16

7. Weight loss and weakness

8. Barium swallow identifies mass
9. Biopsy
iii. Medical and Surgical Management
1. Surgery, chemotherapy, and radiation
2. Resection of the esophagus, Laser therapy
iv. Nursing Management
1. Goal: adequate or improved nutrition and eventually
stable weight
2. Soft foods or high-calorie, high-protein semi-liquid foods
3. Sometimes TPN
4. Post op - No nourishment until bowel sounds return
VI. GASTRIC DISORDERS
a. GASTRITIS
i. Inflammation of the stomach lining
ii. Pathophysiology and Etiology
1. Causes:
a. Dietary indiscretions; reflux of duodenal contents;
b. Use of aspirin, steroids, NSAIDS, alcohol, or caffeine
c. Cigarette smoking; ingestion of poisons or corrosive
substances
d. Food allergies; infection; and gastric ischemia
secondary to vasoconstriction cause by a stress
response.
e. Helicobacter pylori (H. pylori)
2. Chronic irritation leads to ulceration
iii. Assessment Findings
1. Complains of Epigastric fullness, pressure, pain,
anorexia, nausea, and vomiting
2. Bacterial/viral – vomiting, diarrhea, fever, and abdominal
pain
3. Blood emesis or note a darkening of their stool color
4. Diagnostics: Stool testing, gastroscopy, H. pylori testing
iv. Medical and Surgical Management
1. Ingestion of toxins require emergency treatment
2. Eating is restricted and IV fluids given to correct
dehydration and electrolyte imbalances
3. Avoid alcohol and NSAIDS
4. Antacids, H2 antagonists, and proton pump inhibitors
5. Drugs to treat H. pylori
v. Nursing Management
1. Observe color and characteristics of vomitus or stool
that the client passes
2. Teach
b. PEPTIC ULCER DISEASE (PUD)
i. A circumscribed loss of tissue in an area of the GI tract that is in
contact with hydrochloric acid and pepsin
ii. Most occur in the duodenum
iii. Men more affected
iv. Pathophysiology and Etiology
1. Occurs when the normal balance between factors that
promote mucosal injury (gastric acid, pepsin, bile acid,
ingested substances) and factors that protect the
mucosa (intact epithelium, mucus, and bicarbonate
secretion) is disrupted
2. Greatest Risk Factor: H. pylori
 17
a. H. pylori secrete an enzyme that theoretically
depletes gastric mucus, making it more
vulnerable to injury.
3. Other Risk factors: family history, chronic use of
NSAIDS, cigarette smoking, and physiologic stress,
aging and chronic stomach inflammation
4. Ulcers develop when there is prolonged hyperacidity or
chronic reduction in mucus
5. Client may be at high risk for pernicious anemia –
because of poor absorption of vitamin B12
v. Assessment Findings
1. Signs and Symptoms
a. Abdominal pain – burning
b. Pain occurs 1 to several hours after meals and
disturbs sleep
c. Eating food may relieve the pain
d. Back pain suggests the ulcer is irritating the
pancreas
e. Bleeding first sign of ulcer
f. Unexplained weight loss
2. Diagnostic Findings
a. Upper GI series or EGD
(Esophagogastroduodenoscopy pg 642)
b. Biopsy, tests for H. pylori
vi. Medical and Surgical Management
1. Goals: to eradicate the bacteria and reduce the acid
levels in the digestive system to relieve pain and
promote healing
2. Drugs:
a. Antibiotics – amoxicillin (Amoxil) and clarithromycin
(Biaxin); exerts bactericidal effects to eradicate H.
pylori.
b. H2 Antagonists -Tagamet; blacks H2 receptors and
decrease HCl secretion in the stomach, relieving pain
and promoting healing
c. Antacids – used to neutralize existing stomach acid
and provide quick pain relief
d. Proton Pump Inhibitors – black the final step in acid
production; promotes healing and appear to inhibit
the growth of H. pylori
e. Cytoprotective agents - forms a seal over the ulcer,
protecting it from irritation
3. Gastric intubation
4. TABLE 45-3 Surgical Procedures to Treat PUD (pg 669)
a. Vagotomy – a branch of the vagus nerve is cut to
reduce gastric acid secretion
b. Pyloroplasty – the pylorus is repaired or
reconstructed to expand the stomach outlet
narrowed by scarring or improve gastric motility and
emptying
c. Antrectomy – the antrum (lower stomach) is
removed to eliminate a benign ulcer in the lesser
curvature of the stomach if the ulcer has not healed
after 12 weeks of medical treatment or is recurring
d. *Gastroduodensotomy – (Billroth I) part of the
stomach is removed, while the remaining portion is
connected to the duodenum. Usually, a vagotomy
also is performed. This procedure is done to remove
an ulcerated area in the stomach that is prone to
hemorrhage, perforation, and obstruction.
 18
e. *Gastrojejunostomy – (Billroth II) Same as above,
except the remaining portion is connected to the
jejunum in cases of extensive duodenal inflammation
or perforation.
f. Total Gastrectomy – The entire stomach is removed
and the esophagus is jointed to the jejunum to
remove an ulcer high in the stomach near the
Gastroesophageal junction. It is performed to treat a
gastric malignancy.
5. DUMPING SYNDROME – produces weakness,
dizziness, sweating, palpitations, abdominal cramps, and
diarrhea from the rapid emptying (dumping) of large
amounts of hypertonic chyme (a liquid mass of partly
digested food) into the jejunum
a. Risk for pts with Gastrojejunostomy
b. *Causes hypovolemia, syncope, and
hypoglycemia.
vii. Nursing Management
1. Assess type of pain, dietary history, bowel patterns and
stool characteristics, fluids status, and vitals
2. Nursing Process for the Client with a Gastric Disorder (pg
668)
c. Cancer of the Stomach
i. Pathophysiology and Etiology
1. A malignancy characterized by either an enlarged mass
or ulcerating lesion that expands or penetrates several
tissue layers
2. Risk factors: heredity, chronic inflammation,
achlorhydria (absence or free hydrochloric acid in the
stomach), chronic ingestion of highly salted, smokes, or
pickled foods, nitrates and nitrites, tobacco and alcohol
use.
3. Most common type: Adenocarcinoma
ii. Assessment Findings
1. Early symptoms: vague
2. Prolonged feeling of fullness, anorexia, weight loss, and
anemia
3. Occult blood in stool
4. Late symptom: pain
5. Barium swallow, CT scan, and tissue biopsy
iii. Medical and Surgical Management
1. Subtotal (partial) or total Gastrectomy
2. Chemotherapy and radiation
iv. Nursing Management
1. Teaching: diet, lifestyle changes, warning signs
2. Client and Family Teaching 45-1 Discharge Instructions
for the Client with Stomach Cancer (pg 670)
d. Morbid Obesity
i. Defined as a body mass index (BMI) of 40 or higher or a body
weight of more than 20% of ideal
ii. BOX 45-3 Calculating Body Mass Index (BMI) (pg 671)
2
1. BMI = (weight in pounds/ (height in inches) ) x 703
a. Underweight = < 18.5
b. Normal weight = 18.5 to 24.9
c. Overweight = 25 to 29.9
d. Obesity = >30
e. Morbid obesity = >40
iii. Pathophysiology and Etiology
1. 1/3 or population in US is obese
 19
2. Risk factors: genetic predisposition, diet, and lifestyle
habits.
3. Results from excessive caloric intake, too much food,
and a sedentary lifestyle; also a low metabolic rate
4. At risk for: diabetes, heart disease, hypertension, stroke,
osteoarthritis, gallbladder disease, sleep apnea, and
some forms of cancer.
iv. Assessment Findings
1. Often weight 100 pounds more than ideal body weight
2. Hypertension, heart disease, type 2 diabetes.
3. Short of breath
4. Poor self-esteem and suffer from depression.
v. Medical and Surgical Management
1. Prescription medications
2. Lifestyle changes, weight loss, diet restriction
3. Antidepressants
4. Bariatric surgery – gastric bypass surgery; designed to
help clients reduce their weight through surgical
changes to the upper GI digestive system.
a. Restrictive, Malabsorptive, or Combination
vi. Nursing Management
1. CPAP and CIPAP, pain management, breathing and
mobility exercises
2. Discharge teaching related to lifestyle changes
 20
Chapter 46: (pages 674 – 701)
Caring for Clients with Disorders of the Lower Gastrointestinal Tract

I. Altered Bowel Elimination

a. Constipation
i. Pathophysiology and Etiology
1. Condition in which stool becomes dry, compact, and
difficult and painful to pass.
2. Causes: diet low in fiber and water, ignoring or resisting
the urge to defecate, emotional stress, use of drugs that
tend to slow intestinal motility, or inactivity.
3. May also occur from chronic use of laxatives because
such use can cause a loss of normal colonic motility and
intestinal tone.
4. Common problem in older adults, resulting from
inadequate intake of dietary fiber, lack of exercise, and
decreased fluid intake.
ii. Assessment Findings
1. Signs and Symptoms
a. Bowel elimination is infrequent or irregular
b. Feel bloated, distended abdomen
c. Hypoactive bowel sounds
d. Rectal fullness, pressure, and pain when her or
she attempts to eliminate stool
e. Stool passed is hard and dry
f. Rectal bleeding may result
g. Encopresis – liquid stool that passes around an
obstructed stool mass (*Sometimes
misinterpreted as diarrhea)
2. Diagnostic Findings
a. History and physical examination, Barium
enema, Radiographs
iii. Medical and Surgical Management
1. Treating the cause provides the best relief
2. Enema or laxative in oral or suppository form, stool
softener
3. Dietary management promoted
4. Drug Therapy Table 46-1 Agents Used to Treat
Constipation (pg 676)
a. Chemical Stimulants – directly stimulates the nerve
plexus in the intestinal wall, causing increased
movement and stimulation of local reflexes. Leads to
intestinal evacuation
b. Bulk Forming Agents – increases intestinal motility
by increasing fluids in intestinal contents. This in turn
enlarges bulk, stimulates local stretch receptors, and
activates bowel reflex activity
i. Ex: magnesium sulfate (Epsom salts),
magnesium citrate (Citrate of Magnesium),
magnesium hydroxide (Milk of Magnesia),
polycarbophil (FiberCon), and psyllium
(Metamucil).
1. Magnesium products may cause
EKG changes with prolonged use
c. Hyperosmotic Agents – Pulls water into intestine
resulting in distention and peristalsis, leads to
evacuation. Action of drug limited to large intestine.
d. Emollients and Lubricants
 21
5. Nutrition Notes 46-1 The Client with Constipation (pg
677)
a. Consume approximately ½ cup of dried peas or
beans daily. These veggies are low-fat, high-fiber
alternatives to meat. Legumes include splint peas,
black eyed peas, pinto, kidney, and navy beans, and
red and yellow lentils
b. Consume plenty of fruits and veggies daily. Skin and
seeds of fruit are rich in insoluble fiber; whole fruits
are recommended over canned fruit or fruit juice.
c. Consider slowly adding coarse, unprocessed wheat
bran, a natural laxative, to the diet. Mix with juice or
milk; add to muffins, quick bread, or casseroles; or
sprinkle it over cereal, applesauce, or other foods.
d. Seeds and nuts are also sources of fiber
iv. Nursing Process for the Client with Constipation (pg 675 – 678)
1. The following is what I found Important:
a. Increase fluids to 6 to 8 glasses per day
b. For rectal discomfort: apply lubricant in rectum and
around anus with glove; assist client to soak rectal
area in tub of warm water.
b. Diarrhea
i. Pathophysiology and Etiology
1. The passage of larger-than-normal amounts of liquid or
semiliquid stools (more than 3 bowel movements per
day)
2. Results from increased peristalsis
3. 3 major problems associated with severe diarrhea:
a. Dehydration, electrolyte imbalances, and
vitamin deficiencies.
4. May be related to bacterial or viral infection; lactose
intolerance; food allergies; uremia; intestinal disease;
overuse of laxatives; adverse effects of drugs; metabolic
disorders and diseases; overeating, concurrent
medication, and irritable bowel syndrome
ii. Assessment Findings
1. Signs and Symptoms
a. Stools are watery and frequent
b. Urgency and abdominal discomfort
c. Hyperactive bowel sounds
d. Malaise
2. Diagnostic Findings
a. Stool cultures, Colonoscopy, Upper GI series
and Endoscopy
iii. Medical and Surgical Management
1. Limit intake of clear liquids
2. Antidiarrheal agent, Probiotics
3. Fluid and electrolyte replacement by either the oral or IV
route
4. Dietary adjustments, TPN if diarrhea is severe and
prolonged
5. Nutrition Notes 46-2 The Client with Diarrhea (pg 679)
a. Diet low in insoluble fiber to reduce the volume of
stool
b. Foods high in soluble fiber. Ex: oatmeal, ripe
bananas, and applesauce.
c. Mashed potatoes, pasta, bread made with white
flour, white rice, and low-fiber cereals are easy to
tolerate.
 22
d. Yogurt is usually tolerated well and contains
Probiotics. Milk should be avoided.
e. Encourage potassium rich foods as tolerated.
Examples: bananas, canned apricots and peaches,
apricot nectar, orange juice, grapefruit juice, tomato
juice, fish, potatoes, and meat.
iv. Nursing Process for the Client with Diarrhea (pg 679 -680)
1. The following is what I found Important:
a. Limit high sugar drinks  aggravate diarrhea
b. Encourage client to rest in a comfortable position
with legs bent toward the abdomen. This position
relaxes abdominal muscles and reduces discomfort.
c. If dehydrated, offer electrolyte solutions (Gatorade)
d. Report urine output of less than 240 mL in 4 hours
e. Observe for symptoms of sodium and potassium loss,
such as weakness, abdominal or leg cramping, and
dysrhythmias.
f. Avoid caffeine and milk
c. IRRITABLE BOWEL SYNDROME (IBS)
i. Chronic illness characterized by exacerbations and remissions;
refers to several chronic digestive disorders including Crohn’s
disease and ulcerative colitis.
ii. Crohn’s Disease
1. Chronic inflammatory condition can occur in any portion
of the GI tract but predominantly affects the bowel in
the terminal portion of the ileum
2. Pathophysiology and Etiology
a. Hyperemia, edema, and ulcerations
characterize affected areas.
b. Inflamed areas alternating with healthy tissue
(skip lesions)
c. Fistula – inflammatory channels containing
blood, mucus, pus, or stool
d. Causes: unknown; genetic predisposition,
allergic and autoimmune responses, recurrent
attacks on the tissue, stress
3. Assessment Findings
a. Signs and Symptoms
i. Insidious onset
ii. Abdominal pain, distention, and
tenderness in the lower abs
iii. Growth failure common symptom in
children and adolescents
iv. Fever, anorexia, weight loss,
dehydration, and signs of nutritional
deficiencies
v. Exacerbations and remissions
b. Diagnostic Findings
i. Stool cultures – occult blood and
WBC’s in stool
ii. Anemia
iii. WBC count and erythrocyte
sedimentation rate elevated
iv. Barium enema, EGD with biopsy
4. Medical Management
a. High fiber diet or low fiber diet depending on
inflammation and stool patterns
b. Nutritional supplements
 23
c. Vitamins, iron, Antidiarrheal and antiperistalic
drugs, anti-inflammatory corticosteroids, and
antibiotics
d. First line treatment: 5-ASA medications (act as
an anti-inflammatory)
e. Drug Therapy Table 46-2 Agents for Disorders
of the Lower GI Tract (Pages 684 -686) – READ!!
(Lots of info)
i. Antidiarrheals:
1. Absorbent antidiarrheals - act by
coating the walls of the GI tract
and absorbing substances
2. Opiate-related antidiarrheals - act
by slowing overall GI motility
ii. Laxatives, Cathartics, and Bulk-Forming
Agents
iii. Anti-inflammatory 5-Acetylsalicylic Acid
Medications (5-ASA) – act in response to
inflammation; anti-inflammatory
properties
iv. Anti-inflammatory Corticosteroids –
modify enzyme activity in the body and
inhibit inflammatory immune response.
v. Immune Modulating Agents – inhibit the
synthesis and function of RNA and DNA,
impacting immune suppression.
vi. Biologic Agents – works through the
monoclonal antibodies and is specific for
certain tumor necrosis factors.
5. Surgical Management
a. Reserved for complications
b. Intestinal transplant
c. Surgical removal of a large amount of intestine
results in the loss of absorptive surface, called
short bowel syndrome.
d. Removal of colon requires a permanent
ilesotomy
6. Nursing Management
a. Determine the onset, duration, and nature of
the client’s GI problems
iii. Ulcerative Colitis
1. Chronic inflammation limited to the mucosal and
submucosal layers of the colon and rectum
2. Most common in young and middle aged adults
3. Pathophysiology and Etiology
a. Causes: genetic predisposition, infection,
allergy, and abnormal immune response.
b. Inflammation usually begins in the rectum
c. When the inflammation extends beyond the
sigmoid colon the client has ulcerative colitis
d. The lining of colon is thin and tends to bleed
easily
4. Assessment Findings
a. Signs and Symptoms
i. Abrupt onset
ii. Severe diarrhea and expel blood and
mucus along with fecal matter
iii. Cramps and abdominal pain in the
lower left quadrant (LLQ) accompany
diarrhea
 24
iv. Anorexia, dehydration, and fatigue,
weight loss
v. Sudden urge to defecate, Incontinence
during sleep
vi. 10 to 20 stools per day
vii. Exacerbations and remissions
b. Diagnostic Findings
i. Barium enema – inflammation,
Colonoscopy with biopsy
c. Medical and Surgical Management
i. Diet – increased caloric and nutritional
content
ii. Blood transfusions and iron to correct
anemia
iii. Meds: corticosteroids,
iv. Sometimes removal of colon
d. Nursing Management
i. Assess the nature of abdominal pain,
number and frequency of stools,
anorexia, and weight loss
ii. Teach self care
II. Acute Abdominal Inflammatory Disorders
a. Appendicitis
i. Inflammation of a narrow, blind protrusion called the vermiform
appendix located at the tip of the cecum in the right lower
quadrant (RLQ) of the abdomen.
ii. Pathophysiology and Etiology
1. Inflammation begins when the opening of the appendix
narrows or becomes obstructed
2. The appendix enlarges and distends, and the swelling
compresses surrounding blood vessels
3. Unless the inflammation resolves, the appendix can
become gangrenous or rupture, spilling bacteria
throughout the peritoneal cavity.
iii. Assessment Findings
1. Attack of abdominal pain
2. Later pain localizes in the RLQ at McBurney’s point, an
area midway between the umbilicus and the right iliac
crest.
3. Rovsing’s sign – LLQ palpated and can feel pain in the
RLQ
4. Fever, nausea, and vomiting
5. Pain with defecation
6. Paralytic ileus – intestine lacks peristalsis
7. CT scan or abdominal ultrasound show enlarged cecum
8. BOX 46-1 Precautions When Assessing a Client for
Appendicitis (pg 689)
a. Avoid multiple or frequent palpation of the abdomen
– there is a danger of causing the appendix to
ruptures
b. Perform the test for rebound tenderness at the end
of the examination.
c. Do NOT administer laxatives or enemas to a client
who is experiencing fever, nausea, and abdominal
pain, even though the client may complain of feeling
constipated. Laxatives and cathartics may cause the
appendix to rupture.
iv. Medical and Surgical Management
 25
1. Antibiotics
2. Appendectomy – removal of the appendix; before it
spontaneously ruptures
v. Nursing Management
1. Assess v/s, pain, response to antibiotics, comfort
b. Peritonitis
i. Pathophysiology and Etiology
1. The peritoneum becomes inflamed
2. Caused by perforation of a peptic ulcer, the bowel, or the
appendix; abdominal trauma; IBD; ectopic pregnancy; or
infection
3. Vascular shifts to the abdomen, lowering BP and
producing hypovolemic shock or septic shock
ii. Assessment Findings
1. Signs and Symptoms
a. Severe abdominal pain, distention, tenderness,
nausea, and vomiting
b. Pain worsens when abdomen moves to breathe
c. Knees toward abdomen lessen pain
d. Abdomen feels rigid and board-like
e. Bowel sounds absent (paralytic ileus)
f. Pulse rate is elevated and respirations are rapid
and shallow
g. If unresolved – severe weakness, hypotension,
and a drop in body temperature occur as the
client nears death
2. Diagnostic Findings
a. Abdominal radiographs, CT scan or
Ultrasonography
b. Blood and peritoneal fluid cultures – reveals
bacteria
iii. Medical and Surgical Management
1. NG tube used to relieve abdominal distention
2. Antibiotics, analgesics, antiemetics
3. Perforation is surgically closed
iv. Nursing Management
1. Provide frequent explanations and emotional support
III. Intestinal Obstruction
a. Occurs when a blockage interferes with the normal progression of the
intestinal contents through the intestinal tract
b. Classified as mechanical or functional (paralytic ileus)
c. Pathophysiology and Etiology
i. Mechanical obstruction – results from a narrowing of the bowel
lumen with or without a space-occupying mass.
1. TABLE 46-2 Mechanical Causes of Obstruction (pg 691)
a. Adhesions – loops of intestine adhere to areas that
heal slowly or scar after abdominal surgery. The
adhesions cause the intestinal look to kink 3 to 4 days
later.
b. Intussusception – one part of the intestine slips into
another lower part (like a telescope shortening). The
intestinal lumen narrow.
c. Volvulus – the bowel twists and turns on itself,
obstructing the intestinal lumen. Gas and fluid
accumulate in the trapped bowel.
d. Hernia – the intestine protrudes through a weakened
area in the abdominal muscle or wall. Intestinal flow
and blood flow to the area may be completely
obstructed.
 26
e. Tumor – a tumor in the intestinal wall extends into
the intestinal lumen; or a tumor outside the intestine
causes pressure on the intestinal wall. The lumen
becomes partially obstructed; if the tumor is not
removes, complete obstruction results.
ii. Functional obstruction – intestine becomes adynamic from an
absence or normal nerve stimulation to intestinal muscle fibers
1. Can result from inflammatory conditions, electrolyte
disturbances, or adverse drug effects
d. Assessment Findings
i. Signs and Symptoms
1. Nausea and abdominal distention
2. Vomiting – seems to contain bile or fecal matter
3. Severe intermittent cramps
4. Sudden, sustained pain, abdominal distention, and fever
are symptoms of perforation.
5. Functional obstruction – peristalsis is absent, no bowel
sounds
6. Mechanical obstruction – bowel sounds are high pitched
above the obstructed area
7. Pulse and respiratory rates are elevated
8. BP falls, urine output decreases if shock develops
9. Symptoms of shock
ii. Diagnostic Findings
1. Radiographic study of the abdomen
2. Barium enema
3. Metabolic alkalosis
e. Medical and Surgical Management
i. NPO, Antibiotics
ii. Intestinal decompression – to relieve intestinal distention,
cramping, and vomiting
iii. NG tubes, Surgery – for mechanical obstruction
f. Nursing Management
i. Manage pain, maintain fluid balance, help client deal with fear
related to severe condition
ii. Monitor urinary output hourly – report less than 50 mL/hour
(indicates shock)
IV. Diverticular Disorders
a. Diverticulosis and Diverticulitis
i. Diverticula – sacs or pouches caused by herniation of the mucosa
through a weekend portion of the muscular coat of the intestine
or other structure; they can appear anywhere in the GI tract.
ii. Diverticulosis – asymptomatic diverticula
iii. Diverticulitis – inflamed diverticula
iv. Pathophysiology and Etiology
1. Higher in people who have a low intake of dietary fiber
2. Causes: congenital predisposition, weakness associated
with aging
3. Diverticula become inflamed when fecal material is
trapped in one or more blind pouches
4. Has the potential to rupture into the peritoneal cavity or
form a fistular connection with an adjacent organ
v. Assessment Findings
1. Constipations with diarrhea, flatulence, pain and
tenderness in the LLQ, fever, and rectal bleeding
2. Palpable mass may be felt in the lower abdomen
3. Stool appear maroon and resemble “currant jelly”
 27
4. Diagnostics: Barium enema, colonoscopy, CT scan, CBC,
and stool specimen
vi. Medical and Surgical Management
1. Require no treatment if they do not cause symptoms
2. Avoid foods that contain seeds is recommended
3. High fiber diet, Bulk forming agent, Low-residue foods
4. Inflammation subsides with antibiotic therapy
5. Surgery: portion of the colon with diverticula is removed
vii. Nursing Management
1. Assessment of abdomen for pain, tenderness, and
masses
2. Teaching:
a. Bran adds bulk to the diet and can be sprinkled over
cereal or added to fruit juice
b. Avoid the use of laxatives or enemas except when
recommended by the physician
c. Avoid constipation
d. Drink at least 8 to 10 large glasses of fluid each day
e. Exercise regularly
V. Abdominal Hernia
a. Hernia – the protrusion of the intestine through a defect in the abdominal
wall.
b. Reducible hernia – when the protruding structures can be replaced in the
abdominal cavity; placing the client in a supine position and applying
manual pressure over the area may reduce the hernia
c. Irreducible/incarcerated hernia – the intestine cannot be replaced in the
abdominal cavity because of edema of the protruding segment and
constriction of the muscle opening through which it has emerged.
d. Strangulated hernia – blood supply in the trapped segment of the bowel
can be cut off leading to gangrene
e. Pathophysiology and Etiology
i. BOX 46-2 Types of Hernias (pg 694)
1. Inguinal – part of the hernial sac contains the intestine at the
inguinal opening (most common type; more prevalent in men
than women)
a. Direct – hernia extends through inguinal ring; it
follows spermatic cord in males and round ligament
in females
b. Indirect – protrusion follows the posterior inguinal
wall; it often descends into the scrotum in males
2. Umbilical – hernia occurs in the umbilical region, through which
the hernial sac protrudes. This type occurs in children when the
umbilical orifice fails to close shortly after birth. It may occur in
obese adults who have prolonged abdominal distention. (More
frequent in women)
3. Femoral – intestines descend through the femoral ring where
the femoral artery passes into the femoral canal, below the
inguinal ligament. Incidence of strangulation is high. (More
frequent in women)
4. Incisional – this type occurs through the scar of a surgical
incision when healing is impaired. Careful surgical technique,
particularly prevention of wound infection, can prevent
incisional hernias. Obese, older, or malnourished clients are
prone to the development of incisional hernias.
ii. Hernias develop when intra-abdominal pressure increases, such
as while straining to lift something heavy, having a bowel
movement, or coughing or sneezing forcefully
f. Assessment Findings
i. Swelling in the abdomen; protrusion more obvious when
coughing or bearing down
 28
ii. Pain subsides when hernia is reduced
iii. Can cause intestinal obstruction
g. Medical and Surgical Management
i. Surgery is the only method of eliminating a hernia
ii. Truss – an apparatus that presses over the hernia and prevents
protrusion of the bowel
iii. Client may lie supine which manual pressure is applied over the
protruding area to reduce the hernia periodically
iv. Herniorrhaphy – the surgical repair of a hernia; recommended
treatment
1. Performed under anesthesia
v. Hernioplasty – the weakened area is reinforced with wire, fascia,
or mesh; usually for obese patients with reoccurring hernias.
vi. Strangulation is an acute emergency and gangrenous part of the
intestine must be excised
h. Nursing Management
i. Teaching: ways to avoid constipation, control a cough, and
perform proper body mechanics.
ii. Client using a Truss – observe for and treat skin irritation form
friction caused by the continuous rubbing;
1. Tell client they may use cornstarch to absorb moisture.
2. Truss may produce localized edema
iii. Preop: surgery history, drug history, vital signs, auscultates lungs
to identify infectious or respiratory risk factors, clients weight,
duration of hernia, urinary and bowel patterns.
iv. Postop: the nurse inspects the scrotum of male clients because it
is common for edema to follow surgical repair
v. Teaching post op complications: bleeding, infection – must report
to physician; avoid strenuous exertion and heavy lifting
VI. Cancers of the Colon and Rectum
rd
a. Colorectal cancer ranks as the 3 most common cancer among men and
women in the US
b. *For colorectal screening, occult blood testing is recommended every 1 to
2 years and colonoscopy every 5 to 10 years in clients older than 50 yrs of
age.
c. Pathophysiology and Etiology
i. Most common: Adenocarcinoma
ii. Risk factors: genetic disposition; environmental and lifestyle
factors spark the transformation of benign to cancerous state.
d. Assessment Findings
i. Chief characteristic: change in bowel habits, such as alternating
constipation and diarrhea
ii. Occult or frank blood in stool
iii. Client feels dull, vague abdominal discomfort
iv. Late sign: Pain
v. Distended abdomen with palpable mass
vi. BOX 46-3 Symptoms of Colorectal Cancer Related to Location of
the Lesion (pg 696)
1. Right-Sided Lesions: dull abdominal pain; melena (black, tarry
stools)
2. Left-Sided Lesions: abdominal pain and cramping; narrowing of
stool; constipation, abdominal distention; bright red blood in
stool
3. Rectal Lesions: tenesmus (ineffective painful straining with
defecation attempts); rectal pain; feeling of incomplete
evacuation after a bowel movement; alternating constipation
and diarrhea; bloody stools
 29
vii. Diagnostics: fecal occult blood test; sigmoidoscopy; barium
enema; colonoscopy; digital rectal examination
viii. Carcinoembryonic antigen (CEA) elevated test results suggest a
tumor.
e. Medical and Surgical Management
i. Removal of polyps or tumor
ii. Colectomy – surgical removal of the colon
iii. Segmental resection – removal of the cancerous portion of the
colon and rejoins with the remaining portions of the GI tract to
restore normal intestinal continuity
iv. Abdominoperineal resection – wide excision of the rectum and
creation of a sigmoid colostomy; for cancers in the lower third of
the rectum
v. Radiation, chemo, Colostomy
f. Nursing Management
i. Advise and prepare for routine colorectal screening
ii. Client and Family Teaching 46-2 Fecal Occult Blood Testing
(FOBT) (pg 697)
1. 7 to 10 days before and throughout the test:
a. Do not drink alcohol or take aspirin, NSAIDS, vitamin
C, or iron preparations
b. Check with physician if anticoagulants, steroids,
colchicines (for gout), or cemetidine (for peptic ulcer)
have been prescribed
2. 2 days before and throughout the test:
a. Consume a high-fiber diet and avoid red meat,
substituting with poultry and fish
b. Avoid turnips, cauliflower, broccoli, cantaloupe,
horseradish, and parsnips
3. During the test:
a. Collect stool within a toilet liner or bedpan
b. Use an applicator stick and remove a sample from
the center of the stool
c. Apply a thin smear of stool onto the test area
supplied with the screening kit
d. Take care to cover the entire space
e. Place two drops of developer solution onto the test
area
f. Wait 60 seconds
g. Observe for a blue color, indicating a positive
reaction (for more valid results, test samples from
several stool over 3 to 6 days)
VII. Anorectal Disorders
a. Hemorrhoids
i. Dilated veins outside or inside the anal sphincter. Thrombosed
hemorrhoids are veins that contain clots
ii. Pathophysiology and Etiology
1. Chronic straining to have a bowel movement or frequent
defecation with chronic diarrhea likely weakens the
tissue supporting the veins
2. Dry stool passes by the engorged hemorrhoids, which
stretches and irritates the mucosa, giving rise to the local
symptoms of burning, itching, and pain; Passing dry,
hard stool causes the hemorrhoids to bleed.
iii. Assessment Findings
1. External hemorrhoids – pain, itching, and soreness of the
anal area; they appear small, reddish-blue lumps at the
edge of the anus
2. Thrombosed external hemorrhoids – painful best seldom
cause bleeding
 30
3. Internal Hemorrhoids – bleeding; less pain unless they
protrude into the anus; usually protrude each time the
client defecates but retract after defecation
4. Diagnostic: anoscope (instrument for examining the anal
canal) allows visualization of internal hemorrhoids;
Colonoscopy rules out colorectal cancer
iv. Medical Management
1. Small external hemorrhoids may disappear w/o tx
2. Warm soaks, ointment with local anesthetic relief of pain
and itching, topical astringent pads to relieve swelling,
diet to correct constipation, stool softener
3. Tied off with rubber hand
v. Surgical Management
1. Hemorrhoidectomy – the surgical removal of
hemorrhoids; for chronic and severe cases
a. T-binder holds the absorbent gauze in place
vi. Nursing Management
1. Health teaching for self-management
b. Anorectal Abscess
i. An infection with a collection of pus in an area between the
internal and external sphincters
ii. Pathophysiology and Etiology
1. Common in clients with Crohn’s disease
2. Caused by infection by microorganisms from inside the
intestine or through anal intercourse, or insertion of
foreign bodies
3. May eventually develop into a fistulous tract
iii. Assessment Findings
1. Pain aggravated by walking and sitting or other activities
that increase intra-abdominal pressure such as
coughing, sneezing, and straining to have a bowel
movement
2. Swollen mass in the anus
3. Fever and abdominal pain if abscess extends into deeper
tissues
4. Foul smelling drainage leaking from the anus if abscess
ruptures
5. Culture of anal drainage reveals microorganism
iv. Medical and Surgical Management
1. Analgesics and sitz baths
2. Antibiotics
3. Incision to remove infected material
v. Nursing Management
1. Teach client to have scrupulous hand washing after each
bowel movement, use separate hygiene articles, cleanse
the bathtub after each use, and use a condom if having
anal intercourse
c. Anal Fissure
i. A linear tear in the anal canal tissue
ii. Pathophysiology and Etiology
1. Constipation is the leading cause of anal fissures
2. Causes: tear during vaginal deliver, trauma to anus
iii. Assessment Findings
1. Severe pain and bleeding on defecation
2. Constipation
3. Torn area may be visible when inspected
iv. Medical and Surgical management
 31
1. Applying anesthetic creams, ointments, or
suppositories; taking sitz baths and analgesics; prevent
constipation
v. Nursing Management
1. Teach client how to insert a suppository
2. Instruct the client in how to take a sitz bath
3. Discuss strategies to relieve constipation
4. Nursing Care Plan 46-1 The Client With an Anorectal
Condition (pg 699)
a. The following is what I found Important
i. Increase intake of water to 2 L/day
ii. warm compresses/ sitz baths 3-4 times
daily to relax the rectal sphincter
spasm and sooth irritated tissues
d. Anal Fistula
i. A tract that forms in the anal canal
ii. Pathophysiology and Etiology
1. Connection of the original abscess with perianal skin
(FIGURE 46-7 pg 700)
iii. Assessment Findings
1. Pain on defecation
2. Opening of the fistula appears red, and pus leaks for
external opening
3. If superficial, feels cordlike on palpation
4. Diagnostics: colonoscopy or Proctosigmoidoscopy
iv. Medical and Surgical Management
1. Antibiotics, treatment of underlying cause
2. Fistulotomy – incising the fistula along with partial
sphincter divisions
3. Fistulectomy – involves the excision of the fistulous
tract; recommended surgery
4. Secton – nonabsorbable suture of drain that is passed
from the cutaneous opening of the fistula into the lumen
of the anal canal and then back out onto the skin, where
it is tied to itself
v. Nursing Management
1. Teaching
e. Pilonidal Sinus
i. An infection in the hair follicles in the sacrococcygeal area above
the anus
ii. Pathophysiology and Etiology
1. Occurs after puberty
2. Causes: inadequate personal hygiene, obesity, and
trauma to the area
3. FIGURE 46-8 (pg 700)
iii. Assessment Findings
1. Pain and swelling at the base of the spine and purulent
drainage
2. Dilated pits of the hair follicles in the sinus are a unique
characteristic
iv. Medical and Surgical Management
1. Abscess is drained and tissue is incised
2. Purulent material and hair are removed
3. Packing is inserted into the cavity
v. Nursing Management
1. Teach client how to minimize discomfort and facilitates
postop bowel elimination
 32

Chapter 47: (pages 702 – 732)

Caring for Clients with Disorders of the Liver, Gallbladder, or Pancreas

I. Disorders of the Liver

a. BOX 47-1 Functions of the Liver (pg 703)
i. Metabolize glucose
ii. Regulates blood glucose concentration
iii. Converts glucose to glycogen to glucose to maintain normal glucose
levels
iv. Synthesizes amino acids from the breakdown of protein or from lactate
that muscles produce during exercise to form glucose
v. Converts ammonia into urea
vi. Metabolizes proteins and fats
vii. Stores vitamins A, B12, D, and some B-complex vitamins, as well as iron
and copper
viii. Metabolizes drugs, chemicals, bacteria, and other foreign elements
ix. Forms and excretes bile
x. Excretes bilirubin
xi. Synthesizes factors needed for blood coagulation
b. Jaundice
i. Also called icterus, is a greenish-yellow discoloration of tissue
ii. It is a sign of disease
iii. Results from abnormally high concentration of the pigment
bilirubin in the blood
1. Normal levels: 0.2 to 1.3 mg/dL
2. Levels increase when there is excessive destruction of
RBC’s or the liver cannot excrete bilirubin normally
iv. Visible on the skin, oral mucous membranes, and especially the
sclera
v. Two forms of bilirubin: indirect/unconjugated and
direct/conjugated
vi. 3 forms of Jaundice:
1. Hemolytic – caused by excess destruction of RBC’s
2. Hepatocellar – caused by liver disease
3. Obstructive – caused by a block in the passage of bile
between the liver and intestinal tract
4. Table 47-1 Types of Jaundice (pg 705)
c. CIRRHOSIS
i. A degenerative liver disorder caused by generalized cellular
damage
ii. Pathophysiology and Etiology
1. Types:
a. Laennec’s/Alcoholic cirrhosis – the most
common type; results from chronic alcohol
intake and is frequently associated with poor
nutrition; develops over a long period of 30 or
more years
i. Liver takes on “hobnail” appearance –
islands of normal tissue, regenerating
tissue, and scar tissue.
b. Biliary cirrhosis – scarring occurs around the bile
ducts in the liver caused from obstruction and
infection
2. Prognosis based on bilirubin and albumin levels,
presence or ascites, neurologic involvement, and
nutritional status
a. Table 47-2 Child-Pugh Classification of Severity
of Liver Disease (pg 705)
 33
iii. Assessment Findings
1. Signs and Symptoms
a. BOX 47-2 Clinical Manifestations of Cirrhosis
(pg 706)
i. Compensated:
1. Intermittent mild fever; vascular
spiders, palmar erythema
(reddened palms); unexplained
Epistaxis; ankle edema; vague
morning indigestion; flatulent
dyspepsia; abdominal pain; firm,
enlarged liver; splenomegaly
ii. Decompensated:
1. Ascites, Jaundice, weakness,
muscle wasting, weight loss,
continuous mild fever, clubbing of
the fingers, purpura, spontaneous
bruising, Epistaxis, hypotension,
sparse body hair, white nails,
gonadal atrophy
b. Compensated – less severe; signs and
symptoms are more vague
c. Decompensated – as disease progresses; signs
and symptoms are very pronounced and
indicate liver failure
d. Chronic fatigue, anorexia, dyspepsia, nausea,
vomiting, and diarrhea or constipation
e. Clay-colored or whitish stools as result of no bile
in the GI tract
f. Dark or “tea-colored” urine
g. Enlarged liver
h. Gynecomastia (enlarged breasts) and testicular
atrophy
i. Palmar erythema (bright pink palms)
j. Cutaneous spider angiomata (tiny, spider-like
blood vessels)
2. Diagnostic Findings
a. Liver biopsy – obtained percutanously or
through a surgical incision
b. CT, MRI, blood tests, or PT tests
c. Box 47-3 Common Blood Test Findings in
Cirrhosis (pg 706)
i. Increased: bilirubin levels; AST, ALT, and
GGT; globulin level
ii. Decreased: leukocytes and thrombocytes;
platelet count
iii. Low: RBC count; fibrinogen level; albumin
level
iv. Prolonged PT
v. Hypokalemia
iv. Medical and Surgical Management
1. Aim of therapy is to prevent further deterioration
2. Improved nutritional status
3. NO alcohol, sodium restriction
4. Transfusion of platelets
5. Cholestryamine
6. Liver transplantation BOX 47-4 Liver Transplants and
Organ Donation (pg 707)
7. Nutrition Notes 47-1 The Client with Cirrhosis (pg 707)
READ
 34
a. High-calorie, high-protein, carb controlled, with
small frequent meals and use of supplements
b. Fluid restriction for clients with hyponatremia
v. Nursing Management
1. Rise in BP, pulse, and temperature correlates with
alcohol withdrawal
2. Daily weights, I&O
3. *Measure abdomen girth – take largest diameter of the
abdomen (around the umbilicus)
4. Educational teaching
a. May be rejected as a blood donor because of
liver disease
5. **CARE PLAN 47-1 The Client with a Liver Disorder
(pg 709-711)
a. READ!! (its longer)
d. Complications of Cirrhosis
i. Portal Hypertension
1. Congestion and increased fluid pressure in the portal
system
2. Treatment
a. Reduce fluid accumulation and venous pressure
b. Sodium restricted; diuretic prescribed
c. Surgical shunt – uses a graft to decompress the
portal system by diverting blood into the
systemic circulation
d. Transjugular intrahepatic portosystemic shunt
(TIPS) – invasive radiologic procedure involves
the creation of a tract from the hepatic to the
portal vein; relieves portal hypertension
e. DRUG THERAPY TABLE 47-1 Selected Meds
Used for Liver, Gallbladder, and Pancreatic
Disorders (pg 713-714)
i. Liver:
1. Procoagulant: promotes blood
coagulation in bleeding
conditions resulting from liver
disease
a. Ex: vitamin K
2. Aminoglycoside antibiotic:
decreased intestinal bacterial,
thereby decreasing serum
ammonia level
a. Ex: kanamycin
(Kantrex)
3. Laxative and ammonia reduction
agent: degrades intestinal
bacteria
a. Ex: lactulose
4. Bile acid sequestrant: reduces
puritus by binding bile slats for
excretion in feces
a. Ex: Cholestryamine
(Questran)
5. Potassium sparing diuretic:
promotes excretion of sodium
and water, particularly in cases of
ascites
a. Ex: spironolactone
(Aldactone, Spirotone)
6. Immune agents: promotes virus-
fighting capacities
 35
7. Immunosuppressives: prevents
rejection of transplanted organ
ii. Gallbladder
1. Gallstone dissolving agents:
suppresses hepatic synthesis of
cholesterol and cholic acid
iii. Pancreas
1. Pancreatic enzymes: promote
digestion and fat, protein, and
carb absorption
ii. Esophageal Varices
1. Dilated, bulging esophageal veins
2. Vulnerable to bleeding
3. Figure 47-6 Pathogenesis of esophageal varices (pg 712)
a. Portal hypertension results from increased resistance
to portal flow and increased portal venous inflow
b. Pressure gradient increased b/w portal vein and
inferior vena cava
c. Venous collateral circulation develops from high
portal system pressure to systemic veins, forming
esophageal, gastric, and hemorrhoidal varices.
d. Varices may rupture, causing life-threatening
hemorrhage
4. Cardinal sign: Esophageal bleeding
5. Diagnostic: Barium swallow or esophagoscopy
6. Treatment
a. Reduce the potential for bleeding
b. Antitussives and stool softeners
c. Injection sclerotherapy – physician passes an
endoscope orally to locate the varix; then
passes a needle through the endoscope into the
varix and directly injects a sclerosing agent to
solidify and stop circulation to the varix
d. Variceal banding – device with rubber bands at
the end of the endoscope; places the rubber
band over the varix to restrict blood flow to the
varix
e. Distal splenorenal shunt (DSRS)
f. Balloon Tamponade – compresses the varices
and stems the blood flow; uses a Sengstaken-
Blakemore tube; temporary
iii. Ascites
1. Collection of fluid in the peritoneal cavity.
2. Leads to hepatorenal syndrome – cascade of events
that alter fluid distribution and interfere with fluid
excretion
3. Treatment
a. Abdominal paracentesis – removes ascitic fluid
in the abdominal cavity; relieves breathing
difficulty
b. Diuretic therapy, sodium-restricted diet
iv. Hepatic Encephalopathy
1. CNS manifestation of liver failure that often leas to coma
and death
2. Related to increased serum ammonia level
3. Signs and Symptoms
a. Disorientation, confusion, personality changes,
memory loss, flapping tremor (asterixis), a
 36
positive babinski reflex, sulfurous breath odor
(fetor hepaticus), and lethargy to deep coma
b. S/s worsen after client eats a high-protein meal
of has active GI bleeding
4. Treatment
a. Eliminate dietary protein and removing residual
protein
b. Antibiotics - kanamycin
c. Lactulose, Levadopa
e. HEPATITIS
i. Inflammation of the liver; may be acute or chronic
ii. Pathophysiology and Etiology
1. Causes: hepatotoxic chemicals or drugs; lengthy alcohol
abuse; invasion of an infectious microorganism
2. TABLE 47-3 Forms of Viral Hepatitis (pg 716)
TYPE CAUSE MODE OF INCUBATION SIGNS AND SYMPTOMS OUTCOME
TRANSMISSION
Hepatitis A Hep A virus Oral-fecal/saliva; 3-5 weeks With or without symptoms Mild with full recovery
(HAV) water, food, and Preicteric phase:
equipment headache, malaise,
contaminated with fatigue, anorexia, fever
HAV Icteric phase: dark urine,
jaundice, tender liver
Hepatitis B Hep B virus Infected blood or 2-5 months Arthralgias, rash; may May be severe; carrier
(HBV) plasma; sexually occur without symptoms state possible;
transmitted increased risk of
chronic hepatitis,
cirrhosis, and cancer
Hepatitis C Hep C virus Infected blood or 2-20 weeks Similar to HBV, although Frequent occurrence of
(HCV) blood products less severe and without chronic carrier state
jaundice and chronic liver
disease; risk of cancer
Hepatitis D Hep D virus Same as HBV; 2-5 months Similar to HBV Similar to HBV with
(HDV) cannot infect alone; greater likelihood of
occurs as dual carrier state; chronic
infection with HBV hepatitis, and
cirrhosis
Hepatitis E Hep E virus Fecal-oral routes 2-9 weeks Similar to HAV – very Similar to HAV – very
(HEV) severe in pregnant severe in pregnant
women women
Hepatitis G Hep G virus Infected blood or 14-145 days Similar to HCV Causes persistent
(HGV, GB blood products infection; does not
virus-c, or affect clinical course
GBV-C) or cause chronic liver
disease

3. Other Types of Hepatitis:

a. Autoimmune hepatitis, Toxic hepatitis, and
Drug-induced hepatitis
4. BOX 47-5 Risk Factors for Acquiring Blood-borne
Hepatitis (pg 717)
a. History of illicit IV drug use
b. Occupational exposure through sharps injuries
c. Perinatal exposure
d. Blood transfusion
e. Organ transplant
f. Exposure to contaminated equipment that
penetrates the skin
g. Sexual contact with infected persons
h. Hemodialysis
i. Impaired immune response
 37
iii. Assessment Findings
1. Signs and Symptoms
a. Incubation phase: virus replicated within the liver;
asymptomatic; client is considered infectious
b. Preicteric or prodromal phase: nausea, vomiting;
anorexia; fever; malaise; arthralgia; headache; RUQ
discomfort; enlargement of spleen, liver, and lymph
nodes; weight loss; rash; and uticaria
c. Icteric phase: jaundice, pruritus, clay-colored or light
stools, dark urine, fatigue, anorexia, and RUQ
discomfort
d. Posticteric phase: liver enlargement, malaise, and
fatigue; liver function tests begin to return to normal
2. Diagnostic Findings
a. RNA testing – to detect virus
b. ALT and AST levels rise in incubation period and
fall once symptoms appear
c. Prolonged PT and PTT reflects poor liver
function
d. Liver biopsy
iv. Medical and Surgical Management
1. Treatment is symptomatic and includes: bed rest,
balanced diet, IV fluids, vitamins supplements
2. Drug therapy
3. Liver transplant
4. BOX 47-3 Measures for Preventing Viral Hepatitis
Transmission (pg 718)
a. READ!
v. Nursing Management
1. Preventative techniques to control spread
2. Teaching
f. Tumors of the Liver
i. Pathophysiology and Etiology
1. Increased incidence in people with previous hepatitis B
or D virus infections or cirrhosis
2. Causes: TB and fungal and parasitic infections; oral
contraceptives and anabolic steroids
3. They may obstruct bile flow leading to jaundice, liver
failure, portal hypertension, and ascites.
ii. Assessment Findings
1. Jaundice, rain in RUQ, weight loss, bleeding tendencies,
distended abdomen
2. Alpha fetoprotein – serum protein marker for malignant
liver tumor
3. Diagnostics: liver scan, ultrasound, MRI, CT, biopsy
iii. Medical and Surgical Management
1. Hepatic lobectomy – remove primary malignant or
benign tumor
2. Metastatic tumors are inoperable
3. Cryosurgery or cryoablation – used liquid nitrogen to
destroy tumors
4. Chemo, radiation
iv. Nursing Management
1. Keep client comfortable
2. Safety measures
3. Nursing Process for a client having Surgery for a Liver
Disorder (pg 720)
a. READ
II. Disorders of the Gallbladder
 38
a. Cholelithiasis and Cholecystitis
i. Cholelithiasis – stones that form in the gallbladder
ii. Choledo-cholithiasis – stones located in the common bile duct
iii. Cholecystitis – inflammation or infection of the gallbladder; may
be acute or chronic
iv. Pathophysiology and Etiology
1. Always coexist
2. More frequent in women than men
3. Causes: bile stasis, dietary factors, and infection
v. Assessment Findings:
1. Signs and Symptoms
a. Belching, nausea, and RUQ discomfort, with
pain or cramps after high-fat meals
b. Acute Cholecystitis – very sick with fever,
vomiting, tenderness over the liver, and sever
pain called biliary colic.
c. Gallbladder swollen
d. Slight jaundice
e. Urine appears dark brown; stools light colored
2. Diagnostic Findings
a. Cholecystography – gallbladder imaging
b. Ultrasound, CT, or radionuclide imaging
c. Endoscopic retrograde
cholangiopancreatography (ERCP) – locates
stones that have collected in the common bile
duct
d. MRI – to detect gallstones and gallbladder
disorders
vi. Medical and Surgical Management
1. If gallbladder inflamed – NPO; NG tube is inserted and
antibiotics and parenteral fluids are prescribed
2. Low-fat diet
3. Analgesics, anticholingerics, and nitroglycerin – for pain
4. Questran – to relieve pruritus
5. Agents to dissolve gallstones
6. Lithotripsy – nonsurgical procedure using shock waves
generated by a machine, that may be able to break up
some types of gallstones
7. Laparoscopic cholecystectomy – the preferred surgical
procedure for gallbladder removal
a. Figure 47-10 (pg 722)
8. Open cholecystectomy
9. T-tube – a tube used to drain bile
vii. Nursing Management
1. Rest, antispasmodics, or analgesics
2. Low-fat diet
3. After surgery check for increased pain, shock, or signs of
internal bleeding
4. Same-Day Surgery
a. On day of surgery nurse does skin prep, inserts
IV line, and administers sedation.
b. After provide teaching and instructions
5. Cholecystectomy
a. Nursing Care Plan 47-2 (pg 724-725) READ!
b. T-tube collector should be kept below the level
of the incision
 39
c. Measure drainage every 8 hours – if more than
500 mL of bile drains in 24 hours notify
physician
III. Disorders of the Pancreas
a. Acute Pancreatitis
i. Inflammation of the pancreas; ranges from mild to severe and
can be fatal
ii. Pathophysiology and Etiology
1. Pancreas becomes inflamed with its own enzymes
(trypsin) and causes the pancreas to digest itself
(autodigestion – caused by reflux of bile and duodenal
contents into the pancreatic duct)
2. Causes: structural abnormalities, abdominal trauma,
infections, metabolic disorders, vascular abnormalities,
inflammatory bowel disease, hereditary factors,
ingestion of alcohol or certain other drugs, or refeeding
after prolonged fasting or anorexia.
3. Complications: hyperglycemia, necrosis and
hemorrhage, peritonitis, fluid and electrolyte imbalance,
shock, pleural effusion, acute respiratory distress
syndrome, and blood coagulation problems
iii. Assessment Findings
1. Signs and Symptoms
a. Severe mid to upper abdominal pain radiating
to both sides and straight to the back
b. Nausea, vomiting, and flatulence
c. Stools are frothy and foul-smelling from
increased fat in the stool
d. Symptoms worsen after eating fatty foods
e. Relieved when client sits up and leans forward
or curls into a fetal position
f. Bowel sounds are diminished or absent
g. Hypotensive
h. Breathing is shallow from severe pain
i. Bruising around the umbilicus or on the flanks
2. Diagnostic Findings
a. Pancreatic edema and necrosis appear on CT
scan
b. Ultrasound, endoscopic examinations
c. Serum levels
iv. Medical and Surgical Management
1. Relieve pain, reduce secretions, restore fluid and
electrolyte losses, and prevent or treat systemic
complications
2. NPO, NG tube inserted
3. Antibiotics
4. Surgical management involves opening the abdomen to
debride necrotic tissue
5. Sump drains are inserted into the cavity to remove
debris and attached to continuous irrigation
a. FIGURE 47-12 (pg 727)
v. Nursing Management
1. Monitor client for alcohol withdrawal
2. Maintain tube patencies
3. Cardiac monitoring because of dysrhythmias caused by
electrolyte imbalances
b. Chronic Pancreatitis
 40
i. Pathophysiology and Etiology
1. Prolonged and progressive inflammation of the pancreas
2. Caused by alcohol
ii. Assessment Findings
1. Signs and Symptoms
a. Severe to persistent pain, weight loss, and
digestive disturbances such as flatulence,
diarrhea, and vomiting
b. Firm mass may be palpable in the ULQ
c. Urine is dark; stools are light colored and foul
smelling
d. Peripheral edema and ascites develop
2. Diagnostic Findings
a. CT scans, MRI, ultrasound, and ERCP studies
b. Glucose tolerance test
iii. Medical and Surgical Management
1. Depends on cause
2. Alcohol abstinence, clear liquid to blan fat-free diet
3. Drug therapy
a. Demerol, narcotics, pancreatic enzyme
replacements
4. Surgery – partial or total pancreatectomy (removal of
some or all of the pancreas)
iv. Nursing Process for the Client with Pancreatitis (pg 728-730)
1. The following is what I found important:
a. Position client with hob elevated or in semi-
fowlers position – reduces pressure on the
diaphragm from abdominal distention and
promotes lung expansion
b. Maintain low-fat diet
c. Provide a safe environment for the client if at
risk for injury related to alcohol withdrawal
d. Seizure precautions
c. Carcinomas of the Pancreas
i. Just read. It is basically the same as the other cancers….