NUR 149 (CARE OFCLIENTS WITH PROBLEM

IN NUTRITION, AND GASTRO-INTERNAL,

METABOLISM AND ENDOCRINE,
STUDENT ACTIVITY SHEET PERCEPTION AND COORDINATION, (ACUTE
AND CHRONIC))
BS NURSING / SECOND YEAR
Session # 1 (2 hours and 30 minutes)

LESSON TITLE: REVIEW OF SYSTEM (DIGESTIVE Materials:

SYSTEM); DIAGNOSTIC EVALUATION; PAROTITIS; Book, pen and notebook, projector
SIALADENITIS; SALIVARY CALCULUS

LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can: References:
1. Review the anatomy and physiology of the gastrointestinal
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.
system
(2008). Brunner &Suddarth’s Textbook of
2. Identify the risk factors.
Medical-Surgical Nursing 11th Edition.
2. Recognize common signs and symptoms.
Lippincott Williams &Wilkins
3. Identify the diagnostic tests and medical management of the
disorder/s.

SUBJECT ORIENTATION & GETTING TO KNOW EACH OTHER ACTIVITY (30 minutes)
A. You will now take note everything about the subject orientation.

1. Calendar of activities
2. Classroom rules and regulations
3. Computation of grades
4. Grading of modules
5. Election of officers
6. Requirements

B. Answer the following, write your answers in the spaces provided.

The Digestive Tract Quadrants of the Abdomen

a. __________
1. ___________ b. __________
2. ___________ c. __________
3. ___________ d. __________
4. ___________
5. ___________
6. ___________
7. ___________
8. ___________
9. ___________
10. __________
11. __________
12. __________

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 Regions of the Abdomen
1. __________________
2. __________________
3. __________________
4. __________________
5. __________________
6.
__________________ 7.
__________________ 8.
__________________ 9.
__________________

MAIN LESSON (1 hour and 25 minutes)

Read and study these lessons (Chapters 34 and 35 of the book).

Chapter 34
DIAGNOSTIC EVALUATION

A. Serum Laboratory Studies

1.CBC
2. Liver function test
3. Amylase and lipase
4. Carcinoembryonic antigen (CEA)
- to determine the stage and extent of the disease and the prognosis for those with cancer, especially GI and, in
particular, colorectal cancer
5. 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, lung, and gall- bladder cancers;
gallstones; pancreatitis; cystic fibrosis; and liver disease.
6. Alpha-fetoprotein – for liver cancer

B. Stool Test
- Random specimens should be sent promptly to the laboratory for analysis; however, the quantitative 24- to 72-
hour collections must be kept refrigerated until trans- ported to the laboratory.

Fecal occult blood (FOBT)

- is 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 program. Red meats, aspirin, nonsteroidal anti-
inflammatory drugs, turnips, and horseradish should be avoided for 72 hours prior to the study, because they
may cause a false-positive result. Also, ingestion of vitamin C from supplements or foods can cause a false-
negative result.

C. Breath Test
1. Hydrogen Breath Test
Evaluates carbohydrate absorption, in addition to aiding in the diagnosis of bacterial overgrowth in the
intestine and short bowel syndrome.

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 2. Urea Breath Test
Detects the presence of Helicobacter pylori, the bacteria that can live in the mucosal lining of the stomach
and cause peptic ulcer disease.

Nursing Intervention
Avoid antibiotics or loperamide (Pepto Bismol) for 1 month before the test; sucralfate (Carafate) and omeprazole
(Prilosec) for 1 week before the test; and cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac) for 24
hours before the test.

D. Abdominal Ultrasonography
Nursing Interventions
1. Instruct the patient to fast for 8 to 12 hours before the test to decrease the amount of gas in the bowel.
2. If gallbladder studies are being performed, the patient should eat a fat- free meal the evening before the test.
3. If barium studies are to be performed, they should be scheduled after ultrasonography; otherwise, the barium
could interfere with the transmission of the sound waves.

E. Imaging Studies
1. Upper Gastrointestinal Tract Study
An upper GI fluoroscopy delineates the entire GI tract after the introduction of a contrast agent
(radiopaque liquid: barium sulfate). 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. The procedure may be extended to examine the duodenum and
small bowel (small bowel follow- through).

Nursing Interventions
Before:
a. Clear liquid diet, with nothing by mouth (NPO) from midnight the night before the study.
b. Advise to avoid smoking, chewing gum, and using mints because they can stimulate gastric motility.
c. Withhold oral medications on the morning of the study and resumed that evening.
d. When a patient with insulin-dependent diabetes is on NPO, his or her insulin requirements will need to be
adjusted accordingly.
After:
Fluids may be increased to facilitate evacuation of stool and barium.

2. 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.

Nursing Interventions
Before:
a. Assess the patient for allergy to iodine or contrast agent.
b. Empty and cleanse the lower bowel.
- low-residue diet 1 to 2 days before the test
- clear liquid diet and a laxative the evening before
- NPO after midnight
- cleansing enemas until returns are clear the following morning
After:
a. Increase fluid intake.
b. Evaluate bowel movements for evacuation of barium.
c. Note for increased number of bowel movements (barium may draw fluid into the bowel, thus increasing the
intraluminal contents and resulting in greater output).

Contraindications: Active inflammatory disease of the colon; Signs of perforation or obstruction; Active GI bleeding

3. Computed Tomography
CT provides cross-sectional images of abdominal organs and structures. Multiple x-ray images are taken

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 from numerous angles, digitized in a computer, reconstructed, and then viewed on a computer monitor. The
procedure is completely painless, but radiation doses are considerable. CT may be performed with or without oral
or intravenous (IV) contrast, but the enhancement of the study is greater with use of a contrast agent.

Nursing Interventions
Before:
a. Assess the patient for allergies to contrast agents, iodine, or shellfish
- Patients allergic to the contrast agent may be pre- medicated with IV prednisone 24 hours, 12 hours,
and 1 hour before the scan.
b. Assess the patient’s current serum creatinine level
c. Determine the patient’s urine human chorionic gonadotropin.

Before and after:

a. Administrater IV sodium bicarbonate 1 hour before and 6 hours after IV contrast.
b. Administer oral acetylcysteine (Mucomyst) before or after the study.

Both sodium bicarbonate and Mucomyst are free radical scavengers that sequester the contrast
byproducts that are destructive to renal cells.

4. Magnetic Resonance Imaging

MRI is used in gastroenterology to supplement ultrasonography and CT. It is useful in evaluating
abdominal soft tissues as well as blood vessels, abscesses, fistulas, neoplasms, and other sources of bleeding.
Any ferromagnetic objects (metals that contain iron) can be attracted to the magnet and cause injury. Items that
can be problematic or dangerous include jewelry, pacemakers, dental implants, paperclips, pens, keys, IV poles,
clips on patient gowns, and oxygen tanks.

Contraindications: Patients with permanent pacemakers, artificial heart valves and defibrillators, implanted insulin
pumps, or implanted transcutaneous electrical nerve stimulation devices, internal metal devices (aneurysm clips),
intraocular metallic fragments, or cochlear implants.

Nursing Interventions
Before:
a. NPO status 6 to 8 hours.
b. Remove all jewelry and other metals.
c. Remove foil- backed skin patches (NicoDerm, nitroglycerine [Transderm-Nitro], scopolamine [Transderm-
Scop], clonidine [Catapres-TTS])
d. Inform the patient and family:
- that the study may take 60 to 90 minutes
- he close-fitting scanners used in many MRI facilities may induce feelings of claustrophobia
- the machine will make a knocking sound during the procedure
- patients may choose to wear a headset and listen to music or to wear a blindfold during the procedure

F. Endoscopic Procedures
1. Upper Gastrointestinal Fibroscopy/ Esophagogastroduodenoscopy
Fibroscopy of the upper GI tract allows direct visualization of the esophageal, gastric, and duodenal
mucosa through a lighted endoscope (gastroscope). EGD is valuable when esophageal, gastric, or duodenal
disorders or inflammatory, neoplastic, or infectious processes are suspected.

Nursing Interventions
Before:
a. NPO for 8 hours.
b. The patient is given a local anesthetic gargle or spray.
c. Administer Midazolam (Versed) to provide moderate sedation and relieve anxiety.
d. Administer Atropine to reduce secretions, and glucagon to relax smooth muscle.
e. Position the patient in left lateral position to facilitate clearance of pulmonary secretions and provide smooth
entry of the scope.
f. Use a finger or ear oximeters to monitor oxygen saturation.
g. Supplemental oxygen may be administered if needed.

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 h. The patient wears a mouth guard to keep from biting the scope.
After:
a. Assess the patient’s level of consciousness, vital signs, oxygen saturation, pain level, and monitoring for signs
of perforation (pain, bleeding, unusual difficulty swallowing, and rapidly elevated temperature).
b. After the patient’s gag reflex has returned, offer lozenges, saline gargle, and oral analgesic agents to relieve
minor throat discomfort.
c. Remain patients who were sedated in bed until fully alert.
d. After moderate sedation, the patient must be transported home with a family member or friend if the
procedure was performed on an outpatient basis.

2. Fiberoptic Colonoscopy
Direct visual inspection of the large intestine (anus, rec- tum, sigmoid, transcending and ascending colon)
is possible by means of a flexible fiberoptic colonoscope This procedure is used commonly as a diagnostic aid
and screening device. It is most frequently used for cancer screening (Chart 34-3) and for surveillance in patients
with previous colon cancer or polyps. In addition, tissue biopsies can be obtained as needed, and polyps can be
removed and evaluated.

Nursing Interventions
Before:
a. Adequate colon cleansing provides optimal visualization and decreases the time needed for the procedure.
- laxative for 2 nights before the examination and a Fleet’s or saline enema until the return is clear the
morning of the test
- more commonly, polyethylene glycol electrolyte lavage solutions (Go-LYTELY, CoLyte, and Nu-Lytely)
are used as intestinal lavages for effective cleansing of the bowel
- the patient maintains a clear liquid diet starting at noon the day before the procedure
- a sodium phosphate tablet (Osmoprep, Visicol) can be used for colon cleansing
b. Patients with prosthetic heart valves or a history of endocarditis require prophylactic antibiotics before the
procedure.
c. Informed consent is obtained before sedation.
d. Administer an opioid analgesic or sedative agent (midazolam [versed]) to provide moderate sedation and
relieve anxiety
e. Glucagon may be administered to relax the colonic musculature and to reduce spasm during the test.
f. Position the patient on the left side with the legs drawn up toward the chest.
During:
Monitor the patient for changes in oxygen saturation, vital signs, color and temperature of the skin, level of
consciousness, abdominal distention, vagal response, and pain intensity.
After:
a. Maintain the patient on bed rest until fully alert.
b. Monitor the patient for signs and symptoms of bowel perforation (rectal bleeding, abdominal pain or
distention, fever, focal peritoneal signs).
c. Provide written instructions, because the patient may be unable to recall verbal information.
d. If the procedure is performed on an outpatient basis, someone must transport the patient home.
e. Instruct the patient to report any bleeding to the physician.
Contraindications: With suspected or documented colon perforation; Acute severe diverticulitis; or Fulminant
colitis

3. Anoscopy, Proctoscopy, and Sigmoidoscopy

Endoscopic examination of the anus, rectum, and sigmoid and descending colon is used to evaluate
chronic diarrhea, fecal incontinence, ischemic colitis, and lower GI hemorrhage and to observe for ulceration,
fissures, abscesses, tumors, polyps, or other pathologic processes. Biopsies and polypectomies can be
performed during this procedure.

Nursing Intervention
Before: Place the patient on the left side with the right leg bent and placed anteriorly.

Chapter 35
PAROTITIS

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 Parotitis (inflammation of the parotid gland) is the most common inflammatory condition of the salivary
glands. Mumps (epidemic parotitis), a communicable disease caused by viral infection and most commonly
affecting children, is an inflammation of a salivary gland, usually the parotid.

High Risk
1. Children; Elderly
2. Acutely ill or debilitated people with decreased salivary flow from general dehydration or medications

Causative Agent
Staphylococcus aureus (except in mumps)

Clinical Manifestations
1. Fever
2. Swollen, tender glands
3. Ear pain
4. Red and shiny overlying skin
5. Difficulty in swallowing

Medical Management
1. Adequate nutrition, fluid intake, and good oral hygiene.
2. Discontinue medications (tranquilizers, diuretics) that can diminish salivation.
3. Antibiotic therapy and Analgesics

Surgical Management
Parotidectomy

SIALADENITIS
An inflammation of the salivary glands.

Causes
1. Dehydration
2. Radiation therapy
3. Stress; Malnutrition
4. Salivary gland calculi (stones)
5. Improper oral hygiene

Causative Agents
1. S. aureus
2. Streptococcus viridans, or pneumococci
3. In hospitalized or institutionalized patients: Methicillin-resistant S. aureus (MRSA)

Clinical Manifestations
1. Pain
2. Swelling
3. Purulent discharge

Medical Management
1. Antibiotics
2. Corticosteroids
3. Massage, hydration, and warm compresses

Surgical Management
Surgical drainage of the gland or excision of the gland and its duct for chronic and uncontrolled pain

SALIVARY CALCULUS (SIALOLITHIASIS)

Sialolithiasis, or salivary calculi (stones), usually occurs in the submandibular gland. They are formed
mainly from calcium phosphate.

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Education (Department of Nursing) 6 of 10
 Clinical Manifestations
1. Swollen, tender gland
2. Palpable stone
3. With obstruction: sudden, local, and often col- icky pain, which is abruptly relieved by a gush of saliva

Diagnostic Test
Salivary gland ultrasonography or sialography – to demonstrate obstruction of the duct by stenosis

Medical Management
1. Stone extraction
2. Lithotripsy - a procedure that uses shock waves to disintegrate the stone. Lithotripsy requires no anesthesia,
sedation, or analgesia. Side effects can include local hemorrhage and swelling.

Surgical management
Removal of the gland for repeated recurrence

CHECK FOR UNDERSTANDING (15 minutes)

You will answer and rationalize this by yourself. Superimpositions or erasures in you answer/ratio is not allowed. You are
given 15 minutes for this activity.

Multiple Choice
1. You’re performing an abdominal assessment on Brent who is 52 y.o. In which order do you proceed?
A. Observation, percussion, palpation, auscultation
E. Observation, auscultation, percussion, palpation
F. Percussion, palpation, auscultation, observation
G. Palpation, percussion, observation, auscultation
ANSWER: ________
RATIO:___________________________________________________________________________________________
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_________________________________________________________________________________________________

2. While palpating a female client’s right upper quadrant (RUQ), the nurse would expect to find which of the following
structures?
A. Sigmoid colon
B. Appendix
C. Spleen
D. Liver
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. A female client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse
writes down which instruction for the client to follow before the test?
A. Fast for 8 hours before the test
B. Eat a regular supper and breakfast
C. Continue to take all oral medications as scheduled
D. Monitor own bowel movement pattern for constipation
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. Which diagnostic test would be used first to evaluate a client with upper GI bleeding?
A. Endoscopy
B. Upper GI series

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Education (Department of Nursing) 7 of 10
C. Hemoglobin (Hb) levels and hematocrit (HCT)
D. Arteriography
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

5. A patient complains about an inflamed salivary gland below his right ear. The nurse documents probable inflammation
of which gland/s?
A. Buccal
B. Parotid
C. Sublingual
D. Submandibular
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. Parotitis caused by bacteria is treated with which of the following drug classifications?
A. Analgesics
B. Corticosteroids
C. Antipyretics
D. Antibiotics
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. Which of the following are the possible causes of sialadenitis? Select all that apply.
A. Dehydration
B. Stress
C. Dental extraction
D. Improper oral hygiene
E. Frequent ingestion of cold beverages
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. A patient asks, “Is surgery always the treatment of choice for inflamed salivary glands?” Your best response would be:
A. Yes, surgery is always the answer.
B. Surgery is only recommended for children.
C. Elderly is not a candidate for parotidectomy.
D. The procedure is advised for chronic sialadenitis and uncontrolled pain.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

9. Which of the following conditions described as presence of calculi in the salivary glands?
A. Parotitis
B. Sialolithiasis
C. Sialadenitis
D. Mumps
ANSWER: ________

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Education (Department of Nursing) 8 of 10
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. Which of the following medical management is recommended for salivary calculus?
A. Lithotripsy
B. Antibiotic therapy
C. Nephrectomy
D. Endoscopy
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:________________________________________________________________________________________
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2. ANSWER: ________
RATIO:________________________________________________________________________________________
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3. ANSWER: ________
RATIO:________________________________________________________________________________________
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4. ANSWER: ________
RATIO:________________________________________________________________________________________
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5. ANSWER: ________
RATIO:________________________________________________________________________________________
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6. ANSWER: ________
RATIO:________________________________________________________________________________________
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7. ANSWER: ________
RATIO:________________________________________________________________________________________
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8. ANSWER: ________
RATIO:________________________________________________________________________________________
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9. ANSWER: ________
RATIO:________________________________________________________________________________________
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10. ANSWER: ________

RATIO:________________________________________________________________________________________
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LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

DJ Summary

Write the things you have learned in this lesson in the form of a favorite song.
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