Section 1: Gastrointestinal System Alterations
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a. IBS Complications: Irritable Bowel Syndrome is a functional disorder without
structural damage. Key complications include dehydration and fluid/electrolyte
imbalances (especially in diarrhea-predominant IBS), imbalanced nutrition/weight loss,
and psychosocial impacts via the gut-brain axis (anxiety/depression). Alarming
symptoms like blood in stool, fever, or unexpected weight loss indicate more severe
diseases like IBD or cancer, not IBS.
b. Barium Swallow Considerations: Pre-procedure requires NPO after midnight,
removing metal/jewelry, assessing swallowing, and educating on the chalky taste. Postprocedure, stools will be white/chalky for 24-72 hours. Prevent bowel obstruction by
encouraging fluids, high-fiber diets, and ambulation. Report red flags: no bowel
movement in 24-48 hours, severe pain, or N/V.
c. GI Bleeding Assessment: Upper GI bleeds present as melena (dark, tarry stools) or
hematemesis (bright red or "coffee ground" vomit). Lower GI bleeds present as
hematochezia (bright red stool). Systemic signs of hypovolemia include tachycardia,
hypotension, decreased urine output, pale/clammy skin, confusion, and decreasing
serial hemoglobin/hematocrit.
d. Pancreas Importance: The pancreas has an exocrine function (secreting amylase,
lipase, and inactive trypsin for digestion, plus bicarbonate to neutralize stomach acid)
and an endocrine function (secreting insulin and glucagon for metabolic regulation).
Dysfunction leads to malabsorption, weight loss, and steatorrhea (fatty stools), requiring
lifelong enzyme replacement.
e. Crohn’s Disease Interventions: Pharmacological management uses a stepwise
approach (aminosalicylates, corticosteroids, biologic agents). Dietary management
requires avoiding trigger foods (dairy, high fat, caffeine), avoiding fiber during acute
flares, maintaining high protein/calorie intake, and using TPN for severe bowel rest.
Surgery includes bowel resections, ostomies, and fistula repairs.
f. Feeding Tube Complications: Complications include dumping syndrome (osmotic
pull causing diarrhea, hypotension, tachycardia), blood glucose fluctuations, and high
gastric residuals. Mechanical risks include aspiration (keep HOB ≥30 degrees),
peritonitis from displacement, and tube clogging (flush with 30-50 mL warm water).
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g. Parenteral Nutrition (PN) Initiation: PN requires a dedicated central venous line
(PICC), an infusion pump, and a 1.2-micron safety filter. Monitor capillary blood glucose
every 6 hours initially, draw daily labs for formula recalculation, and hang 10% dextrose
if the bag runs out to prevent rebound hypoglycemia. Strict aseptic technique is required
to prevent sepsis.
h. Obesity Factors in GI Disorders: Excess weight increases intra-abdominal pressure
(causing GERD and hernias) and decreases GI motility. A less diverse gut microbiome
and genetic factors contribute. Weight loss medications (GLP-1s) slow motility and can
cause severe constipation or bowel obstructions.
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i. Initiation of TPN: Indicated for severe conditions requiring complete GI rest (severe
pancreatitis, severe IBD flares, GI cancer, bowel obstructions). Clinical criteria include
NPO status >7 days, unintended weight loss >10%, muscle wasting, or persistent
fluid/electrolyte imbalances.
j. Goals of PN: The primary goals are achieving optimal nutrition, providing complete GI
rest, preventing infection, maintaining fluid and electrolyte balance, educating on selfcare, and preventing complications.
k. Gastrostomy Tube Interventions: Verifying placement is the top priority (initial Xray, then pH 1-5; air auscultation is unreliable) to prevent peritonitis. Prevent aspiration
by keeping the HOB elevated to at least 30 degrees. Assess residuals (hold if ≥4 hours
worth), flush regularly for patency, and monitor glucose.
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l. Perforated Peptic Ulcer Manifestations: This life-threatening emergency causes
extreme sudden pain, a rigid, board-like abdomen, rebound tenderness, and absent
bowel sounds. Systemic signs of shock include hypotension, tachycardia, high fever, a
"hot belly," and hematemesis/melena.
m. Bariatric Surgery Nutrition Teaching: Requires lifelong commitment and
counseling. Post-operatively, clients follow the "30 mL rule" and must strictly avoid
straws, carbonation, and high-sugar foods to prevent dumping syndrome. Small,
frequent, high-protein meals are required alongside Vitamin B12 injections.
n. Chronic Gastritis Risk Factors: Risks include H. pylori infection, chronic
NSAID/aspirin use, steroid use, stress, alcohol abuse, food intolerances, tobacco use,
and natural aging (decreased mucosal protection).
o. Gastric Hemorrhage Interventions: 1. Airway protection (suction, oxygen). 2.
Circulatory support (large-bore IV access, fluids, blood products to prevent hypovolemic
shock). 3. Hemodynamic/lab monitoring (vitals, mental status, serial H&H). 4. Gastric
rest (NPO, NG tube for lavage, prep for emergent EGD).
p. IBD Manifestations (Crohn’s vs. UC): Crohn's affects the entire GI tract
transmurally (skip lesions/cobblestone), causing non-bloody steatorrhea, RLQ pain, and
fistulas. Ulcerative Colitis is limited to the colon/rectum mucosa, causing continuous
lesions, bloody diarrhea with mucus, LLQ pain, and carries a high risk for severe
bleeding/perforation.
q. Ostomy Teaching: Focus on preventing leaks to maintain peristomal skin integrity.
Educate on normal stoma appearance (red, pink, moist) versus emergency red flags
(dusky, purple, dark colors indicating ischemia). Provide psychosocial support and refer
to a stoma nurse.
r. Bowel Obstruction Manifestations: Crampy/colicky pain, hard distension, and
inability to pass flatus. Bowel sounds are hyperactive initially, becoming absent later.
Vomiting may be projectile or have a fecal odor. Partial obstructions present with liquid
diarrhea. Severe cases present with signs of shock.
s. Pharmacologic Obesity Misconceptions: Medications are not for minor cosmetic
goals or simple lack of "willpower"; they carry severe risks like thyroid cancer,
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pancreatitis, and bowel obstructions. Weight loss is not permanent upon stopping meds
(GLP-1s) unless lifelong habits change, and these drugs have severe GI side effects.
t. Bariatric Surgery Criteria: Requires a BMI >40 (or >30 with comorbidities like type 2
diabetes or GERD) and approval by a multidisciplinary team (surgeon, dietician,
psychologist). The client must commit to lifelong follow-up and habit changes.
u. Acute Abdominal Disorders Manifestations:
○ Appendicitis: RLQ pain at McBurney's point, rebound tenderness.
○ Cholecystitis: RUQ pain triggered by fat (Murphy’s sign), referred right shoulder
pain.
○ Pancreatitis: Severe epigastric pain radiating to the back, Cullen's/Grey Turner's
signs.
○ Bowel Obstruction: Crampy pain, distension, absent flatus.
○ Diverticulitis: LLQ pain.
○ Peritonitis: Sudden pain, rigid board-like abdomen, "hot belly," shock.
v. Stoma Assessment: Remove the pouch to fully visualize the stoma and skin. A
healthy stoma is red/pink/moist. A dusky, purple, or dark stoma is a medical emergency
indicating necrosis/ischemia.
w. Colon Cancer Screening: Average risk screening starts at age 45, with a
colonoscopy every 10 years. High-risk individuals require earlier/more frequent testing.
x. Hernia Assessment: Present as a visible bulge worsening with activity/Valsalva. A
reducible hernia can be pushed back; an incarcerated hernia is trapped; a strangulated
hernia is a medical emergency lacking blood supply (dusky skin, extreme pain, shock).
Hiatal hernias present with GERD symptoms.
y. Hiatal Hernia Interventions: HOB >30 degrees, remain upright for 2 hours postmeals, weight loss, low-fat diet, avoid triggers (caffeine, spicy, smoking). Meds include
PPIs (pantoprazole) and H2RAs. Severe cases require Laparoscopic Nissen
Fundoplication.
z. Stomach Secretions Physiology: Parietal cells secrete HCl (pH 1-4) and intrinsic
factor (for B12). Chief cells secrete pepsinogen (converts to protein-digesting pepsin).
Endocrine cells secrete gastrin, serotonin, histamine (increases acid), and somatostatin
(decreases acid). A mucus-bicarbonate barrier protects the lining.
aa. Peritonitis Interventions: Emergency condition requiring strict NPO, NG tube
decompression, and immediate surgical notification. Stabilize shock with IV
fluids/electrolytes and oxygen, and administer broad-spectrum IV antibiotics. Prepare for
laparoscopy and lavage.
bb. Diverticulitis Prevention: High-fiber diet (avoid during acute flares), fluid intake of
2.5-3L/day, avoiding Valsalva/straining, regular exercise, weight management, and
smoking cessation.
cc. GERD Risk Factors: Incompetent LES (lower esophageal sphincter), hiatal hernia,
delayed motility, obesity, tobacco, alcohol, age >50, pregnancy, gastric infection w
Helicobacter pylori, and trigger foods (chocolate, caffeine). Medications like NSAIDs,
nitroglycerin, albuterol, calcium channel blockers, and anticholinergics increase risk.
dd. Viral Gastroenteritis Infection Control: Mandatory handwashing with soap, water,
and friction (alcohol hand sanitizer is ineffective against norovirus). Use contact and
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droplet precautions, sanitize the environment, and promote the rotavirus vaccine for
pediatrics.
ee. Crohn’s Diet Recommendations: Avoid trigger foods (dairy, high-fat, caffeine,
alcohol, spicy items) and fiber during acute flares. Eat small, frequent, high-protein/highcalorie meals with vitamin supplements. Severe flares require TPN for bowel rest.
Section 2: Hepatobiliary System Alterations
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a. Hepatic Dysfunction Manifestations: Early signs include profound fatigue and
anorexia. Later signs include RUQ pain, ascites, jaundice, intense pruritus, spider
angiomas, easy bruising/bleeding (coagulopathy, esophageal varices), and hepatic
encephalopathy (confusion, asterixis, fetor hepaticus).
b. Hepatitis Prevention: Fecal-Oral (Hep A & E): Strict handwashing with soap and
water, Hep A vaccine, clean water access. Blood/Body Fluid (Hep B, C, D): Hep B
vaccine (also prevents D), safe needle practices, and Hep C screening (no vaccine for
C). Limit acetaminophen (1000mg/6hrs) and abstain from alcohol.
c. Chronic Liver Disease Pharmacologic Interventions: Administer lactulose to
excrete ammonia via diarrhea (requires fall precautions/skin care). Administer
potassium-sparing diuretics (spironolactone) for ascites. Avoid NSAIDs and sedatives;
use strict caution with altered dosages due to impaired drug metabolism.
d. Hepatic Cirrhosis Risk Factors: Long-term alcohol abuse, chronic viral hepatitis (B
and C), fatty liver disease, autoimmune conditions, genetic factors, and drug misuse.
e. Hepatitis Transmission Modes: "Hepatitis with a vowel comes from the bowel"—
Types A and E are fecal-oral (contaminated food/water). Types B, C, and D are
transmitted via blood and body fluids (needles, sexual contact, childbirth).
f. End-Stage Liver Disease Manifestations: Systemic failure causes hepatic
encephalopathy (asterixis, delirium), massive ascites, caput medusae (bulging abdomen
veins), jaundice, pruritus, coagulopathy (esophageal varices bleeding), hormonal
imbalance (gynecomastia), and profound wasting.
g. Gallbladder Disorder Manifestations: Colicky RUQ pain triggered by high-fat meals
(Murphy's sign), radiating to the right shoulder/back. If the bile duct is obstructed,
jaundice, dark tea-colored urine, clay-colored stools, and steatorrhea will occur.
h. Pancreatic Disorders Risk Factors: Excessive alcohol consumption (most
prevalent), gallstones obstructing the duct, GLP-1 weight loss meds, cystic fibrosis, and
post-ERCP complications.
i. Pancreatic Disorder Manifestations: Severe epigastric pain radiating to the back
(triggered by smelling/eating food), steatorrhea, weight loss, jaundice, and unique
hemorrhagic signs (Cullen’s sign around the umbilicus; Grey Turner’s sign on the
flanks). Elevated lipase and amylase.
j. Post-Cholecystectomy Manifestations: Expected: Right shoulder pain (from CO2
gas) and GI upset/steatorrhea if fat is consumed. Red Flags: Jaundice, dark urine, and
clay-colored stools, indicating remaining gallstones in the bile ducts.
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k. Gallbladder Dietary Restrictions: A strict low-fat diet is required to prevent
gallbladder stimulation and painful biliary colic. Post-operatively, high-fat foods cause
urgent diarrhea/steatorrhea since the body can no longer concentrate bile.
l. TPN Administration Considerations: Requires dedicated central access, a 1.2micron filter, mandatory infusion pump, and strict sterile technique. Glucose must be
checked every 6 hours, and labs drawn daily to recalculate the formula. Hang 10%
dextrose if the bag is interrupted.
m. Pancreatic Disease Pain Management: Severe epigastric pain requires high-dose
IV opioids (e.g., hydromorphone). Oral meds are inappropriate. Complete pancreatic rest
(strict NPO status, TPN if >7 days) is required to stop the trigger.
n. Endoscopic Procedure Complications: High risks include perforation, bleeding,
and aspiration if the gag reflex is suppressed. ERCPs carry a very high risk of inducing
acute pancreatitis. Capsule endoscopy risks capsule retention.
o. Jaundice Interventions: Interventions vary by cause: Obstructive requires
ERCP/surgery to remove the blockage; Hepatic requires antivirals or alcohol abstinence;
Hemolytic requires phototherapy. Symptomatic care includes managing pruritus (cool
showers) and conserving energy.
p. Pancreatitis Complications: Life-threatening complications include shock, ARDS
(enzymes eat fragile lung tissue), MODS, DIC, pancreatic necrosis, and peritonitis.
Long-term complications include diabetes and malabsorption.
q. Peritonitis Care Prioritization: Medical emergency requiring immediate notification
of a physician. Priorities: Maintain strict NPO, provide O2/IV fluid resuscitation for shock,
administer broad-spectrum IV antibiotics, insert an NG tube, and prepare for emergency
surgical washout.
s, t, u, v, w, x. Pancreatitis Care (Cues, Hypotheses, Solutions, Actions,
Outcomes):
○ Cues: Epigastric pain to the back, highly elevated lipase/amylase, Cullen's/Grey
Turner's bruising, and steatorrhea.
○ Hypotheses/Priorities: Risk for ARDS, shock, MODS, DIC, peritonitis, severe
metabolic deficits, and extreme acute pain.
○ Actions/Solutions: The highest priority is absolute pancreatic rest (strict NPO).
Administer aggressive IV fluids, high-dose IV opioids, and TPN if NPO > 5-7
days. Monitor hemodynamics and respiratory status closely.
○ Outcomes: Success is evaluated by pain resolution, ability to advance diet
without symptoms, normalizing lipase/amylase levels, avoidance of
ARDS/shock/peritonitis, and lifelong alcohol abstinence.