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401 PREFINALS • Dysphagia

ANEURYSM Diagnostic Tests

Aneurysm - is a localized • Chest X-ray

sac or dilation formed at a • Computed Tomography Angiography
weak point in the wall of (CTA)
the artery. • Transesophageal Echocardiography

Medical Management

• Control Blood Pressure

• Correcting Risk Factors

Pharmacologic

• Beta blockers
• Metoprolol
Etiologic Classification of Arterial Aneurysms • Carvedilol
• Congenital • Angiotensin Receptor Blockers (ARBs)
• Mechanical (hemodynamic) • Valsartan [Diovan]
• Traumatic (pseudoaneurysms) • Irbesartan [Avapro])
• Inflammatory (noninfectious)
• Infectious (mycotic) Surgical Management
• Pregnancy-related degenerative
• Anastomotic (post-arteriotomy) and graft • Endovascular Grafts Placed
aneurysms Percutaneously
• Thoracic endografts

A. Thoracic Aortic Aneurysm (TAA) B. Abdominal Aortic Aneurysm (AAA)

occurring in the aorta
- occurring in a part of the aorta running through the abdomen
running through the chest
- the walls of aorta become weak
and the part of aorta nearer to the
heart enlarges

Clinical Manifestations

• Back, neck or substernal pain

• Dyspnea, stridor or brassy cough
if pressing on trachea
• Hoarseness
Clinical Manifestations
• Aphonia
• Edema of the face and neck
▪ Patients with (AAA) feel their
• Distended neck vein
heart beating in their abdomen
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when lying down When an abdominal aortic aneurysm measured at
least 5.5 cm (2 in) wide or was enlarging, the
▪ Client’s awareness of a pulsating mass in standard treatment had been open surgical repair
the abdomen, with or without pain, of
followed by abdominal pain and back the aneurysm by resecting the vessel and sewing
a
Aortic calcification noted on x-ray bypass graft in place.
• Mild to severe mid abdominal or lumbar
back pain
• Cool, cyanotic extremities if iliac arteries
are involved

Claudication (ischemic pain with

exercise, relieved by rest)

• Complication: peripheral emboli to lower

extremities

• Rupture and hemorrhage

Assessment Nursing Management

• A pulsatile mass in the • Anticipating a rupture

middle and upper abdomen. • patient may have
• A systolic bruit may be cardiovascular, cerebral,
heard over the mass. pulmonary, and renal
impairment
Diagnostic Findings • Asses all organ systems
• Duplex ultrasonography • Vital signs and Doppler assessment
every 15 minutes
• Computed Tomography Angiogram • Assess for bleeding, pulsation,
swelling, pain, and hematoma
Gerontologic Considerations formation
• Skin changes of the lower extremity,
• Occurs between 60 and 90 lumbar area, or buttocks

Pharmacologic Therapy Dissecting Aorta

• Antihypertensive agents -Occasionally, in an aorta

• Diuretics diseased by arteriosclerosis, a
• Beta blockers tear develops in the intima or the
• ACE inhibitors media degenerates, resulting in a
• ARBs dissection

Endovascular and Surgical Management

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Clinical Manifestations

• Sudden onset of symptoms

• Severe and persistent pain
• The pain is in the anterior chest or Clinical Manifestations
back and extends to the shoulders,
epigastric area, or abdomen The six Ps
• Increased BP
• Pain
• Pallor
Diagnostics Findings • Pulselessness
• Paresthesia
• Arteriography • Poikilothermia (coldness)
• Multidetector-Computed • Paralysis
Tomography Angiography Diagnostic Findings
(MDCTA)
• TEE • transthoracic echocardiogram (TTE)
• duplex ultrasonography
• chest x-ray
• MRA • electrocardiography (ECG)
• Noninvasive duplex
Arterial Embolism and • Doppler ultrasonography
Arterial Thrombosis

• Acute vascular occlusion may be caused by

Medical management
an embolus or acute thrombosis.
• Acute arterial occlusions may result from
• Heparin therapy
iatrogenic injury, which can occur during -an initial IV bolus of 60 U/kg body
insertion of invasive catheters such as weight is given, followed by a
those used for arteriography, PTA or stent continuous infusion of 12 U/kg/h
placement, or an intra-aortic balloon pump, until the patient undergoes
or it may occur as a result of IV drug abuse. endovascular treatment or surgery.
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•is a situation in which blood pressures are
extremely
elevated and must be lowered immediately (not
necessarily to less than 140/90 mm Hg) to halt or
prevent
damage to the target organs (Chobanian et al.,
2003;
Rodriguez et al., 2010).
• Conditions associated with a hypertensive
emergency
Nursing management
include hypertension of pregnancy, acute
myocardial
• Patient remains on bed rest
infarction, dissecting aortic aneurysm, and
• Vital signs are taken initially
intracranial
every 15 minutes
hemorrhage.
• Collaborates with the primary
provider
Assessment will reveal actual or developing
clinical
HYPERTENSIVE CRISIS
dysfunction of the target organ.

A hypertensive crisis is a sudden, severe

• Hypertensive emergencies are acute, life
increase in blood pressure.
threatening blood
➢ The blood pressure reading is 180/120
pressure elevations that require prompt treatment
millimeters of mercury (mm Hg) or greater. in an
➢ A hypertensive crisis is a medical intensive care setting because of the serious
emergency. It can lead to a heart attack, target organ
stroke or other life-threatening health damage that may occur.
problems.
The therapeutic goals are reduction of the mean
blood pressure by 20% to 25% within the first
hour of treatment, a further reduction to a goal
pressure of about 160/100 mm Hg over a period
of up to 6 hours, and then a more gradual
reduction in pressure over a period of days.

PHARMACOLOGY

• The medications of choice in hypertensive

emergencies are those that have an
immediate effect.
Intravenous vasodilators:
❖ sodium nitroprusside (Nitropress),
❖nicardipine hydrochloride (Cardene),
❖clevidipine (Cleviprex),
Hypertensive Emergency ❖fenoldopam mesylate (Corlopam),
❖enalaprilat,
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❖nitroglycerin ❑ACE inhibitors (i.e., captopril [Capoten])
• These medications have immediate actions that ❑alpha2-agonists (i.e., clonidine [Catapres])
are short-lived
(minutes to 4 hours), and they are therefore used ❖Extremely close hemodynamic monitoring of the
for initial patient’s
treatment. blood pressure and cardiovascular status is
required during
Other Medical Management: treatment of hypertensive emergencies and
• Experts also recommend assessing the urgencies.
individual’s fluid volume status. ❖The exact frequency of monitoring is a matter of
• If there is volume depletion secondary clinical
to natriuresis caused by the elevated judgment and varies with the patient’s condition.
blood pressure, then volume ❖Taking vital signs every 5 minutes is appropriate
replacement with normal saline can if the blood
prevent large sudden drops in blood pressure is changing rapidly; taking vital signs at
pressure when antihypertensive 15- or 30-
medications are administered minute intervals in a more stable situation may be
(Rodriguez et al., 2010). sufficient.
❖A precipitous drop in blood pressure can occur
that would
HYPERTENSIVE URGENCY
require immediate action to restore blood
pressure to an
• Describes a situation in
acceptable level.
which blood pressure is
very elevated but there is
no evidence of impending
or progressive target
organ damage (Chobanian
et al., 2003).

❑Elevated blood pressures

associated with severe headaches,
nosebleeds, or anxiety are
classified as urgencies.
❑In these situations, oral agents can
be administered with the goal of
normalizing blood pressure within
24 to 48 hours (Rodriguez et al.,
2010).

PHARMACOLOGY
•Oral doses of fast-acting agents are
recommended for the treatment of
hypertensive urgencies. ARRHYTHMIA
❑beta-adrenergic blockers (i.e., labetalol
[Trandate]), Arrhythmias are
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disorders of the heart 40-60
Rhythm. • VENTRICULAR=
20-40
PR Interval

REPRESENTS TIME FROM

THE BEGINNING OF ATRIAL
DEPOLARIZATION TO THE
BEGINNING OF
VENTRICULAR
DEPOLARIZATION,
MEASURED FROM THE
BEGINNING OF THE P WAVE
TO THE BEGINNING OF THE ASSESSMENT
QRS COMPLEX (O.12-O.20)
-ECG
QRS Complex
-24h Holter monitor
REPRESENTS THE
LENGTH OF TIME FOR -ASSESSMENT
DEPOLARIZATION OF
THE VENTRICULAR -Echocardiogram
MUSCLE AND IS
MEASURED FROM THE -Stress test
BEGINNING OF THE QRS
COMPLEX TO THE END -Coronary angiography
OF THE S WAVE,
SHOULD MEASURE -Electrophysiology study
BETWEEN 0.06-0.10
SECONDS IN DURATION

REPRESENTS THE TOTAL

LENGTH OF TIME FOR
VENTRICULAR MUSCLE TO
BE DEPOLARIZED AND
REPOLARIZED, MEASURED
FROM THE BEGINNING OF
THE QRS COMPLEX TO
THE END OF THE T WAVE,
NORMAL RANGE IS 0.32-
Determine the rate.
0.42
Rhythm regular/ irregular?
Inherent Rates
Find the P wave.
Determine the PR interval
• SA= 60-100
• AV JUNCTION=
Find the QRS
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Any ectopic beats?

Find the T wave.

TREATMENT

• Ca-channel blockers-
Diltiazem

• B-blockers-Propanolol

TREATMENT

• treat the underlying cause

• atropine
• isuprel
• artificial pacing
• prevent further vagal stimulation
• withhold the B-blocker

Arrhythmias-
Disturbance in Conduction

∙ Rate is dependent on the basic rhythm. If the

basic rhythm is sinus,
the rate is constant between 60-100bpm
∙P wave is followed by a QRS complex
∙P-R interval is greater than 0.12 sec. and constant
from beat to beat
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∙ QRS Complex duration is 0.12 sec. or less. Every a. Description.
QRS complex is
preceded by a P wave Multiple, disorganized
∙ Rhythm is regular contraction of the

Arrhythmias- Re-entry of Impulse ventricles.

ATRIAL FIBRILLATION b. Management.
The immediate institution of
CPR while waiting for
defibrillation

Rate is above 300 (300-600) per minute with a Nursing Management

chaotic rhythm.
∙ P wave are non-identifiable, only fibrillatory • Monitor V/S
waves • Assess skin, lung & heart sounds,
∙ P-R interval not measurable peripheral pulses
∙ QRS Complex duration is 0.1 sec. or less • Monitor laboratory studies
∙ Rhythm is irregularly irregular, i.e. irregular with • Give antidysrhythmic & sedative
no medications as ordered
specific pattern Maintain quiet environment
• Administer O2 as prescribed
• Elimination of tobacco, alcohol,
caffeine & other stimulants

Medical Management

• Medications

• IV Fluids
• Bed rest
Atrial Flutter • O2 therapy

Transcutaneous & transvenous

pacing
• Vagal stimulation
• Electrical & Chemical Cardioversion
∙ Rate: 250-400 bpm. • Radiofrequency Ablation
∙ P-wave “saw-tooth” appearance, are known
as Ventricular Asystole
F or flutter waves
∙ P-R Interval is not measurable
∙ QRS Complex duration is 0.1 sec. or less
∙ Rhythm may be regular or irregular

Ventricular Fibrillation
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RESPONSES TO METABOLIC- GASTROINTESTINAL
AND LIVER ALTERATIONS

Anatomy and Physiology

Liver
- Largest organ accessory on the GI
- Metabolizes food, drugs and other by
products
- To amino acids and lipids
Stomach - Produces bile to emulsify fats
 Cardia Pancreas
 Fundus - Exocrine and Endocrine gland
 Body - Exocrine- amylase- CHO-Trypsin- and
 Pylorus Chymotrypsin- CHON- Lipase-fats
Chief Cells - Endocrine- insulin- absorb glucose-
 The gastric chief cell (also known as a glucagon- control blood sugar
zymogenic cell or peptic cell) is a cell in the Physical Assessment
stomach that releases pepsinogen (Inactive
form) and chymosin History:
G-cells secrete gastrin - Gastrin stimulates Abdominal pain
 parietal cell to secrete hydrochloric acid. Dyspepsia
 Parietal Cell – Secrete Hydrochloric Acid Nausea
Mucin Cell – Secrete mucus to help protect Vomiting
 the stomach cell from hydrochloric acid. Diarrhea
Phases of Gastric Secretion Constipation
1. Cephalic Phase – Triggered by sight, smell Fecal incontinence
because of the food presence. Stimulates Jaundice
the vagus nerve. Previous GI disease
2. Gastric Phase – Stimulates by stretch
receptors to release gastric Acid. Inspection:
3. Intestinal Phase – triggered by the release Oral Cavity
of food containing digestive proteins Lips
released in the proximal small intestine. Gums Tongue
Abdominal Quadrant
Inspection: 7S
Symmetrical and movement with respiration. Scar
Striae
Stoma
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Shape of the umbilicus Pyloric stenosis is a narrowing of the opening
Shape of the flank (full, straight) from the stomach to the first part of the small
Skin lesions intestine.

Striae Pigmentation
- Silvery white linear marked about 1-6cm in
pregnant and obese individuals.
- Striae in Cushing’s Syndrome is usually
purple or blue in color.

Shape of the umbilicus

Grey Turner sign is a discoloration of the left flank

associated with acute hemorrhagic pancreatitis.
Shape of the flank

Cullen sign is a hemorrhagic discoloration of the

umbilical area due to intraperitoneal hemorrhage
from any cause; one of the more frequent causes
is acute hemorrhagic panniculitis.

Inspection: 1D
Inspection: 4P
Distention
Prominent veins
Flat
Pulsation visible
Fluid-filled
Peristalsis visible
Fetus (Pregnant) Flatus (Air-filled) Fecal
Pigmentation

Inspection:
Prominent veins
Contour: Flat to round
Caput Medusa
Symmetry: symmetric; note for bulging, masses or
- It is the appearance of distended and engorged
asymmetry
superficial epigastric veins, which are seen
Umbilicus: midline, inverted and no discoloration
radiating from the umbilicus across the abdomen.
Skin: smooth and even in color
Pulsation visible
Contour: Xiphoid to symphysis pubis
Aortic Aneurysm
- It is a balloon-like bulge in the aorta, the large
artery that carries blood from the heart through
the chest and torso.

Peristalsis visible
Intestinal obstruction
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Abdominal Bluge - Stool samples are usually collected on a
- When the patient is in supine position, the random basis unless a quantitative study is
flank is bulging. to be performed.
- Possible causes: - Quantitative 24- to 72-hour collections
- Hernias must be kept refrigerated until transported
- Lipomas to the laboratory.
- Hematomas Fecal occult blood testing (FOBT)
- Undescended Testicles - Guaiac Test
- Tumors - One of the most commonly performed stool
Auscultation: tests.
- Bell: bruit sound Diaphragm: Bowel Sound - It can be useful in initial screening for
- N: 5 – 30 times per min several disorders, although it is used most
- Peristalsis – downward movement of the frequently in early cancer detection
intestine. programs.
- An occasional borborygmus (loud - It should not be performed when there is
prolonged gurgle) may be heard. hemorrhoidal bleeding.
Auscultation: Bowel sound: - Patients were advised to avoid ingesting
- Normoactive - red meats, aspirin, nonsteroidal anti-
- Hypoactive – less than 5times/min inflammatory drugs, turnips, and
Hyperactive – loud, high pitched Absent – horseradish for 72 hours prior to the study
listen for at least 5mins because it was thought that these were
Percussion: associated with false-positive results
- Dullness: Organ like liver, Fluid, Feces - Patients were advised to avoid ingesting
Tympanic: Gas vitamin C from supplements or foods as
Palpation: it was believed that this was associated
- Light: swelling Deep: masses with false-negative results.
Rectal Inspection and Palpation - Increase Fiber intake
- anal canal is approximately 2.5 to 4 cm (1 to 1.6 Fecal Immunologic Test (FIT)
inches) in length the internal and external - Use monoclonal or polyclonal antibodies to
sphincters inspection for lumps, rashes, detect the globin protein in human
inflammation, excoriation, tears, scars, pilonidal hemoglobin.
dimpling, and tufts of hair at the pilonidal area - An antibody that binds to a blood protein
pilonidal cyst, perianal abscess, or anorectal called
fistula or fissure, rectal prolapse, polyps, and - hemoglobin is used to detect any blood
internal hemorrhoids. - Only one fecal stool sample is required
- Dietary restrictions are not required prior
Diagnostic Examination to submission of the stool specimen.
Stool Tests Stool DNA Testing
- Inspecting the specimen for consistency, - relatively new means to detect certain DNA
color, and occult (not visible) blood. related to colon cancer.
- Additional studies: fecal urobilinogen, fecal - The stool DNA test does not require any
fat, nitrogen, Clostridium difficile, fecal dietary or medication restrictions and can
leukocytes, calculation of stool osmolar detect neoplasia anywhere in the colon.
gap, parasites, pathogens, food residues, Non-Invasive Breath Test
and other substances, require laboratory - - Hydrogen breath test was
evaluation. developed to evaluate carbohydrate
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absorption, in addition to aiding in the ● Food and drinks: One hour before the test,
diagnosis of bacterial overgrowth in do not eat or drink anything (including
the intestine and short bowel syndrome. water).
Non-Invasive
Hydrogen Breath Test: Instruction
● Eating a low carbohydrate diet for a couple
of days.
● Avoid foods that may produce gas in the
intestinal tract which could cause
inaccurate test results.
● Breath tests can be done any time before a
colonoscopy prep, but not for four (4)
weeks after a colonoscopy prep, or any test
that requires a bowel prep. Non-Invasive Urea Breath Test
Non-Invasive ● After the procedure
Hydrogen Breath Test: Instruction • Breath samples are sent to the laboratory
● Patient will drink a solution of lactose, where they are tested.
fructose, sucrose, or glucose in water. • May resume normal activities.
● After drinking the solution, pt will be asked • No restrictions.
to breathe into a plastic bag. Abdominal Ultrasonography
● Breath samples are obtained every 15 - A noninvasive diagnostic technique in
minutes for adults, and every 30 minutes which high frequency sound waves are
for children. passed into internal body structures, and
● The breath sample will be analyzed for the ultrasonic echoes are recorded on an
hydrogen content to determine if you are oscilloscope as they strike tissues of
able to properly break down the lactose or different densities.
sucrose, or if you have bacterial - It is particularly useful in the detection of
overgrowth. an enlarged gallbladder or pancreas, the
Non-Invasive Breath Test presence of gallstones, an enlarged ovary,
● Urea breath tests detect the presence of an ectopic pregnancy, or appendicitis.
Helicobacter pylori. Non-Invasive
● the bacteria that can live in the mucosal Abdominal Ultrasonography
lining of the stomach and cause peptic - It is used to look at organs and blood
ulcer disease. vessels in the abdomen:
Non-Invasive - Liver
Urea Breath Test: instruction - Gallbladder
• Four weeks before the test, do not take any - Spleen
antibiotics or Pepto-Bismol® (oral bismuth - Pancreas
subsalicylate). - Kidneys
• Two weeks before the test do not take any - Inferior vena cava
over-the-counter or prescription proton - Aorta
pump inhibitors, such as omeprazole Abdominal Ultrasonography
(Prilosec®), lansoprazole (Prevacid®), - Avoid food and drinks (fast) for eight to 12
pantoprazole (Protonix®), rabeprazole hours before an abdominal ultrasound.
(AcipHex®) or esomeprazole (Nexium®),
dexlansoprazole (Dexilant®).
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- Before the abdominal ultrasound, patient - Instruct regarding dietary changes prior to
will change into a hospital gown and to the study should include a clear liquid diet,
remove any jewelry. with nothing by mouth (NPO) from midnight
- After the procedure, patient will be able to the night before the study.
return to normal activities immediately. - Do not smoke or chew gum during the NPO
Non-Invasive: Nursing Intervention period because these can increase gastric
Abdominal Ultrasonography secretions and salivation.
- If gallbladder studies are being performed, - Bowel cleansing preparatory agent:
the patient should eat a fat-free meal the Polyethylene glycol (PEG)-based solutions
evening before the test. - Oral medications are withheld on the
- If barium studies are to be performed, they morning of the study and resumed that
should be scheduled after ultrasonography. evening, but each patient’s medication
- Patients who receive moderate sedation regimen should be evaluated on an
are observed for about 1 hour to assess for individual basis.
level of consciousness, orientation, and - When a patient with insulin dependent
ability to ambulate. diabetes is NPO, their insulin requirements
Non-Invasive: Fluoroscopy will need to be adjusted accordingly.
Upper Gastrointestinal Tract Study - Follow-up care is provided after the upper
- An upper GI fluoroscopy delineates the GI procedure to ensure that the patient has
entire GI tract after the introduction of a eliminated most of the ingested barium.
contrast agent. - Fluids may be increased to facilitate
- A radiopaque liquid (e.g., barium sulfate) is evacuation of stool and barium.
commonly used thin barium, diatrizoate Minimally Invasive: Blood Study CBC
sodium (Hypaque) and at times water are Comprehensive Metabolic Panel
used due to their low associated risks. - to conduct a broad assessment of various
- AKA Barium Swallow aspects of physical well-being.
- The GI series enables the examiner to - It can detect a range of abnormalities in
detect or exclude anatomic or functional blood sugar, nutrient balance, and liver and
disorders of the upper GI organs or kidney health.
sphincters. - Glucose, Calcium, Sodium, Potassium,
- It also aids in the diagnosis of ulcers, Bicarbonate, Chloride, Blood urea nitrogen
varices, tumors, regional enteritis, and (BUN), Creatinine, Albumin, Total protein,
malabsorption syndromes. Alkaline phosphatase (ALP), Alanine
- Fluoroscopic examination next extends to aminotransferase (ALT), Aspartate
the stomach as its lumen fills with barium, aminotransferase (AST), Bilirubin
allowing observation of stomach motility, Serum Blood study
thickness of the gastric wall, the mucosal Prothrombin time/Partial thromboplastin time
pattern, patency of the pyloric valve, and - is a test used to help diagnose bleeding or
the anatomy of the duodenum. clotting disorders.
- Multiple x-ray images are obtained during - A PT measures the number of seconds it
the procedure, and additional images may takes for a clot to form in the sample of
be taken at intervals for up to 24 hours to blood after substances (reagents) are
evaluate the rate of gastric emptying. added.
Non-Invasive: Nursing Intervention Upper Minimally Invasive:
Gastrointestinal Tract Study - Serum Blood study
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- Triglycerides - measures the amount of damage or disease or certain types of
triglycerides in your blood. anemia.
- Amylase - measures the amount of - Gamma-glutamyltransferase (GGT). GGT is
amylase in your blood or urine. Amylase is an enzyme in the blood. Higher- than-
an enzyme, or special protein, that helps normal levels may indicate liver or bile
you digest food. duct damage.
- Lipase - measures the level of a protein - L-lactate dehydrogenase (LD). LD is an
called lipase in your blood. Lipase helps enzyme found in the liver. Elevated levels
your body absorb fats. When your pancreas may indicate liver damage but can be
is inflamed or injured, it releases more elevated in many other disorders.
lipase than usual. - Prothrombin time (PT). PT is the time it
Liver function tests - are blood tests used to takes your blood to clot. Increased PT may
help diagnose and monitor liver disease or indicate
damage. The tests measure the levels of certain liver damage but can also be elevated if you're
enzymes and proteins in your blood. taking certain blood-thinning drugs, such as
- Alanine transaminase (ALT). ALT is an warfarin.
enzyme found in the liver that helps Carcinoembryonic Antigen (CEA)
convert proteins into energy for the liver - Is a protein that is normally not detected in
cells. When the liver is damaged, ALT is the blood of a healthy person.
released into the bloodstream and levels - When detected it indicates that cancer is
increase. present, although not what type of cancer
- Aspartate transaminase (AST). AST is an is present.
enzyme that helps metabolize amino - Primary providers can use CEA results to
acids. Like ALT, AST is normally present in determine the stage and extent of the
blood at low levels. An increase in AST disease and the patient’s prognosis for
levels may indicate liver damage, disease cancer, especially GI and, in particular,
or muscle damage. colorectal cancer.
- Alkaline phosphatase (ALP). ALP is an Cancer Antigen (CA) 19–9
enzyme found in the liver and bone and is - CA 19-9 is also a protein that exists on the
important for breaking down proteins. surface of certain cells and is shed by
Higher-than-normal levels of ALP may tumor cells, making it useful as a tumor
indicate liver damage or disease, such as a marker to follow the course of the
blocked bile duct, or certain bone diseases. cancer.
- Albumin and total protein. Albumin is one of - CA 19-9 levels are elevated in most patients
several proteins made in the liver. Your with advanced pancreatic cancer,
body needs these proteins to fight but they may also be elevated in other
infections and to perform other functions. conditions such as colorectal,
Lower-than-normal levels of albumin and stomach, and bile duct cancers.
total protein may indicate liver damage or - Elevated levels may also be found in
disease. noncancer conditions.
- Bilirubin. Bilirubin is a substance produced Alpha Fetoprotein
during the normal breakdown of red blood - is a protein produced primarily by the liver
cells. Bilirubin passes through the liver and in a developing baby (fetus).
is excreted in stool. Elevated levels of - AFP is produced whenever liver cells are
bilirubin (jaundice) might indicate liver regenerating. With chronic liver diseases,
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such as hepatitis and cirrhosis, AFP may be - Signs of perforation or obstruction a
chronically elevated. water-soluble contrast study may
- Increased amounts of AFP are found in be performed.
many people with the most common type of - Active GI bleeding
liver cancer called hepatocellular Minimally Invasive: Nursing Intervention
carcinoma and in a rare type of liver Lower Gastrointestinal Tract Study
cancer: hepatoblastoma - Bowel Preparation: emptying and cleansing
Minimally Invasive: Fluoroscopy Lower the lower bowel.
Gastrointestinal Tract Study - A low-residue diet 1 to 2 days before
- Visualization of the lower GI tract is the test, a clear liquid diet and a
obtained after rectal installation of barium. laxative the evening before, NPO
- The barium enema can be used to detect after midnight
the presence of polyps, tumors, or other - Cleansing enemas until returns are
lesions of the large intestine and clear the following morning.
demonstrate any anatomic abnormalities or - Fleet Enema
malfunctioning of the bowel. - Makes sure that barium enemas are
scheduled before any upper GI
studies.
- wear a hospital gown and remove
eyewear, jewelry or removable
dental devices.
- lying on side
- lubricated enema tube will be
inserted into the rectum. A barium
bag will be connected to the tube to
deliver the barium solution into the
colon.
Minimally Invasive: Nursing Intervention Lower
- Each portion of the colon may be readily
Gastrointestinal Tract Study
observed.
● Instruct to hold the enema tube in place. To
- The procedure usually takes about 15 to 30
relax, take long, deep breaths.
minutes, during which time x-ray images
● Patient may be asked to turn and hold
are obtained.
various positions on the exam table.
To determine the cause of signs and symptoms,
● A number of X-rays of the colon will likely
such as the following:
be taken from various angles.
- Abdominal pain
● A barium enema exam typically takes about
- Rectal bleeding
30 to 60 minutes.
- Changes in bowel habits
Post procedure:
- Unexplained weight loss
- increasing fluid intake
- Chronic diarrhea
- evaluating bowel movements for
- Persistent constipation
evacuation of barium
- Abnormal growths (polyps) as part
- noting increased number of bowel
of colorectal cancer screening
movements, because barium has
- Inflammatory bowel disease
high osmolarity
Contraindicated
- Active inflammatory disease of the
colon
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- may draw fluid into the bowel, thus - Patient should wear a hospital gown during
increasing the intraluminal contents the exam
and resulting in greater output. Preparation: After
Minimally Invasive - In most cases, you can go about your day
Hepatobiliary Iminodiacetic Acid (HIDA) after your scan.
- Scan is an imaging procedure used to - Drink plenty of water to help flush
diagnose problems of the liver, gallbladder radioactive material out of the body.
and bile ducts. Blood Glucose Monitoring
- AKA cholescintigraphy or hepatobiliary - It is the immediate measurement of blood
scintigraphy glucose using blood sample from a
fingerstick or heel stick.
- AKA Hemogluco test (HGT) or Capillary
blood glucose (CBG)
- Normal: Adult – 80 – 120mg/dl
- Hypoglycemia:
- Newborn: <30mg/dl
- Children: <50mg/dl
Invasive
Minimally Invasive - Endoscopic ultrasonography (EUS)
Hepatobiliary Iminodiacetic Acid (HIDA)
- A HIDA scan is most often done to evaluate - A specialized enteroscopic procedure that
your gallbladder. aids in the diagnosis of GI disorders by
- It's also used to look at the bile-excreting providing direct imaging of a target area.
function of your liver and to track the flow - A small high-frequency ultrasonic
of bile from your liver into your small transducer is mounted at the tip of the
intestine. fiberoptic scope, which displays images
- Gallbladder inflammation (cholecystitis) that are of higher-quality resolution and
- Bile duct obstruction definition than regular ultrasound imaging.
- Congenital abnormalities in the bile ducts, - may be used to evaluate submucosal
such as biliary atresia lesions, specifically their location and depth
- Postoperative complications, such as bile of penetration.
leaks and fistulas - EUS may aid in the evaluation of diseases
- Assessment of liver transplant and changes in the bowel wall due to
Minimally Invasive ulcerative colitis.
Hepatobiliary Iminodiacetic Acid (HIDA) - Nursing Intervention: Same with abdominal
Risk: Ultrasound
- Allergic reaction to medications containing Esophago-gastroduodenoscopy (EGD)
radioactive tracers used for the scan - It allows direct visualization of the
- Bruising at the injection site esophageal, gastric, and duodenal mucosa
- Radiation exposure, which is small through a lighted endoscope.
- Pregnant or breastfeeding. - It is valuable when esophageal, gastric, or
PREPARATION: BEFORE duodenal disorders or inflammatory,
- Fasting for four hours before HIDA scan. neoplastic, or infectious processes are
- Ask about any medication patient is taking, suspected.
including vitamins and herbal supplements.
- Remove jewelry and accessories
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- views the GI tract through a viewing lens - Midazolam (Versed), a sedative that
and can obtain images through the scope to provides moderate sedation with loss of
document findings. the gag reflex and relieves anxiety during
- Electronic video endoscopes also are the procedure.
available that attach directly to a video - Atropine may be given to reduce secretions
processor, converting the electronic - Glucagon may be given to relax smooth
signals into pictures that are projected on a muscle.
screen. - The patient is positioned in the left lateral
Invasive: position to facilitate clearance of
Endoscopic Retrograde Cholangio- pulmonary secretions and provide smooth
pancreatography (ERCP) entry of the scope.
- Uses the endoscope in combination with x- After the procedure:
rays to view the bile ducts, pancreatic - Assessment includes level of
ducts, and gallbladder. consciousness, vital signs, oxygen
- ERCP is helpful in evaluating jaundice, saturation, pain level, and monitoring for
pancreatitis, pancreatic tumors, common signs of perforation
bile duct stones, and biliary tract disease. - Temporary loss of the gag reflex is
Before: expected; wait until the patient’s gag reflex
- Assess allergies to intravenous (IV) has returned.
contrast dyes. - Patients who were sedated for the
- Not eat, drink or smoke for at least six procedure must remain in bed until fully
hours before the procedure. alert.
During: Fiberoptic Colonoscopy
- Anesthetic spray to numb the throat. - direct visualization of the bowel was the
- Inserts the endoscope only means to evaluate the colon.
- Injects a special dye through the catheter. - These scopes have the same capabilities as
Therapeutic purposes those used for
- Break up and remove stones. Place stents EGD but are larger in diameter and longer.
to open blocked or narrowed ducts. - It is most frequently used for cancer
Diagnostic Purposes : screening and for surveillance in patients
- Checks for signs of blockage or problems. with previous colon cancer or polyps.
- Remove tumors or tissue samples to - Tissue biopsies can be obtained as needed,
biopsy. and polyps can be removed and evaluated.
After
- Assess Gag Reflex
- Instruct to eat soft foods for a day or two
until the soreness subsides.
- Patient may experience some bloating and
nausea.
- Patient may return to work and normal
activities the next day.
Nursing Interventions • Screen for colon and rectal cancer
- NPO for 8 hours prior to the examination. • Detect and evaluate inflammatory and
- Patient is given a local anesthetic gargle or ulcerative bowel disease
spray. • Locate the source of lower GI bleeding and
perform hemostasis by coagulation
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• Determine the cause of lower GI disorders, • Change the position of the patient.
especially when barium and • Encourage the patient to take slow, deep
proctosigmoidoscopy results are breaths.
inconclusive Invasive:
• Assist diagnose colonic strictures and Percutaneous Transhepatic Cholangiography (PTC)
benign or malignant lesions - An x-ray procedure that involves the
• Evaluate the colon postoperatively for injection of a contrast material directly into
recurrence of polyps and malignant lesions the bile ducts inside the liver to produce
• Investigate iron-deficiency anemia of pictures of the bile ducts.
unknown origin - Rarely used for diagnostic purposes
• Remove colon polyps alone due to the multitude of other less
• Remove foreign objects and sclerosing invasive and reliable imaging studies.
strictures by laser
Contraindicated for:
• Pregnant women near term
• Patients with bleeding disorders
• Patients who had a recent acute myocardial
infarction or abdominal surgery
• Patients with ischemic bowel disease,
acute diverticulitis, peritonitis, fulminant
granulomatous colitis, perforated viscus, or
fulminant ulcerative colitis: For these cases
or for screening purposes, virtual
colonoscopy may help visualize polyps
before they become concerns.
After the procedure
Before the procedure
• Observe the patient closely for signs of
● Secure an informed consent.
bowel perforation.
• Obtain a medical history of the patient.
• Obtain and record the patient’s vital signs.
• Provide information about the procedure.
• Instruct patient to resume a normal diet,
• Ensure that the patient has complied with
fluids, and activity as advised by the health
the bowel preparation.
care provider.
• Establish an IV line.
• Provide privacy while the patient rest after
• Provide reassurance.
the procedure.
• Explain to the patient that air may be
• Monitor for any rectal bleeding.
introduced through the colonoscope.
• Encourage increased fluid intake.
• Instruct the patient to empty bladder prior
Invasive:
to the procedure.
Percutaneous Transhepatic Cholangiography (PTC)
• Instruct the patient to remove all metallic
This procedure can be carried out even in the
objects from the area to be examined.
presence of liver dysfunction and jaundice.
• Instruct the patient to cooperate and follow
It is useful for:
directions.
1. distinguishing jaundice caused by liver
During the procedure
disease (hepatocellular jaundice) from that
• Assist with patient positioning as
caused by biliary obstruction
necessary.
2. investigating the GI symptoms of a patient
• Administer medications as ordered.
whose gallbladder has been removed
• Instruct the patient to bear down.
3. locating stones within the bile ducts
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4. diagnosing cancer involving the biliary - Removal of a small amount of liver tissue,
system usually through needle aspiration.
Preparation: - It permits examination of liver cells.
- Fasting: 4 to 8 hour - The most common indication is to evaluate
- Sterile procedure is performed diffuse disorders of the parenchyma and to
- Patient also receives local anesthesia diagnose space- occupying lesions.
- Coagulation parameters and platelet count - Gold Standard for Liver Cancer
should be normal
- Broad-spectrum antibiotics are given
During:
- A flexible needle is inserted into the liver
from the right side in the midclavicular line
immediately beneath the right costal
margin
- Successful entry of a duct is noted when
bile is aspirated or on injection of a
- Percutaneously with ultrasound guidance
contrast agent.
- Transvenously through the right internal
- Ultrasound can be used to guide puncture
jugular vein to right hepatic vein under
of the duct.
fluoroscopic control.
- Bile is aspirated, and samples are sent for
- Laparoscopic Liver Biopsy
bacteriology and cytology
Complication:
- A water-soluble contrast agent is injected
- Peritonitis - caused by blood or bile
to fill the biliary system.
leak after liver biopsy.
- The fluoroscopy table is tilted, and the
- Bleeding
patient is repositioned to allow x-rays to be
- Infection
taken in multiple projections.
- Accidental injury to nearby organ
- Before the needle is removed, as much dye
- Hematoma in the neck
and bile as possible are aspirated to
- Temporary problem with facial
anticipate subsequent leakage into the
nerves
needle tract and eventually into the
- Temporary voice problem
peritoneal cavity, thus minimizing the risk
- Puncture of the lung
of bile peritonitis.
Preparation:
After:
- Patient must sign consent form
- Closely observe the patient for symptoms
- NPO 4-6 hours before procedure
of bleeding, peritonitis, and sepsis.
- Pre-procedure V/S
- Assesses the patient for pain and
- Check labs, especially prothrombin
indications of these complications and
times
reports them promptly to the primary
- Have pt empty bladder immediately
provider
before procedure
- Takes measures to reassure the patient
- Place patient in supine position with
and ensures patient comfort.
pillow underneath back on far-right
- Antibiotic agents are often prescribed to
side of bed- exposing right
minimize the risk of sepsis and septic
side(hypochondriac region). Head
shock.
should be turned to the left and
Invasive:
right arm extended above head
Liver Biopsy
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- Local anesthetic agent instilled into  + valsalva maneuver
biopsy area per MD Management
- Before the procedure instruct  Education (gastrocolic reflex), bowel habit
patient practice breathing in the training, increased fiber and fluid intake,
following way: inhale, exhale, inhale, and judicious use of laxatives (avoid
exhale completely and hold breath laxative abuse)
until MD inserts and removes
needle
After:
- Monitor V/S
- apply pressure to site with sterile
dressing after procedure
- put patient on R side with pillow or
special sandbag in costal area for a
minimum of 2 hours
- tell patient to stay (flat) in bed 12-
14hours
- NPO for about 2 hours and then
resume meal
- avoid coughing, lifting, or straining
for 1–2-week post procedure
CT scan MRI
- Technetium-labeled RBC scintigraphy –
an imaging test that can help detect the
origin of gastrointestinal bleeding.

MANAGEMENT OF PATIENTS WITH

INTESTINAL AND RECTAL DISORDERS

Abnormalities of Fecal Elimination

Constipation
• Abnormal infrequency or irregularity of
defecation;
• Abnormal hardening of stools that makes Diarrhea
their passage difficult and sometimes • An increased frequency of bowel
painful; movements (more than three per day);
• A decrease in stool volume, or retention of • An increased amount of stool (more than
stool in the rectum for a prolonged period; 200 g/day); and
• Sense of incomplete evacuation after • Altered consistency (ie, increased
defecation. liquidity) of stool.
Complications • Acute diarrhea: 71 toor 21d4aysdays;
 Hypertension • Chronic diarrhea: more than 2 to 3 weeks
 Fecal impaction
 Hemorrhoids
 Fissures
 Megacolon
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Types of Diarrhea Irritable Bowel Syndrome
• Clinical Manifestations: IBS-D, IBD-C,
Secretory: high-volume diarrhea; caused by IBS-A
increased production and secretion of water and • Assessment & Diagnosis:
electrolytes by the intestinal mucosa into the ➢ Recurrent abdominal pain at least
intestinal lumen. 3 days a month for the past 3 months
Osmotic: occurs when water is pulled into with two or more of the ff:
the intestines by the osmotic pressure of 1. Improvement with defecation;
unabsorbed particles, slowing the reabsorption 2. Change in freq. of stool;
of water. 3. Change in appearance of stool.
Malabsorptive: Inhibiting effective absorption of Management
nutrients manifested by markers of malnutrition • Goals of Treatment: Relieving abdominal
that include hypoalbuminemia pain, controlling the diarrhea or
Exudative: caused by changes in mucosal integrity, constipation, and reducing stress.
epithelial loss, or tissue destruction by radiation or • For IBS-C: Lubiprostone, a chloride
chemotherapy channel regulator in the gut
• For IBS-D: alosteron (Lotronex)
Complications of Diarrhea • Probiotics (Lactobacillus,
• Potential for cardiac dysrhythmias; Bifidobacterium), complementary medicine
• Loss of bicarbonate;
• Report the ff: Urine output <0.5mL/kg/hr for Acute Inflammatory Intestinal Disorders
2 to 3 consecutive hours, muscle
weakness, parethesia, hypotension, Appendicitis
anorexia and drowsiness.  Inflammation of the appendix
• Chronic Diarrhea: irritant dermatitis  Most common cause of acute surgical
abdomen; most common reason for
Management of Diarrhea emergency abdominal surgery
• Eliminating or treating underlying cause;  Age: commonly occurs between the ages of
• Drug of Choice: Loperamide [Imodium] 10 and 30 years; although may occur at any
• Pharmacologic: Antibiotics, anti- age
inflammatory agents and antidiarrheals (eg, Clinical Manifestations
loperamide [Imodium], diphenoxylate ▪ Initial: Vague epigastric or periumbilical
[Lomotil]) pain (ie, visceral pain that is dull and
During an episode of acute diarrhea: poorly localized); progresses to
• Bed rest, intake of liquids and ▪ Right lower quadrant pain (ie. Parietal pain
foods low in bulk until the acute attack that is sharp, discrete, and well-localized
subsides; ▪ Usually accompanied by a low grade fever
• Recommend a bland diet of semisolid and and nausea and sometimes by vomiting,
solid foods (if able to tolerate food loss of appetite.
intake); ▪ Local tenderness at mcburney’s point
• Avoid caffeine, carbonated beverages, and ▪ Rebound tenderness (ie. Production or
very hot and very cold foods; intensification of pain when pressure is
• Restrict milk products, fat, whole-grain released) may be present
products, fresh fruits, and vegetables for ▪ Rovsing sign: deep palpation of the left iliac
several days fossa causes pain in the right iliac fossa.
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patient may be initially treated with
antibiotics; place a drain in the abscess

Nursing Management: Perioperative Management

▪ IV infusion to replace fluid loss and
promote adequate renal function and
antibiotic therapy to prevent infection.
▪ If there is evidence or likelihood of paralytic
ileus, a nasogastric tube is inserted.
▪ An enema is not administered because it
can lead to perforation.
Nursing Management: Post-operative Management
▪ After surgery, the nurse places the patient
in a high- Fowler’s position.
▪ An opioid, usually morphine sulfate, is
prescribed to relieve pain.
▪ Food is provided as desired and tolerated
on the day of surgery when normal bowel
Psoas sign sounds are present.
▪ Also known as the Ilio-psoas sign. ▪ When tolerated, oral fluids are
Passive extension of the right hip may administered.
cause pain in the right iliac fossa; Diverticular Disease
Obturators sign or Copes sign ▪ Diverticulum is a saclike herniation of
▪ Flexion and internal rotation of the right hip the lining of the bowel that extends
causes pain through a defect in the muscle layer;
▪ Diverticulosis exists when multiple
Assessment and Diagnostic Findings diverticula are present without
▪ History and Physical Exam: Patient is inflammation or symptoms;
usually younger; ▪ Diverticulitis results when food and
▪ CBC: Reveals elevated WBC, neutrophils bacteria retained in a diverticulum produce
▪ Imaging studies (esp. CT Scan if diagnosis infection and inflammation that can impede
is uncertain): Right lower quadrant drainage and lead to perforation or
density or localized distention of the bowel abscess formation.
▪ Pregnancy test (for women): To R/O Cause: Mucosa and submucosal layers of the colon
ectopic pregnancy, before radiologic herniate through the muscular wall because of:
studies are done; • High intraluminal pressure;
▪ Urinalysis: To R/O urinary tract infection • Low volume in the colon (ie, fiber-deficient
▪ Diagnostic laparoscopy: To R/O acute contents);
appendicitis in equivocal cases • Decreased muscle strength in the colon
wall (ie, muscular hypertrophy from
Medical Management hardened fecal masses).
▪ Appendectomy (ie, surgical removal of Assessment and Diagnostic Findings
the appendix) is performed as soon as • Diagnostic Test of Choice: CT with
possible to decrease the risk of perforation. contrast agent if the suspected diagnosis is
▪ If perforation of the appendix diverticulitis; it can also reveal abscesses;
(abscess formation) occurs, the
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• Colonoscopy, permits visualization of the
extent of diverticular disease and allows
the physician to biopsy tissue to rule out
other diseases;
• G Barium enema: If with þ peritoneal
irritation
• Abdominal x-rays may demonstrate free
air under the diaphragm if a perforation
hasoccurred from the diverticulitis.
• Other laboratory tests: Complete blood
cell count, revealing an elevated white
blood cell count, and elevated
erythrocyte sedimentation rate (ESR).
Medical Management
• Can be treated on an outpatient basis
with diet and medication;
• When symptoms occur, rest, analgesics,
and antispasmodics are recommended;
• Diet: Clear liquid diet (initially) then
high-fiber, low-fat diet
• Hospitalization for acute diverticulitis
• Broad-spectrum antibiotics are
prescribed for 7 to 10 days.
• An opioid (eg, meperidine
[Demerol]) is prescribed for
pain relief; G Morphine; Inflammatory Bowel Disease
• Antispasmodics such as propantheline • Inflammatory bowel disease (IBD) refers
bromide and oxyphencyclimine (Daricon) to two chronic inflammatory GI disorders:
may be prescribed Crohn’s disease (ie, regional enteritis)
Surgical Management and ulcerative colitis.
• One-stage resection, in which the • Crohn’s disease is a subacute and chronic
inflamed area is removed and a primary inflammation of the GI tract wall that
end-to-end anastomosis is completed; extends through all layers (ie, transmural
• Multiple-stage procedures for lesion).
complications such as obstruction or Crohn’s Disease Clinical Manifestations
perforation (eg, Hartmann’s procedure)  Onset: insidious
Double Barrel Colostomy  Prominent right lower quadrant abdominal
pain and diarrhea unrelieved by diarrhea
Inflammatory Bowel Disease
 Ulcerative colitis is a recurrent ulcerative
and inflammatory disease of the mucosal
and submucosal layers of the colon and
rectum
 After the superficial mucosa of the colon is
characterized by multiple ulcerations,
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diffuse inflammations, and desquamation or Nursing Management
shedding of the colonic epithelium  Maintaining the function of nasogastric
Assessment and Diagnostic Findings tube;
• Most conclusive diagnostic aid: Barium  Assessing and measuring the output;
Study of upper GI tract, shows a  Assessing for fluid and electrolyte
“string sign” on an x-ray film of the imbalance;
terminal ileum (indicating constriction  Monitoring nutritional status; and
of a segment of intestine);  Assessing improvement (eg, return of
• Confirm Diagnosis: Endoscopy, normal bowel sounds, decreased
colonoscopy, intestinal biopsies, CT scan, abdominal distention, etc.)
barium enema
Intestinal Obstruction Large Bowel Obstruction
• Exists when blockage prevents the normal  Clinical Manifestations: differs clinically
flow of intestinal contents through the from small bowel obstruction d/t relatively
intestinal tract. slower occurrence of symptoms
Two Types of Processes:  PA & Dx Findings: Abdominal x- ray and
1. Mechanical Obstruction: Obstruction abdominal CT or MRI: Distended colon
caused from pressure on the intestinal and pinpoint sight of obstruction; Barium
wall e.g., intussusception, polypoid tumors studies are contraindicated
stenosis, strictures, adhesions, hernias, Medical Management
and abscesses.  Restoration of intravascular volume
2. Functional Obstruction: Intestinal  Correction of electrolyte abnormalities and
musculature cannot propel the contents  Nasogastric aspiration and decompression
along the bowel e.g., muscular dystrophy, Surgical Management
endocrine disorders (e.g., DM), etc. • Colonoscopy (to untwist and decompress
Small Bowel Obstruction: Clinical Manifestations bowel);
• Initial: Crampy pain; wavelike, colicky • Cecostomy (surgical opening of cecum for
• Vomiting; passing of blood, mucus (no pxs urgently in need of relief from
fecal matter, flatus); reverse peristalsis; obstruction);
• Signs of dehydration: intense thirst, • Rectal tube placement (decompress
drowsiness, parched tongue and area lower in the bowel)
mucous membranes; hypovolemic shock if • Colonic stent (as palliative intervention
uncorrected or as bridge for definitive surgery);
Diagnostic & Findings • Surgical resection, colostomy, ileostomy
• Based on symptoms and imaging studies
• Imaging Studies: Abdominal x- ray,
CT-scan (abn. Quantities of gas, fluid, or
both)
• Laboratory Studies: dehydration, loss of
plasma volume, possible infection
Medical Management
• Decompression of bowel thru NGT;
• Monitoring for bowel ischemia (mandatory);
• Surgical intervention (if possibility of
strangulation and tissue necrosis is
suspected)