1. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 1 Abejo
MEDICAL AND SURGICAL NURSING
Gastrointestinal System Lecturer: Mark Fredderick R. Abejo RN,MAN ______________________________________________________________________________________________ OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE GASTROINTESTINAL TRACT
I. UPPER ALIMENTARY CANAL (Digestion)
A. Mouth initial phase of digestion
B. Pharynx
C. Esophagus
D. Stomach  complete digestion
E. First half of duodenum  digestion
II. MIDDLE ALIMENTARY CANAL (Absorption)
A. 2nd half of duodenum
B. Jejunum
C. Ileum
D. 1st half of ascending colon

2. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 2 Abejo
III. LOWER ALIMENTARY CANAL (Elimination)
A. 2nd half of ascending colon
B. Transverse colon
C. Descending colon
D. Sigmoid colon
E. Rectum
IV. ACCESSORY ORGANS
A. Salivary glands – produces 1.2-1.5 L of saliva per day
1. Parotid – below and in front the ear
2. Sublingual
3. Submandibular
B. Vermiform appendix
C. Liver – largest gland, occupies most of R hypochondriac region
1. Glison’s capsule – covers liver, transparent, brown
2. Liver lobules – functional site
D. Gall bladder
E. Pancreas
 Small intestines – initial phase of absorption
 Large intestines – absorption of vitamin K and complete phase of absorption
 Tears: lacrimal gland  lacrimal duct  lacrimal sac  punctae  nasolacrimal gland
I. PAROTITIS (Endemic mumps) – inflammation of the parotid gland
A. ETIOLOGIC AGENT
1. Paramyxovirus virus
B. SIGNS AND SYMPTOMS
1. Swollen parotid gland
2. Earache / otalgia
3. Dysphagia
4. Fever, chills, anorexia, generalized body malaise
C. NURSING MANAGEMENT
1. Strict isolation
2. Meds as ordered
 Antipyretics
 Antibiotics  to prevent secondary infection
 GENTIAN VIOLET HAS NO COOLING EFFECT! Cooling effect may be caused by vinegar!
 Better to have mumps at an early stage, preferably before puberty  may lead to sterility
3. Provide a general liquid to soft diet
4. Apply cold compress or ice pack at affected site
5. Prevent complications
 Cervicitis, oophoritis, vaginitis
 Meningitis
 Orchitis  sterility
II. APPENDECITIS – Inflammation of the vermiform appendix (located at the R. iliac region, produces WBC during fetal life)
A. PREDISPOSING FACTORS
1. Microbial invasion
2. FECALITHS – undigested food particles (tomato, guava seeds)
3. intestinal obstruction
B. SIGNS AND SYMPTOMS
1. (+) Rebound tenderness
2. Low grade fever, anorexia, nausea and vomiting
3. Pain at r iliac region
4. Diarrhea/constipation
5. Tachycardia d/t pain
C. DIAGNOSTICS
1. CBC – mild leukocytosis
2. PE – (+) rebound tenderness
3. Urinalysis – (+) acetone)
D. NURSING MANAGEMENT PRE-OP
1. Secure informed consent
2. Routinary nursing care
 NPO
 Skin preparation
 Avoid enema  may lead to rupture
3. Administer medications as ordered
 antipyretics
 antibiotics

3. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 3 Abejo
 NO ANALGESICS! May mask pain which indicates impending rupture
4. Monitor IO VS and Bowel sounds
5. Avoid heat application  rupture
6. Maintain patent IV line
E. NURSING MANAGEMENT POST-OP
1. If (+) penrose drain (indicates rupture) – place patient on affected site for drainage
2. If (-), position is based on pt. comfort
3. Administer medications as ordered
 Analgesics
 Antibiotics
 Antipyretics PRN
4. Maintain patent IV line
5. Monitor VS IO and bowel sounds (N=borborygmi)
Complications: PERITONITIS AND SEPTICEMIA MC BURNEY’S POINT – incision site for appendectomy
III. LIVER CIRRHOSIS (Laennec’s cirrhosis) – loss of architectural design of liver leading to fat necrosis and scarring; can lead to liver cancer
A. PREDISPOSING FACTORS
1. Alcoholism
2. Malnutrition
3. Viruses
4. Toxicity
 Carbon tetrachloride
5. Use of hepatotoxic agent
B. SIGNS AND SYMPTOMS
1. Early
 Weakness and fatigue
 Anorexia
 Nausea and vomiting
 Tea-colored urine, clay-colored stool
 Decreased sexual urge
 Amenorrhea
 Dyspepsia – indigestion
 Hepatomegaly
 Jaundice
 Urticaria/pruritus
 Loss of pubic/axillary hair
2. Late signs
 Hematologic changes
 Anemia
 Leucopenia
 Bleeding tendencies
 Endocrine changes
 Spider angiomas/ telangiectasis
 Caput medusae (Varicose veins radiating from the umbilicus)
 Palmar erythema
 Gynecomastia
 GIT changes
 Ascites
 Bleeding esophageal varices d/t portal HPN
 Neuro changes
 Hepatic encephalopathy
 Early  Asterixis (flapping hand tremors)

4. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 4 Abejo
 Late  headache, dizziness, confusion, irritability, fetor hepaticus, (ammonia-like breath), decreased LOC  hepatic coma
C. DIAGNOSTICS
1. Liver enzymes
 SGPT (ALT) elevated
 SGOT (AST) elevated
2. Serum cholesterol
 Ammonia elevated
3. Indirect bilirubin / Unconjugated bilirubin elevated
4. CBC low
5. PTT prolonged
6. Hepatic UTZ – fat necrosis of liver lobules
D. NURSING MANAGEMENT
1. Enforce CBR
2. Monitor strictly VS and IO
3. Weigh pt daily and assess for pitting edema
4. Measure abdominal girth and notify physician
5. Restrict Na and fluids
6. Diet high in CHO, moderate in fat, decreased CHON, increased vitamins and minerals
7. Meticulous skin care
8. Prevent complications
 Ascites
 Administer medications as ordered
 Loop diuretics (Furosemide)
 Assist in abdominal paracentesis (empty the bladder pre-op)
 Bleeding esophageal varices
 Administer meds as ordered
 Vitamin K
 Pitressin (to conserve fluids)
 Institute NGT decompression by gastric lavage (ice/cold saline solution)
 Assist in mechanical decompression – insertion of sengstaken-blakemore catheter ( 3-lumen catheter)  decompress esophageal veins prevents bleeding
 Hepatic Encephalopathy
 Assist in mechanical ventilation
 Monitor VS, NVS
 Maintain side rails
 Administer medications as ordered
 Lactulose  for ammonia excretion
PANCREAS Both an endocrine (islets of Langerhans) and exocrine gland (Acinar cells)
IV. PANCREATITIS – an acute or chronic inflammation of the pancreas leading to pancreatic edema, necrosis and hemorrhage d/t autodigestion; idiopathic; TRYPSIN – kills pancreas
A. PREDISPOSING FACTORS (na di hamak naman na wala nito si Rico Yan)
1. Chronic alcoholism
2. Hepatobiliary disorders
3. Drugs:
 Thiazide diuretics - Etacrynic acid Ano daw?
 OCPs
 Pentamide HCl (Pentam) – for AIDS
4. Metabolic disturbances
 Hyperlipidemia
 Hyperparathyroidism
5. Obesity
6. Diet: high in saturated fats
B. S/Sx
1. Severe abdominal pain radiating from the back (left upper quadrant), chest and flank area accompanied by DOB and aggravated by eating (so dapat naka TPN to, uhm, usually an infusion vamine glucose or lipofundin, kung may pera ang patient eh di Nutripak; remember to keep all lines securely taped to prevent embolism)
2. Shallow respirations
3. Tachycardia and palpitations, hypertension
4. Anorexia, N&V, dyspepsia
5. Decreased bowel sounds
6. (+) Cullen’s sign – ecchymoses around umbilicus and (+) Grey-turner’s spots  ecchymoses at the flank area; both are indications of hemorrhage
C. DIAGNOSTICS
1. Serum amylase (very toxic to the body) and lipase elevated
2. Serum Ca low (hypocalcemia)
D. NURSING MANAGEMENT
1. Administer meds as ordered
 Narcotic analgesics
 Meperidine HCl (Demerol)  Respiratory Depression
 DO NOT GIVE MORPHINE  can cause spasm of the sphincter of Oddi
 Smooth muscle relaxation
 Papanarine HCl
 Vasodilators
 NTG
 Antacids (Maalox)
 H2 receptor antagonist

5. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 5 Abejo
 Ranitidine (Zantac)
 Decrease pancreatic stimulation
 Calcium gluconate
 Phosphate binders
 Amphogel
2. Withhold food and fluids (need to rest the GIT)
 Nursing goal: rest the Git
 Upon d/c: high CHO and CHON, low fat
3. Assist in TPN or hyperalimentation
 Complications of TPN
 Infection (so maintain strict asepsis)
 Air embolism
 Hyperglycemia
 Hyponatremia
4. Instruct pt to assume comfortable position
 Fetal position (knee-chest position)
5. Prevent complications
 Chronic hemorrhagic pancreatitis
 Shock
 Septicemia
6. Stress management
 DBE, biofeedback
V. CHOLECYSTITIS/CHOLELITHIASIS – inflammation of the gallbladder with gallstone formation
A. PREDISPOSING FACTORS
1. High risk group: women
2. Obesity
3. Post-menopausal women undergoing estrogen therapy
4. Diet high in saturated fats
5. Sedentary lifestyle
6. Neoplasm
7. Obstruction
B. SIGNS AND SYMPTOMS
1. Severe abdominal pain (RUQ) radiating from the back and chest that usually occurs at night
2. Fatty intolerance (pain after ingestion of high fat meals) characterized by: Anorexia, nausea and vomiting
3. Tea-colored urine and steatorrhea
C. DIAGNOSTICS
1. Gallbladder series (Oral cholecystogram) – confirm presence of gallstones
2. Serum lipase elevated
3. Indirect bilirubin elevated
4. Alkaline phosphatase elevated
5. Transaminases elevated
D. NURSING MGT
1. Narcotic analgesics
 Meperidine HCl (Demerol)
2. Anticholinergic agents
 Atropine sulfate
3. Anti-emetics
 Metoclopramide (Plasil)
 Phenergan
4. Diet low in fat, high CHON and CHO
5. Meticulous skin care
6. Assist in surgery: Cholecystectomy
 Post-op: maintain patency of tube drain (t-tube)
 Monitor for infections
STOMACH
 J-shaped structure
 Widest section of alimentary canal especially p.c.
A. Parts
1. Antrum
2. Fundus
3. Pylorus
B. Valves - prevents reflux
1. cardiac – between esophagus and stomach
2. pyloric – stomach and duodenum
 projectile vomiting
 olive shaped belly
C. Cells
1. Chief cells or zymogenic cells
 Gastric amylase – digests CHO
 Gastric lipase – digests fats
 Pepsin – proteins
 Rennin – milk and milk products
2. Parietal/augentaffin/oxyntic cells
 Produces intrinsic factors  reabsorption of B12 (cyanocobalamin)  maturation of RBCs

6. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 6 Abejo
 Produces HCl acid with pH of 1-2  aids in digestion
3. Endocrine cells
 Secretes gastrin  stimulates HCl Acid secretion
D. FUNCTIONS
1. Mechanical and chemical digestion
2. Storage of food
 CHO and CHON – 1-2 hours
 Fats – 2-3 hours
V. PEPTIC ULCER DISEASE – erosion/excoriation of submucosa/mucosal lining d/t
 Hypersecretion of acid – pepsin
 Decreased resistance of mucosal barrier to HCl acid secretion (neutralizes acidity)
A. INCIDENCE RATE
1. Men
2. Aggressive
B. PREDISPOSING FACTORS
1. Heredity
2. Emotional stress
3. Smoking  vasoconstriction  gastric ischemia
4. Alcoholism  release of histamine  parietal cells to secrete gastrin
5. Irregular diet
6. Rapid eating
7. Ulcerogenic drugs
 Aspirin
 Ibuprofen
 Indomethacin (SE:corneal cloudiness)
 Steroids
 NSAIDs
8. Foods or beverages rich in caffeine
9. Gastrin producing tumors
 Gastrinoma  Zollinger-Ellison’s Syndrome
10. Microbial invasion (Helicobacter pylori)
 Metronidazole
 SE: photosensitivity
 Etampicillin
C. TYPES
1. Severity
 Acute ulcers – submucosal
 Chronic ulcers – deeper underlying tissues; (+) scar formation
2. Location
 Stress (Critically-ill patients)
 Curling’s ulcer
 Burns and trauma  hypovolemia  GIT ischemia  decreased resistance of mucosal barrier to HCl acid secretion
 Cushing’s ulcer
 Head trauma
 CVA/Stroke  increased vagal stimulation  hyperacidity  ulceration
 Gastric
 Duodenal
Differences
Gastric Ulcer
Duodenal Ulcer (90%)
Location
Antrum
Duodenal bulb
Pain
30 mins-1hour p.c.
2-3 hours p.c. 12mn-3am pain
Pain location
Epigastrium
Mid-epigastrium
Pain character
Gaseous and burning, not relieved by food and antacids
Cramping and burping, relieved by food and antacids
Gastric acid secretion
Normal
Increased
Weight
Loss
Gain
Hemorrhage
Hematemesis
Melena
Complications
Hemorrhage, stomach cancer
Perforation
High risk
60 y.o above
20 y.o above
D. DIAGNOSTICS
1. Endoscopy
2. (+) Stool occult blood
3. Gastric analysis reveals
 Normal gastric acid secretion if gastric
 Increased gastric acid secretion if duodenal
4. Upper GI series – confirms ulceration
E. NURSING MANAGEMENT (Diet, Drugs, Surgery)
1. Bland diet  non-irritating, non-spicy
 Avoid beverages and foods high in caffeine or milk and milk containing products
2. Admin meds as ordered
 Antacids
 ACA – aluminum containing antacids
 Aluminum OH gel (Ampho gel)
 SE: constipation, hyperphosphatemia, hypoparathyroidism
 MAD – magnesium containing antacids
 Milk of magnesia
 SE: diarrhea
 Mg + Al preparations (Maalox)  less SE
 H2 receptor antagonists

7. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 7 Abejo
 Cimetidine (Tagamet) – antagonizes oral anti-coagulant, more SEs
 Ranitidine (Zantac) – most common, fewer SE
 Famotidine (Pepsid)
 Give antacids and Cimetidine ONE HOUR APART  decreased antacid absorption and vise versa
 Instruct client to avoid smoking because it decreases effectiveness of drug
 Cytoprotective agents
 Sucralfate (Carafate)  provides a paste- like substance that coats the mucosal lining
 Cytotec (Misoprostol)  causes severe spasm (abortifacient)  uterine cramping  bleeding
 Anticholinergic/Anti-spasmodic agents
 Atropine
 Propanthelene sulfate (Probanthene)
 Sedatives, tranquilizers
3. Assist in surgical procedure: subtotal gastrectomy
 Billroth I (removal of 1/3 of stomach)
 Gastroduodenostomy  gastric stump to the duodenum
 Billroth II
 Gastrojejunostomy  gastric stump to jejunum
 Removal of ½ to ¾ of the stomach, duodenal valve and anastomosis of gastric stump to jejunum
 Complic: DUMPING SYNDROME
 Vagotomy (severe vagus nerve) and pyloroplasty  for drainage
 Decrease vagal stimulation  decrease HCl acid secretion  prevent hemorrhage
F. NURSING MANAGEMENT POST OP
1. Monitor NGT output that includes:
 Immediately after post-op  bright red
 32-46 hours  greenish in color
 48h  dark red  because of influence of HCl acid
2. Administer medications as ordered
 Antimicrobials
 Narcotic analgesics
 Anti-emetics
3. Maintain a patent IV line
4. Monitor VS, IO, Bowel Sounds
5. Prevent complication
 Hemorrhage  shock
 Paralytic Ileus – most common type of complication in all abdominal surgery
 Peritonitis
 Septicemia
 Hypokalemia
 Pernicious anemia
 DUMPING SYNDROME (Billroth II) – rapid emptying of hypertonic food solutions; chyme – food and HCl acid from stomach to jejunum with resultant hypovolemia  dizziness, diaphoresis, palpitation, tachycardia, diarrhea, weakness
 Nursing management for dumping syndrome:
 Provide fluids BEFORE meals
 Avoid fluids/chilled solutions
 Provide a small frequent feeding or 6 equal divided feeding
 Diet low in CHO and sugar moderate CHON and fats
 Instruct pt to lie flat on bed 15-30 minutes after each feeding

8. Medical and Surgical Nursing
Gastro-intestinal Disorder
Prepared: Mark Fredderick Abejo RN, MAN
MS 8 Abejo
VI. DIVERTICULUM – outpouching of the intestinal mucosa particularly the sigmoid colon; DIVERTICULOSIS – multiple diverticulum; DIVERTICULITIS – inflammation of diverticula
A. PREDISPOSING FACTORS
1. High risk: female
2. Congenital weakness of muscular fibers of intestines
3. Obesity
4. Stress
5. Diet: decrease in roughage
B. SIGNS AND SYMPTOMS
1. Intermittent pain at LLQ and tenderness at the rectosigmoid area
2. Alternate bouts of diarrhea/constipation with blood and mucosa
3. Decreased hematocrit/hemoglobin  amnesia
C. DIAGNOSTICS
1. Barium Enema – reveals inflammatory process
2. Decreased hematocrit/hemoglobin (d/t diarrhea)
D. NURSING MANAGEMENT
1. Administer medications as ordered.
 Bulk laxatives
 Anti-cholinergics
 Atropine Sulfate
 Propanthelene Bromide
 Antibiotics for infection
2. Provide dietary intake:
 Diverticulosis – high roughage/fiber with no seeds
 Diverticulitis – low fiber diet
3. Assist in surgical procedure
 Bowel resection: removal of diseased portion of the bowel and creation of colostomy.