Gastrointestinal, Hepatic and Pancreatic Disorders

1. History of Problem
2. General Appearance:
1. Thin, emaciated
2. Obese
3. Skin turgor

3. GI System:
1. Nausea and vomiting: what precipitates it, what relieves it, appearance,
characteristics
2. Pain: location, what precipitates it, what relieves it, radiation how long,
characteristics, quality
3. Elimination pattern: pattern and consistency of stools, laxative use
4. Nutrition: intake and output; difficulties in swallowing; likes and dislikes
(consider cultural diversity here), normal intake per day

4. Examination of Abdomen:
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
5. Associated Symptoms: flatus, eructation, heartburn, pain

In this next section, we're going to review the gastrointestinal, hepatic, and pancreatic disorders. And
some of the disorders that we're going to talk about, first of all, have to do with we're going to be
doing assessment of the client who has a problem in this area.
We're going to do diagnostic tests. We're going to do the intubation, GI intubation, TPN and PPN.
We'll talk about hernia, ostomies, cirrhosis of the liver and hepatitis, gallbladder disease, and
pancreatitis. So that's what's contained in this section.
So let's begin, first of all, by talking about what assessment is. If we think about assessing a client
who has a problem in the GI system or the digestive and excretion system, let's think about what
would be important.
First of all, what does the client look like? Are they obese? Are they emaciated? Are they, what does
their skin turgor look like? Is it within normal limits? Is it tented? What is it that, how does the client
look?
The other thing that's extremely important is to look at what system is affected and to do an
assessment of those systems in the GI tract. So for example, does a client have nausea and
vomiting? And if they do, is it affected by what they eat? Does eating make it feel better? Does
eating make them vomit? What precipitated the nausea or vomiting?
Do they have pain? And if they do, what I usually ask my patients or my clients to do is to take one
finger and to point where it hurts the most because that will give you a better idea as to whether it is
a problem with their gallbladder or is it a problem with their bowel and so forth.
Do they have a problem with stools? Do they have diarrhea? Or do they have constipation? Because
it could very well be that there's an obstruction or perhaps there is an irritation.
The other and most important, I shouldn't say most important, but very important piece to this is
nutrition. Think about what type of foods can they eat. Do certain foods bother them? Do they have a
problem with elimination or with urinary output? Do they have difficulties in swallowing?
And another thing that's important is to find out what type of food they like and what type of foods
they don't like. And that has to do with when, if a client does have to have a change in their diet, it's
much better to try to include some of the foods that they will eat rather than those that they won't
ever eat.
If you told me today I had to eat liver or die, the chances are I'd start making out my will because I
wouldn't want to ever eat liver. So those are the things that you would need to find out from your
client before you would make a diet that's based solely on things that they have a dislike for.
The other thing that would be important is to do an abdominal assessment. And that, remember, has
a sequence of events, look, listen, then feel.And what we're going to do is we're going to be looking
to see if you see any bruise, if you see any distension, is there a, can you see any flow of the
peristalsis.
And then you're going to listen to hear whether they have bowel sounds, are they hyper or
hypoactive or are they within normal range. And of course, is there any pain when you palpate the
abdomen? Do they have any associated symptoms like heartburn, flatus? Do they belch quite a bit?
Those are the things that would be included in the history and that would help you to focus in on, to
do a focused assessment and focus in on the appropriate interventions.

Diagnostic Procedures
1. Upper GI
1. Method: barium swallow
2. Purpose: assessment of esophagus and stomach
3. NPO 6-8 hours before procedure
4. Laxative after procedure
5. Follow-up x-ray 6 hours after procedure

2. Lower GI
1. Method: barium enema
2. Purpose: assessment of large colon
3. Liquid diet before procedure
4. Laxative before and after procedure
5. Initially, feces will be white. Should be normal color within 72 hours.

Focus in on the appropriate interventions. Now, we've talked about diagnostic procedures before, so
I'd like to just review those with you. Remember that we're talking about the GI system. So
remember the GI system starts at the mouth and ends at the anus. That means that there's a lot of
things that happen in between.
And how we evaluate those has to do with putting something in one end or the other to view
whatever is in there. So let's look first at the upper GI. First is a barium swallow. Now, remember
what you're doing is you're swallowing a substance called barium. And what that is is a contrast
media so that it will identify or illustrate for the practitioner whether there is a growth, whether there
is an irritation, is there a narrowing, and so forth. And you're looking at the esophagus and stomach.
Remember, it's the upper GI.
In this case, patient teaching becomes important because these are most often done as an
outpatient. They're going to be NPO at least for about six or seven hours prior to that procedure, and
they're going to be given a laxative after the procedure. And I want you to star that because any time
you give a client barium, whether it's for upper GI or lower GI, the nurse as a manager of care needs
to do two things. Certainly to make sure that they are physiologically and psychologically prepared
for the procedure. But the other thing that is important here is that you're managing what happens to
them afterwards.
If you don't give them a laxative after having barium, it becomes kind of like concrete. It hardens.
They may develop an obstruction. Therefore, that's an important part of this procedure. A lower GI is
the barium enema. And again, it's inserting the barium. And it is the same type of prep. Remember,
in this case, we're looking at the large colon. And so it's doing that type of visualization. It's outlining
or illustrating for the practitioner if there's an obstruction and so forth.
The 24 hours before this procedure, the client is usually put on a liquid diet. And that, again, is to
minimize the amount of fecal material that might be in the bowel.They're also giving a laxative before
and after the procedure. Now, this laxative may not be the same as what we're going to talk about
when we look at the endoscopy procedures. However, remember that they do need to make sure
that there isn't a lot of stool in that large colon because they want to be able to get a really good
picture.
Remember that post-procedure, you need to make sure that the client knows that they're going to
have a very light-colored stool following that because the barium is white. So when it mixes with
stool, even though it may be a very normal stool, it's goingto turn it a different color. And sometimes
that could cause for alarm to those clients. So you need to make sure they know that.

3. Endoscopy (Gastroscopy, Esophagogastric Duodenoscopy)

1. Method: visualization of the inside of the body by means of a lighted tube
2. Purpose: assessment of esophagus, stomach
3. Gag reflex inactivated
4. NPO 6-8 hours before procedure
5. Resume diet only after gag reflex returns
6. Complications: perforation, bleeding, bloating

4. Sigmoidoscopy/Colonoscopy
1. Method: endoscope inserted through the anus
2. Purpose: assessment of sigmoid colon
3. Administer enema before
4. Monitor for complications: perforation, bleeding

Be cause for alarm to those clients, so you need to make sure they know that. Let's look next at
another very common diagnostic procedure. And remember back when we talked about the
respiratory system, we talked about the oscopy. That suffix oscopy, remember, means putting a
lighted instrument into an opening to view something.
Now, we talked about it before. They were viewing the bronchus. In this case, it is an endoscopy
procedure, which means they could either be looking at the esophagus or the duodenum. And the
prefix or the stem word would be slightly different. So it would either be a duodenoscopy, an
esophagoscopy, or a gastroscopy, depending on which portion of the GI system they want to look at.
But all of that, the general term for that is an endoscopy procedure. That is the global term. These
others are the categories underneath it.
Again, putting a lighted instrument into an opening to view something. Now, in this case, they're
putting it in, again, through the mouth. Therefore, the gag reflex is going to be inactivated. They're
going to spray that carbocaine or something similar to that in the back of their throat, and the client
will then not be able to swallow. These clients always are given conscious sedation

.
And remember, we talked about in the perioperative period, we talked about a drug called Versed.
They use Versed, Valium, Morphine, Demerol. There's a number of different drugs that they use in
combination so that the client is awake during the procedure but doesn't remember it later and can
cooperate during that procedure if they need to be turned and so forth. They're NPO at least six
hours, sometimes a little longer, before the procedure. And the important thing to star here is that
you cannot give them anything by mouth until their gag reflex has returned. That's also important.
Now, any time you're putting an instrument into an opening, you always worry about bleeding.
Perforation and bleeding are very real possibilities. And so you're going to be monitoring this client
for the potential for this to occur. Now, remember, however, that when we talked about perfusion
earlier, we said that perfusion, what would happen first is that the client would develop tachycardia
and dyspnea because they have a decrease in oxygenated blood or in fluid. But if this client has a
perforation, because there won't be as much circulating blood volume, that's one of the early
symptoms. And you're going to see changes in vital signs, too. So again, it doesn't matter what the
cause is. It's a problem of perfusion. And that's important.
Now, let's look at the next one, which is a sigmoidoscopy or colonoscopy. Again, that lighted
instrument is still being used. This time, it's put in through the anus, though.It's not put in as an
endoscopy. It's the other end. It's at the anus. Again, we're looking at the part of the GI system, but
it's the sigmoid colon in this case. The client still has to have a bowel prep with an enema.
And the other thing that they have besides an enema is something that I had alluded to earlier. If you
remember, I said that they're given a laxative. Almost every endoscopy procedure, whether it's upper
or lower, if you're looking at any part of the bowel, they're given something called Golight or
Colightly. And it is a bowel prep that is in a container, and they have to drink a lot of it. And what it
does is it evacuates the bowel, and it empties it completely.
The problem that occurs is that they have to drink all of it. It tastes kind of funny.Sometimes it has a
flavoring in it. Putting it over ice will help, but you don't want to put too much ice, because then
you're going to have to drink more of it. And the client needs to not go to the mall shopping or
anything like that after they've taken it, because once it goes through their system, long about an
hour or two after it's completed, they're going to need to stay very close to a bathroom, because all
of the stool is going to be evacuated. Especially elderly clients, you need to tell them to make sure
that they stay home, because it may be bridge night or something, and you want to make sure that
they don't go to play bridge during this period of time.

Gastrointestinal, Hepatic and Pancreatic Disorders

1. History of Problem
2. General Appearance:
 1. Thin, emaciated
2. Obese
3. Skin turgor

3. GI System:
1. Nausea and vomiting: what precipitates it, what relieves it, appearance,
characteristics
2. Pain: location, what precipitates it, what relieves it, radiation how long,
characteristics, quality
3. Elimination pattern: pattern and consistency of stools, laxative use
4. Nutrition: intake and output; difficulties in swallowing; likes and dislikes
(consider cultural diversity here), normal intake per day

4. Examination of Abdomen:
1. Inspection
2. Auscultation
3. Percussion
4. Palpation

E. Associated Symptoms: flatus, eructation, heartburn, pain

Diagnostic Procedures

1. Upper GI
1. Method: barium swallow
2. Purpose: assessment of esophagus and stomach
3. NPO 6-8 hours before procedure
4. Laxative after procedure
5. Follow-up x-ray 6 hours after procedure

2. Lower GI
1. Method: barium enema
2. Purpose: assessment of large colon
3. Liquid diet before procedure
4. Laxative before and after procedure
5. Initially, feces will be white. Should be normal color within 72 hours.

3. Endoscopy (Gastroscopy, Esophagogastric Duodenoscopy)

1. Method: visualization of the inside of the body by means of a lighted tube
2. Purpose: assessment of esophagus, stomach
3. Gag reflex inactivated
4. NPO 6-8 hours before procedure
5. Resume diet only after gag reflex returns
6. Complications: perforation, bleeding, bloating
 4. Sigmoidoscopy/Colonoscopy
1. Method: endoscope inserted through the anus
2. Purpose: assessment of sigmoid colon
3. Administer enema before
4. Monitor for complications: perforation, bleeding

5. Analysis of Gastrointestinal Secretions

1. Stool Analysis:
1. Method: culture, fat analysis, guaiac – no aspirin (ASA), NSAID, red
meat, Vitamin C for 3 days before
2. Purpose: assessment for bacteria, virus, ova & parasites,
malabsorption, blood
3. Do not refrigerate stool samples

6. Evaluation of the Gallbladder and Liver

1. Cholecystogram (Gallbladder Series)
1. Method: dye conjugated in the liver and excreted into the bile that
outlines the gallbladder
2. Purpose: assessment of gallstones, proper gallbladder function
3. Check for allergy to iodine or seafood
4. Telepaque tablets 12 hours before test
5. NPO after midnight
6. Less commonly performed than ultrasound
2. Cholangiogram
1. Method: bile ducts visualized
2. Check for allergy to iodine or seafood
3. Ultrasound of Gallbladder and Liver
1. Strict NPO after midnight prior to procedure
2. Able to visualize if stones are present

6. Flat Plate of the Abdomen

1. No preparation
2. Gives a good overall impression of the abdominal cavity
Sure that they stay home because it may be bridge night or something and youwant to make sure
that they don't go to play bridge during this period of time.
The other type of analysis that we might do is the stool analysis. Now there are a couple of reasons
that we do them. You could look for fat, you could be looking to culture the stool to see if there is a
bacteria that's growing, or you could be looking for blood in the stool as in a stool for guaiac, and it
would be important to not give the client anything that might give them a false positive like eating red
meat because that might be give them a false positive.
Taking aspirin might also cause a false positive and vitamin C also may do that because it causes
the stool to change and so we usually tell them to stop all of those things about three days before
they're going to have this stool analysis.
We can look for a number of things besides fat and so forth and that is we can look for viruses, we
can look for ova and parasites. Remember the one important thing though is you don't put it in the
refrigerator because if you put it in the refrigerator once you've collected that specimen you may kill
whatever bacteria or ova or parasites that are in that stool.

So you want to send it down keep it at room temperature and send it down immediately for analysis.
Gallbladder series really we don't see very much today because ultrasound kind of has taken the
place of this but we do if you do have a cholangiogram or a cholangiogram a dye is used and
whenever you have a dye remember that you have to ask the client if they have any allergies to
iodine or shellfish because any of the dyes that are used have an iodine based so if they have had
that allergy we need to make sure that we note that and they may not be able to take that particular
dye.
So we're not going to spend a lot of time on that just know that the the type of material that they're
given is not a barium it's called telepake. They're telepake tablets and it adheres to the gallbladder
so they can get a really good picture of it.
The flat plate is nothing more than an x-ray.

8. Liver Biopsy
1. Method: removal of liver tissue to rule out liver disease
2. Obtain consent and results of hemostasis tests before the biopsy
3. Usually performed under fluoroscopic guidance
4. Two weeks prior, client must discontinue aspirin, NSAIDS and anticoagulants
5. NPO after midnight
6. Position on left side during biopsy
7. Position on right side after biopsy for two hours
8. Bed rest for prescribed time after biopsy
9. Observe for complications (bleeding, pneumothorax)
Let's look next, though, at the liver biopsy, which also falls under diagnostic categories. Usually this
is done under a fluoroscopy, and it's usually a procedure that requires the client to discontinue using
anything that might cause an increase in bleeding, like aspirin, the Nysads, or any anticoagulants
that they might be on, because the liver is a highly vascular organ, and therefore, and remember
what it controls, there's lots of clotting factors that are produced by the liver, therefore, we want to
make sure that they don't have an increased risk for bleeding.
Any time you do any invasive procedure, remember, the client is at risk for bleeding.Whenever you
put a needle into an organ, that's going to increase their risk.
Now, again, we're doing, we're taking some liver tissue to rule out liver disease, andwe do that with,
for a number of different reasons, certainly not just because a client has cirrhosis of the liver, or who
has hepatitis, but for a number of other reasons as well.They do need a consent form, and again,
we've already talked about consent, and how it's not your job to obtain the consent, but merely to
look at and to make sure that that signature is on that piece of paper, and that the consent has
occurred, and that the client really knows what's going to happen to them.
They are NPO after midnight, they're put on the left side during the biopsy, and a post-biopsy
procedure, they're placed on the right side. Now, one thing that is important is to be looking at that
site in the post-procedure. They're going to have a pressure dressing, remember we said bleeding is
one of the most common complications, and so you're going to be monitoring it for bleeding.
 9. Paracentesis
1. Removal of fluid accumulated in the peritoneum
2. Indicated when ventilation is impaired, abdominal discomfort
1. Therapeutic: to relieve shortness of breath when ventilation is impaired
2. Diagnostic: to examine contents of peritoneal fluid
3. Void immediately prior to procedure
4. During procedure: sitting up with feet resting on stool
5. Fluid should be removed slowly over 30-90 minutes, generally < 1500 cc
6. Bed rest after the procedure
7. Observe for complications - for example, hypovolemia; shock secondary to fluid
shift, tachycardia, oliguria, infection, peritonitis
Bring it for bleeding. Now we've also talked about the word sentesis before. And remember what a
sentesis is. When we talked about thoracentesis, sentesis is removing fluid from an opening. And
usually it's by insertion of a needle.
So if we did a thoracentesis to remove fluid from the thoracic cavity, a paracentesis is putting a
needle into the peritoneal cavity to remove fluid or air sometimes also can be removed that way.
Now, the only time we usually do a paracentesis is if a person has ascites, which is an accumulation
of fluid and electrolytes in their abdomen, because they have difficulty with breathing, because it's
caused them to become uncomfortable. If there isn't that discomfort, they very often will just leave it
alone and not go in and do a paracentesis. So that's really the therapeutic reason for doing a
paracentesis.
If we are doing it for diagnostic reasons, however, then they'll just going to withdraw some of the fluid
so that they are able to analyze what the type of material is contained in the abdomen to see if they
can help to diagnose the condition that the client has.
Important to make sure that they void immediately prior to the procedure for comfort reasons. And
remember what we said before that when you are withdrawing fluid from a cavity, remember we
talked about the thoracentesis and about a bladder, for example, as in a catheter, you wouldn't want
to take a large amount of fluid outbecause it may cause spasm and it will cause a client to have a
great deal of pain.
Now, with a paracentesis, it's done more slowly than a thoracentesis is done. It usually takes about
an hour, maybe longer than that, maybe about an hour and a half.And the client is usually sitting up,
again, with their feet on a stool during the procedure.And again, you take out about 1,200 CCs,
1,000 to 1,200 milliliters of fluid. You can take out up to 1,500 milliliters, but that is the maximum
amount, again, because of that fluid shift and because of the pain.
Now, post-procedure, again, you're gonna be monitoring them for shock, for fluid shift,
pneumothorax, again, think about where we're going and where the lung might beand that there may
be a possibility of that possibility. And also for hypovolemia because of a fluid shift.
Whenever you've removed fluid from the body, remember when we looked at fluid and electrolytes
and we talked about the pressure gradient and the shift of electrolytes,this may cause a fluid shift
and so it may also cause hypovolemia.
When we have a hypovolemia, remember that problem of perfusion, the assessment that we did in
the perfusion, the tachycardia, the tachypnea, the decrease in circulation to the lower extremities
and oliguria, all of those are important as well as monitoring for a change in vital signs.
10. Liver Tests
1. Alkaline phosphatase
1. Elevated in cardiac disorder, bone disease, biliary obstruction
 2. Enzyme found in liver tissue
3. Released during liver damage
2. Prothrombin time
1. Value is prolonged with liver damage
2. Assess extrinsic clotting process
3. Blood ammonia: assess liver's ability to deaminate protein byproducts
4. Serum transaminase studies
1. Elevated in liver disease
2. SGOT, SGPT, LDH, AST, ALT
5. Cholesterol
1. Increased in bile duct obstruction
2. Decreased with liver damage
3. Produced by liver
6. Bilirubin
1. Direct: indicative of pre-hepatic causes
2. Indirect: indicative of post-hepatic causes
Decrease in circulation to the lower extremities, and oliguria, all of those are important, as well as
monitoring for a change in vital signs.
Now the next section is really the liver tests are only lab tests. So you can review those. Those are
all the lab tests that indicate what the liver is. And remember it's important because the liver does a
lot of things like it controls cholesterol,and it also controls blood ammonia levels, and so forth, so that
would be an important part for you to review.
One other part that's a diagnostic is an ultrasound, and ultrasounds are done, we alluded to that
earlier when we said the gallbladder series isn't done anymore, or very rarely because we have
ultrasound, and an ultrasound requires an individual to have a full bladder when you're doing a
gallbladder ultrasound. That sometimes is the most difficult thing because if they have to wait for any
length of time, it's extremely uncomfortable, and they have to void, and then they have to wait until
their bladder fills up again, but there really isn't any prep other than that, and what they can tell here
is if there are any stones in the gallbladder, and that is something that is a very good diagnostic tool,
and is done very frequently.

Gastrointestinal Intubation

1. Types
1. Nasogastric tube: decompression of stomach
2. Salem sump: for continuous or intermittent suction, prevents trauma to stomach
lining
3. Miller-Abbot/Anderson: intestinal suction - Reposition client hourly for insertion
of the tube and movement into the intestines
4. Ewald: removal of secretions through the mouth
5. Sengstaken-Blakemore: for treatment of esophageal varices, requires intensive
care. Not used much because of the trauma and potential complications it
causes for the client. Major complications are rebleeding, pneumonia and
respiratory obstruction.
A very good diagnostic tool and is done very frequently. Now NCLEX, when they look at
gastrointestinal intubation, there are a couple of things that we need to think about here.
First of all, they're not gonna ask you questions about how to insert an NG tube or any of that
because although the technical aspects of nursing are important, what they're focusing in on is the
ability to critically think, to identify the types of tubes and what are the nursing interventions that have
to be employed to go along with them.
So let's take a look at them. First of all, we're gonna talk for a minute about the nasogastric tubes.
We use that to decompress the stomach and those are just a simple tube. They don't, it's a single
lumen tube and it can be hooked to suction or it can be left to gravity.
The second type is one called the Salem sump and you see this the most frequently.We see Salem
sumps used more frequently than a general nasogastric tube. Then the next group that's listed in
your text is the Miller-Abbott or the Anderson tube and these are intestinal tubes.
Now, important to remember that there's a couple of things about this tube. One that when you're
measuring, you're gonna actually have to measure longer because it has to get into the intestine. If
you remember when we measure, we measure from the tip of the nose to the ear to the xiphoid
process. You're gonna have to measure down below the umbilicus on this, for this type of tube
because this is going to go into the intestine.
Once it's inserted, you then have to wait for it to migrate and then have the client will have to have
an abdominal film done so that they can see that it's in the right position before you allow the weight
to be released and keep it in the intestine. So it's a different type of tube. Again, it's for intestinal
decompression rather than, or intestinal suction rather than for the nasal gastric or the gastric
secretion in the stomach. That's the NG tube or the Salem sump.
Now, some of you may have heard of the Ewald tube and an Ewald tube is used in emergency
situations very frequently. It looks like a one inch garden hose. It's black and it's an oral pharyngeal
tube that's put down into the stomach to allow for the gastric secretions to be excreted.
If a client has ingested large amounts of a substance and needs to have their stomach gavaged, we
put down an Ewald tube, it's gavaged and then removed after that.We also may put down some
activated charcoal. Although now the trend is to have the client drink the charcoal rather than putting
it down the tube because it actually coats all the rest of the esophagus as well.
The next type of tube is the Sengsteig and Blakemore tube. And those are used for us to treat
esophageal varices. Although we don't see them used as much anymore, it does require intensive
care. And if you see in textbooks, you may have seen them in a textbook that where the client
actually wears a helmet when they have a Sengsteig and Blakemore tube in.
Because you have to have tension on that tube. It also has a manometer that has to be released
periodically because remember that we're using it for esophageal varices.And we're gonna talk in a
couple of minutes about esophageal varices, but it is to put pressure on the esophagus to prevent
the individual or the client from bleeding profusely.
So it has to be released periodically and the client requires intensive monitoring.You also need to
make sure that there's a scissors kept at the bedside because if you don't, if the client has an
obstructed airway, you need to be able to cut the tube and remove it. So those are the major
complications of course that occur.
And again, you don't see them as frequently as we used to. Although it certainly is still used.
2. Nasogastric Tube Feeding/Suction
2. Feeding Tube Nursing Interventions
 1. Assess placement before each feeding and every 4 hours with continuous
feeding
2. Semi-Fowler's position
3. Check for residual: always refeed unless amount increases
4. Nose and mouth care
5. Hold for aspirates of >100 cc, recheck in one hour
6. Replace aspirated contents to prevent metabolic alkalosis
3. Suction Tube Nursing Interventions
1. Should drain stomach contents
2. Over time should see a decrease in volume of drainage
3. Always irrigate with normal saline
The next section is a nasogastric tube feeding or suction. Remember why we use it.We're using it for
feeding or we're using it to remove secretions.
Anytime you're going to put medication or anything into that tube, it's important to check for
placement. So that's this overriding safety issue that we talked about beforethat we need to make
sure that it is in the correct place.
Now, when we're going to talk about the G tube and we're going to talk about a PEG tube, those are
the types of tubes that you don't have to check for placement. But if you're using an NG tube or a
Salem sump for feeding, you need to make sure that you check for placement prior to putting
anything into that tube.
The other thing is if you're eating, and remember, this is what we're doing. These individuals are
eating. They're going to be in a semi-fowler's position. You don't lie down when you eat. Therefore,
you sit up in a chair.
So you either sit them up in a chair or you put them in a semi-fowler's or high-fowler's position, and
that will promote the digestion of the tube feeding.
The other thing is that you want to make sure that the client is absorbing what you're giving them. So
before you initiate or instill another tube feeding, you need to check for residual.
And that means that you need to put a syringe on the end of that tube and aspirate the stomach
contents. If you have more than 100 milliliters of residual, then you would hold the tube feeding and
check it again in the half an hour because it may mean that the client has a malabsorption.
So you wouldn't just automatically give it even because there's 150 cc's. If it's 100 or less, you would
give the next tube feeding.
The other thing that's important with anyone who has a tube feed, a nasal gastric tube, is that nose
and mouth care is extremely important. That is part of the nursing interventions, and sometimes
these individuals are not able to do it for themselves.
So you need to make sure you remove their dentures. If they have dentures and do really good
mouth care, that's important.

3. Gastrostomy Tube
1. Anterior wall of the stomach is sutured to the abdominal wall and the tube is
sutured in place; skin care is important
 2. Primarily placed for long term feeding needs

4. Percutaneous Endoscopic Gastrostomy (PEG)

1. No need to check placement
2. Primarily placed for long term feeding needs
3. Preferred over gastrostomy tube because of ease of insertion and care
4. Make sure tube is anchored continuously with ring at same number point on
tube. This assures that the stomach is clearly anchored to the abdominal wall
and decreases the chance of complications.

For themselves. So you need to make sure you remove their dentures. If they have dentures and do
really good mouth care, that's important.
Now, the gastrostomy tube that I alluded to before is actually sutured into the stomach, into the
abdominal wall. It's into the anterior wall of the stomach. And it's sutured into place. So if you think
about what happens, you could still have some of the stomach contents coming out around that
tube. And you see that fairly commonly.
So you need to make sure you do really good skin care around that area, because you could have,
remember, digestive enzymes still could also be coming out to the skin surface.
The other thing, of course, is that you use it for feeding the client. And so when you're putting in the
tube feeding, you also need to make sure that the skin around the tube feeding or the tube itself isn't
irritated and it doesn't require any care.
A PEG tube is a percutaneous endoscopy gastrostomy. You don't need to check for placement. And
it's preferred. This is the preferred type of tube, because it's very easy to put it in and it's very easy to
take care of it.
The only thing that isn't the most important thing is to make sure it's anchored properly. Because if
it's not anchored properly, what's going to happen is it's going to become dislodged and then there
will be complications.
Now, the major complication would then be a systemic infection or an irritation to the skin. And if you
see a great deal of skin breakdown, sometimes it's very difficult to clear up. So you need to make
sure that you're managing the care of that client.

5. Total Parenteral Nutrition (TPN)

1. Definition: intravenous administration of a hypertonic solution of glucose,
nitrogen and other nutrients to achieve tissue synthesis and anabolism; lipids
may be given as a supplement; provides 3,000-4,000 calories per day Note:
Any concentration of glucose greater than 10% must be given through a central
intravenous line.
2. Indications for use
1. Inability of the gastrointestinal tract to absorb nutrients adequately (e.g.,
malabsorption syndrome, gastrointestinal obstruction, paralytic ileus,
bowel resection, ulcerative colitis, "gut rest")
 2. Inability to take food by mouth (e.g., neurosurgical problems (coma),
anorexia nervosa)
3. Excessive nutritional needs that cannot be met by the usual methods
(e.g., burns, multiple fractures, carcinoma being treated with
chemotherapy or radiation therapy, severe infections)

3. Nursing Interventions
1. Chest x-ray immediately after subclavian line insertion for proper
placement
2. Assess weight, baseline electrolytes, blood glucose, zinc and copper
levels before treatment begins
3. Maintain aseptic (sterile) technique during dressing changes
4. Maintain infusion rate, do not increase or decrease rate without order;
may cause hyper or hypoglycemia
5. Assess weight daily: should maintain or increase weight while receiving
TPN
6. Monitor for complications
1. Infection-filters and tubing changed with every bottle
2. Hypoglycemia
3. Hyperglycemia
4. Air embolism: Never open central line to air. Chance of air
embolism is decreased with multiple lumen set-ups. When
central line is inserted or opened, have client perform valsalva
maneuver and place in Trendelenburg position.
5. Pneumothorax, especially during insertion
6. Zinc deficiency
7. Fluid overload
8. Hyperglycemic, hyperosmolar nonketotic coma
7. Gradual decrease in rate of solution when discontinuing therapy thereby
avoiding hypoglycemia
8. Continually evaluate effectiveness of therapy. Seek consultation if it is
not effective.

Or a great deal of skin breakdown, sometimes it's very difficult to clear up. So you need to make
sure that you're managing the care of that client.
Now, I'm going to talk for a minute about TPN and PPN, and those are the things that we see being
used very, very commonly today. TPN is given to clients who areunable to take in the amounts or
the types of nutrients that are required for them to sustain life, basically, or to heal. And it is usually
done, it can be done prior to a particular type of surgery. It could be done as a result of a client who
has a cancer or who is on chemotherapy or who has a problem with the GI tract and is on, as an
obstruction or a problem in the esophagus where they're unable to swallow.
And so this is given to them as a, not a supplement, but as a type of feeding that will help them to
promote skin, to promote healing and to promote adequate skin integrity.Now, it is done as a result
of looking at what the client's needs are. So they're going to do lab tests. They're going to look at
what their sodium, potassium, and chlorides and all of that are. And the physician will order this
based on what they're finding, what the findings are.
You are, there are several safety issues that you need to know about when you're giving TPN.
Number one, it is given in a central line. So this client has another problem that, a potential problem
in that, remember that a central line, asepsis, is extremely important and you want to make sure that
anything that is done when you start the tube feeding and so forth, that you make sure that there's
the integrity of that central line is maintained.
So TPN is given in a central line. The other thing that happens is that there is glucose added to this
TPN. So the client needs to have their blood glucose levels monitored. And sometimes they need
insulin while they're on TPN. Now once they finish with the TPN, they may not need that insulin any
longer. But in this case, they will, they may be required to receive insulin during the infusion.
The other thing that's important is TPN, because it has a high concentration of glucose, needs to
have all of their tubing and the filter, and it's always filtered also, changed every 24 hours to prevent
bacterial infection because of the high concentration of glucose. You never piggyback anything into
this TPN. The only thing that could possibly be piggybacked in is lipids. And lipids are piggybacked
in below the filter, because if you put lipids into the filter, it's going to clog up that filter, so you
wouldn't do that. So TPN, you wouldn't put anything other than lipids piggybacked into that.
Now remember the other thing, the other type is PPN, and that's peripheral parenteral nutrition. And
we don't see that used very often, but it can be given in a peripheral line, and it is in a much lower
concentration of glucose. So that's why it can be given peripherally.
Now some of the assessment parameters that are important are to, of course, to weigh the client.
And the reason is, if you're providing their nutrition, then the outcome you would expect to find is that
they would either maintain their weight or gain weight.So that would be a part of the assessment
parameter that you would use to see the effectiveness of this treatment of TPN.
Asepsis, as I talked about, it's a strict sterile technique. Whenever you look, whenever you touch that
central line. And again, make sure that you're monitoring for any air embolism and so forth. And of
course, to make sure that you maintain the integrity of the central line.
Monitoring for a pneumothorax in the immediate insertion, post-insertion period following that
insertion of the central line, is important because, remember what we talked about before, it's going
most often into the subclavian vessel. And therefore, you run the risk of touching the top of the lung
or the apices of the lung, which could cause a pneumothorax.
The other very important piece here is fluid overload. And that weighing the client and monitoring
intake and output is going to also give you some indication of whether the client has fluid overload.
Remember when we talked about perfusion and we talked about listening to lung sounds and all of
those things, that also may tell you that the client has a fluid overload. So the effectiveness of that
treatment is important and we've talked about the parameters for looking at weight and so forth and
how important that is.

Hiatal Hernia

1. Definition: portion of the stomach is herniated through the esophageal hiatus of the
diaphragm
2. Manifestations
1. Heartburn
2. Dysphagia

3. Nursing Interventions
1. Small, frequent meals
2. frequent position during and after meals
 3. Head of bed elevated
4. Antacids
5. Avoid anticholinergic drugs
6. Avoid coughing
7. Reduce intra-abdominal pressure by avoiding lifting and tight clothes around
waist area
8. Reduce spicy food intake

One of the conditions in the GI system that we need to talk about is hiatal hernia.Basically what
happens is that the stomach herniates into the esophagus, or the top, the hiatal part of the
diaphragm.
And clients who have this most often complain of heartburn and difficulty swallowing, or pain on
swallowing. And sometimes they'll complain of chest pain,because as they try to swallow some
particular type of food, pain radiates to their chest.
Again, the nursing interventions are aimed at decreasing these types of symptoms.One way that we
can do it is to tell them, instead of eating three meals a day, to eat small meals throughout the day,
sometimes six or eight meals throughout the day, and that may help to decrease the symptoms that
they have.
The other thing that's very important is to sleep with the head of their bed elevated. Sometimes the
clients will put them up on blocks to prevent them from having reflux, or to have those gastric
contents coming back up into the portion of the esophagus. And, of course, the antacids are also
used.
So those are the three major things that are nursing interventions, or nursing measures that you can
use to help the client decrease their symptoms.
Now, one of the other things that we need to look at is to not give them anticholinergic drugs. And I
just want to mention something here. Remember what anticholinergic drugs do. They dry up
secretion.
So the symptoms of anticholinergic drugs are that they have a visual disturbance.Sometimes their
vision is blurred. They sometimes have a decrease in urinary output, or a urinary retention. Their
mucous membranes get very dry. Again, remember, it's drying up secretion. So sometimes their
mouth gets almost like their saliva is sticky. And they get constipation because, again, you're drying
up secretion.
So those are the four major symptoms that you see that are associated with anticholinergic drugs.
And so for a client who has a hiatal hernia, you wouldn't want to dry up their secretion because
they're already having difficulty with reflux and so forth.
And, of course, whenever you have a client who has reflux, you want to prevent them from coughing
and from increasing anything like bending at the waist and so forththat would increase the pressure
to the upper part of the GI system.
Another thing that, of course, is also important is to make sure that they don't eat foods that are
going to irritate them like hot peppers and all those things that some of us like. Some of us don't like
that anyway, so it isn't going to be a big deal. But for those who do or who put perhaps pepper and
things like that on their food, it might create a problem.
 3. Nursing Interventions
1. Small, frequent meals
2. Upright position during and after meals
3. Head of bed elevated
4. Antacids
5. Avoid anticholinergic drugs
6. Avoid coughing
7. Reduce intra-abdominal pressure by avoiding lifting and tight clothes around
waist area
8. Reduce spicy food intake

Duodenal and Gastric Ulcer

1. Types of Ulcers
1. Chronic duodenal and gastric ulcers
2. Stress ulcers
1. May be caused by physical as well as psychological stress
2. Burns cause Curling's ulcer
3. Steroid therapy
1. Usually occurs at least one to two weeks after stress
2. No pain
3. May be diagnosed due to gastric bleeding and resulting low
hemoglobin and hematocrit

COMPARISON OF CHRONIC DUODENAL AND CHRONIC GASTRIC ULCERS

CHRONIC DUODENAL CHRONIC GASTRIC
Age: Usually 25-50 yrs Usually 50 yrs or more
Sex: M:F 3:1 M:F-2:1
Incidence: 80% 20%
General nourishment: Well-nourished Malnourished
Etiology factors: Most result from Excessive ingestion of
Helicobacter pylori salicylates, smoking
infection, smoking,
O blood type
Acid production in Hypersecretion Normal to hyposecretion
stomach:
-Location: - Within 3 cm. of pylorus

-Pain: - 2-3 hours after meal; - Lesser curvature

night, early morning.
 Ingestion of food relieves - 1/2-1 hour after
pain. Pain is a gnawing meal; rarely at night.
sensation sharply localized Relieved by vomiting.
in mid-epigastrium or in Ingestion of food does not
back. help; sometimes causes
pain.
Vomiting: Uncommon Common: caused by
pyloric obstruction either
by muscular spasm of
pylorus or by mechanical
obstruction from scarring.
Hemorrhage: Melena more common Hematemesis more
than hematemesis common than melena
Malignancy possibility: None Usually less than 10%
Complications: Hemorrhage, perforation Hemorrhage and
and obstruction perforation
Ulcerogenic drugs: Salicylates, butazolidin, Same
steroids
Perhaps a pepper and things like that on their food, it might create a problem. The next section is
talking about the difference between a duodenal and gastric ulcer. And NCLEX would like to test you
on your ability to look at what the symptoms are of these types of ulcers, and then to determine the
nursing interventions.
I'd like to just contrast them for you. And they are in your text, so you can kind of follow along. But I
want to give you some of the key things that you need to look at. The first thing that you need to look
at is the age, because the client who has a chronic gastric ulcer is usually older. They're the type A
personality. They're the person who is under a great deal of stress. That is the client who develops a
gastric ulcer. So you'll see the younger person developing the chronic duodenal ulcer.
Although you certainly can see them develop the gastric ulcer, that's not usually the case. The other
thing that you'll see is that the client who has gastric ulcer has a problem with nutrition. They usually
look like they're malnourished. They usually look like they're emaciated. Whereas the client who has
a duodenal ulcer isn't. They're usually very well nourished. They're usually sometimes even a little bit
overweight. So that nutrition is not a problem.
The other major difference here is pain. And when we look at the client with a gastric ulcer, usually
you see it about an hour or so after they eat. You don't see it most often at night, but you see it right
after they eat. And it's relieved by vomiting. So if they vomit, they feel better. If they eat something, it
doesn't make it feel better. With a client with a duodenal ulcer, if they eat something, it makes them
feel better. And pain is usually very sharp, and it's usually in their mid-epigastric area, rather than in
the abdomen or lower. So it's a very different location, and it's relieved by something that's very
different. And usually, you see it in a duodenal ulcer a couple of hours after eating.
Now, another thing that's also important is to remember that when we look at the type of other
symptoms that these clients have, if you think about the type of irritation that they have, hemorrhage
is most often not a problem, other than that they develop hematemesis with a gastric ulcer. They
usually vomit. Hematemesis means to vomit blood. And that you see with a gastric ulcer. You very
rarely will see it with a duodenal ulcer. You see something called melina. And melina, remember, is
tarry stools. It's blood in the stool that sometimes turns the stool a different color. You don't usually
see vomiting blood.
The treatment is the same for both. So that's not something that would be a variation or something
that would be easy to remember. You're treating them with steroids because of the anti-inflammatory
effect. And again, you would make sure that the client is taking things that would soothe their
stomach during the periods of flare-up.

2. Nursing Interventions
1. Major goal is to prevent complications and allow ulcer to heal
1. Rest: physical and mental; lower stress
2. Eliminate stimulants: caffeine, alcohol, spicy foods, cigarette smoking
3. Diet has no therapeutic effect; milk may be used but is not recommended
4. Antacid: aluminum hydroxide (Amphojel) magnesium carbonate (Maalox)
5. Cimetidine (Tagamet): decreases acid production
6. Ranitidine (Zantac): decreases acid production
7. Sucralfate (Carafate): protects lining of stomach
8. Omeprazole (Prilosec): heals ulcer
9. For H. pylori ulcers: antibiotics

Their stomach during the periods of flare-up. Now, the other thing that's importantis that when we
look at the nursing interventions, the most important thing to remember is nutrition. You need to
make sure that the client has the appropriate nutrition based on what their symptoms are, because
sometimes the diet has no therapeutic effect.
However, in the case of the client with a gastric ulcer, the chronic gastric ulcer, they're losing weight.
So that may be a potential problem. We're given antacids like Amphagil, I mean, that carbonate,
which is Maalox. Those are the drugs that are usually used.
Now, we need to look at those other drugs that we give. If you have a client with a gastric ulcer, a
gastric ulcer, we give them drugs like Tagamet. Tagamet, which decreases acid production, and
Zantac and Prilosec. All those drugs do something with the acid production or acid reflux. They are
also systemic drugs, which means that you give them systemically and they act on the whole
system.
Carafate is a drug that is in this category, but it is not a systemic drug. It actually acts right on the
ulcer itself. And it coats the lining of the stomach and it coats that ulcer so that it protects it and
prevents it from getting irritated so that it will heal.
Sometimes the duodenal ulcer, in fact, many of the duodenal ulcers have beenidentified as being
caused by something called the H. pylori bacteria. And that was discovered by studying cows a few
years ago. And they found that they had the very same symptoms. And if they treated them with
antibiotics and bismuths, then they were cured. And so they found that it was the very same
symptoms. And now we treat these H. pylori type ulcers with antibiotics and Pepto-Bismol, which is
that bismuth solution.
So again, it's a very different treatment for the gastric versus the duodenal ulcer.Now, the steroid
therapy, again, is usually a very limited period of time. Again, it's for the anti-inflammatory effect. So
once that inflammation is decreased, it usually goes away, or we usually stop giving them that drug.
3. Gastric Resection
1. Types
1. Billroth I (gastroduodenostomy)
2. Billroth II (gastrojejunostomy)
3. Total gastrectomy: will cause pernicious anemia
2. Nursing Interventions
1. NG tube in place: do not move as it may stimulate bleeding at surgical
site
2. Evaluate need for KCL in IV to prevent metabolic alkalosis
3. NPO until suture line is totally healed
4. Assess drainage: will initially be sanguineous but should change to
greenish in 2-3days
3. Complications
1. Hemorrhage
2. Pulmonary
3. "Dumping syndrome": due to rapid entry of ingested food into the jejunum
without proper mixing and normal digestive process of the duodenum
1. Early: 5-30 minutes after eating, vertigo, sweating, diarrhea,
nausea; due to fluid shifts
2. Late: 2-3 hours after meals, hypoglycemia occurs due to excess
insulin secretion
3. Intervention: avoid salty, high-carbohydrate meals; eat small,
frequent meals; avoid liquids with meals; lie down after meals (30
- 60 minutes); avoid antispasmodics; eat high-protein, high-fat,
low-carbohydrate meals. No fluids for 1 hour before, with, or 2
hours after meals.
4. Major complication: Peritonitis
Or we usually stop giving them that drug. NCLEX is not going to ask you about specific gastric
resections. You're not going to have to memorize whether it is a type 1, a Biliroth 1, Biliroth 2,
because what those are really identifying is which portion of the gastric area is involved. But
remember, it's the post-op care.
And we've already talked about post-op care. So remember that it's no different.The only difference
in any post-surgical procedure is where is the incision, and what type of tube do I have to manage,
and do they have an IV? Those are the major things that we are looking at. Certainly, it's assessing
for bleeding and vital signs, and that's the basics. But the variation or the difference is, where is the
incision site, do they have a tube, and do they have an IV?
Same thing with this type of client. The only thing that makes this one a little different is that one of
the post-procedure complications or the post-op complications is something called the dumping
syndrome. Now, the dumping syndrome occurs because the undigested food moves right through
the system so fast that it doesn't have a chance to digest. And so the client develops some
symptoms associated with that.
At the very beginning, what happens is they start to sweat. They become very diaphoretic. They
sometimes get very dizzy. Usually about 25 to 30 minutes after eating a meal. The next thing that
will happen is, and remember that what's happening is because it's going so rapidly that there's a
fluid shift that also is involved. Later on, what will happen is the client, because the food has moved
so quickly it hasn't been absorbed, the pancreas is still going to put out insulin to take care of the
food that they signaled was taken in. Yet there isn't any food to take up the insulin, and so
hypoglycemia results.
And the client develops, again, nausea, diarrhea as they shake and so forth because there's too
much insulin and not enough of the food to take it up. Again, what do we do?What are the things that
we can teach our client? And again, NCLEX is going to ask you about teaching the client to help to
manage their care at home. Telling them to avoid things that would be high in sodium or very salty
because, again, that would push the fluid through the system, again, at a much more rapid rate.
Avoid liquids during your meals. In other words, telling them not to drink. We would never, and I want
to talk for a moment about the fact that you would not ever tell a client not to drink at all, to drink any
fluid, but merely to eat their meal and then drink later so that it doesn't push the food along as
quickly and it helps to absorb. Lie down after they eat. That is a very important thing to do because if
they lie down, what will happen is the food that they've ingested will more slowly be digested.
If a client has acid reflux, we would tell them not to lie down because lying down would cause the
reflux to be worse. In this case, we would tell them to lie down. The major complication to this, of
course, is peritonitis. And that's because of the constant irritation that can occur from the food
moving through the system as quickly.

COMPARISON OF CROHN'S DISEASE AND ULCERATIVE COLITIS

CROHN'S DISEASE ULCERATIVE COLITIS
Small Bowel Large Bowel

Pathology: Transmural: primarily Mucosal ulceration of

involving ileum and right lower colon and rectum
colon

Age: 20-30, 40-50 20-40

Etiology factors: Unknown genetic, Jewish Unknown familial, Jewish

Bleeding: Usually not Common, severe

Perianal involvement: Common Rare, mild

Fistulas: Common Rare

Rectal involvement: 20% 100%

Diarrhea: Less severe Severe

Abdominal pain after Yes Yes

eating:
 Weight loss: Yes Yes

Treatment: Steroids: sulfasalazine Steroids: sulfasalazine

(Azulfidine) (Azulfidine)
hyperalimentation; partial partial or complete
or complete colostomy & colostomy and
ileostomy or anastomosis proctocolectomy &
ileostomy

History: Deteriorating, progressive Exacerbations, remissions

Complications: Scarring, obstruction Perforation; susceptible to

cancer; toxic megacolon;
fistulas obstruction,
abscess

Diverticulitis and Diverticulosis

1. Definition:
1. Outpouching of colon is diverticulosis
2. When the outpouching becomes infected it is called diverticulitis
3. Problem: the pouch gets filled with feces, becomes inflamed, can obstruct and
perforate leading to peritonitis

2. Nursing Interventions
1. Prevent by increasing fiber in diet
2. Avoiding all seeds
3. Preventing constipation by using bulk agents and increased water

Food moving through the system as quickly. Now let's look at another another type of disease. And
Amclex is going to look at what are the comparisons again betweenCrohn's disease and ulcerative
colitis. And they're not there's some subtle differences.
The client who has either of these diseases are really suffering from very similar symptoms but the
reasons that they have them are different and some of the manifestations are different. Now
remember what Crohn's disease, that Crohn's disease is in the small bowel whereas ulcerative
colitis usually you see in the large bowel. So that's one of the major differences in the types of
diseases.
The other thing, age can be a factor but you can usually see it in the twenty to forty year old no
matter excuse me, which of the groups that you're looking at whether it's Crohn's or ulcerative colitis.
Usually you don't see any bleeding in the patient with Crohn's disease but in ulcerative colitis it is a
severe bleeding that is very often seen.
The other thing that's also important to remember is that in Crohn's disease you very very often see
anal involvement and you don't see that in ulcerative colitis. There's diarrhea in ulcerative colitis but
not anal involvement whereas you don't see diarrhea in a client with Crohn's disease. Both of them
have pain after eating and both of them have a weight loss.
Now the treatment may be different. The first thing that happens with a client with ulcerative colitis is
they give them steroids. Anti-inflammatories sometimes work. They sometimes decrease the
inflammation enough so that the client will heal over and there isn't the long-term problem. We do
treat Crohn's disease with steroids but most often they also require a colostomy or an ileostomy.
Remember that sometimes those are temporary. They rest the bowel. They do atemporary
colostomy and then they do an end-to-end anastomosis which means areattachment of the bowel
after the healing has occurred for the client with Crohn's disease. Usually it is a couple of months
after the the ostomy has occurred.
The other thing that happens is that the client with Crohn's disease very often has a lot of scarring
and so sometimes a bowel obstruction occurs and they may need a permanent ostomy appliance
whereas in ulcerative colitis because of the constant irritation perforation and of course then sepsis
is also a very real possibility.
Now the other thing that we need to talk about which kind of goes along with that because
sometimes clients who have Crohn's disease they say that they have the very same symptoms as
diverticulitis or diverticulosis. This is where the diverticula in the bowel develop a little pouch. It
pouches out and material gets caught in there and then causes an irritation and so then they have
symptoms based on because they have those irritation and it becomes infected.
When it's infected it's diverticulitis. Long-term it's diverticulosis. Osis is the suffix that means disease
whereas itis means inflammation. Therefore itis is something that occurs in the acute phase. Now if
we give these clients a lot of fiber or increase the roughage in their diet very often they don't develop
any diverticulitis. They may still have diverticulosis but they may have limited symptoms as a result
of that and also not eating anything that might get stuck in one of those little outpouching like nuts or
anything with seeds in them.
Those are the things that we talked about teaching the client to avoid to prevent symptoms. Now the
complications again are the same as what we talked about withulcerative colitis which is perforation.
If you have that constant irritation in one of those pouches that's what happens.

Bowel Obstruction
1. Definition: anything that obstructs the colon; inflammation, tumor
2. Manifestations:
1. Increased bowel sounds proximal to the obstruction
2. No stool
3. Pain
4. Distention
5. Vomiting (projectile from reverse peristalsis)
6. Hypovolemia and shock

3. Nursing Interventions
1. Intestinal tube: refer to care in preceding section
2. Ambulation
3. Treat cause and relieve
4. Surgical intervention; colon resection

What happens. The bowel obstruction is something that we've alluded to when we talked about a
client who has Crohn's disease. We've talked about it again when we justlooked at this type, the
other type of client that has the diverticulitis or diverticulosis.But remember what an obstruction is. It
means that the stool that is going through the bowel is unable to because there's something that's
preventing it.
Now what is that something? It could be a tumor. It could be scarring. It could be a narrowing as a
result of pressure from the outside onto that bowel. Could be from a hernia because it has cut off
that piece of bowel. So regardless of the cause, the symptoms are going to be the same. And that is
that the client will have a decrease or no bowel sounds.
So when you're doing a nursing assessment, you're going to listen to their abdomen.And remember
what we said about the abdominal assessment. It's look, listen, and then feel. So I'm going to look at
their abdomen to see if there's any distention or if I can visualize any bruise. The next thing that I'm
going to do then is look to see if I can observe any masses or anything in their abdomen. The next
thing would be then to listen for bowel sounds and then to palpate to see if I feel any growths or if
the client complains of pain when I palpate.
Most often, they also will have either no stool for a period of time or they'll have a liquid stool.
Because sometimes what will happen is the stool will ooze around that obstruction and become
almost like a diarrhea stool. And it could be also, by the way, for fecal impaction. Because
sometimes the elderly client in particular is at risk for this. The client will either not drink enough or
not eat enough roughage or they're on bed rest or they're bedridden. And so peristalsis will decrease
and the stool output will also decrease.
The symptoms, again, are pain, vomiting sometimes, and an abdominal distention.Think about what
we just talked about when we looked at assessment. Those are the symptoms that you're going to
see or the symptoms that the client will exhibit.
The interventions are aimed at relieving that obstruction. So the first thing is to make sure that
whatever they've taken in, they either don't vomit or it doesn't get into that obstruction so they don't
have any increased pain. So we'll put in an intestinal tube.And an intestinal tube is used because we
want to make sure that we are getting rid of any of the secretions. Another, of course, is to ambulate
them. If, in fact, they've been on bed rest or they're unable to move for themselves, then we need to
make sure we get them moving because that may increase peristalsis. And of course, whatever the
reason is, if it's a tumor, et cetera, we're going to treat the cause.
And that's for a bowel obstruction. Post-op care is no different. What we've talked about before, it's,
again, just where is the incision and what type of tube and or IV do we have to manage.

COMPARISON OF COLOSTOMY AND ILEOSTOMY

COLOSTOMY ILEOSTOMY

Defined: Portion of the colon Portion of the ileum

brought through the brought through the
abdominal wall, creating a abdominal wall creating a
temporary or permanent permanent opening for exit
opening for exit of waste of waste products
products

Areas: Involves large bowel Involves small bowel

 Indications: Inflammatory or obstructive -Crohn's disease
process of the lower -Ulcerative colitis
intestinal tract; trauma to
intestinal tract; cancer of
the rectum or sigmoid
where anastomosis is not
possible

Stool: Semiformed to formed Liquid

Control: May be controlled by diet No control, must wear

and/or irrigation depending appliance at all times
on location in colon, may
be able to control
evacuation

2. Nursing Interventions
1. Preoperative care
1. Emotional support (anticipatory grieving)
2. Client teaching concerning impending surgery (ileostomy/colostomy)
2. Postoperative care
1. General postoperative care
2. Psychological support
3. NG tube
4. Observe stoma, surrounding tissues, and type of excretion (should be
pink; above skin level; may have bloody discharge at first)
5. Teach self-care to client
1. Type of equipment to use and how
2. Skin care
3. Diet: decrease fat and odor forming foods

IV, do we have to manage? Now, we've alluded to ostomies, and let me just talk for a minute about
the difference between a colostomy and an ileostomy, because when NCLEX is going to test you on
the ostomy, it usually has to do with either teaching the client how to take care of themself, or it
could be in assessing the client's condition, the condition of the client's stoma, or the type of
apparatus that they have, and so forth.
The difference between a colostomy and an ileostomy basically is the position that it is on the
abdominal wall and the type of exudate that comes from it. A colostomy is where a portion of the
colon comes through the abdominal wall, and the food has had a chance to digest, because a lot of
the digestive enzymes have gone through the small intestine, has digested the food, and so it comes
out as a formed stool, and it can either be temporary or permanent, depending on what the reason
for the ostomy is.
With an ileostomy, it is a liquid-type stool. It's usually higher up in the abdomen. It's a liquid-type
stool, and the ileum is being brought through the peritoneal wall or the abdominal wall, and again, it's
a continuous stooling, so it's not like you can control it.And you can't really control a colostomy
either, but there are ways that we can prevent a continuous oozing of stool.
Now, remember also that the colostomy exudate can be controlled by diet. We don't usually irrigate
colostomies anymore. It used to be that the client would be taughtto irrigate once a day and
evacuate the bowel, and then there's a little cap that you can put over the ostomy or the stoma, and
the client could go on his merry way for the rest of the day. Well, we don't do that as much anymore,
but certainly it is still done in some cases.
With an ileostomy, there is no control, and they must wear an appliance all the time,and that has to
do with, then, good skin care. Remember that in an ileostomy, the ileum is out on the abdominal
wall, and if the stoma and the apparatus, the appliance that's going around the stoma, isn't a good
fit, and there is any space between that appliance and the stoma, what's going to happen is the
digestive enzymes are going to come out onto the skin and literally begin to digest the skin. Very
difficult to treat, very difficult to clear up once it happens, so prevention, again, is the most important
piece here.
The stoma of a colostomy, although it is in a different place, remember that you still need to have a
really good fit for the appliance. Although the exudate isn't as caustic to the skin, you still want to
make sure that the appliance fits snugly and that it doesn't occlude the stoma. A stoma, whether it is
for an ileostomy or a colostomy, should always be a reddish-pink color. It should never be black, it
should never be cyanotic-looking or pale, because remember that it has to have a blood supply.
Sometimes initially, when you have a brand new colostomy or an ileostomy, there is a little bit of
bloody drainage, and that's normal within the first day or so after the surgery, or sometimes there's a
little bit of mucus that comes out of that stoma, but those are normal things, and to evaluate that
would mean that you would just continue to monitor that stoma.
Again, post-op care is no different for this client than it is for any other post-op patient. The only
difference would be that where is the incision, and do they have any other tubes associated with
that.

Gastrointestinal, Hepatic and Pancreatic Disorders

1. History of Problem
2. General Appearance:
1. Thin, emaciated
2. Obese
3. Skin turgor

3. GI System:
1. Nausea and vomiting: what precipitates it, what relieves it, appearance,
characteristics
2. Pain: location, what precipitates it, what relieves it, radiation how long,
characteristics, quality
3. Elimination pattern: pattern and consistency of stools, laxative use
4. Nutrition: intake and output; difficulties in swallowing; likes and dislikes
(consider cultural diversity here), normal intake per day

4. Examination of Abdomen:
1. Inspection
 2. Auscultation
3. Percussion
4. Palpation
5. Associated Symptoms: flatus, eructation, heartburn, pain

Diagnostic Procedures
1. Upper GI
1. Method: barium swallow
2. Purpose: assessment of esophagus and stomach
3. NPO 6-8 hours before procedure
4. Laxative after procedure
5. Follow-up x-ray 6 hours after procedure

2. Lower GI
1. Method: barium enema
2. Purpose: assessment of large colon
3. Liquid diet before procedure
4. Laxative before and after procedure
5. Initially, feces will be white. Should be normal color within 72 hours.

3. Endoscopy (Gastroscopy, Esophagogastric Duodenoscopy)

1. Method: visualization of the inside of the body by means of a lighted tube
2. Purpose: assessment of esophagus, stomach
3. Gag reflex inactivated
4. NPO 6-8 hours before procedure
5. Resume diet only after gag reflex returns
6. Complications: perforation, bleeding, bloating

4. Sigmoidoscopy/Colonoscopy
1. Method: endoscope inserted through the anus
2. Purpose: assessment of sigmoid colon
3. Administer enema before
4. Monitor for complications: perforation, bleeding

5. Analysis of Gastrointestinal Secretions

1. Stool Analysis:
1. Method: culture, fat analysis, guaiac – no aspirin (ASA), NSAID, red
meat, Vitamin C for 3 days before
2. Purpose: assessment for bacteria, virus, ova & parasites,
malabsorption, blood
3. Do not refrigerate stool samples

6. Evaluation of the Gallbladder and Liver

1. Cholecystogram (Gallbladder Series)
1. Method: dye conjugated in the liver and excreted into the bile that
outlines the gallbladder
2. Purpose: assessment of gallstones, proper gallbladder function
3. Check for allergy to iodine or seafood
 4. Telepaque tablets 12 hours before test
5. NPO after midnight
6. Less commonly performed than ultrasound
2. Cholangiogram
1. Method: bile ducts visualized
2. Check for allergy to iodine or seafood
3. Ultrasound of Gallbladder and Liver
1. Strict NPO after midnight prior to procedure
2. Able to visualize if stones are present
7.

Flat Plate of the Abdomen

1. No preparation
2. Gives a good overall impression of the abdominal cavity

8. Liver Biopsy
1. Method: removal of liver tissue to rule out liver disease
2. Obtain consent and results of hemostasis tests before the biopsy
3. Usually performed under fluoroscopic guidance
4. Two weeks prior, client must discontinue aspirin, NSAIDS and anticoagulants
5. NPO after midnight
6. Position on left side during biopsy
7. Position on right side after biopsy for two hours
8. Bed rest for prescribed time after biopsy
9. Observe for complications (bleeding, pneumothorax)

9. Paracentesis
1. Removal of fluid accumulated in the peritoneum
2. Indicated when ventilation is impaired, abdominal discomfort
1. Therapeutic: to relieve shortness of breath when ventilation is impaired
2. Diagnostic: to examine contents of peritoneal fluid
3. Void immediately prior to procedure
4. During procedure: sitting up with feet resting on stool
5. Fluid should be removed slowly over 30-90 minutes, generally < 1500 cc
6. Bed rest after the procedure
7. Observe for complications - for example, hypovolemia; shock secondary to fluid
shift, tachycardia, oliguria, infection, peritonitis

10. Liver Tests

1. Alkaline phosphatase
1. Elevated in cardiac disorder, bone disease, biliary obstruction
2. Enzyme found in liver tissue
3. Released during liver damage
2. Prothrombin time
1. Value is prolonged with liver damage
2. Assess extrinsic clotting process
3. Blood ammonia: assess liver's ability to deaminate protein byproducts
4. Serum transaminase studies
1. Elevated in liver disease
 2. SGOT, SGPT, LDH, AST, ALT
5. Cholesterol
1. Increased in bile duct obstruction
2. Decreased with liver damage
3. Produced by liver
6. Bilirubin
1. Direct: indicative of pre-hepatic causes
2. Indirect: indicative of post-hepatic causes

Gastrointestinal Intubation
1. Types
1. Nasogastric tube: decompression of stomach
2. Salem sump: for continuous or intermittent suction, prevents trauma to stomach
lining
3. Miller-Abbot/Anderson: intestinal suction - Reposition client hourly for insertion
of the tube and movement into the intestines
4. Ewald: removal of secretions through the mouth
5. Sengstaken-Blakemore: for treatment of esophageal varices, requires intensive
care. Not used much because of the trauma and potential complications it
causes for the client. Major complications are rebleeding, pneumonia and
respiratory obstruction.

2. Nasogastric Tube Feeding/Suction

2. Feeding Tube Nursing Interventions
1. Assess placement before each feeding and every 4 hours with
continuous feeding
2. Semi-Fowler's position
3. Check for residual: always refeed unless amount increases
4. Nose and mouth care
5. Hold for aspirates of >100 cc, recheck in one hour
6. Replace aspirated contents to prevent metabolic alkalosis
3. Suction Tube Nursing Interventios
1. Should drain stomach contents
2. Over time should see a decrease in volume of drainage
3. Always irrigate with normal saline

3. Gastrostomy Tube
1. Anterior wall of the stomach is sutured to the abdominal wall and the tube is
sutured in place; skin care is important
2. Primarily placed for long term feeding needs

4. Percutaneous Endoscopic Gastrostomy (PEG)

1. No need to check placement
2. Primarily placed for long term feeding needs
3. Preferred over gastrostomy tube because of ease of insertion and care
4. Make sure tube is anchored continuously with ring at same number point on
tube. This assures that the stomach is clearly anchored to the abdominal wall
and decreases the chance of complications.
 5. Total Parenteral Nutrition (TPN)
1. Definition: intravenous administration of a hypertonic solution of glucose,
nitrogen and other nutrients to achieve tissue synthesis and anabolism; lipids
may be given as a supplement; provides 3,000-4,000 calories per day Note:
Any concentration of glucose greater than 10% must be given through a central
intravenous line.
2. Indications for use
1. Inability of the gastrointestinal tract to absorb nutrients adequately (e.g.,
malabsorption syndrome, gastrointestinal obstruction, paralytic ileus,
bowel resection, ulcerative colitis, "gut rest")
2. Inability to take food by mouth (e.g., neurosurgical problems (coma),
anorexia nervosa)
3. Excessive nutritional needs that cannot be met by the usual methods
(e.g., burns, multiple fractures, carcinoma being treated with
chemotherapy or radiation therapy, severe infections)

3. Nursing Interventions
1. Chest x-ray immediately after subclavian line insertion for proper
placement
2. Assess weight, baseline electrolytes, blood glucose, zinc and copper
levels before treatment begins
3. Maintain aseptic (sterile) technique during dressing changes
4. Maintain infusion rate, do not increase or decrease rate without order;
may cause hyper or hypoglycemia
5. Assess weight daily: should maintain or increase weight while receiving
TPN
6. Monitor for complications
1. Infection-filters and tubing changed with every bottle
2. Hypoglycemia
3. Hyperglycemia
4. Air embolism: Never open central line to air. Chance of air
embolism is decreased with multiple lumen set-ups. When
central line is inserted or opened, have client perform valsalva
maneuver and place in Trendelenburg position.
5. Pneumothorax, especially during insertion
6. Zinc deficiency
7. Fluid overload
8. Hyperglycemic, hyperosmolar nonketotic coma
7. Gradual decrease in rate of solution when discontinuing therapy thereby
avoiding hypoglycemia
8. Continually evaluate effectiveness of therapy. Seek consultation if it is
not effective.

Hiatal Hernia
1. Definition: portion of the stomach is herniated through the esophageal hiatus of the
diaphragm
2. Manifestations
1. Heartburn
 2. Dysphagia

3. Nursing Interventions
1. Small, frequent meals
2. Upright position during and after meals
3. Head of bed elevated
4. Antacids
5. Avoid anticholinergic drugs
6. Avoid coughing
7. Reduce intra-abdominal pressure by avoiding lifting and tight clothes around
waist area
8. Reduce spicy food intake

Duodenal and Gastric Ulcer

1. Types of Ulcers
1. Chronic duodenal and gastric ulcers
2. Stress ulcers
1. May be caused by physical as well as psychological stress
2. Burns cause Curling's ulcer
3. Steroid therapy
1. Usually occurs at least one to two weeks after stress
2. No pain
3. May be diagnosed due to gastric bleeding and resulting low
hemoglobin and hematocrit

COMPARISON OF CHRONIC DUODENAL AND CHRONIC GASTRIC ULCERS

CHRONIC DUODENAL CHRONIC GASTRIC
Age: Usually 25-50 yrs Usually 50 yrs or more
Sex: M:F 3:1 M:F-2:1
Incidence: 80% 20%
General nourishment: Well-nourished Malnourished
Etiology factors: Most result from Excessive ingestion of
Helicobacter pylori salicylates, smoking
infection, smoking,
O blood type
Acid production in Hypersecretion Normal to hyposecretion
stomach:
-Location: - Within 3 cm. of pylorus
-Pain: - 2-3 hours after meal; - Lesser curvature
 night, early morning.
Ingestion of food relieves - 1/2-1 hour after
pain. Pain is a gnawing meal; rarely at night.
sensation sharply localized Relieved by vomiting.
in mid-epigastrium or in Ingestion of food does not
back. help; sometimes causes
pain.
Vomiting: Uncommon Common: caused by
pyloric obstruction either
by muscular spasm of
pylorus or by mechanical
obstruction from scarring.
Hemorrhage: Melena more common Hematemesis more
than hematemesis common than melena
Malignancy possibility: None Usually less than 10%
Complications: Hemorrhage, perforation Hemorrhage and
and obstruction perforation
Ulcerogenic drugs: Salicylates, butazolidin, Same
steroids

2. Nursing Interventions
1. Major goal is to prevent complications and allow ulcer to heal
1. Rest: physical and mental; lower stress
2. Eliminate stimulants: caffeine, alcohol, spicy foods, cigarette smoking
3. Diet has no therapeutic effect; milk may be used but is not
recommended
4. Antacid: aluminum hydroxide (Amphojel) magnesium carbonate
(Maalox)
5. Cimetidine (Tagamet): decreases acid production
6. Ranitidine (Zantac): decreases acid production
7. Sucralfate (Carafate): protects lining of stomach
8. Omeprazole (Prilosec): heals ulcer
9. For H. pylori ulcers: antibiotics

3. Gastric Resection
1. Types
1. Billroth I (gastroduodenostomy)
2. Billroth II (gastrojejunostomy)
3. Total gastrectomy: will cause pernicious anemia
2. Nursing Interventions
1. NG tube in place: do not move as it may stimulate bleeding at surgical
site
 2. Evaluate need for KCL in IV to prevent metabolic alkalosis
3. NPO until suture line is totally healed
4. Assess drainage: will initially be sanguineous but should change to
greenish in 2-3days
3. Complications
1. Hemorrhage
2. Pulmonary
3. "Dumping syndrome": due to rapid entry of ingested food into the
jejunum without proper mixing and normal digestive process of the
duodenum
1. Early: 5-30 minutes after eating, vertigo, sweating, diarrhea,
nausea; due to fluid shifts
2. Late: 2-3 hours after meals, hypoglycemia occurs due to excess
insulin secretion
3. Intervention: avoid salty, high-carbohydrate meals; eat small,
frequent meals; avoid liquids with meals; lie down after meals
(30 - 60 minutes); avoid antispasmodics; eat high-protein, high-
fat, low-carbohydrate meals. No fluids for 1 hour before, with, or
2 hours after meals.
4. Major complication: Peritonitis

COMPARISON OF CROHN'S DISEASE AND ULCERATIVE COLITIS

CROHN'S DISEASE ULCERATIVE COLITIS
Small Bowel Large Bowel

Pathology: Transmural: primarily Mucosal ulceration of

involving ileum and right lower colon and rectum
colon

Age: 20-30, 40-50 20-40

Etiology factors: Unknown genetic, Jewish Unknown familial, Jewish

Bleeding: Usually not Common, severe

Perianal involvement: Common Rare, mild

Fistulas: Common Rare

Rectal involvement: 20% 100%

Diarrhea: Less severe Severe

Abdominal pain after Yes Yes

eating:
 Weight loss: Yes Yes

Treatment: Steroids: sulfasalazine Steroids: sulfasalazine

(Azulfidine) (Azulfidine)
hyperalimentation; partial partial or complete
or complete colostomy & colostomy and
ileostomy or anastomosis proctocolectomy &
ileostomy

History: Deteriorating, progressive Exacerbations, remissions

Complications: Scarring, obstruction Perforation; susceptible to

cancer; toxic megacolon;
fistulas obstruction,
abscess

Diverticulitis and Diverticulosis

1. Definition:
1. Outpouching of colon is diverticulosis
2. When the outpouching becomes infected it is called diverticulitis
3. Problem: the pouch gets filled with feces, becomes inflamed, can obstruct and
perforate leading to peritonitis

2. Nursing Interventions
1. Prevent by increasing fiber in diet
2. Avoiding all seeds
3. Preventing constipation by using bulk agents and increased water

Bowel Obstruction
1. Definition: anything that obstructs the colon; inflammation, tumor
2. Manifestations:
1. Increased bowel sounds proximal to the obstruction
2. No stool
3. Pain
4. Distention
5. Vomiting (projectile from reverse peristalsis)
6. Hypovolemia and shock

3. Nursing Interventions
1. Intestinal tube: refer to care in preceding section
2. Ambulation
3. Treat cause and relieve
4. Surgical intervention; colon resection

COMPARISON OF COLOSTOMY AND ILEOSTOMY

 COLOSTOMY ILEOSTOMY

Defined: Portion of the colon Portion of the ileum

brought through the brought through the
abdominal wall, creating a abdominal wall creating a
temporary or permanent permanent opening for exit
opening for exit of waste of waste products
products

Areas: Involves large bowel Involves small bowel

Indications: Inflammatory or obstructive -Crohn's disease

process of the lower -Ulcerative colitis
intestinal tract; trauma to
intestinal tract; cancer of
the rectum or sigmoid
where anastomosis is not
possible

Stool: Semiformed to formed Liquid

Control: May be controlled by diet No control, must wear

and/or irrigation depending appliance at all times
on location in colon, may
be able to control
evacuation

2. Nursing Interventions
1. Preoperative care
1. Emotional support (anticipatory grieving)
2. Client teaching concerning impending surgery (ileostomy/colostomy)
2. Postoperative care
1. General postoperative care
2. Psychological support
3. NG tube
4. Observe stoma, surrounding tissues, and type of excretion (should be
pink; above skin level; may have bloody discharge at first)
5. Teach self-care to client
1. Type of equipment to use and how
2. Skin care
3. Diet: decrease fat and odor forming foods
 COMPARISON OF HEPATITIS A; HEPATITIS B; HEPATITIS NON-A, NON-B;
HEPATITIS C
HEPATITIS A HAPATITIS B HEPATITIS HEPATATIS C
(Infectious (Serum Non-A, Non-B
Hepatitis) Hepatitis)

Cause -Virus Virus Thought similar -Transmitted

transmitted by transmitted to type B via blood, by
fecal-oral through personal
contact; often percutaneous contact &
seen during or oral possibly fecal
floods, exposure to the oral route
earthquakes blood of person -Hepatitis C
-Transmitted by with Hepatitis B causes 4% of
the 4F’s: food, hepatitis cases:
fingers, feces, causes 90% of
and floods post
transfusion
hepatitis
-Risk factors
are the same
as Hepatitis B

Manifestations Flu-like, upper- Similar to type Same as type Same as Type

respiratory A without B B, may lead to
infection, respiratory need for liver
headache, symptoms transplantation
malaise, (30%)
jaundice, dark
urine, liver
tenderness

Nursing Enteric Same as type Same as type Same as Type

precautions, A except “blood B B
bed rest, low precaution”
fat diet, fluids, instead of
drug therapy, enteric
reduced to precautions
minimum
 vitamins B12

Prevention Good Mandatory Same as type

sanitation; if in screening of B
contact with blood donors-
infected client, use of
administer disposable
immune serum needles and
globulin within syringes;
2-7days; administer
Hepatitis A Hepatitis B
vaccine is immune
available globulin 2-
7days after
exposure.
Hepatitis B
vaccine: series
of 3 injections
over 6 months

What's the incision, and do they have any other tubes associated with that? Now the next section
that's under this is hepatitis. And a lot of us, I think, have dealt with clients who have hepatitis. And
we are familiar with it in that because we are at high risk, we have been immunized against hepatitis
and have had to have the Hep B series.
And that is something that is required for almost all health care workers. The one thing to remember
is that almost hepatitis A, B, and C all present with very similar symptoms, but they're caused by
different things. Let's talk first about hepatitis A. Hepatitis A is caused by contamination of the fecal
oral route. That means that someone who was handling food, perhaps, or someone who went to
toilet themselves didn't wash their hands appropriately, and fecal material got on either the food or
into their mouth and became systemic. And that caused hepatitis A.

Now we also sometimes see that whenever there's a trauma or a major tragedy like an earthquake
because the water supply has also been contaminated. Most often, however, the fecal oral route is
as we just discussed. Now hepatitis A, if you think about it, remember, is transmitted by the four Fs,
food, fingers, feces, and floods. The four Fs, food, feces, fingers, and floods. Again, flu-like
symptoms, respiratory symptoms.
Now those are no different than you would see for hepatitis B in the beginning. However, as it
progresses, there may be some variations in the symptoms. Now the client will develop jaundice,
which is a yellow discoloration of the skin and the sclera of the eyes. Urine will turn a very dark color
and if you were to palpate their liver or over the liver, they would complain of some tenderness.
Now these clients are placed on enteric precautions. When we talked about precautions, if you
remember, we talk about universal precautions. Now this is an important deviation from that.
Universal precautions are those that we employ for all clients because we assume that they all have
the potential for having an infectious disease. So we protect ourselves by washing our hands,
wearing gloves, masks if needed, and so forth when we're coming in contact with blood or body
secretions.
When we have enteric precautions, this falls under the category of standard-based transmission.
And that is that the standard is that if a client has a problem with feces where their contamination
may occur as a result of contact by feces, then that a special precaution will be taken for handling all
of that type of potentially infectious waste. So enteric precautions are in addition to universal
secretion precautions because it is that standard.
The prevention, of course, is certainly better than trying to cure it, and that is prevention by good
sanitation, hand washing, and making sure that if you come in contact with the infected client that
you wash your hands and protect yourself from contamination. Sometimes clients, if you come in
contact with an infected individual, gamma globulin is given, immune gamma globulin is given, and
it's based on body weight. That will help, it really will help to improve your chances or your immune
system so that you won't become infected with the hepatitis A bacteria.
There also is a hepatitis A vaccine available, however, that is not as readily available as hepatitis B.
Healthcare workers are probably at one of the highest risk groups for hepatitis B. That is called
serum hepatitis. It is passed by contact with blood or body secretions of an individual who has
hepatitis B. Now, when we have come in contact with this individual, the symptoms still remain the
same. The manifestations are the same as hepatitis A. The only difference is they don't usually have
a lot of the respiratory symptoms. That usually comes in with hepatitis A.Hepatitis B usually has all
the other symptoms, the dark urine, jaundice, and so forth without respiratory.
The treatment is, again, the same as A, except that instead of enteric precautions, we're going to
have blood precautions or body secretion precautions. So, again, in addition to universal
precautions, the standard will be the addition of blood precautions. Prevention is aimed at screening
those individuals who are in a high-risk group.That means healthcare workers like you and I,
disposing needles in the appropriate receptacle so that an individual will not run the risk of being
contaminated by accidentally being stuck with a dirty needle.
The other thing, of course, is to have the hepatitis B vaccine. Having the heptovax or hepatitis B
vaccine is a series of three injections, and then you have to have a titer drawn to make sure that you
have active antibodies against hepatitis B. At the present time, there isn't any statistics to show how
long that is actually going to protect you, but we do know that there are individuals who have been
protected for at least 10 years. So, you need to periodically have your blood levels checked to make
sure that you still have active immunity against hepatitis B.
Now, the last one is hepatitis C, and again, blood, personal contact, and possibly faecal oral route is
how this virus is transmitted. Hepatitis C is a very small percentage of the hepatitis cases. Most of
them are A or B. However, we do see about 4% of these cases. The other thing, though, that we
need to remember is that if we have a client who has a transfusion and they get hepatitis, most often
they develop hepatitis C. About 90% of those individuals who have had a transfusion and develop
hepatitis C develop this type of illness.
Now, the manifestations, again, are the same as B, and the other thing that also happens is that it
may affect the liver so negatively, in other words, damage it so much that the individual may need a
liver transplant as a result.So, prevention, again, don't share needles. Make sure that you get rid of
any infected needles or any needles that have been used. Making sure, of course, that you protect
yourself against needle sticks, safe sex to make sure that if you do have sex with an individual who
is infected, that you protect yourself. All of these are measures to prevent the spread of hepatitis C.
Liver Cirrhosis
1. Definition: liver cells destroyed and replaced by scar tissue; cause not clear; frequently
seen in alcoholics, but also occurs in non-alcoholics; associated with nutritional
deficiency with decreased protein intake
2. Functions of the Liver
1. Synthesis of clotting factors (fibrinogen, prothrombin, factors VII, IX, X)
2. Metabolism of hormones (aldosterone, antidiuretic hormone, estrogen,
testosterone)
3. Synthesis of albumin
4. Carbohydrate metabolism
5. Protein metabolism
6. Fat metabolism through bile production
7. Filter action, especially drugs
8. Blood storage

Measures to prevent the spread of hepatitis C. Now the next topic in this section is cirrhosis of the
liver. And cirrhosis, remember, is where the liver cells are destroyed. And basically, it's just like if you
had a cut on your armand you cut the tissue, when it heals, a scar forms.
Scar tissue, as on your arm, as in your liver, as in your heart, causes that organ to not either look or
the way it did prior to the scarring. So the same thing happens with cirrhosis of the liver. Now, do we
see it only in alcoholics? Because I know that a lot of individuals think that that's who gets cirrhosis
of the liver, the individual who is an alcoholic.
But we know that, in fact, it isn't strictly confined to an individual with alcoholism. But we get it in
individuals who are not alcoholics, but who have a problem with nutritional deficiencies. And
therefore, they develop liver disease.
The functions of the liver are listed in your text. And I'd like you to make sure that you review them.
Because as you can see from looking at them, the liver has so many functions, including clotting and
synthesizing not only albumin, but a number of other drugs and so forth, and metabolizing protein,
and getting rid of ammonia, bloodammonia, which is the end product of the breakdown of protein
metabolism.
And of course, bile storage, all of those things listed in your text, so that you can see that it is so
important to make sure that the liver is functioning properly. If not, all of the system is going to start
to fail as a result of the liver failure.

3. Manifestations: these would be the same for a client with liver failure from other causes
also, except for the enlargement of the liver and the alcohol related psychosis
1. Early stage (same as those for Hepatitis)
1. Enlarged liver with fatty infiltration
2. Jaundice
3. GI disturbances
4. Abdominal discomfort

2. Late stage
1. Liver becomes smaller and nodular
 2. Spleen enlarges: anemia
3. Ascites, distended abdominal veins; back-up of pressure in the portal
system
4. Bleeding tendencies; decreased vitamin K and prothrombin
5. Wernicke-Korsakoff psychosis: alcohol related
6. Esophageal varices, internal hemorrhoids; back-up of pressure in portal
area
7. Dyspnea from ascites and anemia
8. Pruritus from dry skin
9. Clay colored stools: no bile
10. Tea-colored urine: bile in urine

Is going to start to fail as a result of the liver failure. Now if a client has cirrhosis, the manifestations
are the same as if they have liver failure. The only difference is the cause is, certainly the cause is
different, but what happens in cirrhosis is that at first the liver gets bigger.
So if you were going to do an assessment, an abdominal assessment, you're going to do a liver
assessment, you would actually be able to feel the tip of the liver when you are performing that
assessment. As it progresses, it gets very nodular and hard and a lot smaller than when the disease
first became evident.
The other thing that happens is that if we were to look at what the symptoms are of a client with
cirrhosis of the liver, very similar to the individual who has hepatitis. Their liver gets bigger, they
develop jaundice, and of course they have all of those GI symptoms, the nausea and so forth. And
as the cirrhosis progresses, there is a fluid accumulation in the abdomen called ascites and that
causes abdominal discomfort and as the abdomen grows, it also causes additional discomfort.
The client who has cirrhosis of the liver also will complain of right upper quadrant pain, they develop
anorexia, again those GI disturbances. In the later stage, and this is where you see individuals who
would be hospitalized. Most of the time in those early stages, they are managed as an outpatient or
you may see them only for a day, but the individual who is in the late stages of cirrhosis of the liver
very often is hospitalized.
The liver is smaller, as I said before, and it becomes very nodular and the ascites really begins to
develop. And remember that when you have ascites, the abdominal veins also get very distended
and so again it causes an increase in pain. And remember that all of the portal system, or those
things that gets rid of all of our waste product and all of the digestive products, is affected by the liver
and its failure.

So you have, let's think about what we, when we look at the liver, let's think about what we said was
one of the major functions of the liver. We said, first of all, that it was responsible for clotting and
because it manufactures all of those clotting factors, the individual who has a failing liver has
bleeding tendencies because they're not putting out those clotting factors any longer, so the liver
plays a big, an important role in this area.

So the individual who doesn't have as much vitamin K, and of course their prothrombin is also
decreased. The individual who has cirrhosis also doesn't deaminate the blood ammonia levels the
way they did before. And so they developed something called Wernicke-Korsakoff psychosis. It is
alcohol related and it is related to a thiamine and niacin deficiency as well as to the increase in blood
ammonia levels.
One of the other things that we talked about earlier was, if you remember we talked about the
Sengsteig and Blakemore tube and that was used for esophageal varices. Well, esophageal varices
result from the portal hypertension and back pressure on the esophagus which dilates the vessels in
the esophagus. And the key word here is painless.

So if you don't see that written, make sure that you write that next to esophageal varices, that it is a
painless condition. The individual doesn't even know they have it until sometimes they'll cough and
all of a sudden begin tobleed profusely. It is not related to anything you don't, if the client develops it,
you can't put ice on their neck or an ice collar on to try to decrease the bleeding because it has to do
with those vessels that are oozing because of thatthat portal hypertension.
And of course the difficulty with breathing because of that ascites in the big belly. Now the other
thing that happens, if you remember we said that a client with cirrhosis has and hepatitis, if you
remember when we talked about hepatitis, we said that they have very dark colored urine. Well the
reason that we have dark colored urine is because bile actually is excreted into the urine rather than
being excreted through the stools.
So the stools become clay colored and the urine becomes dark. It's almost like a tea color.
Sometimes it's even darker than that, it even gets almost like a cola color. And that is a classic
outcome or a classic sign of cirrhosis of the liver. In addition the skin becomes very dry and they
develop itching.
So if you were to look at them, the difference between or the manifestations of hepatitis A, B, and C
andcirrhosis of the liver, you can see that there are very many similarities again because they all one
affects the other. They all are in the gastrointestinal system.

3. End stage
1. Hepatic encephalopathy stages
1. Prodromal: slurred speech, vacant stare, restless; involves neuro
deterioration
2. Impending: asterixis, apraxia, lethargy, confusion
3. Stuporous: noisy, abusive, somnolence
4. Coma: positive Babinski, fetor hepaticas, decorticate/decerebrate
posturing
2. Convulsions
3. Death
Are in the gastrointestinal system. Now, when we look at end stage, and end stage means that the
liver has failed completely.
There is a condition called hepatic encephalopathy. And hepatic encephalopathy means that
because the liver has failed, it causes a degeneration of the brain and the ability to, and the central
nervous system.
So the symptoms then would be those that would be related to central nervous system disorders.
The blank stare, they have this, almost looks like they have a mask on their face rather than being
animated or being able to express themselves. They're very restless.
So because of that neurological involvement and the gradual deterioration of the neurological
system as a result of this encephalopathy stage, you can see that as you look through your text and
you see that we go through the prodromal impending and so forth, you can see that there is a
gradual deterioration so that the individual develops apraxia and asterisks, which is a problem with
movement and apraxia is the inability to perform purposeful movements.
So again, you can see that it is a gradual deterioration of the nervous system, the central nervous
system and the ability to control movement. Eventually, the individual will become comatose.
Now, when they are comatose, they develop a positive Babinski. In an adult, a negative Babinski is
the norm. So a positive Babinski means there's nervous system disorder or central nervous system
involvement.
Fetal hepatica is the smell that develops on their breath as they go through the end stage of
cirrhosis. And of course, decerebrate and decorticate posturing is remember that it's either the C's or
S's and we'll talk more about that when we look at the neurological problems.
Eventually, of course, this will lead to death and there is no way to intervene at this point. By the time
they get to the end stage or hepatic encephalopathy stage, there really isn't any interventions that
you can employ

4. Nursing Interventions: goal is treating the manifestations and maximizing liver functions
1. Encourage client to rest
2. Avoid hepatotoxic drugs and alcohol
3. High-calorie, low-protein (20 - 40 g/day), low-fat, low-sodium diet (Maintain
protein restriction during stages I & II of encephalopathy; no protein allowed
during stages III & IV)
4. Fat-soluble vitamin supplements, folic acid may need to be given intravenously
5. Restrict fluids
6. Albumin IV
7. Weigh client daily
8. Measure abdominal girth
9. Skin care: cool temperature, Aveeno baths, lubricate
10. Monitor intake and output
11. Assess for bleeding, hemorrhoids
12. Diuretics: spironolactone (Aldactone), furosemide (Lasix)
13. Neomycin: reduces intestinal bacteria, thereby decreases breakdown of protein
reducing ammonia levels
14. Lactulose (Heptalac): decreases ammonia levels
15. Thiamine daily
What we can do, though, is encourage them until they get to that stage, encourage them to protect
themselves for as long as they can by avoiding things that are hepatotoxic, encouraging them to get
lots of bed rest or to rest in between any activities,eating a high-calorie and a low-protein diet.
And the reason that you want to make sure that it's a low-protein, again, is because the liver isn't
functioning adequately enough to be able to deaminate the end products of protein metabolism.
Weighing them daily also will give you an indication of whether they are, whether your interventions
are effective or not. And measuring abdominal girth is also important. And if you remember in
abdominal assessment, we did a look, listen, and feelbecause that's part of the abdominal
assessment.
But if an individual also has a descended abdomen, then measuring abdominal girth becomes part
of that abdominal assessment. You also need to make sure that the abdomen is marked so that
everyone is measuring at exactly the same spot and so that the individuals are not saying that
there's been a change when in fact it's not a change but merely the placement of that measuring
device.
The other thing that's also important is to monitor and take an output just as we did for the other fluid
volume assessment. INO is, of course, skin, turgor, mucous membranes. All of those things will tell
us the state of the individual's fluid and electrolyte balance.
We give diuretics to these individuals. And the reason we do, again, is because the individuals are
not able to get rid of some of the waste products and they retain fluid.Remember, the ascites also
becomes very uncomfortable. So by giving Lasix or those types of diuretics, we will also decrease
the amount of fluid that is retained by the patient with cirrhosis.
Neomycin is another drug that we use. And the reason we use neomycin is because it reduces
intestinal bacteria. And the reason we want to do that is because if we reduce intestinal bacteria,
then what happens is protein doesn't break down as readily and so it doesn't release ammonia. And
when it doesn't release ammonia, then the liver doesn't have to work as hard because that's what
gets rid of blood ammonia for us.
Now, the other thing is, because they're in N-stage, and as they progress to N-stage, we give them
thiamine because they have a thiamine and niacin deficiency.
The last type of drug that we use, and it's a very important drug, is something called hepatolac or
lactulose. And lactulose actually acts like a chelating agent, which means that it binds together with
ammonia to get rid of it. So remember, we're going to talk about that again at another point when we
look at lead and a couple of other thingsbecause chelating means that the type of drug you give will
attract certain types of material. In this case, it attracts ammonia and then it gets rid of it, it passes it
off, so that it will decrease blood ammonia levels.
Now, during the stage 1 and 2 of cirrhosis deterioration, there is a protein restriction. However, you
still are allowing the individual to have some protein.
During the N-stage or encephalopathy stage, no protein is allowed at all. We give them no protein,
we just give them carbohydrates and fluids and so forth.

Esophageal Varices
1. Definition: esophageal varices are dilated veins found in the lower esophagus that occur
secondary to portal hypertension; bleeding may result because of coughing, trauma, or
vomiting; bleeding esophageal varices is a medical emergency
2. Nursing Interventions
1. Maintain client airway before insertion of Sengstaken-Blakemore tube
2. Care of client with Sengstaken-Blakemore tube
1. Maintain traction and manometer pressure: 40mmHG
2. Keep scissors by bedside
3. Oral suctioning, mouth care; cannot swallow saliva or will aspirate
4. Deflate gastric balloon every 24-36 hours; usually deflate esophageal balloon
every 12 hours as ordered
3. Semi-Fowler's position
4. Take vital signs
5. Monitor intake and output
6. Vitamin K
7. Vasopressin (Pitressin): vasoconstrictor
8. Endoscopic sclerotherapy
1. Sclerosing agent introduced via endoscope
2. Thromboses and obliterates the distended veins
We give them no protein, we just give them carbohydrates and fluids and so forth.
Now we've already talked about bleeding esophageal varices, so I'm not going to talk about that
again.
Just again remember it is painless, it is an emergency and it requires you to use that Sengstegen
Blakemore tube or some other type of device very similar to that so that you can decrease the risk of
the individual hemorrhaging and to decrease the amount of bleeding that occurs from these vessels.
The other thing that we also give by the way is we give a drug called vasopressin or patresin.
It is a vasoconstrictor and when it constricts the vessels of course it causes the decrease in
bleeding, therefore it is an important drug to be used in this case.
Now that is probably one of the most common of the side effects or the symptoms that occur in an
individual with cirrhosis of the liver or with liver failure.

Gallbladder Disease
1. Definitions
1. Cholecystitis: inflammation of the gallbladder
2. Cholelithiasis: stones in the gallbladder
3. At-risk: fair, fat, forty, oral contraceptive users

2. Manifestations
1. Right upper-quadrant or epigastric pain, shoulder pain
2. Nausea and vomiting
3. Fat intolerance
4. Murphy's sign: Have client take deep breath and palpate the right subcostal
area. If the client has extreme pain and stops breathing on inspiration, this is a
positive Murphy's sign and indicative of acute cholecystitis.
5. Jaundice: indicates obstruction

3. Nursing Interventions
1. Relieve pain - meperidine (Demerol). Do not use morphine.
2. Maintain fluid and electrolytes balance
3. Administer antiemetic prn
4. Maintain low-fat diet

4. Cholecystectomy: postoperative
1. Nursing care same as any abdominal surgery
2. Penrose drain in gallbladder area
3. T-tube to gravity after cholecystostomy and chole-dochostomy: to prevent total
loss of bile drainage, tube may be elevated above level of abdomen
4. Resume regular diet as tolerated

With liver failure. Let's look next, though, at gallbladder disease. And we have talked about some of
the assessments earlier on. And we said that, remember, we don't use the cholangiograms very
much anymore because we use ultrasound to find out the problems with the gallbladder. But we
need to look at the fact that, in fact, an individual may not have gallstones or stones in the
gallbladder, but they may have an inflammation.
So remember, again, those suffixes that we talked about. Itis meaning inflammation. So if you have
a cholecystitis, it means an inflammation of the gallbladder. Litho means stones. So if I have
cholelithiasis, it means I have stones in the gallbladder. And of course, we need to remember that
acronym that we always talk about, the four Fs, fat, female, 40, and fertile, or those individuals on
oral contraceptives, those are the individuals at the highest risk for developing gallbladder disease,
the four Fs, female, fat, fertile, and 40. Those are the individuals who are at highest risk.
Now, what do the manifestations of gallbladder disease look like? Well, the first thing that an
individual will complain of is right upper quadrant pain, and usually after eating something fatty, like
they maybe have had a lot of butter on something, or they may have eaten a bacon, or something
that's a very fatty food. And that right upper quadrant pain sometimes will radiate right through to
their back, or sometimes they'll complain of shoulder pain.But remember, it is the right side, not the
left, that you'll feel the shoulder pain. They have right left shoulder pain. It usually has something to
do with the spleen.
Now, the other thing that happens is that they develop a fat intolerance, and nausea, and vomiting.
Now, your book lists something called Murphy's sign. And although it's in almost every textbook,
Murphy's sign is something that we very rarely talk about, because we do know what it is, we just
don't give it that label. What will happen is you take the patient, or the client, when they take a deep
breath in, they'll have pain right along the right subcostal area, right under the right rib cage. That
means that, in fact, the gallbladder is inflamed. And in fact, they have a problem with their
gallbladder. They have extreme pain. And that's called a positive Murphy's sign.
Now, if they stop breathing, the pain goes away. If they don't take a deep breath in, when they let the
breathout, or if they stop taking that nice deep breath, the pain goes away. That's a Murphy's sign.
It's a positive Murphy's sign. And the other sign, of course, is jaundice, because of the obstruction.
And usually, if they have a stone, it's an obstruction in the common bile duct. And if you remember
what that does, it prevents bile from going where it needs to be. And so the skin takes on a jaundice
color, or a yellowish color.
Now, the nursing interventions, number one, relieve their pain. These individuals are in a great deal
of pain.And when they are having a flare up, they're not going to be able to eat. They're not going to
be able to get comfortable until you give them something. And the drug of choice here is Demerol.
We don't use morphine, because of the fact that morphine may cause spasms in some of the
muscles, especially around the sphincter of Odi.So we don't want to do that. We want to give them,
in fact, Demerol instead.
The other things, of course, are maintaining fluid and electrolyte balance. So we're going to give
them, we'regoing to monitor their lab values. We're going to give them the IV solution that is
appropriate. And of course, giving them anti-emetics if they're vomiting, and so forth. The other thing
that would help to prevent their pain is not to allow them to eat anything that's high in fat. So a low-
fat diet is something that's going to be preventative. It will prevent them from having another flare up.
Post-op, if an individual has to have surgery because they've repeated flare ups, and nothing seems
to work.Remember, again, it's the same as any other abdominal surgery. And individuals, by the
way, who have had abdominal surgery, if you remember when we were doing test questions earlier,
we talked about the fact that an individual who's had abdominal surgery doesn't like to take a deep
breath. So they breathe very shallowly. So that's why they were at high risk for pneumonia. And
remember, we need to encourage them to breathe, and so forth.
So the care for this individual is the same as any other abdominal surgery. Very often, it is done by
laser surgery. We see it done by laser, which means that the individual will not have a T-tube or any
drainage tube. It's an in-and-out surgery. They come in in the morning. They have their gallbladder
out. They stay for a couple of hours.And then they go home. It helps them to, they do actually heal
much more quickly.
However, sometimes, they have to open them and leave them open, or they need to have a T-tube
for drainagebecause there's a great deal of drainage or because there's maybe other problems.
Then a T-tube is left inside. And it comes to the outside. And it's usually either it's a Penrose drain,
and it may be in a Jackson Pratt. And if you remember what a Jackson Pratt collection device is, it
almost looks like a little hand grenade that's attached to a tube. And you deflate it and keep it. And
then put the little stopper in so that it will pull by gravity. It'll pull by suction without applying any
untoward suction on the site. And it will draw any fluids from the wound itself.
Now, an individual who's had their gallbladder out can eat anything they feel comfortable with as
soon as they have healed. And what will happen is, usually after about a month or two following the
surgery, once they feel more like eating again, they eat almost everything because their gallbladder
is no longer affected because they don't have one. So they can eat even fatty foods if they choose
to.

Pancreatitis

1. Definition: inflammation brought about by the digestion of this organ by the very
enzymes it produces. Clients at greatest risk are those suffering from alcohol abuse,
clients with other liver and gallbladder diseases.
2. Manifestations
1. Extreme upper-abdominal pain radiating into back
2. Persistent vomiting
3. Abdominal distention
4. Weight loss
5. Steatorrhea: bulky, pale, foul smelling stools
6. Elevated serum amylase and lipase
7. Pleural effusion

3. Nursing Interventions: rest the organ

1. Administer anticholinergics, antacids, pancreatic extracts: pancrelipase
(Viokase)
2. NPO with nasogastric tube in place: no ice chips or hard candies as these will
stimulate the pancreas
3. IV fluids; may require TPN in moderate or severe cases
4. Provide meperidine (Demerol) for pain relief
5. Administer fat soluble vitamins
6. Home care management/teaching
1. NO alcohol or caffeine
2. Infusion of IV fluids
3. Signs and symptoms of complications to report (fever, nausea, vomiting,
respiratory distress)

They can eat even fatty foods if they choose to. Now, the next topic in this section is one regarding
pancreatitis.And again, remember, itis means inflammation.
And of course, we're talking about the pancreas, so it's an inflammation of the pancreas. And it's
usually because the enzymes that the pancreas excretes are actually literally digesting itself. So the
pancreas is being digested by its own enzymes and it is extremely painful.
So if you were to look at the manifestations, the number one is an underlying extreme upper
abdominal pain, and it radiates into their back. And the pain has been described as excruciating. I've
had individuals who've had a heart attack and they say that this pain is as severe, if not more
severe, than the pain of the MI.
Persistent vomiting, that's the other thing that is very common in an individual with pancreatitis, as
well as abdominal distension.
Now, if I were to look at a patient who's having the itis or inflammation, then I know that I'm going to
see those symptoms. Those are the things I'm going to see. If I were to say, what is the overall
picture, then they're going to have stutteria, which means fatty stools. And remember that they're
having fatty stools because the liver isn't functioning the way it's supposed to, so they can't help to
digest those fats.
And of course, a weight loss, because what they eat is actually passing through their system. Now,
that is not the initial sign. The initial thing in an itis or inflammation is the first three in that list. Of
course, pleural effusion and the others will be a later sign of the patient with pancreatitis.
The interventions are aimed, then, at resting the organs so that it can promote healing. Giving
anticholinergic drugs and antacids are very important because the anticholinergic drugs will dry up
secretions. So remember what we said the anticholinergic drugs do. We talked about that earlier
because of the secretions that they dry up.
The individual has decreased mucous membrane secretion. They have decreased saliva, decreased
urinary output, and of course, a decrease in stooling. So this will help to rest this organ so that it can
promote healing.
The other thing that we give is very similar to those things that we give when a patient has cystic
fibrosis or are unable to digest fats. And that is pancreatic enzymes like lipase, viocase. Those are
all pancreatic replacements that we give to the individual just before they eat or with meals so that
they can help to digest their fats and the foods that they're eating.
The individual who is, when you're trying to rest the pancreas, also remember that in the initial stage,
they are NPO until they start to decrease their pain. And then we may start to feed them things like
low-fat foods and so forth with those pancreatic enzymes.
TPN is also very common in the individual who has pancreatitis. The other thing that you need to
remember is that the medication that we use again for this individual is Demerol. Demerol is the drug
of choice for pain relief.
And again, NCLEX will ask you things about teaching the client to take care of themselves once
they're out of the hospital. So home management also then becomes a very important issue. No
caffeine or alcohol. Anything that's a stimulant will cause an increase in their pain and a problem with
their pancreas again.
They may have to have IV fluids at home until their pancreas has rested enough or is healing. And of
course, if they have any signs of infection like fever, or if they have any signs of occurring symptoms
like nausea, vomiting, and so forth, then they need to immediately call their practitioner.
There is, so what we've talked about in this section is the GI disturbances. And if we remember what
we've done, to recap, we've talked about the diagnostic procedures, which included not only lab
tests, but upper and lower GI procedures and endoscopy procedures.
We've talked about hiatal hernias. We've talked about any of the digestive problems such as
pancreatitis and cirrhosis of the liver and gallbladder disease and ulcers and ostomies. And we've
also talked about the intestinal tubes versus the nasogastric tubes.
To recap then, you need to look at all of those things that have to do with ingestion and digestion. All
the things we've talked about here have to do with ingestion and digestion.

ANXIETY

Anxiety
1. Definition: anxiety and apprehension are tension in response to a perceived physical or
psychological threat (internal or external) resulting in feelings of helplessness and
uncertainty
2. Responses
1. Psychological
1. Fear
2. Impending doom
3. Helplessness
4. Insecurity
5. Low self-confidence
6. Anger
7. Guilt
2. Defense mechanisms
1. Displacement
2. Regression
3. Repression
4. Sublimation

3. Physiological: nervous system

1. Dry mouth
2. Elevated vital signs
3. Diarrhea
4. Increased urination
5. Palpitations
6. Diaphoresis
7. Hyperventilation
8. Fatigue
9. Insomnia
10. Sexual dysfunction
11. Irritability
12. Fidgeting, pacing
4. Behaviors
1. Fight or flight response
2. Talkative, giggly, angry, withdrawn

Hi, I'm Laura McQuinn, and I'm your psychiatric review instructor, and this is Section 2, Anxiety. And
in this section, I'd like to cover the following things, and that would be anxiety, the levels of anxiety,
anxiety disorders, including phobia, obsessive compulsive disorder, post traumatic stress disorder,
the somatoform disorders, the dissociative disorders, and the anti anxiety agents.
Now, to begin, I'd like to define anxiety for you in that anxiety is defined as tensionin response to a
perceived physical or psychological threat, internal or external, and that it results in feelings of
helplessness and uncertainty.
Now, we've all felt anxiety. We all have a pretty good idea of what it's like to feel anxious because in
everyday life, we may experience periods where we feel this anxiety.If we look on our page here
under number three, the physiological responses to anxiety, which are the nervous system things
that we understand that go on when we feel anxious, let's take a look at a few of them.
The first one is A, that dry mouth, B, that elevated vital signs so that our pulse mayget rapid, our
blood pressure may go up, number E, that palpitations where we feel our chest pounding, also
number F, that diaphoresis or that sweating, that sense of anxiety that causes us to sweat, number I,
which is insomnia. We may have trouble getting to sleep or staying to sleep if we're feeling anxious
and K, that irritability that goes on when we feel anxious, sort of jittery feeling, we're sort of pacing,
we feel sort of out of our skin, that sort of apprehension that something isn't right.

LEVELS OF ANXIETY
LEVEL PHYSIOLOGIC COGNITIVE BEHAVIORAL NURSING
RESPONSE STATE CHANGES INTERVENTIO
NS

Mild Slight Perceptual field *- Restlessness *- Listen

(+) discomfort, can be (inability to *- Promote
restlessness; heightened; work toward Insight,
tension relief; learning can goal) problem solving
fidgeting, occur *- Examine
tapping alternatives

Moderate Increased Perceptual field * Focus on *- Calm,

(++) pulse, narrows: immediate rational
respirations, selective in events discussion
shakiness, attention *- Benefits from - Relaxation
voice tremors, guidance of exercises
difficulty others
concentrating,
pacing

Severe Elevated BP Perceptual field - Feelings of +- Listen

increasing threat;
(+++) tachycardia, greatly *- Encourage
purposeless
somatic reduced; activity expression of
complaints, attention feelings
hyperventilation scattered; * - Feeling of * - Concrete
, confusion cannot attend impending activity
doom
 to events even Reduce stimuli
when pointed (channel
out energy into
simple tasks)

Panic - Immobility or - Perceptual - Mute or * - Isolate from

(++++) severe hyper- field closed psychomotor stimuli
activity; cool, * - agitation * - Stay with
clammy skin; Hallucinations * - May strike client
pallor: dilated or delusions out physically * - Remain very
pupils; severe may occur or withdraw calm
shakiness * - Effective - Loss of control * - Decrease
*- Prolonged decision demands
anxiety can making is * - Protect client
lead to impossible safety
exhaustion * - Do not touch
client

* Important
As a nurse, it's important to be able to identify the level of anxiety that our client is having.
Remember, when we talk about the psychiatric disorders, we're talking about disorders that have
anxiety as the underlying thing going on. This is that sort of thing that makes that client sort of jittery
or nervous or not able to sleep or feeling sort of down. So what we need to do is identify how much
anxiety our client is having. The first level of anxiety is that mild-level anxiety, and we all know what
that is.
We've all felt that sort of slight discomfort, that restlessness, and this is good. In fact, mild anxiety is
good for when we get ready to sit for a nursing exam. We want that sort of slight discomfort. It helps
us sort of focus, and that we become more aware of our environment, and this is sort of what we
want to be at when we're taking a test.Now, I really want to focus on the nursing intervention.
These are the things that the nurse does with helping a client with these different levels of anxiety.
The first one is the mild anxiety, and this is where the nurse would just offer a listening ear. The
nurse doesn't need to intervene because the anxiety isn't high, so all the nurse needs to do is sit with
the client, listen, help the client verbalize and promote some insight, some problem-solving, because
this level of anxiety is usually resolved without any sort of significant intervention by the nurse.
The second level is the moderate level, and this is where we start feeling changes in our body,
where we might get that increased pulse or that respirations, that shakiness. Maybe our voice is
trembling a little bit. And during this time, we might have more difficulty concentrating. Our
perceptual field, or the way that we visualize things, is narrowed. With mild anxiety, I sort of think of
that we can take in the room, we can study things around us, but when we have moderate level, our
perceptual field narrows.
That means we can't see so much. We're sort of looking at one thing only. Our mind is focused just
on that one target thing. And so when we have moderate level, our client may not be able to focus
on anything but maybe a test. We've all felt like we had to go take an exam and maybe that we
couldn't concentrate on anything else but that one thing, taking that exam. Maybe we get so that we
don't hear the phone ring or we don't hear somebody ring the doorbell because we're concentrating
and fixated on that one thing.
And that is usually how we identify what moderate level of anxiety is. Now the nursing interventions
get a little bit more so with a client with moderate anxiety. If, like I just said, they're only able to focus
on one thing, this is what the nurse does. They stay calm, they discuss this, they help the client in
this thinking process that they're having difficulty with. And it's during this time that the nurse can
teach one thing, and the one thing might be some sort of relaxation exercise.
This is very important because with the self-care movement that we have, we want to be able to
teach our client to manage their own anxiety, their own stress. And relaxation techniques such as
deep breathing, progressive relaxation where they might relax their fingers, relax their arms, take a
few deep breaths, this is the kind of intervention that we would intervene with clients who have
moderate levels of anxiety.
Now with the severe level of anxiety, we're moved more into that elevated blood pressure, the
tachycardia, the heart's beating faster. They start having a lot of multiple complaints. They may even
be hyperventilating or act very confused as if they can't make a decision. Now with the perceptual
field at this time is just greatly diminished where I said the field was wide open here with mild and it
gets narrower with moderate. With the severe, they just can't focus.
Everything's sort of greatly mixed up, confused, and they have this increasing feeling that
something's wrong,that they feel threatened, that there's something, there's doom, something terrible
is going to happen. This is the kind of anxiety where they can't listen oftentimes to what you're
saying to them because they might be very confused about what's going on. The nurse in this
situation would again offer that listening ear but also would sit with the client, sort of allow them to
sort of talk about what they want to talk about.
If they want to use defense mechanisms, if they want to rationalize what's going on, that's fine. This
is the time we just sit there and we listen. This isn't when we're going to do great problem solving
with the client. They're not able to. We want to reduce environmental stimuli and channel everything
so that they can just do simple tasks.They're not going to be able to do complex tasks at this time.
Of course, the goal during this stage, if we have somebody with severe anxiety, we want to help
reduce the anxiety so it's more manageable. So if we're having severe anxiety, we want to reduce it
so they're having moderate levels of anxiety. And the same if they're having moderate levels of
anxiety, we want to assist to get it to mild. So this is a progressive thing where we're not going to
cure someone of their anxiety right at that moment. We want to reduce the level of anxiety to a
manageable level.
Now the last stage, which is the panic stage of anxiety, this is where the person gets very cool and
clammy skin.They're immobile. They just can't make decisions. Their face is very pale. Their pupils
are dilated. They have really bad shakiness. And this is a very dangerous stage because at the
prolonged stage of anxiety, they can get into a heart attack or they can go into physical exhaustion.
So this is very important for the nurse to be able to assess the client's having a panic level of
anxiety. We need to intervene. We need to make sure that we can assist the client so that they do
not have a heart attack. Some of the things that you may see during this panic stage is that they say,
I think I'm going crazy. I think I am going to die. You cannot convince the client that you're just
having an anxiety attack. No, they think they're going to die.
So you want to be able to help that client because this is the stage where they may also strike out.
They may get violent during this stage because they're frightened. They are pending, you know, this
doom that something awful, terrible is going to happen. To assist this client in this panic stage,
again, this is very important. The nurse does not leave the client alone during this stage.
We stay with the client. Do not touch the client because this can make them strike back at you. But
you want to stay very calm, decrease all stimuli, and protect them. This is a safety thing. If they're
pacing and they're screamingand saying, I'm going to die, I'm going to die, we need to monitor that
client to make sure that they stay safe in that environment.
So the key information when we look at what is going on with the levels of anxiety is that the initial
nursing priority is to reduce the anxiety to a tolerable level since learning cannot occur until the
client's anxiety is manageable. And this is what the nurse does. The nurse uses those same
communication techniques, offering self, listening, staying with the client.

Maladaptive Resposes to Anxiety

1. Anxiety disorders: characterized by fear that is out of proportion to external events;
attacks lasting minutes to hours
1. Panic disorders
1. Definition: sudden onset of intense apprehension, fear or terror (panic
attacks)
2. Physical Manifestations
1. Dyspnea
2. Palpitations
3. Chest pain
4. Faintness, dizziness
5. Fear of dying or going crazy (out of control)
6. Choking
7. Depersonalization or derealization
8. Hyperventilation

3. Nursing Interventions
1. Stay with client and remain calm
2. Reassurance and support
3. Remove anxiety-producing stimuli
4. Have client take deep breaths
5. Distract client from anxiety producing stimuli
6. Provide a paper bag for hyperventilation

So now that I've defined the levels of anxiety, let's take a look at some of the maladaptive responses
to anxiety.We call these anxiety disorders. And anxiety disorders are characterized by fear that is out
of proportion to external events. These attacks lasting minutes to hours.
We've all felt anxiety in different degrees, but maladaptive responses to anxiety, or some of these
known anxiety disorders, are things that we want to recognize, especially if our clients may
experience them. The first is a panic disorder. A panic disorder is a sudden onset of intense
apprehension, fear, or terror, what we call panic attacks. We recognize what a panic attack is when
a client has these physical manifestations.
And let's take a look at a few of these. Under 2, number B, palpitations. Palpitations means that
chest banging.The chest is, you know, hammering away. They feel this crushing sort of pain in their
chest. Under C, it says chest pain. Number E, they have a fear of dying. They're going crazy. You
can't say, this is unreasonable. You're not dying.You're safe. They really, sincerely feel that they're
going to die or go crazy.
Let's take a look at the nursing interventions with that. Or A, we want to stay with the client and
remain calm at all times. The techniques that we want to do with a client or having a panic attack are
to, number C, remove stimuli,and D, offer deep breathing. This is probably the most effective thing
that we can do. As we're sitting with this client,we can say, take a breath. I'm here. I'm with you. And
that we can work with this client to make this anxiety more manageable.

2.
Phobic disorders
1. Definition: persistent or irrational fear of a specific object, activity, or situation
that leads to avoidance (for example: fear of flying)
2. Types
1. Agoraphobia: fear of being away from a safe place or person in which
there is no escape
2. Simple: irrational fear of object or situation
3. Social (Social anxiety disorder): irrational fear that social situations
expose one to possible ridicule or embarrassment

3. Defense Mechanism
1. Repression
2. Displacement
3. Avoidance
4. Nursing Interventions
1. Teach client relaxation techniques
2. Avoid major decision making
3. Utilize behavior modification techniques
4. No competitive situations
5. Provide gradual desensitization experiences
6. Assist client in verbalizing thoughts and feelings of anxiety

Another type of anxiety disorder is the phobic disorders and this is that persistent or irrational fear of
a specific object activity or situation that leads to avoidance. Example of this might be fear of flying.

Phobic disorders we recognize because oftentimes we see acrophobia, arachnophobia, there's all
different kinds of phobias and you know irrational fears of specific objects or things.

Now the most common type if we look under two is agoraphobia. Fear of being away from a safe
place or person in which there's no escape. An example of this would be somebody who's fearful of
leaving their home, that was afraid to go to the grocery store, afraid to go out in public places, afraid
to go to the movie theater, afraid to go to the drugstore.

And this can be very confining. If we think about anxiety disorders and being maladaptive, it's
impairing usoccupationally and socially when we cannot go out in public. This is something that we
all need to do.

So what we need to do is assist the client who's afraid in this situation of a specific object and
overcoming this fear. So if we think about what it is the nurse would do to assist the client who has
an irrational fear of something that's a normal everyday activity.

And what we want to do is look under the nursing interventions to kind of get an idea of what it is that
the nurse does. Here we go with that A, that relaxation technique. So I keep going back to this
because oftentimes you will see questions that have the nurse teaching some sort of relaxation
technique.

And again clients are managing their own anxiety and stress now. And number B, they use behavior
modification. Let me remind you what kind of behavior modification does the nurse use. It's always
positive reinforcement, giving positive reinforcement for gains, for things that someone does well.

And number C, you want to start this because this is usually the treatment of choice for phobic
disorders and that is gradual desensitization. And gradual desensitization means that we gradually
expose someone to the fear that they might have.

Example might be if someone's afraid to go to the grocery store that they go into the grocery store
for maybe two minutes the first time. And then after that they might go in for five minutes. So that is
usually the treatment of choice for phobic disorders is that gradual exposing them to the feared
object or thing.

3. Obsessive-compulsive disorders (OCD)

1. Definition: recurring obsessions or compulsions
1. Obsessions: recurring thoughts of violence, contamination, doubt, and
worry that cannot be voluntarily removed from consciousness.
2. Compulsions: recurring, irresistible impulse to perform acts (for
example: touching, rearranging, checking, opening and closing,
washing)
3. Obsessions and compulsions may occur together or separately
4. Client's attempt to reduce anxiety

2. Characteristics
1. Irrational coping to handle guilt
2. Feelings of inferiority and low self esteem
 3. Compulsion to repeat act
4. Repeating act prevents severe anxiety
5. Defense Mechanisms
1. Displacement
2. Undoing
3. Isolation
4. Reaction formation

3. Nursing Interventions: nursing interventions are aimed at reducing client anxiety.

1. Distract: substitute
2. Do not interrupt compulsive act
3. Schedule time to complete ritual; gradually decrease the time and number of
times ritual performed
4. Provide safety
5. Maintain structure, schedules, activities
6. Demonstrate acceptance of individual
7. Encourage expression of feelings
8. Antianxiety medications may be used to relieve manifestations

Number C, obsessive-compulsive disorders. By definition, obsessive-compulsive disorders are

reoccurring obsessions or compulsions. I think it's important first if we look at defining the
obsessions and then compulsions and then we can talk about it.

Obsessive-compulsive disorder, which is also known as OCD, has a component of obsessions to it.
And obsessions are reoccurring thoughts of violence, contamination, doubt, and worry that cannot
be voluntarily removed from consciousness. Obsessions are the things that your thoughts are
racing. You might think of reoccurring thoughts of, I'm dirty, my hands are dirty, my, I'm feeling, you
know, reoccurring thoughts of guilt. It's my, I'm responsible for this. If I hadn't done this, this wouldn't
have happened.

So obsessions are the sort of those rambling things that are occurring over and over again in
someone's mind who has obsessive-compulsive disorder. Now the second part of this is the
compulsion, and this is the acting out, the recurring irresistible impulse to perform an act. For
example, they might have over and over obsessions of feeling contaminated, of feeling dirty. That's
the obsession. The compulsion would be hand-washing, recurring over and repetitive act of washing
the hands to undo the obsessive thoughts.

Now you can have obsessions without compulsions, but usually what we see in obsessive-
compulsive disorder is both the reoccurring thoughts and then the act or the compulsion or acting
out. Some examples of compulsions that are very common that you might see in test questions
usually involve things like hand-washing. If we look under this, rearranging. They might be checking.
Somebody who has to go back home and make sure that the door is locked. They feel like they left
the oven on. They have to keep going back and checking or looking to make sure. And this is a very
common question that you might see on a nursing exam. It's something to do, how do you help the
client with obsessive- compulsive disorder?

Now let's take a look at the nursing interventions because I think this is the important part where
we've got a client with an OCD who's, for example, maybe washing and re-washing their hands.
Now let's think about this. Is this considered maladaptive? Is this going to impair you socially? Is it
going to impair you occupationally? Can someone work when they have to every 15 minutes get up
and go wash their hands? So again, this becomes maladaptive because it's done in excess.

The thing with obsessive- compulsive disorder that I find interesting is that our society encourages
people to be sort of neat and tidy and orderly. We like people who are organized. Employers like
people that are real neat and tidy. And this is not necessarily a bad thing. It doesn't mean that
because you have traits that someone is very organized and likes to have things done in a timely
manner in a specific way that it's a problem. The only time that obsessive-compulsive disorder gets
to be a problem is when it impairs you occupationally and socially.
Let's look at what we can do though. If we have a client who's washing their hands frequently, we
want to figure out what it is we can do to reduce the anxiety. Remember the underlying cause with
obsessive-compulsive disorder is anxiety, this need to repeat the act. Number D, under two
characteristics, talks about repeating the act preventssevere anxiety. Remembering that, let's look at
the nursing interventions.

Number A, we want to distract the client because we don't want them washing their hands every five,
ten minutes at the sink. We want to substitute things. So we want to maybe take them out on the
recreational area or to the gym or someplace where, again, they can redirect, distract. Number B,
and you want to start this because typically I see questions that ask, do you interrupt the act and tell
them, come on, let's go. Do not interrupt the compulsive act. And the reason we do not interrupt this
compulsive act is that we will make it worse. We will make the anxiety worse because they have not
been able to complete the ritual.

And number C, we want to schedule time to complete the ritual. Gradually decreasing the time and
the number of times the ritual is performed. If we have a client who's washing their hands every ten
minutes, we want to startwith a small goal. Maybe every 15 minutes they're washing their hands. So
it's a gradual, progressive thing where we're getting them to reduce the number of times that they're
doing the ritual.

Number 12 talks about the nursing focus. It is important to remember that the nursing interventions
are aimed at reducing anxiety. Again, with obsessive-compulsive disorders, remember we do not
interrupt the act, we allow time to complete the act, but we do work at reducing the anxiety so that,
again, we will hopefully eliminate obsessive- compulsive activities such as the hand-washing.

Keep in mind, there's also a few things we need to remember with obsessive-compulsive disorder. If
the person is continually washing their hands, what is a problem that we might have? A nursing
problem. And that would be what? Skin integrity. If we have someone washing their hands, their
hands are going to become very dry and cracked. So again, the activity may lead to other additional
nursing problems, and that we need to be aware whatever act they're doing may also cause
problems in other areas of living as well.
 4.
Post Traumatic Stress Disorder
1. Description: Significant, recognizable stressor or trauma outside the usual
range of experience; results in recurrent subjective reexperiencing of the
trauma.
2. Characteristics
1. Recurrent and intrusive
2. Distressing dreams
3. Intense psychological stress
4. Avoidance of stimuli

3. Nursing Interventions
1. Teach relaxation techniques
2. Assess for suicide potential
3. Encourage client to express feelings

Let's take a look at the next one, which is D, post traumatic stress disorder. And by definition, a post
traumatic stress disorder is a significant recognizable stressor or trauma outside the usual range of
experiencing.

Results in reoccurring subjective re experiencing of the trauma. Post traumatic stress disorder, or
PTSD, is characterized by the following things. A, it's recurrent and intrusive. B, it's distressing
dreams. C, intense psychological stress. And D, avoidance of the stimuli.

Now when we think about post traumatic stress disorder, this is very common for maybe war
veterans. Victims of rape may also suffer post traumatic stress disorder.

And we want to think about what the nursing interventions for someone who's experiencing recurring
thoughts of whatever the stressor trauma was. When we look at the nursing interventions, it starts
with A, teaching relaxation techniques.

We want to make sure that the client who's experiencing post traumatic stress learns how to manage
thisthemselves. Learns how to manage the stress that goes along with this stressor or trauma that
might have happened in early childhood.

Maybe a victim of child abuse or rape who doesn't remember until later adulthood may be
experiencing post traumatic stress. Also we want to B, assess for suicide potential because
oftentimes this recurring thought leads theperson to depression and suicidal thoughts.

And of course we want to encourage them to express their feelings. This is very important for post
traumaticstress.
 2. Somatoform disorders: physical manifestations and complaints without organic
impairment (no real pathology, for example: soldiers paralyzed during war with no real
injury)
1. Conversion disorders (hysteria)
1. Definition: alteration in physical function that is an expression of an
unconscious psychological need
2. Characteristics of manifestations
1. Sensory: blindness, deafness, loss of sensation in extremities
2. Motor: mutism, paralysis of extremities, ataxia, dizziness
3. Visceral: headaches, difficulty breathing
4. Convulsive disorder with a typical seizure response
5. Little concern about manifestations: la belle indifference
6. Defense mechanism: repression of conflict and conversion of
anxiety into manifestations
7. Primary gain: suppressing conflict
8. Secondary gain: sympathy or avoidance of unpleasant activity
gained

3. Nursing Interventions
1. Redirect client away from manifestations
2. Encourage client to express feelings
3. Utilize stress reduction techniques
4. Teach client relaxation techniques
5. Understand the symptoms are real to the client
6. Engage client in schedule of daily activities to decrease time spent focusing on
symptoms and counter secondary gain

The next area that I'd like to discuss is the somatoform disorders and somatoform disorders are
physical manifestations and complaints without organic impairment. In a somatoform disorder there's
no real pathology.

An example of this are that soldiers paralyzed during the war with no injury. The somatoform
disorders are very rare disorders and I'd like to sort of take a look at a few of them and the first one
I'd like to discuss is the conversion disorder or the hysteria.

This is defined as an alteration in physical function that is an expression of an unconscious

psychological need. Let me kind of tell you what a conversion disorder might look like. This is
someone, remember that physical manifestations or physical symptoms are shown that aren't real.

There's no organic reason why a person can't move their leg or why a person can't see. And it
usually, if we look under the characteristics, they involve either A sensory or B motor things.

For example, someone who says I'm blind but they're not really blind, they can really see but they
think, you know, they think that they cannot see. Or someone who has loss of sensation in the arm,
a school teacher who says I can't move my arm.
They can physically move their arm but they think they cannot move their arm. Also motor activities
such as paralysis of I can't move my legs. A common one that, and this is a really rare disorder, but I
have seen a few cases where a client says I can't move my leg.

Or a singer who says I can't sing anymore. I've lost my voice. They've lost their ability to speak.
Usually what we see with a conversion disorder is that it's significant to the client's occupation or
stressor.

It's a manifestation of something significant in their life. Makes sense, an opera singer who says I
cannot sing. I've lost their voice. That's significant. A teacher who says I cannot move my arm
because the teacher would need the arm to write on the board if they taught elementary school.

So it's usually very significant to something in their life. Now for this, the nursing intervention is a little
bit different than when we talk about interventions for a psychotic individual because this is
considered a neurotic disorder.

In other words, it's not real but the person really thinks that it is real. Nursing interventions start with
A, redirect away from the manifestation. The nurse who's always, you know, we want the clients to
verbalize.

We want them to discuss their feelings. For this disorder it would not be therapeutic to say tell me
more about why you can't move your arm because why? It's not real. Simply we don't talk about
things that aren't real.

If, you know, they really can move their arm, we're not going to say oh that's too bad, you poor thing.
You can't move your arm. That's, you know, that's so unfortunate that you're not able to do that.

We want to sort of talk about things that are real in the environment and redirect them to activities
that are real. When their anxiety reduces, again this underlying is anxiety, they will lose that, you
know, that desire to hold whatever physical manifestation is real.

Number C, stress reduction techniques. Once the client learns to reduce their anxiety and to deal
with the anxiety, they will be able to engage in activities like stress reduction activities and group
activities.

The opera singer got the voice back. The teacher was able to move their arm back. Under the
nursing focus we want to look at A, we want to understand and this is very important, you want to
start this.

This is not something that we can say I'm sorry, you really can move your arm if you would just try a
little bit harder. Understand the symptoms are real to the client. They really believe they can't do this.

So we can't rationalize with them and say well of course you can. This is something you can do. It's
real to the client. When the anxiety reduces, they will regain the ability to move whatever limb that's
affected.
Number B, engage the client in schedule of daily activities to decrease the time spent focusing on
the symptoms. The more active the client is involved in other things, art therapy or group therapy,
they're not going to be spending the time with everybody hanging around and saying boy, you know,
yeah it's so unfortunate that this happened to you.

There's a thing called secondary gains. Secondary gains means that there's something else we get
from loss of something. And in this case, someone who's an opera singer who can't sing is getting
people to say oh, he was a great opera singer, why he can't sing, what a shame.

He's getting a lot of people sort of talking to him now and getting people paying attention because
that's whatthey call secondary gains. And we want to avoid giving someone secondary gains from
loss of something that's not real.

Again, the concept here is if it's not real, we don't want to spend a lot of time talking about it and sort
of encouraging this thing to continue.

2. Hypochondriasis
1. Definition: exaggerated preoccupation with physical health, not based on real
organic disorders, not pathology
2. Characteristics
1. Multiple manifestations
2. Worried/anxious about manifestations
3. Seeks medical care frequently from multiple health care providers
3. Nursing Interventions
1. Help client express feelings
2. Set limits on rumination
3. Do not feed into the manifestations
Number B, another kind of somatoform disorder is the hypochondrosis, and by definition this is
exaggerated preoccupation with physical health not based on real organic disorders.
I think another good way to kind of give you an idea of what happens in hypochondriacs is that we all
can probably remember a family member way back who had sort of vague complaints. Every time
you ask, you know, great aunt Bessie, you know, how's your back, how are you feeling? She said,
oh, I got my back pain and my arthritis in my bones. There's sort of vague complaints, headaches,
stomach aches, nothing that is, there's a preoccupation with always having some sort of physical
health problem.
Now with this, again, this is real to the client, and what happens is that people stop asking how
you're feeling because they know that the client is going to go on and on with these numerous sort of
vague complaints.Oftentimes these clients will make numerous visits to the doctor's office, and
they'll get pills for that and pills for this, and they're sort of vague complaints, something that, you
know, nothing major, but things that they want attention paid to.
Now the nursing interventions for this is A, help the client express their feelings if they're feeling sad,
if they're having some legitimate things that are going on that are causing this anxiety to have all
these vague complaints.
Number B, set limits on the rumination. Rumination means going on and on and on about
something. This is not a client you want to say, oh, tell me more about your stomach complaints,
because again, this client will go on and on and on about something that's not real.
Number C, do not feed into or play into. This means don't encourage this. Don't have them tell you
more about the manifestations of this illness. What you can do best for a hypochondriac is just
redirect into the activities.
And again, when the anxiety decreases, the client will have less and less desire to have all these
multiple complaints.

3. Psychophysiological/psychosomatic disorders (Stress-related disorders)

1. Definition: stress-related medical disorders with true pathology: psychosocial
factors pre-dispose client to episodes of illness and influence the progression of
manifestations; can be fatal if not treated adequately. These disorders are
characterized by increasing anxiety in addition to the physical manifestations.
Clients are often first treated in medical facilities.
2. Defense Mechanism
1. Repression
2. Introjection

3. Types
1. Migraine
2. Ulcerative colitis
3. Peptic ulcer
4. Eczema
5. Cancer
6. Rheumatoid arthritis

4. Nursing Interventions
1. Care for physical signs
2. Educate client about body/mind relationship
3. Teach client relaxation techniques (for example: biofeedback imagery,
progressive relaxation)
4. Assist client to express thoughts and feelings
5. Encourage self health promotion and regulation activities (for example:
relaxation, exercise)
6. Promote positive lifestyle changes

Number three is the psychophysical disorders. These are what we usually call stress-related
disorders. We can all identify with stress-related disorders. Oftentimes these claims are seen in
medical facilities. They are usually caused by psychosocial factors that predispose the client to
episodes of illness and influence the progression of manifestations. And it can be fatal if treated
inadequately.
These disorders are characterized by increasing anxiety in addition to the physical manifestations.
Clients are often first treated in medical facilities. And that's important to recognize because although
people say that, well, I'm not gonna be a psychiatric nurse, I can assure you that no matter where
you go to work in nursing, you will be a psychiatric nurse. Using that therapeutic communication
skills. And one of the things you can do is help diagnoseand often intervene with clients who are
having stress-related disorders.
Typically we think about stress-related disorders of being things that males have happen to them.
Males typically were supposed to have the high power, high stress jobs and they were coming home
and they were having all peptic ulcers and they were having migraines. And then what they found
was that these were actually related to stress. Stress was making that peptic ulcer worse. Stress
was making that headache worse. And so that what we have to do is treat this as a psychosocial
thing that's happening, what's going on. That has to change in order for what? This disorder to
improve.
Some types, if we look under the types of stress-related disorders would be like migraines, number
three, peptic ulcer. We now see where number five, cancer is being attributed to stress-related
disorders. Also number seven, hypertension is also directly related to what? How much stress we're
having. We're living in a society that has more and more stress. Don't think it's going away anytime
soon. In fact, stress is an important part of our life. We need stress to kind of motivate us. But
recognize that stress is making people physically ill, physically ill.
So as a nurse, we need to know what it is we can do to help and intervene with clients who are
having stress-related disorders. Let's take a look at the nursing intervention. Number one, we have
care for the physical signs, whatever. We have to treat what physically is going on. But number two,
we need to help the client express feelings.Typically, this is a very type A, meaning a perfectionist,
driven person wants to succeed. They're making themselves physically sick by overworking long
hours. And we also want to do three, client education about what stress is doing to them.
Some of the things under four we can use are those relaxation techniques such as biofeedback,
guided imagery, progressive relaxation. These techniques as far as getting exercise, going to the
gym three times a week. These are all ways that we can teach clients to reduce their stress. The
nursing focus under number five. We want to assist the client to express thoughts and feelings. B,
we want to encourage self-health promotion and regulation activities.Again, exercise, relaxation. And
C, promote a positive lifestyle change. These clients may need to change jobs. They may be in very
stressful jobs. They may need to reduce their hours at work that they're doing because this can be
something that can kill us. Stress can kill us. So we need to be very aware that these clients are
everywhere in every hospital setting.

4. Dissociative disorders (hysterical neuroses)

1. Definition: splitting off an idea or emotion from one's consciousness;
"psychological flight" from anxiety (common with abused children)
2. Types
1. Multiple personality
2. Psychogenic fugue
3. Psychogenic amnesia
4. Depersonalization

3. Nursing Interventions
1. Assess client to rule out organic pathology
2. Help client recognize when dissociation occurs
3. Help client express feelings
4. Initiate individual, group, and family psychotherapy
5. Somatic treatment for maladaptive responses to anxiety, insomnia, and stress-related
conditions
Number 4, the dissociative disorders. This is rare and somewhat, you know, somewhat probably will
not experience this in your practice, but by definition a dissociative disorder is a splitting off of an
idea or emotion from one's consciousness.

It's psychological flight from anxiety. We see dissociative disorders common in children. This is
where abused children will dissociate or split off or not look at or recognize what things happened in
their past that do, that does affect them as adults.

Some of the types that we see are like one, multiple personality disorders, and three, the
psychogenic amnesia. We've all heard of someone getting amnesia, getting hit over the head and
not recognizing what is going on.

So what we want to do with this, and this is, I think what's important with this is our nursing
interventions. Number one, we always do assessment and rule out anything that might pathologically
might be going on.

Help the client recognize when dissociation occurs. Again, we want to, three, help the client express
their feelings. We want to look at some of the somatic treatment for maladaptive responses to
anxiety, insomnia, and stress-related conditions.

ANTIANXIETY AGENTS
CHEMICAL GENERIC NAME TRADE NAME MEDICATION
CLASS ALERTS

Benzodiazepine - chlordiazepoxide - Librium - Benzodiazepines:

compounds - diazepam - Valium Warn clients about
- oxazepam - Serax sedating effects,
- clorazepate - Tranxene - Avoid activities
- lorazepam - Ativan requiring mental
- alprazolam - Xanax alertness
- clonazepam - Klonopin - Monitor for signs
- clomipramide HCL - Anafranil of drug
dependence.
- Withdrawal up to
two weeks; risk for
seizure.
- Anafranil,
commonly used for
OCD, should be
cautiously used in
clients with
 cardiovascular
disease and is
potentially
fatal in overdose

Mephenesm-like meprobamate Miltown, Equanil

compounds

Sedating hydroxyzine Vistaril, Atarax Antihistamines tend

antihistamines to cause drying and
sedation

Beta-blockers propranolol Inderal

(SSRI) Selective paroxetine Paxil Shown to be

Serotonin Reuptake effective with Social
Inhibitors Anxiety Disorder.
Allow 2-3 weeks to
note effects

Anxiolytics buspirone BuSpar BuSpar-non-

sedatmg, allow 2-3
weeks to note
effects. Do not use
concurrently with
alcohol or history of
hepatic disease

KEY INFORMATION

Antianxiety medications are not a cure for anxiety, but a temporary means to reduce
anxiety. Antianxiety medications can be highly lethal in overdose. Monitor suicidal
clients closely. Elderly clients are easily sedated and at risk for fall with
benzodiazepines
The next part of our review is on the anti-anxiety agents. The anti-anxiety agents is something that
every nurse will need to be very familiar with. Benzodiazepines in the chemical class are the most
prescribed drugs in the United States. This classification is very large.
If we look at some of the trade names, we might recognize some of these drugs. Librium, Valium,
Cerax, Ativan, Xanax, Klonopin. These are all very common benzodiazepines. Most often I've seen
questions of Ativan. I think all of us have heard of Ativan. We've heard of Valium. These are very
prescribed compounds.
What we want to remember about the benzodiazepines, and these are the significant things that I
would say as a nurse you need to recognize. Warn the clients about its sedating effect.
Benzodiazepines doesn't take much. Very small milligram can put people right to sleep. That's what
they're used for. Anti-anxiety agents calm people down.They help in reducing anxiety. If we're
reducing anxiety, a side effect would be that it would make us calm and sedated.
This can be something that as a nurse we need to know because we need to avoid activities
requiring mental alertness. Most of us have seen prescription bottles, right? If you look on the side of
them, they say do not operate heavy machinery. This will cause sedation. This classification, this is
one of those drugs that you should be very aware of. It does cause sedation.
Monitor for signs of drug dependence. You want to start with that. These medications are addictive.
Long-term use, someone on benzodiazepines, they will become physically addicted to this
medication. The intention for anti-anxiety agents is to reduce anxiety for a temporary time until the
client's anxiety is reduced and then they can manage on their own. So this is a short-term treatment,
usually one to two weeks.
Anti-anxiety agents such as the benzos are not intended for long-term use. We would hope that the
client would eventually be able to manage their own stress and anxiety. Also, we want to monitor for
these signs of drug dependence. If a client is using the drug and needing, requiring the drug for
daily, you know, two times, three times a day just to stay calm.
And understand that we can't just take somebody off of benzodiazepine that's been on it for one to
two years or for a long period of time because they can go through withdrawal because they are
dependent. And of course, if they go through withdrawal, there is an anti-seizure component to these
medications. So if we take them off the benzodiazepines quickly, they are at great risk for seizure.
This is important information to know because a lot of your clients are on benzodiazepines. Other
medications that are used for anti-anxiety agents are sedating antihistamines. Vistaril, we're familiar
with Vistaril, Atarax.Vistaril usually is used preoperatively. What it does is, what, dry secretions. It's
an antihistamine, so it does what? It dries us up. It can cause all that nasal stuffiness.
But Vistaril is also used preoperatively and is in psychiatric practice because it does cause some
sedating effects to it. And remember that antihistamines tend to cause that drying and stuff. So your
clients will be very dry and they often may be very sedated as well. Some clients get very sedated
on antihistamines. Something to remember.
One of the new drugs that are being used, the anxiety drug that's being used is Buspar. Buspar is a
new anti-anxiety agent that is non-sedating. So rather than having someone on a benzodiazepine,
they may often be placed on Buspar, which will not cause all those sedating effects. But note that it
does take 2 to 3 weeks for this medication to work.
Also remember that you do not use concurrently with alcohol or history of hepatic disease. Also I'd
like to mention that you don't mix alcohol with any of these drugs. That would not be a good idea for
the nurse to encourage a client in any way to be using alcohol. But remember that you especially
want to teach that they do not want to use alcohol when taking a benzodiazepine as well.
Under key information, remember that anti-anxiety medications are not a cure for anxiety, but a
temporary means to reduce anxiety. Anti-anxiety medications can be highly lethal. Underline that.
Highly lethal in overdose.Someone who's suicidal may take an overdose of anti-anxiety medication.
So you want to monitor suicidal clients closely. Remember this.

Elderly clients are easily sedated. So if an elderly client is taking a benzodiazepine, they're at risk for
what?Falls. This is a safety question. This is very typically a question that might ask you, you know,
if a client is an elderly client on a benzodiazepine, what would you want to monitor for? And the
answer for that would, of course, be safety and falls.