McKenzie2e ClinicalCompanion

Clinical Companion
MEDICALSURGICAL
NURSING
2nd edition
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Clinical Companion
MEDICALSURGICAL
NURSING
2nd edition
Gayle McKenzie
RN, BSocSc, GC ClinEd, GD CritCare,
MEd, RCNA
Tanya Porter
RN, BN, GDipAdvNsg (Emerg), MEd
Sydney Edinburgh London New York Philadelphia St Louis Toronto
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Mosby
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
2011 Elsevier Australia
This publication is copyright. Except as expressly provided in the Copyright Act 1968
and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication
may be reproduced, stored in any retrieval system or transmitted by any means (including
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Every attempt has been made to trace and acknowledge copyright, but in some cases
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and would welcome any information to redress the situation.
This publication has been carefully reviewed and checked to ensure that the content is as
accurate and current as possible at time of publication. We would recommend, however, that
the reader verify any procedures, treatments, drug dosages or legal content described in this
book. Neither the author, the contributors, nor the publisher assume any liability for injury
and/or damage to persons or property arising from any error in or omission from this publication.
National Library of Australia Cataloguing-in-Publication Data
___________________________________________________________________
McKenzie, Gayle.
Clinical companion : medical-surgical nursing / Gayle McKenzie ; Tanya Porter.
2nd ed.
9780729539968 (pbk.)
Includes index.
NursingHandbooks, manuals, etc.
Surgical nursingHandbooks, manuals, etc.
Porter, Tanya.
610.73
___________________________________________________________________
Publisher: Libby Houston
Developmental Editors: Larissa Norrie and Elizabeth Coady
Publishing Services Manager: Helena Klijn
Editorial Coordinator: Natalie Hamad
Edited by Brenda Hamilton
Proofread by Sarah Newton-John
Indexed by Cynthia Swanson
Cover and internal design by Toni Darben
Typeset by Pindar New Zealand, Auckland
Printed in China by China Translation and Printing Services
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v
Contents
Preface ix
Acknowledgments x
Reviewers xi
1 Medication administration 1
Medication errors 9
2 Documentation 10
3 The nervous system 19
Anatomy and physiology 19
The central nervous system 21
Protecting the brain and spinal cord 25
Assessment 29
Medical disorders 33
Surgical interventions 51
Tests 53
Pharmacology 56
4 The respiratory system 58
Anatomy review 58
Respiratory assessment 62
Restrictive respiratory disorders 66
Obstructive respiratory disorders 74
Medical interventions 83
Common respiratory tests 91
Pharmacology 95
5 The cardiovascular system 98
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vi | Contents
Electrical activity in the heart 103
Assessment 105
Basic rhythms 112
Interventions 134
Tests 138
Pharmacology 145
6 The endocrine system 150
The hypothalamus 152
The pituitary gland 153
Disorders of the pituitary gland 154
The thyroid gland 158
Disorders of the thyroid gland 159
The parathyroid gland 163
Disorders of the parathyroid gland 163
The adrenal gland 165
Disorders of the adrenal gland 166
The pancreas 169
Disorders of the pancreas 171
Pharmacology 174
7 The gastrointestinal system 177
Assessment 182
Tests 205
Pharmacology 209
8 The renal system 213
Assessment 222
Tests 245
Pharmacology 249
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Contents | vii
9 The reproductive system 252
Assessment (male and female) 252
Female anatomy and physiology 253
Female medical disorders 257
Menstrual disorders 268
Breast disorders 269
Surgical interventions (female) 271
Male anatomy and physiology 273
Male medical disorders 276
Surgical interventions (male) 286
Sexually transmitted diseases 286
Pharmacology 286
10 Haematology, oncology and
immunology 288
Haematology: anatomy and physiology 288
Haematology disorders 291
Haematology interventions 298
Haematology pharmacology 298
Oncology: anatomy and physiology 299
Oncology disorders 299
Oncology interventions 303
Immunology: anatomy and physiology 306
Immunology disorders 308
Immunology pharmacology 311
Tests 311
11 Infectious diseases 313
Chain of infection 315
Prevention of infection 317
Infectious diseases 320
Pharmacology 357
12 Trauma and emergency 360
Head injuries 362
Spinal cord injuries (SCI) 363
Maxillofacial injuries 365
Thoracic injuries 367
Abdominal injuries 369
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viii | Contents
Fractures 370
Amputation 372
Shock 374
Burns 379
Complications of trauma 386
13 Operative care 388
Preoperative care 389
Intraoperative care 392
Postoperative care 396
On return to ward (RTW) 397
Wound care 399
Discharge from hospital 402
14 Survival tactics 404
Tips to assist with clinical placement 407
Workload management 409
What else do you need to know? 410
Appendix 1 Life support ow charts 417
Appendix 2 Common abbreviations 420
Appendix 3 Daily management plan 428
Appendix 4 Handover template 429
References 430
Recommended websites 432
Index 433
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ix
Preface
Clinical nursing requires a nurse to often be a jack-of-all-trades
and have a wealth of up-to-date knowledge on hand for all
occasions. It is difcult to remember everything, all the time. We
have endeavoured to provide a text that enables the reader to use
the knowledge they have and apply it to clinical practice in order
to provide optimum patient care.
Clinical Companion: MedicalSurgical Nursing 2e is an easy-
to-access, simple information nder for quick revision of nursing
knowledge and practice. It is designed for all clinical nurses
but particularly for student nurses, graduate nurses and those
returning to the nursing profession after an extended absence.
Before using Clinical Companion: MedicalSurgical Nursing
2e it is essential that the user have prior knowledge of anatomy
and physiology, pathophysiology, assessment and rationales
for interventions, as it is designed to be a quick reminder and
provides only a brief overview of each body system and related
conditions.
Each chapter begins with an overview of the anatomy of
the relevant body system, followed by a how-to system
assessment, conditions relating to the system, common tests and
pharmacology. Throughout the text, the icon ags hints
to assist with nursing care, and learning and development.
Clinical Companion: MedicalSurgical Nursing 2e
is designed to be a quick guide, and more in-depth
information should be sought from other sources.
Gayle McKenzie, Tanya Porter
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x
Acknowledgments
To my boys, Rowan, Stanley and Phineas who make my life
complete.
Tanya Porter
To my mother Avis McKenzie, who continues to be my Rock of
Gibraltar.
A special thanks to my students, both past and present, who
have taught me more than they'll ever know!
Gayle McKenzie
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xi
Reviewers
Sonja Cleary RN, BN, MHlthSc, Grad Cert Tert Edn, MRCNA;
Lecturer/Course Coordinator, Discipline of Nursing and
Midwifery, School of Health Science, RMIT University, VIC
Trinity Farrell CCRN, Grad Dip Nursing (Critical Care);
Lecturer, La Trobe University, VIC
Penny Paliadelis RN, BNurs, MNurs(Hons), PhD, MRCNA,
MACCCN; Associate Professor, Deputy Head of School
(Teaching & Learning), School of Health, Faculty of the
Professions, University of New England, NSW
Lacey Smale BNurs, RN, MRCNA; Lecturer, University of
Canberra, ACT
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177
7
| The gastrointestinal
system
The main function of the gastrointestinal system is to provide
nutrients to the cells of the body. The four major functions
are ingestion (taking in food), digestion (breakdown of food),
absorption (transfer of food products into the circulation) and
elimination (excretion of waste products).
Anatomy and physiology
Parts of the gastrointestinal tract (GIT)
Mouth
Also known as buccal or oral cavity
Contains the salivary glands, which secrete saliva to
moisten food during chewing
Tongue (with cheeks) shapes food into a bolus (rounded
mass) and pushes it into the pharynx.
Pharynx
Oropharynx
Oesophagus
Cricopharyngeal sphincter relaxes so food can enter the
oesophagus.
Stomach
Has four main regions: cardia, fundus, body and pylorus
(includes the pyloric sphincter)
Lies just below the diaphragm
Size varies with distension
If too distended, may cause shortness of breath due to
pressure on the diaphragm
Function:
Temporary storage of food
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178 | Clinical companion: medicalsurgical nursing
Holds about 1.01.5 L
Digestion is begun
Alcohol is absorbed here, but not much food
Food is mixed with gastric acids to form chyme
(semi-uid substance)
Cephalic phasegastric juices are released with the
thought of food
Gastric phasegastric juices are released when food
is eaten
Gastric juice is highly acidic
Destroys most microorganisms
Consists of water, mucus, hydrochloric acid,
pepsin, intrinsic factor (necessary for vitamin B
12

absorption).
Small intestine
Approximately 6 m long
Consists of the duodenum, jejunum and ileum (smallest
to longest)
Note: Any fold of the peritoneum that attaches an
organ to the abdominal wall is called a mesentery.
Function:
Peristalsis
Completion of food digestion
Absorption of food molecules into the bloodstream to
be transported to body cells
Hormones to control the secretion of various enzymes:
Gastrinproduced in pyloric antrum and
duodenal mucosa; stimulates gastric secretion and
motility
Gastric inhibitory peptidesproduced in duodenal
and jejunal mucosa; inhibit gastric secretion and
motility
Secretinproduced in duodenal and jejunal
mucosa; stimulates secretion of bile and pancreatic
enzymes
Cholecystokininproduced in duodenal and
jejunal mucosa; stimulates secretion of bile and
pancreatic enzymes.
Chapter 7 The gastrointestinal system | 179
Large intestine
Consists of the caecum, appendix, ascending colon,
transverse colon, descending colon, sigmoid colon,
rectum and anus (including anal sphincter)
Function:
Water absorption
Mucus secretion (to aid faecal movement)
Bacteria, e.g. Escherichia coli, Lactobacillus bidus
Mouth Parotid
gland
Epiglottis
Pharynx
Oesophagus
Stomach
Pancreas
Splenic
flexure
Transverse
colon
Descending
colon
Ascending
colon
Duodenum
Hepatic
flexure
Common
bile duct
Gallbladder
Cystic
duct
Hepatic
bile duct
Jejunum
Ileum Caecum Sigmoid
colon
Rectum Vermiform
appendix
Teeth
Liver
Submandibular
gland
Sublingual
gland
FIGURE 7.1 Gastrointestinal system
To help break down cellulose and synthesise
vitamin K
Produces atus, which helps move the stool towards
the rectum
Elimination of waste products.
GIT nerve supply
Distension of the GIT stimulates nerves in smooth muscle
and increases peristalsis.
The sympathetic nervous system (SNS) decreases peristalsis
and inhibits GIT activity.
The parasympathetic nervous system (PNS) increases
peristalsis and GIT activity.
Accessory organs of digestion
Liver
Divided into four lobes and surrounded by Glissons
capsule
Blood supply is through the hepatic artery (carries
oxygenated blood to the liver), portal vein (carries nutrient-
lled blood from the stomach and the intestines to the liver)
and the hepatic veins (carry blood away from the liver)
Function:
Produces bile
Metabolises hormones and drugs
Synthesises proteins, glucose and clotting factors
Stores vitamins and minerals
Converts fatty acids to ketones
Metabolises 90% of consumed alcohol.
Bile
Contains water, bile salts, bilirubin, cholesterol and various
inorganic acids
Bile salts are the most important component of digestion,
as they aid in the emulsication of dietary fats and are
necessary for the transport of fatty acids and fat-soluble
vitamins
It is a powerful antioxidant that assists in the removal of
toxins from the liver
The hepatic duct carries bile out of the liver, the cystic duct
takes bile to and from the gallbladder and the common bile
duct takes bile from the cystic and hepatic ducts to the small
intestine.
Bilirubin
Is formed from the breakdown of red blood cells and gives
bile its yellow-green colour
Is transported in the blood attached to plasma albumin
Is converted to urobilinogen in the intestine and reabsorbed
into the portal circulation or excreted in the faeces.
Gallbladder
Collects, concentrates, acidies and stores bile
Food and fat ingestion trigger the release of cholecystokinin
(CCK), which relaxes the valve at the common bile duct,
releasing bile into the small intestine
Bile is moved in and out through the cystic duct.
Pancreas
Lies behind the stomach (between the duodenum and the
spleen)
The pancreatic duct empties into the ampulla of Vater and
joins the common bile duct, allowing pancreatic juices to
empty into the small intestine, where they become activated
Exocrine function:
Releases digestion enzymes into pancreatic duct
Releases inactive pancreatic enzymes into the small
intestine
Endocrine function:
Releases hormonesinsulin, glucagon and
somatostatin.
Exocrine secretes into a duct.
Endocrine secretes into the blood or lymph.
Assessment
Subjective
Ask the patient about:
What the symptoms are and what precipitates or relieves
them
Bowel characteristics (stool description), including altered
bowel habits
Diet and nutrition, including altered eating habits, e.g.
changes in appetite, difculty eating or swallowing, weight
loss or gain
Dentures or any recent dental work
Lifestyle, e.g. stress, smoking, exercise, alcohol
Family history
Past history
Any recent travel (particularly overseas)
Past surgery or hospital admission
Any previous ulcers, GI bleeding etc
Medications (including OTCparticularly aspirin,
NSAIDs or laxatives)
Allergies to medications or foods.
Objective
Examine the mouth and mucous membranes, note colour,
any bleeding, ulcers, missing teeth or odours
Examine the abdomen
Inspection
Observe skin for pigmentation, lesions, striae, scars,
dehydration
Observe the contour and movement of the abdomen
for symmetry and peristalsis
Auscultation
Clockwise over all four quadrants
At least two minutes per quadrant
May need to listen for ve minutes to conrm that
bowel sounds are absent
Bowel sounds are caused by air mixing with uid
during peristalsis
High-pitched and gurgling in the small intestines;
low-pitched and rumbling in the colon
They occur 535 times/minute
Are most audible before mealtimes, e.g. stomach
rumbling
Percussion
Tympany (clear hollow sound) over hollow organs
Dullness over solid organs or masses, e.g. liver,
distended bladder
Palpation
To identify pain and muscle resistance (guarding)
Perform both light and deep palpation of each organ
and each quadrant
Always palpate the most tender or painful region
last
Always inspect, then auscultate, then percuss and
lastly palpate. This will cause the least discomfort
to the patient.
Examine the rectum
Observe for haemorrhoids or polyps
Palpate rectum towards umbilicus (patient in left lateral
position)
Carefully rotate nger
Rectal walls should be smooth and soft
Remove nger and observe glove for faeces, blood or
mucus.
Body mass index (BMI)
The calculation of body fat based on the height and weight of
men and women. It is an indicator only and further assessment
should include the patients gender, age, level of tness, past
medical history and family history.

BMI =
weight (kg)
height (m) height (m)
For adults:
BMI Weight range
< 20.0 Underweight
20.025.0 Normal
25.030.0 Overweight
> 30.0 Obese
Nutrition
A healthy diet should consist of:
Carbohydratesgive energy, e.g. bread, pulses, grains
Fibreno nutritional value, but promotes bowel motility,
e.g. bran, cereals
Proteinsneeded for cell production and maintenance, e.g.
meat, sh, pulses
Fatsneeded for the everyday function of cells, the
hormone system and body temperature regulation, e.g. milk,
butter, cheese, sh
Vitamins and mineralse.g. vitamins A, B
1
(thiamine),
B
2
(riboavin), B
3
(niacin), B
6
(pyridoxine), B
12
(cyanocobalamin), C, D, E and K.
Medical disorders
Anorexia
Lack or loss of appetite. It can occur due to psychological issues
(e.g. anorexia nervosa, low self-esteem, stress) or be related to
disease processes, medications or other treatment regimes.
Appendicitis
Inammation of the appendix. Occurs as a result of obstruction
of the mucous outow from the appendix, causing the appendix
to distend and bacteria to multiply, leading to restricted blood
ow and eventual necrosis and perforation.
Causes
Faecal impaction
Strictures
Viral infection
Ulceration of the mucosa.
Signs and symptoms
Pain in right lower quadrant
Nausea and vomiting
Abdominal rigidity
Later: fever, tachycardia and cessation of pain (if perforation
has occurred).
Diagnosis
Physical examination
Abdominal X-ray, ultrasound or MRI
Blood teststo check WCC elevation.
Treatment
Appendectomy.
Cholelithiasis (gallstones)
Occurs when bile is released that lacks the usual concentration of
bile salts, causing it to become less soluble. This leads to bilirubin,
calcium and cholesterol precipitation and the formation of
gallstones.
Signs and symptoms
Painmid-epigastric or right upper quadrant
Flatulence and indigestion
Nausea
Low-grade fever
Possible jaundice.
Diagnosis
Ultrasound
CT (if stones present)
MRI or ERCP (endoscopic retrograde
cholangiopancreatography
Blood tests to check for complications, e.g. infection.
Treatment
Depends on severity
Low-fat diet
Antibiotics (usually IV)
NGT (if vomiting)
Lithotripsy (the break-up of stones using ultrasonic waves)
Cholecystectomy.
Cirrhosis
Irreversible scarring of the liver that leads to the disruption of
blood ow through the liver.
Types
Post-necrotic
Characterised by the replacement of liver tissue with
nodules of brous tissue
Occurs due to viral hepatitis B or C, autoimmune disease,
or drug or chemical toxicity.
Biliary
Develops in the bile ducts with obstruction of the ow
of bile, and causes inammation and scarring of the bile
ducts
Usually caused by autoimmune disorders, gallstones or
strictures
Signs and symptoms are pruritus, dark urine and pale stools
Treatment includes correction of the obstruction and
treating the symptoms.
Portal or alcoholic
Occurs in three stages:
Fatty changes
Alcohol replaces fat as a fuel for liver metabolism
Alcoholic hepatitis
Inammation and necrosis of liver cells
Cirrhosis
Normal tissue is replaced by scar tissue and blood
ow through the liver is obstructed, causing the
formation of shunts that serve as alternative routes
for the return of portal blood to the heart.
Signs and symptoms
Can be absent until the disease is advanced
Weakness and fatigue
Lack of appetite and weight loss
Nausea
Pruritus
Diarrhoea
Abdominal pain
Palpable, hard liver
Jaundice
Ascites
Peripheral oedema
Mental confusion due to encephalopathy.
Diagnosis
Liver function tests (LFT)
Ultrasound, CT or MRI
Liver biopsy.
Treatment
Cease alcohol intake
Increase carbohydrate and calorie intake to prevent protein
breakdown (to ammonia)
Limit protein intake to decrease ammonia production
Correction of uid and electrolyte imbalances
Treatment of complications with medications
Medications to treat hepatitis (if applicable)
Liver transplant.
Complications
Malnutrition
More frequent infections
Portal hypertension
Oesophageal varices
Bruising and bleeding
Hepatic encephalopathy (due to high ammonia levels)
Osteoporosis
Liver cancer
Liver failure.
Constipation
Infrequent and often difcult evacuation of faeces.
Causes
Inadequate uid and food (particularly bre) intake
Immobility or a sedentary lifestyle
Medications, e.g. opiates
Surgery.
Signs and symptoms
Hyperactive bowel sounds above the obstruction, with no
sounds below the obstruction
Bloating
Abdominal discomfort.
Treatment
Promote uid intake
Promote bre intake to improve muscle tone
Bowel chartnote colour, consistency and frequency
Encourage ambulation
Medications, e.g. laxatives.
Crohns disease
An inammatory bowel disease that can affect any part of the
GIT, from the mouth to the anus, although the terminal ileum is
the most common. It affects all layers of the bowel (transmural
inammation). It is painful and debilitating, and can lead to life-
threatening complications. There is no cure, however symptoms
can be relieved with treatment and some people can go into
remission for months or years.
Signs and symptoms
Pain or cramping (right lower quadrant)
Bloating
Tenderness
Low-grade fever
Weight loss and anorexia
Intermittent non-bloody diarrhoea
Steatorrhoea.
Diagnosis
Blood tests, e.g. WCC, ESR, FBE, U&E
Faecal occult blood test
Barium enema
X-Ray, CT or MRI
Colonoscopy
Sigmoidoscopy
Biopsy.
Treatment
Medications:
Anti-inammatory medications, e.g. corticosteroids,
sulfasalazine, mesalamine
Antibiotics, e.g. metronidazole, ciprooxacin
Immunosuppressants, e.g. azathioprine, iniximab
Aminosalicylates
To relieve symptoms, e.g. anti-diarrhoeals, laxatives, pain
relief
Vitamins and minerals, e.g. iron, calcium, vitamins B
12
, D
Diet restriction
If acute, may need total parenteral nutrition (TPN)
Colectomy and/or ileostomy (if recurrent).
Nursing considerations
Observe faeces for occult blood
Observe for malnutrition and dehydration.
Diarrhoea
An increase in the frequency and uidity of faeces.
Causes
GIT disease, e.g. Crohns disease
Toxins
Medications, e.g. laxative overuse
Parasites, e.g. from travelling
Faecal impaction (liquid stool may seep around the
blockage).
Signs and symptoms
Abdominal cramps
Dehydration
Loose, frequent bowel movements.
Diagnosis
Faecal specimen to test for blood or parasites.
Treatment
Increase uid intake (may need IV uids if severe
dehydration)
Replace electrolytes
Medication, e.g. Lomotil
Treat underlying condition, e.g. parasite infestation,
constipation.
Monitor patients weight
Commence a bowel chart
Patient should avoid high-bre foods.
Diverticular disease or diverticulitis
Inammation and infection of the bulging pouches (diverticula)
in the GIT wall, usually occurs in the large intestine.
Causes
Increased transluminal pressure combined with a weakening
of the bowel wall (often due to straining during bowel
movements)
Food or faeces lodging in the diverticula
Note: In countries where the diet is high is bre, this disease is
relatively unknown.
Signs and symptoms
Often asymptomatic
Pain and tenderness in the left lower quadrant
Nausea +/ vomiting
Low-grade fever
Chills
Irregular bowel habitsdiarrhoea and constipation
Weight loss.
Diagnosis
Abdominal examination
Blood tests (WCC)
CT.
Treatment
Rest and liquid diet initially
Temporarily avoid whole grains, fruit and vegetables
Antibiotics
Analgesia
Bowel resection and temporary colostomy (if severe)
Abscess drainage.
Complications
Peritonitis (if perforation occurs)
Abscess or stula.
Gallbladder cancer
A rare form of cancer that is usually only discovered when the
gallbladder is removed or when the cancer is very advanced.
Cause
Unknown but could be due to toxins.
Signs and symptoms
Often mimics other gallbladder problems such as gallstones
or infection
Right upper quadrant abdominal pain
Nausea and vomiting
Weight loss and loss of appetite
Jaundice
Enlarged gallbladder
Pruritus.
Treatment
Cholecystectomy
Radiation therapy.
Gastro-oesophageal reux disease (GORD)
A backow of gastric or duodenal contents into the oesophagus
that occurs when the oesophageal sphincter does not close
properly. The acidic gastric contents back ow into the oesophagus,
leading to pain, inammation and possible ulceration.
Signs and symptoms
Can be asymptomatic
Heartburn or chest pain that increases when lying down
Dysphagia
Acid reux
Sensation of a lump in the throat
Hoarsness or dry cough.
Diagnosis
Barium meal
Gastroscopy (abnormal changes in the mucosa).
Treatment
Medications
Antacids before meals
Proton pump inhibitors
Histamine-2 antagonists
Reduce weight
Avoid large meals, fatty foods, caffeine, alcohol and tobacco
Surgical removal of the cause, e.g. hernia
Surgery to support the sphincter.
Ensure patient remains sitting upright and sleeps with head
of bed elevated.
Haemorrhoids
Congestion of the veins in the haemorrhoidal plexus, causing
varicose veins in the anal sphincter area. They can be internal or
external. Can be treated with OTC medications, minimally invasive
procedures, e.g. sclerotherapy, or surgery, e.g. haemorrhoidectomy.
Hepatitis
See Ch 11 Infectious diseases.
Inammatory bowel disease (IBD)
There are two main types: Crohns disease and ulcerative colitis.
The cause is unknown but may be autoimmune as a result of the
immune system attacking the GIT. It usually affects people aged
15 to 25 and 55 to 65.
Irritable bowel syndrome (IBS)
A group of symptoms characterised by intermittent and recurrent
abdominal pain associated with an alteration in bowel function.
Not to be confused with IBD.
Causes
Stress
Ingestion of irritants, e.g. coffee, alcohol
Laxative abuse
Other illness, e.g. gastroenteritis.
Signs and symptoms
Abdominal pain relieved by atulence or bowel actions
Diarrhoea or constipation
Mucus in stools
Bloating.
Diagnosis
Sigmoidoscopy
Colonoscopy
CT
Lactose intolerance tests
Blood tests for other diseases, e.g. coeliac disease.
Treatment
Increase dietary bre or bre supplements, e.g. Metamucil
Eliminate high-gas foods from the diet
Medications
Anticholinergics (to relieve symptoms)
Antidiarrhoeal medication, e.g. loperamide.
Observe uid status.
Jaundice
Yellowish discolouration of the sclera of the eye, skin and deep
tissues due to an abnormally high accumulation of bilirubin in
the blood.
Types
Intrahepatic
Caused by liver disease and drugs such as oral
contraceptives, anabolic steroids and chlorpromazine
Conjugated and unconjugated serum bilirubin levels are
abnormally high
Extrahepatic
Occurs due to obstruction of bile ow between the liver
and the intestine, caused by strictures of the bile duct,
gallstones and tumours of the bile duct or the pancreas
Conjugated levels of bilirubin are elevated.
Causes
Excessive destruction of red blood cells (haemolytic
jaundice)
Can occur following a blood transfusion or due to
hereditary diseases or haemolytic disease of the newborn
Decreased uptake of bilirubin by the liver cells
Decreased conjugation of bilirubin
Obstruction of bile ow (obstructive jaundice)
Infection
Liver disease, e.g. hepatitis
Medications.
Signs and symptoms
Pruritus preceding jaundice
Clay-coloured stools
Increase in urinary bilirubin
Abnormally high levels of serum alkaline phosphatase.
Treatment
Phototherapy (for infants)
Treat the cause (for adults).
Liver cancer
Can be primary (occurring in the liver cells) or secondary
(metastases of cancer in another area of the body)
Caused by hepatitis B and C, cirrhosis, exposure to toxins
and ulcerative colitis.
Signs and symptoms
Weakness and fatigue
Anorexia and weight loss
Bloating and abdominal fullness
Dull, aching right upper quadrant abdominal pain
Enlarged liver on palpation
Ascites
Jaundice.
Diagnosis
Liver function tests
Blood test for alpha-fetoprotein (AFP)
Ultrasound, CT, MRI
Liver biopsy.
Treatment
Surgical removal of the affected area of the liver
Radiation therapy
Chemotherapy
Alcohol injection
Radio frequency ablation
Cryoablation
Targetted drug therapy, e.g. Sorafenib
Liver transplant.
Complications
Liver failure
Renal failure
Metastases to other organs.
Pancreatic cancer
One of the most serious forms of cancer as it is seldom detected
in the early stages and spreads rapidly. The cause is unknown.
Signs and symptoms
Usually dont appear until the disease is in the advanced
stages
Upper abdominal pain that radiates to the back
Loss of appetite and weight loss
Jaundice
Pruritus
Nausea and vomiting
Palpable abdominal mass.
Diagnosis
Difcult to diagnose in the early stages
Barium meal
In the later stages, ultrasound, CT, MRI, endoscopic
retrograde cholangiopancreatography (ERCP), endoscopic
ultrasound (EUS)
Percutaneous transhepatic cholangiography (PTC)
Biopsy
Laparoscopy.
Treatment
Whipple procedure
Total pancreatectomy
Distal pancreatectomy
Radiation therapy
Chemotherapy
Targeted therapy, e.g. erlotinib
Palliative care.
Complications
Diabetes
Pain
Metastasis to other vital organs.
Pancreatitis
Inammation of the pancreas, resulting in exocrine dysfunction.
It can be acute or chronic, and occurs when digestive enzymes
attack the pancreas.
Causes
Common:
Biliary disease (gallstones) and long-term alcohol abuse
Less common:
Medications, abdominal surgery or trauma, infectious
disease, pancreatic cancer and genetic diseases.
Signs and symptoms
Increasing symptoms with alcohol and food consumption
Upper abdominal pain
Nausea and vomiting
Fever
Tachycardia
Swollen, tender abdomen on palpation
Flatulence
Weight loss despite normal eating
Dehydration
Hypotension
Bleeding
Steatorrhea.
Diagnosis
Acute
Blood tests for:
Elevated pancreatic enzymes, amylase and lipase
Elevated white blood cell count
Elevated liver function tests, particularly bilirubin
Hyperglycaemia
Hypocalcaemia
Ultrasound, CT, MRI
Chronic
Blood tests as per acute pancreatitis
Faecal specimen
Ultrasound
Pancreatic and bile duct X-ray
Pancreatic function test.
Treatment
Intravenous uid administration
Acute
Nil orally
Analgesia
Reduce or cease alcohol intake and smoking
Surgery to remove gallstones, if applicable
Chronic
Treatment to assist with the cessation of alcohol and drug
use
Analgesia
Enzyme supplements
Smaller, more frequent meals that are low-fat
Treat other conditions, e.g. diabetes, bleeding, infection.
Complications
Infection
Pseudocysts or abscess
Renal failure
Myocardial depression
Acute respiratory distress syndrome (ARDS)
Shock
Disseminated intravascular coagulation (DIC)
Malnutrition
Diabetes
Pancreatic cancer.
Frequent vital signs
Cardiac auscultation (third heart sound may be detectable)
Respiratory assessment
Blood tests as ordered
Arterial blood gases
Monitor neurological status
Monitor renal output
Gastrointestinal auscultation and palpation
Pain assessment.
Small bowel obstruction (SBO)
Complete obstruction of the small intestine or colon, preventing
the movement of any food or uids through the bowel. It may
cause bowel necrosis, perforation of the intestine, leading to
peritonitis and shock, and can be fatal if left untreated.
Types
Simple
Blockage with no further complications
Strangulated
Blood supply to the obstructed section is cut off
Close-looped
Both ends of a bowel section are occluded.
Causes
Mechanical obstruction due to adhesions, carcinomas,
foreign bodies, stenosis or hernias
Non-mechanical obstruction due to electrolyte imbalances,
drug toxicity, thrombosis of a mesenteric vessel or a
paralytic ileus.
Signs and symptoms
Abdominal cramps
Constipation
Nausea and vomiting (of faecal contents)
Abdominal tenderness and distension
Scant or no bowel sounds.
Diagnosis
Physical examination
Abdominal X-rays, CT or MRI.
Treatment
Nasogastric tube (NGT) to decompress the bowel
IV uids and electrolytes
Surgery if signs of strangulation.
Nil orally
Assess bowel sounds for the return of peristalsis
Centrally acting antiemetics only, e.g. metoclopramide
No opiates for pain
No laxatives.
Ulcerative colitis
An inammatory bowel disease that causes chronic inammation
of the mucosa of the colon and rectum. It can be debilitating
and may lead to life-threatening complications. There is no cure,
however with treatment, symptoms can be greatly reduced and
remission can occur.
Signs and symptoms
Diarrhoea that is often bloody
Rectal bleeding
Abdominal cramping relieved by bowel action.
Diagnosis
Blood test
Faecal test
Barium enema
Colonoscopy
X-ray or CT.
Treatment
Medications:
Antibiotics, e.g. metronidazole
Immunosuppressants, e.g. azathioprine, cyclosporine
Antiinammatories, e.g. corticosteroids, sulfasalazine
Antidiarrhoeals, e.g. metamucil, loperamide
Analgesia (not NSAIDs as these may exacerbate
symptoms)
Iron supplements
Bowel resection (of the diseased bowel).
Observe hydration and electrolyte status.
Ulcers
Open sores that develop in the lining of the oesophagus, stomach
or duodenum. They are usually caused by bacterial infection
(H. pylori), medications or gastric acid reux.
Signs and symptoms
Burning sensation or pain in the chest and stomach region
Pain that is relieved after eating
Nausea and vomiting
Haematemesis and/or melaena.
Diagnosis
Barium meal
Gastroscopy
Blood or faecal tests (to detect presence of H. pylori).
Treatment
Medications
Antacids
Proton pump inhibitors, e.g. omeprazole
H
2
-receptor antagonists, e.g. ranitidine
Antibiotics
Cytoprotective agents, e.g. sucralfate
Physical rest.
Medical interventions
Nasogastric tube (NGT)
Types
Wide bore (usually 2 lumens)
Indications:
Decompression
Gastric lavage
Aspiration of gastric contents, e.g. for testing
To give medication, e.g. charcoal
Example: Salem Sump
Small lumen for ventilationprevents the gastric
mucosa from damage if the tube adheres to the lining
during suctioning
Fine bore (usually only 1 lumen)
Indications:
Enteral feeding (short-term)
If need enteral feeding long-term, then a percutaneous
endoscopic gastrostomy (PEG) would be better
Example: Levin.
Check the tube placement:
After each new insertion by chest X-ray, before
commencement of enteral feeding
At the beginning of each shift, by aspirating the
stomach contents and testing with pH indicator strips,
not litmus paper. pH of 5.5 or less indicates correct
placement.
Contraindicated if patient has a base of skull fracture.
Surgical interventions
Appendectomy
Surgical removal of the appendix to prevent rupture or
perforation, or to remove if already ruptured.
Cholecystectomy
Surgical removal of the gallbladder due to the presence of
gallstones or inammation.
Can be either:
Open via a laparotomy, or
Laparoscopiccontraindicated in pregnancy, peritonitis
and bleeding disorders.
Liver transplant
The replacement of the patients liver with a donor liver. Used
for the treatment of chronic hepatitis B and C, bile duct disease,
alcoholic liver disease, autoimmune liver disease, fatty liver
disease, liver cancer and liver failure.
Percutaneous endoscopic gastrostomy
(PEG) tube
An external opening into the stomach, made surgically by piercing
the abdominal wall and placing a tube through. It is also known
as a gastrostomy tube.
Indications
Infants with abnormalities of the mouth
Patients who cannot swallow correctly
Patients receiving long-term enteral feeds, e.g. cystic brosis
and HIV patients.
Complications
Complications of surgery and anaesthesia, e.g. bleeding,
infection.
Always ush the tube well after giving a feed and at the
beginning of your shift
Contraindications for feeding include SBO, paralytic ileus,
severe diarrhoea, peritonitis, peritoneal dialysis, severe
pancreatitis and gastrointestinal ischaemia.
If the tube becomes dislodged and there is no
spare tube, a Foley catheter can be placed in
the opening (with the balloon blown up to stop it
falling out) to prevent the stoma from closing.
Stoma, ileostomy and colostomy
Stoma means any opening
An ileostomy is when there is a surgical stula between the
ileum and the abdominal wall. It is when the colon and the
rectum are removed.
A colostomy is when there is a surgical stula between
the colon and the abdominal wall. It is when the rectum is
removed or part of the colon has been removed to allow for
healing.
Indications
Crohns disease or ulcerative colitis
Bowel or rectal cancer
Trauma.
Observe the stomait should be pink and moist
A stoma has no pain receptors:
Take care when placing the pouch on the stoma
Constriction of the opening could cause skin damage
without the patient feeling pain
Never pierce the pouch to release gas, as this destroys
the odour-proof seal releasing the odour into the
environment.
Tests
Liver function tests
Used to evaluate the functions of the liver.
Alanine aminotransferase (ALT)
Normal levels:
Neonate: < 50 U/L
Adult: < 35 U/L
Used for the detection and monitoring of liver cell damage
Increased levels indicate hepatocellular damage
More specic than AST or LD (see below).
Albumin
Normal levels are 3245 g/L
Used for the assessment of hydration and nutritional status
of patients with protein-losing disorders and liver disease
Decreased levels indicate overhydration, chronic liver
disease, protein-losing disorders such as nephrotic
syndrome, malnutrition and extravascular space shifts such
as in burns patients
Increased levels indicate dehydration.
Alkaline phosphatase (ALP)
Normal levels are:
Neonate: 50300 U/L
Child: 70350 U/L
Adult: 25100 U/L
Used to investigate hepatobiliary or bone disease
Increased levels are seen in liver disease, bone disease, some
bony metastases, and malignancy without liver or bone
metastases
Can also be elevated in some gastrointestinal disorders.
Aspartate aminotransferase (AST)
Normal levels are:
Neonates: < 80 U/L
Adults: < 40 U/L
Used for detection and monitoring of liver cell damage
Increased levels indicate hepatocellular disease.
Bilirubin
Normal levels are:
Total bilirubin: < 20 mmol/L
Direct bilirubin: < 7 mmol/L
Used for the investigation and monitoring of hepatobiliary
disease and haemolysis
Total bilirubin
Comprises unconjugated, conjugated and delta bilirubin
Usually only required for diagnosis
Direct bilirubin
Comprises conjugated and delta bilirubin
Increased levels occur with hepatocellular disease or biliary
disease
May also be increased in anaemia, haemolysis and Gilberts
syndrome, jaundice of newborns
Levels may be normal in cirrhosis, liver failure or hepatic
metastases until the disease is advanced.
Gamma glutamyl transferase (GGT)
Normal levels are:
Female: < 30 U/L
Male: < 50 U/L
Used to assess liver disease
Increased levels occur in cholestatic liver disease and
hepatocellular disease with cholestasis
Increased levels are also seen in diabetic patients with
chronic alcohol and drug excess, pancreatitis and prostatitis.
Globulins
Normal levels are:
Neonate: 1236 g/L
Adult: 2535 g/L
Used to identify hypo- and hypergammaglobulinaemia
Increased levels occur with chronic inammation, infection,
autoimmune disease, liver disease and paraproteinaemia
Decreased levels occur in protein-losing enteropathy,
humoral immunodeciency and nephrotic syndrome.
Lactate dehydrogenase (LD)
Normal levels are 110230 U/L
Used for the non-specic assessment of liver disease or
malignancy and anaemia
Increased levels occur in myocardial infarction, liver disease,
haemolysis, ineffective erythropoiesis, some malignancies,
muscle disease and diseases that cause tissue damage.
Prothrombin time (PT)
Normal levels are 1115 seconds
More sensitive than activated partial thromboplastin time
(APTT) for detection of coagulation deciencies due to
vitamin K deciency and liver disease
Used to screen for deciency of factor VII, X, V, II, I
Can also be expressed as an INR when used to monitor
anticoagulant therapy
Abnormal results are due to liver disease, vitamin K
deciency and the use of oral anticoagulants.
Sigmoidoscopy
An endoscopic examination of the lining of the descending
colon, sigmoid colon, rectum and rectal canal.
Purpose
To diagnose acute or chronic diarrhoea and rectal bleeding
Aids in the assessment of known ulcerative colitis.
Procedure
May need to fast prior
May need to take a laxative or have a bowel washout prior
Will probably have a light sedative
Takes about 1030 minutes.
Complications
Bleeding
Bowel perforation
Vasovagal reaction (severe bradycardia and even cardiac
arrest).
Proctosigmoidoscopy
Endoscopic examination of the lining of the distal sigmoid colon,
rectum and rectal canal.
Purpose
Aids diagnosis of IBD, infections, polyps, stulas and abscesses.
Colonoscopy
A visual examination of the large intestine.
Purpose
To detect and evaluate IBD
To locate lower GIT bleeding
To aid diagnosis of polyps.
Procedure
A light sedative will probably be given
Patient should have a pulse oximeter on at all times
Specimens or biopsies may be taken
Electrocautery may be used to remove polyps or stop
bleeding
Takes about 3060 minutes.
Complications
Bowel perforation
Bleedingfrom the biopsy/polyp removal.
Barium meal or enema
Barium is either swallowed or given as an enema. The patient is
then X-rayed to diagnose their condition.
Upperbarium meal
Examination of the pharynx and oesophagus to investigate
strictures, ulcers and GORD.
Lowerbarium enema
To diagnose inammatory disorders, colorectal cancer,
polyps and diverticulitis.
Endoscopic retrograde
cholangiopancreatography (ERCP)
A radiographic examination of the pancreatic ducts via an
endoscopic tube.
Purpose
To evaluate obstructive jaundice
To diagnose cancer of the duodenum, pancreas or biliary
ducts.
Procedure
A tube is swallowed and inserted until the common bile duct
is visualised
Patient will need a light anaesthetic
Contrast medium will be given.
Complications
Adverse drug reactionfrom the contrast
Bowel perforation
Pancreatitis.
Pharmacology
Alginates
Action:
Create a foam that lies on top of gastric contents,
preventing reux
Example: Gaviscon
.
Antacids
Action:
Weak bases
React with hydrochloride acid to form water-soluble salts
Neutralise the hydrochloric acid
Above a pH of 4, pepsin becomes inactive
Examples: aluminium hydroxide, magnesium carbonate.
Antiemetics
All antiemetics work by blocking the dopamine or 5-hyd-
roxytryptamine (5-HT3) receptors in the chemoreceptor trigger
zone in the brain.
Dopamine antagonists
Action:
Block dopamine receptors at low doses, and 5-HT3 at
high doses
Increase tone in the lower oesophagus
Increase gut motility
Stomach and duodenum empty more quickly
Example: metoclopramide.
5-hydroxytryptamine (5-HT3) antagonists
Action:
Selectively block the 5-HT3 receptors
Example: ondansetron.
Antiemetic-antipsychotics
Action:
Dopamine receptor antagonists
Example: prochlorperazine.
Antihistamines
Action:
Act on the H
1
receptors
Block the vomiting centre in the brain
Example: promethazine.
Aminosalicylates
Action:
Unknown; thought to work by causing inhibition of
leucocyte chemotaxis
Have an antiinammatory effect
Treatment must continue for at least two years after patient
has been symptom-free
Example: sulfasalazine.
Anti-diarrhoeal agents
Action:
Reduce gastric motility, therefore water and electrolyte
absorption is increased
Example: loperamide.
Histamine H
2
receptor antagonists
Action:
Block the histamine H
2
receptors
Decrease intracellular cyclic adenosine monophosphate
(cAMP)
Decrease proton pump activity
Therefore decrease acid secretion
Example: ranitidine.
Laxatives
Bulk-forming
Action:
Increase intestinal volume
Cause intestinal wall distension
Stimulate the emptying reex
Example: ispaghula husk (Fybrogel).
Osmotic
Action:
Make the uid in the bowel hypertonic
Water wont be reabsorbed, therefore there is more uid
in the bowel
Intestinal wall distension
Defaecation reex
Example: lactulose.
Softening
Action:
Lubricate and soften the intestinal contents
Act like a detergent
Examples: liquid parafn, docusate.
Stimulant
Action:
Irritate the intestinal wall and stimulate peristalsis
Example: senna.
Proton pump inhibitors
Action:
Inhibit the enzyme hydrogen/potassium ATPase
Lower the acidity of gastric juices
Take 35 days for full effect if used for prophylactic use
Example: omeprazole.

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