MEDICAL-SURGICAL 2 : PTM1
Care of Clients with Gastrointestinal
Disorders
Abdominal Pain
O - Onset: “When did the pain begin?”
L - Location: “Please point where exactly you
fee the
pain.”
D - Duration: “How long does the pain last?”
C - Characteristic: “Please describe the pain
you feel
in your abdomen.”
A - Aggravating: “What triggers the pain?”
R - Relieving: “What relieves the pain?”
T - Timing: “When does the pain occur?”
S - Severity: “Please rate your pain from 110”
Dyspepsia
• Upper abdominal discomfort
associated with eating
• Most common symptom of patients
with GI
 dysfunction
• Typically caused by fatty foods, salads,
coarse vegetables, and highly
seasoned foods
Intestinal Gas
• Accumulation of gas in GI tract
• Belching: expulsion of gas from
stomach through the mouth
• Flatulence: expulsion of gas from the
rectum
• May indicate food intolerance or gallbladder
Disease
Nausea and Vomiting
• Nausea is a vague, uncomfortable
sensation
of sickness that may or may not be followed
by vomiting
• Vomiting is a physiologic protective
response
that limits the effects of noxious agents by
emptying the stomach contents and
secretions of small intestine
• Triggers: odors, activity, medications, food
Intake
Change in Bowel Habits
• Diarrhea: an abnormal increase in
frequency and
liquidity of stool or in daily stool weight or
volume
• Commonly occurs when the contents
move so rapidly through the intestine
and colon that there is inadequate
time for the GI secretions and oral
contents to be absorbed.
• Constipation: a decrease in frequency of
stool, or stools that are hard, dry, and of
smaller volume than typical
Change in Stool Characteristics
• Normal stool: light to dark brown
• Melena: Black tarry stool indicative of
upper GI bleeding
• Hematochezia: Bright red blood in stool
• Steatorrhea: Fatty stool
• Acholic stool: light- gray or clay- colored
stool resulting from decreased or absent
conjugated bilirubin
Diagnostic Tests for GI Disorders
Fecal Occult Blood Test (FOBT)/
Guaiac Test
• Stool for occult blood
• Done to detect GI bleeding
• Preparation:
• High fiber diet for 48-72 hours
• Avoid red meat, poultry, turnips, horse
radish,
• cauliflower, and melon – false positive
result
• Avoid vitamin C – false negative result
• Hold 48hrs prior: steroids, iron,
indomethacin, colchicine
• 3 stool specimens will be collected for
three consecutive days
Stool for Ova, Parasites, and E.
histolytica (OPEH)
• Clean technique
• Send fresh, warm specimen (within 30
mins)
Stool for Culture and Sensitivity
• Identifies microorganism and determines
appropriate antibiotic therapy
• Sterile technique
• Use sterile collection tube and sterile
cotton- tipped applicator to collect
Specimen
Abdominal Ultrasound (UTZ)
• Ultrasonography is a noninvasive
diagnostic technique in which highfrequency sound waves are passed into
the internal body structures, and the
ultrasonic echoes are recorded on an
oscilloscope as they strike tissues of
different densities.
• Used to detect:
• Enlargement of gallbladder, pancreas,
presence of gallstones, ectopic
pregnancy, appendicitis
• Sound waves cannot travel through bones,
gas, or fluid
• Nursing interventions:
• NPO 8 to 12 hours prior to UTZ
• If for gallbladder studies, fat-free meal
the
• evening before
• Schedule barium studies after
• ultrasonography since barium
interferes with
• sound wave transmission
UGI Tract Study (Barium Swallow)
• Visualizes esophagus, stomach, duodenum,
and jejunum
• Contrast medium: Barium sulfate –
white,
chalky substance
• X-rays are taken on standing, and lying
Position
• Nursing interventions:
• Pre procedure:
• NPO 6-8 hours
• Post procedure:
• Laxatives, as ordered
• Increase OFI
• Inform client that stool may become
white
• for 24-72 hours
LGI Tract Study (Barium
Enema)
• Visualization of colon through x- rays after
rectal installation of barium
• Barium enema is C/I for patients with
active inflammatory diseases, fistula, or
suspected
perforation of colon.
• Diatrizoic acid is used instead
(water-soluble iodinated contrast
medium)
• Nursing interventions:
• Low- residue diet 1 to 2 days before
• Clear liquid diet and laxative the
evening
• before
• NPO post-midnight
• Cleansing enema until clear in AM of
• procedure
• Schedule before any upper GI studies
Computed Tomography (CT) Scan
• Provides cross- sectional images of
abdominal organs and structures.
• Used to detect and localize many
inflammatory conditions in the colon
(appendicitis, diverticulitis, regional enteritis,
and ulcerative colitis)
• Painless procedure, but uses radiation
• Nursing interventions:
• Clear liquid diet in AM
• If using contrast medium:
• NPO 2-4 hours
• Check for allergies to seafood and
iodine
• Assess for claustrophobia
• Instruct client to remain still during
entire procedure
Magnetic Resonance Imaging (MRI)
• Noninvasive technique that uses magnetic
fields and radiowaves to produce images of
area being studied
• Used to evaluate abdominal soft tissues as
well as blood vessels, abscesses, fistulas,
neoplasms, and other sources of bleeding
• Nursing Interventions:
• Pre- procedure:
• NPO 6-8 hours
• Remove all jewelries and other metals
• Inform patient and family that
procedure lasts
• for 60 to 90 minutes, inform that the
MRI
• machine will make a knocking sound
during
• the procedure
• Assess for claustrophobia
• Contraindications:
• Pacemakers
•
•
Aneurysm clips
Orthopedic screws
Upper GI Endoscopy
• Direct visualization of esophagus,
stomach, and duodenum
• Nursing interventions (Pre op):
• Obtain written consent
• NPO 6-8 hours
• Administer Atropine sulfate, as
ordered
• Administer
sedatives/narcotics/tranquilizers, as
ordered
• Remove dentures or bridges
• Lidocaine spray is applied to the
posterior pharynx to depress gag
reflex.
• Instruct not to swallow saliva
• Nursing Interventions (Post op):
• Position to side- lying position
• NPO until gag reflex returns
• NSS gargle
• Monitor VS
• Assess: bleeding, crepitus, fever,
neck/throat
• pain, dyspnea, dysphagia,
back/shoulder pain
Lower GI Endoscopy
• Proctosigmoidoscopy: Direct
visualization of sigmoid and rectum
• Colonoscopy: Direct visualization of
the colon
• Nursing Interventions (Pre op)
• Obtain written consent
• Clear liquid diet 24 hours before
procedure
• Administer laxative/cathartic, as
ordered
• Cleansing enema until clear
• Position to knee-chest/lateral position
during procedure
• Assess for vasovagal stimulation
• Nursing Interventions (Post op):
• Position to supine for a few minutes
• Assess for signs of perforation –
bleeding, pain, fever
• Hot Sitz bath to relieve discomfort in
anorectal area
Common Nursing Procedures for Clients
with GI Disorders
• Gastrointestinal Decompression
• Enteral Feeding (NGT, PEG/PEJ)
• Parenteral Nutrition
Gastric and Intestinal Decompression
• The removal of gas or fluid to prevent
gastric and intestinal distention
• Achieved through the use of nasogastric
tubes (NGT) or nasoenteric tubes
Nasoenteric Tubes
Nursing interventions:
• After insertion of nasoenteric tubes,
turn patient to the RIGHT side. This
facilitates passage of tube to the
duodenum.
• Shortening of length of tube from the
outside indicates passage of tube to
duodenum
Enteral Feeding
Nasogastric Tube Feeding
• Also called gastric gavage
• Feeding formula should be at ROOM
TEMPERATURE. Cold formula causes
cramps.
• Position: semi- fowler’s to high- fowler’s
• Check NGT placement:
• BEST- xray
• Check pH of Gastric secretions (Should
be acidic with pH of 1-3)
• Note color of aspirate (greenish or
yellowish)
• Introduce 10 mL of air into NGT and
auscultate epigastric area for gurgling
sounds
• After each feeding, instill 30 to 60 mL of
water
• Have the client remain in semi- to highfowler’s position for 30 to 60 minutes after
feeding
Gastrostomy/Jejunostomy Feeding
• Gastrostomy: stoma is in the stomach
• A procedure in which an opening is created
into the stomach either for the purpose of
administering nutrition, fluids, and
medications via a feeding tube, or for gastric
decompression.
• Preferred way of enteral feeding for
nutritional
support of greater than 4 weeks
• Jejunostomy: stoma is in the jejunum
• A surgically placed opening in the jejunum
for the purpose of administering nutrition,
fluids, and medications
• Indicated when gastric route is not
accessible, or to decrease aspiration risk
when stomach is not functioning adequately
to process and empty food or fluids
vein
• Type of solution: hypertonic (25% to 35%)
• Nursing interventions:
• Administer TPN at ROOM
TEMPERATURE
• Consume TPN within 24 hours
• Change IV tubing every 24 hours
• Use an infusion pump to maintain a
steady infusion rate
• If infusion is delayed, DO NOT catch
up. Notify physician.
• Monitor urine and blood glucose
levels.
• Provide skin care on the catheter
insertion site
Care of Clients with Upper Gastrointestinal
Disorders
• Feeding should be at ROOM temperature
• Position: semi- to high- fowler’s position
• Check patency:
• Instill 15 to 30 ml of water
• Have the client remain in semi- to highfowler’s position for 30 to 60 mins after
feeding
Parenteral Nutrition
• A method of providing nutrients to the
body by an IV route
• Goals:
• To improve nutritional status
• Establish a positive nitrogen balance
• Maintain muscle mass
• Promote weight maintenance or gain
• Enhance healing process
Positive Nitrogen Balance
• Positive nitrogen balance is necessary
to create an anabolic environment, allowing
the body to build new muscle
Total Parenteral Nutrition (TPN)
• Primary purpose: to administer glucose
• Indications:
• Clients who need extensive nutritional
support over an extended period of
time
• Site of catheter insertion: SUBCLAVIAN
Stomatitis
• A painful disorder characterized by
inflammation and ulcerations in the mouth,
including the lips, tongue, and mucous
membranes
Herpetic Stomatitis
• Causative agent: Herpes simplex
virus (HSV) type 1
• Clinical manifestations:
• Diffuse, shiny erythematous
involvement of the gingiva with edema
and gingival bleeding
• Initially, lesions appear as spherical
• gray vesicles dispersed in different
areas
• After 24 hours, the vesicles rupture
and form painful small ulcers with a
red, elevated halo- like margins and a
depressed yellow and grayish- white
center.
Aphthous Stomatitis (Canker sores)
• Cause: Not well- understood
• Local altered immune response
• Systemic: Iron deficiency, vitamin B6
or B12 deficiency, DM, inflammatory
bowel disease, immunosuppression
• Clinical Manifestations
• Small, white painful ulcers
• Well- circumscribed lesion
Other Causes of Stomatitis
• Radiation therapy
• Chemotherapy
Medical Management:
• Lidocaine hydrochloride (Xylocaine):
topical anesthetic
• Acyclovir (Zovirax), if cause is HSV
• Analgesics, as ordered
Nursing Management
• Monitor caloric and food intake
• Provide soft, bland foods during acute
episodes
• Diet as tolerated (DAT) as the sores
heal
• Encourage small, frequent feedings
• Encourage to drink room temperature
liquids
• Provide/Assist with mouth care:
• Let patient rinse mouth with NSS
after
• eating
• Avoid alcohol- based mouthwash
• Use soft- bristled toothbrush
Esophageal Varices
Varices (sing. Varix)
• an enlarged, tortuous vein usually
occurring in the distal esophagus
• Cause:
• Portal hypertension
•Complications:
• Rupture of varices
• UGI Bleeding
•Clinical Manifestations:
• Generally asymptomatic
• GI bleeding manifestations:
• Hematemesis
• Coffee- ground emesis
• Melena
• Abdominal bloating
• Hypotension, tachycardia
Medical Management:
• Octreotide acetate (Sandostatin) IV
• Given to control bleeding by decreasing
blood flow to the GI tract, thus lowering
pressure in the portal system
• Balloon tamponade
• Uses Sengstaken-Blakemore tub
Balloon Tamponade
• The tube is passed into the
esophagus where a balloon will be
inflated to put direct pressure onto
the bleeding varices
• The balloon is periodically deflated
to prevent esophageal necrosis
•Nursing Responsibilities:
• Keep patient on NPO
• Elevate HOB to 30 to 45 degrees
• WOF: dyspnea
• Prepare at bedside: scissors
• If w/ respiratory distress, cut the tube
as this is a medical emergency
Medical Management:
• Sclerotherapy
• A procedure in which a caustic
substance is injected into the varix.
• An esophagogastroduodenoscopy
(EGD) is performed and a sclerosing
agent will be injected using a special
needle
•
Several treatment sessions are needed
to create a scar tissue that will
permanently stop the bleeding
• Esophageal ligation
• This procedure involves placing a
rubber band or O- ring on the varix
• An EGD is performed to guide the
placement of the bands
Surgical Management:
• Portacaval shunt (aka portosystemic
shunt)
• Relieves the pressure on the
• esophageal veins by redirecting blood
• from the portal vein to the inferior
vena
• cava
• Some blood bypasses the liver and
reenters the circulatory system
General Nursing Management:
• Place patient on bed rest if with active
bleeding
• May perform out of bed activities if no
bleeding but avoid strenuous activity and
Valsalva maneuvers
Hiatal Hernia
Hiatal Hernia (Diaphragmatic Hernia)
• The opening of the diaphragm through
which the esophagus passes becomes
enlarged, and part of the upper stomach
moves up into the lower portion of the
thorax
• Women >Men
• Sliding hiatal hernia (Type 1)
• Occurs when the upper
stomach and the gastroesophageal
junction are displaced upward and
slide in and out of the thorax
• 95% of hiatal hernia cases
• Primary cause: muscle weakness in
the esophageal hiatus – caused by
aging, congenital muscle weakness,
obesity, trauma, surgery, or prolonged
increases in intraabdominal pressure
• Paraesophageal hernia/Rolling hernia
(Type 2)
• Occurs when all or part of the
stomach pushes through the
diaphragm beside the
esophagus
• Most often the fundus and
greater curvature of the
stomach
• Primary cause: anatomical
Defect
• Clinical Manifestations:
• 91% are asymptomatic (Smith &
Shahjehan, 2021)
• Pyrosis: heartburns
• Dysphagia (difficulty swallowing),
odynophagia
(painful swallowing) due to compression
of esophagus
• Dyspnea
• Abdominal pain
• Nausea and vomiting
• Gastric distention, belching, flatulence
• Diagnostics:
• Barium swallow: confirmatory test
• Esophagogastroduodenoscopy
(EGD): the passage of fiberoptic tube
through the mouth and throat into the
digestive tract for visualization of the
esophagus, stomach, and small
intestine
• Chest CT scan
• Complication
• Erosive esophagitis
• Esophageal cancer
• Medical Management:
• Antiemetics- to relieve n&v
• Metoclopramide (Plasil)
• Ondansetron (Zofran)
• Promethazine (Phenergan)
• Antacids- neutralizes the acid in the
stomach
• Aluminum hydroxide
• Magnesium hydroxide
• H2- receptor antagonist- to suppress
secretion of gastric acid
• Cimetidine (Tagamet)
• Ranitidine (Zantac)
• Famotidine (Pepcid)
• Proton pump inhibitors- to suppress gastric
acid secretions
• Esomeprazole (Nexium)
• Lansoprazole (Prevacid)
• Omeprazole (Losec)
Surgical Management:
• Nissen Fundoplication
• Reserved for extreme cases which
involves gastric outlet obstruction or
suspected strangulation
• The upper part of the stomach is
wrapped around the LES to
strengthen the sphincter, prevent
acid reflux, and repair a hiatal
hernia.
• “Gastric wrap- around”
• Nursing Management:
• Relieve pain through antacids
• Modify diet:
• High- protein diet to enhance LES
pressure
• Small frequent feedings- prevent
gastric distention and prevents further
protrusion of stomach into thoracic
cavity
• Instruct client to eat slowly and chew
food properly
• Avoid foods and beverages that
decrease LES pressure such as fatty
•
•
•
•
foods, cola beverages, coffee, tea,
chocolate, alcohol
Let the client assume upright position
before and after eating for 1 to 2
hours
Instruct client to avoid eating at least
3 hours before bedtime
Advise client to reduce body weight, if
obese.
Advise client to promote lifestyle
changes:
• Elevate HOB 6 to 12 inches for
sleep
• Avoid factors that increase
abdominal pressure
• like use of constrictive clothing,
straining at stool, heavy lifting,
bending, stooping, vigorous
coughing
• Avoid cigarette smoking as
smoking causes rapid and
significant drop in LES pressure
Gastroesophageal Reflux Disease
(GERD)
• A disorder characterized by backflow of
gastric or duodenal contents into the
esophagus.
• Causes:
• Incompetent LES
• Pyloric stenosis
• Hiatal hernia
• Motility disorder of esophagus
• Risk Factors:
• Aging
• Smoking
• Coffee drinking
• Alcohol consumption
• Gastric infection with Helicobacter
pylori
• Clinical Manifestations:
• Pyrosis (described as burning
sensation in the esophagus)
• Dyspepsia
• Regurgitation (spitting up of food from
the esophagus or stomach without
nausea or forceful contractions of the
abdominal muscles)
• Dysphagia and odynophagia
• Complications:
• Dental erosion
• Ulceration of the pharynx and
esophagus
•
Pulmonary complication (aspiration
pneumonia)
• Diagnostics:
• Barium swallow- to evaluate
damage to esophageal mucosa
• Ambulatory 12- to 36- hour
esophageal pH monitoring- to
evaluate degree of acid reflux
Medical Management:
• Antacids- neutralizes the acid in the
stomach
• Aluminum hydroxide
• Magnesium hydroxide
• H2- receptor antagonist- to suppress
secretion of gastric acid
• Cimetidine (Tagamet)
• Ranitidine (Zantac)
• Famotidine (Pepcid)
• Proton pump inhibitors- to suppress
gastric acid secretions
• Esomeprazole (Nexium)
• Lansoprazole (Prevacid)
• Omeprazole (Prilosec)
• Nursing Management:
• Low fat diet
• Avoid caffeine, tobacco, beer, milk,
and other stimulating foods
• Avoid eating or drinking 2 hours
before bedtime
• Encourage to maintain normal body
weight
• Avoid tight- fitting clothes
• Elevate HOB by at least 30 degrees
Gastritis
• Inflammation of the gastric mucosa
• Affects men and women equally
Acute Gastritis
• Lasts for several hours to few days
• May be erosive or non- erosive
• Erosion loss of epithelium no mucus
• Caused by local irritants:
• Aspirin and NSAIDs
• Alcohol
• Gastric radiation therapy
• Caused by Helicobacter pylori
• Releases toxins which are associated
with stomach mucosal inflammation
and host tissue damage (Malik et al.,
2021)
• Clinical Manifestations:
• Gastrointestinal Symptoms:
• Hematemesis
• Epigastric pain (rapid onset)
• Melena
• Anorexia
• Nausea and vomiting
• Systemic manifestations:
• Possible signs of shock
• Collaborative Management
• Reduce irritation of gastric mucosa
• Relief of symptoms
Medical Management:
• H2- receptor antagonist
• Proton- pump inhibitors
• Antiemetic, if with n&v
• Antibiotic therapy if with H. pylori
Nursing Management:
• Maintain on NPO until acute symptoms
subsides
• Maintain IV fluids, as ordered
• In severe cases, NG tube may be used
to monitor for bleeding, to lavage
precipitating agent from stomach, or
to keep stomach empty and free of
noxious stimuli
• Monitor VS and check vomitus for
blood
Chronic Gastritis
• Results from repeated exposure to
irritating agents or recurring episodes of
acute gastritis
• Gastric epithelial and mucosal cell atrophy
• More common in older adults
• Causes (ABC):
• Autoimmune- Hashimoto’s thyroiditis,
Grave’s Disease
• Bacterial- chronic H. pylori infection
•
Chemical- long term aspirin/NSAID
therapy
• Clinical Manifestations:
• Gastrointestinal Symptoms:
• Vague epigastric discomfort relieved
by eating
• Intolerance to spicy or fatty foods
• Nausea and vomiting
• Early satiety
• Pyrosis
• Belching
• Sour taste in mouth
• Systemic manifestations:
• Pernicious Anemia
• Fatigue
• Collaborative Management
• Eliminate specific cause
Medical Management:
• Control underlying pathology
• Discontinue irritating medications
• Antibiotic combinations for Chronic H.
pylori gastritis
• Vitamin B12 therapy, if with pernicious
anemia
Nursing Management:
• Non- irritating diet (no spices, non
fatty)
• Provide small frequent feedings
• Advice client about smoking cessation
and reduction of alcohol consumption
• Stress management
Peptic Ulcer Disease (PUD)
• A condition characterized by erosion of the
GI mucosa resulting from digestive action of
HCl acid and pepsin.
• Commonly occurs in the stomach (gastric
ulcer) and proximal duodenum (duodenal
ulcer)
• Precipitating factors:
• Helicobacter pylori infection
•
Gram- negative bacillus found
within gastric epithelial cells.
• Releases toxins which are
associated with stomach mucosal
inflammation and host tissue
damage (Malik et al., 2021)
• Accounts for 90% of duodenal
ulcers and 70% to 90% of gastric
ulcers
• Non- steroidal Anti-inflammatory
Drugs (NSAIDs)
• Prostaglandin normally protects
the gastric mucosa
• NSAIDs block prostaglandin
synthesis by inhibiting the COX-1
enzyme, resulting in decreased
gastric mucus and bicarbonate
production and a decrease in
mucosal blood flow.
• Medications
• Steroids, Fluorouracil, KCl
• Zollinger- Ellison Syndrome
• Benign or malignant tumor in the
pancreas or duodenum causes
increase in gastric acid secretion
• Stress
• Stress stimulates SNS. However,
constant exposure to stress
exhausts the SNS and activates.
Parasympathetic Nervous System
which increases gastric motility
and HCl production.
• Fatty, spicy, highly acidic foods
• Type A Personality
• Perfectionist, workaholics – have
increased gastric motility and HCl
acid secretion
• Type O Blood
• Individuals with type O blood
have higher pepsinogen levels
which is activated into pepsin.
Pepsin +HCl= aggressor to the GI
mucosa
• Diagnostics:
• Upper GI endoscopy:
• Allows direct visualization of
inflammatory changes, ulcers,
and lesions
• Urea breath test:
• Detects the presence of H. pylori
Urea Breath Test
• The test is based on the principle that
orally administered urea becomes broken
down into ammonia and bicarbonate through
the action of an enzyme urease which is
produced in large amounts by H. pylori.
• Uses 14C- urea as tracer which will be
taken by the patient PO
•
•
Taken on an empty stomach
S/E: diarrhea, abdominal cramps,
confusion, dizziness, weakness
• Administer cimetidine and antacids 1
hour apart as antacids decrease the
absorption of oral cimetidine
• Cytoprotective agents: coats ulcers and
enhances prostaglandin synthesis
• DOC: Sucralfate (Carafate)
• Administer on an empty stomach
• S/E: constipation
• Administer 1 hour apart from antacids
• H. pylori treatment:
• Triple therapy
• Quadruple therapy
Triple Therapy for H. pylori:
• PPI BID
• Clarithromycin 500 mg BID
• Amoxicillin 500 mg BID or Metronidazole
(Flagyl) 500 mg BID
• Taken for 10-14 days
Gastric vs Duodenal Ulcers
• Clinical Manifestations:
• Dull, aching, gnawing epigastric pain
Medical Management:
• Antacids: neutralizes HCl
• Best administered 1 to 2 hours after eating
as this is the peak time of HCl secretion
• Aluminum- Magnesium hydroxide
(Maalox)
• Milk of Magnesia
• Aluminum- Magnesium Trisilicate
(Gaviscon)
•
• Calcium carbonate (Tums)
• H2- receptor blockers: reduces HCl
secretions
•Quadruple Therapy for H. pylori:
• Bismuth subsalicylate 525mg QID
• Tetracycline 500 mg BID
• Metronidazole 250 mg QID
• PPI OD
• Taken for 10-14 days
Surgical Management:
• Recommended for patient with intractable
ulcers (those failing to heal after 12 to 16
weeks of medical treatment), lifethreatening hemorrhage, perforation, or
obstruction or those with Zollinger-Ellison
Syndrome that is unresponsive to
medications.
• Vagotomy: Severing of the vagus nerve.
• Decreases gastric acid by diminishing
cholinergic stimulation to the parietal
cells, making them less responsive to
gastrin
• Pyloroplasty: surgical dilatation of the
pyloric sphincter to treat bleeding duodenal
ulcers
• Longitudinal incision is made into the
pylorus and transversely sutured
closed to enlarge the outlet and relax
the muscle
•
•
•
• Antrectomy: surgical removal of the
antrum portion of the stomach (50%) with
anastomosis to either duodenum or jejunum
• Billroth I (Gastroduodenostomy):
removal of the lower portion of the
stomach (which contains cells that
secrete gastrin) as well as a small
portion of the duodenum and pylorus.
The remaining segment is
anastomosed to the duodenum.
•
Billroth II (Gastrojejunostomy):
removal of the lower portion of the
stomach with anastomosis to the
jejunum. A duodenal stump remains
and is oversewn.
• Subtotal gastrectomy: removal of
75% of the distal stomach with
Billroth I or II repair.
• Nursing Management:
• Relieve pain through medications, as
ordered
• Encourage client to adhere to dietary
modifications
•Dietary modifications:
• DAT when asymptomatic
• Bland diet during exacerbation
•
•
Advise client to eat slowly and chew
food properly
Small, frequent feeding during
exacerbation
Instruct to avoid the following:
• Fatty foods, coffee, tea, chocolate,
cola drinks, spices, alcohol
• Bedtime snacks
• Binge eating
• Large quantities of milk
Encourage client to quit smoking
Enhance coping through stress
therapy:
• Develop recreation and hobbies
• Have regular pattern of exercise
• Stress reduction at home and at
work
Clients Having Gastric Surgeries
• Preop Care
• Provide psychosocial support
• Teach client DBCT
• Provide nutritional support as
ordered
• Ensure consent form is signed
• Inform client and family on post op
measures (e.g., presence of NGT,
oxygen therapy, blood transfusion,
TPN)
• Post op Care
• Promote patent airways and
ventilation
• Position to semi- fowler’s position
• Reinforce DBCT exercises and
incentive spirometry
• Administer analgesics before
activities, as ordered
• Splint incisions
• Facilitate early ambulation
• Prevent potential complications:
• Prevent bleeding which is
highest during the first 24 hours
and on the 4th to 7th day post
op due to non healing
• Monitor NGT drainage.
Reddish for the first 12
hours then becomes dark
red
• Avoid unnecessary irrigation
or repositioning of NGT
• Leakage from anastomosis
• Monitor for signs of leakage
(e.g.,
•
dyspnea, pain, and fever when
oral fluids are initiated)
• Monitor for signs of peritonitis
(e.g., severe abdominal pain,
abdominal rigidity, fever)
Care of Clients with Lower
Gastrointestinal Disorders
Dumping Syndrome
• A group of unpleasant vasomotor and GI
symptoms caused by rapid emptying of
gastric contents into the jejunum.
• Common cause:
• Billroth II procedure
• Clinical Manifestations:
• Early Signs (5-30 mins pc)
• Diarrhea
• Weakness
• Abdominal cramps
• Tachycardia
• Pallor
• Diaphoresis
• Nausea
• Late Signs (2 to 3 hours pc)
• Hyperglycemia (initially)
• Hypoglycemia
• Collaborative Management:
• Position patient to LEFT SIDE- LYING
after meals
• Provide small, frequent feedings
• HIGH- PROTEIN DIET. Protein empties
in the stomach lowly.
• Limit carbohydrates
• Instruct patient to drink water AFTER
MEALS not within meals
• Octreotide- decrease GI symptoms
• Acarbose- for clients with late
dumping
• Billroth II to Billroth I conversion
•
•
•
•
•
•
•
•
•
•
Jejunum
Ileum
Cecum
Appendix
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus
Function of Small Intestines
Main function: absorption of nutrients
• Duodenum- mixing with biliary and
pancreatic secretions
• Jejunum- CHO, CHON, fats, sodium,
chloride
• Ileum- Vitamin B12 and bile Salts
Function of Large Intestines
Main function: Reabsorption of
water and electrolytes
• Done through a slow, weak peristaltic
movement
• Intermittent, strong peristaltic waves
may occur after a meal is eaten
Acute Abdomen
• “Surgical abdomen”
• Sudden onset of abdominal pain without
traumatic etiology and requires swift surgical
intervention to prevent peritonitis, sepsis,
and septic shock.
• Causes:
• Appendicitis
• Diverticulitis
• Intestinal Obstruction
Appendix
• The appendix is a small wormlike
appendage that is attached to the cecum. It
measures about 3 to 4 inches long.
• Normally, it fills with by products of
digestion and empties regularly into the
cecum; however, this emptying process is
ineffective making it at risk for obstruction
and infection.
Appendicitis
• Inflammation of the appendix
• Causes:
• Obstruction of the appendix by:
• Fecalith
• Foreign bodies
• Infection
•
•
•
•
•
•
•
• Clinical Manifestations:
• Diffuse abdominal pain that eventually
becomes localized to RLQ
• (+) McBurney’s Sign: rebound
tenderness on RLQ
Anorexia, nausea and vomiting
Rigid abdomen, guarding behavior
(+) Rovsing’s sign: RLQ pain upon
deep palpation of LLQ
• Decreased or absent bowel sounds
• High grade fever: 38̊C- 38.5 ̊C
• (+) Psoas sign: Pain on passive
extension of the right thigh. Patient
lies on left side. Examiner extends
patient's right thigh while applying
counter resistance to the right hip.
• (+) Obturator sign: Pain on passive
internal rotation of the flexed thigh.
Examiner moves lower leg laterally
while applying resistance to the lateral
side of the knee, resulting in internal
rotation of the femur.
Diagnostics:
• Abdominal CT Scan: (+) enlargement
and inflammation of appendix
(enlargement of at least 6mm is
suggestive), Confirmatory test
• Complete Blood Count (CBC):
• (+) Leukocytosis:
• WBC> 10,000/mm3;
• WBC> 20,000/mm3 indicates
peritonitis
• Pregnancy Test (for females):
• To rule out ectopic pregnancy
• Urinalysis:
• To rule out UTI
Complications
• Rupture of appendix
• Peritonitis
Collaborative Management:
• Decrease peristalsis
• Bed rest
• Maintain NPO
• Provide pain relief by COLD application
• Avoid factors that increase peristalsis:
• Hot compress over abdomen
• Laxatives
• Enema
• Initiate and maintain IV therapy
• Administer antibiotics, as ordered
Surgical Management:
• Appendectomy
• Surgical removal of the appendix by
laparotomy or laparoscopy
Appendectomy
• Method of Anesthesia: Spinal
anesthesia
• Flat on bed 6 to 8 hours post op to
prevent spinal headache
• Monitor return of sensation in the
lower extremities
• Post op nursing care:
• Facilitate early ambulation (Day 0- day
of surgery)
• Post op position: HIGH- FOWLER to
reduce tension on incision and
abdominal organs
• DAT if bowel sounds are present
• Instruct to avoid heavy lifting post op,
but can resume normal activity within
2 to 4 weeks
Ruptured Appendicitis
Clinical Manifestations:
• Sudden relief of abdominal pain
followed by onset of intense
abdominal pain
• Abdominal rigidity
• Leukocytosis (WBC >20,000/mm3)
Surgical Management:
• Exploratory Laparotomy Appendectomy
Diverticular Diseases
• Diverticulum- saclike herniation of the
lining of the bowel that extends through a
defect in the muscle layer
• Diverticulosis- presence of multiple
diverticula without inflammation or
symptoms
• Diverticulitis- a diverticulum that
becomes inflamed, causing perforation and
potential complications
• Commonly occurs in the sigmoid colon
• Commonly affects older population
• Risk Factors:
• Age
• Low fiber diet (a.k.a. low residue diet)
• Obesity
• History of cigarette smoking
• (+) family history
• Clinical Manifestations: (Diverticulosis)
• Asymptomatic
• Chronic constipation with episodes of
diarrhea
• Anorexia
• Nausea
• Abdominal distention
• LLQ pain (70% of cases)
• Low grade fever
• Diagnostics:
• Colonoscopy
• Screening test
• Permits visualization of the extent
of diverticular disease
• Abdominal CT Scan w/ contrast
• Confirmatory test
• CBC:
• (+) leukocytosis
• Low Hgb, especially if with frank
blood in stool
• Complications:
• Abscess
• Obstruction
• Fistula
• Peritonitis
• Hemorrhage
Medical Management:
• Hinchey Classification:
• Guide to determine treatment of
diverticulitis
• Stage I:
• Outpatient treatment
• Rest, oral fluids, analgesic
• Clear liquid diet until inflammation
subsides; then a high- fiber, low fat
diet
• Stage II:
• May require hospitalization
• NPO
• Nasogastric suctioning if with vomiting
or distention
• IV fluids, as prescribed
• Broad-spectrum antibiotics, as ordered
DOC: Ampicillin- sulbactam (Unasyn)
• Analgesics, as ordered
DOC: (Oxycodone)
• Stage III or IV:
• Surgical candidates
• Hartmann procedure:
• Resection of the colon
Hartmann procedure
• One- stage resection:
• The inflamed area is removed and a
primary end-toend anastomosis is
completed
• Multi- stage resection:
• Used for diverticulitis with
complications
• Stage 1- colostomy creation
• Stage 2- colostomy take down and
anastomosis
• Nursing Management:
• High- fiber diet
• Bulk- forming laxatives, as ordered
• DOC: Psyllium fiber
• Liberal fluid intake of 2,000 mL/day
• Avoid nuts and seeds (sesame seeds,
cucumber, tomatoes, popcorn)
• Encourage an individualized exercise
program
Intestinal Obstruction
• Exists when a blockage prevents the
normal flow of intestinal contents through
the intestinal tract
• Etiology may be mechanical or functional
• Mechanical obstruction:
• Obstruction results from pressure in
the intestinal wall
• Causes:
• Surgical adhesions- most common
cause
• Hernia
• Chron’s disease
• Intussusception
• Volvulus
• Neoplasm
• Functional (paralytic) obstruction:
• Intestinal musculature cannot propel
the contents along the bowel
• Causes: Paralytic ileus (lack of
intestinal peristalsis and bowel
sounds)
• Most common and may result after an
abdominal surgery, hypokalemia, and
thoracic and lumbar spinal fractures
Small Bowel Obstruction (SBO)
• Clinical Manifestations:
• Crampy, wavelike and colicky pain above
and below the blockage
• Absent fecal matter and flatus, but may
pass blood and/or mucus
• Reflux vomiting
• Dehydration: extreme thirst, drowsiness,
generalized malaise, aching, parched tongue
and mucus membranes
• Diagnostics:
• Abdominal x- ray and CT scan:
• (+) abnormal quantities of gas, fluid,
or both in the intestines and
sometimes collapsed distal bowel
• CBC
• High Hct (hematocrit is the percentage
of RBC in blood)
• Possibly increased WBC
• Electrolytes
• Hypokalemia
• Low hydrogen ions
Medical Management:
• Rest the bowel!
• NG decompression x 3 days
Surgical Management:
• Dependent on the cause
• Hernia- herniorrhaphy
• Adhesions- adhesiolysis
• Nursing Management:
• Maintain function of NG tube
• Monitor NG output q4H or as ordered
• Assess for fluid and electrolyte
imbalance
• Monitor nutritional status
• Assess for manifestations consistent
with resolution (normal bowel sounds,
decreases distention, verbalization of
relief, passage of flatus or stool)
• WOF: discrepancies in I &O, worsening
of pain or distention, and increased
NG output
Large Bowel Obstruction (LBO)
• Clinical manifestations:
• Slow onset of symptoms
• Constipation- may be the only
presenting symptom for weeks
• Altered stool shape (ribbon- like)
• Bleeding
• Abdominal distention (late sign)
• Diagnostics:
• Abdominal x-ray and abdominal CT or
MRI
• (+) distended colon
• Pinpoints the site of the obstruction
Medical Management:
• IV fluids to restore fluid and
electrolyte balance
• NG aspiration and decompression
• Surgical Management:
• Colonoscopy: performed to untwist
and decompress the bowel
• Cecostomy: surgical opening into the
cecum for patients who are poor
surgical risks; provides an outlet for
releasing gas and a small amount of
drainage.
• Nursing Management:
• Monitor for worsening of symptoms
• Administer IV fluids and electrolytes,
as ordered
• Prepare patient for surgery if
unresponsive to non-surgical
interventions
Peritonitis
• Inflammation of the peritoneum (serous
membrane lining the abdominal cavity)
• Causes:
• Bacteria (E. coli and Klebsiella,
Proteus, Pseudomonas, and
Streptococcus species)
• Fungal
• External causes: abdominal surgery or
trauma (GSW, stab wound)
•
Categories of Peritonitis:
• Primary peritonitis:
• Occurs as a result of spontaneous
bacterial infection of ascitic fluid
• Most commonly affects adults with
liver failure
• Secondary peritonitis:
• Occurs secondary to perforation of
abdominal organs with spillage that
infects the serous peritoneum
• Tertiary peritonitis:
• Occurs as a result of suprainfection in
a patient who is immunocompromised
Clinical Manifestations:
• Abdominal pain: initially diffuse but
eventually localizes and becomes more
intense over the site of maximal peritoneal
irritation
• Abdominal guarding and rigidity (“boardlike abdomen”)
• Anorexia, nausea and vomiting
• Diminished peristalsis leading to paralytic
ileus
• Fever (37.8 to 38.5)
• Signs of early shock: restlessness,
tachycardia, hypotension, weakness, pallor,
diaphoresis, oliguria
Diagnostics:
• CBC
• Leukocytosis with increase in
immature neutrophils (bands)
• Low hgb and hct, if with blood loss
• Abdominal UTZ
• (+) Abscess (localized collection of
purulent material surrounded by
inflamed tissues) and fluid collections
• CT scan
• (+) abscess formation
• Peritoneal aspiration and culture and
sensitivity of aspirated fluid
• Reveals infection and identify
causative organism
Medical Management:
• Fluid replacement with isotonic fluids
• Analgesics for pain
• Antiemetics
• NPO
• Intestinal intubation and suctioning
• Oxygen therapy
• I.V. Broad- spectrum antibiotics
Surgical Management:
• Directed toward excision, resection with or
without anastomosis, repair, and drainage
Nursing Management:
• Monitor VS, I&O
• Bed rest in semi- fowler’s position
• Encourage DBE to prevent respiratory
complications
Acute Gastroenteritis
• Inflammation of the mucosa of the
stomach and small intestine
• Mainly characterized by sudden onset
diarrhea accompanied by nausea, vomiting,
and abdominal cramping
• Cause: Ingestion of infectious organism
• Virus- Rotavirus, Norovirus
• Bacteria- E. coli, Shigella, Salmonella,
C. difficile
• Parasite- Giardia lamblia, Entameoba
histolytica
• Diagnostics:
• Stool culture- indicated ONLY for
diarrhea > 3-5 days
• Stool for OPEH
Medical Management - Rehydration
• Oral rehydration salts (ORS)
• Hydrite- volume per volume
• replacement.
• Electrolyte drinks
• Gatorade
• Pocari sweat
• IV rehydration, as ordered
Medical Management - Control of diarrhea
• Antidiarrheal agents, as ordered
•
Loperamide (Diatabs/Imodium)inhibits peristalsis, delays transit of
intestinal contents, increases
absorption of water from stools
• Diphenoxylate with atropine (Lomotil)Decreases peristalsis and intestinal
motility
Medical Management- Eliminate causative
organism
• Rifaximin, as ordered
• Nonabsorbable antibiotic used to treat
E. coli traveller's diarrhea
• C. difficile infection
• Metronidazole (Flagyl)- first- line drug
for mild cases
• Vancomycin (Vancocin)- used for
severe infections
Nursing management:
• Observe contact precaution, especially
for C. difficilediarrhea (handwashing,
gloves, and gown)
• Place patient with C. difficile in private
rooms, and use disposable
thermometers and stethoscopes
• Encourage oral fluids
• Maintain IV-line patency
• Encourage bed rest- to rest bowel
• BRAT diet- Banana, Rice, Applesauce,
and Toast. These foods help thicken
stool consistency
Irritable Bowel Syndrome (IBS)
• A chronic functional disorder characterized
by recurrent abdominal pain associated with
disordered bowel movements
• Affects women > men
• Diagnosed in adults younger than 45 years
old
• Triggers:
• Chronic stress
• Sleep deprivation
• Surgery
• Infections
• Diverticulitis
• Food (milk, yeast products, eggs,
wheat products, red meat)
• Types of IBS:
• IBS- C: main symptom is constipation
• IBS- D: main symptom is diarrhea
• IBS- M: main symptom is a
combination of constipation and
diarrhea
• Clinical manifestations:
• Abdominal pain:
• Precipitated by eating
• Relieved by defecation
• Bloating and distention
• Manifestations must be present for at
least 3 months
• Diagnostics:
• Stool diary
• Bristol Stool Form Scale
Medical Management:
• Probiotics (Lactobacillus) for
abdominal bloating and gas, as
ordered
• Dicyclomine (Bentyl) for abdominal
pain, as ordered
• IBS- C:
• Psyllium fiber
• IBS-D:
• Anti-diarrheal agents
• Loperamide
• Alosetron (Lotronex): for severe
IBS-D that persists for at least 6
months and is unresponsive to
therapies
Nursing Management:
• Lifestyle modification
• Emphasize and reinforce good
sleep habits and good dietary
habits
• Encourage to eat at regular times
and to avoid food triggers
• Do not take fluid with meals as
this may result to bloating
• Encourage smoking cessation and
avoidance of alcoholic beverages
Inflammatory Bowel Disease (IBD)
• A group of chronic disorders: Chron’s
disease and Ulcerative colitis that result in
inflammation or ulceration (or both) of the
bowel.
• Exact cause: UNKNOWN
• Risk factors:
• (+) family history
• Caucasian
• Jewish
• Living in a northern climate
• Living in an urban area
• Abdominal CT scan
• More sensitive tool for diagnosing
Chron’s disease
• Highlights bowel wall thickening
and mesenteric edema
• Abdominal MRI
• Sensitive and specific in terms of
identifying pelvic and perianal
abscess and fistulae
• Complications:
• Intestinal obstruction
• Perianal disease
• Enterocutaneous fistula (an abnormal
opening between the small bowel and
the skin)
Chron’s Disease
• Regional enteritis
• Subacute and chronic inflammation of the
GI tract wall that extends through all the
layers
• Most commonly occurs is the distal ileum
and the ascending colon
• Characterized by periods of remission and
exacerbation
• Clinical Manifestations:
• Diarrhea
• Right lower quadrant pain unrelieved
by defecation
• Crampy
• Occurs after meals
• Avoidance behavior: avoids intake of
food
• Weight loss, malnutrition, anemia
• “Cobblestone” appearance of affected
bowel
• Bowel ulceration separated by
edematous patches
• Diagnostics:
• Barium studies
• (+) “string sign”: indicates
constriction of a segment of the
intestine
Ulcerative Colitis
• Chronic ulcerative and inflammatory
disease of the mucosal and submucosal
layers of the colon and rectum
• Characterized by unpredictable periods of
remission and exacerbation
• Inflammatory changes begin in the rectum
and progress proximally through the colon
• Clinical Manifestations:
• Bloody or purulent diarrhea (6 or more
Liquid stools/day)
• Left lower quadrant pain
• Intermittent tenesmus
• Anorexia, weight loss, dehydration
• Fever
• Diagnostics:
• Colonoscopy
• (+) friable, inflamed mucosa with
exudates and ulcerations
• Stool analysis
• (+) blood
• Laboratories
• CBC: Low Hgb, low Hct,
leukocytosis
• Elevated C- reactive protein
IBD Management
• Dietary Modifications
• Diet: low- residue, high- protein, highcalorie diet to rest bowel and meet
nutritional needs
• Avoid triggers of diarrhea:
• Avoid milk, cold foods, and
smoking
• TPN, as prescribed for severe
malnutrition
• Pharmacologic Management:
• Sulfasalazine (Azulfidine)
• Effective for mild or moderate
inflammation
• Prevent recurrence
• Metronidazole (Flagyl)
• Used if with complications such as
abscess or fistula formation
• Corticosteroids
• Prednisone PO
• Hydrocortisone IV
• Immunomodulators
• Azathioprine (Imuran)
• Used as maintenance regimen to
prevent relapse
•Surgical Management:
• Chron’s Disease
Total colectomy with ileostomy
Colectomy: excision of the entire
colon
Ileostomy: surgical opening into the
ileum
• Stoma is found at the RLQ
• Drainage is watery and occurs at
frequent intervals
• Ulcerative colitis:
• Proctocolectomy with ileostomy
Proctocolectomy: complete excision
of colon, rectum, and anus
Hernias
• A hernia occurs when the wall of a muscle
weakens, and the intestine protrudes
through the muscle wall of a cavity
Umbilical Hernias
• A portion of the intestine protrudes
through the umbilicus
• Risk factors:
• Multiparity
• Liver cirrhosis
• Ascites
Abdominal Hernias
• Occurs in the midline of the abdomen
between the umbilicus and the xiphoid
process.
Inguinal Hernias
• Most common type
• Occurs in the groin area
• Clinical Manifestations: (Hernias)
• Bulging over herniated area which
appears when patient stands or
strains, and disappears when supine
• Pain (may or may not be present)
Hernia Complications
• Incarcerated hernia
• Hernias that do not return to the
abdominal cavity with rest or
manipulation and cause complete
bowel obstruction
• Strangulated hernia
• Similar characteristic with incarcerated
hernias but blood supply to hernia is
cut off
Medical Management
• Hernia truss
• A device that applies pressure to the
hernia, thus keeping the intestine in
the abdominal cavity.
Surgical Management
• Herniorrhaphy
• Involves making an incision in the
abdominal wall, replacing the
contents of the hernial sac,
repairing the weakened tissue, and
closing the opening.
• Hernioplasty
• Involves replacing the hernia into
the abdomen and reinforcing the
weakened muscle wall with wire,
mesh, or fascia
Hemorrhoids
• Dilated portions of veins in the anal canal
• May be internal or external
Types:
• Internal hemorrhoids- located above the
internal sphincter
• First degree: do not prolapse and
protrude into anal canal
• Second degree: prolapse outside the
anal canal during defecation but
reduce spontaneously
• Third degree: prolapsed to the
extent that they require manual
reduction
• Fourth degree: prolapsed to the
extent that they not be reduced
• External hemorrhoids
• Appear outside the external sphincter
• Causes:
• Constipation- most common
• Pregnancy
• Obesity
• Liver cirrhosis
• Right- sided heart failure
• Clinical Manifestations:
• Constipation
• Anal pain
• Rectal bleeding with defecation
(hematochezia)
• Anal itchiness
Collaborative Management:
• High- residue diet and increased oral fluid
intake
• Bulk- forming laxatives, as ordered. DOC:
Psyllium
• Cold packs to anal area followed by warm
sitz bath
• Astringents, as ordered to reduce
engorgement. DOC: witch hazel
• Sclerotherapy
• Sclerosing agent: 5% phenol in saline
• The sclerosing agent is injected into
the base of the hemorrhoid to cause
blood vessel thrombosis, which helps
prevent prolapse.
• Rubber band ligation
• Hemorrhoid is visualized through an
anoscope, and the proximal portion is
grasped with an instrument
• A small rubber band is then slipped
over the hemorrhoid.
• Tissue distal to the rubber band
becomes necrotic after several days
and sloughs off
• Hemorrhoidectomy:
• Surgical excision of hemorrhoids
• Rectal sphincter is dilated digitally
• Hemorrhoids are removed with a
clamp and cautery, or are ligated and
then excised
• Pre- op:
• Low residue diet to reduce bulk of
Feces
• Post- op:
• Administer analgesics, as ordered
• Assist client to side- lying or prone
position
• Apply ice packs over dressing for
the first 12 hours to prevent
bleeding
• Warm sitz bath 12 to 24 hours
post op. Best time to do sitz bath
is after every bowel movement.
•
•
Administer stool softeners, as ordered
Encourage increase oral fluids and
high-residue diet
• WOF: rectal bleeding, suppurative
drainage, continued pain on
defecation, continued constipation
Care of Clients with Fecal Diversions
(Ostomy)
•
Monitor for fecal drainage.
Fecal Diversion
• Reroutes the flow of feces when the normal
functioning of the bowel is hindered by
disease, obstruction, or traumatic injury
• May be temporary or permanent
Ostomy
• A surgically created procedure to divert
fecal stream of the intestinal tract through
the abdominal wall or into an artificially
created reservoir
• Ileostomy: surgical creation of an
opening into the ileum or small
intestine
• Colostomy: surgical opening into the
colon by means of a stoma to allow
drainage of contents of the colon
Indications:
• IBD
• Diverticulitis
• Colorectal cancer
Nursing Care:
• Preoperative preparation:
• Routine preop care
• Postoperative Care:
• Encourage early ambulation
• Administer analgesics, as ordered
• Monitor stoma for color and size
• Normal: pink to bright red and shiny
• Slight edema for 5 to 7 days
• Should protrude ½ to ¾ inch over the
abdomen
• Abnormal: cyanotic/pale/ashen/dusky
• Stoma Care:
• Gently ask the client to look at the
stoma. If the client refuses to do so,
encourage him/her the verbalize
feelings
• Inform client that the stoma ha no
touch or pain sensation
• Cleanse stoma initially with sterile
NSS until healed
• Instruct to report discoloration ASAP
to physician.
• Skin Care:
• Ileostomy:
• Instruct client to wear pouch at all
times.
• Stoma should be rechecked 3 weeks
post op and final size and type of
appliance is selected in 3 months
• Ileostomy and Colostomy:
• Wash the skin around the stoma
with warm water and mild soap. Pat
dry.
• When pouch seal leaks, change
pouch immediately
• Use skin barrier (Karaya paste) to
protect peristomal skin from
irritation
• Promoting Nutrition
• Low residue diet for the first 6 to 8
weeks
• Strained fruits and vegetable are
recommended
• Avoid foods that are high in fiber or
hard-to-digest kernels (popcorn,
coconut)
• Encourage increase oral fluids
especially during summertime for
•
clients with ileostomy. Sport drinks
may be used
• If fecal drainage is too watery, restrict
fiber
• If fecal drainage is excessively dry,
increase salt intake
• Supporting a positive self- concept:
• Encourage client to verbalize feelings,
fears, and concerns about stoma
• Encourage client to participate in
stoma care. When the client starts to
ask about the ostomy and ostomy
care, that signals readiness for health
education.
• Preventing sexual dysfunction:
• Advise couple on the following:
• Explore positions the minimize stress
and pressure on the pouch
• Empty and clean the pouch before
sexual activity
• Used smaller- sized pouch or pouch
cover during sexual activity
• Use an abdominal binder to hold
pouch secure
MEDICAL-SURGICAL 2 : PTM2
Hepato-Biliary and Pancreatic Disorders
Hepatobiliary System
• Liver
• Intrahepatic bile ducts
• Extrahepatic bile ducts
• Gall bladder
Functions of the liver
• Glucose metabolism
• Glycogenesis- conversion of glucose into
glycogen
• Glycogenolysis- reverse conversion of
glycogen into glucose
• Ammonia conversion
• Fat metabolism
• Vitamin and Iron storage- liver stores
vitamins A, B, and D, iron, copper
• Bile formation
• Bilirubin excretion
• Drug metabolism
Liver Function Tests
Jaundice
Jaundice- yellowish or greenish-yellow
discoloration of body tissues due to
increased blood bilirubin concentration
Causes:
• Liver disease
• Obstruction of bile flow
• Excessive RBC destruction
Gall Bladder
• Pear-shaped, hollow, saclike organ
• Composed mostly of smooth muscles
• Has a capacity of 30 to 50 mL
• Functions as storage depot for bile
Bile
• Composed of water and electrolytes
(Na+, K+, Ca++, Cl-, HCO3-) as well as
significant amounts of lecithin, fatty acids,
cholesterol, bilirubin, and bile salts
• Helps in emulsification of fats
Gall Bladder Stones
Cholelithiasis – gall bladder stones
Choledocholithiasis – stones in the
common bile duct (CBD)
• Made up of cholesterol crystals
• Form in sterile gall bladder
Risk Factors (5Fs):
• F- Female
• F- Fat
• F- Forty
• F- Fertile
• F- Fregnant
Clinical Manifestations
• May be asymptomatic
• Biliary colic- excruciating pain associated
with the temporary obstruction of the cystic
duct or CBD
• Trigger: heavy meal
• Location: RUQ
• Characteristics: radiates to back or
right shoulder, associated with nausea
and vomiting
• (+) Murphy’s sign - increased discomfort
or inspiratory arrest (a catching of the
breath) during deep inspiration when the
examiner palpates the RUQ
• Fever
• Jaundice
• Dark colored urine
• Acholic stool – grayish or clay colored
stool
• Vitamin deficiency of fat- soluble vitamins
Types of Gall Bladder Stones
Pigment stones
• Made up of calcium bilirubinate
• Brown pigment stones – form in infected
bile
• Black pigment stones – form in sterile gall
bladder
Cholesterol stones
Diagnostics:
Abdominal ultrasound –diagnostic
procedure of choice
• More accurate if patient is placed on NPO
overnight to distend the gallbladder
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
• Diagnostic: permits the direct visualization
of the hepatobiliary system using a flexible
fiberoptic endoscope
• Therapeutic: treatment of confirmed
choledocholithiasis
• Initial position: Left semi- prone
ERCP- Nursing Care
Before the procedure:
• Facilitate signing of consent
• Reinforce instructions on procedure and
how he/she can cooperate
• Place on NPO as ordered
• Monitor patient closely, esp. if moderate
sedation is used
After the procedure:
• Monitor vital signs
• Assess for signs of perforation or infection
• Monitor for side effects of medications used
during procedure
• Monitor for return of gag and cough reflex
Management
Goals:
• Reduce incidence of acute episodes of
gallbladder pain and cholecystitis
Strategies:
• Dietary and supportive management
• Pharmacotherapy
• Endoscopic or surgical procedures
Acute episodes:
• Rest
• IV fluids
• Nasogastric suctioning
• NPO
• Analgesics, as ordered
• Meperidine (Demerol)- drug of choice
for acute cholecystitis
• NSAIDs – for biliary colic
• Antibiotics, as ordered
Diet after an acute episode:
• Low- fat liquid (e.g., protein- and
carbohydrate- rich powdered supplements
stirred into skim milk)
• Cooked fruits, rice or tapioca, lean meats,
mashed potatoes, non–gas-forming
vegetables, bread, coffee, or tea may be
added as tolerated.
• Avoid eggs, cream, pork, fried foods,
cheese, rich dressings, gas- forming
vegetables, and alcohol
Pharmacotherapy
• Ursodeoxycholic acid (UDCA)
• Indication:
• Small, radiolucent cholesterol
stones
• Patients who refuse surgery
• Patients who is a contraindication
to surgery
• MOA: inhibits cholesterol synthesis and
secretion, thereby desaturating bile
Laparoscopic Cholecystectomy
• Gallbladder removal through a small
incision made through the abdominal wall at
the umbilicus
• Standard therapy for symptomatic
gallstones
• ERCP may be done prior to procedure if
CBD is obstructed by gallstones.
Preoperative Care
• Facilitate signing of consent
• Reinforce education on:
• Possible open abdominal approach
• Type of anesthesia: general
• Turning, deep- breathing exercises,
and early ambulation
• Inform on possible necessity of drainage
tubes and NGT and suction during the
postoperative period
Postoperative Care
• Monitor v/s and I&O
• Facilitate turning, DBE, and early
ambulation
• Diet:
• Immediate post op: low fat, high
protein, high carbohydrate diet
•
Upon discharge: no special dietary
instructions but to avoid excessive fats
x 4 to 6 weeks
• Instruct that BM may increase in frequency
(1-3 x a day) and diminishes over a period of
weeks to months
Pancreas
• A J-shaped, soft, lobulated, retroperitoneal
organ.
• It lies transversely, although a bit
obliquely, on the posterior abdominal wall
behind the stomach
• Has both exocrine and endocrine functions
• Exocrine Pancreas
• Produces highly alkaline secretions
• Amylase: CHO digestion
• Trypsin: CHON digestion
• Lipase: Fat digestion
• Secretin increases HCO3- secretion from
pancreas
• Cholecystokinin (CCK) stimulate release of
digestive enzymes
Pancreatitis
• Pancreatitis- inflammation of the pancreas
• Types:
• Acute pancreatitis- medical emergency
with high mortality rate
• Chronic pancreatitis- undetectable in
early stage
Acute Pancreatitis
• Interstitial Edematous Pancreatitis
• Most common type
• (-) necrosis but pancreas become
enlarged due to inflammatory edema
• Milder form but places patient at risk
for hypovolemic shock, fluid and
electrolyte imbalance, and sepsis
• Necrotizing Pancreatitis
• Necrosis is evident in peripancreatic
parenchyma or in tissue surrounding
gland
•
More widespread and complete
enzymatic digestion of gland
• Causes: “I GET SMASHED”
• I - Idiopathic
• G - Gall stones
• E - Ethanol (Alcohol)
• T - Trauma
• S - Steroids
• M - Mumps/Malignancy
• A - Autoimmune
• S - Scorpion stings
• H-Hypercalcemia/Hypertriglyceridemia
• E - ERCP
• D – Drugs
• Clinical Manifestations
• Severe abdominal pain – major
symptom
• Diffuse and difficult to localize
• Typically occurs in midepigastrium
24 to 48 hours after a very heavy
meal or alcohol ingestion
• Unrelieved by antacids and
vomiting
• Accompanied by abdominal
distention, poorly defined palpable
abdominal mass, and decreased
peristalsis
• Board- like abdomen – indicative of
peritonitis
• Cullen’s sign – hemorrhagic
discoloration of umbilical area due to
intraperitoneal hemorrhage
• Grey Turner’s sign – discoloration of
left flank
• Nausea and vomiting – may be bile
stained
• Fever, jaundice, mental confusion,
agitation
• Hypotension
• Tachycardia
• Cyanosis
• Cold, clammy extremities
•
•
Elevated serum amylase and lipase
within 24 hour of the onset of
symptoms
Hyperglycemia, hypocalcemia
• Complications
• Local:
• Pancreatic cysts or abscess
• Acute fluid collections in or near
the pancreas
• Systemic:
• Pulmonary insufficiency with
hypoxia
• Shock
• Kidney disease
• GI bleeding
Medical Management
• NPO – to inhibit pancreatic stimulation
• Nasogastric suction if with abdominal
distention and paralytic ileus
• Enteral feeding – preferred route to meet
nutritional needs
• Total Parenteral Nutrition (TPN), if enteral
route is not tolerated
• Pain control using opioids (i.e., morphine,
fentanyl, hydromorphone)
• Antibiotics, if with infection only
• Intensive insulin therapy/Continuous
insulin infusion if with hyperglycemia
• IV Calcium gluconate if with tetany
• If shock is present:
• Give plasma or plasma volume
expanders (e.g., dextran or albumin)
• Dopamine IV – to increase SVR
• PLR – fluid of choice to correct electrolyte
imbalance
Surgical Management
• ERCP with/without lap chole if gall
stones are the cause
• Laparotomy
• Performed by making a large incision
in the abdomen to gain access to the
peritoneal cavity.
• Done to assist in diagnosis, establish
pancreatic drainage,
• Pancreatic Surgery
• Resect or debride an infected, necrotic
pancreas
Nursing Management
• Pain Control
• Assess pain score regularly
• Administer opioids, as ordered
• Institute non- pharmacologic pain
relief interventions
• Facilitate and maintain NPO
• Institute bed rest - to decrease the
metabolic rate and reduce the
secretion of pancreatic and gastric
enzymes.
• Refer increasing severity of pain to
physician ASAP
• Improving breathing pattern
• Place in semi- Fowler’s position - to
decrease pressure on the diaphragm
by a distended abdomen and to
increase respiratory expansion.
• Change positions frequently – to
prevent atelectasis and pooling of
secretions
• Facilitate DBE and coughing, instruct
on use of incentive spirometry
• Improving nutritional status
• Monitor daily weights
• Administer enteral/parenteral
nutrition, as prescribed
• Monitor blood glucose q4-6H or as
ordered
• Facilitate high protein, low fat diet
once acute symptoms subside
• Instruct to avoid heavy meals and
alcoholic beverages
• Maintaining skin integrity
• Assess surgical wound, drainage sites,
and skin for signs of infection,
inflammation, and breakdown
• Provide wound care as prescribed
• Prevent contact of intact skin with
drainage
• Facilitate turning to sides q2H
• Use specialty beds as indicated to
prevent skin breakdown
Chronic Pancreatitis
• Clinical Manifestations
• Recurring attacks of severe upper
abdominal and back pain,
accompanied by vomiting
•
•
•
•
•
•
Unresponsive to opioids
Triggered by food
Frequency and duration increases
over time
Weight loss – due to anorexia and/or
fear that eating will precipitate an
attack
Impaired protein and fat digestion
Steatorrhea – stools with high fat
content
MEDICAL-SURGICAL 2 : PTM3
Care of Clients with Endocrine Disorders
Overview of the Endocrine System
• Endocrine system plays a vital role in
orchestrating cellular interactions,
metabolism, growth, reproduction, aging and
response to adverse conditions.
• The system uses chemical transmitters
known as hormones to regulate and
integrate body functions by acting on local or
distant target sites
• Negative feedback mechanism is deployed
to maintain homeostasis
• Disorders of the endocrine system are
manifested as hyperfunction or hypofunction
of a specific endocrine gland
Pituitary Gland (Hypophysis)
• Master gland of the body
• Divided into the anterior PG
(adenohypophysis) and posterior PG
(neurohypophysis)
• Controlled by the hypothalamus
Anterior Pituitary Gland
(Adenohypophysis)
• Growth hormone (GH)
• Also known as somatotropin
• Stimulates growth of bone and muscle
• Promotes protein synthesis and fat
metabolism
• Decreases carbohydrate metabolism
• Insulin antagonist
• Adrenocorticotropic hormone (ACTH)
• Stimulates synthesis and secretion of
adrenal cortical hormones
• Thyroid- stimulating hormone (TSH)
• Stimulates synthesis and secretion of
thyroid hormones
• Follicle Stimulating hormone (FSH)
• Female: stimulates growth of ovarian
follicle
• Male: stimulates sperm production
• Luteinizing hormone (LH)
• Female: stimulates development of
corpus luteum; release of oocyte
• Male: stimulates secretion of
testosterone
• Prolactin
• Prepares female breast for
breastfeeding
Posterior Pituitary Gland
(Neurohypophysis)
• Antidiuretic Hormone (ADH)
• Increases water reabsorption by
kidney
• Oxytocin
• Stimulate contraction of pregnant
uterus
• Milk ejection
Thyroid Gland
• Thyroid hormones: triiodothyronine (T3)
and thyroxine (T4)
• Increase metabolic rate
• Increase responsiveness to
catecholamines
•
•
Stimulate SNS activity
Necessary for fetal growth and
development
• Calcitonin (Thyrocalcitonin)
• Lowers blood calcium and phosphate
level
• When calcitonin is high, serum
calcium is low
• When calcitonin is low, serum
calcium is high
Parathyroid Gland
• Parathyroid hormone (PTH)
• Regulates serum calcium
• PTH elevates serum calcium but
LOWERS phosphorus level
• Increase PTH, hypercalcemia
• Decreased PTH, hypocalcemia
Pancreas
• Endocrine function is
performed by the islets of Langerhans
Adrenal Glands
• Located atop the kidneys
• Divided into the adrenal cortex and adrenal
medulla
• Adrenal cortex= adrenocortical
hormones
• Adrenal medulla= adrenomedullary
hormones
Adrenocortical Hormones: Sugar, Salt,
Sex
• Glucocorticoids (Cortisol: Sugar)
• Regulate blood glucose level
• Enhance gluconeogenesis
• Insulin antagonist
• Has anti- inflammatory effect
• Decrease T- lymphocyte participation
in cell-mediated immunity
• Increase gastric acid and pepsin
production
• Mineralocorticoids (Aldosterone: Salt)
• Increases sodium retention
• Increases potassium and hydrogen
• excretion
• “pro- sodium, anti- potassium”
• Sex hormones (Androgen and estrogen)
• Responsible for some secondary sex
characteristics in females, but works
as gonadal steroids in males
• Insulin
• Secreted by beta cells
• Lowers blood glucose by facilitating
glucose transport across cell
membranes of muscle, liver, and
adipose tissues
• Promotes glycogenesis
• Glucagon
• Secreted by alpha cells
• Increases blood glucose concentration
by stimulation of glycogenolysis and
gluconeogenesis
Adrenomedullary Hormones
• Epinephrine and norepinephrine
• Serves as neurotransmitters for the
SNS
Disorders of the Pituitary Gland
Disorders of the Anterior Pituitary Gland
• Acromegaly
• Hypopituitarism
Disorders of the Posterior Pituitary Gland
• Diabetes insipidus (DI)
• Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)
•
•
Normal: GH <0.4 mcg/L
Acromegaly: GH > 0.4 mcg/L
Disorders of the Anterior Pituitary Gland
Acromegaly
• A rare condition characterized by
overproduction of growth hormone (GH).
• Prevalence rate: 28-137 cases/million
population (Kamusheva et al., 2020)
• Cause:
• Idiopathic hyperplasia of the APG
• Pituitary tumor (adenoma)- most
common
• Clinical Manifestations:
• A - Arthralgia/Arthritis
• B - Blood pressure raised
• C - Carpal Tunnel Syndrome
• D - Diabetes
• E - Enlarged organs, head, hand, face,
feet
• F - Field defect (visual impairment)
• G - Gynecomastia
• Prognosis: Shorter than average life span
• Diagnostic tests:
• Serum Growth Hormone
• Diagnostic Criteria> 0.4 mcg/L
• Insulin- like Growth Factor 1 (IGF-1)
• Mediates peripheral action of GH
• Normal: 135-449 ng/mL
• Elevated IGF-1 is diagnostic of
acromegaly
• Oral Glucose Tolerance Test (OGTT)
• GH secretion is normally inhibited by
glucose
• Baseline GH levels are obtained
before ingestion of 75- or 100- gm
oral glucose
• GH levels are then measured at
30, 60, 90, and 120 minutes
Medical Management
• Octreotide acetate (Sandostatin)
• Somatostatin analogue
• Reduces GH and IGF-1 to normal
• Given SQ 3x a week
• GH levels are measured every 2 weeks
to guide drug dosing, and then every
6 months until desired response is
obtained
Surgical Therapy
• Transsphenoidal hypophysectomy:
• Removal of the pituitary gland
• Treatment of choice for small pituitary
tumors
Incision is made in the inner aspect of the
upper lip and gingiva. The sella turcica is
entered through the floor of the nose and the
sphenoid sinuses.
Postoperative nursing care:
• Position: Low- fowlers position (30degrees) at all times to reduce pressure on
sella turcica and decrease headaches
• Provide mouth care q4H to keep surgical
area clean and free of debris
• Avoid toothbrushing for at least 10 days to
protect suture line
• Instruct patient to avoid vigorous
coughing, sneezing, and straining at stool to
prevent cerebrospinal fluid leakage
• WOF: clear nasal discharge, persistent and
severe generalized or supraorbital headache
• CSF leak usually resolves within 72
hours
when treated with head elevation and bed
rest
• Report to physician increasing urine output
and low specific gravity as they may indicate
the development of diabetes insipidus
• Essential hormones of target organs are
replaced postoperatively, as ordered
Radiation Therapy
• Used when surgery failed to produce a cure
or patients are poor candidates
• Given in combination with medications
• May also be used to shrink tumor prior to
surgery
•
Panhypopituitarism (Simmond’s
disease)
• Total failure of the pituitary gland
that results to deficiency of all
pituitary hormones
•
Sheehan’s syndrome
• Hypopituitarism caused by
postpartum pituitary necrosis
• Causes:
• Pituitary tumor- most common
• Autoimmune disease
• Infection
• Pituitary infarction
• Destruction/Removal of pituitary gland
• Clinical Manifestations:
• Early (associated with spaceoccupying lesion):
• Headache
• Visual changes
• Loss of smell
• Nausea and vomiting
• Seizures
Acromegaly vs Gigantism
• Management:
• Surgical removal of tumor
• Radiation therapy
• Lifelong hormone replacement therapy
Disorders of the Posterior Pituitary
Gland
Hypopituitarism
• A rare disorder that involves a
decrease in one or more of the pituitary
hormones.
Types:
• Selective hypopituitarism
• Deficiency of one pituitary
hormone
Diabetes Insipidus (DI)
• Most common disorder of the
neurohypophysis
• Characterized by a deficiency in antidiuretic
hormone (ADH)
• Clinical Manifestations:
• Polyuria: Large urine volume
• UO= 2 to 20L/day
• Very dilute urine
• Urine Specific Gravity: 1.001 to
1.005
• Polydipsia, craves cold water (2 to
20L)
• Hypovolemia
• Thirst
• Tachycardia
• Hypotension
Urine Osmolality
• A measure of the number of dissolved
particles in a fluid.
• Used to evaluate the balance between
water and dissolved particles in the urine
• Measurement of concentration
• Normal: 250-900 mOsm/kg
Urine Specific Gravity
• A measure of the concentration of
particles in urine and the density of urine
compared with density of water.
• Provides information on the kidney’s ability
to concentrate urine
• Normal: 1.010 to 1.020
• Diagnostics:
• Fluid Deprivation Test
• Urine osmolality are measured at
the beginning and end of test
• Fluids are withheld for 8 to 12
hours or until 3% to 5% of body
weight is lost
• Desmopressin acetate (DDAVP) is
given intranasally or SQ
Central DI
Management:
• Desmopressin (DDAVP)
• A synthetic vasopressin
• Given intranasally q12 to 24 hours
• Caution: CAD
• Chlorpropamide (Diabinese) and
• Carbamazepine (Tegretol)
• Helps decrease thirst associated
with central DI
• During acute episodes:
• Hypotonic IV fluids or D5 Water, as
ordered to replace urine output
• Encourage increased oral fluids as
tolerated
• Monitor VS, urine output and specific
gravity
• Monitor level of consciousness and for
signs of dehydration
Nephrogenic DI
Management:
• Low- sodium diet (no more than
3g/day) helps decrease urine output
• Thiazide diuretics, as ordered
• Hydrochlorothiazide,
Chlorothiazide
• Reduces flow to the ADHsensitive distal nephrons
• Indomethacin (Indocin), as ordered
• NSAID
• Helps increase renal
responsiveness to ADH
Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)
• Excessive secretion of ADH from the
pituitary gland even in the face of subnormal
serum osmolality
•
Provide frequent oral care and
distractions to decrease discomfort r/t
thirst from fluid restrictions
Management (Severe hyponatremia):
• Seizure precautions
• IV Hypertonic (3%) saline solution
(administer slowly), as ordered
• Furosemide (Lasix), as ordered
• Loop diuretic
• Promotes diuresis
• Used ONLY if serum sodium is at least
125 mEq/L
• Fluid restriction of 500mL/day, as
ordered
• Obtain daily weights
• Clinical Manifestations:
• Dilutional hyponatremia (Na <135
mEq/L)
• Headache- earliest sign
• Serum hypo- osmolality
• Concentrated urine
• Oliguria
• Weight gain
• Diagnostics
• Serum Na <135 meq/L
• Serum osmolality <280 mOsm/kg
• Urine Specific Gravity > 1.025
Management (Mild/mod hyponatremia)
• Fluid restriction to 800 to 1000
mL/day, as ordered
• Obtain daily weights
• Position HOB flat or elevated no more
than 10 degrees (to enhance venous
return to heart and increase left atrial
filling pressure, thereby reducing
release of ADH)
• Place on seizure precautions
Management:
• Tolvaptan (Samsca)
• Vasopressin V2 receptor antagonists
• It works by increasing the amount of
water released from the body as urine.
Removing fluid from the body helps to
increase the level of sodium in the
blood.
• Used to treat euvolemia-hyponatremia
in HOSPITALIZED patients
• Monitor closely to prevent rapid
correction of serum sodium
Management (Chronic SIADH):
• Demeclocycline (Declomycin)
• Inhibits ADH- induced water
reabsorption and promotes water
diuresis
• Typically used when patients find
severe fluid restriction unacceptable
and the underlying disorder cannot be
corrected
• Use ice chips or sugarless gum to decrease
thirst
• Teach patient to supplement diet with
sodium and potassium, especially when loop
diuretics are prescribed
Disorders of the Thyroid Gland
Thyroid Hormones
• Triiodothyronine (T3)
• Thyroxine (T4)
• Calcitonin
Thyroid Hormone Synthesis
Regulation of Thyroid Hormones
Euthyroid: thyroid hormone level is within
normal
Goiter
• A goiter is an enlarged thyroid gland
• Cause:
• Iodine deficiency
• Goitrogens- foods or drugs that
contain thyroid inhibiting agents
• Thyroid cells are stimulated to grow which
may result to an overactive
(hyperthyroidism) or underactive
(hypothyroidism) thyroid
• Types:
• Nontoxic goiter:
• Diffuse enlargement of the thyroid
gland that does not result from a
malignancy or inflammatory process
• Thyroid hormones are normal
• Nodular goiter:
• Thyroid- hormone secreting nodules
that function independent of TSH
stimulation
• Benign nodules
• May be multinodular goiter
(multiple nodules) or solitary
autonomous nodule (single
nodule)
• Toxic nodular goiter:
• Nodular goiters associated with
hyperthyroidism
• Prevention:
• Iodine supplementation
• Use of iodized salt
• Limit intake of goitrogenic foods
• ASIN law (RA 8172)
• Act for Salt Iodization Nationwide
(ASIN)
• Requires the addition of iodine to all
salt intended for animal and human
consumption in order to eliminate
micronutrient malnutrition in the
country
Management:
• Thyroid hormone replacement to prevent
further enlargement
• Levothyroxine (Synthroid)
• Surgery is required to remove large goiters
Hyperthyroidism
• A form of thyrotoxicosis resulting from an
excessive synthesis and secretion of
endogenous and exogenous thyroidhormones
by the thyroid
• Causes:
• Grave’s disease - most common
• Toxic nodular goiter
• Toxic adenoma
• Thyroiditis
• Excessive ingestion of thyroid
hormone
Grave’s Disease
• An autoimmune disorder that results from
an excessive output of thyroid hormones
caused by an abnormal stimulation of the
thyroid gland by circulating immunoglobulins
• Affects women> men
• Occurs between 30-40 years old
• May be precipitated by emotional shock,
stress, or infection
• Clinical Manifestations:
• Basic concept: Everything is HIGH,
FAST, and WET
• Presenting symptom: nervousness
Ophthalmopathy
• Exophthalmos- protrusion of eyeballs
resulting from fluid accumulation at the
fatpads behind the eyelids
• Dalyrimple’s sign (Thyroid stare)bright- eyed stare and infrequent blinking
• Von Graafe’s sign (lid lag)- long and
deep palpebral fissure that is still evident
even when looking down
• Jeffrey’s sign- forehead remains smooth
when patient looks up
Dermopathy
• Thickened and hyperpigmened skin at the
pretibial area
• Assessment and Diagnostics:
• Enlarged thyroid; soft and may
pulsate
• Decreased TSH, Increase Free T4
• Normal TSH: 0.5 -5.0 mIU/L
• Normal free T4: 0.9 to 1.7 ng/dL
• Radioactive iodine uptake:
• Measures the rate of iodine uptake by
the thyroid
• Uses Iodine123 (I123) and a count is
made over
the thyroid gland using a scintillation counter
• Scintillation counter detects the
gamma rays released from the
breakdown of I123
• Hyperthyroidism: HIGH uptake of I123
Medical Management:
• Radioactive Iodine Therapy
• Goal: eliminate the hyperthyroid
state with the administration of
sufficient radiation in a single
dose.
• Agent: Iodine 131 (I131)
• Contraindicated in pregnancy and
lactation
• Mechanism of action:
• The radioactive isotope of
iodine becomes concentrated
inside the thyroid gland
destroying ONLY the thyroid
cells without jeopardizing other
radiosensitive tissues
• Pre- treatment:
• Methimazole
• Anti-thyroid
• Started 4 to 6 weeks prior
to treatment
• Stopped 3 days before and
resumed 3 days after RAI
Therapy
• Nursing Interventions:
• PATIENTS IS RADIOACTIVE and
may contaminate others through
saliva, urine, or radiation emitting
from the body
• Isolate patient
• Anti- thyroid medications
• Mechanism of action: prevents
formation of thyroid hormones by
blocking iodine utilization
• DOC:
• Propylthiouracil (PTU)
• Methimazole (Tapazole)
• Nursing Management:
• Instruct to take medication early in
the morning on an empty stomach
30 minutes before eating to avoid
decrease in absorption
• Advise patient that it may take
weeks until symptom relief occurs
• WOF: fever and sore throat
• Adjunctive therapy
• Beta- blockers
•
•
Propranolol, metoprolol
Decreases HR, systolic blood pressure,
and anxiety
Eye Care for Exophthalmos:
• Artificial tears to prevent excessive
dryness
• Tinted eyeglasses
• Eye shield
Surgical management
• Indications:
• Pregnant women who are allergic to
antithyroid medications
• Large goiters
• Patients who are unable to take antithyroids
Subtotal Thyroidectomy
• Surgical removal of about 5/6 of the
thyroid tissue
• Requires a euthyroid state prior to conduct
• Pre-medications:
• Anti-thyroid
• Iodine compounds
• Potassium iodide (KI), Lugol’s
solution, Saturated Solution of
Potassium iodide (SSKI)
• MOA: reduce the size and
vascularity of thyroid gland
• Administer with milk or fruit juice
to increase palatability
• Administer using a straw to
prevent staining of teeth
• Post operative Care:
• POSITION: semi-fowler’s with head,
neck, and shoulders erect
• Monitor surgical site for bleeding and
edema:
• Check dressing and back of neck
• WOF: respiratory distress
• Prepare at bedside: tracheostomy set,
oxygen, and suction equipment
• Assess for laryngeal nerve damage
• Let client speak q hourly
• Expected: mild hoarseness
• Abnormal: Severe hoarseness with
high-pitched voiced and stridor
• Monitor for signs of hypocalcemia and
tetany:
• WOF:
• (+) Trousseau’s sign
• (+) Chvostek’s sign
•
Nursing responsibility: Prepare
Calcium gluconate at bedside
Thyrotoxicosis (Thyroid Storm)
• A form of severe, life- threatening
hyperthyroidism
• Causes: stress (surgery, RAI), infection
• Clinical Manifestations:
• Hyperpyrexia (T >38.5C)
• Extreme tachycardia (HR > 130 bpm)
• Exaggerated symptoms of
hyperthyroidism
• Altered mental status (delirium,
psychosis, coma)
Management:
• Ice packs, paracetamol
• Humidified oxygen
• IV fluids with dextrose
• Propylthiouracil (PTU), Lugol’ssolution,
dexamethasone
Hypothyroidism
• Results from suboptimal levels of thyroid
hormones
• Affects women > men
• Commonly occurs between 40 to 70 years
old
• Types:
• Primary hypothyroidism- dysfunction
of the thyroid gland
• Secondary hypothyroidism- the
dysfunction originates from the
pituitary gland
• Cretinism- hypothyroidism in children
• Causes:
• Hashimoto’s thyroiditis (most
common):
• An autoimmune form of thyroiditis
in which the person’s own immune
system attacks the thyroid gland
• Atrophy of thyroid gland with aging
• RAI therapy, thyroidectomy
• Medications (Lithium, iodine
compounds, and anti- thyroids)
• Head and neck radiation therapy
• Diagnostics:
• Clinical Manifestations
•
Basic concept: “Everything is low,
slow, and dry”
• Early:
• Hoarseness of voice
• Extreme fatigue
• Loss of libido
• Amenorrhea
• Skin dryness
• Late:
• Cold intolerance
• Hypothermia
• Expressionless and masklike facie
• Weight gain even without increase in
food intake
• Bradycardia
• Alopecia
• Constipation
• Apathy
• Sensitivity to opioids is increased
• Atherosclerosis
• Myxedema: accumulation of
mucopolysaccharides in the
subcutaneous tissue
Myxedema Coma
• A rare life- threatening condition
• Decompensated state of severe
hypothyroidism
• Common among undiagnosed
hypothyroidisms
• Precipitated by:
• Infection
• Opioids
• Clinical Manifestations:
• Altered mental status (initial
manifestation)
• Respiratory depression
• Hyponatremia, hypoglycemia
• Hypotension, bradycardia,
hypothermia
Medical management
• Goal: restore normal metabolic state
•
•
Levothyroxine (Synthroid)
• Taken on an empty stomach
• Avoid strawberry, peaches,
cabbage
• Dose is gradually increased to
prevents
• hyperthyroidism
• Caution: may increase oxygen
demand which
• triggers angina or ACS
• Discontinue immediately if with
angina or
• dysrhythmia
T3 and T4 IV replacement for
myxedema coma
Disorders of the Parathyroid Gland
Parathyroid Glands
• Embedded in the posterior aspect of the
thyroid gland
• Secretes parathormone (PTH)
• Increases serum calcium level, but
decreases phosphorus level
• Vitamin D enhances effects of hormone
Hyperparathyroidism
• Overproduction of parathormone and is
characterized by bone decalcification and the
development of renal calculi
• Types:
• Primary hyperparathyroidism
• Parathyroid adenoma – most
common
• Long- term lithium therapy
• Secondary hyperparathyroidism
• A compensatory response to
conditions that induce
hypocalcemia
• CKD, vitamin D deficiency
•
• Clinical Manifestations:
• Fatigue
• Muscle weakness
• Constipation
• Nausea and vomiting
• Dysrhythmias
• Hypertension
• Kidney stones
• Pathologic fractures
• Skeletal pain and tenderness
• Shortening of body stature
• Diagnostics
• Serum calcium level
• Normal: 8.5-10.5 mg/dL
• Hyperparathyroidism: elevated
• Intact PTH
• Normal: 14-72 pg/mL
• Hyperparathyroidism: elevated
• Serum phosphorous level
• Normal: 2.5- 4.5 mg/dL
• Hyperparathyroidism: decreased
• Bone Mineral Density (BMD)
Hyperparathyroidism: T score of -2.5 or less
at any site or previous fragility fracture
Medical management
• Hydration therapy
• Increased fluid intake to 2,000mL or
more to prevent renal calculi
• PNSS IV- fluid of choice as sodium
enhances excretion of calcium
• Mobility
• Bones subjected to the normal stress
of walking give up less calcium. Bed
rest increases calcium excretion and
the risk of renal calculi.
• Gallium nitrate (Ganite)
• Anti- hypercalcemic
• Alendronate (Fosamax)
• Bisphosphonates
Inhibit osteoclastic bone resorption,
normalizing serum calcium levels
Surgical Management:
• Parathyroidectomy:
• Removal of one or more of the
parathyroid glands
• Postoperative care:
• Position: Semi- Fowler’s
• WOF respiratory distress, bleeding at
post operative site
• Prepare at bedside: tracheostomy set
Hypercalcemic Crisis
• Occurs with extreme elevation of calcium
levels greater than 13 mg/dL
• Cause: dehydration
Management:
• Rapid rehydration with large volume of
isotonic fluid
• Loop diuretic (e.g., Furosemide) if with
edema
• Calcitonin- promotes renal excretion of
calcium
• Corticosteroids- promotes calcium
deposition in bone
• Dialysis
Hypoparathyroidism
• Hyposecretion of parathyroid hormone
• Cause:
• Subtotal thyroidectomy (most
common)
• Abnormal parathyroid development
• Clinical Manifestations:
• Hypocalcemia (Ca++ < 8.5mg/dL)
• Tetany: general muscle hypertonia,
with tremor and spasmodic or
uncoordinated contractions occurring
with or without efforts to make
voluntary movement
Latent Tetany:
• Numbness, tingling, and cramps in the
extremities
• Stiffness of hands and feet
Overt Tetany:
• Bronchospasm
• Laryngospasm
• (+) Trousseau’s sign: carpopedal spasm
resulting from occlusion of the blood flow to
the arm for 3 minutes
• (+) Chvostek’s sign: sharp tapping over
the facial nerve causes spasm or twitching of
mouth, nose, eye
• Seizures
• Dysrhythmias
• Photophobia
Medical Management:
• Goal: increase serum calcium to 8.5 to
10.5 mg/dL
• Vitamin D3 (calciferol)
• Hydrochlorothiazide (Hydrodiuril)decreases urinary calcium excretion
• Calcium gluconate very slow IVTT - if
hypocalcemia is after thyroidectomy
• Aluminum hydroxide gel (Amphojel) after
meals to bind phosphate and promote its
excretion through the GI tract
• Place patient on seizure precaution
• Have a tracheostomy set, oxygen, and
suction available at bedside
• Provide a high- calcium, low- phosphorus
diet
• Broccoli, tomato, banana, kidney
beans
• Avoid cheese, milk and milk products,
and egg yolk
• Avoid spinach which contains oxalate
that forms insoluble calcium
substances
Disorders of the Adrenal Glands
Pheochromocytoma
• A tumor of the chromaffin
cells of the adrenal medulla (usually benign;
10% malignant)
• Peak incidence at 40-50 years old
• Affects men and women equally
• High familial tendency
• Clinical Manifestations:
• Headache
• Hyperhidrosis
• Hypertension
• Hypermetabolism
• Hyperglycemia
• Diagnostics:
• Vanillylmandelic Acid (VMA) Test
• Measures urinary excretion of
catecholamine metabolite
• Specimen: 24- hour urine sample
• Avoid coffee and tea, banana,
chocolate, vanilla, and aspirin
• Normal: 1.4-6.5mg/24 hours
• Clonidine suppression test
• Clonidine suppresses release of
neurogenically mediated
catecholamines
• (+): clonidine does not suppress
catecholamine levels
Medical Management (ABC):
• Alpha- Adrenergic blocker
• Phenoxybenzamine (Dibenzyline)
• Given 10 to 14 days prior to surgery
• S/E: orthostasis, nasal stuffiness,
fatigue, retrograde ejaculation
• Beta- Adrenergic blocker
• Propranolol (Inderal)
• Initiated once alpha- adrenergic
control is achieved
• Calcium Channel Blocker
• Nifedipine (Adalat)
• Alternative treatment if blood pressure
control is inadequate or patient is
unable to tolerate side effects
Surgical Management:
• Adrenalectomy
• Removal of one or both adrenal glands
• Definitive treatment of
pheochromocytoma
• Pre-operative preparation: control blood
pressure
• Complication:
• Hypertensive crisis (Intra/Post- Op)
• Results from the manipulation of the
tumor during surgical excision
• Mgt:
• Sodium nitroprusside (Nitropress)
• Phentolamine (OraVerse)
Nursing Management:
• Institute bed rest with HOB elevated to
promote orthostatic decrease in BP during
episodes of hypertension or tachycardia
• Monitor vital signs, ECG, fluid and
electrolytes, and blood glucose levels
Cushing’s Syndrome
• A clinical condition that results from
chronic exposure to excess corticosteroids,
particularly glucocorticoids
• Affects women > men
• Cause:
• Steroids (most common exogenous)
• Cushing’s Disease: Presence of ACTHsecreting pituitary adenoma (most
common endogenous)
• Hyperplasia of adrenal gland (less
common)
• Ectopic production of ACTH by
malignancies
• Clinical manifestation:
• Moon - face
• Buffalo hump
• Virilization (women): appearance of
masculine traits and recession of
feminine traits
• Truncal obesity but thin extremities
• Purple/Red Striae
•
•
•
•
•
•
•
Easy bruising
Menstrual disorders
HTN
Unexplained hypokalemia
Sleep disturbances
Hyperglycemia
Osteoporosis, Pathologic fractures
• Diagnostics:
• Serum cortisol level
• Normal:
• high in early morning (6 to 8
am): 10-20 mcg/dL;
• low in the evening (4 to 6 pm):
3-10 mcg/dL
• Abnormal: disruption of normal
variation
• Dexamethasone suppression test
• Dexamethasone 1mg (low dose) or
8 mg (high dose) PO at bedtime,
then plasma cortisol and ACTH
levels are obtained at 8am the next
morning
Collaborative Management:
• Transsphenoidal hypophysectomy
• Done if cause is a pituitary tumor
• Adrenalectomy (Laparoscopic):
• Done if cause is adrenal hypertrophy
• Post operative care:
• Symptoms of adrenal insufficiency
may appear 12 to 48 hours after
surgery
• Hydrocortisone is given for several
months
• Adrenal enzyme inhibitor
• Metyrapone (Metopirone),
Ketoconazole (Nizoral)
• Used if cause is an ectopic ACTH
production
• Dose reduction
• Done if cause of syndrome is the
administration of corticosteroids
• Dose is tapered to the minimum
dosage needed to treat underlying
disease process
Addison’s Disease
• Primary adrenocortical insufficiency
• Occurs when the adrenal glands are
damaged and cannot secret adrenocortical
hormones
• Causes:
• Autoimmune or idiopathic atrophy
• Abrupt withdrawal of corticosteroids
• Adrenalectomy
• Infections (i.e., tuberculosis and
histoplasmosis)
• Clinical Manifestations:
• Muscle weakness
• Anorexia
• GI symptoms
• Emaciation
• Dark pigmentation of knuckles, knees,
and elbows, dehydration
• Hypoglycemia, hyponatremia,
hyperkalemia
• Emotional lability
• Bronze pigmentation of skin
Medical Management:
• Hydrocortisone (Solu- cortef), as ordered
• Fludrocortisone (Florinef), as ordered
• Dietary:
• High sodium, low potassium
• Small, frequent feedings if with
anorexia
Addisonian Crisis
• Hypotension, cyanosis, fever, n&v, signs of
shock
• Cause: stress, exposure to cold, acute
infection, decreased salt intake, dehydration
Management:
• High-dose hydrocortisone IV
• 5% dextrose in normal saline IV- to
reverse hypotension
• Vasopressors, if with persistent
hypotension
Primary Aldosteronism
• Excessive production of aldosterone
• Cause:
• Tumor of the adrenal gland (solitary
adrenocortical adenoma)
• Clinical Manifestations:
• Hypertension
• Hypokalemia
• Muscle weakness
• Fatigue
• Dysrhythmias
• Diagnostics:
• Captopril Challenge Test (CCT)
• ACE inhibitors normally block the
activity of RAAS
•
Give 25-50 mg captopril PO after
sitting/standing for at least 1
hours with blood samples drawn at
time zero and after 2 hours for
plasma renin activity (PRC) and
plasma aldosterone measurements
• (+): Plasma aldosterone is >/= 8.5
ng/dL AND renin remain suppressed
Collaborative Management
• Laparoscopic adrenalectomy:
• Done to achieve total surgical removal
of adrenal tumor
• Less complications and shorter
hospital stay
• Spironolactone (Aldactone)
• Potassium- sparing diuretic
• Controls hypertension without causing
further hypokalemia
MEDICAL-SURGICAL 2: PTM4
Care of Clients with Diabetes Mellitus
Diabetes Mellitus (DM)
• A group of metabolic disease characterized
by hyperglycemia.
• Hyperglycemia- elevated blood
glucose level
• Normal blood glucose: 80-120 mg/dL
• A chronic, multisystem disease related to
abnormal insulin production, impaired insulin
utilization, or both
• A disorder of glucose metabolism related to
absence or insufficient insulin supply and/or
poor utilization of the insulin
• General Risk Factors
• Family history
• Obesity
• Race/Ethnicity (i.e., AfricanAmericans, Hispanics,
• Native Americans, Asian American,
Pacific Islander)
• Age ≥ 45 years old
• Previously identified impaired fasting
glucose
• Hypertension (≥140/90)
• Decreased HDL, increased
triglycerides
• History of gestational diabetes/
delivery of babies over 9lbs
• Types:
• Type I Diabetes Mellitus
• Juvenile- onset diabetes
• Insulin- dependent diabetes
mellitus (IDDM)
• Type II Diabetes Mellitus
• Adult- onset diabetes
• Non-Insulin- Dependent Diabetes
Mellitus (NIDDM)
• Classical Signs
• Polyuria: increased frequency and
volume of urine
• Polydipsia: increased thirst sensation
• Polyphagia: increased hunger
sensation
Type 1 Diabetes Mellitus
• Characteristics:
• Acute onset
• Usually before 30 years old
• Patient is thin
• Etiology:
• Destruction of beta cells by
• Genetics
• Immunologic
• Environmental
Type 2 Diabetes Mellitus
• Characteristics:
• Most prevalent type
• Slow onset
• Usually after 30 years old
• Common among obese
• Risk Factors:
• Overweight/Obesity
• Old age
• Family history of DM type 2
• African Americans, Asian Americans,
Hispanics, Native Hawaiians or other
Pacific Islanders, and Native
Americans
• Etiology:
• Insulin resistance: decreased tissue
sensitivity to insulin
• Unknown cause
• Impaired insulin secretion
Medical Management
• Goal: Achieve euglycemia without episodes
of hypoglycemia while maintaining a high
quality of life
Insulin Therapy
• Historically, insulin was derived from beef
and pork pancreas
• Recent insulin preparations are genetically
engineered human insulins derived from
E.coli or yeast cells using recombinant DNA
technology
• Commonly given subcutaneously,
butregular insulin may be given IV/SQ
• Dose is prepared in “units”
Insulin Preparations
• Groups insulin according to onset (O), peak
(P), and duration (D)
• Rapid- acting, Short- acting, Intermediateacting, Very Long-acting
Rapid- Acting Insulin
• Diagnostic Criteria
• Symptoms of DM plus casual plasma
glucose concentration greater than or
equal to 200 mg/dL; OR
• Fasting plasma glucose greater than or
equal to 126 mg/dL; OR
• Two- hour post load glucose greater
than or equal to 200mg/dL during an
oral glucose tolerance test; OR
• HbA1-C greater than or equal to 6.5%
• Glycosylated hemoglobin
• Measures the percentage of
hemoglobin that carries glucose
• Reflects glucose control for the
past 3 months
Short- Acting Insulin
Intermediate- Acting Insulin
Very Long- Acting Insulin
Combination Insulin Therapy
• A short- or rapid-acting insulin is mixed
with intermediate-acting insulin in the same
syringe.
• This allows the patient to have both
mealtime and basal coverage without having
to administer two separate injections.
Combining Insulins in One Syringe
1. Wash hands.
2. Gently rotate NPH insulin bottle.
3. Wipe off tops of insulin vials with alcohol
sponge.
4. Draw back amount of air into the syringe
that equals total dose. (Ex. 48 units of air for
36 units NPH and 12 units regular insulin)
Insulin Regimen
Storage of Insulin
• Heat and freezing alter insulin molecule
• In use insulin vials and pens
• ROOM temperature for up to 4 weeks
• Unopened insulin vials and pens
• Stored in the REFRIGERATOR
• Pre-filled insulin syringe
• Prefilled syringes with two different
insulins
• Store in refrigerator for up to 1
week ONLY
• Prefilled syringes with only one type of
insulin
• Store in refrigerator for up to 30
days ONLY
• Store in a vertical position with needle
pointed up (to avoid clumping of
suspended insulin in the needle)
• Before injection, gently roll prefilled
syringes between the palms 10 to 20
times (to warm the insulin and
resuspend the particles)
Insulin Administration
• Route:
• Subcutaneous
• Regular insulin can be given IV
• PO is contraindicated because insulin
is inactivated by gastric acid
• Golden rule: Never assume that because
the patient already uses insulin, he or she
knows and practices the correct insulin
injection technique
Systemic allergic reaction
• Rare
• Begins immediately after injection and
becomes generalized urticaria
• Treatment is desensitization
• Small doses of insulin are given in
increasing amounts
Lipodystrophy
• Lipoatrophy- loss of subcutaneous fat and
appears as a slight dimpling or more serious
pitting of SQ
• Cause: repeated use of an injection
site
• Management: rotate injection sites
• Lipohypertrophy - development of
fibrofatty masses at the injection site
Morning Hyperglycemia
• An elevated blood glucose level on arising
in the morning
• Causes: Dawn Phenomenon or Somogyi
Effect
Complications of Insulin Therapy
Dawn Phenomenon
• Normal glucose level until approximately
3AM when blood glucose begins to rise
• The elevation is associated with the release
of growth hormone which decreases tissue
sensitivity to insulin
Dawn = DOWN insulin
Local allergic reaction
• Appears at the injection site 1 to 2 hours
after administration
• S/Sx: redness, swelling, tenderness, and
induration
• Usually resolves spontaneously, otherwise
insulin type is changed
Somogyi Effect
• High dose evening/bedtime insulin
produces a decline in blood glucose during
the night
• Hypoglycemia triggers release of
counterregulatory hormones (i.e., glucagon,
epinephrine, growth hormone, cortisol)
Teach patients to rotate the injection within one
anatomic site, such as the abdomen, for
at least 1 week before using a different site, such as
the right thigh. (This allows for better insulin
absorption)
which produces rebound hyperglycemia in
the AM
SoMogyi = So MOch insulin
Morning Hyperglycemia Diagnostics
• Check CBG
Morning Hyperglycemia Management
Oral Hypoglycemic Agents (OHA)
✓Biguanides
✓Sulfonylureas
✓Meglitinides
✓Alpha Glucosidase inhibitor
✓Thiazolidinediones
✓DDP-4 Inhibitor
Biguanides
• Metformin (Glucophage)
• MOA: reduces glucose production by the
liver and enhances tissue sensitivity at the
tissue level
• S/E: lactic acidosis, diarrhea
• NRSG RESP: Needs to be held 1-2 days
before IV contrast media given and for 48 hr
after
Sulfonylureas
• Glipizide (Glucotrol), Glyburide (Glynase),
Glimepiride (Amaryl)
• MOA:
• Stimulate beta cells to secrete insulin
• Decrease glycogenolysis and
gluconeogenesis.
• Enhance cellular sensitivity to insulin.
• S/E: weight gain, hypoglycaemia
Meglitinides
• Nateglinide (Starlix), Repaglinide (Prandin)
• MOA: stimulates a rapid but short- lived
release of insulin from the pancreas
• S/E: Weight gain, hypoglycemia
Alpha Glucosidase Inhibitor
• “Starch blocker”
• Acarbose (Precose), Miglitol (Glyset)
• MOA: slows down the absorption of CHO in
the small intestine
• S/E: Gas, abdominal pain, diarrhea
• NRSG RESP: Taken with the first bite of
each main meal
Thiazolidinediones
• “Insulin sensitizers”
• Pioglitazone (Actos), Rosiglitazone
(Avandia)
• MOA: increases insulin sensitivity,
transport, and utilization at target tissues
• S/E:
• Pioglitazone: increases risk for bladder
cancer and exacerbates heart failure
• Rosiglitazone: increases risk for
cardiovascular events
Dipeptidyl Peptidase-4 (DPP-4)
Inhibitors
• Linagliptin (Trajenta), Sitagliptin (Januvia)
• MOA: stimulate release of insulin from beta
cells, decrease hepatic glucose production
• S/E: pancreatitis, allergic reactions
Sodium- Glucose CoTransporter 2
(SGLT2) Inhibitor
• Canagliflozin (Invokana); Empagliflozin
(Glyxambi)
• MOA: blocks the reabsorption of glucose by
the kidney, increasing glucose excretion, and
lowering blood glucose levels
Dietary Modifications
Diabetes Meal Planning
- A non-specific guide for when, what, and
how much food to consume to receive
adequate nutrition while maintaining blood
glucose at the target range
- Must take into consideration a patient’s
goals, preferences, and lifestyle
Characteristics of Diabetes Diet
• Includes more non-starchy vegetables
• High- fiber, fewer added sugars and refined
grains
• Whole foods are preferred over highly
processed foods
• Total calories will be prescribed by
physician
• Caloric distribution:
• CHO: 50% to 60%
• Fats: 20% to 30%
• CHON: 10-15% to 20%
• The plate method is a simple, visual way
to make sure the patient gets enough nonstarchy vegetables and lean protein while
limiting the amount of higher-carb foods
eaten that have the highest impact on blood
sugar levels.
• The appropriate plate size is a 9-inch
dinner plate
• Fill half with nonstarchy vegetables
• Nonstarchy vegetables are lower in
carbohydrate, so they do not raise blood
sugar very much.
• Examples: asparagus, cabbage, carrots,
cauliflower, cucumber, eggplant, okra, green
beans, tomatoes
• Fill one quarter with a lean
protein
• Animal- based:
• Chicken, eggs
• Fish
• Shellfish
• Lean beef, pork
• Cheese
• Plant- based:
• Beans
• Nuts
• Tofu
• Fill one quarter with carb foods.
• Whole grains
• Starchy vegetables (squash, potato,
kamote)
• Dairy products (milk, yogurt, soy milk)
• Water is the best choice because it
contains no calories or carbohydrates and
has no effect on blood sugar. Other zero- or
low-calorie drink options include:
• Unsweetened tea (hot or iced)
• Unsweetened coffee (hot or iced)
• Sparkling water/club soda
• Flavored water or sparkling water
without added sugar
• Diet soda or other diet drinks
Exercise
• Lowers blood glucose levels by increasing
the uptake of glucose by body muscles and
by improving insulin utilization
• Guidelines:
• Exercise 3x per week with no more
than 2 consecutive days without
exercise
• Perform resistance training 2x a week
if with type 2 DM
• Exercise at the same time of the day
and for the same duration each
session
• Use proper footwear and, if
appropriate, other protective
equipment
• Avoid trauma to lower extremities
• Inspect feet daily after exercise
• Avoid exercise in extreme heat or cold
•
Avoid exercise during periods of poor
metabolic control
• Stretch for 10 to 15 minutes before
exercising
• Precaution:
• Patients with blood glucose greater
than 250 mg/dL and who have
ketones in the urine should not
exercise until urine test results are
negative for ketones and the blood
glucose level is closer to normal.
• Exercising with elevated blood glucose
increases secretion of glucagon,
growth hormone, and catecholamines.
• Patients who are on insulin therapy
should be taught to eat a 15- g CHO
snack (a fruit exchange) or a snack of
complex carbohydrate with a protein
to prevent hypoglycemia.
Self- monitoring of Blood Glucose
(SMBG)
• Enables the patient to make decisions
regarding food intake, activity patterns, and
medication dosages.
• Produces accurate records of daily glucose
fluctuations and trends, and it alerts the
patient to acute episodes of hyperglycemia
and hypoglycemia.
• Provides patients with a tool for achieving
and maintaining specific glycemic goals.
• Recommended for all insulin- treated
patients with DM
• HbA1-c (Glycosylated Hgb) is also
monitored to review glucose control over the
past 3 months.
• Target parameters:
• Pre- prandial CBG: 80-130 mg/dL
• Post- prandial CBG (1-2 hours PC): <
• 180mg/dL
•
HbA1c: < 7%
• Non-diabetics: 4%- 5.6%
Acute Complications of DM
Hypoglycemia
• Means low blood sugar
• Occurs when blood glucose falls to less
than 80 mg/dL
• Severe hypoglycemia is when glucose
levels are less than 40mg/dL
• Causes:
• Too much medication
• Too little food
• Excessive physical activity
Management of Hypoglycemia
• “Rule of 15”
• Give 15 grams of fast- acting
carbohydrate by mouth (e.g., 4-6 oz
of soda, 8-10 lifesavers, 4-6 oz orange
juice, or 1tbsp honey)
• Wait 15 minutes then recheck blood
glucose.
• If blood glucose is still < 70mg/dL,
give another 15-g fast acting
carbohydrate
• Once blood sugar is stable and next
meal is more than 1 hour away, give
additional food of longer- acting
combination plus protein or fat once
symptoms subside.
• Crackers with peanut butter
• 2 slices of white bread plus
skimmed milk
• Notify physician if symptoms do not
subside after two to three
administrations of fast- acting
carbohydrates
Severe Hypoglycemia
• CBG <40mg/dL
• Clinical Manifestations:
• Unconsciousness or difficulty arousing
from sleep
• Seizures
• Disoriented behaviour
Management:
• Glucagon 1mg SQ/IM
• Return of consciousness may take up
to 20 minutes after administration
• Provide snack on awakening to
prevent recurrence of hypoglycemia,
except if with nausea
• If nauseous, position to side lying
• D50W (50% dextrose in water)
• 25 to 50 mL of D50W IV Push
• Used in hospital settings
• Ensure IV-line patency
Diabetic Ketoacidosis (DKA)
• A life- threatening complication of type 1
DM
• Causes:
• Decreased or missed dose of insulin
• Illness or infection
• Undiagnosed or untreated DM
• Clinical Manifestations
Management:
• Fluid Replacement
• PNSS (0.9% NaCl) at 0.5 to 1L per
hour for 2 to 3 hours
• Half-strength NSS (0.45% NaCl) if
hypertensive or hypernatremic
• WOF: fluid overload (bounding pulse,
crackles, headache)
• Restoring Electrolytes
• Important: rehydration and insulin
cause a drop in potassium level
• Rehydration increases potassium
excretion via urine
• Insulin transports potassium from the
extracellular into the intracellular
compartment
• Potassium chloride IV infusion
• INCORPORATE KCl into IV bottle. DO
NOT GIVE KClVIA IV PUSH SINCE IT
CAUSES CARDIAC ARREST
• Use infusion pump for accurate
delivery
• Apply cold compress on IV site
• Hold if patient is not urinating
• Reversing acidosis and hyperglycemia
• Regular insulin
• Given via intravenous route at a slow,
continuous rate
• Infuse D5NSS or D5 0.45%NSS when
blood glucose levels reach 250 to 300
mg/dL to avoid rapid drop in the blood
glucose level during treatment
Hyperglycemic Hyperosmolar NonKetotic Syndrome (HHNKS)
• A metabolic disorder of type 2 DM
• Characterized by severe hyperglycemia and
hyperosmolarity
• Occurs most often in older adults (50 to 70
years old)
• Causes:
• Infection
• Illness (e.g., stroke, MI)
• Medications that exacerbate
hyperglycemia (thiazides)
• Treatment/Procedures (dialysis or
surgery)
• Clinical Manifestations:
• Blood glucose levels from 600 to
• 2000mg/dL
• Hypotension
• Profound dehydration (dry mucous
membranes, poor skin turgor)
• Tachycardia
• Variable neurologic signs (ALOC,
seizures, hemiparesis)
Management:
• Same as DKA
• Monitor closely for fluid overload
Chronic Complications of DM
Angiopathy
• Damage to blood vessels secondary to
chronic hyperglycemia
• Etiology:
• Accumulation of damaging byproducts of glucose metabolism, such
as sorbitol, which is associated with
damage to nerve cells;
• Formation of abnormal glucose
molecules in the basement membrane
of small blood vessels such as those
that circulate to the eye and kidney;
• A derangement in red blood cell
function that leads to a decrease in
oxygenation to the tissues.
Macrovascular Complications
• Diseases of the large and medium-size
blood vessels that occur with greater
frequency and with an earlier onset in people
with diabetes
• Preventive Management:
• Risk reduction:
• Weight reduction
• Smoking cessation
• Control of BP
• Dietary modification (Low salt, low fat)
• Exercise
Microvascular Complications
• Result from thickening of the vessel
membranes in the capillaries and arterioles
in response to conditions of chronic
hyperglycemia.
• Specific to diabetes
Proliferative Diabetic Retinopathy
• Most severe form
• Occurs in late stage of diabetic retinopathy
• Neovascularization sec. to complete
occlusion of retinal vessel
• Patient sees black or red spots or lines;
blindness if left untreated
Management:
• Laser photocoagulation therapy
• Reduces risk of vision loss
• Destroys the ischemic areas of the retina
that produce growth factors that encourage
neovascularization.
Diabetic Retinopathy
• Process of microvascular damage to the
retina as a result of chronic hyperglycemia,
nephropathy, and hypertension in patients
with diabetes.
Non- proliferative Diabetic Retinopathy
• Most common form
• Occurs in early stage of diabetic
retinopathy
• Microaneurysm sec. to partial occlusion of
retinal vessel
• Asymptomatic, but vision may be affected
if macula is involved
• Preventive Management:
• Dilated eye exam within 5 years after
onset of DM type 1 and annually thereafter
• Maintain good glycemic control
• Manage BP
Diabetic Nephropathy
• A microvascular complication associated
with damage to the small blood vessels that
supply the glomeruli of the kidney.
• Results to end-stage kidney disease
• Hypertension accelerates its progression