APO REVIEW CENTER

Dr. Godfrey Franco

GASTROINTESTINAL 3. Digestion
DISORDERS  Breakdown (Most critical aspect)
o Mechanical (Chewing)
Medical-Surgical: o Chemical (Building blocks)
1. Human comfort  Intolerance
2. Oxygenation  Body cannot
3. Fluid and electrolyte Balance, Ionic concentration, pH breakdown food
4. Perception, Coordination, Ambulation chemically.
5. Metabolism  Example is
Lactose
Intolerance
Care of the Patients with Altered
Metabolism 4. Absorption
 Bioavailable
METABOLISM  Food in the bloodstream except FA and
1. Rate of metabolite use. lipids.
 Affected by:
o Age 5. Excretion
o Body Build  Most effective and efficient
 Determines efficiency of  Removal of waste products
metabolite use.  Passage of flatus and feces
 Ideal body weight.  Rebound propulsion seen in patients with
o Diet intestinal obstructions.
o Environment
 Warm: Faster metabolism STRUCTURE
 Cold: Slower metabolism 1. Upper GI Tract (Mouth to Stomach)
 Environmental  1st sign of problem in the UGIT
manipulation is an o Nausea and vomiting
independent nursing  2nd sign
action. o Heartburn
2. Balance between metabolic use and metabolic
storage. 2. Lower GI Tract (Intestines to Anus)
 Use = Storage  1st sign of problem in LGIT
 To determine: o Diarrhea
o Body weight o Constipation
o Adaptation (To heat and cold) o Absent movement
3. Process of biochemical responses.  2nd sign
 Diagnostics: o Pain
o Blood Glucose
o Enzymes 3. Accessory Organs (Secretion)
o Electrolytes  Enzymes (Pancreas)
4. Protective response = survival o Produced by demand
a. Liver  Bile (Liver)
b. Kidneys o Emulsifies fat
c. Adrenals (Modulation) o Excretion of excessive cholesterol
d. Pituitary (Modulation)  Hormones
 Acids
*Gastrointestinal = Endocrine*
 Lubricants
o Most significant = Mucin
FUNCTIONS OF THE GASTROINTESTINAL
SYSTEM General Considerations:
1. Ingestion 1. Assessment of GIT dysfunction.
 Most significant  What do you need to report?
 Controlled by the parasympathetic nervous  Warning signs:
system (ANS) reflex called HUNGER which o Call the physician if a warning sign
is triggered every 2 – 3 hours. is observed.
o Normal Therapeutic Intake: 1. Obstruction
 6 times a day  Pain
o 3 Major Meals (Not relieved by meds)
o Mandatory – Midnight Snack which  Bowel sounds
prevents wasting.  (Before obstruction)
o TPN  (After obstruction)
 Regulate every 6 hours.  Elimination
 Nursing Implications: o Change in pattern
o Maximum Therapeutic Intake = 6x o Diarrhea: Early
o No fasting Constipation: Intermediate
Absent: Severe
2. Propulsion o History of last defecation
 Ability of any part of the body to push 2. Perforation
products.  Pain “Sharp”
 Peristalsis.  Fever (Early sign of perforation)
o 1 way process.  Shock
o “Transit time” o “Slide” changes in VS
 Time it takes for the food  Temperature is the
to travel from the mouth first sign to slide
anus. 3. Failure
 24 – 72 hours.  Organ stops to function
 APO REVIEW CENTER
Dr. Godfrey Franco
 Cardinal sign: DEFICIT i. Antibiotics (TB drugs)
ii. NSAIDs (For arthritis)
2. Diet: “Regular” iii. Psych Medications (Need 6 weeks
 Complete: – 2 months to take effect)
o CHO
o CHON 5) Gender / Personality
o Fats  Gender: M>F
 Nutrient – Rich o Food selection
 Restrictions * o Stress management
o Only if it is ordered.  Personality
 Avoid fasting. o Type A – Rigid
o Not unless ordered. o Type B – Passive
o Type C – Combination
3. Encourage self-care.
 To foster INDEPENDENCE. ICD Volume 10
o If all choices are pertaining to self- A. GERD – initial
care, answer the choice with B. PUD
HYGIENE. a. Gastric
b. Duodenal
4. Medications (As ordered)
 Delivery / Precautions Pathophysiology:
o Most GI drugs are given alone. GASTRIC
1. Starvation
o Drugs to be given alone should
a.  HCl
have a grace period of 2 hours
apart. b.  Mucus lining
2. Irritation
 Monitor effects.
a. HCl continuously increases (Rebound)
o Side Effects
3. Build-up of Carbon Dioxide
 Decrease patient’s
4. Pressure accumulates in the cardiac sphincter
discomfort.
5. Reflux of gastric contents into the esophagus
 Physiologic reaction
6. GERD
 Ex. Rashes
o Adverse Effects
***CHN:
 Prevented. If GERD affects the client’s ADL, advise to seek medical
 Through familiarity of the consult.
medication by reading the
drug’s literature.
GASTRIC
 SAFETY 1. Ulcerogenic Diet
o Challenge physician if medication is
a.  Fat
deemed to be unsafe for the b. NSAIDs – irritant
patient.
2.  HCl
3. Hyperacidity
5. Community / Home-based Management
GASTRIC
1. Inflammation
HYPERACIDITY DISORDERS 2. Irritation
 Increased HCl 3. Imbalance in the normal flora of the GUT
  HCl =  pH 4.  HCl
5. Hyperacidity
General Risk Factors:
1) Lifestyle DUODENAL
a. Stress 1. Stress
b. Diet: Ulcerogenic 2. Production of Epinephrine
 Fatty & oily foods 3. Vasoconstriction of Duodenum
 Spicy 4. Premature emptying of Duodenum
 Caffeine 5. Duodenum – not build for acidic environment
 Raw preparations 6. Hyperacidity of Duodenum
c. Vices
 Smoking (Nicotine) Peptic Ulcer Disease
 Alcoholism (Aldehyde = Fat) Gastric Duodenal
d. Obesity “Poor man”
e. Self-medication*** “Stress”
“Traditional”
 Chronic use of NSAIDs
o Natural irritant of the Ulceration
stomach.  Membrane of mucosa is gradually removed.
2) Starvation
 Person who skips meals is in starvation 1. PAIN
 Exposed nerve-endings
3) Infections  Epigastric
 Helicobacter pylori
o Dormant Gastric Duodenal
 E. coli Pain IMMEDIATELY after
Pain DELAYED
ingesting food.
4) Iatrogenic 2 – 5 minutes 2 – 3 hours after eating
 Caused by medical interventions
a. NGT 2. INTOLERANCE
o Replaced every 3 days  Nausea
b. Mechanical ventilation  Vomiting
c. Chronic Drug Therapy  Diarrhea
 APO REVIEW CENTER
Dr. Godfrey Franco
o Esomeprazole
3. BLEEDING o Omeprazole
Gastric Duodenal  Totally inhibit gastric acid
Coffee-ground vomitus Black, tarry stools  Achlorhydia
Hematemesis Melena  Should be given alone.
 Short term basis only.
4. PERFORATION o Can lead to metabolic
5. SHOCK wastage.
o Not used more than 2
MANAGEMENT weeks
“Pillars of Management”  Encourage patient to eat (Patient
by DOH may have anorexia)
 Philippine Setting d. Coating Agents
o Hyperacidity  Examples:
o DM o Sucralfate
o MI o Amphogel
 Meant to be taken as a whole.
Pillars  Amphogel
1. LIFESTYLE MODIFICATION o Bitter
 Diet: o Tell pt to ingest very fast.
o Regular but restrict ulcerogenics. o Use with caution among
  Vices stone formers.
 Weight management. e. Cytoprotective Agents
o Slowly  Enhance healing
o 6 weeks  Example:
 Minimum timeframe for o Misoprostol (Cytotec)
weight modification.  Misoprostol is a highly-regulated
 Health Education medication.
o Barrier: Source of Information o Look for S2
 If belief is beneficial  It is abortifacient.
 ALLOW
 If belief is harmful 3. SURGERY
 INTERVENE a. Vagotomy
o Feedback  Surgical resection of vagus nerve.
 Measure of effectiveness  Contraindicated to patients with
 Psychomotor arrhythmia.
 Can explain/demonstrate  Nursing care:
o Assess heart rate.
2. MEDICATIONS  <60 – report
a. Antacids o WOF diaphragmatic
 Neutralization of HCl irritation. Report.
 Does not cure.  Hiccup
 Example: Maalox  Cough
o Should be given alone. b. Pylorotomy
o Use with caution among:  Surgical resection of pylorus.
 Stone formers  Nursing care:
 Arrhythmias o Splinting when coughing.
 Neuromuscular o Maintenance of abdominal
Pathologies incision.
Parkinsons o Incision is transverse.
MS o Taping should always
MG follow the anatomical line
GBS of the organ.
CVA 
 SE:

o Constipation
c. Billroth Procedure
Al-based  Billroth I
o Diarrhea o Gastroduodenostomy
Mg-based
 Billroth II
 Meant to be swallowed as a whole
o Gastrojejunostomy
(Solid form)
Post-surgery:
 Best given with meals.
 Assess NGT. Never accept post-
b. H2-Receptor Inhibitors
billroth procedure pt. without NGT.
 Examples:
 Modify feeding plan/procedure.
o Cimetidine
o High-fowler’s when
o Famotidine
feeding.
o Ranitidine o Supine after feeding.
 Should be given alone.  Observe for
o H2-blockers BEFORE residue.
antacid.  >30 cc – report
o Reduce before neutralize. o If with diarrhea, replace
 If given orally, meant to be taken as volume by volume.
a whole.  Inform that they will have difficulty
 If parenterally, observe platelet gaining weight for the rest of their
count because it could cause  lives.
platelets.
c. Proton-pump Inhibitors
 Example:
 APO REVIEW CENTER
Dr. Godfrey Franco
INTESTINAL OBSTRUCTION o Avoid spicy and gas-
 Always considered as a “surgical emergency”. forming foods
 Comfort
Functional factors: o Never palpate for
1. Tumors tenderness unless
2. Foreign Body ordered.
o Seeds of fruits. o Ask pt. to flex and report if
3. Adhesions*** there is any tenderness.
o Products of injury. c. NPO
o Any pt. with a history of abdominal surgery is  Designated time frames of NPO***
at risk.  Prevent aspiration.
o Abdominal infections.
 Typhoid. 2. Post-surgical care
 Hepa a. Assess for bleeding
 AGE  Covert
 Abdomen
Biological factors:  1st sign: ANXIETY
1. Parasites b. Wound care
a. Ascariasis.  Initial dressing maintained for 24
2. Volvulus o Best: any member of
a. Hyperactive bowel sounds surgical team.
b. Twisting. o Not unless there is
3. Intussusception bleeding.
a. Telescoping.  Beyond 24, floor nurses can
perform regular wound care.
Congenital factors:  Changing of dress:
1. Merkel’s Diverticulum o NCLEX: 12
o 1% probability (Filipinos)
o PI: 24 or PRN
 Maintain asepsis.
Neurogenic factors:
o Handwashing.
1. Paralytic ileus
2. Neurogenic shock c. Deep breathing exercises / Coughing
exercises
 Splinting technique
LUMINAL OBSTRUCTION d. Spirometry
Pathophysiology
 Force lung expansion.
1. Interruption of intestinal flow.
 Splinting technique
2. Increase in the rate of peristalsis.
3. Diarrhea (Early sign of obstruction)  Achieve 500 – 700 ml
a. Watery  10 good breaths in 1 hour in a
b. Will not persist more than 24 hrs. day cycle
4. Gradual remodification of peristaltic activity. e. Ambulation
a.  BS – before  Early ambulation
b.  BS – after  As soon as they regain
5. Neurogenic reflex consciousness in the room, within
6. Reverse peristalsis 24
a. Pass out flatus/feces in the mouth  Guidelines***
7. Nausea/Vomiting of fecaloid material. f. Pain management
8. Incarcerated obstruction  Do not let pt. walk without pain
9. Pain due to spasm or damaged tissues. meds.
10. Shock: Circulatory  Best time to give pain meds:
o Anticipatory
Secondary manifestations: o Before pain, give drug.
 Anorexia  Round-the-clock
  Abdominal Girth g. Diet
 Fever***  Non-irritating
o Septic shock o Less oil, not spicy, no gas
formers
Management:  How long?
1. Prepare for surgery - Resection and anastomosis o At 6 weeks, once stoma
a. Insert an NGT (To decompress abdomen) has been closed, patient
 Fecaloid material can return to regular diet.
 Decrease in abdominal girth. h. Activity
b. Inform pt. about Colostomy  Can perform any activity except
 Permanency: Temporary SWIMMING.
Concerns:  Need to empty colostomy bag
 Placement before activity.
o Assess! o 1/3 full – empty
o Priority i. Sexual activity
 Color  Right away, can resume.
o Red, pinkish, skin tone  As long as it is a
o Color change – 6 weeks physiological need and
 Elevation would not harm patient.
o Decrease everyday after ii. Occupation
surgery  NCLEX: 6-18 weeks
o Maximum – 6 weeks  Local: 6 weeks can
 Output resume activity in earliest
o Feces possible time.
o Flatus iii. Danger signs
 APO REVIEW CENTER
Dr. Godfrey Franco
 Signs and symptoms of o Home management
obstruction.
 Initial – DIARRHEA 3. Activity
 WPL – within physical limitations
CHOLELITHIASIS
Risk factors: 4. Lifestyle modification
Primary:  Diet**
1. Fat  Increase OFI
 Most significant factor o Usual + 500-1000 ml
2. Forty  Follow up
 Slow metabolism o Within 1st year of surgery
 Stone-former  Every 3 months
3. Female o Beyond first year
4. Fertile  PRN

Secondary: PANCREATITIS
1. Vices  Inflammation of one lobe of the pancreas
2. Sedentary activity
3. Pathologic factor ACUTE
a. Typhoid fever  History of alcoholism (Chronic, intense)
b. Hepatitis  Heavy meal
4. Malignancy
o Pressure exerted on pancreas
Pathophysiology  Diet
o Fat
1. Bile stasis
o Spicy
 Produced gradually and consistently
Has 3 components: (Aqueous State) o Processed
 Bile pigments  Position
 Bile salts o Supine – most dangerous
 Cholesterol o Exert pressure against pancreas
2. Precipitation  Substance Concoction
 Process of natural separation of a o Wrong mixtures
component of a mixture. o Antidepressants with alcohol
3. Sedimentation  Trauma
 Formation of a mud-like structure which o Retroperitoneal
will lead to more bile stasis which
becomes a cycle. CHRONIC
4. Calcification  Alcohol
 1st to leave – water  Inflammation
o Making it more dry  Tumor ***
 Calcium goes in, water moves out  Spasm
5. Obstruction  Stone formation
 Cycle goes on.
 Decrease delivery of bile *Insidious bleeding, minimal.
6. Fat intolerance
 Nausea Pathophysiology
 Vomiting 1. Irritation, increased pressure, obstruction
 Diarrhea 2. Increased pancreatic secretion
7. Pain 3. Lobular distention
 Ischemia due to blockage. 4.  Pancreatic enzyme use
 Pain will only appear after HIGH fat  General intolerance (nausea, vomiting,
intake. diarrhea)
 Quality 5. Distention will aggravate cause
o Debilitating 6. Lobular distention will stimulate pancreas to 
o 1 hr after eating high fat secretion, which becomes a cycle.
 Radiation: 7. AUTODIGESTION – tissues burned
8. Intense abdominal pain
o Right flank
 Caused by any type of intake
 After heavy meal
Management:
1. Surgery – CHOLECYSTECTOMY 9. Bleeding (Often accompanies pain)
a. Assess patency of drain  Twillight signs
 T-tube o Cullen’s:
o Wolfian:
 1st 24
 Assess when pt. is lying down.
o Surgical debris 10. May lead to shock.
 Beyond 24
o Bile Management:
Acute
b. Diet 1. Surgery
 NCLEX: Low fat a. Whipple’s Procedure
 Local: DAT  Focused on damage of
autodigestion.
2. Pain management
 Meperidine (Demerol) Chronic
o No spasmodic changes 1. DOC: Pancrease
o Given PRN a. Oral form
b. Capsule
o WOF Dependence
c. Not given directly to the mouth.
 NSAID d. Do NOT give it alone.
 APO REVIEW CENTER
Dr. Godfrey Franco
i. May cause autodigestion of the
mouth.
e. Give with something such as:
i. Juices that are acidic
1. Kalamansi
2. Orange
3. Pineapple
4. Cranberry
ii. Soup
1. Homogenous soup
a. Broth
b. Meat soup (Beef)
f. Teach to effectively blot dry the mouth.

2. Analgesic
a. Don’t give morphine.
b. Meperidine (Demerol)

3. Lifestyle Modification
a. Diet:
i. DAT but decreased intake
ii. SFF
b.  Alcohol
i. Encourage the benefits/good
effects.
c. Discourage self-medication
i. Wrong combination = pancreatitis
4. Warning Signs
a. Intense pain
b. General intolerance

*Chronic – only with home-based management