NATURE OF VOMITUS CYTOLOGIC CULTURE and GRAM STAIN

TESTING – to identify the CAUSATIVE

Color/Taste/Consistency Possible Source MICROORGANISM
 Yellowish or greenish - May contain bile
 Bright red (arterial) Hemorrhage – peptic NURSING CARE
ulcer  Provide ORAL CARE EVERY 2 HOURS
 Dark red (venous) Hemorrhage – and twice at night
esophageal or gastric varices  Use SOFT-BRISTLED TOOTHBRUSH OR
 “Coffee ground” - Digested blood from FOAM SWABS to stimulate gums and
slowly bleeding gastric or duodenal ulcer clean the oral cavity
 Undigested food - Gastric tumor, ulcer,  Use SODIUM BICARBONATE solution
obstruction, bile (baking soda), WARM SALINE or
 “Bitter” taste - Bile Chlorhexidine 2% aqueous mouth wash
 “Sour” or “acid” - Gastric contents in rinsing the mouth
 Fecal components - Intestinal obstruction  Avoid COMMERCIAL MOUTHWASHES
 Provide SOFT, BLAND and NONACIDIC
foods
DISORDERS OF THE MOUTH  Apply TOPICAL ANALGESICS or
ANESTHETICS as prescribed
STOMATITIS  Administer prescribed medication

Definition DRUG THERAPY

 Inflammation of the oral cavity

TYPES OF STOMATITIS  ANTI-INFLAMMATORY AGENTS AND

IMMUNE MODULATORS
1) Primary
APHTHOUS STOMATITIS or canker sores – o Triamcinolone in Benzocaine
MOST COMMON TYPE o Dexamethasone
o Levamisole
2) Secondary o Amlexanox
candidiasis or oral thrush o Thalidomide (IM)
may be due to overgrowth of normal flora
 SYMPTOMATIC TOPICAL AGENTS FOR
ETIOLOGY PAIN
 Infection e.g. herpes zoster or
cytomegalovirus, HFMD, syphilis and etc. o Benzocaine
 Allergy to coffee, potatoes, cheese, nuts, o Camphor phenol
citrus fruits o 15 ml 2% viscous Lidocaine gargle
 Vitamin deficiency e.g. Vitamin B, folate, of mouthwash every 3 hours
zinc, and iron (maximum of 8 doses per day)
 Systemic disease e.g. HIV, chronic renal
failure, inflammatory bowel disease DISORDERS OF THE GASTROINTESTINAL
 Irritants e.g. tobacco and alcohol SYSTEM
 Chemotherapy and Radiation
 Trauma Disorders of the Esophagus

CLINICAL MANIFESTATIONS GASTROESOPHAGEAL REFLUX DISEASE

 CANKER SORES – whitish gray center and (GERD)
erythematous ring
 Whitish plaque-like lesion, appears red and DESCRIPTION
sore when wiped away – COMMON IF
WITH CANDIDIASIS  BACKWARD FLOW (reflux) of
 Dysphagia gastrointestinal contents into the esophagus
 Dry or hot sensation on area of lesions  MOST COMMON upper GI disorder
 Elevation of temperature – RARE  Common in PEOPLE OVER AGE 45
pain  Considered a disease process when acid is
excessive and causes undesirable
symptoms such as pain and respiratory
distress
LABORATORY ASSESSMENT
CAUSES
COMPLETE BLOOD COUNT – may reveal
INFECTION  INAPPROPRIATE RELAXATION of lower
esophageal sphincter or inability of the LES
to close fully
  Avoid SPICY and ACIDIC FOODS
PREDISPOSING FACTORS  SMALL FREQUENT FEEDINGS (4-6 small
 Ingestion of LARGE MEALS meals)
 Conditions associated with DECREASED  Avoid foods 3 hours before going to bed
GASTRIC EMPTYING  Standing ,Sitting or High fowler’s position
 Recumbent or SUPINE positioning after after eating
eating
 Insertion of nasogastric tube (NGT) LIFESTYLE CHANGES
 INCREASED INTRAABDOMINAL and
INTRAGASTRIC PRESSURE e.g.  ELEVATE HEAD OF THE BED 6-8 inches
pregnancy, wearing of tight belts, obesity, for sleep
bending over, ascites  DO NOT LIE DOWN 3-4 hours after eating
 Avoid NICOTINE and ALCOHOL
FACTORS THAT RELAX LOWER ESOPHAGEAL  LOSE WEIGHT – if the patient is obese
SPHINCTER TONE  Avoid CONSTRICTIVE CLOTHING,
STRAINING or BENDING OVER
 Fatty foods , Chocolate
 Caffeinated beverages SURGICAL MANAGEMENT
 Citrus fruits, tomatoes and tomato products
 Peppermint, spearmint  LAPAROSCOPIC NISSEN
 Alcohol FUNDOPLICATION (LNF)
 Nicotine in cigarette smoke
 High levels of estrogen and progesterone o WRAPPING and ANCHORING a
 Medications e.g. calcium channel blockers portion of the stomach fundus
( calcibloc), anticholinergic drugs (ASO4) around the lower esophageal
sphincter
ASSESSMENT
NURSING CARE AFTER SURGERY
SUBJECTIVE DATA  Elevate head of the bed at least 30 degrees
 HEARTBURN – suggests reflux to lower the diaphragm and facilitate lung
 DYSPHAGIA – suggests narrowing of expansion
lumen  Facilitate insertion of NGT to prevent
excessive tightening of the fundoplication
 Monitor drainage of NGT (should be normal
OBJECTIVE DATA yellowish green within the first 8 hours after
 Dyspepsia – MOST COMMON SYMPTOM; surgery)
occurs 30-60 minutes after meals and with  Check placement every 4-8 hours
reclining position  Avoid alcohol, caffeinated and carbonated
 Regurgitation – with sour or bitter taste foods
 Hypersalivation  Monitor for dysphagia (sign that
 Dysphagia fundoplication is too tight)
 Odynophagia – sharp substernal pain on  Monitor for gas bloat syndrome
swallowing  Administer simethicone 80 mg QID for
 Eructation (belching) excessive gas as per doctor’s order
 Pyrosis – burning sensation in the
esophagus
 Chronic cough ENDOSCOPIC THERAPIES
 Aspiration pneumonia
 Respiratory distress
STRETTA PROCEDURE
DIAGNOSTIC TESTS  PURPOSE – to INHIBIT THE ACTIVITY of
the vagus nerve
 24-hour ambulatory esophageal pH  Use of radiofrequency energy through
monitoring – most accurate method ; allows needles to induce THERMAL BURN in the
for observation of the frequency of reflux gastroesophageal junction; tiny lesions
episodes and their associated symtoms occur initially and as it heals ,it tightens the
 Upper endoscopy tissues and increases muscle mass at the
LES
 Esophageal manometry (measures the
rhythmic muscle contractions (peristalsis)  Lasts 45 minutes; recovery time is 1-2 days
that occur in esophagus when swallowing)
ENTERYX PROCEDURE
MANAGEMENT  PURPOSE – to TIGHTEN the lower
esophageal sphincter
DIET THERAPY  INJECTION OF SOFT, SPONGY
 Avoid CAFFEINATED AND CARBONATED PERMANENT IMPLANT made of liquid
foods polymeric material into the LES muscle
  pain relieved by food
PATIENT CARE AFTER ENDOSCOPIC  anorexia
THERAPIES  nausea and vomiting
 Maintain on CLEAR LIQUIDS for 24 hours  intolerance of fatty or spicy foods
 After the DAY 1 – shift to SOFT DIET such  pernicious anemia
as custard, pureed vegetables, mashed
potatoes DIAGNOSTIC TEST
 Avoid NSAIDs and ASPIRIN for 10 days
 Give LIQUID MEDICATIONS as much as  Esophagogastroduodenoscopy with biopsy
possible
 Avoid NGT INSERTION for at least 1 month
 Watch out for CHEST or ABDOMINAL DRUG THERAPY
PAIN, BLEEDING, DYSPHAGIA,  H2 Receptor Antagonists
SHORTNESS OF BREATH, NAUSEA or  Antacids
VOMITING  Proton Pump Inhibitors
 Vitamin B12 (if there is pernicious anemia)
Disorders of the Stomach and Small Intestine  Triple Therapy (if there is H. Pylori in
biopsy)
GASTRITIS 1) 1 Bismuth subsalicylates or
 Inflammation of the stomach mucosa proton pump inhibitor (omeprazole)
2) 1 Antibiotic (metronidazole)
CLASSIFICATION 3) 1 Antibiotic (tetracycline,
 Acute – includes erosive gastritis and stress clarithromycin, amoxicillin)
ulcers  DRUGS TO AVOID – aspirin, ibuprofen
 Chronic – includes non-erosive gastritis

Types of chronic gastritis

 Type A – inflammation of the glands in the
fundus and body
 Type B – inflammation of the glands from DIET THERAPY
fundus to antrum  Instruct client to limit intake of foods and
 Atrophic – diffuse inflammation and spices that cause distress e.g. Tea, cola,
destruction of deeply located glands chocolate, mustard, pepper and hot spices
 Instruct client to avoid alcohol and tobacco
 Give soft, bland diet and smaller, more
ETIOLOGY frequent meals

ACUTE GASTRITIS STRESS REDUCTION

 Local irritants (drugs, alcohol, corrosive  Progressive muscle relaxation
substances)  Cutaneous stimulation
 Bacterial invasion by salmonella, E. Coli  Guided imagery
and H. Pylori)  Distraction
CHRONIC GASTRITIS SURGICAL MANAGEMENT
 May occur due to bile acid reflux  Partial/ total gastrectomy
(complication of gastrojejunal surgery or  Pyloroplasty (surgery to widen the opening
peptic ulcer disease) in the lower part of the stomach (pylorus) so
 Chronic use of irritants that the stomach contents can empty into
 Illustration of maldigestion in chronic the small intestine
gastritis  Vagotomy (surgical procedure that involves
resection of the vagus nerve to reduce
ASSESSMENT acidity of the stomach)
ACUTE GASTRITIS PEPTIC ULCER DISEASE
 ulceration of the gastric mucosa, duodenum
 rapid onset of epigastric pain and rarely the lower esophagus and
 Pain not relieved by food jejunum
 Anorexia
 Nausea and vomiting TYPES
 Dyspepsia 1. Gastric Ulcers
 gastric hemorrhage 2. Duodenal Ulcers
 hematemesis 3. Stress Ulcers (Curling’s Ulcer or
Cushing’s Ulcer – result of critical illness and
CHRONIC GASTRITIS severe physical or emotional stress

 vague epigastric pain  Curling’s Ulcer – due to hypovolemic shock,

  Major surgery sepsis, severe burns and
hypoxia DIET THERAPY
 Cushing’s Ulcer – aftermath of cerebral
trauma which cause stimulation of vagus  Bland diet
and increase Hcl production  Small frequent feedings (6 small meals/day)
 Avoid caffeine-containing foods (coffee, tea
PATHOPHYSIOLOGY or cola)
PREDISPOSING FACTORS  Avoid tobacco and alcohol

 Stress MANAGEMENT FOR HYPOVOLEMIA

 Irregular hurried meals  Monitor vital signs, intake and output
 Smoking and alcoholism  Monitor serum electrolytes to determine
 Caffeinated, fatty, spicy, acidic foods need for replacement
 Ulcerogenic medications – Aspirin, NSAIDs,  Administer ISOTONIC SOLUTIONS (NSS
Steroids or lactated Ringer’s)
 GI disorders – Gastritis, Zollinger-Ellison  Perform BLOOD TRANSFUSION as
Syndrome prescribed to expand blood volume
 Type A personality  If there is active bleeding, administer
 Type O blood FRESH FROZEN PLASMA

MANAGEMENT FOR BLEEDING

COMPLICATIONS  Monitor for the following:
 Hemorrhage o signs of SHOCK (hypotension, chills,
 Perforation palpitations, diaphoresis, weak
 Pyloric Obstruction thready pulse)
 Intractable Disease o Occult blood
o hematocrit, hemoglobin and
ASSESSMENT coagulation studies
o Perform GASTRIC
 HISTORY DECOMPRESSION OR LAVAGE
 Alcohol and tobacco use o AVOID NSAIDS to minimize GI
 Use of corticosteroids, aspirin and NSAIDs bleeding
o Vasopressin(Pitressin) a
CLINICAL MANIFESTATIONS vasoconstricting drug
 Epigastric tenderness
 Rigid, boardlike abdomen with rebound
tenderness
 Diminishing hyperactive bowel sounds ENDOSCOPIC THERAPY
 Dyspepsia
 Vomiting GOAL: promote blood clot formation

DIAGNOSTIC TESTS METHODS OF ENDOSCOPIC THERAPY

(1) THERMAL CONTACT – heater probe or
 Low hemoglobin and hematocrit multielectrocoagulation
(2) Inject bleeding site with diluted EPINEPHRINE
 Positive occult blood test
(3) Laser therapy
 Barium examination
(4) Mechanical clip
 Esophagogastroduodenoscopy (most
accurate) CLIENT PREPARATION
 Elevated Immunoglobulin G antibodies o Administer SEDATIVES e.g. midazolam and
(suggest H. Pylori infection) meperidine
 Fecalysis o Place on NPO 6 hours prior the procedure
DRUG THERAPY CARE AFTER THE PROCEDURE
o Resume diet once gag reflex is present
 TRIPLE THERAPY (most successful
regimen) MANAGEMENT FOR PERFORATION
1) Bismuth compound or proton-pump
inhibitor (omeprazole) o Replace lost fluids, blood and electrolytes
2) Metronidazole
o Administer antibiotics
3) Tetracyline or Clarithromycin and
o Place on NPO
Amoxicillin
o Gastric lavage or decompression
 HYPOSECRETORY DRUGS o Monitor for signs of septic shock (fever,
1) Histamine Receptor Antagonists pain, tachycardia, lethargy or anxiety)
2) Proton Pump Inhibitors
3) Prostaglandin Analogues SURGICAL MANAGEMENT FOR OBSTRUCTION
 o Gastroduodenostomy (Billroth I)  Malaise
o Gastrojejunostomy (Billroth II)  Abdominal tenderness
o Partial Gastrectomy  SIGNS OF DEHYDRATION
o Pyloroplasty enlargement of the pyloric o Poor skin turgor
sphinter o Dry mucous membranes
o Hypotension
CLIENT PREPARATION o Oliguria

Insert NGT connected to suction to remove MANAGEMENT

secretions and empty the stomach
FLUID REPLACEMENT
1. Mouth  Monitor vital signs, I and O and weight (1 kg
2. Esophagus- LES weight loss is equivalent to 1 L loss)
3. Stomach  Administer HYPOTONIC IV FLUIDS (0.45%
o Cardia NaCl)
o Fundus  Oral Rehydration Salts (Oresol)
o body  If with HYPOKALEMIA – Incorporate
o Pylorus potassium supplements
4. Small intestine-(longest)  Observe standard precautions
o Duodenum
o Jejunum DIET THERAPY
o Ileum (ileocecal valve and vermiform  IF NOT ACTIVELY VOMITING – clear
appendix) liquids with electrolytes
5. Large intestine  IF VOMITING – NPO
 Ascending colon  IF TREATED – crackers, toast and jelly
 Transverse colon  IF IMPROVING – bland diet
 Descending colon  AVOID caffeine
o Sigmoid colon
o Rectum
6. Anus DRUG THERAPY
 Racecadotril (Hidrasec) and
 LOPERAMIDE (IMODIUM) – to inhibit
POST-OPERATIVE CARE peristalsis
 Monitor placement, patency and drainage of  BISMUTH SUBSALICYLATES (PEPTO-
NGT BISMUL) – to reduce watery volume of stool
 Monitor for DUMPING SYNDROME ( suppresses H. Pylori and assist in healing
of mucosal lesions)
SIGNS AND SYMPTOMS OF DUMPING  ANTIBIOTICS
SYNDROME o NORFLOXACIN OR
CIPROFLOXACIN – If caused by
MANAGEMENT FOR DUMPING SYNDROME bacteria
 Small frequent feeding o TRIMETHOPRIM -
 Do not take fluids with meals SULFAMETHOXAZOLE (BACTRIM)
 Advise high-protein, high-fat, low-to-
moderate carbohydrate diet
 Administer pectin to prevent the syndrome
SKIN CARE
 Avoid toilet paper and harsh soap
GASTROENTERITIS  Use warm water and absorbent cotton
 Inflammation of the mucous membranes of  Apply cream, oil or gel to excoriated skin
the stomach and the intestinal tract  Provide sitz bath
 CLASSIC MANIFESTATION – increase in
the frequency and water content of the Disorders of the Lower GI Tract
stools or vomiting
INFLAMMATORY BOWEL DISEASES
TYPES  ULCERATIVE COLITIS – chronic
 VIRAL – caused by norwalk virus or inflammatory process affecting the mucosa
rotavirus and submucosa of the SIGMOID COLON
 BACTERIAL – caused by E. Coli, and RECTUM
campylobacter enteritis or shigellosis
CROHN’S DISEASE (REGIONAL ENTERITIS)
ASSESSMENT  subacute or chronic inflammatory bowel
 Nausea and vomiting (first 2 days of illness) disease affecting segmental areas along the
 Diarrhea ENTIRE WALL OF THE GI TRACT; most
 Myalgia commonly noted within the TERMINAL
 Headache ILEUM
 TOTAL PROCTOCOLECTOMY WITH
CLINICAL MANIFESTATIONS PERMANENT ILEOSTOMY
 Terminal ileum is pulled through the
DRUG THERAPY abdominal wall and forms a stoma or
ostomy
1. SALICYLATE COMPOUNDS
Drug Name – Sulfasalazine (Azulfidine)
Indication – Management of ulcerative colitis
Action – inhibit prostaglandin synthesis to reduce
inflammation IRRITABLE BOWEL SYNDROME
Adverse effects – leukopenia and anemia  Also known as SPASTIC BOWEL OR
Client Instructions MUCUS COLITIS
(1) take the drug with a full glass of  Different from ulcerative colitis because
water there is no inflammation or ulceration
(2) take the drug after meals to present
prevent GI discomfort
RISK FACTORS
2. ORAL OR INTRAVENOUS  Emotional stress or anxiety, depression
CORTICOSTEROIDS  Diverticulitis
Drug Name – Prednisone  Intolerance to gastric stimulants such as
Indication – to reduce inflammation caffeine or spicy foods or lactose
Adverse Effects – hyperglycemia, osteoporosis,
 Diet high in fats
peptic ulcer disease, increased risk for infection
 Smoking and alcohol
3. IMMUNOSUPPRESIVE DRUGS  CAUSE : UNKNOWN
Should be given in combination with steroids to be  INCIDENCE
effective  Common among women, Caucasians and
Drug Name – cyclosporine, mercaptopurine Jewish population
Indication – to reduce inflammation
Adverse Effects – thrombocytopenia, leukopenia, PATHOPHYSIOLOGY AND CLINICAL
anemia, renal failure, infection, headache, MANIFESTATIONS
stomatitis, hepatotoxicity

4. ANTI-DIARRHEAL DRUGS – diphenoxylate HCl DIAGNOSTIC TESTS

and loperamide (imodium)
 Contrast studies
5. INFLIXIMAB (REMICADE)  Barium enema
given for refractory disease or for toxic megacolon  Colonoscopy
an immunoglobulin G that neutralizes activity of  Manometry and electromyography- to study
tumour necrosis factor intraluminal pressure changes that
generated spasticity
DIET THERAPY
NURSING INTERVENTIONS
If client has severe symptoms:  Administer anti-diarrheals, antispasmodics,
 NPO bulk-forming laxatives as ordered
 Total Parenteral Nutrition (TPN)  Encourage high-fiber diet and avoid fatty
and gas forming foods (carbonated
Avoid: beverages, cauliflower or beans)
 Whole-wheat grains  Instruct client to avoid alcohol and tobacco
 Nuts  Encourage to increase oral fluids intake but
 fresh fruits and vegetables should not be taken with meals because it
 lactose containing foods can result to distention.
 caffeinated beverages  Instruct on lifestyle changes (regular
 Pepper exercise, adequate rest periods, stress
 Alcohol management)
 smoking  Anticholinergics and Ca channel blockers

SURGICAL MANAGEMENT

INDICATIONS FOR SURGERY

 Bowel perforation DIVERTICULOSIS AND DIVERTICULITIS
 Toxic megacolon
TWO FORMS OF DIVERTICULAR DISEASE
 Hemorrhage
(1) DIVERTICULOSIS – asymptomatic multiple
 Colon cancer
out-pouching of the intestinal mucosa
 Failure of conventional treatment WITHOUT INFLAMMATION
 (2) DIVERTICULITIS – symptomatic multiple
out-pouching of the intestinal mucosa WITH ASSESSMENT
INFLAMMATION; causes retention of  Acute abdominal pain at RLQ or
hardened stool; 20% of patients with McBurney’s point (halfway between the
diverticulosis results to diverticulitis. umbilicus and the anterior iliac crest)
 Anorexia, nausea and vomiting
 Rigid and guarded abdomen
INCIDENCE  Blumberg sign (rebound tenderness)
 More common in older adults  Rovsign sign upon palpation LLQ pain in the
 More prevalent in men RLQ increases
PREDISPOSING FACTORS  Fever (temperature of 38-38.5 °C)
 Diet low in fiber  Psoas or Copes psoas or obraztsova’s Sign
 Diet high in refined carbohydrates (lateral position with right hip flexion)
 Decreased or absent bowel sounds
COMPLICATIONS
 Bowel perforation and peritonitis DIAGNOSTIC TESTS
 Bowel obstruction  WBC Count
 Hemorrhage o
Leukocytosis: WBC
 Shock above10,000/mm3
PATHOPHYSIOLOGY o
Perforation: suggested if WBC is
ASSESSMENT above 20,000/mm3
 Acute onset of crampy abdominal pain in  Ultrasound may reveal enlarged appendix
the left lower quadrant  Barium Enema or CT Scan
 Abdominal distention o
Ordered if symptoms are recurrent
 Low-grade fever or prolonged
 Chronic constipation with intervals of o
May reveal presence of fecalith
diarrhea
 Occult bleeding  Neuro-Spec imaging uses a technetium
 Nausea and vomiting labelled anti-CD 15 monoclonal antibody
 Leukocytosis that selectively binds to neutrophils at the at
injection site.
DIAGNOSTIC TESTS  Uses gamma camera
 Barium enema and colonoscopy  Diagnosis within 1 hour
(contraindicated if there is diverticulitis due
to the danger of perforation) MANAGEMENT
 Complete blood count – increase ESR and  Maintain patient on NPO for possible
WBC admission
 Urinalysis  Administer IV fluids as prescribed to prevent
 CT Scan – procedure of choice & can reveal fluids and electrolyets imbalance
abscess  Maintain patient in semi-Fowler’s position to
prevent upward spread of infection
NURSING INTERVENTIONS  DO NOT GIVE LAXATIVE NOR ENEMA to
 Instruct client to eat high-fiber foods prevent perforation of the appendix
 Encourage to increase fluids  DO NOT APPLY LOCAL HEAT to prevent
 Administer bulk laxatives and inflammation and perforation; instead apply
anticholinergics as prescribed COLD compress
 Encourage client to lose weight and avoid
activities that increase intra-abdominal SURGICAL MANAGEMENT
pressure such as straining at stool (valsalva
maneuver), vomiting, lifting, bending, lifting LAPAROSCOPY
or tight clothing  A small incision in the umbilicus is made
and a small endoscope is used to visualize
SURGICAL MANAGEMENT the appendix if diagnosis is not definitive
 Colon resection with temporary colostomy
LAPAROTOMY
APPENDICITIS  An open approach in which large abdominal
 Inflammation of the vermiform appendix incision is made
 More common in males 10-30 years of age
APPENDECTOMY
ETIOLOGY  Removal of the inflamed appendix
 Obstruction by fecal impaction, kinking of  Guided with laparoscopy
the appendix, parasites or infections  Done with spinal anesthesia
 Low fiber diet
 High intake of refined carbohydrates

PATHOPHYSIOLOGY NURSING CARE AFTER APPENDECTOMY

  Maintain client flat on bed for 6-8 hours o Oxygen if there is dyspnea due to
 Monitor for return of sensation in the lower ascites
extremities o Analgesics (meperidine or
 Maintain on NPO until peristalsis returns morphine)
 Instruct client to ambulate after 24 hours o Antiemetics (metoclopramide)
 Tell the client that he can resume normal  Monitor daily weight, intake and output to
activities within 2-4 weeks monitor fluid status
 Side lying with knees flexed to lessen pain
 NGT insertion to decompress the stomach
and intestine
PERITONITIS  Maintain client on NPO
 Inflammation of the peritoneum, the serous
membrane lining the abdominal cavity and SURGICAL MANAGEMENT
covering the viscera  Abdominal surgery guided by exploratory
laparotomy
TYPES OF PERITONITIS  Appendectomy if there is appendicitis
1. PRIMARY  Colon resection with or without colostomy if
acute bacterial infection resulting from there is bowel perforation
contamination of the peritoneum through the
vascular system NURSING CARE AFTER SURGERY
May occur from tuberculosis, cirrhosis and
ascites  Maintain patient in SEMI-FOWLER’S
2. SECONDARY POSITION to promote drainage of
bacterial invasion resulting from acute peritoneal contents and allow adequate lung
bacterial abdominal disorder expansion
May occur from gangrenous bowel, visceral  Perform PERITONEAL IRRIGATION as
perforation, bile leakage, blunt or penetrating prescribed
trauma(gunshot wound)
 Check for presence of abdominal distention
or pain (suggestive of irrigant retention)
CLINICAL MANIFESTATIONS
 Assess incision, dressing and drains
 RIGID, BOARDLIKE ABDOMEN
 Instruct client to AVOID LIFTING for at least
(CLASSIC SIGN)
6 weeks
 Abdominal pain diffuse and become
localized near the site of inflammation.
COMPLICATIONS
 Distended abdomen
 Sepsis- major cause of death
 Nausea, anorexia and vomiting
 Wound evisceration and dehiscence
 Diminishing bowel sounds
 Inability to pass flatus or feces HEMORRHOIDS
 Rebound tenderness in the abdomen  Dilated and painful veins in the rectum, anal
 High fever canal, inside or outside the anal sphincter
 Dehydration
 Oliguria CLASSIFICATIONS
 Hiccups  Internal – hemorrhoids ABOVE the anal
sphincter
DIAGNOSTIC ASSESSMENT  External – hemorrhoids BELOW the anal
 ELEVATED WBC: 20,000/MM3 sphincter
 Hgb and Hct may be low
 Altered levels of K+, Na +. Cl - RISK FACTORS
 Abdominal x-ray may show free air and  Familial tendency
fluid in the peritoneum  Straining at stool
 CT Scan or ultrasound - changes in  Prolonged sitting or standing
abdominal organs  Pregnancy , prolonged labor
 Peritoneal Lavage may reveal the following  Obesity
o WBC: 500/ml  Portal hypertension
o RBC: 50,000/ml  Anal intercourse
o Gram stain: (+) bacteria  Colon malignancy
o Culture reveals: E.coli, klebsiella,
proteus, pseudomonas PATHOPHYSIOLOGY
o If untreated can result to septic
shock and death ASSESSMENT
 Bleeding with defecation of hard stool and
MANAGEMENT pain – due to stretching and irritation of
 Administration of the following as prescribed mucosa
o IV fluids to replace lost fluids  External hemorhoids- extreme pain due to
(isotonic) thrombosis and edema ; appear reddish
o Broad spectrum antibiotics blue lump
  Internal hemorrhoids- not usually painful, PATHOPHYSIOLOGY
until it bleeds & prolapse when enlarged ;
some protrudes during defecation and SIGNS AND SYMPTOMS
retracts after defecation
DIAGNOSTIC TESTS
DIAGNOSTIC TESTS  Ultrasonography – Dx procedure of
 Digital rectal examination choice. Accurate,can be used even if pt liver
 Sigmoidoscopy dysfunction and jaundice. 95% stone
 Colonoscopy rules out colorectal CA detection
 Endoscopic Retrograde
NURSING INTERVENTIONS Cholangiopancreatography (ERCP)
 Instruct client on the importance of HIGH-  Visualization of gallbladder, cystic duct,
FIBER DIET and INCREASED FLUID common hepatic duct,and common bile
INTAKE duct.
 Instruct client to take STOOL SOFTENERS  IV cholangiogram- radiographic image of
and use ointments such as dibucaine, anti- the bile ducts that is obtained by
inflammatory, or astringents medication that cholangiography
causes contraction or constriction of  Prolonged Prothrombin time
tissues)  CBC - leukocytosis
 Apply ICE PACKS for several hours  Cholecystography ( gallbladder imaging) -
followed by warm packs
TYPES OF CHOLECYSTOGRAPHY
SURGICAL MANAGEMENT 1) ORAL – done 10 HOURS after administration of
 HEMMORHOIDECTOMY- removal of contrast medium
hemorrhoid 2) INTRAVENOUS – done 10 MINUTES after
Internal and external packing secured by a administration of contrast medium
T-binder
 Cryosurgery – application of extreme low
temperature to destroy or remove diseased ORAL CHOLECYSTOGRAPHY – radiographic
tissue (prolonged wound healing) examination of the gallbladder
 Rubber band ligation- internal
hemorrhoids PURPOSES OF ORAL CHOLECYSTOGRAPHY
( anoscope & small rubber band)
1) To detect gallstones
PREOPERATIVE CARE 2) Assess the ability of the gallbladder to fill,
 Advise low residue diet concentrate and store a dyelike, iodine –based
 Administer stool softeners radiopaque contrast medium.
 NURSING CARE AFTER
HEMORRHOIDECTOMY NURSING CONSIDERATIONS
 Watch out for bleeding
1) ASSESS FOR ALLERGIES to iodine, seafood,
 Place the client in PRONE OR SIDE-LYING
or contrast media
POSITION
2) Administer contrast medium 10-12 hours before
 Administer analgesics as prescribed x-ray study
 Administer stool softeners 3) Instruct patient to remain NPO AFTER TAKING
 Offer warm Sitz baths 3-4 times a day THE CONTRAST medium to prevent contraction
and emptying of the gallbladder
3) DEFER THE PROCEDURE IF PATIENT IS
Disorders Involving the Accessory Organs JAUNDICED!!!

CHOLELITHIASIS and CHOLECYSTITIS

PREPARING A PATIENT FOR
 CHOLELITHIASIS – STONE FORMATION CHOLECYSTOGRAPHY
in the gallbladder and accessory ducts  Instruct to have FAT FREE DINNER
 CHOLEDOCHOLITHIASIS- stone formed at  Place patient on NPO 2 HOURS BEFORE
the Common Bile Duct the test
 CHOLECYSTITIS – INFLAMMATION of the
gallbladder PREPARING A PATIENT FOR
CHOLANGIOGRAPHY
RISK FACTORS: 5F’s  ASSESS FOR ALLERGY TO IODINE!!!
 Female gender  Instruct to drink ample amount of fluids after
 Fat (Obesity) the procedure to promote excretion of dye
 Fair (Caucasian)  Instruct that a burning sensation and
 Forty (age) nausea can occur during dye administration.
 Fertile (multigravida; use of contraceptive
pills) NURSING CARE AFTER CHOLANGIOGRAPHY
 Check for HYPERSENSITIVITY REACTION
  Instruct client that excretion of dye would Pancreas
cause BURNING SENSATION during
urination  Large elongated accessory organ of
 NURSING INTERVENTIONS digestion
 Administer MEPERIDINE HCL (drug of  secretes bicarbonate and pancreatic
choice) as prescribed for pain relief enzymes aiding in the process of digestion
 AVOID ADMINISTERING MORPHINE!!! – (exocrine function- amylase,lipase,trypsin)
it may cause spasm of the sphincter of Oddi  contains the islets of Langerhans composed
 Use BAKING SODA or CALAMINE- of beta cell secreting insulin and alpha cells
CONTAINING LOTIONS for pruritus secreting glucagon
 Encourage LOW-FAT DIET
 Administer BILE SALTS such as PANCREATITIS
Chenodeoxycholic acid (chenodiol)or  Inflammation of the pancreas
Ursodioxycholic acid (UDCA) ursodiol  CAUSE is unknown; linked with
 Used to dissolve gallstone autodigestion

SURGICAL MANAGEMENT TYPES

 Cholecystectomy  Acute – vary from mild, self-limiting
disorder to severe, fatal and does not
PREOPERATIVE NURSING CARE respond to any treatment.
 Administer IV fluids to replace electrolytes - edema and inflammation confined to
 Administer vitamin K injection, especially if the pancreas
prothrombin time is prolonged as per  Chronic –continuous and prolong with
doctor’s order fibrosis

RISK FACTORS
POSTOPERATIVE NURSING CARE  Alcohol abuse
 Place patient in SEMI-FOWLER’S  MEDICATIONS: Antihypertensives,
POSITION to promote lung expansion diuretics, antimicrobials,
 NGT DECOMPRESSION to prevent gastric immunosuppresives, oral contraceptives
distention  GI DISORDERS: Biliary obstruction and
 LOW-FAT DIET for 2-3 months intestinal diseases
 Encourage ambulation after 24 hours
 Encourage to resume normal activities PATHOPHYSIOLOGY
within 2-3 days
 Monitor T-Tube if common bile duct ASSESSMENT
exploration was done
Other manifestation
 Grey Turner’s Spot or sign
T-TUBE INSERTION o Bluish flank discoloration
 Cullen sign
 Purpose: to DRAIN BILE o Bluish periumbilical discoloration

Drainage Characteristics
 It should be BROWNISH RED for the first DIAGNOSTIC TESTS
24 hours  Elevated serum and urinary amylase, serum
 It should be 300-500 ML for the first 24 lipase, serum bilirubin, alkaline
hours phosphatase, and sedimentation rate
 White blood cell count
Nursing Responsibilities  Fecal fat determinations
 Place drainage bottle or Jack son Pratt AT  Blood and urine glucose
THE LEVEL OF THE INCISION
NURSING INTERVENTIONS
Types of Colostomy  Administer MEPERIDINE HCL (DEMEROL)
 Ascending Colostomy as ordered
o On the right abdomen drainage is  AVOID MORPHINE SULFATE!!!
watery  Place client on NPO DURING ACUTE
 Transverse or Double barrel colostomy PHASE
o Right stoma- semi formed feces  bland, LOW-FAT DIET, LOW CHON, HIGH
o Left stoma-drains mucus CHO; avoid alcohol
 Descending and Sigmoid Colostomy  NGT DECOMPRESSION insertion to
o Well formed feces remove gastrin and prevent further
stimulation of the pancreas
 Administer CALCIUM SUPPLEMENTS
(WITH VITAMIN D) if there is hypocalcemia
  Administer INSULIN as ordered if there is  Elevated Aspartate Aminotrasferase (AST)
hyperglycemia (SGOT) 4.8-19U/L, Alanine Aminotrasferase
(ALT)(SGPT) 2.4-17 U/L, bilirubin TB- 0-
Surgical Management 0.9mg/dL
 Pancreatectomy - surgical removal of part  Prolonged prothrombin time (PT) (N) 11-16
or all of the part of pancreas seconds
 Decreased serum albumin
 CBC reveals anemia
 Serum ammonia = Normal: 150-250mg/dL,
LIVER CIRRHOSIS 10-80 ug/dl
 Irreversible chronic inflammatory disease
characterized by massive degeneration and PREPARING A PATIENT FOR ULTRASOUND OF
destruction of hepatocytes resulting in a THE LIVER
disorganized lobular pattern of regeneration  Place patient on NPO 8-12 hours before the
procedure
TYPES/CAUSES  Administer laxative a night before the test
(1) LAENNEC’S – caused by ALCOHOLISM or  Maintain adequate hydration
hepatotoxic drugs
(2) POST-NECROTIC – caused by viral PREPARING A PATIENT FOR LIVER BIOPSY
HEPATITIS or industrial hepatotoxins  Place patient on NPO 2-4 hours before the
(3) BILIARY – caused by BILIARY PROBLEMS test
(4) CARDIAC – caused by CONGESTIVE HEART
 ADMINISTER VITAMIN K
FAILURE (CHF)
 Monitor prothrombin time
 Position patient in LEFT LATERAL
HEPATITIS POSITION with pillow under right shoulder
 Instruct to HOLD BREATH 5-10 seconds
Types: during needle insertion
 Hepatitis A (HAV): Infectious H.
NURSING CARE AFTER LIVER BIOPSY
 Hepatitis B (HBV): Serum H.
 Turn the patient to sides q4 hours
 Hepatitis C (HCV): non-A, non-B/Post-
transfusion H.  Place on bed rest for 24 hours
 Hepatitis D (HDV): Delta H.  Monitor for signs of bleeding

PATHOPHYSIOLOGY NURSING INTERVENTIONS

 Place client on BED REST with bathroom
Portal Hypertension privileges
 Normal portal vein pressures range from 5–  Offer LOW-PROTEIN, HIGH
10 mm Hg. CARBOHYDRATES and vitamins (ADEK,
 Refers to elevated pressures in the portal B-complex)
venous system.  RESTRICT AMOUNT OF ORAL FLUIDS
 Venous pressure more than 5 mm Hg and eliminate alcohol intake
greater than the inferior vena cava pressure  Provide meticulous skin care
is defined as portal hypertension.  Monitor weight, intake and output and
ABDOMINAL GIRTH
ASSESSMENT  Assist in paracentesis if necessary
 Monitor for bleeding of esophageal varices
 ↓ vitamin K absorption → bleeding  Perform tap water or NSS enema as per
tendencies doctor’s order
 ↓ glycogen stores → hypoglycemia  Avoid giving aspirin (causes bleeding) and
 ↓ serum albumin → ↓ hydrostatic pressure sedatives (hepatotoxic)
→ edema and ascites
 ↓ bilirubin metabolism → hyperbilirubinemia MEDICATIONS FOR A PATIENT WITH
→ jaundice CIRRHOSIS
 Portal hypertension → esophageal varices, (1) ANTACID – to prevent GI bleeding
hepatomegaly (2) SPIRONOLACTONE (Potassium-sparing
 ↑ ADH → hyponatremia diuretic) – diuretic of choice to manage ascites;
does not cause hypokalemia
 ↑ serum ammonia → hepatic
(3) FUROSEMIDE – diuretic given if patient has
encephalopathy
hyperkalemia after prolonged use of spironolactone
 Spider nevi or angioma
(4) VITAMIN K – prevents bleeding tendencies
DIAGNOSTIC TESTS
(5) INTRAVENOUS ALBUMIN – to manage ascites
 LIVER BIOPSY (definitive test) and edema
 Abdominal x-ray (6) DUPHALAC (Lactulose) – reduces levels of
 Ct scan ammonia
 Endoscopy
(7) NEOMYCIN SULFATE – reduce colonic
bacteria responsible for ammonia formation

PREVENTION OF BLEEDING OF ESOPHAGEAL

VARICES
 Avoid Valsalva maneuver
 Avoid bending or stooping
 Avoid hot spicy foods
 Avoid lifting heavy objects

INTERVENTIONS FOR BLEEDING

ESOPHAGEAL VARICES
 Place patient in SEMI-FOWLER’S
POSITION to prevent aspiration
 Suction the mouth
 Perform gastric lavage with tap water
 Insert SENGSTAKEN-BLAKEMORE TUBE
 Administer IV fluids, blood transfusion as
ordered
 Administer VASOPRESSIN to constrict
splanchnic arteries

PREPARING A PATIENT FOR PARACENTESIS

 Ask to empty bladder to prevent puncture
 Check serum protein studies
 Place patient in sitting or upright position

NURSING CARE AFTER PARACENTESIS

 Check urine output
 Watch out for board-like abdomen (sign of
PERITONITIS)
 Monitor for signs of hypovolemic shock