Gastrointestinal Disorder (3rd Class)

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 Hernia
•Protrusion of organ or structure
through a weakening in abdominal
wall which may be congenital or
acquired
•If can be manipulated back: reducible
•If not: Incarcerated
•Strangulation:
•Gangrene can occur

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Clinical features

•Lump in groin or umbilicus

•Swelling after lying, coughing and exercise
•Pain if strangulation and incarceration
•Nausea, vomiting

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 Treatment

• Truss (pad worn next to skin held in place under

pressure by belt)
• Hernioplasty ( insert mesh, wire, plastic to
strengthen abdominal wall)
• Herniorrhaphy (repair defect in abdominal
musculature)
• Avoid palpation of strangulated hernia
• Avoid coughing

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 Treatment Contd..

• Splint the area

• Deep breathing and spirometry: to prevent
respiratory complications
• No sternous exercise and heavy lifting until
permitted

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 Clinical Features

• Asymptomatic
• Cramping: Left lower quadrant increases
with coughing, straining, or lifting, blood
in stools
• Flatulence
• Chronic constipation
• Anorexia
• Fever

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Q. The patient with peritonitis is NPO and complaining of
thirst. Which is the priority action?
a. Increase the I.V. infusion rate.
b. Use diversion activities.
c. Provide frequent mouth care.
d. Give ice chips every 15 minutes

Answer: Provide frequent mouth care

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 Peritonitis
• Inflammation of the peritoneum, serous membrane
lining the abdominal cavity and covering the viscera
• Most commonly by : E coli
• C/F: Constant diffuse pain, patient lies still, tender
abdomen, nausea, vomiting, fever, leukocytosis,
paralytic ileus, sign of hypovolemia and shallow
respiration
• Management: NPO, bed rest, respiratory support,
NG decompression, fowler's position, analgesics,
TPN, antibiotics, treating the underlying cause.
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 Cholecystitis and Cholelithiasis
• Cholecystitis: Inflammation of the gall bladder
• Acute inflammation is associated with gall stone
• Chronic cholecystitis is associated with incomplete
emptying of the gall bladder muscle wall diseases
• Assessment: nausea, vomiting, indigestion, belching,
flatulence, epigastric pain that radiates to the scapula 2
to 4 hours after eating fatty foods and may persists for
4 to 6 hours , Pain localized in right upper quadrant

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 Cholecystitis and Cholelithiasis
• Murphy’s sign: Cannot take a deep breath when
the examiner’s fingers are passed below the
hepatic margin because of pain
• Elevated temperature , tachycardia, signs of
dehydration in inflammation condition
• Biliary obstruction: jaundice, dark orange and
foamy urine, stetorrhea and clay-coloured feces,
pruritis

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Interventions
• NPO
• NG compression for severe vomiting
• Analgesics (if possible morphine and codeine
are avoided because they can cause the spasm
of the sphincter of ODDI and increase
pain) , antispasmodics, anticholinergic(to
relax smooth muscles)
• Instruct for small, low fat meal , avoid gas
forming food
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Surgery

• Cholecystectomy, choledocholithotomy
• Post op: monitor for respiratory complications, encourage
coughing deep breathing, early ambulation, splinting ,
advance diet from clear liquids to solids

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Q. Which of the following intervention should be included in
management of acute pancreatitis?

a. Application of hot water bag in abdomen

b. Administration of morphine sulphate
c. Administration of Tramadol
d. Maintaining NPO status

Answer: d
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 Pancreatitis
• Acute or Chronic
• Associated escape of the pancreatic enzymes in
surrounding tissue
• Assessment: abdominal pain, sudden onset at a mid
epigastric or left upper quadrant location with
radiation to the back, Abdominal tenderness and
guarding , Nausea and vomiting
• Pain aggravated by a fatty meal , alcohol or lying in
recumbent position
• Cullen’s sign: discoloration of the abdomen and
the periumbilical area
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 Pancreatitis Contd…

• Turner’s sign: bluish discoloration of the

flanks
• Absent or decreased bowel sounds
• Elevated white blood cells count, glucose,
bilirubin, alkaline phosphatase, urinary
amylase
• Elevated serum lipase and amylase level
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 Cause
"I GET SMASHED":

• Idiopathic, • I = A = Autoimmune
• G = Gall stones • S = Scorpion poison
• E = Ethanol • H = Hypercalcemia
• T = Trauma Hypertriglyceridemia
• S = Steroids • E = ERCP
• M = Mumps • D = Drugs

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 Interventions
• NPO status, hydration with IV fluids as prescribed
• Total Parental Nutrition
• NG tube to decrease gastric distension Administer
pethidine instead of morphine
• Administer antacids, H2 receptor antagonist
• Administer anticholinergic (diphenhydramine,
benzotropine) - to decrease vagal stimulation,
decrease GI motility
• Limit fat and protein intake
• Administer insulin and oral hypoglycemic agents as
needed
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Hepatitis
• Goal of the treatment- resting the inflamed liver
• Types
• Hepatitis A virus (HAV)-infectious hepatitis
• Hepatitis B virus (HBV)-serum hepatitis
• Hepatitis C- post transfusion hepatitis
• Hepatitis D-Delta agent hepatitis
• Hepatitis E- enterically transmitted or epidemic
• Hepatitis G virus- non A, Non B, Non C

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 Stages of Hepatitis
• Pre-icteric Stage-flu like symptoms, malaise , fatigue,
anorexia, N/V, serum bilirubin and enzymes levels
are elevated
• Icteric stage- jaundice, pruritic, brown coloured
urine, lighter coloured stools, decrease in pre icteric
phase symptoms
• Post icteric stage-increased energy levels, subsiding
pain, minimal to absent GI symptoms, serum
bilirubin and enzymes levels returns to normal
• Laboratory findings- ALT (normal:4-36 U/L), AST
(N: 8-33U/L) Alkaline phosphatase (N:13-39U/L)
and total bilirubin (N:<1.5 mg/dL)
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 Hepatitis A

• Incubation P:2- 6w
• Infection P.: 2-3 w before and 1 w after
jaundice
• Risk-Young children, institutionalized people,
health care personnel
• Transmission-Feco-oral, person to person,
parenteral, contaminated foods, water, poorly
washed utensils
• Testing :HAV antibodies(anti-HAV) in blood;
Elevated IgM-ongoing infection ,Elevated
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IgG-previous infection
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Prevention of Hepatitis A

• Hand washing, stool and needle precautions,

TxT of water
• Serological Screening, Hepatitis A vaccine
prophylaxis to individuals travelling to countries
with poor or uncertain sanitation
• Immuno Globulin within the period of
incubation and within 2 weeks of exposure
• Vaccine Recommendation for family members
• Pre exp prophylaxis –travelling countries with
poor or uncertain sanitation conditions
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 Hepatitis B
• Incubation P: 6 to 24 weeks
• Risk-drug addict, long term hemodialysis, health
care personnel
• Transmission-parenteral, blood or body fluid
contact, infected saliva or semen, contaminated
needles, sexual contact, parenteral, perinatal period,
blood or body fluid contact at birth
• Testing : presence of hepatitis B antigen-antibody
systems in the blood , presence of hep B surface
antigen, if HBsAg presents after 6 mths the
considered as carrier
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Prevention of Hepatitis B

• Hand washing, screening of blood donor

• Testing of all pregnant woman
• Needle precautions
• Avoid sexual contact with people of HBsAg
• Hepatitis B vaccine
• Hep B immunoglobulin is for individuals exposed the HBV through
sexual contact or through percutaneous or trans mucosal routes for
those who have never had hepatitis B before or received hepatitis B
vaccine

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 Hepatitis C
• Incubation P: 5 to 10 weeks
• Risk-drug addict, client receiving frequent
transfusion health care personnel
• Transmission-parenteral, same as B
• Testing :Anti HCV is the antibody to HCV is
the most accurate in detection
• Complications : Hepato cellular carcinoma
• Prevention : strict hand washing, needle
precautions, screening of blood donors

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 Hepatitis D
• Incubation period:7 to 8 weeks
• Occurs with hepatitis B (infection only in
the presence of active HBV )
• Transmission and risk of infection are the
same as for HBV
• Transmission-parenteral, same as B
• Testing :Serological HDV determination
Early –antigen , later anti HDV antibody
• Complications: CLD, fulminant hepatitis
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 Hepatitis E
• It is water born virus
• Prevalent in areas where sewage disposal
is inadequate , contaminated river
• Incubation P:2-6w, Infection P.: 2-3 w
before and 1 w after jaundice
• Testing :detection of IgM and IgG
antibodies to hep E (anti-HEV)

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Hepatitis G
• Hepatitis G is non- A, non-B, non-C hepatitis
• Autoantibodies are absent
• Risk factors similar to those of Hep C
• Hepatitis G virus has been found in some blood donors, IV
drug users, hemodialysis clients, and clients with hemophilia
• It does not appear to cause significant liver diseases

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Q. The student nurse is teaching the family of a patient with liver
failure. The nurse instruct them to limit which foods in the
patient’s diet?
a. Meats and beans
b. Butter and gravies
c. Potatoes and pastas
d. Cakes and pastries

Answer: a
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Q. Mr. X has severe pruritus due to having hepatitis B. What is the best
intervention for his comfort?
a. Give tepid baths.
b. Avoid lotions and creams.
c. Use hot water to increase vasodilation.
d. Use cold water to decrease the itching.

Answer: a

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 Hemorrhoids
• Dilated varicose vein of the anus ;Internal ,
external or prolapsed
• Internal hemorrhoids lie above the anal
sphincter so cannot be seen on inspection
;Prolapsed- can be thrombosed or inflamed
• Caused by portal hypertension , straining ,
irritation, increased venous and abd. pressure
• Assessment: bright red bleeding , rectal pain,

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Cirrhosis
• Chronic progressive disease of the liver
characterized by diffuse degeneration and
destructions of the hepatocytes, formation of
scar tissues
• Complication : portal hypertension , ascities ,
bleeding esophageal varices, coagulation
defects (deranged PT (Normal :9- 11 /13 secs)
• Decreased synthesis of bile fats in liver
prevents the absorption of fat soluble
vitamins

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Cirrhosis Contd..
• Without Vit K and clotting factors II,VII,IX and X the client
is prone to bleeding
• Jaundice: unable to metabolise bilirubin
• Portal systemic encephalopathy: altered level of
consciousness, neurological symptoms , impaired thinking
and neuromuscular disturbances
• Hepatorenal syndromes : progressive renal failure associated
with renal failure

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Cirrhosis contd…
•Hematological: anemia
• Dermatological: itching caput medusa , pruritis , spider angioma
•GI: abdominal pain, anorexia, ascites, clay coloured stools , fetor
hepaticus, malnutrition
•Renal: increased renal bilirubin
•Endocrine: increased glucocorticoids
•Cardio: peripheral edema, fatigue
•Pulmonary: dyspnea

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Interventions

• Elevate the head of the bed

• Provide supplemental vitamins (B complex,vitamins
A,C,K,Folic acid and thiamine )
• Restrict sodium intake and fluid intake
• Initiate enteral feedings /parenteral
• Administer diuretics
• Monitor I/O chart

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 Interventions contd…

• Weigh , abdominal girth

• Monitor LoC, assess for tremors and delirium
• Monitor asterexis: coarse tremor, rapid, non
rhythmic extension or flexions in the wrist and
fingers , fetor hepaticas
• Maintain gastric Intubation
• Avoid opoids, sedatives
• Administer neomycin: to inhibit protein synthesis
for basteria and decreas the production of ammonia
• Administer lactulose, Vit K
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 Thank You

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