Nursing of Adult Patientswith

Medical & Surgical Conditions

Gastrointestinal

Accessory Organ

Disorders

Diagnostic Studies• Serum Bilirubin Test

– Normal Values• Direct bilirubin: 0.1 to 0.3 mg/dl• Indirect bilirubin: 0.2 to 0.8 mg/dl• Total bilirubin: 0.1 to 1.0 mg/dl• Total bilirubin

in newborns: 1 to 12 mg/dl

– Rationale• Used to diagnose liver disease, biliary obstruction, erythroblastosis

fetalis, and hemolytic anemia

– Nursing Interventions• NPO

Diagnostic Studies• Liver Enzyme Tests

– Normal Values• AST (SGOT): 5-40 IU/L

– elevated with MI, hepatitis, cirrhosis, hepatic necrosis, hepatic tumor, acute pancreatitis, acute renal failure, and acute hemolytic anemia

• ALT (SGPT): 5-35 IU/L– elevated with hepatitis, cirrhosis, hepatic necrosis, hepatic tumors,

and hepatotoxic drugs.

• LDH: 45-90 U/L– elevated with MI, pulmonary infarction, hepatic disease, pacreatitis,

hemolytic anemia, and skeletal muscle disease.

Diagnostic Studies• Alkaline Phosphatase: 30-85 ImU/L

– elevated in obstructive disorders of the biliary tract, hepatic tumors, cirrhosis, primary and metastatic tumors, hyperparathyroidism, metastatic tumor in bones and healing fractures

• Gamma GT: 4-38 U/L– elevated with hepatitis, cirrhosis, hepatic tumors, hepatotoxic

drugs, MI (4-10 days after), CHF, and alcohol ingestion

– Rationale• Liver is storehouse for many enzymes

• Injury or diseases affecting the liver will cause release of these enzymes into the bloodstream

Diagnostic Studies

• Serum Protein Test– Normal Values

• Total Protein: 6-8 g/dl

• Albumin: 3.2-4.5 g/dl

• Globulin: 2.3 to 3.4 g/dl

• Albumin globulin (A/G ratio): 1.2 to 2.2 g/dl

– Rationale• The liver metabolizes protein, esp. albumin. If the liver

is diseased it loses the ability to metabolize the albumin and the serum albumin level is decreased

Diagnostic Studies

• Oral Cholecystography (Gallbladder Series)– Rationale

• Provides x-ray visualization of the gallbladder after ingestion of a radiopaque dye.

• The following factors are necessary for adequate dye concentration:

– Ingestion fo correct number of dye tablets– Adequate absorption of the dye from the GI tract; no vomiting or

diarrhea– Abstinence from food the morning of the test– Patency of the cystic duct– Concentration of the cye within the gallbladder

Diagnostic Studies

– Nursing Interventions• Assess for allergies to iodine

• Administer 6 Telepaque tablets orally, after the evening meal

• NPO after midnight

Diagnostic Studies

• Intravenous Cholangiography (IV Cholangiogram)– Rationale

• Radiographic dye is administered IV

• Allows visualization of the hepatic and common bile ducts and also the gallbladder if the cystic duct is patent

• Used to visualize stones, strictures, or tumors of the hepatic duct, common bile duct, and gallbladder.

Diagnostic Studies

• Operative Cholangiography– Rationale

• Common bile duct is injected directly with radiopaque dye.

• Visualization of stones or other obstructions during surgery to prevent unneccessary common bile duct exploration

Diagnostic Studies• T-Tube Cholangiogram

– Rationale• Demonstrates good flow of contrast into the

duodenum• Diagnose retained ductal stones and/or leaks in ducts

– Nursing Interventions• T-tube to closed drainage system• Cover site with sterile dressing, if t-tube removed• Assess for allergies to iodine• NPO after midnight

Diagnostic Studies

• Ultrasound of the Liver, Gallbladder, and Biliary System– Rationale

• Visualization of deep structures by recording the reflections of ultrasonic waves directed in to the tissue

– Nursing Interventions• NPO after midnight

• Should be done before barium studies or after all barium has been expelled

Diagnostic Studies

• Gallbladder Scanning– Rationale

• Injection of technetium 99 is given and scan is done to visualize the gallbladder and biliary tract

• Used to diagnose acute cholecystitis

– Nursing Interventions• NPO after midnight

Diagnostic Studies• Liver Biopsy

– Rationale• Needle is inserted through the abdominal wall into the

liver to remove a piece of liver tissue

• Used to diagnose cirrhosis, hepatitis, drug-related reactions, granuloma, and tumors

– Nursing Interventions• Informed consent

• NPO for 4-8 hours

• Assess lab results for normal platelet count and prothrombin time

Diagnostic Studies

• After biopsy– Assess for s/s of bleeding

– Vital signs every 15 min x 1hr, every 30 min x 4 hrs, then every 4 hrs

– Assess for s/s of pneumothorax

– Bed rest for 24 hrs

Diagnostic Studies

• Liver Scanning– Rationale

• Radionuclide is given IV

• Geiger counter is used to record the distribution of radioactive particles in the liver

– Nursing Interventions• NPO after midnight

Diagnostic Studies• Blood Ammonia

– Normal Value• 15 to 110 micrograms/dl

– Rationale• Ammonia is normally converted into urea and then

excreted by the kidneys• Liver dysfunction or altered blood flow to the liver causes

blood ammonia levels to rise and BUN (blood urea nitrogen) to decrease

– Nursing Interventions• Notify lab if patient is currently taking Neomycin; can

cause decreased ammonia levels

Diagnostic Studies

• Hepatitis Virus Studies– Rationale

• Diagnose specific virus causing hepatitis– A, B, C, D, and E

Diagnostic Studies• Serum Amylase Test

– Normal Value• 25 to 125 U/L

– Rationale• Damage to pancreas cells or obstruction to the pancreatic ductal

flow will cause an outporing of this enzyme and absorption into the bloodstream

• Levels will rise within 12 hours of onset of pancreatic disease.• Rapidly cleared by the kidneys; levels may return to normal

within 48-72 hrs

– Nursing Interventions• Note administration of any IV dextrose; can cause a false-

negative result

Diagnostic Studies

• Urine Amylase Test– Normal Value

• 3-35 IU/hr

– Rationale• Disorders affecting the pancreas will cause elevated

amylase levels in the urine because the kidneys rapidly clear amylase

• Levels remain elevated in the urine for 7-10 days• Used to diagnose pancreatitis in patients who have had

symptoms for 3 days or longer

Diagnostic Studies

– Nursing Interventions• Urine collection may be 2 hr spot urine, 6 hr, 12 hr,

or 24 hr collection.– Record exact time collection is begun

– Discard first urine specimen

– Collect all subsequent urine, including the last urine voided exactly 2, 6, 12, or 24 hrs after collection began

– Urine should be kept on ice during collection period

Diagnostic Studies

• Ultrasound of Pancreas– Rationale

• Provides diagnostic information with the use of ultrasonography of the pancreas

• Used to diagnose carcinoma, pseudocyst, pancreatitis, and pancreatic abcess

– Nursing Interventions• NPO for 8 hours before test• Gas or barium will interfere with sound wave

transmission

Diagnostic Studies

• Computerized Tomography of the Abdomen– Rationale

• Cross-sectional image

• Used to diagnose inflammation, tumors, cysts, ascites, aneurysm, and cirrhosis of the liver

– Nursing Interventions• NPO after midnight

• Some patients may experience claustrophobia

Diagnostic Studies

• Endoscopic Retrograde Cholangiopancreatography of the Pancreatic Duct (ERCP)– Rationale

• A fiberoptic duodenoscope is inserted through the oral pharynx, through the esophagus and stomach, and into the duodenum. Dye is injected for radiographic visualization of the CBD and pancreatic duct.

• Used to diagnose obstructive jaundice, remove common bile duct stones, and place biliary and pancreatic duct stents to bypass obstructions

Diagnostic Studies

– Nursing Interventions• NPO for 8 hours before test

• Informed consent

• Must remain still for 1-2 hours

• After procedure– NPO until gag reflex returns

– Assess for abdominal pain, tenderness and guarding

– Assess for s/s of pancreatitis

• abd. pain, nausea, vomiting, and diminished or absent bowel sounds

Cirrhosis• Etiology/Pathophysiology

– Chronic, degenerative disease of the liver

– Scar tissue restricts the flow of blood to the liver

– Types of cirrhosis• Laennec’s cirrhosis

– history of chronic ingestion of alcohol

• Postnecrotic cirrhosis– viral hepatitis, exposure to hepatotoxins, or infection

• Primary biliary cirrhosis– destruction of the bile ducts

• Secondary biliary cirrhosis– chronic biliary tree obstruction (gallstones, tumor, etc.)

Cirrhosis

– Alteration of liver function• Reduced ability to metabolize albumin

• Obstruction of portal vein

• Increased pressure in the veins that drain the GI tract

• Complications– Portal Hypertension

• increased venous pressure in the portal circulation caused by compression or occlusion in the portal or hepatic vascular system

– Ascites

• accumulation of fluid and albumin in the peritoneal cavity

• Esophageal Varicosities– veins in the upper part of the body distend, including the

esophageal veins due to portal hypertension. They may rupture causing severe hemorrhage

Cirrhosis

• Hepatic Encephalopathy– Brain damage due to elevated ammonia levels

– Inaapropriate behavior, disorientation, flapping hand tremors, twitching of the extremities, stupor, and coma

Cirrhosis

• Signs & Symptoms– Early stages

• Abdominal pain

• Liver is firm and easy to palpate

– Late stages• dyspepsia

• changes in bowel habits– constipation or diarrhea

• Nausea and vomiting

• gradual weight loss

Cirrhosis• ascites

• enlarged spleen

• spider angiomas

• anemia

• bleeding tendencies– cannot absorb vitamin K, or produce clotting factors

• epistaxis

• purpura

• hematuria

• bleeding gums

Cirrhosis• jaundice

– yellow discoloration of the skin, mucous membranes and sclerae or the eyes

– caused by abnormal amounts of bilirubin in the blood

• mental disorientation

Cirrhosis• Treatment

– Eliminate the cause• alcohol, hepatotoxins, environmental exposure to harmful

chemicals

– Diet• Well balanced

• High-calorie (2500 to 3000 cal/day)

• Moderate protein (75 g/day)

• Low fat

• Low sodium (1000 to 2000 mg/day)

• Supplemental vitamins and folic acid

Cirrhosis– Antiemetics

• Benadryl & Dramamine• Contraindicated: Vistaril, Compazine, and Atarax

– Treatment of Complications• Ascites

– Bedrest

– Strict I&O

– Restrict fluids to 500 -1000 cc/day

– Restrict sodium to 1000-2000 mg/day

– Diuretics: Aldactone, Lasix, HCTZ

– Vitamin Supplements: Vitamin K, Vitamin C and folic acid

– LeVeen Peritoneal-Jugular Shunt

– Paracentesis

LeVeen Peritoneal Jugular Shunt Paracentesis

Cirrhosis

• Ruptured Esophageal Varices– Maintain airway

– Establish IV

– Vasopressin drip to control bleeding

• IV or directly into the superior vena cava

– Sengstaken-Blakemore tube

– Endoscopic sclerotherapy

– Portacaval shunt

• divert blood from the portal vein to the inferior vena cava

– Blood transfusion

Sengstaken-Blakemore Tube

Cirrhosis

• Hepatic Encephalopathy– Decrease protein in diet

– Avoid drugs which are detoxified by the liver

– Lactulose

• Oral or retention enema

• decreases the pH of the bowel which decreases the production of ammonia

– Neomycin

• inhibits protein synthesis in bacteria, therefore decreasing the production of ammonia

Hepatitis

• Etiology/Pathophysiology– Inflammation of the liver resulting from several

types of viral agents or exposure to toxic substances

– Hepatitis A• Most common

• Incubation 10-40 days

• Oral-fecal trasmission

Hepatitis– Hepatitis B

• Incubation 28-160 days

• Transmission by contaminated serum; blood transfusion, contaminated needles, dialysis, or direct contact with infected body fluids

– Hepatitis C• Incubation 2 weeks to 6 months (usually 6-9 weeks)

• Transmitted through contaminated needles and blood transfusions

– Hepatitis D• Coinfection with hepatitis B

• Incubation 2-10 weeks

Hepatitis

– Hepatitis E• Fecal contamination of water

• Rare in the U.S.; usually in developing countries

• Incubation 15-64 days

Hepatitis

• Signs & Symptoms– General malaise– Aching muscles– Photophobia– Headaches– Chills– Abdominal pain– Dyspepsia– Nausea

Hepatitis

– Diarrhea– Constipation– Pruritus– Hepatomegaly– Enlarged lymph nodes– Weight loss– Jaundice– Dark amber urine– Clay colored stools

Hepatitis

• Treatment– Treat signs and symptoms– Small frequent meals

• low-fat, high carbohydrate

– IV fluids for dehydration• Vitamin C for healing

• Vitamin B-complex for absorption of fat soluble vitamins

• Vitamin K for coagulation

– Avoid unnecessary medications, esp seditives

Hepatitis– Gamma globulin or immune serum globulin

• should be given to anyone exposed to Hepatitis A

• may be given 2 weeks before and 1 week after onset of symptoms

– Hepatitis B imune globulin (HBIG)• should be given to anyone exposed to Hepatitis B

– Hepatitis B Vaccine• should be given to persons identified as high risk for developing

Hepatitis B– healthcare personnel

– high-risk lifestyle (drug users, homosexual men, prostitutes)

– infants born to mothers who are Hepatitis B positive

Liver Abscesses

• Etiology/Pathophysiology– May be single of multiple– Abscess forms in the liver due to an invading

bacteria

Liver Abscesses

• Signs & Symptoms– Fever– Chills– Abdominal pain and tenderness in the RUQ– Hepatomegaly– Jaundice– Anemia

Liver Abscesses

• Treatment– IV antibiotics– Percutaneous drainage of liver abscess– Open surgical drainage

Cholecystitis & Cholelithiasis• Etiology/Pathophysiology

– An obstruction, gallstone, or tumor prevents bile from leaving the gallbladder and the trapped bile acts as an irritant causing inflammation.

– Risk factors:• Female

• Native American or white

• Obesity

• Pregnancy

• Diabetes

• Multiparous women

• Use of birth control

Cholelithiasis

Cholelithiasis

Cholecystitis & Cholelithiasis• Signs & Symptoms

– Indigestion after eating foods high in fat

– Severe, colicky pain in the right upper quadrant• may radiate around the midtorso to the right scapular area

– Anorexia

– Nausea & vomiting

– Flatulence

– Increased heart & respiratory rates

– Diaphoresis

Cholecystitis & Cholelithiasis

– Low grade fever– Elevated WBC– Mild jaundice– Steatorrhea (fatty stool)– Dark amber urine

Cholecystitis & Cholelithiasis• Treatment

– Mild attacks• Bedrest

• NG tube to suction

• NPO

• IV fluids

• Antispasmodic/Analgesic– Demerol: decreases incidence of spasms of the sphincter of

Oddi

• Antibiotics

• Avoid spicy foods when allowed PO intake

Cholecystitis & Cholelithiasis– Lithtripsy

• A machine discharges a series of shock waves through water or a cushion that breaks the stone into fragments

– Cholecystectomy (Removal of the gallbladder)

• Laparoscopic– Oral liquids post-op– Outpatient or discharged next day– Resume moderate activity in 48-72 hrs

• Open– Jackson-Pratt drain– T-tube– NG tube– Routine post-op care

T-Tube

Pancreatitis• Etiology/Pathophysiology

– Inflammation of the pancreas• Acute or Chronic

– Predisposing Factors• Alcohol

• Trauma

• Infectious disease

• Certain drugs

– Obstruction of the pancreatic duct may cause a rupture and enzymes digest the pancreas

Pancreatitis

Pancreatitis• Signs & Symptoms

– Abdominal pain

– Anorexia

– Nausea & vomiting

– Malaise

– Restlessness

– Low-grade fever

– Jaundice

– Weight loss

– Steatorrhea

– Tachycardia

Pancreatitis• Treatment

– NPO– IV fluids– NG tube– Antiemetics– Demerol 75 -100 mg q 3-4 hrs

• Avoid morphine; causes spasms of the sphincter of Oddi

– Anticholinergics– atropine or Pro-Banthine

– Antacids or Tagamet (prevent ulcers)

Pancreatitis

– Hyperalimentation• may be required to maintain nutrition

– Prevention• bland, low-fat, high-protein, high-carbohydrate diet

• no alcohol or gastric stimulants (coffee)

• may need oral hypoglycemic agents if destruction or the islets of Langerhans

Cancer of the Pancreas• Etiology/Pathophysiology

– Unknown– Risk factors

• cigarette smoking

• exposure to chemical carcinogens

• diabetes mellitus

• pancreatitis

• diet high in meat, fat and coffee

– May be metastisis form the lung, stomach, duodenum or CBD

– May live only 4-8 months after diagnosis

Cancer of the Pancreas

Cancer of the Pancreas• Signs & Symptoms

– Anorexia

– Fatigue

– Nausea

– Flatulence

– Change in stools

– Steady, dull aching pain in the epigastic area

– Weight loss

– Jaundice

– Onset of diabetes mellitus

Cancer of the Pancreas• Treatment

– Surgery• Whipple procedure

– resection of the antrum of the stomach, duodenum, and part of the pancreas

– anastomosis between the stomach, CBD, and pancreatic ducts and the jejunum

• Total pancreatectomy with resection of parts of the GI tract

– Chemotherapy– 5-FU and BCNU– Gemzar

– Radiation

Whipple Procedure