ASSESSMENT OF METABOLIC AND -aka Esophagoscopy, gastroscopy, upper GI

GASTROINTESTINAL, LIVER ALTERATIONS endoscop

-to visualize and assess the esophagus, stomach, and
upper portion of the duodenum
>>Guiac test to assist in diagnosis of bleeding, ulcers,
inflammation, tumor, and cancer
-first to be demonstrated as effective at reducing -no activity restrictions unless by medical direction
cancer mortality
-non-invasive stool test

(Kuipers, 2020)

-positive at a level of about 2mL/day or

higher
-preferentially detect lower GI bleeding

(Wu, 2021)

>>Hepatobiliary test

-Esophageal mucosa is normally yellow-pink

-Hepatobiliary iminodiacetic acid (HIDA) scan
-to confirm dx of cholecystitis or biliary obstruction
when other imaging is equivocal (Bladh & M., 2019)

(Pua et al., 2019)

ERCP

>>CBG -Endoscopic retrograde cholangiopancreatography

-Blood glucose monitoring
-way of testing the concentration of glucose in the
blood (glycemia)
-performed by piercing the skin on the finger to
draw blood and then applying the blood to a
chemically active disposable 'test-strip'
-Track normal level and goal level before and after
meals and prior to bedtime
-Indicate weekly goals and track progress
-List physician's info in case of an
emergency
-Track daily levels and moods to see any
impact
-To visualize and assess the pancreas and common
bile ducts for occlusion or stricture
-allows direct visualization of the pancreatic and
biliary ducts with a flexible endoscope and, after
injection of iodinated or noniodinated contrast
material, with x-rays
-no activity restrictions
-Tissue specimens collected during the procedure
should be placed in appropriate containers

(Westfall, 2020)

>>EGD

-Esophagogastroduodenoscopy
>C.I. (Contraindications) -Three Primary Disorders
-Patients with conditions associated with adverse 1. erosive gastritis
reactions to contrast medium (e.g., asthma, food 2. peptic ulcer disease
allergies, or allergy to contrast medium) 3. oesophageal varices
(Bladh & M., 2019)
>Pathophysiology
S&S
PTC -nausea and vomiting (haematemesis, vomiting
blood)
-hyperactive bowel sounds and diarrhea
-Percutaneous transhepatic cholangiography -black and tarry (melaena) or frankly bloody
-to visualize the biliary system in (haematochezia)
order to evaluate persistent upper -increased blood urea nitrogen (BUN) levels.
abdominal pain after cholecystectomy and to -blood may be occult (hidden)
determine the presence and cause of obstructive
jaundice >Dx (diagnosis)
-liver capsule is punctured with a thin needle under -full blood count (FBC) with haemoglobin and
fluoroscopic guidance; contrast medium is injected haematocrit
-visualizes the biliary ducts without depending on -Blood type and crossmatch (for transfusion)
the gallbladder’s concentrating ability -Serum electrolytes, osmolality and BUN
-Liver function tests and a coagulation profile
>C.I. (Contraindications) -upper endoscopy
-Patients with conditions associated with adverse
reactions to contrast medium (e.g., asthma, food >Tx (Treatment)
allergies, or allergy to contrast medium) -stemming the bleeding
-restoring cardiovascular stability
-maintaining airway
-IVF (NSS) through large-bore intravenous catheter
liver biopsy
>Nsg Care
- can be used to: -prevent GI bleeding
-confirm or refute the clinical diagnosis -identifying people at risk and instituting regular
-identify additional clinically unsuspected gastric pH monitoring and maintenance of drug
conditions; assess severity, progression, and therapy
complications of disease
-evaluate response to and complications of
treatment (Ignatavicius, 2021)

(Dooley et al., 2018)

Intra-abdominal hypertension compartment

syndrome (abdominal hypertension)
GI Bleeding
- a constellation of the physiologic sequelae of
-The gastrointestinal tract can be subjected to increased intra-abdominal pressure, (IAP), termed
trauma and exposed to toxins, infection with intra-abdominal hypertension, (IAH)
pathogens
-Helicobacter pylori (H. pylori) (Ivatury, 2019)
-GI’s rich supply of blood can result in significant
bleeding when a vessel is eroded or abnormally
distended (varices) Liver Failure
-upper portion of the tract is more commonly
affected. -Acute liver failure, or fulminant hepatic failure
-rapid onset of severe liver dysfunction with no
history of liver disease
-often accompanied by hepatic encephalopathy
-most common cause -> drugs
>S&S
-jaundice, coagulation abnormalities,
encephalopathy
-changes in cognitive function (1st clinical sign)
-cerebral edema, renal failure, hypoglycemia,
metabolic acidosis, sepsis, and multiorgan failure.
- high Serum bilirubin; prolonged PT time
>Dx
-blood chemistries (especially glucose)
-complete blood count (CBC)
-acetaminophen level
-screening for other drugs and toxins
- α1-antitrypsin levels
-ammonia levels
-autoantibodies (ANAs and ASMAs)
- CT or MRI
>Nsg Mgt.
-planning for transfer to a transplant center
should begin in patients with grade 1 or 2
encephalopathy
-Assess pt regularly for baseline LOC and
orientation; report any changes to the
HCP
-Avoid the use of any sedatives due to
their effects on mental status
-Closely observe the patient to prevent
injuries and pad bedrails to avoid injury
from possible seizures
-Monitor I&O
-Skin and oral care
-higher in men than in women
-associated with gallstones in women and with
alcoholism in men
>Manifestations
-develops suddenly
and -pain commonly radiates to the back
-relieved somewhat by sitting up and leaning
forward
-pain often is initiated by a fatty meal or excessive
alcohol intake
-nausea and vomiting, abdominal distension and
rigidity, decreased bowel sounds, tachycardia,
hypotension, elevated temperature, and cold,
clammy skin
(Ignatavicius, 2021)
Diabetic Ketoacidosis
-occurs most often in patients with type 1 DM
-uncontrolled hyperglycemia, metabolic acidosis,
and increased production of ketones
-results from the combination of insulin deficiency
and an increase in hormone release
-increased liver and kidney glucose production
-decreased glucose use in peripheral tissues

(Brown, 2020)

Acute Pancreatits

-autodigestion
-release of pancreatic enzymes into the
tissue of the pancreas itself; leads to
haemorrhage and necrosis
-gallstones and chronic alcohol abuse account for 80%
of acute pancreatitis causes (Ignatavicius, 2021)

>Pathophysiology
-more common in adults
Hyperglycemia (LeMone, 2017)

-elevated blood glucose levels

-S&S: blurred vision, headache, weakness, fatigue,
drowsiness, anorexia, nausea, and abdominal pain Medical/Surgical Management:

>Inspection i. Volume restoration/Fluid Therapy

-(+) flushed skin, polyuria, polydipsia, vomiting, and
evidence of dehydration. +polyphagia -critical for intravascular, interstitial, and
-deterioration in LOC intracellular volume and restoration of renal
-if ketoacidosis occurs, breathing becomes deep and perfusion
rapid; breath may have a fruity odor -replaces the fluid and electrolyte deficiencies while
simultaneously reducing plasma glucose
> Auscultation concentrations and counter regulatory hormones
-hypoactive bowel sounds
(Loriaux & Vanek, 2022)
>Palpation
-abdominal tenderness
ii. Nasogastric Suction Tubes
>Percussion
-diminished deep tendon >Indications
reflexes -Evaluation of GI bleeding (history of melena, bright
red blood per rectum, or coffee ground emesis)
-decompression of the GI tract (partial/complete
(Urden et al., 2021) small bowel obstruction)
-Prevent aspiration and gastric dilation in intubated
patients
-gastric lavage and/or removal of toxins
HYPEROSMOLAR HYPERGLYCAEMIC STATE (HHS)
>Contraindications
-occurs in people who have type 2 DM -facial trauma
-plasma osmolarity of 340 mmol/kg or greater -severe coagulopathy
-has a higher mortality rate -esophageal strictures and alkali ingestions
than DKA
-most common precipitating factor is infection
-onset: 24 hours to 2 weeks (Ganti, 2022)
-increased urine output -> plasma volume decreases;
glomerular filtration rate (GFR) drops
iii. Esophagogastric Balloon Tamponade
>S&S
-dry skin and mucous membranes -a very effective way to control esophageal bleeding
-extreme thirst -used if the patient is not able to have a second
-altered LOC endoscopy or TIPS procedure
-tube is placed through the nose and into the
Note: Metabolic acidosis is not part of the pathology; stomach
despite elevated blood glucose, sufficient insulin is -attached balloon is inflated to apply pressure to the
present to prevent metabolism of fats with the bleeding variceal area
resulting fatty acids and ketones of DKA.

>Tx (Ignatavicius, 2021)

-correcting fluid and electrolyte imbalances
-lowering blood glucose levels with insulin
iv. Billrith I and II
-commonly used in partial gastrectomy procedures
-Billroth I aka gastroduodenostomy (A)
-Billroth II aka gastrojejunostomy (B)
>Complications
-Dumping syndrome
-duodenal or jejunal anastomosis
-undigested food bolus may rapidly enter the
duodenum or jejunum
(LeMone, 2017)
v. Transjugular Intrahepatic Portosystemic Shunt
-procedure that involves TIPS cannula in a guide wire
positioned into the right portal vein
(Kahn et al., 2018)
-an interventional radiology procedure where a stent
is inserted to ameliorate the complications from
portal hypertension
- used to combat the downstream effects of portal
hypertension; esophageal variceal bleeding that has
not been controlled via medical or endoscopic
management
>Contraindications
-severe elevation in right heart pressures or
pulmonary hypertension
-congestive heart failure
- active infections systemically or within the liver
-concurrent bleeding diatheses
( Koutroulis & Tsarouhas, 2021)
vi. Liver transplantation
-option for many people with
end-stage liver disease or localized HCC
- Liver disease r/t chronic viral hepatitis = leading
reason for liver transplantation
-using both deceased (cadaver) and live donor livers
-Postoperative complications of liver transplant:
bleeding, infection, and rejection
(Brown, 2020)
vii. Reverse Hydration
-Fluid resuscitation
-most effective treatment for the person in
hypovolaemic shock
-management of septic and neurogenic shock
-administered alone or in combination as part of
fluid replacement therapy in treating shock
>Solutions
-CRYSTALLOID SOLUTIONS -increase fluid volume in
both the intravascular and the interstitial space
 -contain dextrose or electrolytes dissolved
in water (Brown, 2020)
-management of shock are either isotonic
or hypotonic
-COLLOID SOLUTIONS -contain substances (colloids) x. Rapid Hydration
that do not diffuse through capillary walls
-colloids tend to remain in the vascular -overhydration
system and increase the osmotic pressure of the -causes a dilutional hyponatremia and reduces the
serum sodium concentration to critically low levels
-causes fluid to move into the vascular
compartment from the interstitial space -> plasma (Urden et al., 2021)
volume expansion

11. Pharmacological Management

(LeMone, 2017)
Complementary and Alternative Therapy
viii. Reverse Ketoacidosis
▪ Ginger
-insulin therapy for DKA and HHS
-easy to titrate -May be effective for nausea and vomiting in
-has a rapid onset and short duration of action pregnancy for short periods
-May interact with anticoagulants and increase risk
for bleeding
(Winter et al., 2021) -Use with caution in people with gallbladder disease

(Brown, 2020)
ix. Electrolyte replacement

- amount and type of solution is determined by the ▪ Bitter gourd (Ampalaya)

normal daily maintenance
-Tonicity is a key factor in determining the
appropriate solution to correct imbalances
>Solutions
-Hypotonic -has a lower osmolality when compared
to plasma
- dilutes ECF, lowering serum osmolality
-Osmosis then produces a movement of
water from ECF to interstitial spaces and
cells, causing cells to swell
-Isotonic -osmolality similar to plasma
- isotonic solution expands only ECF and the
fluid does not move into cells
-makes isotonic solutions the ideal fluid
replacement for patients with ECF volume
deficits
-Hypertonic - higher osmolality than plasma
- The higher osmotic pressure draws water
out of the cells into ECF
- useful in the treatment of hyponatremia
and trauma patients with head injury
-Medicinal properties of bitter gourd include:
antidiabetic, antiviral, antitumor, antileukemic,
antibacterial, antihelmintic, antimutagenic,
antimycobacterial, antioxidant, antiulcer, anti-
inflammatory, hypocholesterolemic,
hypotriglyceridemic, hypotensive, immunostimulant,
and insecticidal properties
- fruits and the seeds contain cucurbitacin-B,
lycopene, and B-carotene, which are known to have
anticancer actions
-contains charantin and plant insulin, clinically
demonstrated to have hypoglycemic and
antihyperglycemic activities
-seeds - tx for ulcers, liver, and spleen problems,
diabetes, high cholesterol, interstinal parasites, heal
wounds, and stomachache
(Kole et al., 2020))
Assessment for Responses to altered Elimination

▪ Diagnostic Assessment
i. Non Invasive (McCall, 2020)

▪ Urinalysis ▪ Renal ultrasound

-Assessment of renal function. Systemic illness can -highly sensitive and specific test for hydronephrosis
frequently produce an abnormal urinalysis - valuable in the initial evaluation of hematuria and
stone disease
(Winter et al., 2021) >Indications
-Flank and/or back pain with consideration for
urolithiasis and abscess
-To screen urine for multiple markers to assist in -Acute renal injury/failure with concern for
diagnosing disorders such as UTIs, kidney and liver obstruction
disease -Hematuria
-to assess hydration status -Abdominal trauma
-Further evaluation of abnormal findings of the
kidney on other imaging studies
-Planning and guidance for interventional
procedures

(Bladh & M., 2019)

▪ 24-urine collection

-pooled urine specimen collected over a 24-hour

period to allow quantitative analysis of a urine ( Fulgham & Gilbert , 2017)
analyte
-requires a large, clean, preferably wide-mouth
container capable of holding several liters ii. Invasive
-label should be affixed to the container, and not to
the lid ▪ Serum studies intravenous pyelography
- tests that require a 24-hour urine specimen:
creatinine clearance (a kidney function test), and -also called intravenous urography (IVU)
urobilinogen (a liver function test)
-evaluates structures of the urinary tract, filling of
the renal pelvis with urine, and transport of urine via
the ureters to the bladder
-determine whether the patient has an allergy to

>Preparation
- light evening meal
-taking a non-gas-forming laxative
- NPO for 8 hours

(Cooper et al., 2019)

“Halamang Gamot”

- Plant drugs are also known to play a major role in

the management of liver diseases
-300 preparations in Indian system of medicine for
the treatment of jaundice and chronic liver diseases
-polyherbal formulations
-Silymarin from Silybum marianum, ellagic acid from
Eucalyptus maculata, curcumin from Curcuma longa,
picroliv from P. kurroa, phyllanthin and
hypophyllanthin from P. niruri, glycyrrhizin from
Glycyrrhiza glabra, methoxy benzoic acid from
Capparis spinosa, and andrographolide from A.
paniculata

(Muriel, 2017)
 References
Bladh, M. L., & M., V. L. A. (2019). Davis's
comprehensive manual of Laboratory and
diagnostic tests with nursing implications.
FA Davis Company.
Brown, D. (2020). Lewis's medical-surgical nursing:
Assessment and management of clinical
problems. Elsevier Australia ACN (a division
of Reed International Books Australia Pty
Ltd).
Cooper, C., Kim D., Gosnell, & Kelly. (2019).
Foundations and Adult Health Nursing E-
Book. Google Books (8th ed.). Elsevier
Health Sciences;Mosby. Retrieved October
5, 2022, from
https://books.google.com.ph/books?id=juJ1
DwAAQBAJ&pg=PA1654&dq=Ser
um+studies+intravenous+pyelography&am
p;hl=en&sa=X&ved=2ahUKEwiErp
PV3Mf6AhUBO3AKHZ_9AzQQ6AF6BAgIEAI#
v=onepage&q=Serum%20studies%20in
travenous%20pyelography&f=false.
Dooley, J. S., Lok, A. S., Garcia-Tsao, G., & Pinzani, M.
(2018). Sherlock’s Diseases of the Liver and
Biliary System. Google Books.
https://books.google.com.ph/books?id=lDlf
DwAAQBAJ&printsec=frontcover&dq=liver+
biopsy+procedure&hl=en&sa=X&ved=2ahU
KEwiY18OQl8X6AhXX6jgGHX2KAwEQ6AF6B
AgDEAI#v=onepage&q=liver%20biopsy%20
procedure&f=false
Fulgham, P. F., & Gilbert , B. R. (2017). Practical
Urological Ultrasound (2nd ed.). Humana
Press.
Ganti, L. (2022). Atlas of Emergency Medicine
Procedures, 2nd Edition (2nd ed.). Springer.
Ignatavicius, D. D. (2021). Medical-Surgical Nursing:
Concepts for Interprofessional Collaborative
Care. Elslevier.
Ivatury, R. (2019). Abdominal Compartment
Syndrome. Google Books.
https://books.google.com.ph/books?id=JtN
DzAEACAAJ&dq=Intra-
abdominal+hypertension+compartment+sy
ndrome&hl=en&sa=X&ved=2ahUKEwj8h4S
Am8X6AhX_1jgGHd4-D68Q6AF6BAgLEAI
Kahn, S. L., Arslan, B., Masrani, A., & Oxford
University Press. (2013). Interventional and
Endovascular Tips and Tricks of the Trade.
Google Books.
https://books.google.com.ph/books?id=h2F
mDwAAQBAJ&printsec=frontcover&dq=.+tr
ansjugular+intrahepatic+portosystemic+shu
nt&hl=en&sa=X&ved=2ahUKEwir05Oe9cT6
AhUv7zgGHekgDdAQ6AF6BAgLEAI#v=onep
age&q=.%20transjugular%20intrahepatic%2
0portosystemic%20shunt&f=false
Kole, C., Matsumura, H., & Behera, T. K. (2020). The
Bitter Gourd Genome. Google Books.
https://books.google.com.ph/books?id=CCL
NDwAAQBAJ&printsec=frontcover&dq=bitt
er+melon+ampalaya+METABOLIC+AND+GA
STROINTESTINAL,+LIVER+ALTERATIONS&hl=
en&sa=X&ved=2ahUKEwjv3veRgMX6AhV8z
DgGHQ2KAqAQ6AF6BAgGEAI#v=onepage&
q&f=false
Koutroulis, I., & Tsarouhas, N. (2021). Emergency
Management of the Hi-Tech Patient in
Acute and Critical Care (Vol. 1). John Wiley
& Sons.
Kuipers, E. J. (2020). Encyclopedia of
Gastroenterology. Google Books.
https://books.google.com.ph/books?id=zCL
LDwAAQBAJ&pg=PA675&dq=guaiac+test&h
l=en&sa=X&ved=2ahUKEwjttb6d7sT6AhWIF
ogKHShdD4oQ6AF6BAgJEAI#v=onepage&q=
guaiac%20test&f=false
LeMone, P. (2017). Medical-Surgical Nursing: Critical
Thinking for person-centred care (3rd ed.,
Vol. 1). Pearson Australia.
Loriaux, L., & Vanek, D. (2022). Endocrine
emergencies: Recognition and treatment.
Springer.
McCall, R. (2020). Phlebotomy Essentials, Enhanced
Edition. Google Books.
https://books.google.com.ph/books?id=CDz
pDwAAQBAJ&pg=PA407&dq=24+hour+urin
e+collection&hl=en&sa=X&ved=2ahUKEwj5
x7yekcX6AhXjumMGHbU0D_MQ6AF6BAgFE
AI#v=onepage&q=24%20hour%20urine%20
collection&f=false
Muriel, P. (2017). Liver pathophysiology: Therapies
and antioxidants. Elseveir/Academic Press.
Pua, B. B., Covey, A. M., & Madoff, D. C.
(2019). Interventional Radiology. Google
Books.
https://books.google.com.ph/books?id=7fp
yDwAAQBAJ&printsec=frontcover&dq=hep
atobiliary+iminodiacetic+acid+(HIDA)+scan
&hl=en&sa=X&ved=2ahUKEwiHipDvjMX6Ah
XA_DgGHcMwD-
AQ6AF6BAgCEAI#v=onepage&q=hepatobili
ary%20iminodiacetic%20acid%20(HIDA)%20
scan&f=false
Westfall, L. (2020). Diabetes: Diabetics Log Book -
Blood Sugar Level Monitor - Diabetes
Journal - Blood Glucose Monitor - Diabetes
Tracker. Google Books.
https://books.google.com.ph/books?id=Mu
wvzQEACAAJ&dq=capillary+blood+glucose
&hl=en&sa=X&ved=2ahUKEwiJxJKkjsX6AhW
5-jgGHXD8BXoQ6AF6BAgDEAI
Winter, W. E., Holmquist, B., Sokoll, L. J., & Bertholf,
R. L. (2021). Handbook of Diagnostic
Endocrinology. Academic Press is an imprint
of Elsevier.
Wu, G. Y. (2021). Management of Occult GI Bleeding.
Google Books.
https://books.google.com.ph/books?id=824
vEAAAQBAJ&printsec=frontcover&dq=guaia
c+occult+test&hl=en&sa=X&ved=2ahUKEwj
Fh6uniMX6AhXD-
zgGHWPPB8oQ6AF6BAgHEAI#v=onepage&
q=guaiac%20occult%20test&f=false

Urden, L. D., Stacy, K. M., & Lough, M. E. (2021).

Critical care nursing: Diagnosis and
management. ELSEVIER - HEALTH Science.