Clinical Companion: Medical-Surgical Nursing 2e - McKenzie

Clinical CompanionMEDICAL–SURGICAL NURSING

2nd edition

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Clinical CompanionMEDICAL–SURGICAL NURSING2nd edition

Gayle McKenzieRN, BSocSc, GC ClinEd, GD CritCare, MEd, RCNA

Tanya PorterRN, BN, GDipAdvNsg (Emerg), MEd

Sydney Edinburgh London New York Philadelphia St Louis Toronto

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Mosbyis an imprint of Elsevier

Elsevier Australia. ACN 001 002 357(a division of Reed International Books Australia Pty Ltd)Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067

© 2011 Elsevier Australia

This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher.

Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation.

This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication.

National Library of Australia Cataloguing-in-Publication Data___________________________________________________________________

McKenzie, Gayle. Clinical companion : medical-surgical nursing / Gayle McKenzie ; Tanya Porter.

2nd ed.

9780729539968 (pbk.) Includes index.

Nursing—Handbooks, manuals, etc. Surgical nursing—Handbooks, manuals, etc.

Porter, Tanya.

610.73___________________________________________________________________

Publisher: Libby HoustonDevelopmental Editors: Larissa Norrie and Elizabeth CoadyPublishing Services Manager: Helena KlijnEditorial Coordinator: Natalie HamadEdited by Brenda HamiltonProofread by Sarah Newton-JohnIndexed by Cynthia SwansonCover and internal design by Toni DarbenTypeset by Pindar New Zealand, AucklandPrinted in China by China Translation and Printing Services

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Contents

Preface ixAcknowledgments xReviewers xi

1 Medication administration 1Medication errors 9

2 Documentation 10

3 The nervous system 19Anatomy and physiology 19The central nervous system 21Protecting the brain and spinal cord 25Assessment 29Medical disorders 33Surgical interventions 51Tests 53Pharmacology 56

4 The respiratory system 58Anatomy review 58Respiratory assessment 62Medical disorders 64Restrictive respiratory disorders 66Obstructive respiratory disorders 74Medical interventions 83Surgical interventions 86Common respiratory tests 91Pharmacology 95

5 The cardiovascular system 98Anatomy and physiology 98

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Electrical activity in the heart 103Assessment 105Basic rhythms 112Medical disorders 118Interventions 134Tests 138Pharmacology 145

6 The endocrine system 150The hypothalamus 152The pituitary gland 153Disorders of the pituitary gland 154The thyroid gland 158Disorders of the thyroid gland 159The parathyroid gland 163Disorders of the parathyroid gland 163The adrenal gland 165Disorders of the adrenal gland 166The pancreas 169Disorders of the pancreas 171Pharmacology 174

7 The gastrointestinal system 177Anatomy and physiology 177Assessment 182Medical disorders 184Medical interventions 202Surgical interventions 203Tests 205Pharmacology 209

8 The renal system 213Anatomy and physiology 213Assessment 222Medical disorders 224Medical interventions 231Surgical interventions 241Tests 245Pharmacology 249

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Contents | vii

9 The reproductive system 252Assessment (male and female) 252Female anatomy and physiology 253Female medical disorders 257Menstrual disorders 268Breast disorders 269Surgical interventions (female) 271Male anatomy and physiology 273Male medical disorders 276Surgical interventions (male) 286Sexually transmitted diseases 286Pharmacology 286

10 Haematology, oncology and immunology 288Haematology: anatomy and physiology 288Haematology disorders 291Haematology interventions 298Haematology pharmacology 298Oncology: anatomy and physiology 299Oncology disorders 299Oncology interventions 303Immunology: anatomy and physiology 306Immunology disorders 308Immunology pharmacology 311Tests 311

11 Infectious diseases 313Chain of infection 315Prevention of infection 317Infectious diseases 320Pharmacology 357

12 Trauma and emergency 360Head injuries 362Spinal cord injuries (SCI) 363Maxillofacial injuries 365Thoracic injuries 367Abdominal injuries 369

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Fractures 370Amputation 372Shock 374Burns 379Complications of trauma 386

13 Operative care 388Preoperative care 389Intraoperative care 392Postoperative care 396On return to ward (RTW) 397Wound care 399Discharge from hospital 402

14 Survival tactics 404Tips to assist with clinical placement 407Workload management 409What else do you need to know? 410

Appendix 1 Life support fl ow charts 417Appendix 2 Common abbreviations 420Appendix 3 Daily management plan 428Appendix 4 Handover template 429References 430Recommended websites 432Index 433

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ix

Preface

Clinical nursing requires a nurse to often be a jack-of-all-trades and have a wealth of up-to-date knowledge on hand for all occasions. It is diffi cult to remember everything, all the time. We have endeavoured to provide a text that enables the reader to use the knowledge they have and apply it to clinical practice in order to provide optimum patient care.

Clinical Companion: Medical–Surgical Nursing 2e is an easy-to-access, simple information fi nder for quick revision of nursing knowledge and practice. It is designed for all clinical nurses but particularly for student nurses, graduate nurses and those returning to the nursing profession after an extended absence.

Before using Clinical Companion: Medical–Surgical Nursing 2e it is essential that the user have prior knowledge of anatomy and physiology, pathophysiology, assessment and rationales for interventions, as it is designed to be a quick reminder and provides only a brief overview of each body system and related conditions.

Each chapter begins with an overview of the anatomy of the relevant body system, followed by a how-to system assessment, conditions relating to the system, common tests and pharmacology. Throughout the text, the icon fl ags hints to assist with nursing care, and learning and development.

Clinical Companion: Medical–Surgical Nursing 2e is designed to be a quick guide, and more in-depth information should be sought from other sources.

Gayle McKenzie, Tanya Porter

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Acknowledgments

To my boys, Rowan, Stanley and Phineas who make my life complete.

Tanya Porter

To my mother Avis McKenzie, who continues to be my Rock of Gibraltar.

A special thanks to my students, both past and present, who have taught me more than they'll ever know!

Gayle McKenzie

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Reviewers

Sonja Cleary RN, BN, MHlthSc, Grad Cert Tert Edn, MRCNA; Lecturer/Course Coordinator, Discipline of Nursing and Midwifery, School of Health Science, RMIT University, VIC

Trinity Farrell CCRN, Grad Dip Nursing (Critical Care); Lecturer, La Trobe University, VIC

Penny Paliadelis RN, BNurs, MNurs(Hons), PhD, MRCNA, MACCCN; Associate Professor, Deputy Head of School (Teaching & Learning), School of Health, Faculty of the Professions, University of New England, NSW

Lacey Smale BNurs, RN, MRCNA; Lecturer, University of Canberra, ACT

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177

7 | The gastrointestinal system

The main function of the gastrointestinal system is to provide nutrients to the cells of the body. The four major functions are ingestion (taking in food), digestion (breakdown of food), absorption (transfer of food products into the circulation) and elimination (excretion of waste products).

Anatomy and physiologyParts of the gastrointestinal tract (GIT)■ Mouth

● Also known as buccal or oral cavity● Contains the salivary glands, which secrete saliva to

moisten food during chewing● Tongue (with cheeks) shapes food into a bolus (rounded

mass) and pushes it into the pharynx.■ Pharynx■ Oropharynx■ Oesophagus

● Cricopharyngeal sphincter relaxes so food can enter the oesophagus.

■ Stomach● Has four main regions: cardia, fundus, body and pylorus

(includes the pyloric sphincter)● Lies just below the diaphragm● Size varies with distension

● If too distended, may cause shortness of breath due to pressure on the diaphragm

● Function:● Temporary storage of food

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● Holds about 1.0–1.5 L● Digestion is begun

– Alcohol is absorbed here, but not much food– Food is mixed with gastric acids to form chyme

(semi-fl uid substance)– Cephalic phase—gastric juices are released with the

thought of food– Gastric phase—gastric juices are released when food

is eaten● Gastric juice is highly acidic

– Destroys most microorganisms– Consists of water, mucus, hydrochloric acid,

pepsin, intrinsic factor (necessary for vitamin B12 absorption).

■ Small intestine● Approximately 6 m long● Consists of the duodenum, jejunum and ileum (smallest

to longest)● Note: Any fold of the peritoneum that attaches an

organ to the abdominal wall is called a mesentery.● Function:

● Peristalsis● Completion of food digestion● Absorption of food molecules into the bloodstream to

be transported to body cells● Hormones to control the secretion of various enzymes:

– Gastrin—produced in pyloric antrum and duodenal mucosa; stimulates gastric secretion and motility

– Gastric inhibitory peptides—produced in duodenal and jejunal mucosa; inhibit gastric secretion and motility

– Secretin—produced in duodenal and jejunal mucosa; stimulates secretion of bile and pancreatic enzymes

– Cholecystokinin—produced in duodenal and jejunal mucosa; stimulates secretion of bile and pancreatic enzymes.


Chapter 7 The gastrointestinal system | 179

■ Large intestine● Consists of the caecum, appendix, ascending colon,

transverse colon, descending colon, sigmoid colon, rectum and anus (including anal sphincter)

● Function:● Water absorption● Mucus secretion (to aid faecal movement)● Bacteria, e.g. Escherichia coli, Lactobacillus bifi dus

Mouth Parotidgland

Epiglottis

Pharynx

Oesophagus

Stomach

Pancreas

Splenicflexure

Transversecolon

Descendingcolon

Ascendingcolon

Duodenum

Hepaticflexure

Commonbile duct

Gallbladder

Cysticduct

Hepaticbile duct

Jejunum

IleumCaecum Sigmoidcolon

RectumVermiformappendix

Teeth

Liver

Submandibulargland

Sublingualgland

FIGURE 7.1 Gastrointestinal system



– To help break down cellulose and synthesise vitamin K

– Produces fl atus, which helps move the stool towards the rectum

● Elimination of waste products.

GIT nerve supply■ Distension of the GIT stimulates nerves in smooth muscle

and increases peristalsis.■ The sympathetic nervous system (SNS) decreases peristalsis

and inhibits GIT activity.■ The parasympathetic nervous system (PNS) increases

peristalsis and GIT activity.

Accessory organs of digestionLiver■ Divided into four lobes and surrounded by Glisson’s

capsule■ Blood supply is through the hepatic artery (carries

oxygenated blood to the liver), portal vein (carries nutrient-fi lled blood from the stomach and the intestines to the liver) and the hepatic veins (carry blood away from the liver)

■ Function:● Produces bile● Metabolises hormones and drugs● Synthesises proteins, glucose and clotting factors● Stores vitamins and minerals● Converts fatty acids to ketones

■ Metabolises 90% of consumed alcohol.Bile■ Contains water, bile salts, bilirubin, cholesterol and various

inorganic acids■ Bile salts are the most important component of digestion,

as they aid in the emulsifi cation of dietary fats and are necessary for the transport of fatty acids and fat-soluble vitamins

■ It is a powerful antioxidant that assists in the removal of toxins from the liver



■ The hepatic duct carries bile out of the liver, the cystic duct takes bile to and from the gallbladder and the common bile duct takes bile from the cystic and hepatic ducts to the small intestine.

Bilirubin■ Is formed from the breakdown of red blood cells and gives

bile its yellow-green colour■ Is transported in the blood attached to plasma albumin■ Is converted to urobilinogen in the intestine and reabsorbed

into the portal circulation or excreted in the faeces.

Gallbladder■ Collects, concentrates, acidifi es and stores bile■ Food and fat ingestion trigger the release of cholecystokinin

(CCK), which relaxes the valve at the common bile duct, releasing bile into the small intestine

■ Bile is moved in and out through the cystic duct.

Pancreas■ Lies behind the stomach (between the duodenum and the

spleen)■ The pancreatic duct empties into the ampulla of Vater and

joins the common bile duct, allowing pancreatic juices to empty into the small intestine, where they become activated● Exocrine function:

● Releases digestion enzymes into pancreatic duct● Releases inactive pancreatic enzymes into the small

intestine● Endocrine function:

● Releases hormones—insulin, glucagon and somatostatin.

Exocrine secretes into a duct.Endocrine secretes into the blood or lymph.



AssessmentSubjectiveAsk the patient about:■ What the symptoms are and what precipitates or relieves

them■ Bowel characteristics (stool description), including altered

bowel habits■ Diet and nutrition, including altered eating habits, e.g.

changes in appetite, diffi culty eating or swallowing, weight loss or gain

■ Dentures or any recent dental work■ Lifestyle, e.g. stress, smoking, exercise, alcohol■ Family history■ Past history

● Any recent travel (particularly overseas)● Past surgery or hospital admission● Any previous ulcers, GI bleeding etc● Medications (including OTC—particularly aspirin,

NSAIDs or laxatives)● Allergies to medications or foods.

Objective■ Examine the mouth and mucous membranes, note colour,

any bleeding, ulcers, missing teeth or odours■ Examine the abdomen

● Inspection● Observe skin for pigmentation, lesions, striae, scars,

dehydration● Observe the contour and movement of the abdomen

for symmetry and peristalsis● Auscultation

● Clockwise over all four quadrants– At least two minutes per quadrant– May need to listen for fi ve minutes to confi rm that

bowel sounds are absent● Bowel sounds are caused by air mixing with fl uid

during peristalsis



– High-pitched and gurgling in the small intestines; low-pitched and rumbling in the colon

– They occur 5–35 times/minute– Are most audible before mealtimes, e.g. stomach

rumbling● Percussion

● Tympany (clear hollow sound) over hollow organs● Dullness over solid organs or masses, e.g. liver,

distended bladder● Palpation

● To identify pain and muscle resistance (guarding)● Perform both light and deep palpation of each organ

and each quadrant● Always palpate the most tender or painful region

last

Always inspect, then auscultate, then percuss and lastly palpate. This will cause the least discomfort

to the patient.

■ Examine the rectum● Observe for haemorrhoids or polyps● Palpate rectum towards umbilicus (patient in left lateral

position)● Carefully rotate fi nger● Rectal walls should be smooth and soft● Remove fi nger and observe glove for faeces, blood or

mucus.

Body mass index (BMI)The calculation of body fat based on the height and weight of men and women. It is an indicator only and further assessment should include the patient’s gender, age, level of fi tness, past medical history and family history.

BMI = weight (kg)

height (m) × height (m)



For adults:

BMI Weight range

< 20.0 Underweight

20.0–25.0 Normal

25.0–30.0 Overweight

> 30.0 Obese

NutritionA healthy diet should consist of:■ Carbohydrates—give energy, e.g. bread, pulses, grains■ Fibre—no nutritional value, but promotes bowel motility,

e.g. bran, cereals■ Proteins—needed for cell production and maintenance, e.g.

meat, fi sh, pulses■ Fats—needed for the everyday function of cells, the

hormone system and body temperature regulation, e.g. milk, butter, cheese, fi sh

■ Vitamins and minerals—e.g. vitamins A, B1 (thiamine), B2 (ribofl avin), B3 (niacin), B6 (pyridoxine), B12

(cyanocobalamin), C, D, E and K.

Medical disordersAnorexiaLack or loss of appetite. It can occur due to psychological issues (e.g. anorexia nervosa, low self-esteem, stress) or be related to disease processes, medications or other treatment regimes.

AppendicitisInfl ammation of the appendix. Occurs as a result of obstruction of the mucous outfl ow from the appendix, causing the appendix to distend and bacteria to multiply, leading to restricted blood fl ow and eventual necrosis and perforation.

Causes■ Faecal impaction



■ Strictures■ Viral infection■ Ulceration of the mucosa.

Signs and symptoms■ Pain in right lower quadrant■ Nausea and vomiting■ Abdominal rigidity■ Later: fever, tachycardia and cessation of pain (if perforation

has occurred).

Diagnosis■ Physical examination■ Abdominal X-ray, ultrasound or MRI■ Blood tests—to check WCC elevation.

Treatment■ Appendectomy.

Cholelithiasis (gallstones)Occurs when bile is released that lacks the usual concentration of bile salts, causing it to become less soluble. This leads to bilirubin, calcium and cholesterol precipitation and the formation of gallstones.

Signs and symptoms■ Pain—mid-epigastric or right upper quadrant■ Flatulence and indigestion■ Nausea■ Low-grade fever■ Possible jaundice.

Diagnosis■ Ultrasound■ CT (if stones present)■ MRI or ERCP (endoscopic retrograde

cholangiopancreatography■ Blood tests to check for complications, e.g. infection.



Treatment■ Depends on severity■ Low-fat diet■ Antibiotics (usually IV)■ NGT (if vomiting)■ Lithotripsy (the break-up of stones using ultrasonic waves)■ Cholecystectomy.

CirrhosisIrreversible scarring of the liver that leads to the disruption of blood fl ow through the liver.

Types■ Post-necrotic

● Characterised by the replacement of liver tissue with nodules of fi brous tissue

● Occurs due to viral hepatitis B or C, autoimmune disease, or drug or chemical toxicity.

■ Biliary● Develops in the bile ducts with obstruction of the fl ow

of bile, and causes infl ammation and scarring of the bile ducts

● Usually caused by autoimmune disorders, gallstones or strictures

● Signs and symptoms are pruritus, dark urine and pale stools● Treatment includes correction of the obstruction and

treating the symptoms.■ Portal or alcoholic

● Occurs in three stages:● Fatty changes

– Alcohol replaces fat as a fuel for liver metabolism● Alcoholic hepatitis

– Infl ammation and necrosis of liver cells● Cirrhosis

– Normal tissue is replaced by scar tissue and blood fl ow through the liver is obstructed, causing the formation of shunts that serve as alternative routes for the return of portal blood to the heart.



Signs and symptoms■ Can be absent until the disease is advanced■ Weakness and fatigue■ Lack of appetite and weight loss■ Nausea■ Pruritus■ Diarrhoea■ Abdominal pain■ Palpable, hard liver■ Jaundice■ Ascites■ Peripheral oedema■ Mental confusion due to encephalopathy.

Diagnosis■ Liver function tests (LFT)■ Ultrasound, CT or MRI■ Liver biopsy.

Treatment■ Cease alcohol intake■ Increase carbohydrate and calorie intake to prevent protein

breakdown (to ammonia)■ Limit protein intake to decrease ammonia production■ Correction of fl uid and electrolyte imbalances■ Treatment of complications with medications■ Medications to treat hepatitis (if applicable)■ Liver transplant.

Complications■ Malnutrition■ More frequent infections■ Portal hypertension■ Oesophageal varices■ Bruising and bleeding■ Hepatic encephalopathy (due to high ammonia levels)■ Osteoporosis■ Liver cancer



■ Liver failure.

ConstipationInfrequent and often diffi cult evacuation of faeces.

Causes■ Inadequate fl uid and food (particularly fi bre) intake■ Immobility or a sedentary lifestyle■ Medications, e.g. opiates■ Surgery.

Signs and symptoms■ Hyperactive bowel sounds above the obstruction, with no

sounds below the obstruction■ Bloating■ Abdominal discomfort.

Treatment■ Promote fl uid intake■ Promote fi bre intake to improve muscle tone■ Bowel chart—note colour, consistency and frequency■ Encourage ambulation■ Medications, e.g. laxatives.

Crohn’s diseaseAn infl ammatory bowel disease that can affect any part of the GIT, from the mouth to the anus, although the terminal ileum is the most common. It affects all layers of the bowel (transmural infl ammation). It is painful and debilitating, and can lead to life-threatening complications. There is no cure, however symptoms can be relieved with treatment and some people can go into remission for months or years.

Signs and symptoms■ Pain or cramping (right lower quadrant)■ Bloating■ Tenderness■ Low-grade fever



■ Weight loss and anorexia■ Intermittent non-bloody diarrhoea■ Steatorrhoea.

Diagnosis■ Blood tests, e.g. WCC, ESR, FBE, U&E■ Faecal occult blood test■ Barium enema■ X-Ray, CT or MRI■ Colonoscopy■ Sigmoidoscopy■ Biopsy.

Treatment■ Medications:

● Anti-infl ammatory medications, e.g. corticosteroids, sulfasalazine, mesalamine

● Antibiotics, e.g. metronidazole, ciprofl oxacin● Immunosuppressants, e.g. azathioprine, infl iximab● Aminosalicylates● To relieve symptoms, e.g. anti-diarrhoeals, laxatives, pain

relief● Vitamins and minerals, e.g. iron, calcium, vitamins B12, D

■ Diet restriction● If acute, may need total parenteral nutrition (TPN)

■ Colectomy and/or ileostomy (if recurrent).

Nursing considerations■ Observe faeces for occult blood■ Observe for malnutrition and dehydration.

DiarrhoeaAn increase in the frequency and fl uidity of faeces.

Causes■ GIT disease, e.g. Crohn’s disease■ Toxins■ Medications, e.g. laxative overuse



■ Parasites, e.g. from travelling■ Faecal impaction (liquid stool may seep around the

blockage).

Signs and symptoms■ Abdominal cramps■ Dehydration■ Loose, frequent bowel movements.

Diagnosis■ Faecal specimen to test for blood or parasites.

Treatment■ Increase fl uid intake (may need IV fl uids if severe

dehydration)■ Replace electrolytes■ Medication, e.g. Lomotil®■ Treat underlying condition, e.g. parasite infestation,

constipation.

Nursing considerations■ Monitor patient’s weight■ Commence a bowel chart■ Patient should avoid high-fi bre foods.

Diverticular disease or diverticulitisInfl ammation and infection of the bulging pouches (diverticula) in the GIT wall, usually occurs in the large intestine.

Causes■ Increased transluminal pressure combined with a weakening

of the bowel wall (often due to straining during bowel movements)

■ Food or faeces lodging in the diverticulaNote: In countries where the diet is high is fi bre, this disease is relatively unknown.



Signs and symptoms■ Often asymptomatic■ Pain and tenderness in the left lower quadrant■ Nausea +/– vomiting■ Low-grade fever■ Chills■ Irregular bowel habits—diarrhoea and constipation■ Weight loss.

Diagnosis■ Abdominal examination■ Blood tests (WCC)■ CT.

Treatment■ Rest and liquid diet initially■ Temporarily avoid whole grains, fruit and vegetables■ Antibiotics■ Analgesia■ Bowel resection and temporary colostomy (if severe)■ Abscess drainage.

Complications■ Peritonitis (if perforation occurs)■ Abscess or fi stula.

Gallbladder cancerA rare form of cancer that is usually only discovered when the gallbladder is removed or when the cancer is very advanced.

Cause■ Unknown but could be due to toxins.

Signs and symptoms■ Often mimics other gallbladder problems such as gallstones

or infection■ Right upper quadrant abdominal pain■ Nausea and vomiting



■ Weight loss and loss of appetite■ Jaundice■ Enlarged gallbladder■ Pruritus.

Treatment■ Cholecystectomy■ Radiation therapy.

Gastro-oesophageal refl ux disease (GORD)A backfl ow of gastric or duodenal contents into the oesophagus that occurs when the oesophageal sphincter does not close properly. The acidic gastric contents back fl ow into the oesophagus, leading to pain, infl ammation and possible ulceration.

Signs and symptoms■ Can be asymptomatic■ Heartburn or chest pain that increases when lying down■ Dysphagia■ Acid refl ux■ Sensation of a lump in the throat■ Hoarsness or dry cough.

Diagnosis■ Barium meal■ Gastroscopy (abnormal changes in the mucosa).

Treatment■ Medications

● Antacids before meals● Proton pump inhibitors● Histamine-2 antagonists

■ Reduce weight■ Avoid large meals, fatty foods, caffeine, alcohol and tobacco■ Surgical removal of the cause, e.g. hernia■ Surgery to support the sphincter.



Nursing considerations■ Ensure patient remains sitting upright and sleeps with head

of bed elevated.

HaemorrhoidsCongestion of the veins in the haemorrhoidal plexus, causing varicose veins in the anal sphincter area. They can be internal or external. Can be treated with OTC medications, minimally invasive procedures, e.g. sclerotherapy, or surgery, e.g. haemorrhoidectomy.

HepatitisSee Ch 11 Infectious diseases.

Infl ammatory bowel disease (IBD)There are two main types: Crohn’s disease and ulcerative colitis. The cause is unknown but may be autoimmune as a result of the immune system attacking the GIT. It usually affects people aged 15 to 25 and 55 to 65.

Irritable bowel syndrome (IBS)A group of symptoms characterised by intermittent and recurrent abdominal pain associated with an alteration in bowel function. Not to be confused with IBD.

Causes■ Stress■ Ingestion of irritants, e.g. coffee, alcohol■ Laxative abuse■ Other illness, e.g. gastroenteritis.

Signs and symptoms■ Abdominal pain relieved by fl atulence or bowel actions■ Diarrhoea or constipation■ Mucus in stools■ Bloating.

Diagnosis■ Sigmoidoscopy



■ Colonoscopy■ CT■ Lactose intolerance tests■ Blood tests for other diseases, e.g. coeliac disease.

Treatment■ Increase dietary fi bre or fi bre supplements, e.g. Metamucil®■ Eliminate high-gas foods from the diet■ Medications

● Anticholinergics (to relieve symptoms)● Antidiarrhoeal medication, e.g. loperamide.

Nursing considerations■ Observe fl uid status.

JaundiceYellowish discolouration of the sclera of the eye, skin and deep tissues due to an abnormally high accumulation of bilirubin in the blood.

Types■ Intrahepatic

● Caused by liver disease and drugs such as oral contraceptives, anabolic steroids and chlorpromazine

● Conjugated and unconjugated serum bilirubin levels are abnormally high

■ Extrahepatic● Occurs due to obstruction of bile fl ow between the liver

and the intestine, caused by strictures of the bile duct, gallstones and tumours of the bile duct or the pancreas

● Conjugated levels of bilirubin are elevated.

Causes■ Excessive destruction of red blood cells (haemolytic

jaundice)● Can occur following a blood transfusion or due to

hereditary diseases or haemolytic disease of the newborn■ Decreased uptake of bilirubin by the liver cells



■ Decreased conjugation of bilirubin■ Obstruction of bile fl ow (obstructive jaundice)■ Infection■ Liver disease, e.g. hepatitis■ Medications.

Signs and symptoms■ Pruritus preceding jaundice■ Clay-coloured stools■ Increase in urinary bilirubin■ Abnormally high levels of serum alkaline phosphatase.

Treatment■ Phototherapy (for infants)■ Treat the cause (for adults).

Liver cancer■ Can be primary (occurring in the liver cells) or secondary

(metastases of cancer in another area of the body)■ Caused by hepatitis B and C, cirrhosis, exposure to toxins

and ulcerative colitis.

Signs and symptoms■ Weakness and fatigue■ Anorexia and weight loss■ Bloating and abdominal fullness■ Dull, aching right upper quadrant abdominal pain■ Enlarged liver on palpation■ Ascites■ Jaundice.

Diagnosis■ Liver function tests■ Blood test for alpha-fetoprotein (AFP)■ Ultrasound, CT, MRI■ Liver biopsy.



Treatment■ Surgical removal of the affected area of the liver■ Radiation therapy■ Chemotherapy■ Alcohol injection■ Radio frequency ablation■ Cryoablation■ Targetted drug therapy, e.g. Sorafenib■ Liver transplant.

Complications■ Liver failure■ Renal failure■ Metastases to other organs.

Pancreatic cancerOne of the most serious forms of cancer as it is seldom detected in the early stages and spreads rapidly. The cause is unknown.

Signs and symptoms■ Usually don’t appear until the disease is in the advanced

stages■ Upper abdominal pain that radiates to the back■ Loss of appetite and weight loss■ Jaundice■ Pruritus■ Nausea and vomiting■ Palpable abdominal mass.

Diagnosis■ Diffi cult to diagnose in the early stages■ Barium meal■ In the later stages, ultrasound, CT, MRI, endoscopic

retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS)

■ Percutaneous transhepatic cholangiography (PTC)■ Biopsy■ Laparoscopy.



Treatment■ Whipple procedure■ Total pancreatectomy■ Distal pancreatectomy■ Radiation therapy■ Chemotherapy■ Targeted therapy, e.g. erlotinib■ Palliative care.

Complications■ Diabetes■ Pain■ Metastasis to other vital organs.

PancreatitisInfl ammation of the pancreas, resulting in exocrine dysfunction. It can be acute or chronic, and occurs when digestive enzymes attack the pancreas.

Causes■ Common:

● Biliary disease (gallstones) and long-term alcohol abuse■ Less common:

● Medications, abdominal surgery or trauma, infectious disease, pancreatic cancer and genetic diseases.

Signs and symptoms■ Increasing symptoms with alcohol and food consumption■ Upper abdominal pain■ Nausea and vomiting■ Fever■ Tachycardia■ Swollen, tender abdomen on palpation■ Flatulence■ Weight loss despite normal eating■ Dehydration■ Hypotension■ Bleeding



■ Steatorrhea.

Diagnosis■ Acute

● Blood tests for:● Elevated pancreatic enzymes, amylase and lipase● Elevated white blood cell count● Elevated liver function tests, particularly bilirubin● Hyperglycaemia● Hypocalcaemia

● Ultrasound, CT, MRI■ Chronic

● Blood tests as per acute pancreatitis● Faecal specimen● Ultrasound● Pancreatic and bile duct X-ray● Pancreatic function test.

Treatment■ Intravenous fl uid administration■ Acute

● Nil orally● Analgesia● Reduce or cease alcohol intake and smoking● Surgery to remove gallstones, if applicable

■ Chronic● Treatment to assist with the cessation of alcohol and drug

use● Analgesia● Enzyme supplements● Smaller, more frequent meals that are low-fat● Treat other conditions, e.g. diabetes, bleeding, infection.

Complications■ Infection■ Pseudocysts or abscess■ Renal failure■ Myocardial depression



■ Acute respiratory distress syndrome (ARDS)■ Shock■ Disseminated intravascular coagulation (DIC)■ Malnutrition■ Diabetes■ Pancreatic cancer.

Nursing considerations■ Frequent vital signs■ Cardiac auscultation (third heart sound may be detectable)■ Respiratory assessment■ Blood tests as ordered■ Arterial blood gases■ Monitor neurological status■ Monitor renal output■ Gastrointestinal auscultation and palpation■ Pain assessment.

Small bowel obstruction (SBO)Complete obstruction of the small intestine or colon, preventing the movement of any food or fl uids through the bowel. It may cause bowel necrosis, perforation of the intestine, leading to peritonitis and shock, and can be fatal if left untreated.

Types■ Simple

● Blockage with no further complications■ Strangulated

● Blood supply to the obstructed section is cut off■ Close-looped

● Both ends of a bowel section are occluded.

Causes■ Mechanical obstruction due to adhesions, carcinomas,

foreign bodies, stenosis or hernias■ Non-mechanical obstruction due to electrolyte imbalances,

drug toxicity, thrombosis of a mesenteric vessel or a paralytic ileus.



Signs and symptoms■ Abdominal cramps■ Constipation■ Nausea and vomiting (of faecal contents)■ Abdominal tenderness and distension■ Scant or no bowel sounds.

Diagnosis■ Physical examination■ Abdominal X-rays, CT or MRI.

Treatment■ Nasogastric tube (NGT) to decompress the bowel■ IV fl uids and electrolytes■ Surgery if signs of strangulation.

Nursing considerations■ Nil orally■ Assess bowel sounds for the return of peristalsis■ Centrally acting antiemetics only, e.g. metoclopramide■ No opiates for pain■ No laxatives.

Ulcerative colitisAn infl ammatory bowel disease that causes chronic infl ammation of the mucosa of the colon and rectum. It can be debilitating and may lead to life-threatening complications. There is no cure, however with treatment, symptoms can be greatly reduced and remission can occur.

Signs and symptoms■ Diarrhoea that is often bloody■ Rectal bleeding■ Abdominal cramping relieved by bowel action.

Diagnosis■ Blood test■ Faecal test



■ Barium enema■ Colonoscopy■ X-ray or CT.

Treatment■ Medications:

● Antibiotics, e.g. metronidazole● Immunosuppressants, e.g. azathioprine, cyclosporine● Antiinfl ammatories, e.g. corticosteroids, sulfasalazine● Antidiarrhoeals, e.g. metamucil, loperamide● Analgesia (not NSAIDs as these may exacerbate

symptoms)● Iron supplements

■ Bowel resection (of the diseased bowel).

Nursing considerations■ Observe hydration and electrolyte status.

UlcersOpen sores that develop in the lining of the oesophagus, stomach or duodenum. They are usually caused by bacterial infection (H. pylori), medications or gastric acid refl ux.

Signs and symptoms■ Burning sensation or pain in the chest and stomach region■ Pain that is relieved after eating■ Nausea and vomiting■ Haematemesis and/or melaena.

Diagnosis■ Barium meal■ Gastroscopy■ Blood or faecal tests (to detect presence of H. pylori).

Treatment■ Medications

● Antacids● Proton pump inhibitors, e.g. omeprazole



● H2-receptor antagonists, e.g. ranitidine● Antibiotics● Cytoprotective agents, e.g. sucralfate

■ Physical rest.

Medical interventionsNasogastric tube (NGT)Types■ Wide bore (usually 2 lumens)

● Indications:● Decompression● Gastric lavage● Aspiration of gastric contents, e.g. for testing● To give medication, e.g. charcoal

● Example: Salem Sump™● Small lumen for ventilation—prevents the gastric

mucosa from damage if the tube adheres to the lining during suctioning

■ Fine bore (usually only 1 lumen)● Indications:

● Enteral feeding (short-term)● If need enteral feeding long-term, then a percutaneous

endoscopic gastrostomy (PEG) would be better● Example: Levin.

Nursing considerations■ Check the tube placement:

● After each new insertion by chest X-ray, before commencement of enteral feeding

● At the beginning of each shift, by aspirating the stomach contents and testing with pH indicator strips, not litmus paper. pH of 5.5 or less indicates correct placement.

■ Contraindicated if patient has a base of skull fracture.



Surgical interventionsAppendectomySurgical removal of the appendix to prevent rupture or perforation, or to remove if already ruptured.

CholecystectomySurgical removal of the gallbladder due to the presence of gallstones or infl ammation.■ Can be either:

● Open via a laparotomy, or● Laparoscopic—contraindicated in pregnancy, peritonitis

and bleeding disorders.

Liver transplantThe replacement of the patient’s liver with a donor liver. Used for the treatment of chronic hepatitis B and C, bile duct disease, alcoholic liver disease, autoimmune liver disease, fatty liver disease, liver cancer and liver failure.

Percutaneous endoscopic gastrostomy (PEG) tubeAn external opening into the stomach, made surgically by piercing the abdominal wall and placing a tube through. It is also known as a gastrostomy tube.

Indications■ Infants with abnormalities of the mouth■ Patients who cannot swallow correctly■ Patients receiving long-term enteral feeds, e.g. cystic fi brosis

and HIV patients.

Complications■ Complications of surgery and anaesthesia, e.g. bleeding,

infection.



Nursing considerations■ Always fl ush the tube well after giving a feed and at the

beginning of your shift■ Contraindications for feeding include SBO, paralytic ileus,

severe diarrhoea, peritonitis, peritoneal dialysis, severe pancreatitis and gastrointestinal ischaemia.

If the tube becomes dislodged and there is no spare tube, a Foley catheter can be placed in

the opening (with the balloon blown up to stop it falling out) to prevent the stoma from closing.

Stoma, ileostomy and colostomy■ Stoma means ‘any opening’■ An ileostomy is when there is a surgical fi stula between the

ileum and the abdominal wall. It is when the colon and the rectum are removed.

■ A colostomy is when there is a surgical fi stula between the colon and the abdominal wall. It is when the rectum is removed or part of the colon has been removed to allow for healing.

Indications■ Crohn’s disease or ulcerative colitis■ Bowel or rectal cancer■ Trauma.

Nursing considerations■ Observe the stoma—it should be pink and moist■ A stoma has no pain receptors:

● Take care when placing the pouch on the stoma● Constriction of the opening could cause skin damage

without the patient feeling pain■ Never pierce the pouch to release gas, as this destroys

the odour-proof seal releasing the odour into the environment.



TestsLiver function testsUsed to evaluate the functions of the liver.

Alanine aminotransferase (ALT)■ Normal levels:

● Neonate: < 50 U/L● Adult: < 35 U/L

■ Used for the detection and monitoring of liver cell damage■ Increased levels indicate hepatocellular damage■ More specifi c than AST or LD (see below).

Albumin■ Normal levels are 32–45 g/L■ Used for the assessment of hydration and nutritional status

of patients with protein-losing disorders and liver disease■ Decreased levels indicate overhydration, chronic liver

disease, protein-losing disorders such as nephrotic syndrome, malnutrition and extravascular space shifts such as in burns patients

■ Increased levels indicate dehydration.

Alkaline phosphatase (ALP)■ Normal levels are:

● Neonate: 50–300 U/L● Child: 70–350 U/L● Adult: 25–100 U/L

■ Used to investigate hepatobiliary or bone disease■ Increased levels are seen in liver disease, bone disease, some

bony metastases, and malignancy without liver or bone metastases

■ Can also be elevated in some gastrointestinal disorders.

Aspartate aminotransferase (AST)■ Normal levels are:

● Neonates: < 80 U/L● Adults: < 40 U/L



■ Used for detection and monitoring of liver cell damage■ Increased levels indicate hepatocellular disease.

Bilirubin■ Normal levels are:

● Total bilirubin: < 20 mmol/L● Direct bilirubin: < 7 mmol/L

■ Used for the investigation and monitoring of hepatobiliary disease and haemolysis

■ Total bilirubin● Comprises unconjugated, conjugated and delta bilirubin● Usually only required for diagnosis

■ Direct bilirubin● Comprises conjugated and delta bilirubin

■ Increased levels occur with hepatocellular disease or biliary disease

■ May also be increased in anaemia, haemolysis and Gilbert’s syndrome, jaundice of newborns

■ Levels may be normal in cirrhosis, liver failure or hepatic metastases until the disease is advanced.

Gamma glutamyl transferase (GGT)■ Normal levels are:

● Female: < 30 U/L● Male: < 50 U/L

■ Used to assess liver disease■ Increased levels occur in cholestatic liver disease and

hepatocellular disease with cholestasis■ Increased levels are also seen in diabetic patients with

chronic alcohol and drug excess, pancreatitis and prostatitis.

Globulins■ Normal levels are:

● Neonate: 12–36 g/L● Adult: 25–35 g/L

■ Used to identify hypo- and hypergammaglobulinaemia■ Increased levels occur with chronic infl ammation, infection,

autoimmune disease, liver disease and paraproteinaemia



■ Decreased levels occur in protein-losing enteropathy, humoral immunodefi ciency and nephrotic syndrome.

Lactate dehydrogenase (LD)■ Normal levels are 110–230 U/L■ Used for the non-specifi c assessment of liver disease or

malignancy and anaemia■ Increased levels occur in myocardial infarction, liver disease,

haemolysis, ineffective erythropoiesis, some malignancies, muscle disease and diseases that cause tissue damage.

Prothrombin time (PT)■ Normal levels are 11–15 seconds■ More sensitive than activated partial thromboplastin time

(APTT) for detection of coagulation defi ciencies due to vitamin K defi ciency and liver disease

■ Used to screen for defi ciency of factor VII, X, V, II, I■ Can also be expressed as an INR when used to monitor

anticoagulant therapy■ Abnormal results are due to liver disease, vitamin K

defi ciency and the use of oral anticoagulants.

Sigmoidoscopy■ An endoscopic examination of the lining of the descending

colon, sigmoid colon, rectum and rectal canal.

Purpose■ To diagnose acute or chronic diarrhoea and rectal bleeding■ Aids in the assessment of known ulcerative colitis.

Procedure■ May need to fast prior■ May need to take a laxative or have a bowel washout prior■ Will probably have a light sedative■ Takes about 10–30 minutes.

Complications■ Bleeding



■ Bowel perforation■ Vasovagal reaction (severe bradycardia and even cardiac

arrest).

ProctosigmoidoscopyEndoscopic examination of the lining of the distal sigmoid colon, rectum and rectal canal.

Purpose■ Aids diagnosis of IBD, infections, polyps, fi stulas and abscesses.

ColonoscopyA visual examination of the large intestine.

Purpose■ To detect and evaluate IBD■ To locate lower GIT bleeding■ To aid diagnosis of polyps.

Procedure■ A light sedative will probably be given

● Patient should have a pulse oximeter on at all times■ Specimens or biopsies may be taken■ Electrocautery may be used to remove polyps or stop

bleeding■ Takes about 30–60 minutes.

Complications■ Bowel perforation■ Bleeding—from the biopsy/polyp removal.

Barium meal or enemaBarium is either swallowed or given as an enema. The patient is then X-rayed to diagnose their condition.

Upper—barium meal■ Examination of the pharynx and oesophagus to investigate

strictures, ulcers and GORD.



Lower—barium enema■ To diagnose infl ammatory disorders, colorectal cancer,

polyps and diverticulitis.

Endoscopic retrograde cholangiopancreatography (ERCP)A radiographic examination of the pancreatic ducts via an endoscopic tube.

Purpose■ To evaluate obstructive jaundice■ To diagnose cancer of the duodenum, pancreas or biliary

ducts.

Procedure■ A tube is swallowed and inserted until the common bile duct

is visualised■ Patient will need a light anaesthetic■ Contrast medium will be given.

Complications■ Adverse drug reaction—from the contrast■ Bowel perforation■ Pancreatitis.

PharmacologyAlginates■ Action:

● Create a foam that lies on top of gastric contents, preventing refl ux

■ Example: Gaviscon®.

Antacids■ Action:

● Weak bases● React with hydrochloride acid to form water-soluble salts● Neutralise the hydrochloric acid



● Above a pH of 4, pepsin becomes inactive■ Examples: aluminium hydroxide, magnesium carbonate.

AntiemeticsAll antiemetics work by blocking the dopamine or 5-hyd-roxytryptamine (5-HT3) receptors in the chemoreceptor trigger zone in the brain.

Dopamine antagonists■ Action:

● Block dopamine receptors at low doses, and 5-HT3 at high doses

● Increase tone in the lower oesophagus● Increase gut motility

● Stomach and duodenum empty more quickly■ Example: metoclopramide.

5-hydroxytryptamine (5-HT3) antagonists■ Action:

● Selectively block the 5-HT3 receptors■ Example: ondansetron.

Antiemetic-antipsychotics■ Action:

● Dopamine receptor antagonists■ Example: prochlorperazine.

Antihistamines■ Action:

● Act on the H1 receptors● Block the vomiting centre in the brain

■ Example: promethazine.

Aminosalicylates■ Action:

● Unknown; thought to work by causing inhibition of leucocyte chemotaxis

● Have an antiinfl ammatory effect



■ Treatment must continue for at least two years after patient has been symptom-free

■ Example: sulfasalazine.

Anti-diarrhoeal agents■ Action:

● Reduce gastric motility, therefore water and electrolyte absorption is increased

■ Example: loperamide.

Histamine H2 receptor antagonists■ Action:

● Block the histamine H2 receptors● Decrease intracellular cyclic adenosine monophosphate

(cAMP)● Decrease proton pump activity● Therefore decrease acid secretion

■ Example: ranitidine.

LaxativesBulk-forming■ Action:

● Increase intestinal volume● Cause intestinal wall distension● Stimulate the emptying refl ex

■ Example: ispaghula husk (Fybrogel®).

Osmotic■ Action:

● Make the fl uid in the bowel hypertonic● Water won’t be reabsorbed, therefore there is more fl uid

in the bowel● Intestinal wall distension● Defaecation refl ex

■ Example: lactulose.

Softening■ Action:



● Lubricate and soften the intestinal contents● Act like a detergent

■ Examples: liquid paraffi n, docusate.

Stimulant■ Action:

● Irritate the intestinal wall and stimulate peristalsis■ Example: senna.

Proton pump inhibitors■ Action:

● Inhibit the enzyme hydrogen/potassium ATPase● Lower the acidity of gastric juices● Take 3–5 days for full effect if used for prophylactic use

■ Example: omeprazole.


Education

Clinical Companion: Medical-Surgical Nursing 2e - McKenzie