University of the East RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

Aurora Boulevard, Quezon City

College of Nursing

WORKSHEET FOR NCM 102 (ALTERATION IN GASTRO-INTESTINAL SYSTEM) WORKSHEET NUMBER 2

COMMON DIAGNOSTIC TEST RELATED TO GASTRO-INTESTINAL SYSTEM

Serum Laboratory

SERUM TEST Complete blood count (please identify all test) 1.White blood cell count 2. White blood cell (WBC) differential count

DESCRIPTION The complete blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute.

NORMAL FINDINGS/ RESULTS

INDICATION FOR GIT ALTERATION

4,300 and 10,800 cells per cubic millimeter (cmm)

NURSING CONSIDERATION/ PREPARATION/HEALTH TEACHING There is no special preparation needed. Explain to the patient that his blood will be drawn and when the needle is inserted to draw blood, the client may feel moderate pain, though most people feel only a prick or a stinging sensation. Afterward there may be some throbbing or

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3.Red blood cell count 4. Hemoglobin (Hb)

bruising. 4.2 to 5.9 million cells/cmm Male: 13 to 18 grams per deciliter Female: 12 to 16 grams per deciliter Male: 45% to 52% Female: 37% to 48% 80 to 100 femtoliters 27 to 32 picograms 32% to 36%

5. Hematocrit (Hct) 6. Mean corpuscular volume (MCV) 7. Mean Corpuscular Hemoglobin (MCH) 8. Mean Corpuscular Hemoglobin Concentration (MCHC) 9. Red Cell Distribution Width (RDW) 10. Platelet count 11.Mean Platelet Volume (MPV) Liver function tests (please identify all test) 1. Albumin (Alb) 2. Alanine transaminase

11 to 15 150,000 to 400,000/ cmm 7.5-11.5 femtolitre Liver function tests (LFTs or LFs), are groups of clinical biochemistry laboratory blood assaysdesigned to give information about the state of a patient's liver. There is no special preparation needed. The nurse must first disinfect the area before sticking the needle into the vein.

3.5 to 5.3 g/dL 9 to 40 IU/L

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(ALT) 3. Aspartate transaminase (AST) 4. Alkaline phosphatase (ALP) 5. Total bilirubin (TBIL) 6. Direct bilirubin (Conjugated Bilirubin) 7. Gamma glutamyl transpeptidase (GGT) Amylase A determination of serum amylase, which is useful in the diagnosis of acute pancreatitis and after operations in which the pancreas might have been injured. 23 to 85 units per liter Increased blood amylase levels may occur due to:

10 to 35 IU/L 30 to 120 IU/L 0.21.2 mg/dL 0.10.4 mg/dL 0 to 42 IU/L

Cholecystitis Gastroenteritis (severe) Infection of the salivary glands (such as mumps) or a blockage Intestinal blockage Macroamylasemia Pancreatic or bile duct blockage

No special preparation is needed. However ,the patient should avoid alcohol before the test. The health care provider may ask the client to stop taking drugs that may affect the test. NEVER stop taking any medications without first consulting the doctor.

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Perforated ulcer The patient is NPO for 8 hours prior to the procedure. Advise the patient to stop taking drugs that may affect the test such as birth control pills, codeine, indomethacin etc.

Lipase

The lipase test is a blood test performed to determine the serum level of a specific protein (enzyme lipase) involved in digestion.

0 to 160 units per liter (U/L)

Higher-than-normal levels may be due to:

Blockage of the bowel Celiac disease Cholecystitis (with effects on the pancreas) Duodenal ulcer Gastroenteritis (severe)

CEA

The carcinoembryonic antigen (CEA) test measures the amount of this protein that may appear in the blood of some people who have certain kinds of cancers, especially large intestine (colon and rectal)cancer.

0 to 2.5 micrograms per liter (mcg/L) In smokers, the normal range is 0 to 5 mcg/L

Macrolipasemia Higher than normal levels may be due to:

Cholecystitis Colon cancer Diverticulitis Heavy smoking Inflammatory bowel diseases (such as ulcerative colitis) Pancreatic cancer Pancreatitis Peptic ulcer

Smoking may increase CEA levels. If the client is a smoker, ask him not to smoke few hours before the procedure.

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Diagnostic Test

PROCEDURE STOOL TEST

DESCRIPTION It is the basic examination of the stool which includes inspecting the specimen for consistency, color and occult blood. Additional studies, including Clostridium difficile, fecal leukocytes, calculation of stool osmolar gap, parasites, pathogens, food residues, and other substances, require laboratory evaluation.

NURSING CONSIDERATIONS/ PREPARATION/HEALTH TEACHING The stool appears brown, soft, and well- If the patient is taking any medications, formed in consistency. these must be screened as some can No blood, mucus, pus, bacteria, viruses, affect test results. A patient is usually fungi, or parasites are present in the discouraged as well from taking stool. The shape of the stool is tubular, reflecting its passage through the colon. aspirin, alcohol, vitamin C, ibuprofen Normal pH of stool is about 6. Less than and certain types of food if his fecal 2 milligrams per gram (mg/g) of certain sample will be checked for any sign of sugars called reducing factors are present blood. Recent travel and X-Ray tests in the stool. can also affect the results of fecalysis. The patient must urinate first to prevent any urine from mixing with his feces later on. He must also wear gloves when it's time to handle stool and transfer it to a safer container. This will prevent any possibilities of being contaminated or infected by bacteria found within the stool. If the patient is suffering from diarrhea, placing a plastic wrap and securing it under the toilet seat could facilitate the collection process. Collected samples must be brought to the doctor's office or laboratory as soon as possible. Delays could compromise the quality
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NORMAL RESULT/FINDINGS

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BREATH TEST

This test determines the amount of hydrogen expelled in the breath after it has been produced in the colon (on contact of galactose with fermenting bacteria) and absorbed into the blood.

ABDOMINAL ULTRASOUND

It is a non-invasive diagnostic technique in which high-frequency sound waves are passed into internal body structures and the ultrasonic echoes are recorded on an oscilloscope as they strike tissues of different densities.

of the sample. Prior to hydrogen breath testing, the patient fasts for at least 12 hours. On the day of the test, the patient should not eat or drink anything in the morning. He may take his medications with a small amount of water. If the patient is diabetic requiring insulin or diabetic pills, ask his physician if he should change his morning dose. Generally, half of the normal long acting insulin is given. Oral hypoglycemic medications are usually not taken that morning until completion of the test and resumption of eating meals. Two hours before the test, patient should brush teeth. Advise patient not to eat, drink, chew gum or tobacco, smoke cigarettes, eat breath mints or candy before or during the test. Sleep or exercise while the test is being done will not be allowed. The patient fasts for 8 to 12 hours before the test to decrease the amount of gas in the bowel. If gallbladder studies are being performed, the patient should eat a fat-free meal the evening before the test. If barium studies are to be performed, the nurse should make sure they are scheduled after this test; otherwise, the barium will interfere with the transmission of the sound
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UPPER GIT TRACT STUDY

It involves fluoroscopic examination of the upper gastrointestinan tract after the introduction of a contrast agent, usually barium. It includes the esophagus, stomach and upper small intestine (duodenum).

A normal upper GI series shows a healthy, normally functioning, and unobstructed digestive tract. Hiatal hernia, obstructions, inflammation (including ulcers or polyps of the esophagus, stomach, or small intestine), or irregularities in the swallowing mechanism are just a few of the possible abnormalities that may appear on an upper GI series. Additionally, abnormal peristalsis, or digestive movements of the esophagus, stomach, and small intestine can often be visualized on the fluoroscopic part of the exam, and in the interpretation of the SBFT.

waves. Education regarding dietary changes prior to the study should include a clear liquid diet, with nothing by mouth from midnight the night before the study. The nurse advises against smoking, chewing gum and using mints because they can stimulate gastric motility. Typically, oral medications are withheld on the morning of the study and resumed that evening, but each patients medication regimen should be evaluated on an individual basis. When a patient with insulin-dependent diabetes is NPO, his or her insulin requirements will need to be adjusted accordingly. Follow-up care is provided after the upper GI procedure to ensure that the patient has eliminated most of the ingested barium. Fluids may be increased to facilitate evaluation of stool and barium. Preparation of the patient includes emptying and cleansing the lower bowel. This often necessitates a lowresidue diet 1 to 2 days before the test (the preparation required by different x-ray departments may vary); a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear

LOWER GIT TRACT STUDY

It is the visualization of the lower gastrointestinal tract through x-ray images after rectal installation of barium.

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the following morning. The nurse makes sure that barium enemas are scheduled before any GI studies. If the patient has active inflammatory disease of the colon or patients has sign of perforation or obstruction, enemas are contraindicated. Active GI bleeding may prohibit the use of laxatives and enemas. Postprocedural patient education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements. COMPUTED TOMOGRAPHY This provides cross-sectional images of abdominal organs and structures. Multiple x-ray images are taken from numerous angles, digitized in the computer, reconstructed and then viewed on a computer monitor. The patient should not eat or drink for 6 to 8 hours before the test.Any allergies to contrast agents, iodine, or shellfish; the patients current serum creatinine level; and human chorionic gonadotropin must be determined before administration of a contrast agent. Patients allergic to the contrast agent may be premedicated with IV prednisone 24 hours, 12 hours, and 1 hour before the scan. In addition, renal protective measures include the administration of IV sodium bicarbonate 1 hour before and 6 hours after IV contrast and oral acetylcysteine before or after study.

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MAGNETIC RESONANCE IMAGERY

It is a medical imaging technique used in radiology to visualize detailed internal structures. MRI makes use of the property of nuclear magnetic resonance (NMR) to image nuclei of atoms inside the body.

POSITRON EMMISION TOMOGRAPHY

PET is a test that uses a special type of camera and a tracer (radioactive chemical) to look at organs in the body. The tracer usually is a substance (such as glucose) that can be used (metabolized) by cells in the body.

Any ferromagnetic objects can be attracted to the magnet and can cause injury. Items that can be problematic or dangerous include jewelry, pacemakers, dental implants, pens, keys, paperclips, IV poles, clips on patients gown, and oxygen tanks. MRI is contraindicates in patients with permanent pacemakers, artificial heart valves and defribrillators, implanted insulin pumps, or implanted transcutaneous electrical nerve stimulation devices. It is also contraindicated for patients with internal metal devices, intraocular metallic fragments, or cochlear implants. Foil-backed skin patches should be removed because of risk of burns. Advise the client to stop taking medicines and herbal remedies 24 hours before you have this test. If the client takes insulin to control diabetes, he may need to take less than his normal dose. Talk with the doctor if there are any adjustments in the dose of the insulin. Smoking, drinking alcohol or caffeine 24 hours before the test is not allowed. The client should be NPO 8 hours prior to the procedure. This test is contraindicated for pregnant or breast feeding clients.
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SCINTIGRAPHY

It is a diagnostic test in which a two-dimensional picture of a body radiation source is obtained through the use of radioisotopes.

Assess if the patient has claustrophobia. The patient should be NPO 6-12 hours prior to the procedure. Also, before the cardiac examination patient is advised to eat a piece of chocolate, in order to empty gall bladder so that it does not interfere interpretation of results. It is contraindicated if the patient is pregnant. If patient is breast feeding, it should not be resumed until 24 hrs after injection. The stomach must be empty prior to the examination so ask the client not eat or drink after 10 p.m. the night prior to the study.

GI MOTILITY STUDIES

It is a diagnostic procedure wherein a small tube is swallowed to monitor the digestive tract for a few hours then ingestion of a small amount of food or medication will follow for further monitoring. It is the direct visualization of the mucosa of the esophagus, stomach and duodenum using a flexible fiberoptic scope.

ESOPHAGEAL ASTRODUODENOSCOPY

The patient should be NPO for 8 hours prior to the examination. Before the introduction of the endoscope, the patient is given a local anesthetic gargle or spray. The nurse also may administer atropine to reduce secretions, and may give glucagon, if needed and prescribed, to relax smooth muscle. The nurse positions the patient on the left side to facilitate
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saliva drainage and to provide easy access for the endoscope. After the procedure, the nurse instructs the patient not to eat or drink until the gag reflex returns (in 1 to 2 hours), to prevent aspiration of food or fluids into the lungs. The nurse places the patient in the Simms position until he or she is awake and then places the patient in the semi-Fowlers position until ready for discharge. After gastroscopy, assessment by the nurse includes observing for signs of perforation, such as pain, bleeding, unusual difficulty swallowing, and an elevated temperature. The nurse monitors the pulse and blood pressure for changes that can occur with sedation. The nurse can test the gag reflex by placing a tongue blade onto the back of the throat to see whether gagging occurs. After the patients gag reflex has returned, the nurse can offer lozenges, saline gargle, and oral analgesics to relieve minor throat discomfort. Patients who were sedated for the procedure must stay on bed rest until fully alert. After moderate sedation, the patient must be accompanied and transported home if the procedure was performed on an
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COLONOSCOPY

Colonoscopy is the endoscopic examination of the colon and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It may provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected lesions.

ANOSCOPY

An anoscopy is an examination using a small, rigid, tubular instrument called an anoscope (also called an anal speculum). This is
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outpatient basis. The nurse instructs the patient not to drive for 10 to 12 hours if sedation was used. The physician may prescribe a laxative for 2 nights before the examination and a Fleets or saline enema until the rectum is clear the morning of the test. However, more commonly, polyethylene glycol electrolyte lavage solutions are used as intestinal lavages for effective cleansing of the bowel. The patient maintains a clear liquid diet starting at the noon the day before the procedure. Then the patient ingests the lavage solution orally at intervals over 3-4 hours. If necessary, the nurse can give the solution through a feeding tube if the patient cannot swallow. The use of lavage solution is contraindicated in patients with intestinal obstruction or inflammatory bowel disease. Monitoring for elderly after a bowel prep is important because of their diminished ability to compensate for fluid loss. After a therapeutic procedure, the nurse instructs the patient to report any bleeding to the physician. These examinations require only limited bowel preparation, including a warm tap water or Fleets enema until returns are clear. Dietary

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PROCTOSCOPY

inserted a few inches into to the anus in order to evaluate problems of the anal canal. Proctoscopy is the endoscopic examination of the anal canal using a proctoscope (An instrument consisting of a tube or speculum equipped with a light) Sigmoidoscopy is a procedure by which a doctor inserts either a short and rigid or slightly longer and flexible fiber-optic tube into the rectum to examine the lower portion of the large intestine (or bowel). This permits the noninvasive visualization of the mucosa throughout the entire small intestine.

SIGMOIDOSCOPY

restrictions usually are not necessary, and sedation usually is not required. During the procedure, the nurse monitors vital signs, skin color and temperature, pain tolerance, and vagal response. After the procedure, the nurse monitors the patient for rectal bleeding and signs of intestinal perforation (ie, fever, rectal drainage, abdominal distention, and pain). On completion of the examination, the patient can resume regular activities and dietary practices.

SMALL BOWEL ENTEROSCOPY

Patients are fasted for between 8 and 12 h prior to the procedure. As the capsule usually leaves the stomach within 30 min, the patient is allowed to drink after 2 h and eat after 4 h. The procedure requires moderate sedation so advise the client not to get out of bed after administration of analgesia.

MANOMETRY AND ELECTROPHYSIOLOGICAL STUDIES

These are methods used for evaluating patients with GI motility disorders. The manometry test measures changes in intraluminal pressures and the coordination of the muscle activity in the GI tract with the pressures transmitted to a computer analyzer.
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GASTRIC ANALYSIS

It is examination of the contents of the stomach, primarily to determine the quantity of acid present and incidentally to ascertain the presence of blood, bile, bacteria, and abnormal cells. It also yields information about the secretory activity of the gastric mucosa and the presence or degree of gastric retention in patients thought to have pyloric or duodenal obstruction.

The patient is NPO for 8 to 12 hours before the procedure. Any medications that affect gastric secretions are withheld for 24-48 hours before the test. Smoking is not allowed on the morning of the test because it increases gastric secretions.

LAPAROSCOPY

It is a minimally invasive procedure used as a diagnostic tool and surgical procedure that is performed to examine the abdominal and pelvic organs,

It is very important that the patient receive realistic counseling before surgery and prior to giving informed consent . There is usually a presurgical exam two weeks before the surgery to gather a medical history and obtain blood and urine samples for laboratory testing. It is important that the patient inform the doctor completely about any prior surgeries, medical conditions, or medications taken on a regular basis, including such nonsteroidal antiinflammatory drugs (NSAIDs) as aspirin . For some procedures, an autologous (self) blood donation may be suggested prior to the surgery to replace blood
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that may be lost during the procedure. Chest x rays may also be required. For some obese patients, weight loss may be necessary prior to surgery. Immediately before to surgery, t he patient should shower at least 24 hours prior to the surgery, and gently but thoroughly cleanse the umbilicus (belly button) with antibacterial soap and water using a cotton-tipped swab. the patient may be asked to eat lightly 24 hours prior to surgery and fast at least 12 hours prior to surgery. Bowel cleansing with a laxative may also required, allowing the it to be more easily visualized and to prevent complications in the unlikely event of bowel injury. Those who are have diabetes or have hypoglycemia may wish to schedule their procedures early in the morning to avoid low blood sugar reactions. Questions will be asked regarding current medications and dosages, allergies to medication, previous experiences with anesthesia (that is, allergic reactions, and previous experiences regarding time-toconsciousness), and a variety of other questions. Following laparoscopy, patients are required to remain in a recovery area until the immediate effects of anesthesia subside and until
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normal voiding is accomplished. Vital signs are monitored to ensure that there are no reactions to anesthesia or internal injuries present.

Prepared by: ZANDRALINE R. ONG, MSN, RN ALEXIS BITAGHOL, RN LEVEL III Faculty

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