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401 PREFINALS • Dysphagia

ANEURYSM Diagnostic Tests

Aneurysm - is a localized • Chest X-ray

sac or dilation formed at a • Computed Tomography Angiography
weak point in the wall of (CTA)
the artery. • Transesophageal Echocardiography

Medical Management

• Control Blood Pressure

• Correcting Risk Factors

Pharmacologic

• Beta blockers
• Metoprolol
Etiologic Classification of Arterial Aneurysms • Carvedilol
• Congenital • Angiotensin Receptor Blockers (ARBs)
• Mechanical (hemodynamic) • Valsartan [Diovan]
• Traumatic (pseudoaneurysms) • Irbesartan [Avapro])
• Inflammatory (noninfectious)
• Infectious (mycotic) Surgical Management
• Pregnancy-related degenerative
• Anastomotic (post-arteriotomy) and graft • Endovascular Grafts Placed
aneurysms Percutaneously
• Thoracic endografts

A. Thoracic Aortic Aneurysm (TAA) B. Abdominal Aortic Aneurysm (AAA)

occurring in the aorta
- occurring in a part of the aorta running through the abdomen
running through the chest
- the walls of aorta become weak
and the part of aorta nearer to the
heart enlarges

Clinical Manifestations

• Back, neck or substernal pain

• Dyspnea, stridor or brassy cough
if pressing on trachea
• Hoarseness
Clinical Manifestations
• Aphonia
• Edema of the face and neck
▪ Patients with (AAA) feel their
• Distended neck vein
heart beating in their abdomen
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when lying down
▪ Client’s awareness of a pulsating mass in
the abdomen, with or without pain,
followed by abdominal pain and back
Aortic calcification noted on x-ray
• Mild to severe mid abdominal or lumbar
back pain
• Cool, cyanotic extremities if iliac arteries
are involved
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When an abdominal aortic aneurysm measured at
least 5.5 cm (2 in) wide or was enlarging, the
standard treatment had been open surgical repair
of
the aneurysm by resecting the vessel and sewing
a
bypass graft in place.

Claudication (ischemic pain with

exercise, relieved by rest)

• Complication: peripheral emboli to lower

extremities

• Rupture and hemorrhage

Assessment Nursing Management

• A pulsatile mass in the • Anticipating a rupture

middle and upper abdomen. • patient may have
• A systolic bruit may be cardiovascular, cerebral,
heard over the mass. pulmonary, and renal
impairment
Diagnostic Findings • Asses all organ systems
• Duplex ultrasonography • Vital signs and Doppler assessment
every 15 minutes
• Computed Tomography Angiogram • Assess for bleeding, pulsation,
swelling, pain, and hematoma
Gerontologic Considerations formation
• Skin changes of the lower extremity,
• Occurs between 60 and 90 lumbar area, or buttocks

Pharmacologic Therapy Dissecting Aorta

• Antihypertensive agents -Occasionally, in an aorta

• Diuretics diseased by arteriosclerosis, a
• Beta blockers tear develops in the intima or the
• ACE inhibitors media degenerates, resulting in a
• ARBs dissection

Endovascular and Surgical Management

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Clinical Manifestations

• Sudden onset of symptoms

• Severe and persistent pain
• The pain is in the anterior chest or Clinical Manifestations
back and extends to the shoulders,
epigastric area, or abdomen The six Ps
• Increased BP
• Pain
• Pallor
Diagnostics Findings • Pulselessness
• Paresthesia
• Arteriography • Poikilothermia (coldness)
• Multidetector-Computed • Paralysis
Tomography Angiography Diagnostic Findings
(MDCTA)
• TEE • transthoracic echocardiogram (TTE)
• duplex ultrasonography
• chest x-ray
• MRA • electrocardiography (ECG)
• Noninvasive duplex
Arterial Embolism and • Doppler ultrasonography
Arterial Thrombosis

• Acute vascular occlusion may be caused by

an embolus or acute thrombosis.
• Acute arterial occlusions may result from
iatrogenic injury, which can occur during
insertion of invasive catheters such as
those used for arteriography, PTA or stent
placement, or an intra-aortic balloon pump,
or it may occur as a result of IV drug abuse.
Medical management
• Heparin therapy
-an initial IV bolus of 60 U/kg body
weight is given, followed by a
continuous infusion of 12 U/kg/h
until the patient undergoes
endovascular treatment or surgery.
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•is a situation in which blood pressures are
extremely
elevated and must be lowered immediately (not
necessarily to less than 140/90 mm Hg) to halt or
prevent
damage to the target organs (Chobanian et al.,
2003;
Rodriguez et al., 2010).
• Conditions associated with a hypertensive
emergency
Nursing management
include hypertension of pregnancy, acute
myocardial
• Patient remains on bed rest
infarction, dissecting aortic aneurysm, and
• Vital signs are taken initially
intracranial
every 15 minutes
hemorrhage.
• Collaborates with the primary
provider
Assessment will reveal actual or developing
clinical
HYPERTENSIVE CRISIS
dysfunction of the target organ.

A hypertensive crisis is a sudden, severe

increase in blood pressure.
➢ The blood pressure reading is 180/120
millimeters of mercury (mm Hg) or greater.
➢ A hypertensive crisis is a medical
emergency. It can lead to a heart attack,
stroke or other life-threatening health
problems.
• Hypertensive emergencies are acute, life
threatening blood
pressure elevations that require prompt treatment
in an
intensive care setting because of the serious
target organ
damage that may occur.
The therapeutic goals are reduction of the mean
blood pressure by 20% to 25% within the first
hour of treatment, a further reduction to a goal
pressure of about 160/100 mm Hg over a period
of up to 6 hours, and then a more gradual
reduction in pressure over a period of days.

PHARMACOLOGY

• The medications of choice in hypertensive

emergencies are those that have an
immediate effect.
Intravenous vasodilators:
❖ sodium nitroprusside (Nitropress),
❖nicardipine hydrochloride (Cardene),
❖clevidipine (Cleviprex),
Hypertensive Emergency ❖fenoldopam mesylate (Corlopam),
❖enalaprilat,
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❖nitroglycerin
• These medications have immediate actions that
are short-lived
(minutes to 4 hours), and they are therefore used
for initial
treatment.
Other Medical Management:
• Experts also recommend assessing the
individual’s fluid volume status.
• If there is volume depletion secondary
to natriuresis caused by the elevated
blood pressure, then volume
replacement with normal saline can
prevent large sudden drops in blood
pressure when antihypertensive
medications are administered
(Rodriguez et al., 2010).
HYPERTENSIVE URGENCY
• Describes a situation in
which blood pressure is
very elevated but there is
no evidence of impending
or progressive target
organ damage (Chobanian
et al., 2003).
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❑ACE inhibitors (i.e., captopril [Capoten])
❑alpha2-agonists (i.e., clonidine [Catapres])
❖Extremely close hemodynamic monitoring of the
patient’s
blood pressure and cardiovascular status is
required during
treatment of hypertensive emergencies and
urgencies.
❖The exact frequency of monitoring is a matter of
clinical
judgment and varies with the patient’s condition.
❖Taking vital signs every 5 minutes is appropriate
if the blood
pressure is changing rapidly; taking vital signs at
15- or 30-
minute intervals in a more stable situation may be
sufficient.
❖A precipitous drop in blood pressure can occur
that would
require immediate action to restore blood
pressure to an
acceptable level.

❑Elevated blood pressures

associated with severe headaches,
nosebleeds, or anxiety are
classified as urgencies.
❑In these situations, oral agents can
be administered with the goal of
normalizing blood pressure within
24 to 48 hours (Rodriguez et al.,
2010).

PHARMACOLOGY
•Oral doses of fast-acting agents are
recommended for the treatment of
hypertensive urgencies. ARRHYTHMIA
❑beta-adrenergic blockers (i.e., labetalol
[Trandate]), Arrhythmias are
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disorders of the heart 40-60
Rhythm. • VENTRICULAR=
20-40
PR Interval

REPRESENTS TIME FROM

THE BEGINNING OF ATRIAL
DEPOLARIZATION TO THE
BEGINNING OF
VENTRICULAR
DEPOLARIZATION,
MEASURED FROM THE
BEGINNING OF THE P WAVE
TO THE BEGINNING OF THE ASSESSMENT
QRS COMPLEX (O.12-O.20)
-ECG
QRS Complex
-24h Holter monitor
REPRESENTS THE
LENGTH OF TIME FOR -ASSESSMENT
DEPOLARIZATION OF
THE VENTRICULAR -Echocardiogram
MUSCLE AND IS
MEASURED FROM THE -Stress test
BEGINNING OF THE QRS
COMPLEX TO THE END -Coronary angiography
OF THE S WAVE,
SHOULD MEASURE -Electrophysiology study
BETWEEN 0.06-0.10
SECONDS IN DURATION

REPRESENTS THE TOTAL

LENGTH OF TIME FOR
VENTRICULAR MUSCLE TO
BE DEPOLARIZED AND
REPOLARIZED, MEASURED
FROM THE BEGINNING OF
THE QRS COMPLEX TO
THE END OF THE T WAVE,
NORMAL RANGE IS 0.32-
Determine the rate.
0.42
Rhythm regular/ irregular?
Inherent Rates
Find the P wave.
Determine the PR interval
• SA= 60-100
• AV JUNCTION=
Find the QRS
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Any ectopic beats?

Find the T wave.

TREATMENT

• Ca-channel blockers-
Diltiazem

• B-blockers-Propanolol

TREATMENT

• treat the underlying cause

• atropine
• isuprel
• artificial pacing
• prevent further vagal stimulation
• withhold the B-blocker

Arrhythmias-
Disturbance in Conduction

∙ Rate is dependent on the basic rhythm. If the

basic rhythm is sinus,
the rate is constant between 60-100bpm
∙P wave is followed by a QRS complex
∙P-R interval is greater than 0.12 sec. and constant
from beat to beat
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∙ QRS Complex duration is 0.12 sec. or less. Every a. Description.
QRS complex is
preceded by a P wave Multiple, disorganized
∙ Rhythm is regular contraction of the

Arrhythmias- Re-entry of Impulse ventricles.

ATRIAL FIBRILLATION b. Management.
The immediate institution of
CPR while waiting for
defibrillation

Rate is above 300 (300-600) per minute with a Nursing Management

chaotic rhythm.
∙ P wave are non-identifiable, only fibrillatory • Monitor V/S
waves • Assess skin, lung & heart sounds,
∙ P-R interval not measurable peripheral pulses
∙ QRS Complex duration is 0.1 sec. or less • Monitor laboratory studies
∙ Rhythm is irregularly irregular, i.e. irregular with • Give antidysrhythmic & sedative
no medications as ordered
specific pattern Maintain quiet environment
• Administer O2 as prescribed
• Elimination of tobacco, alcohol,
caffeine & other stimulants

Medical Management

• Medications

• IV Fluids
• Bed rest
Atrial Flutter • O2 therapy

Transcutaneous & transvenous

pacing
• Vagal stimulation
• Electrical & Chemical Cardioversion
∙ Rate: 250-400 bpm. • Radiofrequency Ablation
∙ P-wave “saw-tooth” appearance, are known
as Ventricular Asystole
F or flutter waves
∙ P-R Interval is not measurable
∙ QRS Complex duration is 0.1 sec. or less
∙ Rhythm may be regular or irregular

Ventricular Fibrillation
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RESPONSES TO METABOLIC- GASTROINTESTINAL
AND LIVER ALTERATIONS

Anatomy and Physiology

Liver
- Largest organ accessory on the GI
- Metabolizes food, drugs and other by
products
- To amino acids and lipids
Stomach - Produces bile to emulsify fats
 Cardia Pancreas
 Fundus - Exocrine and Endocrine gland
 Body - Exocrine- amylase- CHO-Trypsin- and
 Pylorus Chymotrypsin- CHON- Lipase-fats
Chief Cells - Endocrine- insulin- absorb glucose-
 The gastric chief cell (also known as a glucagon- control blood sugar
zymogenic cell or peptic cell) is a cell in the Physical Assessment
stomach that releases pepsinogen (Inactive
form) and chymosin History:
G-cells secrete gastrin - Gastrin stimulates Abdominal pain
 parietal cell to secrete hydrochloric acid. Dyspepsia
 Parietal Cell – Secrete Hydrochloric Acid Nausea
Mucin Cell – Secrete mucus to help protect Vomiting
 the stomach cell from hydrochloric acid. Diarrhea
Phases of Gastric Secretion Constipation
1. Cephalic Phase – Triggered by sight, smell Fecal incontinence
because of the food presence. Stimulates Jaundice
the vagus nerve. Previous GI disease
2. Gastric Phase – Stimulates by stretch
receptors to release gastric Acid. Inspection:
3. Intestinal Phase – triggered by the release Oral Cavity
of food containing digestive proteins Lips
released in the proximal small intestine. Gums Tongue
Abdominal Quadrant
Inspection: 7S
Symmetrical and movement with respiration. Scar
Striae
Stoma
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Shape of the umbilicus Pyloric stenosis is a narrowing of the opening
Shape of the flank (full, straight) from the stomach to the first part of the small
Skin lesions intestine.

Striae Pigmentation
- Silvery white linear marked about 1-6cm in
pregnant and obese individuals.
- Striae in Cushing’s Syndrome is usually
purple or blue in color.

Shape of the umbilicus

Grey Turner sign is a discoloration of the left flank

associated with acute hemorrhagic pancreatitis.
Shape of the flank

Cullen sign is a hemorrhagic discoloration of the

umbilical area due to intraperitoneal hemorrhage
from any cause; one of the more frequent causes
is acute hemorrhagic panniculitis.

Inspection: 1D
Inspection: 4P
Distention
Prominent veins
Flat
Pulsation visible
Fluid-filled
Peristalsis visible
Fetus (Pregnant) Flatus (Air-filled) Fecal
Pigmentation

Inspection:
Prominent veins
Contour: Flat to round
Caput Medusa
Symmetry: symmetric; note for bulging, masses or
- It is the appearance of distended and engorged
asymmetry
superficial epigastric veins, which are seen
Umbilicus: midline, inverted and no discoloration
radiating from the umbilicus across the abdomen.
Skin: smooth and even in color
Pulsation visible
Contour: Xiphoid to symphysis pubis
Aortic Aneurysm
- It is a balloon-like bulge in the aorta, the large
artery that carries blood from the heart through
the chest and torso.

Peristalsis visible
Intestinal obstruction
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Abdominal Bluge
- When the patient is in supine position, the
flank is bulging.
- Possible causes:
- Hernias
- Lipomas
- Hematomas
- Undescended Testicles
- Tumors
Auscultation:
- Bell: bruit sound Diaphragm: Bowel Sound
- N: 5 – 30 times per min
- Peristalsis – downward movement of the
intestine.
- An occasional borborygmus (loud
prolonged gurgle) may be heard.
Auscultation: Bowel sound:
- Normoactive -
- Hypoactive – less than 5times/min
Hyperactive – loud, high pitched Absent –
listen for at least 5mins
Percussion:
- Dullness: Organ like liver, Fluid, Feces
Tympanic: Gas
Palpation:
- Light: swelling Deep: masses
Rectal Inspection and Palpation
- anal canal is approximately 2.5 to 4 cm (1 to 1.6
inches) in length the internal and external
sphincters inspection for lumps, rashes,
inflammation, excoriation, tears, scars, pilonidal
dimpling, and tufts of hair at the pilonidal area
pilonidal cyst, perianal abscess, or anorectal
fistula or fissure, rectal prolapse, polyps, and
internal hemorrhoids.
Diagnostic Examination
Stool Tests
- Inspecting the specimen for consistency,
color, and occult (not visible) blood.
- Additional studies: fecal urobilinogen, fecal
fat, nitrogen, Clostridium difficile, fecal
leukocytes, calculation of stool osmolar
gap, parasites, pathogens, food residues,
and other substances, require laboratory
evaluation.
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- Stool samples are usually collected on a
random basis unless a quantitative study is
to be performed.
- Quantitative 24- to 72-hour collections
must be kept refrigerated until transported
to the laboratory.
Fecal occult blood testing (FOBT)
- Guaiac Test
- One of the most commonly performed stool
tests.
- It can be useful in initial screening for
several disorders, although it is used most
frequently in early cancer detection
programs.
- It should not be performed when there is
hemorrhoidal bleeding.
- Patients were advised to avoid ingesting
red meats, aspirin, nonsteroidal anti-
inflammatory drugs, turnips, and
horseradish for 72 hours prior to the study
because it was thought that these were
associated with false-positive results
- Patients were advised to avoid ingesting
vitamin C from supplements or foods as
it was believed that this was associated
with false-negative results.
- Increase Fiber intake
Fecal Immunologic Test (FIT)
- Use monoclonal or polyclonal antibodies to
detect the globin protein in human
hemoglobin.
- An antibody that binds to a blood protein
called
- hemoglobin is used to detect any blood
- Only one fecal stool sample is required
- Dietary restrictions are not required prior
to submission of the stool specimen.
Stool DNA Testing
- relatively new means to detect certain DNA
related to colon cancer.
- The stool DNA test does not require any
dietary or medication restrictions and can
detect neoplasia anywhere in the colon.
Non-Invasive Breath Test
- - Hydrogen breath test was
developed to evaluate carbohydrate
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absorption, in addition to aiding in the
diagnosis of bacterial overgrowth in
the intestine and short bowel syndrome.
Non-Invasive
Hydrogen Breath Test: Instruction
● Eating a low carbohydrate diet for a couple
of days.
● Avoid foods that may produce gas in the
intestinal tract which could cause
inaccurate test results.
● Breath tests can be done any time before a
colonoscopy prep, but not for four (4)
weeks after a colonoscopy prep, or any test
that requires a bowel prep.
Non-Invasive
Hydrogen Breath Test: Instruction
● Patient will drink a solution of lactose,
fructose, sucrose, or glucose in water.
● After drinking the solution, pt will be asked
to breathe into a plastic bag.
● Breath samples are obtained every 15
minutes for adults, and every 30 minutes
for children.
● The breath sample will be analyzed for
hydrogen content to determine if you are
able to properly break down the lactose or
sucrose, or if you have bacterial
overgrowth.
Non-Invasive Breath Test
● Urea breath tests detect the presence of
Helicobacter pylori.
● the bacteria that can live in the mucosal
lining of the stomach and cause peptic
ulcer disease.
Non-Invasive
Urea Breath Test: instruction
• Four weeks before the test, do not take any
antibiotics or Pepto-Bismol® (oral bismuth
subsalicylate).
• Two weeks before the test do not take any
over-the-counter or prescription proton
pump inhibitors, such as omeprazole
(Prilosec®), lansoprazole (Prevacid®),
pantoprazole (Protonix®), rabeprazole
(AcipHex®) or esomeprazole (Nexium®),
dexlansoprazole (Dexilant®).
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● Food and drinks: One hour before the test,
do not eat or drink anything (including
water).
Non-Invasive Urea Breath Test
● After the procedure
• Breath samples are sent to the laboratory
where they are tested.
• May resume normal activities.
• No restrictions.
Abdominal Ultrasonography
- A noninvasive diagnostic technique in
which high frequency sound waves are
passed into internal body structures, and
the ultrasonic echoes are recorded on an
oscilloscope as they strike tissues of
different densities.
- It is particularly useful in the detection of
an enlarged gallbladder or pancreas, the
presence of gallstones, an enlarged ovary,
an ectopic pregnancy, or appendicitis.
Non-Invasive
Abdominal Ultrasonography
- It is used to look at organs and blood
vessels in the abdomen:
- Liver
- Gallbladder
- Spleen
- Pancreas
- Kidneys
- Inferior vena cava
- Aorta
Abdominal Ultrasonography
- Avoid food and drinks (fast) for eight to 12
hours before an abdominal ultrasound.
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- Before the abdominal ultrasound, patient
will change into a hospital gown and to
remove any jewelry.
- After the procedure, patient will be able to
return to normal activities immediately.
Non-Invasive: Nursing Intervention
Abdominal Ultrasonography
- If gallbladder studies are being performed,
the patient should eat a fat-free meal the
evening before the test.
- If barium studies are to be performed, they
should be scheduled after ultrasonography.
- Patients who receive moderate sedation
are observed for about 1 hour to assess for
level of consciousness, orientation, and
ability to ambulate.
Non-Invasive: Fluoroscopy
Upper Gastrointestinal Tract Study
- An upper GI fluoroscopy delineates the
entire GI tract after the introduction of a
contrast agent.
- A radiopaque liquid (e.g., barium sulfate) is
commonly used thin barium, diatrizoate
sodium (Hypaque) and at times water are
used due to their low associated risks.
- AKA Barium Swallow
- The GI series enables the examiner to
detect or exclude anatomic or functional
disorders of the upper GI organs or
sphincters.
- It also aids in the diagnosis of ulcers,
varices, tumors, regional enteritis, and
malabsorption syndromes.
- Fluoroscopic examination next extends to
the stomach as its lumen fills with barium,
allowing observation of stomach motility,
thickness of the gastric wall, the mucosal
pattern, patency of the pyloric valve, and
the anatomy of the duodenum.
- Multiple x-ray images are obtained during
the procedure, and additional images may
be taken at intervals for up to 24 hours to
evaluate the rate of gastric emptying.
Non-Invasive: Nursing Intervention Upper
Gastrointestinal Tract Study
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- Instruct regarding dietary changes prior to
the study should include a clear liquid diet,
with nothing by mouth (NPO) from midnight
the night before the study.
- Do not smoke or chew gum during the NPO
period because these can increase gastric
secretions and salivation.
- Bowel cleansing preparatory agent:
Polyethylene glycol (PEG)-based solutions
- Oral medications are withheld on the
morning of the study and resumed that
evening, but each patient’s medication
regimen should be evaluated on an
individual basis.
- When a patient with insulin dependent
diabetes is NPO, their insulin requirements
will need to be adjusted accordingly.
- Follow-up care is provided after the upper
GI procedure to ensure that the patient has
eliminated most of the ingested barium.
- Fluids may be increased to facilitate
evacuation of stool and barium.
Minimally Invasive: Blood Study CBC
Comprehensive Metabolic Panel
- to conduct a broad assessment of various
aspects of physical well-being.
- It can detect a range of abnormalities in
blood sugar, nutrient balance, and liver and
kidney health.
- Glucose, Calcium, Sodium, Potassium,
Bicarbonate, Chloride, Blood urea nitrogen
(BUN), Creatinine, Albumin, Total protein,
Alkaline phosphatase (ALP), Alanine
aminotransferase (ALT), Aspartate
aminotransferase (AST), Bilirubin
Serum Blood study
Prothrombin time/Partial thromboplastin time
- is a test used to help diagnose bleeding or
clotting disorders.
- A PT measures the number of seconds it
takes for a clot to form in the sample of
blood after substances (reagents) are
added.
Minimally Invasive:
- Serum Blood study
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- Triglycerides - measures the amount of
triglycerides in your blood.
- Amylase - measures the amount of
amylase in your blood or urine. Amylase is
an enzyme, or special protein, that helps
you digest food.
- Lipase - measures the level of a protein
called lipase in your blood. Lipase helps
your body absorb fats. When your pancreas
is inflamed or injured, it releases more
lipase than usual.
Liver function tests - are blood tests used to
help diagnose and monitor liver disease or
damage. The tests measure the levels of certain
enzymes and proteins in your blood.
- Alanine transaminase (ALT). ALT is an
enzyme found in the liver that helps
convert proteins into energy for the liver
cells. When the liver is damaged, ALT is
released into the bloodstream and levels
increase.
- Aspartate transaminase (AST). AST is an
enzyme that helps metabolize amino
acids. Like ALT, AST is normally present in
blood at low levels. An increase in AST
levels may indicate liver damage, disease
or muscle damage.
- Alkaline phosphatase (ALP). ALP is an
enzyme found in the liver and bone and is
important for breaking down proteins.
Higher-than-normal levels of ALP may
indicate liver damage or disease, such as a
blocked bile duct, or certain bone diseases.
- Albumin and total protein. Albumin is one of
several proteins made in the liver. Your
body needs these proteins to fight
infections and to perform other functions.
Lower-than-normal levels of albumin and
total protein may indicate liver damage or
disease.
- Bilirubin. Bilirubin is a substance produced
during the normal breakdown of red blood
cells. Bilirubin passes through the liver and
is excreted in stool. Elevated levels of
bilirubin (jaundice) might indicate liver
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damage or disease or certain types of
anemia.
- Gamma-glutamyltransferase (GGT). GGT is
an enzyme in the blood. Higher- than-
normal levels may indicate liver or bile
duct damage.
- L-lactate dehydrogenase (LD). LD is an
enzyme found in the liver. Elevated levels
may indicate liver damage but can be
elevated in many other disorders.
- Prothrombin time (PT). PT is the time it
takes your blood to clot. Increased PT may
indicate
liver damage but can also be elevated if you're
taking certain blood-thinning drugs, such as
warfarin.
Carcinoembryonic Antigen (CEA)
- Is a protein that is normally not detected in
the blood of a healthy person.
- When detected it indicates that cancer is
present, although not what type of cancer
is present.
- Primary providers can use CEA results to
determine the stage and extent of the
disease and the patient’s prognosis for
cancer, especially GI and, in particular,
colorectal cancer.
Cancer Antigen (CA) 19–9
- CA 19-9 is also a protein that exists on the
surface of certain cells and is shed by
tumor cells, making it useful as a tumor
marker to follow the course of the
cancer.
- CA 19-9 levels are elevated in most patients
with advanced pancreatic cancer,
but they may also be elevated in other
conditions such as colorectal,
stomach, and bile duct cancers.
- Elevated levels may also be found in
noncancer conditions.
Alpha Fetoprotein
- is a protein produced primarily by the liver
in a developing baby (fetus).
- AFP is produced whenever liver cells are
regenerating. With chronic liver diseases,
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such as hepatitis and cirrhosis, AFP may be
chronically elevated.
- Increased amounts of AFP are found in
many people with the most common type of
liver cancer called hepatocellular
carcinoma and in a rare type of liver
cancer: hepatoblastoma
Minimally Invasive: Fluoroscopy Lower
Gastrointestinal Tract Study
- Visualization of the lower GI tract is
obtained after rectal installation of barium.
- The barium enema can be used to detect
the presence of polyps, tumors, or other
lesions of the large intestine and
demonstrate any anatomic abnormalities or
malfunctioning of the bowel.
- Each portion of the colon may be readily
observed.
- The procedure usually takes about 15 to 30
minutes, during which time x-ray images
are obtained.
To determine the cause of signs and symptoms,
such as the following:
- Abdominal pain
- Rectal bleeding
- Changes in bowel habits
- Unexplained weight loss
- Chronic diarrhea
- Persistent constipation
- Abnormal growths (polyps) as part
of colorectal cancer screening
- Inflammatory bowel disease
Contraindicated
- Active inflammatory disease of the
colon
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- Signs of perforation or obstruction a
water-soluble contrast study may
be performed.
- Active GI bleeding
Minimally Invasive: Nursing Intervention
Lower Gastrointestinal Tract Study
- Bowel Preparation: emptying and cleansing
the lower bowel.
- A low-residue diet 1 to 2 days before
the test, a clear liquid diet and a
laxative the evening before, NPO
after midnight
- Cleansing enemas until returns are
clear the following morning.
- Fleet Enema
- Makes sure that barium enemas are
scheduled before any upper GI
studies.
- wear a hospital gown and remove
eyewear, jewelry or removable
dental devices.
- lying on side
- lubricated enema tube will be
inserted into the rectum. A barium
bag will be connected to the tube to
deliver the barium solution into the
colon.
Minimally Invasive: Nursing Intervention Lower
Gastrointestinal Tract Study
● Instruct to hold the enema tube in place. To
relax, take long, deep breaths.
● Patient may be asked to turn and hold
various positions on the exam table.
● A number of X-rays of the colon will likely
be taken from various angles.
● A barium enema exam typically takes about
30 to 60 minutes.
Post procedure:
- increasing fluid intake
- evaluating bowel movements for
evacuation of barium
- noting increased number of bowel
movements, because barium has
high osmolarity
 Prepared By: BANTOLINAO & ELARCOSA
- may draw fluid into the bowel, thus
increasing the intraluminal contents
and resulting in greater output.
Minimally Invasive
Hepatobiliary Iminodiacetic Acid (HIDA)
- Scan is an imaging procedure used to
diagnose problems of the liver, gallbladder
and bile ducts.
- AKA cholescintigraphy or hepatobiliary
scintigraphy
Minimally Invasive
Hepatobiliary Iminodiacetic Acid (HIDA)
- A HIDA scan is most often done to evaluate
your gallbladder.
- It's also used to look at the bile-excreting
function of your liver and to track the flow
of bile from your liver into your small
intestine.
- Gallbladder inflammation (cholecystitis)
- Bile duct obstruction
- Congenital abnormalities in the bile ducts,
such as biliary atresia
- Postoperative complications, such as bile
leaks and fistulas
- Assessment of liver transplant
Minimally Invasive
Hepatobiliary Iminodiacetic Acid (HIDA)
Risk:
- Allergic reaction to medications containing
radioactive tracers used for the scan
- Bruising at the injection site
- Radiation exposure, which is small
- Pregnant or breastfeeding.
PREPARATION: BEFORE
- Fasting for four hours before HIDA scan.
- Ask about any medication patient is taking,
including vitamins and herbal supplements.
- Remove jewelry and accessories
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- Patient should wear a hospital gown during
the exam
Preparation: After
- In most cases, you can go about your day
after your scan.
- Drink plenty of water to help flush
radioactive material out of the body.
Blood Glucose Monitoring
- It is the immediate measurement of blood
glucose using blood sample from a
fingerstick or heel stick.
- AKA Hemogluco test (HGT) or Capillary
blood glucose (CBG)
- Normal: Adult – 80 – 120mg/dl
- Hypoglycemia:
- Newborn: <30mg/dl
- Children: <50mg/dl
Invasive
- Endoscopic ultrasonography (EUS)
- A specialized enteroscopic procedure that
aids in the diagnosis of GI disorders by
providing direct imaging of a target area.
- A small high-frequency ultrasonic
transducer is mounted at the tip of the
fiberoptic scope, which displays images
that are of higher-quality resolution and
definition than regular ultrasound imaging.
- may be used to evaluate submucosal
lesions, specifically their location and depth
of penetration.
- EUS may aid in the evaluation of diseases
and changes in the bowel wall due to
ulcerative colitis.
- Nursing Intervention: Same with abdominal
Ultrasound
Esophago-gastroduodenoscopy (EGD)
- It allows direct visualization of the
esophageal, gastric, and duodenal mucosa
through a lighted endoscope.
- It is valuable when esophageal, gastric, or
duodenal disorders or inflammatory,
neoplastic, or infectious processes are
suspected.
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- views the GI tract through a viewing lens
and can obtain images through the scope to
document findings.
- Electronic video endoscopes also are
available that attach directly to a video
processor, converting the electronic
signals into pictures that are projected on a
screen.
Invasive:
Endoscopic Retrograde Cholangio-
pancreatography (ERCP)
- Uses the endoscope in combination with x-
rays to view the bile ducts, pancreatic
ducts, and gallbladder.
- ERCP is helpful in evaluating jaundice,
pancreatitis, pancreatic tumors, common
bile duct stones, and biliary tract disease.
Before:
- Assess allergies to intravenous (IV)
contrast dyes.
- Not eat, drink or smoke for at least six
hours before the procedure.
During:
- Anesthetic spray to numb the throat.
- Inserts the endoscope
- Injects a special dye through the catheter.
Therapeutic purposes
- Break up and remove stones. Place stents
to open blocked or narrowed ducts.
Diagnostic Purposes :
- Checks for signs of blockage or problems.
- Remove tumors or tissue samples to
biopsy.
After
- Assess Gag Reflex
- Instruct to eat soft foods for a day or two
until the soreness subsides.
- Patient may experience some bloating and
nausea.
- Patient may return to work and normal
activities the next day.
Nursing Interventions
- NPO for 8 hours prior to the examination.
- Patient is given a local anesthetic gargle or
spray.
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- Midazolam (Versed), a sedative that
provides moderate sedation with loss of
the gag reflex and relieves anxiety during
the procedure.
- Atropine may be given to reduce secretions
- Glucagon may be given to relax smooth
muscle.
- The patient is positioned in the left lateral
position to facilitate clearance of
pulmonary secretions and provide smooth
entry of the scope.
After the procedure:
- Assessment includes level of
consciousness, vital signs, oxygen
saturation, pain level, and monitoring for
signs of perforation
- Temporary loss of the gag reflex is
expected; wait until the patient’s gag reflex
has returned.
- Patients who were sedated for the
procedure must remain in bed until fully
alert.
Fiberoptic Colonoscopy
- direct visualization of the bowel was the
only means to evaluate the colon.
- These scopes have the same capabilities as
those used for
EGD but are larger in diameter and longer.
- It is most frequently used for cancer
screening and for surveillance in patients
with previous colon cancer or polyps.
- Tissue biopsies can be obtained as needed,
and polyps can be removed and evaluated.
• Screen for colon and rectal cancer
• Detect and evaluate inflammatory and
ulcerative bowel disease
• Locate the source of lower GI bleeding and
perform hemostasis by coagulation
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• Determine the cause of lower GI disorders, • Change the position of the patient.
especially when barium and • Encourage the patient to take slow, deep
proctosigmoidoscopy results are breaths.
inconclusive Invasive:
• Assist diagnose colonic strictures and Percutaneous Transhepatic Cholangiography (PTC)
benign or malignant lesions - An x-ray procedure that involves the
• Evaluate the colon postoperatively for injection of a contrast material directly into
recurrence of polyps and malignant lesions the bile ducts inside the liver to produce
• Investigate iron-deficiency anemia of pictures of the bile ducts.
unknown origin - Rarely used for diagnostic purposes
• Remove colon polyps alone due to the multitude of other less
• Remove foreign objects and sclerosing invasive and reliable imaging studies.
strictures by laser
Contraindicated for:
• Pregnant women near term
• Patients with bleeding disorders
• Patients who had a recent acute myocardial
infarction or abdominal surgery
• Patients with ischemic bowel disease,
acute diverticulitis, peritonitis, fulminant
granulomatous colitis, perforated viscus, or
fulminant ulcerative colitis: For these cases
or for screening purposes, virtual
colonoscopy may help visualize polyps
before they become concerns.
After the procedure
Before the procedure
• Observe the patient closely for signs of
● Secure an informed consent.
bowel perforation.
• Obtain a medical history of the patient.
• Obtain and record the patient’s vital signs.
• Provide information about the procedure.
• Instruct patient to resume a normal diet,
• Ensure that the patient has complied with
fluids, and activity as advised by the health
the bowel preparation.
care provider.
• Establish an IV line.
• Provide privacy while the patient rest after
• Provide reassurance.
the procedure.
• Explain to the patient that air may be
• Monitor for any rectal bleeding.
introduced through the colonoscope.
• Encourage increased fluid intake.
• Instruct the patient to empty bladder prior
Invasive:
to the procedure.
Percutaneous Transhepatic Cholangiography (PTC)
• Instruct the patient to remove all metallic
This procedure can be carried out even in the
objects from the area to be examined.
presence of liver dysfunction and jaundice.
• Instruct the patient to cooperate and follow
It is useful for:
directions.
1. distinguishing jaundice caused by liver
During the procedure
disease (hepatocellular jaundice) from that
• Assist with patient positioning as
caused by biliary obstruction
necessary.
2. investigating the GI symptoms of a patient
• Administer medications as ordered.
whose gallbladder has been removed
• Instruct the patient to bear down.
3. locating stones within the bile ducts
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4. diagnosing cancer involving the biliary - Removal of a small amount of liver tissue,
system usually through needle aspiration.
Preparation: - It permits examination of liver cells.
- Fasting: 4 to 8 hour - The most common indication is to evaluate
- Sterile procedure is performed diffuse disorders of the parenchyma and to
- Patient also receives local anesthesia diagnose space- occupying lesions.
- Coagulation parameters and platelet count - Gold Standard for Liver Cancer
should be normal
- Broad-spectrum antibiotics are given
During:
- A flexible needle is inserted into the liver
from the right side in the midclavicular line
immediately beneath the right costal
margin
- Successful entry of a duct is noted when
bile is aspirated or on injection of a
- Percutaneously with ultrasound guidance
contrast agent.
- Transvenously through the right internal
- Ultrasound can be used to guide puncture
jugular vein to right hepatic vein under
of the duct.
fluoroscopic control.
- Bile is aspirated, and samples are sent for
- Laparoscopic Liver Biopsy
bacteriology and cytology
Complication:
- A water-soluble contrast agent is injected
- Peritonitis - caused by blood or bile
to fill the biliary system.
leak after liver biopsy.
- The fluoroscopy table is tilted, and the
- Bleeding
patient is repositioned to allow x-rays to be
- Infection
taken in multiple projections.
- Accidental injury to nearby organ
- Before the needle is removed, as much dye
- Hematoma in the neck
and bile as possible are aspirated to
- Temporary problem with facial
anticipate subsequent leakage into the
nerves
needle tract and eventually into the
- Temporary voice problem
peritoneal cavity, thus minimizing the risk
- Puncture of the lung
of bile peritonitis.
Preparation:
After:
- Patient must sign consent form
- Closely observe the patient for symptoms
- NPO 4-6 hours before procedure
of bleeding, peritonitis, and sepsis.
- Pre-procedure V/S
- Assesses the patient for pain and
- Check labs, especially prothrombin
indications of these complications and
times
reports them promptly to the primary
- Have pt empty bladder immediately
provider
before procedure
- Takes measures to reassure the patient
- Place patient in supine position with
and ensures patient comfort.
pillow underneath back on far-right
- Antibiotic agents are often prescribed to
side of bed- exposing right
minimize the risk of sepsis and septic
side(hypochondriac region). Head
shock.
should be turned to the left and
Invasive:
right arm extended above head
Liver Biopsy
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- Local anesthetic agent instilled into  + valsalva maneuver
biopsy area per MD Management
- Before the procedure instruct  Education (gastrocolic reflex), bowel habit
patient practice breathing in the training, increased fiber and fluid intake,
following way: inhale, exhale, inhale, and judicious use of laxatives (avoid
exhale completely and hold breath laxative abuse)
until MD inserts and removes
needle
After:
- Monitor V/S
- apply pressure to site with sterile
dressing after procedure
- put patient on R side with pillow or
special sandbag in costal area for a
minimum of 2 hours
- tell patient to stay (flat) in bed 12-
14hours
- NPO for about 2 hours and then
resume meal
- avoid coughing, lifting, or straining
for 1–2-week post procedure
CT scan MRI
- Technetium-labeled RBC scintigraphy –
an imaging test that can help detect the
origin of gastrointestinal bleeding.

MANAGEMENT OF PATIENTS WITH

INTESTINAL AND RECTAL DISORDERS

Abnormalities of Fecal Elimination

Constipation
• Abnormal infrequency or irregularity of
defecation;
• Abnormal hardening of stools that makes Diarrhea
their passage difficult and sometimes • An increased frequency of bowel
painful; movements (more than three per day);
• A decrease in stool volume, or retention of • An increased amount of stool (more than
stool in the rectum for a prolonged period; 200 g/day); and
• Sense of incomplete evacuation after • Altered consistency (ie, increased
defecation. liquidity) of stool.
Complications • Acute diarrhea: 71 toor 21d4aysdays;
 Hypertension • Chronic diarrhea: more than 2 to 3 weeks
 Fecal impaction
 Hemorrhoids
 Fissures
 Megacolon
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Types of Diarrhea
Secretory: high-volume diarrhea; caused by
increased production and secretion of water and
electrolytes by the intestinal mucosa into the
intestinal lumen.
Osmotic: occurs when water is pulled into
the intestines by the osmotic pressure of
unabsorbed particles, slowing the reabsorption
of water.
Malabsorptive: Inhibiting effective absorption of
nutrients manifested by markers of malnutrition
that include hypoalbuminemia
Exudative: caused by changes in mucosal integrity,
epithelial loss, or tissue destruction by radiation or
chemotherapy
Complications of Diarrhea
• Potential for cardiac dysrhythmias;
• Loss of bicarbonate;
• Report the ff: Urine output <0.5mL/kg/hr for
2 to 3 consecutive hours, muscle
weakness, parethesia, hypotension,
anorexia and drowsiness.
• Chronic Diarrhea: irritant dermatitis
Management of Diarrhea
• Eliminating or treating underlying cause;
• Drug of Choice: Loperamide [Imodium]
• Pharmacologic: Antibiotics, anti-
inflammatory agents and antidiarrheals (eg,
loperamide [Imodium], diphenoxylate
[Lomotil])
During an episode of acute diarrhea:
• Bed rest, intake of liquids and
foods low in bulk until the acute attack
subsides;
• Recommend a bland diet of semisolid and
solid foods (if able to tolerate food
intake);
• Avoid caffeine, carbonated beverages, and
very hot and very cold foods;
• Restrict milk products, fat, whole-grain
products, fresh fruits, and vegetables for
several days
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Irritable Bowel Syndrome
• Clinical Manifestations: IBS-D, IBD-C,
IBS-A
• Assessment & Diagnosis:
➢ Recurrent abdominal pain at least
3 days a month for the past 3 months
with two or more of the ff:
1. Improvement with defecation;
2. Change in freq. of stool;
3. Change in appearance of stool.
Management
• Goals of Treatment: Relieving abdominal
pain, controlling the diarrhea or
constipation, and reducing stress.
• For IBS-C: Lubiprostone, a chloride
channel regulator in the gut
• For IBS-D: alosteron (Lotronex)
• Probiotics (Lactobacillus,
Bifidobacterium), complementary medicine
Acute Inflammatory Intestinal Disorders
Appendicitis
 Inflammation of the appendix
 Most common cause of acute surgical
abdomen; most common reason for
emergency abdominal surgery
 Age: commonly occurs between the ages of
10 and 30 years; although may occur at any
age
Clinical Manifestations
▪ Initial: Vague epigastric or periumbilical
pain (ie, visceral pain that is dull and
poorly localized); progresses to
▪ Right lower quadrant pain (ie. Parietal pain
that is sharp, discrete, and well-localized
▪ Usually accompanied by a low grade fever
and nausea and sometimes by vomiting,
loss of appetite.
▪ Local tenderness at mcburney’s point
▪ Rebound tenderness (ie. Production or
intensification of pain when pressure is
released) may be present
▪ Rovsing sign: deep palpation of the left iliac
fossa causes pain in the right iliac fossa.
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Psoas sign
▪ Also known as the Ilio-psoas sign.
Passive extension of the right hip may
cause pain in the right iliac fossa;
Obturators sign or Copes sign
▪ Flexion and internal rotation of the right hip
causes pain
Assessment and Diagnostic Findings
▪ History and Physical Exam: Patient is
usually younger;
▪ CBC: Reveals elevated WBC, neutrophils
▪ Imaging studies (esp. CT Scan if diagnosis
is uncertain): Right lower quadrant
density or localized distention of the bowel
▪ Pregnancy test (for women): To R/O
ectopic pregnancy, before radiologic
studies are done;
▪ Urinalysis: To R/O urinary tract infection
▪ Diagnostic laparoscopy: To R/O acute
appendicitis in equivocal cases
Medical Management
▪ Appendectomy (ie, surgical removal of
the appendix) is performed as soon as
possible to decrease the risk of perforation.
▪ If perforation of the appendix
(abscess formation) occurs, the
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patient may be initially treated with
antibiotics; place a drain in the abscess
Nursing Management: Perioperative Management
▪ IV infusion to replace fluid loss and
promote adequate renal function and
antibiotic therapy to prevent infection.
▪ If there is evidence or likelihood of paralytic
ileus, a nasogastric tube is inserted.
▪ An enema is not administered because it
can lead to perforation.
Nursing Management: Post-operative Management
▪ After surgery, the nurse places the patient
in a high- Fowler’s position.
▪ An opioid, usually morphine sulfate, is
prescribed to relieve pain.
▪ Food is provided as desired and tolerated
on the day of surgery when normal bowel
sounds are present.
▪ When tolerated, oral fluids are
administered.
Diverticular Disease
▪ Diverticulum is a saclike herniation of
the lining of the bowel that extends
through a defect in the muscle layer;
▪ Diverticulosis exists when multiple
diverticula are present without
inflammation or symptoms;
▪ Diverticulitis results when food and
bacteria retained in a diverticulum produce
infection and inflammation that can impede
drainage and lead to perforation or
abscess formation.
Cause: Mucosa and submucosal layers of the colon
herniate through the muscular wall because of:
• High intraluminal pressure;
• Low volume in the colon (ie, fiber-deficient
contents);
• Decreased muscle strength in the colon
wall (ie, muscular hypertrophy from
hardened fecal masses).
Assessment and Diagnostic Findings
• Diagnostic Test of Choice: CT with
contrast agent if the suspected diagnosis is
diverticulitis; it can also reveal abscesses;
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• Colonoscopy, permits visualization of the
extent of diverticular disease and allows
the physician to biopsy tissue to rule out
other diseases;
• G Barium enema: If with þ peritoneal
irritation
• Abdominal x-rays may demonstrate free
air under the diaphragm if a perforation
hasoccurred from the diverticulitis.
• Other laboratory tests: Complete blood
cell count, revealing an elevated white
blood cell count, and elevated
erythrocyte sedimentation rate (ESR).
Medical Management
• Can be treated on an outpatient basis
with diet and medication;
• When symptoms occur, rest, analgesics,
and antispasmodics are recommended;
• Diet: Clear liquid diet (initially) then
high-fiber, low-fat diet
• Hospitalization for acute diverticulitis
• Broad-spectrum antibiotics are
prescribed for 7 to 10 days.
• An opioid (eg, meperidine
[Demerol]) is prescribed for
pain relief; G Morphine; Inflammatory Bowel Disease
• Antispasmodics such as propantheline • Inflammatory bowel disease (IBD) refers
bromide and oxyphencyclimine (Daricon) to two chronic inflammatory GI disorders:
may be prescribed Crohn’s disease (ie, regional enteritis)
Surgical Management and ulcerative colitis.
• One-stage resection, in which the • Crohn’s disease is a subacute and chronic
inflamed area is removed and a primary inflammation of the GI tract wall that
end-to-end anastomosis is completed; extends through all layers (ie, transmural
• Multiple-stage procedures for lesion).
complications such as obstruction or Crohn’s Disease Clinical Manifestations
perforation (eg, Hartmann’s procedure)  Onset: insidious
Double Barrel Colostomy  Prominent right lower quadrant abdominal
pain and diarrhea unrelieved by diarrhea
Inflammatory Bowel Disease
 Ulcerative colitis is a recurrent ulcerative
and inflammatory disease of the mucosal
and submucosal layers of the colon and
rectum
 After the superficial mucosa of the colon is
characterized by multiple ulcerations,
 Prepared By: BANTOLINAO & ELARCOSA
diffuse inflammations, and desquamation or
shedding of the colonic epithelium
Assessment and Diagnostic Findings
• Most conclusive diagnostic aid: Barium
Study of upper GI tract, shows a
“string sign” on an x-ray film of the
terminal ileum (indicating constriction
of a segment of intestine);
• Confirm Diagnosis: Endoscopy,
colonoscopy, intestinal biopsies, CT scan,
barium enema
Intestinal Obstruction
• Exists when blockage prevents the normal
flow of intestinal contents through the
intestinal tract.
Two Types of Processes:
1. Mechanical Obstruction: Obstruction
caused from pressure on the intestinal
wall e.g., intussusception, polypoid tumors
stenosis, strictures, adhesions, hernias,
and abscesses.
2. Functional Obstruction: Intestinal
musculature cannot propel the contents
along the bowel e.g., muscular dystrophy,
endocrine disorders (e.g., DM), etc.
Small Bowel Obstruction: Clinical Manifestations
• Initial: Crampy pain; wavelike, colicky
• Vomiting; passing of blood, mucus (no
fecal matter, flatus); reverse peristalsis;
• Signs of dehydration: intense thirst,
drowsiness, parched tongue and
mucous membranes; hypovolemic shock if
uncorrected
Diagnostic & Findings
• Based on symptoms and imaging studies
• Imaging Studies: Abdominal x- ray,
CT-scan (abn. Quantities of gas, fluid, or
both)
• Laboratory Studies: dehydration, loss of
plasma volume, possible infection
Medical Management
• Decompression of bowel thru NGT;
• Monitoring for bowel ischemia (mandatory);
• Surgical intervention (if possibility of
strangulation and tissue necrosis is
suspected)
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Nursing Management
 Maintaining the function of nasogastric
tube;
 Assessing and measuring the output;
 Assessing for fluid and electrolyte
imbalance;
 Monitoring nutritional status; and
 Assessing improvement (eg, return of
normal bowel sounds, decreased
abdominal distention, etc.)
Large Bowel Obstruction
 Clinical Manifestations: differs clinically
from small bowel obstruction d/t relatively
slower occurrence of symptoms
 PA & Dx Findings: Abdominal x- ray and
abdominal CT or MRI: Distended colon
and pinpoint sight of obstruction; Barium
studies are contraindicated
Medical Management
 Restoration of intravascular volume
 Correction of electrolyte abnormalities and
 Nasogastric aspiration and decompression
Surgical Management
• Colonoscopy (to untwist and decompress
bowel);
• Cecostomy (surgical opening of cecum for
pxs urgently in need of relief from
obstruction);
• Rectal tube placement (decompress
area lower in the bowel)
• Colonic stent (as palliative intervention
or as bridge for definitive surgery);
• Surgical resection, colostomy, ileostomy