NCM 118: Responses to Alterations/Problems and its

Pathophysiologic Basis in Life-Threatening

Conditions, Acutely Ill/Multi-Organ Problems, High
Acuity and Emergency Situation
Responses to Metabolic-Gastrointestinal and Liver Alterations

MARK ANTHONY M. SERGIO, RN MAN

I. ASSESSMENT on altered GI function
1. General Nutritional Status Interview
• Should begin with questions regarding client’s dietary habits
• Questions should elicit information about average daily intake of food and liquids, types and quantities
consumed, where and when food is eaten, and any conditions or diseases that affect intake of absorption
Questions: • Food intake history, time, food/ drink, amount, method of preparation

2. Health History
• Elicit a description of present illness and chief complaint or symptoms through COLDSPA
(Characteristics, Onset, Location, Duration, Precipitating Factors, and Alleviating Factors)
• Family history, prenatal history, medications, use of tobacco and alcohol
• Complete nutritional history including 24-hour dietary intake

On altered Hepato-Biliary and Pancreatic Disorders

• Elicit description of present illness and chief complaint
o Onset, course, duration, location, and precipitating and alleviating factors
o Cardinal signs and symptoms indicated altered hepatic, biliary, and pancreatic function include:
▪ Jaundice, pruritus
▪ Changes in urine and stool color
▪ Vague to severe abdominal pain especially after eating fatty foods
▪ Abdominal tenderness and distention
▪ Easy bruising and bleeding
• Alcohol consumption
• Diet high in fat
• Infectious agents (transmitted through nonsterile needle puncture, unprotected sexual activity, ingestion of
potentially contaminated food, etc.)
• Recent blood transfusion
• Medications and herbal remedies
o Some sample drugs with high potential for hepatotoxicity
▪ NSAIDS (ibuprofen, acetaminophen, etc.)
▪ Antiseizure medications (phenytoin, valproic acid)
▪ TB drugs (isoniazid, pyrazinamide)
3. Physical Assessment
• The general physical assessment is IPPA (inspection, palpation, percussion, auscultation).
• But for abdominal physical assessment, have it in this order: Inspection, auscultation, percussion, palpation
a. Inspection
b. Auscultation
• Auscultate bowel sounds before percussion and palpation (5-30 clicks/ min using diaphragm of stethoscope for 5
min)
• Normal bowel sounds occur 5-30 times a min or every 5-15 seconds
• Auscultate in all abdominal quadrants
• Auscultate for vascular sounds (bruits, hepatic friction rub)

c. Percussion
• Percuss all 4 quadrants noting tympany and dullness

d. Palpation
• Palpate deeply over all 4 quadrants for any masses and note location, size and shape, pulsation
• Palpate liver, spleen, kidneys, aorta for enlargement
• Always palpate tender areas last, because if you start there, you may aggravate the pain and make the patient
uncomfortable.
DIAGNOSTIC ASSESSMENT
NON-INVASIVE

1. GUAIAC TEST
• Looks for hidden (occult/ old) blood in a stool sample
• Detect GI bleeding (GI cancer)
• ncrease fiber diet (48-72 hours)
• No red meats, poultry, fish, turnips, horse radish, melons, salmon, sardines
o Avoid red/ colorful food that may alter stool color for examination)
• Withhold 48 hours: iron, steroids, indomethacin, colchicine, vitamin C
o These will cause stool discoloration and may cause false positive results
•Three stool specimens (3 successive days)
•Hydrogen peroxide will be placed.
o Positive bleeding: BLUE color
2. HEPATOBILIARY SCAN/ LIVER SCAN
• Non-invasive nuclear medicine study using radioactive materials to show size and shape of liver tissue and
visualize replacement of liver tissue with scars, cysts, and tumors
• Radioactive agent is injected IV which is taken up by the liver/ hepatocytes and excreted rapidly through the
biliary tract
• Patient is placed on NPO and NO opioids given 4H before procedure

3. RADIONUCLIDE IMAGING/ CHOLESCINTOGRAPHY

• Procedure is more or less the same with liver scan but this time, images of the gallbladder and biliary tract are
obtained after IV administration of radioactive agent.

4. BARIUM SWALLOW
• An examination of the upper GIT under fluoroscopy after the client drinks a contrast medium: barium
sulfate (BaSO4)
• To visualize the esophagus, stomach, duodenum, and jejunum
5. BARIUM ENEMA
• An examination of the lower GIT
• A fluoroscopic and radiographic examination of large intestine is performed after rectal instillation of BaSO4
• Indicated for detecting bowel obstruction and cause of diarrhea and constipation
• Contraindication
o Patients with color perforation or fistula
INVASIVE

1. COMPLETE BLOOD GLUCOSE (CBG) MONITORING

• Convenient way of monitoring blood glucose patterns and can be useful aid in guiding treatment changes in
patients with Type 1 and Type 2 diabetes, especially during periods of illness or frequent hypoglycemia
• Let patient fast prior to extraction 2-3 hours prior to getting CBG. Collect before lunch.
• rotate sites
• discard first drop of blood because it is considered as “dirty blood”

2. ESOPHAGOGASTRODUODENOSCOPY (EGD)
• An upper GI fibroscopy
• Done with fiberscopes
• After sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters, and
duodenum
• Tissue specimens can be obtained for direct visualization of esophagus, stomach, and duodenum
• Esophagus → stomach → duodenum
3. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
• Endoscopic visualization of common bile, pancreatic, and hepatic ducts with a flexible fiber-optic
endoscope inserted into the esophagus, passed through the stomach and into the duodenum
• The common bile duct and the pancreatic duct are cannulated and contrast medium is injected into the
ducts, permitting visualization and radiographic evaluation.
4. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY (PTC)
• A fluoroscopic examination of the intrahepatic and extrahepatic biliary ducts after injection of contrast medium
into the biliary tree through percutaneous needle injection
• Useful for distinguishing jaundice caused by liver disease (hepatocellular jaundice) from that caused by
biliary obstruction, for investigating the gastrointestinal symptoms of a patient whose gallbladder has been
removed, for locating stones within the bile ducts, and for diagnosing cancer involving biliary system.
5. LIVER BIOPSY
• Sampling liver tissue by needle aspiration for histologic analysis
• Can establish a diagnosis of specific liver disease
• Physician inserts biopsy needle by way of transthoracic (intercostal) or transabdominal (subcostal) route
III. METABOLIC-GI AND LIVER ALTERATIONS

1. ACUTE GI BLEEDING
• Gastrointestinal bleeding – refers to any bleeding that starts in the GI tract
• Bleeding may come from any site along the GI tract, but is often divided into:
o Upper GI Bleeding – The upper GI includes the esophagus (tube from mouth to stomach), stomach, and
first part of the small intestine
o Lower GI Bleeding – the lower GI includes much of the small intestine, large intestine or bowels, rectum, and
anus

Etiology
Signs and Symptoms/ Clinical Presentation
• Hematemesis
• Melena – black stools; old blood; upper GIT bleeding
• Hematochezia – red stools; fresh blood; lower GIT bleeding
• Syncope
• Dyspepsia (indigestion)
• Epigastric pain
• Heartburn
• Diffuse abdominal pain
• Dysphagia
• Weight loss
• Signs of shock
o Hypotension
o Decreased pulses
o Decreased urine output
• Jaundice

Diagnostic Exams
• Endoscopy – considered the GOLD STANDARD for diagnosis of GI bleeding
• EGD
• Colonoscopy
• Radiographic procedures
• Serum blood studies
Treatment: Fluid resuscitation
• Adequate resuscitation and stabilization is essential
• Px with active bleeding should receive IVF (e.g. 500 mL of NS or RL over 30 minutes) while being
crossmatched for blood transfusion
• Blood transfusion
o Must be individualized
o Approach is to initiate BT if hemoglobin is <7 g/dL (70 mg/L)
• Hemostasis
o Early intervention to control bleeding is important to minimize mortality, particularly in elderly px
• Airway
o Endotracheal intubation should be considered in px who have inadequate gag reflexes or are
obtunded or unconscious, particularly if they will be undergoing upper endoscopy
• Active variceal bleeding
o Can be treated with endoscopic banding, injection sclerotherapy, or transjugular intrahepatic
portosystemic shunting (TIPS) procedure
• General support
o Supplemental oxygen via nasal cannula
o NPO
o PIVC (16G / 18G) or a central venous line should be inserted
o Placement of a pulmonary artery catheter
o Elective endotracheal intubation
Nursing Management
• All critically ill px should be considered at risk for stress ulcers and therefore GI hemorrhage. • Maintaining
gastric fluid pH 3.5-4.5 is a goal of prophylactic therapy
• Major nursing interventions are:
o Administering volume replacement
o Controlling bleeding
o Maintaining surveillance for complications (i.e. hemorrhagic shock)
o Educating family and px

2. INTRA-ABDOMINAL HYPERTENSION (IAH) AND ABDOMINAL COMPARTMENT SYNDROME (ACS)

• Intrabdominal pressure – pressure concealed within the abdominal cavity
• Intraabdominal hypertension (IAH)
o Sustained pathological elevation of IAP greater than or equal to 12 mmHg
• Abdominal Compartment Syndrome (ACS)
o Organ dysfunction caused by intraabdominal pressure >20 mmHg
o This is a MEDICAL EMERGENCY
• Prevalence o IAH and ACS are not only r/t trauma
▪ IAH and ACS are equally prevalent in medical px
▪ Can be found in every critical care population

Effects of Increase IAP

• Renal
o Compression of renal veins and collecting systems
o Oliguria, activation of RAA system, acute tubular necrosis, and renal failure (if prolonged)
• Neurological
o ↑ ICP (↑ BP ↓ PULSE ↓ RR)
o ↓ Cerebral perfusion pressure (CPP)
• Gastrointestinal
o Edema
o Necrosis
Intra-abdominal Pressure Monitoring
• The gold standard for diagnosing intra-abdominal hypertension
• Measure IAP at least q 4-6 hours
• IAP is measured by measuring bladder pressure
o Requires placement of indwelling urinary catheter
o Drainage bag clamped
o Px in flat supine position (recommended)
▪ If not tolerated, may place in supine 30-degree reverse Trendelenburg
▪ Note px position at the time of pressure measurement in medical record
o Instill 25 mL of sterile 0.9% normal saline thru catheter
o Transducer attached to catheter sample port (transducer zeroes to mid axillary line, at the level of the iliac
crest)
o Obtain pressure reading during end-expiration
o Subtract instilled volume from urine output
o Monitor for trends and signs of organ dysfunction

Treatment
• Titrate therapies for IAP <= 15 mmHg
• Optimize fluid status
• Optimize systemic perfusion
o Goal abdominal perfusion pressure (AP) of >= 60 mmHg
o APP = MAP – IAP
• Evacuate intraintestinal contents
• Evacuate intra-abdominal lesions
• Improve abdominal wall compliance
• Consider emergent abdominal decompression
o Percutaneous drain to remove fluid
o Decompressive Celiotomy
o Bedside laparotomy

3. LIVER FAILURE
• An uncommon condition in which rapid deterioration of liver function results in coagulopathy and alteration in
mental status
• Liver failure indicated that liver has sustained injury

Types of Liver Failure

• Fulminant Hepatic Failure
o Encephalopathy starts within 8 weeks
• Non Fulminant Hepatic Failure
o Encephalopathy starts between 8-26 weeks
Acute Liver Failure
• Is a rare condition characterized by the ABRUPT onset of severe liver injury
• Loss of liver function that occurs rapidly—in days or weeks—usually in a person who has no pre-existing liver
disease
• It’s a MEDICAL EMERGENCY that requires hospitalization

Signs and Symptoms

• Jaundice
• Hepatic encephalopathy
o Mental confusion
o Difficulty concentrating
o Disorientation
• Pain and tenderness in the upper right side of the stomach
• Electrolyte imbalances
o Hypoglycemia
o Hypokalemia
o Hypomagnesemia
o Hypocalcemia
o Hypophosphatemia
• Melena
• Ascites •
Ankle edema
• Malaise, drowsiness, and muscle tremors
• Bleeding, cerebral edema, hematemesis, coma
Pharmacological Management
• Treatment of acute liver failure consists of drugs and liver transplantation
• Pharmacological management includes certain antidotes to reverse the effects of ALF and various medication
to reduce ICP
o Penicillin G
o Activated charcoal
o N-acetylcysteine
o Osmotic diuretics
o Barbiturate
o Benzodiazepine
o Anesthetic agents

Nursing Managements
• Assess, report, and record S/S and reactions to treatment
• Monitor fluids I&O closely
• Provide adequate diet with high proteins, CHO, and vitamins (carefully in encephalopathy)
• Monitor for signs of possible bleeding
• For coagulopathy / GIT bleeding
o Vit. K can be given to treat abnormal PT
• Hypotension should be treated with fluids
• Pulmonary complications – mechanical ventilation may be required
• HOB should elevated to 30 degrees
• Monitor neurologic status
o Goal is to maintain ICP below 20 mmHg, and CPP above 50-60 mmHg
o Judicious administration of sedation and analgesia for px experiencing agitation during certain stages of
hepatic encephalopathy

4. ACUTE PANCREATITIS
• Occurs suddenly as 1 attack or can be recurrent with resolutions
• condition where the pancreas becomes inflamed (swollen) over a short period of time
• Can be a medical emergency
• Due to self-digestion of pancreas by its own proteolytic enzymes (pepsin, trypsin and chymotrypsin)

Assessment
• Acute steady and severe epigastric pain that occur in the umbilical area and may radiate into the back
• Associated with ingestion of alcohol or fatty meal (cardinal sign)
• Pain is usually the main symptom in pancreatitis and is aggravated when lying down
• Nausea & vomiting worsens with oral intake and does not relieve the pain
• Vital signs:
o Fever
o Hypotension
o Tachycardia
• Abdominal rigidity, tenderness, distention, and decreased bowel sounds
• Grey Turner’s Sign
o Reddish-brown to bluish discoloration along the flanks and represents accumulation of blood in the area; a
sign of severe necrotizing pancreatitis
• Cullen Sign
o Bluish discoloration around the umbilicus
o Also a sign of severe necrotizing pancreatitis
• Steatorrhea
o Fat content increase in volume as pancreatic insufficiency worsens
Diagnostic Exams
• ↑ Serum lipase, amylase levels
• ↑ urine amylase
• Leukocytosis
• Hyperglycemia
• Hypocalcemia
• Increase C-reactive protein
• Increase bilirubin and liver function test (indicates hepatic involvement)
• Imaging studies (Abdominal x-ray, UTZ, CT Scan)

Medical Management
• Narcotic analgesics
o Drug of choice: Meperidine (Demerol)
• Antiemetics, antispasmodics, and anticholinergics
• Somatostatin – a treatment for acute pancreatitis, inhibits the release of pancreatic enzymes
o Known to inhibit GI, endocrine, exocrine, pancreatic, and pituitary secretions, as well as modify
neurotransmission and memory formulation in the CNS
• Fluid resuscitation and electrolyte replacement
• Insulin administration as prescribed
• Antibiotics
Therapeutic Management
• NPO with NGT
• IV and TPN (total parenteral nutrition)
• Peritoneal lavage
• Cholecystectomy after acute pancreatitis is resolved

Nursing Management
• Administer pain management as ordered
• Keep NPO with gastric decompression
• Monitor lab results, v/s, I&O, bowel sounds
• Maintain bed rest and may increase activity as tolerated
• Place px in knee-chest position
• Oral feeding is resumed when amylase levels return to normal and when pain is relieved
• Small, frequent, low fat, feedings with no alcohol after acute phase

5. HYPERGLYCEMIA
• Medical term describing an abnormally high blood glucose level
• Hallmark sign of diabetes (both type 1 and 2 DM)

Signs and Symptoms

• 3 Ps
o Polyuria
o Polydipsia
o Polyphagia
• Viscous blood – poor circulation
• Altered sensation
• Glycosuria
• Diabetic foot
• Risk for infection and dehydration
• Hot and dry skin
• HTN (with headache)
• Fatigue, blurred vision, slurring of speech

Precautionary Measures
• Follow diabetes meal plan, exercise program, and medication routine
• If blood sugar levels are above target range, drink extra liquids
• Monitor blood sugar often

Treatment
• Control of high glucose level
o Raise insulin dose as prescribed
o Recommend dietary changes
o Recommend more exercise (at least 3 times/week)
o Recommend closer glucose monitoring
6. DIABETIC KETOACIDOSIS (DKA)
• A life-threatening complication of DM that develops when severe insulin deficiency occurs • The main clinical
manifestations:
o Hyperglycemia
o Dehydration and electrolyte loss
o Acidosis
• Occurs in px with Type I DM
• Causes:
o Decreased or missed dose of insulin
o Illness or infection

Assessment
• Elevated blood glucose level: 300-800 mg/dL
• Decreased serum bicarbonate and pH
• Sodium and potassium may be low
• Glycosuria; polyuria; dehydration
• Metabolic acidosis: Kussmaul’s breathing
• Sweet breath odor
• When to CALL physician
o Decreased consciousness
o Difficulty breathing
o Fruity breath
Implementation
• Restore circulating blood volume
• Treat dehydration with rapid IV infusions (e.g. bolus PNSS to promote circulation and dilute sugar)
• Treat hyperglycemia with IV regular insulin
• Cardiac monitoring & electrolyte replacement
• Treat acidosis according to cause (check ABG)
o Antacid: Sodium bicarbonate

Prevention
• Restore circulating blood volume
• Educate px in recognizing early s/s of DKA
• Emphasize not to eliminate insulin doses when nausea and vomiting occur
• Should have available foods for use on a “sick day”
• Drink fluids q hour to prevent dehydration
• In people with infections or who are on insulin pump therapy, measuring urine ketones can give more information
than glucose measurements alone
7. HYPERGLYCEMIC-HYPEROSMOLAR NONKETOTIC SYNDROME
• AKA Hyperosmolar hyperglycemic state
• Extreme hyperglycemia without ketosis and acidosis
• Characterized by hyperglycemia, hyperosmolarity, and dehydration without ketosis
• Occurs in px with Type II DM
• Onset is usually slow and takes hours or days to develop
• Causes
o Leading cause: inadequate fluid replacement
o Insufficient insulin
o Major stresses

Signs and Symptoms

• Blood glucose is from 600-1200 mg/dL
• Hypotension
• Dehydration
• Tachycardia
• Mental status changes and neurological deficits
• Seizures
• Polydipsia, polyuria, increased plasma osmolality
o (> 320 mosm/kg)
o (NV: 275-295 mOsm/kg),
o high urine specific gravity (>1.010)
Implementation
• volume restoration
IMPLEMENTATION/ MANAGEMENT OF METABOLIC-GI AND LIVER ALTERATIONS

MEDICAL-SURGICAL MANAGEMENT

1. NASOGASTRIC SUCTION TUBES

• Nasogastric tubes = primarily inserted for decompression of stomach
Types:
a. LEVIN (Single lumen) Pump
o (channel within a tube or catheter) and is made of plastic/rubber. This is tube is connected to low
intermittent suction (30-40 mmHg) to avoid erosion or tearing of the stomach lining
b. SALEM (Double Lumen) Pump
o radiopaque (easily seen on x-ray), clear plastic, double-lumen gastric tube. The blue port vent is always
open to air for continuous atmospheric irrigation; prevent reflux by having the blue vent port above patient’s
waist
2. ESOPHAGOGASTRIC BALLOON TAMPONADE TUBES
• Done via placement of Sengstaken-blakemore or Minnesota tube which are multi-lumen gastric tubes,
placed nasally & extended into the stomach; there are two balloons:
o Esophageal balloon – at the esophageal area, when inflated, tamponades the bleeding in the esophagus
o Gastric balloon - serves as anchor
a. Sengstaken-Blakemore tube
• triple lumen gastric tube (one lumen allows inflation of esophageal balloon, the other allows inflation of
gastric balloon while third lumen allows for gastric aspiration)
b. Minnesota tube
• quadruple lumen gastric tube; a modified Sengstaken-blakemore tube with an additional lumen for
aspirating esophagopharyngeal secretions
Nursing Considerations:
• Closely monitor patient’s condition and lumen pressure
• Careful surveillance of patient’s vital signs, oxygen saturation, and cardiac rhythm (a change may indicate
new bleeding)
• Monitor respiratory status and observe for respiratory distress
o If respiratory distress= CUT balloon ports and REMOVE tube.
o Keep scissors at bedside
• Provide support for patient
• Deflate esophageal balloon for about 30 minutes every 12 hours or according to hospital policy/procedure

3. BILLROTH I AND II
• Subtotal Gastrectomy = a generic term referring to any surgery that involves partial removal of the stomach,
may be accomplished by either a Billroth I or a Billroth II procedure.

Billroth I
• Surgeon removes part of the distal portion of the stomach, including the antrum.
• The remainder of the stomach is anastomosed to the duodenum
• This combined procedure is more properly called gastroduodenostomy
• It decreases the incidence of dumping syndrome that often occurs after a Billroth II procedure.
Billroth II
• Billroth II resection involves reanastomosis of the proximal remnant of the stomach to the proximal jejunum
• Pancreatic secretions and bile continue to be secreted into the duodenum, even after gastrectomy
• Surgeons prefer the Billroth II technique for treatment of duodenal ulcer because recurrent ulceration
develops less frequently after this surgery.
• WOF: Dumping Syndrome – rapid gastric emptying in which your food moves too quickly from the stomach to the
duodenum = let patient lie on the LEFT SIDE
4. TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPS)
• Involves the threading of a cannula into the portal vein via the transjugular route
• an expandable stent is inserted & serves as an intrahepatic shunt between the portal circulation & hepatic vein,
reducing portal hypertension.
5. LIVER TRANSPLANTATION
• Surgery to remove a diseased liver and replace it with a healthy one.
Indications:
• Liver transplantations is needed for patients who are likely to die because of liver failure
• Common conditions requiring liver transplant include:
o Noncholestatic cirrhosis
o Biliary atresia
o Acute hepatic necrosis
• Where does a liver for a transplant come from?
Two types:
a. Living donor transplantation
b. Cadaveric transplantation
• Liver transplant surgery takes between 6 and 12 hours
Post-op: • Patient is advised to stay in the hospital for an average of 1-3 weeks to ensure that new liver is
working
• Patient is required to take lifetime medicines (e.g. immunosuppressive medications) to prevent rejection
and infections
Complications:
a. Rejection
• Immune system works to destroy foreign substances that invades the body. The immune system,
however, can’t distinguish between transplanted liver and unwanted invaders, such as viruses and bacteria.
• Therefore, immune system may attempt to attack and destroy the new liver. This is called rejection episode
• Antirejection medications are given to ward off the immune attack
b. Infection
• Because antirejection drugs that suppress immune system are needed to prevent the liver from being rejected, it
places patient at increased risk for infections
6. BARIATRIC SURGERY
• Gastric bypass and other weight-loss surgeries—known collectively as bariatric surgery—involves making
changes to the digestive system to help lose weight.
• Done when diet and exercise haven’t worked or when you have serious health problems because of your weight

Types:
a. Biliopancreatic diversion with duodenal switch
b. Roux-en Y Gastric bypass
c. Sleeve gastrectomy
Indications:
• Done to help lose excess weight and reduce risk of potentially life-threatening weight-related health problems,
including:
• Heart disease and stroke
• High blood pressure
• Nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH)
• Sleep apnea
• Type 2 diabetes
• In general, bariatric surgery could be an option if:
o Body mass index (BMI) is 40 or higher (extreme obesity)
o BMI is 35-39.9 (obesity), and patients who have serious weight-related health problems
Post op: • Careful respiratory monitoring for 24-48 hours post-op • Assess and educate patients of anastomotic
leaks (leakage of gastric contents at the site of anastomosis is a potentially life-threatening complication which
would lead to sepsis if left untreated)
• NPO for at least 1-2 days
• Diet: Liquids → pureed, very soft foods → regular foods
• Frequent medical checkups to monitor health in first several months after surgery

7. REVERSE HYDRATION - drinking plenty of fluids, such as water, diluted squash or diluted fruit juice
8. REVERSE KETOACIDOSIS - Insulin reverses diabetic ketoacidosis
9. ELECTROLYTE REPLACEMENT
10. RAPID HYDRATION