FAR EASTERN UNIVERSITY

INSTITUTE OF HEALTH SCIENCES AND NURSING

DEPARTMENT OF NURSING

NUR 1219 MEDICAL-SURGICAL NURSING 3

ACUTE BIOLOGIC CRISIS

MODULE 4 ALTERED METABOLIC- LOWER GASTROINTESTINAL BLEEDING

GASTROINTESTINAL AND LIVER Causes:
FUNCTIONS • Polyps
• Inflammatory disease
Topic Outline
1. Acute GI Bleeding • Diverticulosis
2. Liver Failure • Cancer
3. Acute Pancreatitis • Vascular ectasias
4. Diabetic Ketoacidosis • Hemorrhoids
5. Intra-abdominal HPN
Pharmacological Management
METABOLIC-GASTROINTESTINAL DISEASES Pharmacological treatments to decrease gastric acid
ACUTE GI BLEEDING secretion and/or reduce acid effects on gastric mucosa
Gastrointestinal bleeding (GI bleed), also known as • Histamine Blockers
o Cimetidne
gastrointestinal hemorrhage, is all forms of bleeding in
the gastrointestinal tract, from the mouth to the rectum. o Famotididne
o Nizatidine
o Ranitidine
• Proton Pump Inhibitors
o Esomeprazole
o Omeprazole
o Pantoprazole
o Lansoprazole
• Mucosal Barrier Enhancers
o Sucralfate
o Colloidal bismuth
• Antacids
o Aluminum hydroxide
o Calcium carbonate
o Magnesium hydroxide
Classified into: o Magnesium oxide
1. Upper GI bleeding
2. Lower GI bleedin g Nursing Diagnosis
1. Fluid volume deficit r/t decreased circulating
UPPER GASTROINTESTINAL BLEEDING blood volume.
Causes: 2. Altered tissue perfusion r/t decreased
• Duodenal Ulcer circulating blood volume
• Gastric/Peptic Ulcer 3. Risk for fluid volume excess r/t fluid overload
• Esophageal or Gastric varices from treatment regimen
• Mallory-Weiss Tear
Patient Outcomes:
Clinical Signs & symptoms: • Adequate circulating blood volume
• Hematemesis • Adequate tissue perfusion
• Melena • Normal fluid/volume status
• Hematochezia
• Abdominal discomfort Nursing Management and Interventions
• Symptoms of hypovolemic shock To promote adequate circulating blood volume
o Hypotension 1. Monitor vital signs for hemodynamic instability
o Tachycardia and orthostatic change
o Cool, clammy skin 2. Monitor ECG, skin, urine output, amount and
o Change in LOC characteristics of GI secretions
o Decreased urine output 3. Monitor response to blood and fluid
o Decreased gastric motility replacement
 4. Monitor laboratory values: serial Hct, Hgb, Cirrhosis is a chronic disease characterized by
BUN, potassium, sodium replacement of normal liver tissue with diffuse fibrosis
5. Monitor bowel sounds that disrupts the structure and function of the liver.
6. Monitor for clinical manifestations of There are three types of cirrhosis or scarring of the liver:
perforation: severe persistent abdominal pain; • Alcoholic cirrhosis, à in which the scar tissue
board-like abdomen characteristically surrounds the portal areas.
7. Gastric lavage as ordered until clear This is most frequently caused by chronic
8. Administer medications & parenteral fluids alcoholism and is the most common type of
9. Prepare patient for endoscopy, assist as cirrhosis.
necessary & monitor for complications • Postnecrotic cirrhosis,à in which there are
broad bands of scar tissue. This is a late result
To promote adequate tissue perfusion of a previous bout of acute viral hepatitis.
1. Monitor vital signs every 15 minutes until • Biliary cirrhosis,à in which scarring occurs in
stable the liver around the bile ducts. This type of
2. Measure RAP, PAOP, cardiac output every cirrhosis usually results from chronic biliary
hour until stable obstruction and infection (cholangitis); it is
3. Monitor for tachycardia, chest pain, ST- much less common than the other two types.
segment elevation, diaphoresis, and
cool/clammy extremities PATHOPHYSIOLOGY
4. Measure urine output every hour Alcoholic cirrhosis is characterized by episodes of
5. Monitor level of consciousness necrosis involving the liver cells, which sometimes
6. Assess bowel sounds occur repeatedly throughout the course of the disease.
7. Monitor for elevated bilirubin The destroyed liver cells are gradually replaced by scar
8. Notify the physician of changes and tissue. Eventually, the amount of scar tissue exceeds
abnormalities that of the functioning liver tissue. Islands of residual
To promote normal volume status normal tissue and regenerating liver tissue may project
1. Monitor hemodynamic response to fluid from the constricted areas, giving the cirrhotic liver its
administration characteristic hobnail appearance. The disease usually
2. Monitor breath sounds at least every hour has an insidious onset and a protracted course,
during fluid administration occasionally proceeding over a period of 30 or more
3. Monitor for restlessness or anxiety, dyspnea, years.
tachycardia, coughing, crackles, frothy sputum,
dysrhythmias, abnormal ABG results, blood CLINICAL MANIFESTATIONS
pressure, increased RAP, jugular vein Common Clinical manifestations presentations of
distention compensated cirrhosis are:
4. Record accurate I&O hourly • Intermittent mild fever
5. Document and report any abnormalities • Vascular spiders
• Palmar erythema
LIVER FAILURE • Unexplained epistaxis
Chronic liver disease (CLD) or cirrhosis of the liver • Ankle edema
is one of the leading cause of death in the Philippines. • Vague morning indigestion
Hepatic failure also results from chronic liver disease, • Flatulent dyspepsia
in which healthy liver tissue is replaced by fibrotic • Abdominal pain
tissue.29 This form of liver failure is called cirrhosis. • Firm, enlarged liver
Finally, liver cells can be replaced by fatty cells or tissue • Splenomegaly
and is known as fatty liver disease.
Common Clinical manifestations presentations of
HEPATIC (Liver) CIRRHOSIS decompensated cirrhosis are:
• Jaundice
• Ascites
• Weakness
• Muscle wasting
• Weight loss
• Continuous mild fever
• Clubbing of fingers
• Spontaneous bruising (dt Variceal bleeding)
• Epistaxis
• Hypotension
 DIAGNOSTIC FINDINGS 5. Restrict sodium
• Ultrasound scanning 6. Frequent change in position
• CT 7. Provide skin care
• MRI 8. Protect the patient with cirrhosis from falls and
• Radioisotope liver scans other injuries
o give information about liver size and 9. Orient the patient to time and place and explain
hepatic blood flow and obstruction. all procedures.
Diagnosis is confirmed by liver biopsy.
• Arterial blood gas analysis may reveal a Medical and Nursing Interventions
ventilation–perfusion imbalance and hypoxia 1. The patient with liver failure is at risk for
• Hypoalbuminemia bleeding complications because of decreased
• Increase serum bilirubin, cholesterol, APT, synthesis of clotting factors. Patients with a
AST, ALT prolonged prothrombin time and partial
• Prolonged prothrombin and partial thromboplastin time and a decreased platelet
thromboplastin time count should be protected from injury through
the use of padded side rails and assistance with
MANAGEMENT all activity.
Medical Management 2. Needlesticks should be kept to a minimum.
1. Antacids or histamine-2 (H2) antagonists 3. Blood products may be ordered in severe cases.
2. Vitamins and nutritional supplements 4. Antacids, proton pump inhibitors, or H2-
3. Potassium-sparing diuretics (Spironolactone) blockers are ordered to prevent gastritis and
or triamterene (Dyrenium) bleeding from stress ulcers.
4. Avoidance of alcohol 5. Administration of all drugs metabolized by the
5. Immunosuppressants liver must be restricted. The administration of
6. Folic acid and iron are prescribed to prevent such drugs could cause acute liver failure in a
anemia patient with chronic disease.
6. Nursing assessment of respiratory rate, breath
Nursing Diagnosis sounds, and pulse oximetry values is critical.
1. Activity intolerance related to fatigue, lethargy, 7. Frequent monitoring of abdominal girth alerts
and malaise the nurse to fluid accumulation
2. Imbalanced nutrition: less than body 8. Positioning the patient in a semi-Fowler’s
requirements, related to abdominal distention position also allows for free diaphragm
and anorexia movement
3. Impaired skin integrity related to pruritus from 9. Frequent deep-breathing and coughing
jaundice and edema exercises and changes in position are important
4. High risk for injury related to altered clotting to facilitate full/optimal breathing.
mechanisms and altered level of consciousness 10. Ascites is medically managed through bed rest,
5. Disturbed body image related to changes in a low sodium diet, fluid restriction, and diuretic
appearance, sexual dysfunction, and role therapy
function 11. Close monitoring of the serum creatinine level,
6. Chronic abdominal pain related to enlarged the BUN level, electrolytes (Na & K) and urine
tender liver and ascites output is important for the early detection of
7. Fluid volume excess related to ascites and renal impairment.
edema formation
8. Risk for imbalanced body temperature: ACUTE PANCREATITIS
hyperthermia related to inflammatory process Acute pancreatitis is an inflammation of the pancreas.
of cirrhosis or hepatitis
9. Ineffective breathing pattern related to ascites
and restriction of thoracic excursion secondary
to ascites, abdominal distention, and fluid in the
thoracic cavity

Nursing Management
1. Promote rest
2. Provide oxygen therapy
3. Improve client’s nutritional status (high-protein
diet, if tolerated, supplemented by vitamins of
the B complex, as well as A, C, and K)
4. Encourages the patient to eat. If ascites is
present, give small, frequent meals.
 CLINICAL MANIFESTATIONS ASSESSMENT AND DIAGNOSTIC FINDINGS
• Severe abdominal pain 1. Laboratory determination
• Abdominal guarding • Glucose tolerance test
• Abdominal distention • Increased Serum Amylase and Lipase
• A rigid or boardlike abdomen • Fecal fat analysis (steatorrhea)
• Nausea and vomiting 2. Imaging Studies
• Hypotension • ERCP
• Fever, jaundice, mental confusion, and • CT scan
agitation • MRI
• tachycardia, cyanosis, and cold, clammy skin • Ultrasound
• Respiratory distress and hypoxia
MANAGEMENT
ASSESSMENT AND DIAGNOSTIC FINDINGS Medical Management
1. Laboratory determination 1. Management of abdominal pain and discomfort
• Increased Serum Amylase is similar to that of acute pancreatitis
• Increased Serum Lipase 2. Endoscopy to remove pancreatic duct stones,
• Urinary Amylase – increased correct strictures, and drain cysts may be
• WBC effective in selected patients to manage pain
• Hyperglycemia and relieve obstruction
• Hypocalcemia 3. Emphasize to the patient and family the
• Glycosuria importance of avoiding alcohol and foods that
• bilirubin have produced abdominal pain and discomfort
2. Imaging Studies in the past.
• ERCP 4. Surgical intervention
• CT scan – Pancreaticojejunostomy -> a side-to-side
anastomosis or joining of the pancreatic duct to
MEDICAL MANAGEMENT the jejunum, allowing drainage of the
1. Pain management – analgesia; opioids pancreatic secretions into the jejunum.
(Morphine, Fentanyl, Dilaudid) o A Whipple resection
2. Intensive care – monitored in ICU with (pancreaticoduodenectomy)- to
hemodynamic & blood gas monitoring; relieve the pain of chronic pancreatitis.
correction of fluid and blood loss and low
albumin levels is necessary to maintain fluid Nursing Diagnosis
volume and prevent renal failure. 1. Acute abdominal pain related to abdominal
3. Respiratory care - close monitoring of distention; peritoneal irritation
arterial blood gases to use of humidified 2. Imbalanced nutrition: less than body
oxygen to intubation and mechanical requirements related to inadequate dietary
ventilation intake, impaired pancreatic secretions,
4. Biliary drainage - Placement of biliary drains increased nutritional needs secondary to acute
(for external drainage) and stents (indwelling illness,
tubes) in the pancreatic duct through 3. Hyperthermia
endoscopy 4. Fluid and electrolyte disturbances
5. Surgical intervention - (diagnostic
laparotomy) to establish pancreatic drainage, Nursing Management
or to resect or débride a necrotic pancreas. 1. Relieving pain and discomfort
6. Post-acute management – antacids, low fat & 2. Improving breathing pattern
low protein diet; ERCP 3. Improving nutritional status
4. Maintaining skin integrity
CHRONIC PANCREATITIS
Chronic pancreatitis is an inflammatory disorder Nursing Interventions
characterized by progressive destruction of the 1. Monitor and record vital sings, skin color,
pancreas. temperature, urine output & daily weight
2. Measure and record episodes of vomiting
CLINICAL MANIFESTATIONS 3. Frequently assesses the pain and the
1. Pain on LUQ radiating to the back – intense and effectiveness of the pharmacologic (and
constant, occurring at unpredictable intervals; nonpharmacologic) interventions
often lasting for several days 4. Assess RR and monitor arterial blood gas levels
2. Weight loss & monitor for signs of respiratory distress
3. Malabsorption, steatorrhea and diarrhea 5. Position in upright or semi-Fowler’s position
6. Administer O2 therapy a prescribed
 7. Administer intravenous fluid and electrolytes, Goals: to restore normal metabolism and
enteral or parenteral nutrition as prescribed; correct fluid and electrolyte deficiencies.
monitor closely blood glucose levels &
administer insulin as prescribed. MANAGEMENT AND NURSING
8. Parenteral fluids and electrolytes are prescribed INTERVENTIONS
to restore and maintain fluid balance. 1. Obtain blood and urine samples immediately:
9. Nasogastric suction may be used to relieve 2. Test blood for glucose, ketone, BUN,
nausea and vomiting electrolytes, complete blood count, arterial pH,
10. Provide frequent oral hygiene PO2 and PaCO2.
11. Instruct and explain why oral food or fluid 3. Obtain urine specimen at prescribed time and
intake is not permitted. measure sugar, acetone, and volume.
12. Enforce bed rest, turn the patient every 2 hours; Catheterize only if a voided specimen cannot be
13. If post-surgery, carry out wound care as obtained.
prescribed and take precautions to protect intact 4. Set up chronological flow chart that includes
skin from contact with drainage; carefully vital signs, clinical manifestations, laboratory,
assesses the wound, drainage sites, and skin for data and therapy.
signs of infection, inflammation, and 5. Carry out a rapid physical examination to look
breakdown. for infection, myocardial infarction, stroke, etc.
14. Counsel patient to avoid excessive use of coffee 6. Record vital signs, state of hydration, and
and spicy foods; and eliminate alcohol mental status.
7. Start intravenous infusion of isotonic saline
solution
DIABETIC KETOACIDOSIS 8. Give insulin as directed
Diabetic ketoacidosis results from the absence of 9. As the serum glucose falls, glucose is added to
effective insulin, which causes hyperglycemia, the infusion, and the insulin dose is reduced as
ketonuria, dehydration, and acidosis. directed.
10. Determinations of serum glucose, ketone
PATHOPHYSIOLOGY bicarbonate, and potassium are done every6-8
• Glucose no longer enters muscle cells and fat is hours.
metabolized to produce energy. 11. Monitor ECG and vital signs
• Free fatty acids are converted to ketone bodies 12. Patient education - seek medical advice when
in the liver à metabolic acidosis. there are symptoms of diabetic ketoacidosis.
• Relative or absolute insulin deficiency, cellular
dehydration and volume depletion, acidosis, INTRAABDOMINAL HYPERTENSION
and protein catabolism.

CLINICAL MANIFESTATIONS
1. Early Manifestations
2. Polyuria, polydipsia, fatigue, malaise,
drowsiness
3. Flushed, dry skin and mucous membrane
4. Anorexia, headache, abdominal pains
5. Muscle cramps, nausea, vomiting, constipation,
abdominal pain
6. Later Manifestations
7. Kussmaul breathing-very deep respiratory
movements
8. Sweetish odor of the breath due to ketonemia
9. Hypotension and weak, thready pulse
10. Stupor and coma

DIAGNOSIS EVALUATION
1. Blood Glucose elevated, bicarbonate • Intra-Abdominal Hypertension (IAH)is
decreased, arterial pH decreased, strongly defined as intraabdominal pressure (IAP) of at
positive plasma ketone, Electrolytes vary with least 12 mm Hg; it causes compression of
state of hydration; often hyperkalemic. intraabdominal contents and leads to renal, gut,
2. Urine. Strongly positive for sugar and ketone, and hepatic ischemia.
and moderately positive for protein. • Abdominal compartment syndrome (ACS) is
a serious complication that may occur when
large volumes of fluid are administered. It may
 also occur after trauma, abdominal surgery, ileus, sepsis, ruptures, abdominal aneurysm,
severe pancreatitis, or sepsis (Brush, 2007). abdominal tumors, cirrhosis, ascites and full
• Intra-Abdominal Pressure (IAP) is the thickness burns
pressure within the abdominal cavity. • Obstetrical conditions: preeclampsia, and
• Abdominal Perfusion Pressure (APP) is a pregnancy-related DIC
measure of the adequacy of abdominal blood • Ascites
flow. APP is calculated by subtracting the IAP • Pancreatitis
from the mean arterial pressure (MAP). APP in • Ileus
patients with IAH or ACS should be maintained • Sepsis
at 60 mmHg or higher (Lee, 2012). APP = • Major burns
MAP-IAP • Continuous ambulatory peritoneal dialysis
• Morbid obesity
ABDOMINAL COMPARTMENT SYNDROME
• Severe intra-abdominal infection
• Defined as sustained pressures of >20 mmHg
with or without an APP <60 mmHg associated GRADING OF ABDOMINAL COMPARTMENT
with new organ dysfunction or failure. Intra- SYNDROME
abdominal pressures in this range can cause The WSACS (2012), states the following grading
rapid decline in organ function and lead to system for intra-abdominal hypertension:
multiple organ failure if not treated (Lee, 2012). Grade Intraabdominal Pressure (mmHg)
I 12-25
II 16-29
III 21-25
IV ³25

MANAGEMENT
IAP can be measured directly or indirectly.
• Direct measurement is obtained via a needle or
catheter in the peritoneal space, and IAP is
measured using a fluid column or pressure
CAUSES OF ABDOMINAL COMPARTMENT transducer system. This is the most accurate
SYNDROME method but associated with side effects such as
The cause of IAH or ACS are categorized into bowel perforation and peritonitis.
two sections, primary and secondary conditions. • IAP is usually measured indirectly via the
Primary conditions are the ones that need surgical or patient's bladder. The changes in intravesical
interventional radiological treatment. Secondary pressure demonstrate an accurate reflection of
conditions are due to medical causes that do not require intra-abdominal pressure (IAP)
surgery or radiological intervention as initial therapy • Patients with two or more risk factors for IAH
(Lee, 2012). should have a baseline IAP performed and if
elevated should have continued serial
Primary: measurements
• Trauma- blunt and penetrating abdominal • IAP is measured 4 hourly or more frequently if
trauma, pelvic fractures, bowel perforation and IAP greater than 12mmHg or the patient is
hemorrhage hypotensive, has decreased urine output or a
• Liver transplants tense abdomen
• An increased IAP reading should be rechecked
• Ruptured abdominal aortic aneurysm
to ensure there is not a technical problem e.g. a
• Post-operative bleeding
blocked catheter
o Retroperitoneal hemorrhage
• If IAP greater than 12mmHg then medical
• Mechanical intestinal obstruction
management of IAH should be instituted in a
• Abdominal surgery-decreased abdominal wall timely manner to prevent further morbidity and
compliance secondary to post-surgical mortality. Renal impairment can occur with
abdominal packing or, tight surgical closures IAP as low as 10-15mmHg.
• Bleeding pelvic fractures • Excessive fluid administration should be
avoided as it is strongly associated with ACS.
Secondary: The patient will need close clinical monitoring
• Massive volume replacement status-post of organ function.
surgery or trauma
• Rapid fluid resuscitation in the setting of SIRS NURSING INTERVENTIONS
(Systemic Inflammatory Response Syndrome), 1. Monitor the patient's vital signs and surgical
peritonitis, pancreatitis, bowel obstruction, wound closely.
 2. Report signs and symptoms of infection to the
healthcare provider.
3. Assess the patient's pain using a valid and
reliable pain intensity rating scale.
4. Perform a gastrointestinal assessment every
shift or more frequently if needed.
5. Assess the patient's nutritional status and
ambulation status for changes from baseline.
6. For patients who had surgery, monitor for signs
and symptoms of infection (drainage, fever,
abdominal distension and firmness, increased
pain); monitor nutrition, ambulation, and bowel
sounds; and monitor intake and output,
particularly if the patient has wound drainage,
anorexia, or decreased fluid intake.

PATIENT EDUCATION
Patients who've had surgery for abdominal
compartment syndrome should be taught:
1. the signs and symptoms of infection and to
notify their healthcare provider immediately if
they notice these signs and symptoms or have
pain (or worsening pain) at the operative site.
2. To report decreased appetite and fluid intake.
3. Teach patients about their prescribed pain
medications and to notify their healthcare
provider if their pain isn't adequately
controlled.
4. Encourage patients to keep follow-up
appointments with their healthcare providers.
5. By understanding abdominal compartment
syndrome and how to promptly recognize it and
intervene, you could help your patient avoid
complications and death.

REFERENCES:
Smeltzer, S. Bare, B., Hinkle, J. & Cheever, K
(2010). Brunner & Suddarth’s Textbook
of Medical-Surgical Nursing, 12th ed. Wolters
Kluwer/ Lippincott Williams& Wilkins,
Philadelphia, USA
Hinkle, J. and Cheever, K. (2018). Brunner and
Suddarth’s Textbook of Medical-Surgical
Nursing. (14th ed.). Wolters Kluwer: Health
Lippincott Williams & Wilkins, Philadelphia,
USA
Sole, M., Klein, D. & Moseley, M. (2013). Introduction
to Critical Care Nursing (6th ed.). Elsevier Inc.
St. Louis, Missouri, USA