IX.

GASTROINTESTINAL
1. Diagnostic Tests c. Abdominal mass- swollen PANCREAS
a. Upper GI d. Rigid board-like abdomen (guarded)
 Looks at the sophagus and stomach with dye  What does it mean? PERITONITIS
 NPO past midnight e. Bruising around umbilical area (CULLEN sign) ; flank
 No smoking area (GREY TURNER’S sign).
- Smoking increases motility which will affect the f. Fever (inflammation)
test g. N/V
h. Jaundice
b. Barium Enema i. Hypotension = BLEEDING or ASCITIS
Clear liquids
Laxative or enemas until clear; may have to drink gallon 3. Dx:
of Go-Lytely. Yummy >_<! a.  Serum lipase and amylase
Make sure patient has a BOWEL MOVEMENT post- b. WBC
procedure c. Blood sugar
d. SGOT, SGPT -liver enzymes
c. Gastroscopy (SGPT= ALT, SGOT= AST)
 NPO pre-procedure e. PT, PTT – PROLONGED. (BLEEDING)
 Sedated f.  Serum bilirubin
 NPO until what returns?______ g. H/H (Hemoglobin & Hematocrit )
 Watch for perforation
 Why down BLEEDING , up DEHYDRATED.
d. Liver Biopsy Down because of bleeding and increase in hemoglobin
Two main functions of the liver because dehydration (more concentrated).
1)__________body
2) Helps to ___________ Blood ***Please note that all normal ranges for blood test depend
on the lab performing the test.

 clotting studies pre-procedure 4. Tx:

 Vital signs pre-procedure a. Goal: Control pain
 How do you position this patient? 1)  gastric secretions (KEEP NPO, NGT to suction, bed
Exhale and hold (gets the diaphragm out of the rest)
way  Want the stomach empty and dry
 Post-op: Lie on ________side
Vital Signs 2) Pain Medications with opiod PCA :
 PCA narcotics morphine sulfate(Morphine®),
e. Paracentesis hydromorphone (Dilaudid®)
 removal of fluid form the peritoneal cavity (ascites)  Fentanyl patches
 have patient void
 position 3) Steroids, why? INFLAMMATION
 vital signs
4) Anticholinergics, why? DRY UP THE STOMACH
ACIDS
A. Pancreatitis:  Benzotropine
1. Pathophysiology: (Cogentin®)Diphenoxylate/Atropine (Lonox®)
a. The pancreas has two separate functions:
1) Endocrine- INSULIN 5) Pantoprazole (Protonix®) (proton pump inhibitor)
2) Exocrine- DIGESTIVE enzymes 6) Ranitidine HCI (Zantac®), Famotidine (Pepcid®) (H2
receptor antagonist)
b. Two types of pancreatitis:
1) Acute: #1 cause = ALCOHOL 7) Antacids
#2 cause = gallbladder disease 8) Maintain fluid and electrolyte balance
2) Chronic: #1 cause = Alcohol 9) Maintain nutritional status → ease into a diet

2. S/S: 10) Maintain Insulin ProductionWHY?

a. Pain- Does the pain increase or decrease with eating?  PANCREAS IS SICK
INCREASE  STEROIDS MAKE IT GO UP
 GETTING A TPN
b. Abdominal distention/ascites (losing protein rich fluids
like enzymes and blood into the abdomen) → ascites Normal Lab Values Normal Lab Values
AST=8-40 U/L Amylase: 45-200 U/L (dye)  Post-procedure Lie on RIGHT side
ALT= 10-30 U/L Lipase: 0-110 U/L Vital signs, worried about HEMORRHAGE.

Hemoglobin: Hematocrit: 4. Tx:

Male: 14-18 g/dl Male: 40-54% a. Antacids, vitamins, diuretics
Female: 12-16 g/dl Female: 38-47% b. No more ALCOHOL (don’t need more damage)
c. I & O and daily WEIGHT (Any time you have ascites
*TESTING STRATEGY* you have a fluid volume problem)
Pancreas client = Keep stomach empty and dry.
d. Rest
11) Daily weights e. Prevent bleeding (bleeding precautions)
12) Eliminate alcohol f. Measure abdominal girth, why? ASCITIS
13) Refer to AA if this is the cause.
g. Monitor jaundice – good SKIN care, CUT
B. Cirrhosis: FINGERNAILS.
 Liver DETOXIFYING the body. h. Avoid NARCOTICS - liver can’t metabolize drugs well
 Helps your blood to CLOT when it’s sick.
 The liver helps to metabolize (break down)  Never give tylenol to people with liver problem
DRUGS, DECREASE THE DOSE. NEVER  Antidote for acetaminophen overdose Acetycysteine
GIVE ASPIRIN. (Mucomyst )
 The liver synthesizes ALBUMIN
i. Paracentesis:
 Removal of fluid from the PERITONAL cavity
1. Pathophysiology:
(ascites)
 Liver cells are destroyed and are replaced with
 Have client void before
connective/scar tissue→ alters the
 Position SITTING UP/FOWLERS
CIRCULATION within the liver→ the BP in the liver goes
 Complication: shock
UP, this is called portal HYPERTENTION
 What are you looking for in VS durng/after
paracentesis? VS with shocy clients,BP goes DOWN and
2. S/S: HR go UP
a. FIRM, nodular liver
b. Abdominal pain – liver capsule has stretched
c. Chronic dyspepsia (GI upset) *TESTING STRATEGY*
d. Change in BOWEL habits - Anytime you are pulling fluids→ throw them into shock.
e. Ascites - If you give a liver patient narcotics, it is the same as
f. Splenomegaly- immune sustem has kicked in double dosing them.
g.  serum albumin – HOLD ON THE FLUID IN THE
VASCULAR SPACE j. Diet:
h.  ALT & AST – LIVER ENZYMES   protein
i. Anemia  Low Na diet
j. Can progress to hepatic encephalopathy/coma

*TESTING STRATEGY* C. Hepatic Coma:

If your liver is sick your 1. Pathophysiology:
#1 concern = Bleeding. a. When you eat protein, it transforms into AMMONIA,
Never give Tylenol to liver people. and the liver converts it to urea. Urea can be excreted
When spleen is enlarged the immune system is involved. through the kidneys without difficulty.

3. Dx: b. When the liver becomes impaired then it CANNOT

a. Ultrasound make this conversion, so what chemical builds up in the
b. CT, MRI blood? AMMONIA
c. Liver biopsy c. What does this chemical do to the LOC? DECREASE
 Clotting studies pre- PT and PTT
 Vital signs pre-procedure 2. S/S:
a. Minor mental changes/motor problems
 How do you position this client? SUPINE b. Difficult to AWAKE.
WITH RIGHT ARM BEHIND THE HEAD c. Asterixis- FLAPPING FINGERS
 Exhale and hold DIAPHRAM d. HANDWRITING changes
Why? To get the DIAPHRAM out of the way. e. Reflexes will .
f. EEG SLOWS DOWN.
g. What is Fetor? Breath smells like AMMONIA.VERY
STONG BREATH SMELL.
 Some think it smels like wine, fresh cut grass, acetone)
h. Anything that increases the ammonia level will aggravate
the problem.
i. Liver people tend to be GI bleeders.
Describe EVL or Endoscopic Sclerotherapy? When its
used?
EVL or Endoscopic sclerotherapy are more commonly used
for esophageal varices.
- uses a banding procedure and Endoscopic sclerotherapy is
when the physician injects a sclerosing agent in the varices
via an endoscope.

3. Tx: E. Peptic Ulcers:

a. Lactulose (Lactulax®, Duphalac®) ( serum ammonia) 1. Pathophysiology:
b. Neomycin Sulfate (decreases ammonia-producing a. Common cause of GI BLEEDING
bacteria in the gut) b. Can be in the esophagus, stomach, duodenum
c.Cleaning enemas (to get rid of blood) c. Mainly in males or females? MALES, BUT
d.  PROTEIN in the diet INCREASING IN FEMALES
e. Monitor serum ammonia d. Erosion is present
Let’s Get Normal Straight First!
Protein→ Breaks down to ammonia→ The Liver converts 2. S/S:
ammonia to urea→ Kidneys excrete the urea a. Burning PAIN usually on the mid-epigastric area/back
b. Heartburn (dyspepsia)
*TESTING STRATEGY*
If you give liver client narcotics it’s the same thing 3. Dx:
as double dosing them. a. Gastroscopy (EGD, endoscopy):
1) NPO pre
D. Bleeding Esophageal Varices 2) Sedated
3) NPO until what returns? GAG REFLEX
1. Pathophysiology: 4) Watch for perforation by watching for PERFORATION,
a. High BP in the liver (PORTAL HTN) forces collateral bleeding, or SWALLOWING.
circulation to form.
 This circulation forms in 3 different places→ b. Upper GI:
stomach, esophagus, rectum 1) Looks at the esophagus and stomach with dye
2) NPO past midnight
b. When you see an alcoholic client that is GI bleeding it is 3) No smoking, chewing gum, or mints. Remove the
usually esophageal nicotine patch, too.
varices.  Smoking  stomach SECRETIONS which
 Usually no problem until RUPTURES. will affect the test

2. Tx: 4. Tx:
a. Replace BLOOD
a. Medications:
b. VS
1) Antacids: Liquids or tablets? LIQUIDS (to COAT
c. CVP
stomach)
d. Oxygen (any time someone is ANEMIC, Oxygen is
 Take when stomach is empty and at bedtime –
needed)
when stomach is empty acid can get on ulcer…
take antacid to protect ulcer.
e. Octreotide (Sandostatin®) (lowers BP in the liver.)
f. Sengstaken Blakemore Tube (balloon tamponade)
2) Proton Pump Inhibitors: ( acid secretions)
 What is the purpose? To hold PRESSURE on
 Omeprazole (Prilosec®), Lansoprazole (Prevacid®),
bleeding varices
Pantoprazole (Protonix®), Esomeprazole (Nexium®)
 It is an infrequently used emergency procedure that may
be used to stabilize clients with severe hemorrhage. It
3) H2 antagonist: Ranitidine (Zantac®), Famotidine
should be used more than 12 hours. Many of the safety
(Pepcid®)
implications for the Blakemore tube can be applied to other
 GI Cocktail (donnatel, viscous lidocaine, Mylanta II®)
oropharynx or nasopharynx tubes.
 Antibiotics for H. Pylori: Clarithromycin (Biaxin®),
Amoxicillin (Amoxil®), Tetracycline (Panmycin®),
g. Cleansing enema (to get rid of blood)
Metronidazole (Flagyl®)
h. Lactulose (Neo-Fradin®) ( ammonia)
 Sucrafata (Carafate®): forms a barrier over wound so
i. Saline lavage (to get blood out of STOMACH)
acid can’t get on the ulcer
j. Neomycin (decreases ammonia producing bacteria)
b. Client Teaching: Lay on left side to keep food in the
  STRESS stomach.
 Stop SMOKING
 Eat what you can tolerate; avoid temperature extremes
and extra spicy foods; avoid CAFFEINE (irritant). H. Ulcerative Colitis and Crohn’s
 Need to be followed for one year Disease:
1. Pathophsiology:
5. Classifications: a. Ulcerative Colitis→ ulcerative inflammatory bowel
a. Gastric ulcers: laboring person; malnourished, pain is disease
usually half hour to 1 hour after meals; food doesn’t help,  Just in the large intestine
but VOMITTING does; vomit blood
b. Crohn’s Disease→ also called Regional Enteritis;
b. Duodenal ulcers: executives; well-nourished; night time inflammation and erosion of the ILEUM * but can be
pain is common and 2-3 hours after meals; FOOD helps; found anywhere in the small or large intestine
blood in stools
2. S/S:
F. Hiatal Hernia: a. Diarrhea
b. Rectal bleeding
1. Pathophysiology: c. Weight loss
a. This is when the hole in the diaphragm is too large so the
d. Vomiting
STOMACH moves up into the thoracic cavity.
e. Cramping
b. Other causes of hiatal hernia: congenital abnormalities,
f. Dehydration
trauma, and SURGERY
g. Blood in stools
h. Anemia
2. S/S: i. Rebound tenderness
a. Heartburn  What is rebound tenderness? Push in → let
b. FULLNESS after eating go→ HURTS
c. Regurgitation  What does it mean? Peritoneal
d. Dysphagia (difficulty SWALLOWING) INFLAMMATION
j. Fever
3. Tx:
a. Small frequent meals 3. Dx:
b. Sit up 1 hour after eating Keep the stomach in down a. CT
position. b. Colonoscopy
c. Elevate HOB (keep stomach in down position)  Pre-op
d. Surgery  CLEAR liquid diet for 12-24 hours.
e. Teach life style changes and healthy diet  NPO 6-8 hours pre
 Avoid NSAIDs
G. Dumping Syndrome:  Laxatives or enemas until CLEAR
 Go-LYTELY®
1. Pathophysiology:  Sedated for procedure
 The stomach empties too quickly and the client
experiences many uncomfortable to severe side effects
 Post op watch for PERFORATION. We are going to
 usually secondary to gastric bypass, gastrectomy, or gall
assume the WORST! The signs of perforation are
bladder disease.
pain and unusual discomfort
2. S/S: c. Barium Enema
a. Fullness
 BE or lower GI
b. Palpitations
 Done if colonoscopy was incomplete
c. Faintness
d. weakness, cramping, diarrhea
4. Tx:
3. Tx: a. Diet:
a. Semi-recumbent with meals  High fiber or low fiber? LOW FIBER
b. Lie down after meals Trying to limit motility to help save fluid.
c. No FLUIDS with meals (drink in between meals)
d.  CARBS (carbs empty fast)  Avoid cold foods or hot foods and smoking
All of these can INCREASE motility.
*TESTING STRATEGY*
b. Medications:
 Anti-diarrheals  The further down the colon the stoma is, the more
Only given with mildly symptomatic ulcerative formed the stool will be because WATER is being drawn
colitis clients; does not work well in severe cases. out. The stool is more normal.
 Antibiotics
 Steroids ( INFLAMMATION)  When you irrigating an ostomy what same principles do
 Biologics (adalimumab [Humira] and infliximab you use?
[Remicade])- newest class of medication Same principles as if you were administering an enema
- interfere with body’s immune response. Act
selectively.  Anytime you are giving an enema and if the client starts
to cramp you do what?
c. Surgery: If the client starts to cramp, stop the fluids, lower the
1) Ulcerative Colitis: bag and or check the temp of the fluid
 Total Colectomy (ilesostomy formed)
 Kock’s ileostomy or a J Pouch (no external
bag) I. Appendicitis:
- A Koch’s Pouch has a nipple valve that
opens and closes to EMPTY intestines 1. Pathophysiology:
-The J Pouch procedure removes the  Related to a LOW fiber diet
colon and attaches the ileum into
the rectum. 2. S/S:
 Remove colon/rectum and attach ileum to anal area →  Generalized pain initially
temporary colostomy Eventually localizes in the right lower quadrant
- Anytime someone has a GI tract surgery & they return (McBurney’s POINT)
with a temporary colostomy, the purpose of the colostomy  Rebound tenderness
is to allow the intestines time to rest & heal.  Nausea and vomiting
 Get good hx (abdominal pain 1st then N & V)
2) Crohn’s: (try not to do surgery)  Anorexia
 May remove only the ILEUM area.
 The client may end up with an ileostomy or a 3. Dx:
colostomy. It just depends on the area affected.  WBC 
 Ultrasound
d. Post op Care:  CT
Ostomy in the = ileostomy  Do not do enemas or laxatives because you are worried
Ostomy in the colon = colostomy about what? RUPTURE/PERFORATION

1) Ileostomy Care: 4. Tx:

 Continuous LIQUID drainage).
 Avoid foods hard to digest; rough foods  motility.
 Gatorade® or a similar electrolyte replacement drink
in the summer
 At risk for kidney stones (always a little
DEHYDRATED)
2) Colostomy Care:
 What happens as waste moves through the colon?
Water and nutrients are being absorbed and the STOOL is
forming.
 Colostomy → ascending and transverse→ semi
LIQUID
stools
 Colostomy→ descending or sigmoid→ semi formed or
FORMED.
 Which one do you irrigate? SIGMOID & DECENDING
 Why irrigate? FOR REGULARITY OF STOOLS
 When is the best time to irrigate? Same TIME everyday
After a MEAL
 Surgery
Most done via laparoscope unless perforated.
 After any major abdominal surgery, what is the position
of choice? SITTING ON THE RIGHT SIDE(?) Elevate
HOB
*TESTING STRATEGY*
#1 thing to worry about is rupture.
Positioning is very important to learn as a brand new nurse.
Never want pressure on a suture line.
J. Hyperalimentation (total parental
nutrition) (TPN):
1. Nursing Considerations:
 Keep refrigerated to store; warm for administration; let
sit out for a few minutes prior to hanging.
 Central line needed
 Filter needed
 Nothing else should go through this line (dedicated
line)

 Discontinued gradually to avoid HYPOGLYCEMIA

 Daily WEIGHTS
 May have to start taking INSULIN
 Accu-checks q6 hours

 Check URINE (for GLUCOSE & KETONES)

 Do not mix ahead- mixture changes everyday according
to electrolytes.
 Can only be hung 24 hours
 Change tubing with each new bag.

 IV bag may be covered with dark bag to prevent

chemical breakdown.
 Needs to be on a pump
 Home TPN-emphasize hand washing
 Most frequent complication→ INFECTION

*TESTING STRATEGY*
Protein can’t leak through the glomerulus unless there is
kidney damage.

2. Assisting the MD insert a central line:

 Have saline available for flush; do not start fluids until
positive confirmation of placement (CXR). (3) 10cc syringe
 Position? TRENDELENBURG to distend veins.
 If air gets in the line what position do you put the
client in? LEFT SIDE TREDELENBURG
 When you are changing the tubing, how can you avoid
getting air in the line? Clamp it off, Valsalva
Take a deep BREATH and HUMMMMMM
If air emoblus is susppected in the heart → may be taken to
cath lab for air removal

 Why is an x-ray done post-insertion?

Check for PLACEMENT
Make sure your client does not have a PNEUMOTHORAX.

*Push/pause when administering meds via central line.

NCLEX® Critical Thinking Exercise:

A nurse is assisting a physician inserting a central line, for a
client diagnosed with sepsis. After inserting the central line.
Which of the following options would be most appropriate?
1. Start the ordered antibiotics.
2. Allow the physician to start the antibiotics as ordered.
3. Check for blood return and if present start the antibiotics
ordered.
4. Administer the stat antibiotics after you have
confirmation of placement of the central line.