Responses to Metabolic-Gastrointestinal ● Use abdominal percussion to

and Liver Alterations determine the size and

location of abdominal organs
1. Understanding the GI System and detect excessive
Assessment: accumulation of fluid and air.
a. Health History ● Begin percussion in the right
Current health Status lower quadrant and proceed
● Pain clockwise covering all four
● Heartburn quadrants
● Nausea ● Use direct or indirect
● Vomiting percussion
● Altered bowel habits ● Abdominal palpation includes
Previous Health Status light and deep touch to
● Ulcer determine the size, shape,
● gallbladder disease position and tenderness of
● inflammatory bowel major abdominal organs and
● Disease to detect masses and fluid
● GI bleeding accumulation
Family History
● Ulcerative colitis Eliciting Abdominal Pain
● Colon cancer ● Rebound tenderness
● Stomach ulcers ● Iliopsoas sign
● Diabetes ● Obturator sign
● Alcoholism
● Crohn’s Disease 3. Assessing the liver
Lifestyle Pattern ● Percussing the liver allows you to
● Occupation estimate the size
● Home life ● Hepatomegaly is commonly
● Financial status associated with hepatitis and other
● Stress level liver disease
● Recent life ● Percussing the liver
● Changes
4. Assessing the rectum
Physical Examination ● Perform a rectal examination
1. Assessing the mouth ○ First inspect the perianal
2. Assessing the abdomen area
● Before inspecting the ○ ask the patient to strain, this
abdomen, mentally divide it may reveal internal
into 4 quadrants hemorrhoids, polyps or
● Auscultation provides fissure
information about bowel ● Palpate the rectum
motility and the underlying
vessels and organs
 - Inborn errors of metabolism (End stage
Diagnostic Tests liver disease, PPU)
● Esophagogastrodoudenoscopy - Those who have “taning”
(EGD) - Inability of therapies that offer long-term
survival
● Colonoscopy
- Those who do not have
● Endoscopy
contraindications/comorbidities (cardio-
pulmonary disease)
Laboratory Tests - Those who don’t have cancer
● Liver-Spleen Scan - Those who don’t have AIDS/STD’s
● MRI - No experience or history of chronic
● Fecal Analysis alcoholism/ drug addiction
● Percutaneous Liver Biopsy
● Peritoneal Fluid Analysis LeVeen Shunt Insertion (PVS-
Peritoneovenous shunt)
- From peritoneum connecting between
TREATMENTS:
the peritoneum cavity and the systemic
Drug therapy:
venous circulation
 Ammonia detoxicants
- Ascitic fluid is drain from abdominal
- Lactulose
cavity into the superior vena cava
- This device is use to control ascites
 Antacids
using LeVeen tube
- Aluminum hydroxide
- Magnesium hydroxide
Complications:
- Calcium carbonate
- Leakage of the ascitic fluid from the
incision
 Antidiuretic hormone
- Wound infection
- Vasopressin
- Subcutaneous bleeding (continuous
bleeding, patient may develop DIC or
 Antiemetics Disseminated intravascular coagulation-
- Dolasetron which is common in OB)
- Metoclopramide
Gastrointestinal Intubation
 Histamine-2 Receptor Antagonists  Nasoenteric
- Famotidine - Insertion of tube from mouth to small
- Ranitidine intestine
 Nasogastric
 Proton pump Inhibitors - Mouth to stomach
- Lansoprazole
- Omeprazole - How to measure: tip of nose, to tip of
pinna, to xiphoid process)
SURGERY: - Small intestine (Alkaline) = determine by
Liver Transplantation checking the pH, when still acid and the
- Life threatening liver problem litmus paper turns to red- acid; when
- Those who do not respond to any blue= alkaline (meaning the tube is in
treatments the duodenum)
Patients’ candidate to have liver transplantation: - Washing/ aspirating stomach contents=
- Congenital biliary abnormalities GASTRIC LAVAGE
- Chronic hepatitis - Feeding (GASTRIC GAVAGE)
 2. Minnesota esophagogastric tamponade
TYPES OF NG TUBES: tube
1. Levin tube
- One entry port
- For feeding or aspirating

2. Salem sump tube

- Used in ICU and CCU
- Has y-connector (pig tail)
- Allows atmospheric air to enter the
stomach
- Yung blue kay like pigtail which allows
atmospheric air to enter pt’s stomach.
So the tip of salem sump tube is just
float or nasa gitna so there is no
potential na makainjure sya stomach - 4 lumen/ entry ports
- - 2 balloons for: gastric balloon
inflammation (elongated balloon- for
MULTILUMEN ESOPHAGEAL TUBE esophageal balloon; the other balloon is
PLACEMENT for gastric balloon)
- Has many entry-ports - 1 lumen= pressure monitoring port
- For emergency - 1 lumen= gastric balloon inflammation
- One entry port is for inflating the balloon - 1 lumen= gastric aspiration lumen part
- There are a lot of entry port wherein ang - 1 lumen= esophageal aspiration lumen
isang entry port kay sa inflating balloon - 1 lumen= esophageal balloon pressure
para pag may ruptured varices sa end monitoring port
part of esophagus to be used as - 1 lumen= esophageal balloon-inflation
esophageal tamponade lumen

1. Linton tube
3. Sengstaken-blakemore tube
- 3 entry ports
- Lower part of tube has balloon (for
compression when there is bleeding
- 1 port= gastric balloon inflation
- 1 port= for esophageal aspiration
- 1 port= gastric aspiration

- 3 entry ports
- Prevent bleeding
- Monitor patient for any signs and
symptoms of bleeding
- 1 lumen= gastric inflation
- 1 lumen= esophageal inflation
- 1 lumen= gastric aspiration
Complication: - Catheter is directly inserted into the
- Necrosis of tissue (has frequency of central venous line (superior vena cava_
inflating and deflating given by the via subclavian vein
physician)
2. Peripheral parenteral nutrition
NASOENTERIC DECOMPRESSION TUBE - Inserted in periphery
- Use to aspirate intestinal contents for - Full calorie needs
analysis or to correct intestinal - To minimize risk of infection and
obstruction complication

1. Miller- Abbott Tube

COMMON GI DISORDERS:

1. Acute GI bleeding
2. Acute pancreatitis
3. Bowel infarction
4. Liver cirrhosis
5. Hepatic failure and encephalopathy
6. Intra-abdominal hypertension
- Has 2 entry port (one for suction; the
other is for bag inflation)

2. Dennis sump tube

NUTRITIONAL SUPPORT
Enteral (by mouth)
- Via NGT, nasoenteric tube or
gastrostomy tube

Parenteral nutrition
- Food is given via IV
- Expensive, high caloric intake
- Monitor blood sugar kasi pwede mag
shoot up ang sugar; be alter of
hyperglycemia

Types:
1. Total parenteral nutrition
- Lipids, amino acids
RESPONSES TO ALTRED PERCEPTION
Anatomy and Physiology 2 MAJOR GROUPS OF NERVES
Function of Nervous System 1. Cranial nerves
- Provide rapid communication and integration - 12 pairs of nerves
between various organs, as well as with the - From base of the brain and relay
outside environment. information between the brain and the
- It detects changes within the body and in its head and neck regions
surroundings, and responds accordingly. - CN X (vagus): internal organs
- Fast communication is achieved by means of
electrical signals known as nerve impulses,
2. Spinal nerves
which are generated and carried by specialized
- 31 pairs arise from segments of the
cells, called neurons
spinal cord and innervate the trunk and
Major Components of the Nervous System limbs
 Brain - Communicate with the brain via spinal
- Enclosed and protected in the cranium cord
- Central processing center - Mixed nerves
- it receives information, makes decision
and coordinates the body response
PERIPHERAL NS
 Somatic
 Spinal cord - Includes sensory nerves from the skin,
- Enclose in the spinal column muscles, bones and joints and motor
- Functions as a communication gateway nerves that innervate skeletal muscles
between the brain and the trunk and - Control voluntary muscular contractions
the limbs as well as involuntary somatic reflexes

 Nerves  Visceral
- Cordlike structures that conduct - Includes sensory division that detects
information, similar to electricity- changes in the viscera like the organs
conducting wires in the thoracic and abdominal cavities
- Composed of axons of neurons, the and motor division that controls cardiac
cell bodies of which are clustered in muscle, smooth muscle of internal
know-like structures called ganglia organs and glands
- Ganglia commonly serve as relay - It produces, for example faster heart
centers, where neurons synapse and rate and breathing rate during physical
transmit information to each other exercise, and slower cardiorespiratory
rate during sleep
CNS : brain and spinal cord
PNS: nerves and ganglia Autonomic NS, acting independently of the body’s
consciousness and voluntary control
Sensory Nerve Fibers
- Carry sensory information from sensory Neurologic Assessment
receptors to CNS  Health History
- Patients current state of health
- Ask reason of hospitalization; chief
Motor Nerves complaint
- Conduct instructions from the CNS to effector - Common complaint: headache, any
organs like muscle and glands motor disturbance like weakness in
upper/ lower extremities or presence
Mixed Nerve
paresis/ paralysis, complaints of
- Both sensory and motor
 seizure, sensory deviation or any  Abnormal
altered LOC extension
- Previous health status  None
- Head injury r/t accidents, history of
major illnesses, surgeries , allergies
- Speech
- Lifestyle
- Slurred speech
- Smoking, drug addiction, education
level, occupation, hobbies
- Family’s health - Cognitive Functions
- Family history of disease like cardiac, - Consider educational level
renal disease, hypertension, cancer, - Test memory: remote and recent
mental disease etc. - Assess orientation
 Physical Examination - Attention span
- Mental Status
- 3 Parameters : Assess LOC, speech,
cognitive functions - Cranial Nerve Functions
- LOC - 12 cranial nerves
- 4 levels: alert, obtunded/lethargic,  Olfactory
stuporous, coma  Optic
1. Alert- oriented, follow command,  Oculomotor
immediately responds, completely  Trochlear
and appropriately responds to any  Trigeminal
stimuli (verbal/pain)  Abducens
2. Obtunded/lethargy – drowsy but  Facial
delayed response to verbal  Acoustic/vestibulocochlear
stimuli, sleep again  Glossopharyngeal
3. Stuporous – respond to pain  Vagus
stimuli, need vigorous stimuli for  Spinal Accessory
patient to respond  Hypoglossal
4. Comatose- totally no response - Checking brain stem function
- Tool used GSC- Glasgow coma scale o Oculocephalic reflex
 Eye opening response (4)  Doll’s eye – eye goes to the
 Spontaneous, eye side where the head is
opening to speech, turned, or no movement of
pain, none eyes.
 Verbal response (5)  NORMAL: eyes move to the
 Oriented opposite side.
 Confused  Indicates: deep coma, severe
 Inappropriate brain stem damage
words - Oculovestibular reflex
 Incomprehensible  Instilling of ice or cold water
words in the ear
 Normal: eye movement is
 None
goes to the instilled ear
 Motor response (6)
 Before checking, assess that
 Immediately when
there is no ear infection and
asked
tympanic membrane is intact
 Localizes
because to prevent infection
 Withdraw and additional injury to the
 Abnormal flexion patient’s ear
(decerebrate,
decorticate)
  If the patient is conscious  Lifting of the
there is nystagmus(kadali) testicles : indicates
 Comatose, brain stem intact L1, L2
lesions – no movement
- Pupils sizes
- PERRLA
 Pupils are Equal, Round,
Reactive to Light and
Accommodation
- Sensory Function
- Check or assess the ability or function
of sensory receptors to detect stimuli
- Test 5 sensations
 Pain
 Light touch
 Vibration
 Position
- Motor Functions
Deep Tendon
- Aid in evaluating in different structures
0 – absent
in the neuro like cerebral cortex,
corticospinal tracts, muscles, 1+ - present reflex but nawawala
cerebellum, and nasal ganglia 2+ - normal
- Assess the muscular parts like 3+ - increased reflexes
resistance of muscle to passive 4+ - hyperactive
stretching, arm muscle movement, leg Superficial reflexes
movement, weakness of the periphery  Abdomen - 0 or 1+
- Test balance: Romberg’s Test
Diagnostic Tests
- Reflexes
 Imaging Studies
- Assess the deep tendon reflex and
o Computed Tomography Scan
superficial reflexes to assess the
o Magnetic Resonance Imaging
integrity of the sensory receptor organs
o Positron Emission Tomography Scan
- Testing the Deep tendon reflex
 This provides the colorimetric
 Biceps
information about the brain’s
 Triceps
metabolic activity
 Brachioradialis
o Skull and Spinal X-rays
 Pattelar
 Achilles tendon reflex  Angiography
- Superficial reflexes o Uses radio optic contrast medium
 Pharyngeal reflex  Check if the patient is allergic
 Gag reflex to iodine or shellfish
 Abdominal reflex o Cerebral angiography
 Test the thoracic o Digital subtraction angiography
spinal segments  Highlights the cerebral blood
(T8,9,10) vessel
 Cremasteric Reflex  Uses fluoroscopy
 Test the lumbar  Computer aided
area (L1,L2)  Uses dye to see if there are
blood clots, emboli,
 Tongue blade to
aneurysm
scratch the inner
 Electrophysiologic studies
part of the thigh
o Electroencephalography (EEG)
  Records the brain’s electrical  For cerebral edema
activity o Diuretics
 Used to diagnosed patients o Thrombolytics
with seizure activity, brain  Surgery
injury, intracranial lesion or o Craniotomy
any masses, tumors, TIA, to  Surgery commonly involves
rule out if patient is brain opening the skull and expose
dead. the brain
o Evoked Potential Studies (EPS)  Indicated for ventricular
 Used to measure the nervous shunting, excising tumors or
system electrical response to abscess, aneurysm for
visual, auditory or sensory aneurysm tapping
stimulus  Patient are at risk for
 Other Tests infections, hemorrhage,
o Lumbar Puncture respiratory compromise and
 Common in spinal anesthesia increased ICP
 2 positions:  Signs and Symptoms for
 Fetal position (llie increased ICP:
down)  Vomiting
 Knees are flexed  Nausea
(sitting)  Headache
 Used for CS  Increased BP
 Aspirate of CSF (increase- systolic;
 Indicated to detect blood in decrease –
the CSF or for CSF analysis, diastolic)
used to inject dye for any  Widening pulse
radiologic studies pressure
 Contraindicated to patients  Change of mental
with lumbar deformity and for status
patients with infection in the o Restlessn
puncture site ess
 Used in caution for patients o Confusio
with increased ICP
n
o Transcranial Doppler Studies
o Seizure
 Visualize the blood flow in
 Shall breathing
the cerebral arteries
 If not managed pt
 Provides the information for
will go to coma
the presence, quality, and
o Cerebral aneurysm repair
nature of blood flow in the
brain  Clipping of aneurysm
 Other Treatments
o Barbiturate Coma
Treatments  Conventional treatment
 Medication Therapy  Injecting high IV dose of
o Analgesics short acting barbiturate
o Anticonvulsants  Pentobarbital
o Anticoagulants and antiplatelets  Reduce the patient’s
o Barbiturates metabolic rate and cerebral
o Benzodiazepines blood flow
 ULTIMATE GOAL: relieve
o Calcium channel blockers
increased ICP and protect
o Corticosteroids
cerebral tissue
  Risky 2. Jacksonian seizure
 Last resort 3. Sensory seizure
INCREASED ICP 4. Complex partial seizure
- Increased ICP is defined as a 5. Secondarily generalized partial seizure
sustained elevation in pressure above 6. Generalized seizure
20mmHg 7. Absence seizure/petit mal seizure
- ICP<15mmHg – Intracranial 8. Myoclonic seizure
hypertension 9. Clonic seizure
 Acute 10. Tonic seizure
 Chronic 11. Generalized clonic-tonic seizure
12. Atonic seizure
Levels ICP in mmHg
Normal 5-15
Mild 16-20
Moderate 21-30
Severe 31-40
Very Severe 41 & Above

 Cerebrospinal fluid drainage

o Insertion of tube or catheter to drain if
there is presence of infection in the
CSF or hydrocephalus
o Goal is to the reduced ICP to desired
level and maintain
o Fluid is drawn from the lateral ventricle
 Procedure is ventriculostomy
 Plasmapheresis
o Blood from the patient flows in the cell
from formed elements
o Separates plasma and plasma will be
filtered to remove toxins, O2 antibodies

Common Disorders
 Acute Spinal Cord Injury
 Arteriovenous malformation
o Arteries are dilated and tangled
o Usually in cerebral blood vessels
 Cerebral aneurysm
 Encephalitis
 Guillain-Barre Syndrome
o Muscle weakness
o Peripheral nerves are demyelinated
o Autoimmune and progressive
 Head injury
o Contusion
o Concussion
 Meningitis
 Stroke
 Seizure

Types of Seizure
1. Partial seizure