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Anatomy of the Accessory Organs (GI Unit 2)
Liver, Gallbadder and Pancreas (2012)
WORD WALL
ASCITES
ERUCTATION
ICTERUS
CIRRHOSIS
Assessment of the patient with Liver Disease
Health History
Past Medical History
Review of Systems
Functional Assessment
PE
Diagnostic Tests and Procedures
For Lower GI
System
Review Stool Specimens
O&P
C&S
OB( occult blood)
Fecal Fat
Imaging Studies
HIDA scan
CT
MRI
US
Another Radiological Study..
Barium Enema
NPO after MN
Cathartics and enemas (observe results)
Assess abdomen
Colonoscopy
To visualize colon and obtain specimens
NPO 6-8 hrs prior
Bowel cleanse
Sedation
Sigmoidoscopy
Visualize rectum and sigmoid colon
Enema prior to exam
Sedation optional
Observe for bleeding after
Lower GI Disorders and Related
Nursing Interventions
Diverticulosis
Multiple Diverticula present in colon
Cause: unknown
Related factors: low fiber diet, age, constipation, obesity and emotional tension
Signs & Symptoms
Asymptomatic
Change in bowel habits (Constipation/Diarrhea)
Pain in left lower abdomen
Tx. High fiber diet
Diverticulitis
Inflammation of diverticula
Complication of diverticulosis
Cause: stool impacted in diverticula
Complications….
Severe bleeding
Obstruction
Perforation (rupture)
Peritonitis
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Fistula formation
Medical Treatment
Bedrest
NPO and IV Fluids
GI decompression
Analgesics
ABX
Surgical Treatment
Colon resection
Colostomy
Hartmann Procedure
Colostomy
Surgical opening between the colon and the surface of the body; creation of a stoma
Named for the part of colon where located
Temporary or Permanent
Ostomy Care
Assess:
Stoma color Q shift
Bowel function
Bowel sounds, distention, tenderness
Clean w/ H20, cover w/ ointment or paste (see pg. 434)
Abdominal Hernia
Muscle weakness resulting in intestine protruding through muscle
Reducible
Irreducible or incarcerated
Incarcerated hernias have  obstructed peristaltic flow; severe abd. Pain, distention, vomiting & cramps
Strangulated hernia is deprived of blood flow
Types of Hernias
Inguinal
Femoral
Umbilical
Incisional
Surgical Treatment
Herniorrhaphy
Hernioplasty
Truss
What are Post Op Nursing Interventions for Hernia Pts.
Assess bowel and bladder function
Assess wound healing
Teach to avoid stress on healing wound
Intestinal Obstruction
Adhesions
Strangulated hernia
Tumor
Volvulus
Intussuseption
 Volvulus
 Intussuseption
 Normal Anatomy
 Adhesions
Signs & Symptoms
Abdominal pain
N/V ( possible projectile)
Constipation
Bloating
Medical Treatment
NGT for decompression
IV hydration
Surgery may be needed
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Medications…
Non-narcotic analgesics
Antibiotics
THINK….
What are 3 nursing diagnosis and related nursing interventions for the patient with an intestinal obstruction???
Irritable Bowel Syndrome
AKA Spastic colon, spastic colitis, mucus colitis, irritable colon
Most common GI complaint
Unknown cause
Signs & Symptoms
Abdominal pain
Cramping
Flatulence
Constipation/Diarrhea
Diagnostic Tests
UGI
BE
Sigmoidoscopy
Treatment
Reduce stress
Counseling
High fiber diet/Metamucil
Lifestyle changes
Adeq. Fluids & regular meal patterns
Medications
Sedatives
Xanax
Anti-spasmodic
Bentyl
Anti-diarrheal
Immodium
Constipation
Infrequent, hard, dry stools
Tumors
Frequent laxative use
Inactivity
low Fluid intake & low fiber diet
Treatment
Fiber supplements
Laxatives
Stool softeners
Or a combination of above
Nursing Interventions
Teach patient to Increase…
Fiber
Fluids
Activity
Diarrhea
Loose stools with increased frequency
S/S  pain, abdominal cramps, urgency, flatus
Complications….
Dehydration
Electrolyte imbalances
Metabolic acidosis
Malabsorption leading to malnutrition and anemia
Nursing Interventions
NPO, IV, TPN if severe sx
I&O, daily weight
Record T-A-C of stool
Time-Amount-Color
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Motility reducers
Monitor electrolytes
Inflammatory Bowel Disease
( IBD )
Crohn’s Disease
Ulcerative Colitis
Unknown cause
? Autoimmune reactions tx with steroids
Crohn’s Disease
Lesions affect the entire thickness of bowel; can occur anywhere in the colon or small intestine
Signs & Symptoms
Variable depending upon areas affected
N/V & epigastric pain
Abdominal pain, tenderness and cramping
Rectal bleeding & diarrhea
S/S ( cont’d)
Weight loss
Steatorrhea
When sm bowel involved
Electrolyte imbalance
Iron deficiency anemia
Amino acid mal-absorption
Long Term Complications
Hemorrhage
Bowel obstruction
Fistulas
Abscesses
Perforation(rupture)
Ulcerative Colitis
Inflammation & ulceration of the mucous membrane in colon
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S/S:
Fever, anorexia, wt. loss
Frequent, watery stools with mucous & blood
Long Term Complications
Fissures
Abscesses
Increased risk of colon CA
Toxic megacolon
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 Megacolon
Hirschsprung's disease
Presents as Megacolon
Hirschsprung's disease is a condition that affects the large intestine (colon) and causes problems with passing stool.
It's present when a baby is born (congenital) and results from missing nerve cells in the muscles of a portion of the
baby's colon.
Diagnostic Tests  IBD
BE w/ small Bowel follow- through
Colonoscopy w/ biopsy
Ultrasound
CAT
Med/Surg. Management
Control inflammation steroids
Relieve symptoms
Maintain fluid and electrolytes
Provide adequate nutrition
Prevent complications
Limit milk products
High cal, low residue, non-spicy, caffeine free diet
Surgical Intervention
Colectomy  curative for ulcerative colitis NOT for Crohn’s disease
Recurrence can recur at site of anastamosis
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Medications used alone or in combination….
Corticosteroids
Immunosupressants
Antidiarrheals
Anticholinergics
Antibiotics and others…
Appendicitis
Inflammation of the appendix
If ruptured peritonitis develops which may be fatal
Signs & Symptoms
Pain at McBurney’s Point
N/V
Fever
Rebound tenderness
Pt also cannot straighten the right leg without pain.
Treatment
Appendectomy
Pre-op Orders:
NPO
IV fluids
Appendectomy
Post-op Orders
 NPO until BS return then advance diet as tolerated
 V.S., TC & DB
 Assess wound for s/s infection
 OOB ASAP
 Peritonitis
 Inflammation of peritoneum
 Contamination of the peritoneal cavity
 Abscesses, septicemia, hypovolemic shock, paralytic ileus and organ failure.
 Signs & Symptoms
 Pain over affected area
 Fever
 Tachycardia
 N/V
 Tachypnea
 S/S (cont’d )
 Distended, board-like abdomen ( rigidity )
 Paralytic ileus
 Treatment
 Surgery to repair cause
 Abdominal cavity irrigation with NS and abx soln
 IV abx.
 Nursing Interventions
 NPO w/ NGT
 IV fluids
 Monitor drains
 Elevate HOB
 For abd. Distention and BS
 V.S.
 Activity as tolerated
 C&DB
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Cough and Deep Breath
 Analgesics
 Colorectal CA
rd
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3 most common CA in women
Risk factors:
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Over 45
Hx of polyps
Hx of IBD
Signs & Symptoms
Change in bowel habits
Wt loss
Abd cramping
Rectal bleeding
Diagnostic Tests
Colonoscopy
BE
CEA
Carcinoembryonic Antigen
CBC
Surgical Treatment
Polypectomy
Colon resection
Chemo
Radiation
What are Post Op Nursing Interventions for Colorectal CA
NPO w/ NGT
C&DB (Cough and deep breath)
Early ambulation
Assess wound for infection
Opioid analgesics
Hemorrhoids
Varicosed veins of rectum
Internal or external
Risk factor:
Increased intra-abd pressure
Signs & Symptoms are ???
Non surgical treatment consists of ???
 Surgical Treatment
 Ligation
 Sclerotherapy
 Thermocoagulation
 Laser surgery
 hemorrhoidectomy
 Post op Nursing Interventions
 Pain control
 Assess for rectal bleeding, keep area clean
 Monitor stools passed after surgery, provide stool softeners
 VS
 Ambulate
 Anal Fissure
 Laceration between the anal canal and perianal skin
 Usually heal spontaneously
 Anorectal Abscess
 Infection of tissue around the anus
 What are s/s…..?
 Treatment…?
 I&D
 Anal Fistula
 Abnormal opening between anal canal and perianal skin
 S/S pruritus and discharge
 TX sitz baths, excision of fistula & surrounding skin
 Temporary colostomy PRN
 Pilonidal Cyst
 Cyst in sacrococcygeal area
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Easily infected
Usually requires surgical excision
Care similar to hemorrhoidectomy
Critical Thinking Question
A 44-year-old man presents to the emergency department with severe nausea and vomiting that he has been
experiencing for 2 days. He complains of severe abdominal pain and a fever. His abdomen is distended and tender.
What type of data should the nurse include in the assessment of this patient? What is the significance of these
data?
Disorders of the Accessory Organs
Gallbladder, Pancreas and Liver
WORD WALL
FLATUS
DYSPEPSIA
REGURGITATION
CATHARTIC
Diagnostic Tests
CT
Liver Scan
Ultrasonography
MRI
Biopsy ( liver, needle, open)
ERCP
Lab Tests
PT, PTT, INR
Bilirubin
Serum protein
Alk. Phosphatase
AST, ALT,LDH
Cirrhosis of the Liver
Chronic, progressive disease of the liver
40-60 yrs. highest incidence
Related to alcoholic liver disease or chronic viral infection
Signs & Symptoms
Early weight loss, fever, fatigue, heaviness in rt. Upper abdomem
Progimpaired metabolism, GI disturbances, congestion of bloodflow causes ^ pressure of intestines, stomach,
esophag.
Later signs and symptoms…
Jaundice
From >Bilirubin
Ascites
Abd pain
Peripheral neuropathy
Bilirubin is the yellow breakdown product of normal heme catabolism. Heme is found in hemoglobin, a principal
component of red blood cells. Bilirubin is excreted in bile and urine, and elevated levels may indicate certain diseases.
It is responsible for the yellow color of bruises, urine, and the yellow discoloration in jaundice.
Dyspnea
Bleeding disorders
Dry puritic skin
Confusion
Clay colored stool
Complications…
Portal hypertension
Esophageal varices
Ascites
Hepatic encephalopathy
Esophageal Varices
Distended esophageal blood vessels
Caused by ^ pressure in portal system
Bleed easily
TX for Bleeding Varices
Drug therapy
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Surgical ligation
Esophageal – gastric balloon
Sclerotherapy
TX for Ascites
Na+ restriction diet and diuretics
Paracentesis
Shunts pic 854 Fig. 39-6
TIPS –Transjugular intrahepatic portosystemic shunt is often preferred as it reduces pressure in the portal system
with fewer complications.
Hepatic Encephalopathy
Liver unable to detoxify ammonia
Ammonia is a breakdown product of protein metabolism. Excessive ammonia in the blood causes neurologic
symptoms including cognitive disturbances declining level of consciousness and changes in neuromuscular function
Ammonia
Tx is directed toward reducing ammonia formation. Goal is achieved by drug therapy and reduction of protein intake.
Lactulose decreases ammonia absorption in the bowel.
Hepatic Encephalopathy
Asterixis- most common sign
Asterixis ( Liver Flap) is a motor disturbance marked by irregular flapping of fingers and wrists when hands and arms
are outstretched.
Assess by asking the pt. to extend both arms.
Nursing Care for the patient with Cirrhosis
Emollient baths( oatmeal or baking soda )
Blood transfusions
Due to bleeding varicies
Low Na, high vitamin diet
Small frequent meals
Nrsg Care (cont’d)
No ETOH
Diuretics
Vitamin K
Daily weight
Abd. girth measurements
THINK….
What are 3 nursing diagnosis and related nursing interventions when caring for the patient with cirrhosis of the
liver??/
Critical Thinking Question
A patient who has end stage liver disease is experiencing signs and symptoms of hepatic encephalopathy.
What interventions should the nurse implement for a patient with this diagnosis.
Liver Transplantation
Only cure for end stage liver disease
Patients ranked by acuity and need
Nursing assessments focus on: neuro status, VS, respiratory status, and indicators of bleeding.
Provide usual post op care
Lifelong drug therapy is needed
Hepatitis
Inflammation & swelling of the liver
Bile channels are compressed
Blood flow through liver is impaired
Signs & Symptoms
Fatigue / lethargy
Nausea
Abd pain
Joint and muscle aches
Decreased appetite
S/S ( cont’d)
Jaundice
Hepatomegaly
Dark urine
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Puritis
Treatment Goal…
To promote healing and manage symptoms
Allow liver to regenerate
Prevent transmission
Medications
Alphainterferon
Ribavirin
Antipyretics
Antiemetics
Avoid hepatotoxic drugs
Dietary Changes
High cal, high carb, high pro
Low fat
Vitamin supplements
No ETOH
Liver Cancer
Primary site  rare
Frequent site metastasis
Signs & Symptoms
Same as cirrhosis
Tx Lobectomy, Chemo,
Radiation
Gallbladder Disease
Cholecystitis - inflammation of gallbladder
Cholelithiasis – gallstones
5 F’s
Signs & Symptoms
RUQ pain 2-4 hours after meals
N/V
Flatulence
Indigestion, belching
S/S ( cont’d)
Steatorrhea
Clay colored stools
Increased WBC, serum and urinary bilirubin and enzymes
Medical Treatment
Low fat diet
Demerol
ABX
UDCA, and MTBE
Ursodeoxycholic acid is the oral bile salt in current use. It is prescribed for small cholesterol stones or for those who
are poor surgical risks.
 MTBE
 Methyl tert-butyl ether are agents which are instilled in the GB through a catheter. The physician instills and
aspirates the drug repeatedly until fluoroscopy show the stones have dissolved or are not responding
Surgical Treatment
Endoscopic Sphincterotomy
Extracorporeal Shock Wave Lithotripsy
Cholecystectomy
Post Op Nursing Care
T, C, & DB
NGT
Monitor T-tube
IV’s
Incentive spirometer
Common Bile Duct Obstruction
Stones block bile flow within common bile duct
Intense spasmotic pain
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Trmt ERCP
Nursing Care
VS
IV hydration
ABX
Analgesics
Monitor lab results
Pancreatitis
Inflammation of the pancreas
May be acute or chronic
Causes
Signs & Symptoms
Severe, sudden onset abdominal pain in ULQ
Vomiting
Flushing
Fever
S/S (cont’d)
Tachypnea
Tachycardia
Tender, distended abdomen
Bowel sounds may be absent
Elevated serum amylase
Medical Management
Pain control Demerol
NPO; TPN
Anticholinergics, Antispasmodics
Pancrease  to reduce steatorrhea
THINK???
What are Nursing Interventions for Pancreatitis?
Pancreatic Cancer
Tumors usually malignant
Prognosis poor
Metastasizes quickly
Most die within 1 yr of diagnosis
Signs & Symptoms
Pain
Jaundice
Weight loss
Glucose intolerance
Surgical Procedures
See page 874 Figure 39-13
Most often procedures preformed are Side-to-side and the Whipple
Nursing Care
PCA for pain control
Monitor I & O
VS
Monitor blood glucose
Emollient lotions/Benadryl
You’re done with
GI Unit 2…..
Time for the Post Test !
YIPPEEE !!!!