Medical Surgical Nursing The GASTRO-INTESTINAL system Local Board Review The GIT System: Anatomy and Physiology

The GIT is composed of two general parts (23 26 foot long) The main GIT starts from the mouthEsophagusStomachSILI The accessory organs are the 1. Salivary glands 2. Liver 3. Gallbladder 4. Pancreas The GIT ANATOMY The Mouth Contains the lips, cheeks, palate, tongue, teeth, salivary glands, masticatory/facial muscles and bones Anteriorly bounded by the lips Posteriorly bounded by the oropharynx The Mouth Important for the mechanical digestion of food The saliva contains SALIVARY AMYLASE or PTYALIN that starts the INITIAL digestion of carbohydrates The GIT ANATOMY The Esophagus A hollow collapsible tube Length- 10 inches Made up of stratified squamous epithelium Posterior to the trachea and heart The GIT PHYSIOLOGY The Esophagus Functions to carry or propel foods from the oropharynx to the stomach The GIT ANATOMY The stomach J-shaped organ in the epigastrium Contains four parts- the fundus, the cardia, the body and the pylorus The cardiac sphincter prevents the reflux of the contents into the esophagus The pyloric sphincter regulates the rate of gastric emptying into the duodenum Capacity is 1,500 ml! The GIT PHYSIOLOGY The functions of the stomach are generally to digest the food (proteins) and to propel the digested materials into the SI for final digestion The Glands and cells in the stomach secrete digestive enzymes: The GIT PHYSIOLOGY Stomach: 1. Parietal cells- HCl acid and Intrinsic factor 2. Chief cells- pepsin digestion of PROTEINS! 3. Antral G-cells- gastrin 4. Argentaffin cells- serotonin 5. Mucus neck cells- mucus

The GIT ANATOMY The Small intestine Grossly divided into the Duodenum, Jejunum and Ileum The ileum is the longest part (about 12 feet) Longest segment of the GI tract 7000cm Area for secretion and absorption Ileo-cecal valve controls passage of intestinal contents in the large intestines The GIT physiology The intestinal glands secrete digestive enzymes that finalize the digestion of all foodstuff Enzymes for carbohydrates disaccharidases Enzymes for proteins dipeptidases and aminopeptidases Enzyme for lipids intestinal lipase The GIT ANATOMY The Large intestine Approximately 5 feet long, with parts: 1. The cecum widest diameter, prone to rupture 2. The appendix 3. The ascending colon 4. The transverse colon 5. The descending colon 6. The sigmoid most mobile, prone to twisting 7. The rectum The GIT Physiology Absorbs water Eliminates wastes Bacteria in the colon synthesize Vitamin K Appendix participates in the immune system The GIT Physiology SYMPATHETIC Generally INHIBITORY! Decreased gastric secretions Decreased GIT motility But: Increased sphincteric tone and constriction of blood vessels PARASYMPATHETIC Generally EXCITATORY! Increased gastric secretions Increased gastric motility But: Decreased sphincteric tone and dilation of blood vessels Functions of the Digestive System 1. To breakdown food particles into the molecular form for digestion. 2. To absorb into the bloodstream the small molecules produced by digestion 3. To eliminate undigested and unabsorbed foodstuffs and other waste products from the body Process of digestion begins with this act Saliva is excreted from 3 pairs of glands Parotid submaxillary

 sublingual 1.5 liters of saliva is secreted daily Saliva contains enzyme Ptyalin or salivary amylase Contains mucus and water which helps to lubricate the food facilitating swallowing As food is swallowed the epiglottis covers the trachea Esophageal sphinter relaxes to permit bolus of food to enter the stomach Gastric Function Stomach mixes and stores foods with secretion Secretes gastric acid, HCL 2.4L per day Also secretes Pepsin and Intrinsic factor Function of gastric secretion is to breakdown food and destroy most ingested bacteria Chyme, food mixed with gastric secretions Pyloric sphincter Small intestines function Digestive process continues in the duodenum. Accessory digestive organs, pancreas, liver and gall bladder Digestive enzymes a. Trypsin digest proteins b. Amylase digest starch c. lipase digest fats Bile emulsifies fats Carbohydrates disaccharrides sucrose, maltose and galactose monosacharides glucose and fructose major role is absorption duodenum iron and calcium jejunum fats, protein, carbohydrate, Na, chloride ileum - Vit B12 and bile salts Colonic function 4 hrs after eating residual waste passes through the ileo-cecal valve Bacteria assist in completing the breakdown of waste material 12 hours after a meal Feces 75% water, 25% solid Indole and skatole bile The GIT ANATOMY The Liver The largest internal organ Located in the right upper quadrant Contains two lobes- the right and the left The hepatic ducts join together with the cystic duct to become the common bile duct The GIT Physiology: LIVER Functions to store excess glucose, fats and amino acids Also stores the fat soluble vitamins- A, D and the water soluble- Vitamin B12 Produces the BILE for normal fat digestion The Von Kupffer cells remove bacteria in the portal blood Detoxifies ammonia into urea The GIT anatomy The gallbladder Located below the liver

The cystic duct joins the hepatic duct to become the bile duct The common bile duct joins the pancreatic duct in the sphincter of Oddi in the first part of the duodenum The GIT Physiology Stores and concentrates bile Contracts during the digestion of fats to deliver the bile Cholecystokinin is released by the duodenal cells, causing the contraction of the gallbladder and relaxation of the sphincter of Oddi The GIT anatomy

The pancreas A retroperitoneal gland Functions as an endocrine and exocrine gland The pancreatic duct (major) joins the common bile duct in the sphincter of Oddi The GIT Physiology The exocrine function of the pancreas is the secretion of digestive enzymes for carbohydrates, fats and proteins Pancreatic amylase carbohydrates Pancreatic lipase (steapsin) fats Trypsin, Chymotrypsin and Peptidases proteins Bicarbonate to neutralize the acidic chyme. Stimulated by SECRETIN! Assessment The NURSING PROCESS in GIT Disorders Assessment Health history Nursing History PE Laboratory procedures Clinical history and manifestations Elicit information regarding; - pain, indigestion - intestinal gas, nausea and vomitting - hematemesis - changes in bowel habits and characteristics - current medication intake - tobacco and alcohol use The ABDOMINAL examination The sequence to follow is: Inspection Auscultation Percussion Palpation Physical Assessment Assessment of the mouth, abdomen and rectum Lie the patient supine with knee flexed Inspect for previous scars, shape

Bowel sounds - normoactive BS q 5 to 20 secs - hypoactive 1-2 sounds in 2 minutes - hyperactive 5-6 sounds in < 30secs - absent no sound in >3-5 mins

Laboratory Procedures COMMON LABORATORY PROCEDURES FECALYSIS Examination of stool consistency, color and the presence of occult blood. Special tests for fat, nitrogen, parasites, ova, pathogens and others Occult Blood Testing Instruct the patient to adhere to a 3-day meatless diet No intake of NSAIDS, aspirin and anti-coagulant Screening test for colonic cancer Breath Test Urea breath test - detect the presence of Helicobacter Pylori Hydrogen breath test - evaluate carbohydrate absorption Upper GIT study: barium swallow Examines the upper GI tract Barium sulfate is usually used as contrast Detect or exclude anatomic or functional derangement of the upper GI organ or sphincter Aids in the diagnosis of ulcers, varices, tumors, regional enteritis and malabsorption syndrome Upper GIT study: barium swallow Pre-test: NPO post-midnight, low residue diet Post-test: Laxative is ordered, increase pt fluid intake, instruct that stools will turn white, monitor for obstruction COMMON LABORATORY PROCEDURES Lower GIT study: barium enema Examines the lower GI tract Barium is instilled rectally Pre-test: Clear liquid diet and laxatives, NPO postmidnight, cleansing enema prior to the test Lower GIT study: barium enema Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn white, monitor for obstruction Detects the presence of tumors, polyps and other lesions of the small intestines Demonstrate any abnormal anatomy or malfunction of the bowel. COMMON LABORATORY PROCEDURES Gastric analysis Aspiration of gastric juice to measure pH, appearance, volume and contents Pre-test: NPO 8 hours, avoidance of stimulants, drugs and smoking Post-test: resume normal activities Yields information about the secretory activity of the gastric mucosa Presence or degree of gastric retention in patients thought to have pyloric or duodenal obstruction Useful for diagnosis of Zollinger Ellison Syndrome COMMON LABORATORY PROCEDURES EGD

(esophagogastroduodenoscopy) Visualization of the upper GIT by endoscope Pre-test: ensure consent, NPO 8 hours, pre-medications like atropine and anxiolytics COMMON LABORATORY PROCEDURES EGD Esophagogastroduodenoscopy Pretest: NPO Intra-test: position : LEFT lateral to facilitate salivary drainage and easy access COMMON LABORATORY PROCEDURES EGD (esophagogastroduodenoscopy) Post-test: NPO until gag reflex returns, place patient in SIMS position until he awakens, monitor for complications, saline gargles for mild oral discomfort COMMON LABORATORY PROCEDURES Lower GI- scopy Use of endoscope to visualize the anus, rectum, sigmoid and colon Evaluate rectal bleeding, acute or chronic diarrhea, change in bowel patterns, ulcerations, polyps, tumors Pre-test: consent, NPO 8 hours, cleansing enema until return is clear COMMON LABORATORY PROCEDURES Lower GI- scopy Intra-test: position is LEFT lateral, right leg is bent and placed anteriorly Post-test: bed rest, monitor for complications like bleeding and perforation COMMON LABORATORY PROCEDURES Cholecystography Examination of the gallbladder to detect stones, its ability to concentrate, store and release the bile Pre-test: ensure consent, ask allergies to iodine, seafood and dyes; contrast medium is administered the night prior, NPO after contrast administration COMMON LABORATORY PROCEDURES Cholecystography Post-test: Advise that dysuria is common as the dye is excreted in the urine, resume normal activities COMMON LABORATORY PROCEDURES Paracentesis Removal of peritoneal fluid for analysis COMMON LABORATORY PROCEDURES Paracentesis Pre-test: ensure consent, instruct to VOID and empty bladder, measure abdominal girth

COMMON LABORATORY PROCEDURES Paracentesis Intra-test: Upright on the edge of the bed, back supported and feet resting on a foot stool COMMON LABORATORY PROCEDURES Liver biopsy Pretest Consent NPO Check for the bleeding parameters

COMMON LABORATORY PROCEDURES Liver biopsy Intratest Position: Semi fowlers LEFT lateral to expose right side of abdomen COMMON LABORATORY PROCEDURES Liver biopsy Post-test: position on RIGHT lateral with pillow underneath, monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week COMMON GIT SYMPTOMS AND MANAGEMENT CONSTIPATION DIARRHEA DUMPING SYNDROME COMMON GIT SYMPTOMS AND MANAGEMENT CONSTIPATION An abnormal infrequency and irregularity of defecation Multiple causations COMMON GIT SYMPTOMS AND MANAGEMENT CONSTIPATION: Pathophysiology Interference with three functions of the colon 1. Mucosal transport 2. Myoelectric activity 3. Process of defecation COMMON GIT SYMPTOMS AND MANAGEMENT NURSING INTERVENTIONS 1. Assist physician in treating the underlying cause of constipation 2. Encourage to eat HIGH fiber diet to increase the bulk 3. Increase fluid intake 4. Administer prescribed laxatives, stool softeners 5. Assist in relieving stress COMMON GIT SYMPTOMS AND MANAGEMENT Diarrhea Abnormal fluidity of the stool Multiple causes Gastrointestinal Diseases Hyperthyroidism Food poisoning COMMON GIT SYMPTOMS AND MANAGEMENT Diarrhea Nursing Interventions 1. Increase fluid intake- ORESOL is the most important treatment! 2. Determine and manage the cause 3. Anti-diarrheal drugs COMMON GIT SYMPTOMS AND MANAGEMENT DUMPING SYNDROME A condition of rapid emptying of the gastric contents into the small intestine usually after a gastric surgery Symptoms occur 30 minutes after eating COMMON GIT SYMPTOMS AND MANAGEMENT PATHOPHYSIOLOGY Foods high in CHO and electrolytes must be diluted in the jejunum before absorption takes place. COMMON GIT SYMPTOMS AND MANAGEMENT PATHOPHYSIOLOGY

The rapid influx of stomach contents will cause distention of the jejunum early symptoms COMMON GIT SYMPTOMS AND MANAGEMENT PATHOPHYSIOLOGY The hypertonic chyme will draw fluid from the blood vessels to dilute the high concentrations of CHO and electrolytes COMMON GIT SYMPTOMS AND MANAGEMENT Later, there is increased blood glucose stimulating the increased secretion of insulin Then, blood glucose will fall causing reactive hypoglycemia COMMON GIT SYMPTOMS AND MANAGEMENT DUMPING SYNDROME ASSESSMENT FINDINGS: early symptoms 1. Nausea and Vomiting 2. Abdominal fullness 3. Abdominal cramping 4. Palpitation 5. Diaphoresis COMMON GIT SYMPTOMS AND MANAGEMENT DUMPING SYNDROME ASSESSMENT FINDINGS: LATE symptoms: 6. Drowsiness 7. Weakness and Dizziness 8. Hypoglycemia COMMON GIT SYMPTOMS AND MANAGEMENT DS NURSING INTERVENTIONS 1. Advise patient to eat LOW-carbohydrate HIGH-fat and HIGH-protein diet 2. Instruct to eat SMALL frequent meals, include MORE dry items. 3. Instruct to AVOID consuming FLUIDS with meals COMMON GIT SYMPTOMS AND MANAGEMENT DS NURSING INTERVENTIONS 4. Instruct to LIE DOWN after meals 5. Administer anti-spasmodic medications to delay gastric emptying GIT SYMPTOMS AND MANAGEMENT PERNICIOUS ANEMIA Results from Deficiency of vitamin B12 due to autoimmune destruction of the parietal cells, lack of INTRINSIC FACTOR or total removal of the stomach GIT SYMPTOMS AND MANAGEMENT PERNICIOUS ANEMIA ASSESSMENT Severe pallor Fatigue Weight loss Smooth BEEFY-red tongue Mild jaundice Paresthesia of extremities Balance disturbance GIT SYMPTOMS AND MANAGEMENT NURSING INTERVENTION for Pernicious Anemia Lifetime injection of Vitamin B 12 weekly initially, then MONTHLY Conditions of the GIT UPPER GI system CONDITION OF THE ESOPHAGUS HIATAL HERNIA

Protrusion of the esophagus into the diaphragm thru an opening Occurs more often in women Two types- Sliding hiatal hernia ( most common) and Axial hiatal hernia ASSESSMENT Findings in Hiatal hernia 1. Heartburn 2. Regurgitation 3. Dysphagia 4. 50%- without symptoms DIAGNOSTIC TEST Barium swallow and fluoroscopy NURSING INTERVENTIONS 1. Provide small frequent feedings 2. AVOID supine position for 1 hour after eating 3. Elevate the head of the bed on 8-inch block 4. Provide pre-op and post-op care CONDITION OF THE ESOPHAGUS Esophageal Varices Dilation and tortuosity of the submucosal veins in the distal esophagus ETIOLOGY: commonly caused by PORTAL hypertension secondary to liver cirrhosis This is an Emergency condition! ASSESSMENT findings for EV 1. Hematemesis 2. Melena 3. Ascites 4. jaundice 5. hepatomegaly/splenomegaly ASSESSMENT findings for EV Signs of Shock- tachycardia, hypotension, tachypnea, cold clammy skin, narrowed pulse pressure DIAGNOSTIC PROCEDURE Esophagoscopy CONDITION OF THE ESOPHAGUS NURSING INTERVENTIONS FOR EV 1. Monitor VS strictly. Note for signs of shock 2. Monitor for LOC 3. Maintain NPO 4. Monitor blood studies 5. Administer O2 6. prepare for blood transfusion 7. prepare to administer Vasopressin and Nitroglycerin 8. Assist in NGT and Sengstaken-Blakemore tube insertion for balloon tamponade 9. Prepare to assist in surgical management: Endoscopic sclerotherapy 1. Variceal ligation 2. Shunt procedures Conditions of the Stomach Gastro-esophageal reflux Backflow of gastric contents into the esophagus Usually due to incompetent lower esophageal sphincter , pyloric stenosis or motility disorder Symptoms may mimic ANGINA or MI

ASSESSMENT ( for GERD) Heartburn Dyspepsia Regurgitation Epigastric pain Difficulty swallowing Ptyalism Odynophagia or dysphagia Diagnostic test Endoscopy or barium swallow Gastric ambulatory pH analysis Note for the pH of the esophagus, usually done for 24 hours The pH probe is located 5 inches above the lower esophageal sphincter The machine registers the different pH of the refluxed material into the esophagus Conditions of the Stomach NURSING INTERVENTIONS 1. Instruct the patient to AVOID stimulus that increases stomach pressure and decreases GES pressure 2. Instruct to avoid spices, coffee, tobacco and carbonated drinks 3. Instruct to eat LOW-FAT, HIGH-FIBER diet 4. Avoid foods and drinks TWO hours before bedtime 5. Elevate the head of the bed with an approximately 8inch block Conditions of the Stomach 6. Administer prescribed H2-blockers, PPI and prokinetic meds like cisapride, metochlopromide 7. Advise proper weight reduction Barrets Esophagus Result from long standing untreated GERD Precancerous condition that can lead to adenocarcinoma of the esophagus More common in middle aged men Heartburn and symptoms of peptic ulcer and esophageal strictures Diverticulum Outpouching of mucosa and submucosa that protrude through a weak portion of the musculature Zenkers diverticulum, most common and frequent in men older than 60 years old Dysphagia, fulness in the neck, belching, regurgitation of undigested food gurgling noises after eating Diverticulum becomes filled with food and regurgitate when assuming a recumbent position causing coughing Halitosis and sour taste is common Barium swallow Surgical removal of the diverticuli Cancer of the esophagus >3x more common in men

 Occurs in the fifth decade of life Chronic irritation, ingestion of alcohol and tobacco use GERD and Barrets Esophagus Usually squamous cell epidermoid type Clinical manifestation Dyspahgia Mass in the throat Regurgitation of undigested foods Foul breath and hiccups Conditions of the Stomach GASTRITIS Inflammation of the gastric mucosa May be Acute or Chronic Etiology: Acute- bacteria, irritating foods, NSAIDS, alcohol, bile and radiation Etiology: Chronic- Ulceration, bacteria, Autoimmune disease, diet, alcohol, smoking Conditions of the Stomach PATHOPHYSIOLOGY OF Gastritis Insults cause gastric mucosal damage inflammation, hyperemia and edema superficial erosions decreased gastric secretions, ulcerations and bleeding Conditions of the Stomach ASSESSMENT (Acute) Dyspepsia Headache Anorexia Nausea/Vomiting ASSESSMENT (Chronic) Pyrosis Singultus Sour taste in the mouth Dyspepsia N/V/anorexia Pernicious anemia Conditions of the Stomach DIAGNOSTIC PROCEDURE EGD- to visualize the gastric mucosa for inflammation Low levels of HCl Biopsy to establish correct diagnosis whether acute or chronic Conditions of the Stomach NURSING INTERVENTIONS 1. Give BLAND diet 2. Monitor for signs of complications like bleeding, obstruction and pernicious anemia 3. Instruct to avoid spicy foods, irritating foods, alcohol and caffeine 4. Administer prescribed medications- H2 blockers, antibiotics, mucosal protectants 5. Inform the need for Vitamin B12 injection if deficiency is present Conditions of the Stomach PEPTIC ULCER DISEASE An ulceration of the gastric and duodenal lining May be referred as to location as Gastric ulcer in the stomach, or Duodenal ulcer in the duodenum

Most common Peptic ulceration: anterior part of the upper duodenum Conditions of the Stomach PATHOPHYSIOLOGY of PUD Disturbance in acid secretion and mucosal protection Increased acidity or decreased mucosal resistance erosion and ulceration Conditions of the Stomach GASTRIC ULCER Ulceration of the gastric mucosa, submucosa and rarely the muscularis Risk factors: Stress, smoking, NSAIDS abuse, Alcohol, Helicobacter pylori infection, type A personality and History of gastritis Incidence is high in older adults Acid secretion is NORMAL Conditions of the Stomach ASSESSMENT (Gastric Ulcer) Epigastric pain Characteristic: Gnawing, sharp pain in the midepigastrium 1-2 hours AFTER eating, often NOT RELIEVED by food intake, sometimes AGGRAVATING the pain! Nausea Vomiting is more common Hematemesis Weight loss Conditions of the Stomach DIAGNOSTIC PROCEDURES 1. EGD to visualize the ulceration 2. Urea breath test for H. pylori infection 3. Biopsy- to rule out gastric cancer Conditions of the Stomach NURSING INTERVENTIONS 1. Give BLAND diet, small frequent meals during the active phase of the disease 2. Administer prescribed medications- H2 blockers, PPI, mucosal barrier protectants and antacids 3. Monitor for complications of bleeding, perforation and intractable pain 4. provide teaching about stress reduction and relaxation techniques Conditions of the Stomach NURSING INTERVENTIONS FOR BLEEDING 1. Maintain on NPO 2. Administer IVF and medications 3. Monitor hydration status, hematocrit and hemoglobin Conditions of the Stomach 4. Assist with SALINE lavage 5. Insert NGT for decompression and lavage 6. Prepare to administer blood transfusion 7. Prepare to give VASOPRESSIN to induce vasoconstriction to reduce bleeding 8. Prepare patient for SURGERY if warranted Conditions of the Stomach SURGICAL PROCEDURES FOR PUD Total gastrectomy, vagotomy, gastric resection, Billroth I and II, pyloroplasty

SURGICAL PROCEDURES FOR PUD Post-operative Nursing management 1. Monitor VS 2. Post-op position: FOWLERS 3. NPO until peristalsis returns 4. Monitor for bowel sounds 5. Monitor for complications of surgery 6. Monitor I and O, IVF 7. Maintain NGT 8. Diet progress: clear liquid full liquid six bland meals 9. Manage DUMPING SYNDROME Condition of the Duodenum DUODENAL ULCER Ulceration of duodenal mucosa and submucosa Usually due to increased gastric acidity Condition of the Duodenum DUODENAL ULCER ASSESSMENT PAIN characteristic: Burning pain in the mid-epigastrium 2-4 HOURS after eating or during the night, RELIEVED by food intake Condition of the Duodenum DIAGNOSTIC TESTS EGD and Biopsy Condition of the Duodenum NURSING INTERVENTIONS 1. Same as for gastric ulceration 2. Patient teaching-avoid alcohol, smoking, caffeine and carbonated drinks Take NSAIDS with meals Adhere to medication regimen CONDITIONS OF THE SMALL INTESTINE CROHNS DISEASE Also called Regional Enteritis An inflammatory disease of the GIT affecting usually the small intestine ETIOLOGY: unknown The terminal ileum thickens, with scarring, ulcerations, abscess formation and narrowing of the lumen CONDITIONS OF THE SMALL INTESTINE ASSESSMENT findings for CD 1. Fever 2. Abdominal distention 3. Diarrhea 4. Colicky abdominal pain 5. Anorexia/N/V 6. Weight loss 7. Anemia CONDITIONS OF THE LARGE INTESTINE ULCERATIVE COLITIS Ulcerative and inflammatory condition of the GIT usually affecting the large intestine The colon becomes edematous and develops bleeding ulcerations Scarring develops overtime with impaired water absorption and loss of elasticity CONDITIONS OF THE LARGE INTESTINE

ASSESSMENT findings for UC 1. Anorexia 2. Weight loss 3. Fever 4. SEVERE diarrhea with Rectal bleeding 5. Anemia 6. Dehydration 7. Abdominal pain and cramping NURSING INTERVENTIONS for CD and UC 1. Maintain NPO during the active phase 2. Monitor for complications like severe bleeding, dehydration, electrolyte imbalance 3. Monitor bowel sounds, stool and blood studies 4. Restrict activities= rest and comfort 5. Administer IVF, electrolytes and TPN if prescribed Monitor complications of diarrhea 6. Instruct the patient to AVOID gas-forming foods, MILK products and foods such as whole grains, nuts, RAW fruits and vegetables especially SPINACH, pepper, alcohol and caffeine 7. Diet progression- clear liquid LOW residue, high protein diet 8. Administer drugs- anti-inflammatory, antibiotics, steroids, bulk-forming agents and vitamin/iron supplements CONDITIONS OF THE LARGE INTESTINE APPENDICITIS Inflammation of the vermiform appendix APPENDICITIS ETIOLOGY: usually fecalith, lymphoid hyperplasia, foreign body and helminthic obstruction CONDITIONS OF THE LARGE INTESTINE APPENDICITIS PATHOPHYSIOLOGY Obstruction of lumen increased pressure decreased blood supply bacterial proliferation and mucosal inflammation ischemia necrosis rupture CONDITIONS OF THE LARGE INTESTINE ASSESSMENT FINDINGS for Appendicitis 1. Abdominal pain: begins in the umbilicus then localizes in the RLQ (Mc Burneys point) 2. Anorexia 3. Nausea and Vomiting 4. Fever 5. Rebound tenderness and abdominal rigidity (if perforated) 6. Constipation or diarrhea CONDITIONS OF THE LARGE INTESTINE DIAGNOSTIC TESTS 1. CBC- reveals increased WBC count 2. Ultrasound 3. Abdominal X-ray CONDITIONS OF THE LARGE INTESTINE NURSING INTERVENTIONS 1. Preoperative care NPO Consent Monitor for perforation and signs of shock CONDITIONS OF THE LARGE INTESTINE

NURSING INTERVENTIONS 1. Preoperative care Monitor bowel sounds, fever and hydration status POSITION of Comfort: RIGHT SIDELYING in a low FOWLERS Avoid Laxatives, enemas & HEAT APPLICATION 2. Post-operative care Monitor VS and signs of surgical complications Maintain NPO until bowel function returns If rupture occurred, expect drains and IV antibiotics CONDITIONS OF THE LARGE INTESTINE 2. Post-operative care POSITION post-op: RIGHT side-lying, SEMI- FOWLERS to decrease tension on incision, and legs flexed to promote drainage Administer prescribed pain medications CONDITIONS OF THE LARGE INTESTINE Hemorrhoids Abnormal dilation and weakness of the veins of the anal canal Variously classified as Internal or External, Prolapsed, Thrombosed and Reducible CONDITIONS OF THE LARGE INTESTINE Hemorrhoids PATHOPHYSIOLOGY Increased pressure in the hemorrhoidal tissue due to straining, pregnancy, etc dilatation of veins CONDITIONS OF THE LARGE INTESTINE Internal hemorrhoids These dilated veins lie above the internal anal sphincter Usually, the condition is PAINLESS CONDITIONS OF THE LARGE INTESTINE External hemorrhoids These dilated veins lie below the internal anal sphincter Usually, the condition is PAINFUL CONDITIONS OF THE LARGE INTESTINE ASSESSMENT findings for Hemorrhoids 1. Internal hemorrhoids- cannot be seen on the peri-anal area 2. External hemorrhoids- can be seen 3. Bright red bleeding with each defecation 4. Rectal/ perianal pain 5. Rectal itching 6. Skin tags CONDITIONS OF THE LARGE INTESTINE DIAGNOSTIC TEST 1. Anoscopy 2. Digital rectal examination CONDITIONS OF THE LARGE INTESTINE NURSING INTERVENTIONS 1. Advise patient to apply cold packs to the anal/rectal area followed by a SITZ bath 2. Apply astringent like witch hazel soaks 3. Encourage HIGH-fiber diet and fluids 4. Administer stool softener as prescribed CONDITIONS OF THE LARGE INTESTINE Post-operative care for hemorrhoidectomy

1. Position: Prone or Side-lying 2. Maintain dressing over the surgical site 3. Monitor for bleeding 4. Administer analgesics and stool softeners 5. Advise the use of SITZ bath 3-4 times a day DIVERTICULOSIS AND DIVERTICULITIS Diverticulosis Abnormal out-pouching of the intestinal mucosa occurring in any part of the LI most commonly in the sigmoid Diverticulitis Inflammation of the diverticulosis CONDITIONS OF THE LARGE INTESTINE PATHOPHYSIOLOGY Increased intraluminal pressure, LOW volume in the lumen and Decreased muscle strength in the colon wall herniation of the colonic mucosa CONDITIONS OF THE LARGE INTESTINE ASSESSMENT findings for D/D 1. Left lower Quadrant pain 2. Flatulence 3. Bleeding per rectum 4. nausea and vomiting 5. Fever 6. Palpable, tender rectal mass CONDITIONS OF THE LARGE INTESTINE DIAGNOSTIC STUDIES 1. If no active inflammation, COLONOSCOPY and Barium Enema 2. CT scan is the procedure of choice! 3. Abdominal X-ray CONDITIONS OF THE LARGE INTESTINE NURSING INTERVENTIONS 1. Maintain NPO during acute phase 2. Provide bed rest 3. Administer antibiotics, analgesics like meperidine (morphine is not used) and anti-spasmodics 4. Monitor for potential complications like perforation, hemorrhage and fistula 5. Increase fluid intake 6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping 7. introduce soft, high fiber foods ONLY after the inflammation subsides 8. Instruct to avoid activities that increase intra-abdominal pressure CONDITION OF THE LIVER Liver Cirrhosis A chronic, progressive disease characterized by a diffuse damage to the hepatic cells The liver heals with scarring, fibrosis and nodular regeneration CONDITION OF THE LIVER Liver Cirrhosis ETIOLOGY: Post-infection, Alcohol, Cardiac diseases, Schisostoma, Biliary obstruction Liver physiology and Pathophysiology

CONDITION OF THE LIVER ASSESSMENT FINDINGS 1. Anorexia and weight loss 2. Jaundice 3. Fatigue 4. Early morning nausea and vomiting 5. RUQ abdominal pain 6. Ascites 7. Signs of Portal hypertension CONDITION OF THE LIVER NURSING INTERVENTIONS 1. Monitor VS, I and O, Abdominal girth, weight, LOC and Bleeding 2. Promote rest. Elevated the head of the bed to minimize dyspnea 3. Provide Moderate to LOW-protein (1 g/kg/day) and LOW-sodium diet 4. Provide supplemental vitamins (especially K) and minerals 5. Administer prescribed Diuretics= to reduce ascites and edema Lactulose= to reduce NH4 in the bowel Antacids and Neomycin= to kill bacterial flora that cause NH production 6. Avoid hepatotoxic drugs Paracetamol Anti-tubercular drugs 7. Reduce the risk of injury Side rails reorientation Assistance in ambulation Use of electric razor and soft-bristled toothbrush 8. Keep equipments ready including SengstakenBlakemore tube, IV fluids, Medications to treat hemorrhage CONDITION OF THE LIVER Conditions of the Accessory organs The Gallbladder CONDITION OF THE GALLBLADDER Cholecystitis Inflammation of the gallbladder Can be acute or chronic Cholecystitis Acute cholecystitis usually is due to gallbladder stones CONDITION OF THE GALLBLADDER Cholecystitis Chronic cholecystitis is usually due to long standing gall bladder inflammation Cholelithiasis Formation of GALLSTONES in the biliary apparatus Predisposing FACTORS F Female Fat Forty Fertile Fair Pathophysiology Supersaturated bile, Biliary stasis Stone formation Blockage of Gallbladder Inflammation, Mucosal Damage and WBC infiltration

CONDITION OF THE GALLBLADDER ASSESSMENT findings for cholecystitis 1. Indigestion, belching and flatulence 2. Fatty food intolerance 3. Epigastric pain that radiates to the scapula or localized at the RUQ 4. Mass at the RUQ 5. Murphys sign 6. Jaundice 7. dark orange and foamy urine CONDITION OF THE GALLBLADDER DIAGNOSTIC PROCEDURES 1. Ultrasonography- can detect the stones 2. Abdominal X-ray 3. Cholecystography 4. WBC count increased 5. Oral cholecystography cannot visualize the gallbladder 6. ERCP: revels inflamed gallbladder with gallstone CONDITION OF THE GALLBLADDER NURSING INTERVENTIONS 1. Maintain NPO in the active phase 2. Maintain NGT decompression CONDITION OF THE GALLBLADDER NURSING INTERVENTIONS 3. Administer prescribed medications to relieve pain. Usually Demerol (MEPERIDINE) Codeine and Morphine may cause spasm of the Sphincter increased pain. Morphine cause MOREPAIN 4. Instruct patient to AVOID HIGH- fat diet and GASforming foods 5. Assist in surgical and non-surgical measures 6. Surgical procedures- Cholecystectomy, Choledochotomy, laparoscopy CONDITION OF THE GALLBLADDER PHARMACOLOGIC THERAPY Analgesic- Meperidine Chenodeoxycholic acid= to dissolve the gallstones Antacids Anti-emetics CONDITION OF THE GALLBLADDER Post-operative nursing interventions 1. Monitor for surgical complications 2. Post-operative position after recovery from anesthesiaLOW FOWLERs 3. Encourage early ambulation 4. Administer medication before coughing and deep breathing exercises 5. Advise client to splint the abdomen to prevent discomfort during coughing 6. Administer analgesics, antiemetics, antacids 7. Care of the biliary drainageor T-tube drainage 8. Fat restriction is only limited to 4-6 weeks. Normal diet is resumed Conditions of the accessory organs The pancreas: Exocrine function CONDITION OF THE PANCREAS Pancreatitis Inflammation of the pancreas Can be acute or chronic

Etiology and predisposing factors Alcoholism Hypercalcemia Trauma Hyperlipidemia Etiology and predisposing factors Biliary tract disease - cholelithiasis Bacterial disease PUD Mumps CONDITION OF THE PANCREAS PATHOPHYSIOLOGY of acute pancreatitis Self-digestion of the pancreas by its own digestive enzymes principally TRYPSIN CONDITION OF THE PANCREAS PATHOPHYSIOLOGY of acute pancreatitis Spasm, edema or block in the Ampulla of Vater reflux of proteolytic enzymes auto digestion of the pancreas inflammation CONDITION OF THE PANCREAS PATHOPHYSIOLOGY of acute pancreatitis Autodigestion of pancreatic tissue Hemorrhage, Necrosis and Inflammation KININ ACTIVATION will result to increased permeability Loss of Protein-rich fluid into the peritoneum HYPOVOLEMIA CONDITION OF THE PANCREAS ASSESSMENT findings 1. Abdominal pain- acute onset, occurring after a heavy meal or alcohol intake 2. Abdominal guarding 3. Bruising on the flanks and umbilicus 4. N/V, jaundice 5. Hypotension and hypovolemia 6. Signs of shock CONDITION OF THE PANCREAS DIAGNOSTIC TESTS 1. Serum amylase and serum lipase 2. Ultrasound 3. WBC 4. Serum calcium 5. CT scan 6. Hemoglobin and hematocrit CONDITION OF THE PANCREAS NURSING INTERVENTIONS 1. Assist in pain management. Usually, Demerol is given. Morphine is AVOIDED 2. Assist in correction of Fluid and Blood loss 3. Place patient on NPO to inhibit pancreatic stimulation 4. NGT insertion to decompress distention and remove gastric secretions 5. Maintain on bed rest 7. Position patient in SEMI-FOWLERs to decrease pressure on the diaphragm 8. Deep breathing and coughing exercises 9. Provide parenteral nutrition 10. Introduce oral feedings gradually- HIGH carbo, LOW FAT 11. Maintain skin integrity

12. Manage shock and other complications food and give blood transfusion Quick Summary Peptic Ulcer Ulceration of mucosa; In the stomach or duodenum Outstanding Symptom: PAIN Nursing Goal: Allow ulcer to heal, prevent complication Rest: physical and Mental Eliminate certain foods Medications: antacid, H2 blockers, Proton Pump inhibitors, antibiotics, mucosal protectants Surgery: Vagotomy, Billroth 1 and 2 Quick Summary Liver Cirrhosis Destruction of liver with replacement by scars Common causes: alcoholism, post-hepatitic Manifestations related to liver derangements Jaundice, Ascites, splenomegaly, bleeding, enceph

PTH is stimulated by a DECREASED Calcium level

ENDOCRINE DISEASES Hormones chemical receptors that regulate organ function in concert with nervous system. Negative feedback mechanism The ANATOMY of the Endocrine System The endocrine system is composed of ductless glands that release their hormones directly into the bloodstream The Hypothalamus controls most of the endocrinal activity of the pituitary gland The ANATOMY of the Endocrine System The pituitary gland controls most of the activities of the other endocrine glands The ANATOMY of the Endocrine System The Pituitary Gland Is divided into two parts- the anterior or adenohypophysis and the posterior or the neurohypophysis The PHYSIOLOGY of the Endocrine System: Anterior Pituitary Secretes the following hormones: 1. Growth hormone 2. Prolactin 3. Gonadotrophins- LH and FSH 4. Stimulating hormones and trophic hormones ACTH TSH MSH The PHYSIOLOGY of the Endocrine System: Posterior Pituitary Stores and releases 1. OXYTOCIN 2. ADH/Vasopressin The ANATOMY of the Endocrine System The THYROID gland Located in the anterior neck lateral to the trachea Contains two lobes connected by the isthmus Microscopically composed of thyroid follicles where the hormones are produced and stored The PHYSIOLOGY of the Endocrine System: Thyroid Produces the thyroid hormones by the thyroid follicles: 1. Tri-iodothyronine or T3 2. Tetra-iodothyronine or thyroxine or T4 The Parafollicular cells secrete CALCITONIN The PARAthyroid glands Located at the back of the thyroid glands Four in number Secretes PARATHYROID hormone (PTH) that controls calcium and phosphorus levels

The ANATOMY of the Endocrine System The Adrenal Glands Located above the kidneys Composed of two parts- the outer Adrenal Cortex and the inner Adrenal medulla T he PHYSIOLOGY of the Endocrine System: Adrenal Cortex Secretes three types of STEROID hormones 1. Glucocorticoids- like Cortisol, cortisone and corticosterone 2. Mineralocorticoids- like Aldosterone 3. Sex hormones- like estrogen and testosterone The PHYSIOLOGY of the Endocrine System: Adrenal Medulla Essentially a part of the SYMPATHETIC autonomic system Secretes Adrenergic Hormones: 1. Epinephrine 2. Nor-epinephrine The ANATOMY of the Endocrine System The Pancreas This retroperitoneal organ has both endocrine and exocrine functions The endocrine function resides in the ISLETS of Langerhans The islets have three types of cells- alpha, beta and delta cells The PHYSIOLOGY of the Endocrine System: The Pancreas The ALPHA cells secrete GLUCAGON The BETA cells secrete INSULIN The DELTA cells secrete SOMATOSTATIN COMMON LABORATORY PROCEDURES Hormone Levels Assay These are blood examinations for the levels of individual hormones COMMON LABORATORY PROCEDURES Hormone Levels Assay Measurements can also be done after stimulation and suppression of the secretions- Stimulation and Suppression tests COMMON LABORATORY PROCEDURES Hormone Levels of T3/T4 Usually done to diagnose hypo/hyperthyroidism COMMON LABORATORY PROCEDURES Hormone Levels of T3/T4 If T3 is elevated, T4 is elevated and TSH is depressed Primary HYPERthyroidism COMMON LABORATORY PROCEDURES Hormone Levels of T3/T4 If T3 is depressed,T4 is depressed and TSH is elevated Primary HYPOthyoidism

COMMON LABORATORY PROCEDURES Radio-Active iodine uptake (RAI) This is a thyroid function test to measure the absorption of the injected iodine isotope by the thyroid tissue COMMON LABORATORY PROCEDURES Radio-Active iodine uptake (RAI) Increased uptake may indicate HYPERfunctioning gland Decreased uptake my indicate HYPOfunctioning gland COMMON LABORATORY PROCEDURES Thyroid Scan Performed to identify nodules or growth in the thyroid gland RAI is used COMMON LABORATORY PROCEDURES Thyroid Scan Pretest- Check for pregnancy, Thyroid medication may be withheld temporarily, advise NPO Post-test- Ensure proper disposal of body wastes BMR It measures the oxygen consumption under basal conditions of overnight fast and rest from mental and physical exertion. it can be estimated from the oxygen consumed over a timed interval by analysis of samples of expired air The test indirectly measures metabolic energy expenditure or heat production. Results are expressed as the percentage of deviation from normal after appropriate corrections have been made for age, sex, and body surface area. Low values are suggestive of hypothyroidism, and high values reflect thyrotoxicosis. COMMON LABORATORY PROCEDURES FASTING BLOOD GLUCOSE Aids in the diagnosis of Diabetes Pre-test: NPO for 8 hours Normal FBS- 80-109 mg/dL DM- 126 mg/dL and above COMMON LABORATORY PROCEDURES GLUCOSE tolerance test Aids in the diagnosis of DM Pre-test: Provide high-carbohydrate foods x 3 days, instruct to avoid caffeine, alcohol and smoking, NPO 10 hours prior to test COMMON LABORATORY PROCEDURES GLUCOSE tolerance test Post-test: avoid strenuous activity for 8 hours Normal OGTT- 1 and 2 hours post-prandial- glucose is less than 200 mg/dL COMMON LABORATORY PROCEDURES Glycosylated Hemoglobin A 1-C Blood glucose bound to RBC hemoglobin Reflects how well blood glucose is controlled for the past 3 months FASTING is NOT required! COMMON LABORATORY PROCEDURES Glycosylated Hemoglobin A 1-C Normal level- expressed as percentage of total hemoglobin

N- 4-7% Good control- 7.5%or less Fair control- 7.5 % to 8.9% Poor control- 9% and above DISORDERS OF THE ENDOCRINE GLAND Disorders are generally grouped into: 1. HYPER- when the gland secretes excessive hormones 2. HYPO- when the gland does not secrete enough hormones DISORDERS OF THE ENDOCRINE GLAND Hyper and Hypo can be classified as PRIMARY when the Gland itself is the problem or SECONDARY when the pituitary or the hypothalamus is causing the problem Disorders of the PITUITARY GLAND DISORDERS OF the PITUITARY GLAND HYPOPITUITARISM Hyposecretion of the anterior pituitary gland CAUSES: Congenital, Post-partal necrosis, infection and tumor DISORDERS OF the PITUITARY GLAND HYPOPITUITARISM PATHOPHYSIOLOGY: Depends on the major hormone/s depleted Panhypopituitarism (simmonds disease) total absence of all pituitary secretions Postpartum pituitary necrosis (Sheehans syndrome occur in women with severe blood loss, hypotension at the time of delivery. Complication of radiation therapy to the head and neck area Total destruction of the pituitary gland by means of trauma, tumor or vascular lesions. Pituitary Tumors 1. Eosinophilic tumors Gigantism or acromegally 2. Basophilic tumors Cushing syndrome 3. Chromophobic tumors 90% Diagnostics Physical examination and history CT scan MRI Hormone levels determination Surgical management Hypophysectomy - removal of pituitary tumor used to treat Cushing syndrome - palliative measures to relieve bone pain from malignant metastasis of breat and prostate Ca DISORDERS OF the PITUITARY GLAND Hypopituitarism: ASSESSMENT Findings 1. Retarded physical growth due to decreased GH dwarfism 2. Low intellectual development 3. poor development of secondary sexual characteristics

DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS 1. Provide emotional support to the family 2. Encourage client and family to express feelings 3. Administer prescribed hormonal replacement therapy DISORDERS OF the PITUITARY GLAND HYPERPITUITARISM The hyper-secretion of the gland ACROMEGALY CAUSES: tumor, congenital disorder PATHOPHYSIOLOGY Depends on the hormone/s that is/are increased DISORDERS OF the PITUITARY GLAND ASSESSMENT FINDINGS for Hyper-pituitarism 1. Increased growth Gigantism or Acromegaly 2. large and thick hands and feet 3. Visual disturbances 4. Hypertension, hyperglycemia 5. Organomegaly DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS 1. Provide emotional support to clients and family 2. Provide frequent skin care 3. Prepare patient for surgery- removal of pituitary gland DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS Post-operative care 1. Monitor VS, LOC and neurologic status 2. Place patient on Semi-Fowlers Post-operative care 3. Monitor for Increased ICP, bleeding, CSF leakage 4. Instruct patient to AVOID sneezing, coughing and nose-blowing 5. Monitor development of DI- measure I and O 6. Administer prescribed medications- antibiotics, analgesics and steroids DISORDERS OF the PITUITARY GLAND: Posterior gland DIABETES INSIPIDUS A hypo-secretion of ADH CAUSES: Conditions that increase ICP, Surgical removal of post pit. tumor PATHOPHYSIOLOGY Decreased ADH failure of tubular reabsorption of water increased urine volume ASSESSMENT findings 1. Polyuria of more than 4 liters of urine/day 2. Polydipsia 3. Signs of Dehydration 4. Muscle pain and weakness 5. Postural hypotension and tachycardia Diagnostic test Fluid deprivation test 8-12 hrs or 3-5% wt loss. Inability to increase specific gravity and osmolality DIAGNOSTIC TEST 1. Urinary Specific gravity very low, 1.006 or less 2. Serum Sodium levels high

Medical management Objectives 1. To replace ADH 2. Ensure adequate fluid replacement 3. identify and correct the underlying intracranial pathology NURSING INTERVENTIONS 1.Monitor VS, neurologic status and cardiovascular status 2. Monitor Intake and Output 3. Monitor urine specific gravity 4. Provide adequate fluids 5. Administer Chlorpropamide or Clofibrate as prescribed to increase the action of ADH if decreased Hypolipidemic effect, diuretic effect 6. Administer VASOPRESIN. Desmopressin or Lypressin are given intranasal. Pitressin is given IM Longer duration and fewer side effects DISORDERS OF the PITUITARY GLAND: Posterior gland SIADH Hyper-secretion of ADH abnormally CAUSES: tumor, paraneoplastic syndromes, head injury, infections DISORDERS OF the PITUITARY GLAND: Posterior gland SIADH PATHOPHYSIOLOGY Increased ADH water re-absorption water intoxication, hypervolemia DIAGNOSTIC TEST for SIADH 1. Urine specific gravity is increased (concentrated) 2. Hyponatremia 3. CBC shows hemodilution DISORDERS OF the PITUITARY GLAND: Posterior gland ASSESSMENT findings 1. Signs of Hypervolemia 2. Mental status changes 3. Abnormal weight gain 4. Hypertension 5. Anorexia, Nausea and Vomiting 6. HYPOnatremia DISORDERS OF the PITUITARY GLAND: Posterior gland NURSING INTERVENTIONS 1. Monitor VS and neurologic status 2. Provide safe environment 3. Restrict fluid intake (less than 500cc/day) 4. Monitor I and O and daily weight 5. Administer Diuretics and IVF carefully 6. Administer prescribed Demeclocycline to inhibit action of ADH in the kidney Disorders of the ADRENAL GLAND Functions as part of ANS Secretes adrenaline and cathecolamines Epinephrine, increase blood circulation to vital organs, fight or flight response

Catecholamines, release free fatty acids increase BMR and elevate blood glucose levels

Adrenocortical Insufficiency (addisons disease) adrenal cortex function is inadequate to meet the patients need for cortical hormones Tuberculosis and histoplasmosis, steroid use DISORDERS OF the ADRENAL GLAND Hypo-secretion: ADDISONS Disease Decreased secretion of adrenal cortex hormones, especially glucocorticoids and mineralocorticoids CAUSE: tumor, idopathic, surgery These hormones are essential for life, if not treated patient will die. DISORDERS OF the ADRENAL GLAND PATHOPHYSIOLOGY Decreased Glucocorticoids decreased resistance to stress DISORDERS OF the ADRENAL GLAND PATHOPHYSIOLOGY Decreased mineralocorticoids decreased retention of sodium and water Hypovolemia DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings for Addisons disease 1. Weight loss 2. GI disturbances 3. Muscle weakness, lethargy and fatigue 4. Hyponatremia 5. Hyperkalemia 6. Hypoglycemia 7. dehydration and hypovolemia 8. Increased skin pigmentation 9. leukocytosis Addisonian Crisis Cyanosis, classic signs of circulatory shock, pallor, apprehension, rapid and weak pulse, rapid respirations and low blood pressure Medical management 1. combating circulatory shock 2. Restore blood circulation 3. Administering fluids and corticosteroids DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor VS especially BP 2. Monitor weight and I and O 3. Monitor blood glucose level and K 4. Administer hormonal agents as prescribed 5. Observe for ADDISONIAN crisis 6. Educate the client regarding lifelong treatment, avoidance of strenuous activities, stress and seeking prompt consult during illness DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 7. Provide a high-protein, high carbohydrate and increased sodium intake

DISORDERS OF the ADRENAL GLAND ADDISONIAN crisis A life-threatening disorders caused by acute severe adrenal insufficiency CAUSES: Severe stress, infection, trauma or surgery DISORDERS OF the ADRENAL GLAND ADDISONIAN crisis PATHOPHYSIOLOGY Overwhelming stimuli mobilize body defense decreased stress hormones inadequate coping DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings for Addisonian Crisis= severe lahat 1. Severe headache 2. Severe pain 3. Severe weakness 4. Severe hypotension 5. Signs of Shock DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Administer IV glucocorticoids, usually hydrocortisone 2. Monitor VS frequently 3. Monitor I and O, neurological status, electrolyte imbalances and blood glucose 4. Administer IVF 5. Maintain bed rest 6. Administer prescribed antibiotics DISORDERS OF the ADRENAL GLAND Hyper-secretion: CUSHINGS DISEASE A condition resulting from the hyper-secretion of glucocorticoids from the adrenal cortex CAUSES: Pituitary tumor, adrenal tumor, abuse of steroids, bronchogenic Ca PATHOPHYSIOLOGY Increased Glucocorticoids exaggerated effects of the hormone Common in women 20-40 y/o Virilization, appearance of musculine traits an d recession of feminine traits, hirsutism, breast atrophy, menses cease, enlarge clitoris, voice deepens DISORDERS OF the ADRENAL GLAND ASSESSMENT FINDINGS for Cushing 1. Generalized muscle weakness and wasting 2. Truncal obesity 3. Moon-face, oily skin 4. Buffalo hump 5. Easy bruisability 6. Reddish-purplish striae on the abdomen and thighs 7. Hirsutism and acne 8. Hypertension 9. Hyperglycemia 10. Osteoporosis 11. Amenorrhea

DIAGNOSTIC TESTS 1. Serum cortisol level 2. Serum glucose and electrolytes Dexamethasone suppression test Medical management Surgical removal by transphenoidal hypophysectomy, 90% success rate DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor I and O , weight and VS 2. Monitor laboratory values- glucose, Na, K and Ca 3. Provide meticulous skin care 4. Administer prescribed medications like aminogluthetimide to inhibit adrenal hyperfunctioning 5. Prepare client for surgical management- pituitary surgery and adrenalectomy 6. Protect patient from infection 7. Improve body image 8. Provide a LOW carbohydrate, LOW sodium and HIGH protein diet DISORDERS OF the ADRENAL GLAND Hyper-secretion: CONNS DISEASE Hyper-secretion of Aldosterone from the adrenal cortex CAUSES: pituitary tumor, adrenal tumor DISORDERS OF the ADRENAL GLAND Hypersecretion: CONNS DISEASE PATHOPHYSIOLOGY Increased Aldosterone exaggerated effects DISORDERS OF the ADRENAL GLAND ASSESSMENT findings in CONNS disease 1. Symptoms of HYPOkalemia 2. Hypertension 3. Hypernatremia 4. Headache, N/V 5. Visual changes 6. Muscles weakness, fatigue and nocturia DISORDERS OF the ADRENAL GLAND DIAGNOSTIC TEST 1. Urine gravity- low (due to polyuria) 2. Serum Sodium- high 3. Serum Potassium- very low 4. Increased urinary Aldosterone DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor VS, I and O and urine sp gravity 2. Monitor serum K and Na 3. Provide Potassium rich foods and supplements 4. Administer prescribed diuretic- Spironolactone 5. Maintain sodium-restricted diet 6. Prepare patient for possible surgical interventions DISORDERS OF the ADRENAL GLAND Hyper-secretion: Pheochromocytoma Increased secretion of epinephrine and nor-epinephrine by the adrenal medulla CAUSE: tumor Benign and originates from chromaffin cells men=women 40-50 y/o PATHOPHYSIOLOGY

Increased Adrenergic hormones exaggerated sympathetic effects

DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings in Pheochromocytoma 1. Hypertension 2. Severe headache 3. Palpitations 4. Tachycardia 5. Profuse sweating and Flushing 6. Weight loss, tremors 7. Hyperglycemia and glycosuria DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor VS especially BP 2. Monitor for HYPERTENSIVE crisis 3. Avoid stimulation that can cause increased BP 4. Administer Anti-hypertensive agents like alphaadrenergic blockers- Phenoxybenzamine 5. Prepare Phentolamine for hypertensive crisis 6. Monitor blood glucose and urine glucose 7. Promote adequate rest and sleep periods 8. provide HIGH calorie foods and Vitamins/mineral supplements 9. Prepare patient for possible surgery Disorders of the THYROID GLAND Thyroid Function Thyroid hormone - T3 - T4 Secretion is controlled by TSH (Thyrotropin) control the cellular metabolic activity T4 weak hormone, maintains body metabolism in a steady state(4.5-11.5ng/dl) T3 5x as potent as T3, more rapid metabolic function (70-220ng/dl) Function Accelerates metabolic processes by increasing the level of specific enzymes that contributes to oxygen consumption Influence cell replication and important in brain development Necessary for normal growth Role of Iodine Essential to thyroid function for synthesis of its hormones Ingested in diet and absorbed in the blood Assessment and diagnostic findings Inspection for swelling and assymetry Palpated for size, symmetry, tenderness Auscultation of audible vibration or bruit Thyroid function Test TSH has a sensitivity and specificity of greater than 95% (.4 6.15 mU/ml) FT4 correlate with metabolic status and are elevated in Hyperthyroidism and decrease in Hypothyroidism. Fine needle aspiration biopsy - safe and accurate method of detecting malignancy

Thyroid scan - location, size, shape and anatomic function of thyroid gland - Hot, Cold DISORDERS OF the THYROID GLAND HYPOsecretion: HYPOTHYROIDISM A hypothyroid state characterized by decreased secretions of T3 and T4 Definition a. Thyroid gland produces insufficient amount of thyroid hormone b. Myxedema: characteristic accumulation of nonpitting edema in connective tissues throughout body; water retention in mucoprotein deposits in interstitial spaces c. More common females aged 30 60 Pathophysiology a. Primary (more common) 1. Defect in thyroid gland 2. Congenital defects 3. Post treatment of hyperthyroidism 4. Thyroiditis 5. Iodine deficiency b. 1. 2. Secondary Deficiency in TSH (pituitary gland) Peripheral resistance to thyroid hormones

DISORDERS OF the THYROID GLAND ASSESSMENT findings for Hypothyroidism 1. Lethargy and fatigue 2. Weakness and paresthesia 3. COLD intolerance 4. Weight gain 5. Bradycardia, constipation 8. Forgetfulness and memory loss 9. Slowness of movement 10. Menstrual irregularities and cardiac irregularities 11. Dry hair and skin, loss of body hair 12. Generalized puffiness and edema around the eyes and face Specific Conditions a. Iodine Deficiency 1. Dietary foods grown in iodine poor soil 2. Use of non-iodized salt 3. Medications, such as lithium carbonate, amiodarone (Cordarone) Hashimotos Thyroiditis 1. Autoimmune disorder 2. Antibodies produced against thyroid tissue Myxedematous coma 1. Life-threatening complication of long-standing and untreated hypothyroidism 2. Hyponatremia, hypoglycemia, acidosis 3. Precipitated by stressors, failure to take thyroid replacement meds 4. Treatment includes restoring balance throughout systems and increasing thyroid hormone levels Diagnostic Tests a. Serum thyroid antibodies (TA): antibodies in Hashimotos Thyroiditis b. TSH test: (from pituitary) elevated with primary hypothyroidism c. T3 and T4: decreased for diagnosis of hypothyroidism d. T3 uptake test; decreased with hypothyroidism RAI uptake test 1. Oral or intravenous dose of radioactive iodine (131I or 123I) given to client 2. Thyroid scanned after 24 hours 3. Uptake decreased with hypothyroidism 4. Size and shape of gland revealed f. Serum cholesterol is elevated DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Monitor VS especially HR 2. Administer hormone replacement: usually Levothyroxine( Synthroid)-should be taken on an empty stomach 3. Instruct patient to eat LOW calorie, LOW cholesterol and LOW fat diet 4. Manage constipation appropriately 5. Provide a WARM environment 6. Avoid sedatives and narcotics because of increased sensitivity to these medications 7. Instruct patient to report chest pain promptly Nursing Diagnoses

Causes Chronic lymphocytic thyroiditis Atrophy of gland with aging Therapy for hyperthyroidism - radioactive iodine, thyroidectomy Medications, lithium, iodine, antithyroid Radiation to head and neck Iodine deficiency and excess DISORDERS OF the THYROID GLAND HYPOsecretion: HYPOTHYROIDISM PATHOPHYSIOLOGY Decreased T3 and T4 decreased basal metabolism Signs and Symptoms: Slow onset over months to years a. Metabolism: slowed 1. Intolerance to cold 2. Sleepiness 3. Fatigue, weakness b. Cardiovascular 1. Bradycardia, alterations in blood pressure 2. Tendency for development of congestive heart failure, myocardial infarction c. Gastrointestinal 1. Enlarged tongue, anorexia, vomiting 2. Constipation d. Neuromuscular: Apathy, slow movement and thinking e. Other 1. Goiter: thyroid gland enlarges in attempt to produce more hormone 2. Edema in hands, feet, face; dry skin and hair

a. Decreased Cardiac Output b. Constipation c. Risk for Impaired Skin Integrity: due to over all edema high risk for skin breakdown: preventative interventions DISORDERS OF the THYROID GLAND HYPERfunctioning: HYPERTHYROIDISM Called GRAVES DISEASE A hyperthyroid state characterized by increased circulating T3 and T4 Pathophysiology a. Autoimmune reactions (Graves disease) b. Excess secretion of TSH from pituitary gland c. Neoplasms (toxic multinodular goiter) d. Thyroiditis e. Excessive intake of thyroid medications Women >8x more than men Second and forth decade Signs and symptoms Metabolism 1. Hypermetabolism 2. Increased appetite with weight loss 3. Heat intolerance, increased sweating Cardiovascular 1. Systolic hypertension 2. Tachycardia, atrial fibrillation 3. Dysrhythmias, palpitations 4. Possibly angina, congestive heart failure Gastrointestinal 1. Increased peristalsis with diarrhea 2. Hyperactive bowel sounds Neuromuscular 1. Nervousness, restlessness 2. Insomnia 3. Fine tremor 4. Emotional lability (mood swings) Other 1. Fine hair 2. Smooth and warm skin DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Hyperthyroidism 1. Weight loss 2. HEAT intolerance 3. Hypertension 4. Tachycardia and palpitations 5. Exopthalmos 6. Diarrhea 7. Warm skin 8. Diaphoresis 9. Smooth and soft skin Oligomenorrhea to amenorrhea 10. Fine tremors and nervousness 11. Irritability, mood swings, personality changes and agitation Graves disease 1. Most common cause of hyperthyroidism 2. Antibody against TSH receptor site 3. Cause unknown, but hereditary link 4. More common in females aged 20 40

Signs and symptoms a. Signs of hyperthyroidism plus b. Enlarged thyroid gland (goiter) c. Proptosis (forward displacement of eyes) causing blurred vision, diplopia, lacrimation, photophobia d. Exophthalmos (forward protrusion of eyes) causing corneal dryness, irritation, ulceration e. Changes in menstruation Toxic Multinodular Goiter 1. Nodules in thyroid tissue secrete excessive thyroid hormone 2. Usually female in 60 70s, has had goiter for a number of years Thyroiditis 1. Viral infection of thyroid 2. May become chronic and lead to hypothyroidism Diagnostic findings Thyroid gland is enlarged Thrill often can be palpated and bruit is heard over the thyroid arteries a. Serum thyroid antibodies (TA): antibodies in Graves disease b. TSH test: (from pituitary) suppressed with primary hyperthyroidism c. T3 and T4: elevated for diagnosis of hyperthyroidism, thyroiditis d. T3 uptake test; elevated with hyperthyroidism e. RAI uptake test Oral or intravenous dose of radioactive iodine (131I) given to client Thyroid scan after 24 hours Size and shape of gland revealed Uptake is increased with Graves disease Thyroid suppression test 1. RAI and T4 measured and then remeasured after client takes thyroid hormone 2. No suppression with hyperthyroid Medications 1. Antithyroid medications: block synthesis of thyroid hormones a. Propylthiouracil (PTU) b. Methimazole (Tapazole) 2. Beta-adrenergic blockers: control symptoms (tachycardia, tremor, etc.) a. Propanolol (Inderal) b. Atenolol (Tenormin); for those with cardiac or asthma problems Radioactive Iodine Therapy 1. Process: a. Iodine is taken up by thyroid b. Concentrates in the thyroid gland and destroys cells c. Less hormone is produced d. Dose given orally e. Results occur in 6 to 8 weeks 2. Not to be given to pregnant women 3. Client often hypothyroid after treatment Surgery

Subtotal thyroidectomy: only part of thyroid removed 2. Total thyroidectomy to treat cancer of thyroid: client will need life-long thyroid replacement 3. Prior to surgery: get client into euthyroid state 4. Iodine (Potassium Iodide) given prior to surgery to decrease size and vascularity of thyroid DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Provide adequate rest periods in a quiet room 2. Administer anti-thyroid medications that block hormone synthesis- Methimazole and PTU 3. Provide a HIGH-calorie diet, HIGH protein 4. Manage diarrhea 5. Provide a cool and quiet environment 6. Avoid giving stimulants 7. Administer PROPRANOLOL for tachycardia 8. Administer IODIONE preparation- Lugols solution and SSKI to inhibit the release of T3 and T4 9. Prepare clients for Radioactive iodine therapy 10. Prepare patient for thyroidectomy 11. Manage thyroid storm appropriately Nursing Diagnoses a.Risk for Decreased Cardiac Output b. Disturbed Sensory Perception: Visual 1. Interventions to protect eye from corneal irritation and to maintain moisture 2. Lubricants and taping eyes shut at night c. Imbalanced Nutrition-Less than body requirements: Diet high in protein and calories d. Disturbed Body Image: Exophthalmos may continue post treatment DISORDERS OF the THYROID GLAND Thyroid storm An acute LIFE-threatening condition characterized by excessive thyroid hormone CAUSE: Manipulation of the thyroid during surgery causing the release of excessive hormones in the blood DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Thyroid Storm 1. HIGH fever 2. Tachycardia and Tachypnea 3. Systolic HYPERtension 4. Delirium and coma 5. Severe vomiting and diarrhea 6. Restlessness, Agitation, confusion and Seizures DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Maintain PATENT airway and adequate ventilation 2. Administer anti-thyroid medications such as Lugols solution, Propranolol, and Glucocorticoids 3. Monitor VS 4. Monitor Cardiac rhythms 5. Administer PARACETAMOL ( not Aspirin) for FEVER 6. Manage Seizures as required. 7. Provide a quiet environment DISORDERS OF the THYROID GLAND THYROIDECTOMY Removal of the thyroid gland DISORDERS OF the THYROID GLAND

1. 2.

PRE-OPERATIVE CARE - Thyroidectomy 1. Obtain VS and weight 2. Assess for Electrolyte levels, glucose levels and T3/T4 levels DISORDERS OF the THYROID GLAND PRE-OPERATIVE CARE - Thyroidectomy 3. Provide pre-operative teaching like coughing and deep breathing, early ambulation and support of the neck when moving 4. Administer prescribed medications DISORDERS OF the THYROID GLAND POST-OPERATIVE CARE - Thyroidectomy 1. Position patient: Semi-Fowlers, neck on neutral position 2. Monitor for respiratory distress- apparatus at bedsidetracheostomy set, O2 tank and suction machine! 3. Check for edema and bleeding by noting the dressing anteriorly and at the back of the neck 4. LIMIT client talking 5. Assess for HOARSENESS Expected to be present only initially, limit excess vocalization If persistent, may indicate damage to laryngeal nerve! 6. Monitor for Laryngeal Nerve damage Respiratory distress, Dysphonia, voice changes, Dysphagia and restlessness 7. Monitor for signs of HYPOCALCEMIA and tetany due to trauma of the parathyroid 8. Prepare Calcium gluconate 9. Monitor for thyroid storm DISORDERS OF the PARATHYROID GLAND Hypo-functioning: HYPOPARATHYROIDISM Hypo-secretion of parathyroid hormone CAUSES: tumor, removal of the gland during thyroid surgery Pathophysiology a. Often due to damage or removal of parathyroid glands during thyroidectomy b. Hypocalcemia, elevated blood phosphate levels, decreased activation of Vitamin D in intestines DISORDERS OF the PARATHYROID GLAND Hypo-functioning: HYPOPARATHYROIDISM PATHOPHYSIOLOGY Decreased PTH deranged calcium metabolism DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for HypoParaThyroidism 1. Signs of HYPOCALCEMIA 2. Numbness and tingling sensation on the face 3. Muscle cramps 4. (+) Trosseaus and (+) Chvosteks signs 5. Bronchospasms, laryngospasms, and dysphagia 6. Cardiac dysrhythmias 7. Hypotension 8. Anxiety, irritability ands depression DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 1. Monitor VS and signs of HYPOcalcemia 2. Initiate seizure precautions and management 3. Place a tracheostomy set. O2 tank and suction at the bedside 4. Prepare CALCIUM gluconate

5. Provide a HIGH-calcium and LOW phosphate diet 6. Advise client to eat Vitamin D rich foods 7. Administer Phosphate binding drugs DISORDERS OF the PARATHYROID GLAND Hyper-functioning: HYPERPARATHYROIDISM Hyper-secretion of the gland CAUSE: Tumor Pathophysiology a. Often due to damage or removal of parathyroid glands during thyroidectomy b. Hypocalcemia, elevated blood phosphate levels, decreased activation of Vitamin D in intestines DISORDERS OF the PARATHYROID GLAND Hyper-functioning: HYPERPARATHYROIDISM PATHOPHYSIOLOGY Increase PTH increased CALCIUM levels in the body DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for Hyperparathyroidism 1. Fatigue and muscle weakness/pain 2. Skeletal pain and tenderness 3. Fractures\ 4. Anorexia/N/V epigastric pain 5. Constipation 6. Hypertension 7. Cardiac Dysrhythmias 8. Renal Stones DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 1. Monitor VS, Cardiac rhythm, I and O 2. Monitor for signs of renal stones, skeletal fractures. Strain all urine. 3. Provide adequate fluids- force fluids 4. Administer prescribed Furosemide to lower calcium levels 5. Administer NORMAL saline 6. Administer calcium chelators 7. Administer CALCITONIN 8. Prepare the patient for surgery Client with Cancer of Thyroid 1. Types a. Papillary thyroid carcinoma 1. More common in female in 40s 2. Usually single nodule 3. Risks: exposure of area to xray, nuclear fallout, family history b. Follicular thyroid cancer: more common in female in 50s Diagnosis a. Palpable firm nontender nodule in thyroid b. Usually no elevation in thyroid hormones c. Thyroid scans, needle biopsy of nodule Treatment a. Subtotal or total thyroidectomy b. Radioactive iodine therapy with 131I c. Client will need continued medical followup; thyroid replacement d. 95% survival rate without metastasis Selected Endocrine PHARMACOLOGY Endocrine Medications Anti-diuretic hormones Enhance re-absorption of water in the kidneys Used in DI 1. Desmopressin and Lypressin intranasally 2. Pitressin IM Endocrine Medications Anti-diuretic hormones SIDE-effects Flushing and headache Water intoxication Thyroid Medications Thyroid hormones Levothyroxine (Synthroid) and Liothyroxine (Cytomel) Replace hormonal deficit in the treatment of HYPOTHYROIDSM Thyroid Medications Thyroid hormones Side-effects 1. Nausea and Vomiting 2. Signs of increased metabolism= tachycardia, hypertension Thyroid Medications Thyroid hormones Nursing responsibility 1. Monitor weight, VS 2. Instruct client to take daily medication the same time each morning WITHOUT FOOD 3. Advise to report palpitation, tachycardia, and chest pain 4. Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes ANTI-Thyroid Medications ANTI-THYROID medications Inhibit the synthesis of thyroid hormones 1. Methimazole (Tapazole) 2. PTU (prophylthiouracil) 3. Iodine solution- SSKI and Lugols solution Side-effects N/V Diarrhea AGRANULOCYTOSIS Most important to monitor ANTI-Thyroid Medications ANTI-THYROID medications Nursing responsibilities 1. Monitor VS, T3 and T4, weight 2. The medications WITH MEALS to avoid gastric upset ANTI-Thyroid Medications ANTI-THYROID medications Nursing responsibilities 3. Instruct to report SORE THROAT or unexplained FEVER 4. Monitor for signs of hypothyroidism. Instruct not to stop abrupt medication

ANTI-Thyroid Medications ANTI-THYROID medications Lugols Solution Used to decrease the vascularity of the thyroid T3 and T4 production diminishes Given per orem, can be diluted with juice Use straw STEROIDS Replaces the steroids in the body Cortisol, cortisone, betamethasone, and hydrocortisone STEROIDS Side-effects HYPERglycemia Increased susceptibility to infection Hypokalemia Edema STEROIDS Side-effects If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension, cataract, mood changes, hirsutism, and fragile skin STEROIDS Nursing responsibilities 1. Monitor VS, electrolytes, glucose 2. Monitor weight edema and I/O STEROIDS Nursing responsibilities 3. Protect patient from infection 4. Handle patient gently 5. Instruct to take meds WITH MEALS to prevent gastric ulcer formation STEROIDS Nursing responsibilities 6. Caution the patient NOT to abruptly stop the drug 7. Drug is tapered to allow the adrenal gland to secrete endogenous hormones Quick Review Hypothyroidism Hyposecretion of thyroid hormones Common causes: Iodine deficiency, Hashimotos Manifestations: related to hypo-metabolic state: constipation, weight gain, cold intolerance, poor appetite, mental slowness Nursing Management: Provide warm environment LOW calorie diet, HIGH fiber Avoid sedatives Drugs: Hormone replacement Hyperthyroidism Hyper-secretion of thyroid hormones Common cause: Graves, Toxic goiter Manifestation: increased metabolism: weight loss, diarrhea, heat intolerance, hypertension Nursing Management: Adequate rest and sleep Cool environment HIGH calorie foods Eye care Drugs: anti-thyroid: PTU and methimazole, propranolol Care of patients after thyroidectomy