 main clinical features:
○ Hyperglycemia
○ DHN and electrolytes loss
○ Acidosis
● 3 Ps
● Blurred Vision
● Marked fatigue
● Headache
● Hypotension
● Weak, rapid pulse
● Anorexia, nausea, vomiting & abdominal pain
● Acetone breath (fruity odor)
● Kussmaul respirations
● Mental status changes
37
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MEDICAL SURGICAL NURSING (PRELIM) NCM 116 LECTURE

○ Anal canal, internal and external sphincter - Intestinal gas

● Collection of subjective data PAST HEALTH HISTORY

PRESENT HEALTH HISTORY FAMILY HISTORY

● Activities, exercises, stress level REGIONS AND QUADRANTS OF ABDOMEN

Key Points For Assessment:

OBSERVE COLORATION OF SKIN

● Nonhealing, redness, inflamed, keloids

● Changes in mole size, color, border symmetry,

● Purple or bluish discoloration around umbilicus

INSPECT ABDOMINAL CONTOUR

● from organ enlargement, large masses, bulging of

● Diminished abdominal respiration

● Exaggerated pulsation with abdominal aortic

NATURE OF VOMITUS ● Electrolyte imbalances

DISORDER OF THE MOUTH

2. Other characteristics with specific problem

TYPE OF DRUG CONSIDERATIONS

General Tetracycline USUAL DOSE - 250mg/10ml for

Herpes Acyclovir USUAL DOSE - 5mg/kg for 1

Fungal Nystatin USUAL DOSE - 600,000 units

Anti-Inflammatory Agents And Immune Modulators Cause:

DISORDER OF THE GASTROINTESTINAL SYSTEM

INDICATION: management of heartburn

Subjective Data: HISTAMINE RECEPTOR ANTAGONISTS

Nursing Care After Surgery:

Assessment And Diagnostic Findings Pathophysiology

DISORDER OF THE STOMACH AND SMALL INTESTINE

Types Of Chronic Gastritis

PARAMETER GASTRIC ULCER DUODENAL ULCER

Hemorrhage Hematemesis more Melena more common Hyposecretory Drugs

Mucosal Barrier Fortifiers

DISORDER OF THE LOWER GI TRACT (DISORDERS

● Immunosuppressive Drugs Post-operative Care

TOTAL PROCTOCOLECTOMY WITH PERMANENT

DANGER SIGNS! distention.

IRRITABLE BOWEL SYNDROME 2.) WITHOUT INFLAMMATION DIVERTICULITIS

Risk Factors Incidence

Nursing Care After Surgery

Risk Factors Pre- operative Care

DISORDER INVOLVING THE ACCESSORY

Pathophysiology Purposes Of Oral Cholecystography

Preoperative Nursing Care:

ORAL CHOLECYSTOGRAPHY PANCREAS

in the process of digestion (exocrine function-amylase ● Fecal fat determinations

PORTAL HYPERTENSION Diagnostic Test

Preparing A Patient For Ultrasound Of The Liver

Preparing A Patient For Liver Biopsy

Nursing Care After Liver Biopsy

Medication For Patient With Cirrhosis

Prevention Of Bleeding Of Esophageal Varices

Interventions For Bleeding Of Esophageal Varices

Preparing A Patient For Paracentesis

Nursing Care After Paracentesis

THE ENDOCRINE SYSTEM

ANTERIOR PITUITARY GLAND DYSFUNCTION

POSTERIOR PITUITARY GLAND DYSFUNCTION

(ANTERIOR) HYPERPITUITARISM (+BASOPHILIC OR EOSINOPHILIC TUMOR)

POSTERIOR PITUITARY GLAND

(ANTERIOR) HYPOPITUITARISM (+CHROMOPHOBIC TUMOR)

POSTERIOR PITUITARY GLAND (HYPOPITUITARISM)

OTHER ORGANS / GLANDS INVOLVED IN ENDOCRINE SYSTEM:

REVIEW OF NORMAL STRUCTURES AND FUNCTIONS ● Thyrotropic Hormones (TSH)