DIGESTIVE

SYSTEM

by :

Hermie M. Pueyo M.D.,R.N.

 Digestive System
- is a system responsible for the :
1. ingestion
2. digestion
3. absorption of nutrients
4. elimination of waste products of digestion.
 Gastro-Intestinal
Tract
 Accessory Organs
Oral structures
- formation of bolus by process of chewing
and mixing of foods
Pharynx
- provides passageway for foods, fluids and
air
- divided into :
1. nasopharynx
2. oropharynx
3. hypopharynx
Salivary glands (accessory organ)
- produce saliva that moisten food to form bolus
- secrets enzyme ptyalin that is needed in
chemical breakdown of starches
- parotid, sub maxillary, sublingual
Esophagus
- 25 cm long, locate
behind trachea
- serves as passageway of food
- upper esophageal sphincter
(voluntary)
- lower esophageal or
cardiac sphincter
(involuntary)
- Epiglottis –
a flap of cartilage that keeps
food out of larynx during
swallowing
Stomach- chyme formation, capacity 1500 ml
- cardiac (entrance )
- fundus (reservoir for food)
- body (secretion of HCL, intrinsic factor,
pepsin and lipase)
- pylorus (outlet)
Small intestine
- absorption of nutrients
- longest segment of GI tract (20 ft.)
- surceases, maltase's, lactases,
- peptidase, lipase

- Duodenum
( CBD and pancreatic duct)
( Ligaments of Treitz )
- Jejunum
(absorb most of nutrients)
- Ileum
(Vitamin B 12 absorption)
Large intestine
- absorption of water & Na,
- secretion mucus (Goblet's) and HCO3
- formation of feces, Vitamin K synthesis
Accessory organs
LIVER - a highly vascularized organ
located on the right upper quadrant
of the abdomen divided into lobe
- secretes bile
- synthesize clotting factors
- metabolize glucose protein and fat,
- drug metabolism
- ammonia conversion to urea

GALL BLADDER - stores bile; secretion is

mediated by hormone cholecystokinin
PANCREAS - located on the LUQ
- head, body and tail
- mixed-type gland
exocrine - amylase, lipase, trypsin, and
secretin (HCO3)
endocrine - insulin, glucagons, & somatostatin
 Peritoneum
- a serous membrane that
lines the peritoneal cavity

Visceral
- line the visceral organs
Parietal
- lines the inner abdominal wall
Innervation
- govern by autonomic
nervous system

Sympathetic NS
- decrease gastric
secretion and motility
- constrict sphincter and
blood vessels
Parasympathetic NS
- increase gastric
secretion and motility
- relax sphincter
Blood supply
Abdominal Aorta
- supply oxygenated blood
- gastric and celiac artery
hepatic artery
superior mesenteric artery
inferior mesenteric artery
Portal Vein
- drain blood from GI tract
towards liver
- gastric and splenic
superior mesenteric vein
inferior mesenteric vein
Gastro-Intestinal Wall
Physical Examination

Inspection - scar, distention, masses,dryness

Auscultation - bell for bruit
diaphragm for bowel sound
normal = sound heard every 5 to 15 seconds
Percussion - tap to produce sound
(direct & indirect)
dull signifies mass such as liver
tympanetic signifies gas
flat signifies water
Palpation - light (swelling) and deep (masses)
Digital rectal examination - using index finger
Abdominopelvic Quadrants
Abdominopelvic Regions
The correct order for physical assessment
of the abdomen is?.

a. inspect, auscultate, percuss and palpate

b. inspect, palpate, auscultate and percuss
c. inspect, percuss, palpate, and auscultate
d. inspect, palpate, percuss and auscultate
 RELATED
DISEASES AND
DISORDERS
Stomatitis – inflammation of oral mucosa.

Etiology:
Infectious , dryness, trauma

Nursing managements:
- avoid mouthwash
- bland diet, avoid spicy and acid containing
foods
- consume lukewarm or cold foods and fluids
ice chips for pain management

Medications :
antibiotics, acyclovir, antifungal, analgesic
A patient develops stomatitis secondary to
radiation therapy for oral cancer. Which of
the following nursing instructions would be
most helpful?..

a. Gargle with mouthwash and

rinse thoroughly after each meal
b. Use ice cold liquids such as tea or
cola to relieve discomfort
c. Use a toothbrush soaked in saline to clean
the mouth
d. Drink citrus juices
Parotitis
- inflammation of the parotid glands
Sialadenitis
- inflammation of salivary glands.

Etiology :
Parotitis – virus (mumps),
Staphylococcus (bacteria)
Sialadenitis – dehydration, calculi, radiation,
stress
Clinical manifestations :
pain an swelling of salivary glands, fever
purulent discharges on the salivary ducts

Management :
- increase oral fluid, oral hygiene
- sugarless candy or gum
- viral (self-limiting), bacterial (antibiotics)
- analgesic (NSAID) and
anti-pyretic (paracetamol)
 Acute-Tonsillopharyngitis
(ATP)
- inflammation of tonsils and pharyngeal
mucosa.

Etiology:
Infectious agents
1. bacteria
(Streptococcus)
2. viruses
Clinical manifestations:
- fever, headache, body malaise, sore
throat
- difficulty of breathing and
inability to eat (indication for
admission)

Nursing management:
- gargle warm saline solution
- small frequent feeding
- avoid sweets
- antibiotic (Erythromycin)
- surgery: tonsillectomy for recurrent and
chronic tonsillitis
 Post- tonsillectomy
- Prone to side lying position to facillitate
drainage
- Frequent swallowing may indicate hemorrhage
- Discourage coughing & clearing of throat
- Do not give the child any straws, forks or sharp

objects that can be put in the mouth

Gastroesophageal Reflux Disease
(GERD)
– is excessive reflux of hydrochloric
acid into the esophagus.

Etiology:
- incompetent LES
- aggravated by increase
in abdominal pressure
such as :
pregnancy and obesity
 Clinical manifestations:
- pyrosis (burning sensation in the esophagus)
- regurgitation of sour-tasting gastric secretions
- dysphagia (difficulty in swallowing),
- odynophagia (pain on swallowing)
- symptoms mimicking those of heart attack
Diagnostics:
 Barium Swallow
NPO before the procedure

laxative and increase fluids after procedure

 Esophagoscopy – consent; assess Gag reflex
Nursing Management:
- Eat low fat, high fiber diet,
- Avoid foods spicy or acidic foods, tobacco,
caffeine and alcohol
- Avoid food and drinks 3 hours before bedtime
or lying down after eating.
- Elevate the head 6-8 inches during sleeping
- Lose weight if necessary
- Administer medications:
antacids, H2- blockers, Proton-pump inhibitors
- Surgery : Nissen fundoplication
Which of the following instruction is appropriate
for a nurse to give to a patient
who has gastroesophageal reflux disease?
..
1. “Take prescribed antacids before eating.”
2. “Place blocks under
the head of the bed.”
3. “Eat a high-fat, low protein diet.”
4. “Lie down for one hour after eating.”
Hiatal Hernia
- also known as esophageal
or diaphragmatic hernia
- a portion of the stomach herniates through
the diaphragm and into the thorax due t
weakening of the diaphragmatic muscle

aggravated by :
- pregnancy
- obesity
- ascites
Clinical Manifestation
heartburn, dysphagia, regurgitation
feeling of fullness

Management :
- same as GERD
- prepare for herniorrhapy
A client with hiatal hernia routinely experiences
heartburn after eating. The nurse tells the client
to avoid which of the following aggravating
factors of this condition? ….

a. Sitting upright following meals

b. Taking histamine receptor antagonist
medications
c. Taking in small, frequent bland meals
d. Lying recumbent following meals
Gastritis
– Inflammation of the stomach mucosa
Etiology :
acute (transient intermittent inflammation)
- local irritants : drugs, alcohol, corrosive subs.
- allergy and bacterial endotoxins : E.coli
- stress
chronic
- H.pylori infection
- bile acid reflux or to peptic ulcer disease
- chronic use of local irritants
- may progress to atrophic gastritis leading to
pernicious anemia and CA
Clinical Manifestations :
- mild to severe abdominal discomfort or pain
- intolerance to spicy or fatty foods
- vomiting
- may lead to PUD

Nursing Interventions :
- correct fluid and electrolyte imbalances
- diet and life style modification to prevent
exacerbation
- avoid cigarette smoking & alcohol consumption
- medications : antacids, H2 blockers, antibiotics
misoprostol, sucralfate
Peptic Ulcer Disease
ulceration in the mucosa in the :
- duodenum (duodenal ulcers)
- stomach (gastric ulcers)
- esophagus and jejunum
brought by:
- excessive secretions of HCl
- diminished protective effect
of mucosal barrier
- poor blood supply
( Curling’s and Cushing)
Etiology:
- Infection (Helicobacter pylori)
- Tobacco smoking and alcohol use
- Use of NSAIDs and corticosteroids
- Chronic anxiety and stress; type A
personality

Clinical manifestations:
- pain described as burning, aching
gastric ulcer (pain aggravated by eating)
*CA
duodenal ulcers (pain relieved by eating)
- pyrosis, nausea, vomiting, epigastric
tenderness
- hematemesis, melena
Laboratory Findings:
endoscopy and biopsy for presence of H. pylori
(NPO, left side lying position, Gag reflex)

Nursing management:
- avoid foods that had previously caused pain
( fatty foods, coffee, tea, cola)
- eat three regular meals per day; small frequent
meals and bland diet in acute phase.
- quit smoking, avoid alcohol, decrease stress
- monitor complications :
hemorrhage , perforation and obstruction
- cool saline lavage not iced saline in case of
bleeding
Medications:
- antacids (taken 1 hr after meals)
- H2-blockers ( 30 mins before meals or with
meals, at bedtime, 1 hr apart
from other Rx)
- mucosal barrier ( 1 hr before meals)
- Proton Pump Inhibitors (before breakfast)
- antibiotics (Clarithromycin, Flagyl)
- anticholinergics ( 1 hr after meals )
Surgical management :
- vagotomy
- distal subtotal gastrectomy
Billroth I and II
 Dumping Syndrome
- ingested food rapidly enters the jejunum without
proper mixing
Manifestation : Osmotic diarrhea, abdominal pain
hypotension and hypoglycemia
Nursing managements:
- small frequent high protein, high fat, low CHO
- lying down after meals
- don’t take large fluids with meals
Gastroenteritis
- various common specific & nonspecific
intestinal disorders characterized by
inflammation of the stomach & small
intestine.

Etiology:
- Bacterial food poisoning
(Salmonella, Shigella, staphylococcus aureus)
- Adenoviruses and enteroviruses
- Chemotherapy and radiation therapy
- Side effects of certain drugs (antibiotics)
Clinical manifestations:
- signs of dehydration
- fluids and electrolytes imbalances
metabolic alkalosis ( vomiting )
metabolic acidosis ( diarrhea )

Laboratory findings:
stool exam (fresh stool)
- shows leukocytes, blood, fats, parasites,ova

Nursing management:
- fluid replacement is very important by giving
ORS and IV fluids (started with Isotonic sol’n.)
- closely monitor intake and output
- proper hand washing (fecal-oral route)
 Appendicitis
- inflammation of the vermiform appendix.

Etiology:
- obstruction of the
appendix lumen
a. fecaliths
b. neoplasm
Clinical manifestation:
- nausea and vomiting
- epigastric pain then localized on the RLQ
(McBurney’s point)
- direct and rebound tenderness at the RLQ
associated with fever
- Rovsing’s sign, Psoas’ sign
- cessation of pain indicates rapture

Laboratory findings:
- CBC (leukocytosis= >10X109/L)
Nursing Management:
- NPO, position patient on dorsal recumbent
and low Fowler’s to relax the abdomen
- no enema, laxatives or warm compress
( lead to perforation)
- no analgesic as much a possible
- surgery: appendectomy
(done under spinal anesthesia)
 perianal vein.
Etiology:
- portal vein hypertension
(internal hemorrhoids – occur above
pectinate line)
- constipation, diarrhea and prolonged straining
(external hemorrhoids – occur below
pectinate line)
Clinical manifestations:
- prolapsing enlarged mass in the anal
area with or without pain
- fresh blood on the stools
- constipation

Diagnostics : DRE and proctoscopy

Nursing management:
- elevation of the buttocks allows to
reduce prolapsed
- for pain: initially apply cold packs followed by
warm sitz bath
- high fiber diet & enough fluids
- Medications:
topical anesthetic ( Nupercaine )
stool softeners (ducosate sodium –Colace )
-Surgery:
hemorrhoidectomy - hot sitz bath 12 hrs after
 Post –Hemorrhoidectomy

Pain Management and Promote Bowel

Elimination is very important
 Analgesic
 Side lying position
 Stool softeners as prescribed
 Hot Sitz bath after defecation
 High fiber diet, high fluid intake, regular
exercise
Hepatitis
- inflammation of the liver parenchyma.

Etiology:
- Infection: Hepa A & E viruses (fecal-oral route)
Hepa B, C, & D viruses (blood and body
fluids)
- Alcohol consumption
- Drugs (INH)

Clinical manifestations:
- jaundice, yellowish sclerae (icteresia)
- fever, anorexia, RUQ pain, hepatomegaly
- clay colored stool, tea-colored urine
- pruritus (accumulation of bile salts under the
skin)
Laboratory findings:

- Hepatitis profile (Serologic markers)

- Liver function studies
elevated ALT (alanine aminotransferase)
SGPT (serum glutamic pyruvic
transaminase; NV = 0-47iu/L)
elevated AST (aspartate aminotransferase)
SGOT (serum glutamic oxaloacetic
transaminase; 10-40 iu/L)
- UTZ
Nursing management:
- bed rest in severe and in acute symptoms
- enteric precautions (Hepa A)
- blood & body fluids precautions (Hepa B)
- low fat, high calorie, high carbo,
high protein diet
- no alcoholic beverages
- avoid hepatotoxic prescriptions
- Oral cholestyramine – bile salts binder
Cirrhosis
group of chronic diseases in which liver
tissue is gradually replaced by scar tissue;
resulting to gradual loss of liver function.
Etiology:
1. Laennec’s cirrhosis (most common)
- alcoholism and poor nutrition
2. Postnecrotic cirrhosis
- previous viral hepatitis
3. Billiary cirrhosis
- chronic billiary obstruction & infection
4. Cardiac cirrhosis
- right sided CHF
Clinical manifestations:
- hematemesis (ruptured esophageal varices)
- hemorrhoids, ascites, edema, splenomegaly
- hepatomegaly ( on early stage)
- jaundice, increased bleeding tendencies
- asterexis (hepatic encephalopathy)
- fetor hepaticus – foul smelling breath

Diagnostics :
Liver biopsy gives a definitive diagnosis
- hold breath for 15 sec at the end of expiration
during needle aspiration
- right side lying position after procedure
Nursing management:
- Early stage diet: high protein, vitamins
high carbohydrates
- Advance stage diet: low fat, low protein & low
salt diet
- Avoid alcohol, avoid hepatotoxic drugs
- Medications : Vitamin K, diuretics, laxatives,
antibiotics
- Sengstaken-Blakemore tube insertion
(for bleeding esophageal varices)
- Paracentesis (for ascites )
A client with ascites and elevated serum
ammonia level secondary to cirrhosis, is
receiving dietary instructions. The nurse
knows that the client has understanding of
his dietary needs if he selects a menu that
is?..
a. High in protein, law in salt
b. High in calories, low protein
c. Low in carbohydrates, high in fat
d. Low in calcium and potassium
Cholecystitis
- inflammation of gallbladder

Etiology:
- cholelithiasis or
choledocholithiasis
bile and cholesterol
- bacterial invasion

Predisposing factors :
- female, fat, forty
Clinical manifestations:

- intolerance to fatty foods, indigestion

- nausea, vomiting, flatulence
- fever, severe RUQ pain radiating to scapula
- Murphy’s sign, jaundice

Laboratory findings:
- CBC (leukocytosis), UTZ
Management:
- Pain management is very important
- Fluids and electrolytes replacement
- Semi-Fowler’s position
- weight reduction diet if needed
- avoid fatty and fried foods
- Medications: antibiotics, anti-spasmodic,
analgesics (Demerol)
-Surgery: cholecystectomy (open or
laparoscopic)
Which of the following instructions should a
nurse give to a patient who has gas pains
following laparoscopic cholecystectomy?
…
a. increase fluid intake
b. eat foods that are high in fiber
c. get up and move around
d. lie on your abdomen
Pancreatitis - inflammatory condition of
the
pancreas.
1. Acute
- occurs suddenly as
one attack
- or it can be recurrent
with resolutions
2. Chronic
- continual inflammation
& destruction of the
pancreas, with scar
formation (irreversible)
Etiology:
autodigestion of the pancreas by its own
enzyme
alcoholism (most common)

Clinical manifestations:
- severe abdominal pain LUQ radiating to the
back
- nausea & persistent vomiting, dehydration
- steatorrhea, hyperglycemia
- Turner’s and Cullen’s sign
- muscle spasm (hypocalcemia)
- increased serum amylase (NV= 40-180 u/dl)
- increased lipase level (NV= 10-150 iu/L)

Nursing management:
- NPO in acute stage;
then may shift to small frequent bland, low
fat,
moderate carbo and moderate protein diet
- long term avoidance of alcohol.
- NGT insertion
- Monitor for signs of:
hyperglycemia, hypocalcemia, infection and
shock
- Medication: antacids, analgesics , insulin,
pancreatic enzymes, (morphine is
A 46/M admitted to the hospital with a
diagnosis of acute pancreatitis. In
assessing the clients condition, the nurse
should expect to find an elevation in
which of the following serum levels?

a. Amylase
b. Bilirubin
c. Cholesterol
d. SGPT
 partial or complete impairment to the
forward flow of intestinal contents.

Etiology:
- Adhesions (fibrous bands of scars that
adheres
abdominal structures)
- Intussusception (proximal bowel telescope
the bowel distal to it)
- Volvulus (twisting of a bowel in a stationary
focus)
- Hernias (abnormal protrusion of an organ or
its part
through the structure that normally
contain it.)
- incarcerated and strangulated
Clinical manifestations:
- signs of complete obstruction
(pain, vomiting, absolute constipation,
and abdominal distention)
- signs of partial obstruction
(alternating diarrhea and constipation,
ribbon-like stools)

Laboratory and Radiologic findings:

- Plain abdominal X-ray (air-fluid levels)
- Barium studies (shows obstructing mass)
- CT scan for tumors
Nursing Management:

- NPO, IV fluids, NGT insertion

- Monitor signs of infection and dehydration
- replace fluids and electrolytes through IV
- Administer narcotics judiciously
- hydrostatic reduction
- Surgery:
Exploratory-laparatomy
to relieve the obstruction
Creation of ostomy for palliative treatment
Jejunostomy, Ileostomy &
Colostomies
– artificial opening of intestinal tract,
surgically created and brought to the
abdominal surface for the purpose of
elimination.

Types:
1. Single – barrel (usually permanent)
2. Double –barrel (usually temporary)
3. Loop (usually temporary)
Post – op care nursing management:

- low residue diet for first 6 weeks,

high carbo – high protein thereafter
- No nuts, beans or corn allowed
- Notify physician if stoma is dark blue,
blackish or purple in color.
- Observe and record the description of any
drainage from stoma
- ileostomy (liquid or semi-liquid stool)
- colostomy (feces or liquid to soft stool)
- drain the ostomy bag if 1/3 full
- Cleanse skin gently and pat dry; do not rub
- Colostomy irrigation (like doing enema to
stimulate emptying of the colon)
usually done 5-7 days
- ileostomies & ascending colostomies are not
irrigated
- if possible, patient should be sitting upright on
toilet for procedure
- Observe for readiness of self stoma care
- Optimal recovery within 3 months.
Which of the following statements would a
nurse include in the preoperative instruction
of a patient who is schedule for an ileostomy? ..

a. “ You will have one formed bowel movement

per day.”
b. “ The stool drainage will be of liquid
consistency.”
c. “ The pouch will be located on the left side
of your abdomen.”
d. “ You will be taught how to irrigate your bowel
through the stoma.
 FOLLOW
YOUR
DREAMS

 LUCK IS FOR
THE
UNPREPARED
Endocrine System
By :

Hermie M. Pueyo M.D., R.N.

ENDOCRINE
SYSTEM
 are groups of
endocrines glands
(ductless) that
secrets hormones
 HORMONES
 chemical substances secreted by endocrine glands
directly into the blood stream to act on specific target
cells.
Regulated by :
Negative feedback mechanism – most of the
hormone
Positive feedback mechanism – oxytocin

Feedback – exert regulatory influence on the

hypothalamus, pituitary, or the specific gland

•Endocrine disorders arise from under secretion or over

secretion of specific hormones
 Hypothalamus
 Located anterior and inferior
to the thalamus above the
brainstem

 It is the link between the

nervous and endocrine
system

 Secret releasing hormones

to stimulate the pituitary to
release stimulating hormones
and specific hormones
Pituitary Gland
- called the “master gland”
- pea sized located in the sella turcica
- divided into two lobes
anterior lobe - adenohypophysis
posterior lobe - neuroypophysis
Hormones of the Pituitary Gland
I. Posterior Lobe Hormones
a. Oxytocin
- stimulate uterine and
mammary contractions (milk ejection)
b. Antidiuretic Hormone (ADH) or Vasopressin
- stimulate water absorption of
distal renal tubule
- in large amount cause vasoconstriction
II. Anterior Lobe Hormones
a. Growth Hormone (GH)
- growth of muscle and bone
b. Prolactin

- milk production
c. Thyroid Stimulating Hormone (TSH)
- thyroid hormone production
d. Adrenocorticotropic Hormone (ACTH)
e. Follicle Stimulating Hormone (FSH)
- stimulate ovaries to develop mature
follicles
- stimulate testes to develop
seminiferous tubules
f. Luteinizing Hormone (LH)
- initiates ovulation in the ovaries and
forms corpus luteum
- stimulate interstitial cells of Leydig
to produce testosterone
g. Melanocyte Stimulating Hormone (MSH)
- pigmentation
hyroid Gland
- H or butterfly shape glands with 2 lateral lob
located at the anterior surface of the neck
made up of lobules : follicular & parafollicula
cells
Thyroid Hormones

a. Thyroxine (T4) and Triiodothyronine (T3)

- regulate cellular metabolic activity

- also helps for normal growth and
development
b. Thyrocalcitonin
- inhibit bone resorption thus it
lowers blood Ca++
Parathyroid Glands
- usually four small glands embedded in
the
postero-lateral surface of the thyroid
Parathyroid Hormone
- increase calcium resorption from kidney,

intestine and bone

elevate blood Ca++

- increase renal excretion of phosphorus;

decrease blood phosphorous or phosphate
Pancreas
- elongated organ lying horizontally in
the
upper right posterior of the abdomen
behind the stomach
Exocrine – lipase, amylase, trypsin
Endocrine -
a. Glucagon (Alpha Cells)
- gluconeogenesis
b. Insulin (Beta Cells)
- facilitate cellular absorption of
glucose, amino acids & fatty acids
c. Somatostatin (Delta cells)
- suppress the release of glucagon
and insulin
Adrenal Glands (Suprarenal Glands)
- located at the upper poles of the
kidney
- consist of outer cortex and inner
medulla
I. Hormones Secreted by Adrenal
Medulla

a. Epinephrine and Norepinephrine

- fight or flight response (sympathetic)
tachycardia, increased CO,
vasoconstriction, increased alertness
- converts glycogen into glucose in liver
II. Adrenal Cortex
- Sugar, Salt, and Sex
a. Glucocorticoids (Cortisol)
- increase blood glucose
(gluconeogenesis)
- suppress inflammatory response
- promotes sodium retention,
potassium loss
b. Mineralcorticoids (Aldosterone)
- sodium absorption and potassium
loss
c. Adrenal Sex Hormones (Androgen &
Estrogen)
Gonads
- its function is primarily for
reproduction
- exerts minor metabolic effects
I. Testis - located outside pelvic cavity
- mixed-type gland
exocrine - production of sperm
endocrine - testosterone
II. Ovaries
- located inside the pelvic cavity
- release egg during ovulation
 Estrogen - development of secondary sexual
characteristic and mammary ducts
 Progesterone – prepare implantation,
development of mammary tissues
ENDOCRINE
DISORDERS
 DISORDERS OF
PORTERIOR PITUITARY
GLAND
I. Diabetes Insipidus (D.I.)
II. Syndrome of Inappropriate
Anti- Diuretic Hormone Secretion
(S.I.A.D.H.)
Diabetes Insipidus
 is a disorder of body water excretion
caused by deficiency of ADH
(vasopressin)

Etiology
1. idiopathic
2. head trauma, neurosurgery,
tumors, vascular disease
Clinical Manifestations
 Marked polyuria
- daily output of 5 to 20 liters of the
urine
- a specific gravity of 1.000 to 1.005
 Polydipsia (intense thirst)
- drinks 4 to 40 liters of fluid daily
 Weight loss and signs of dehydration
 Relative hypernatremia

Diagnostics : Water Deprivation

Test
Nursing Interventions for
DI
 Measure fluid intake & output
accurately
 Obtain daily weights
- persistent weight loss is poor sign
 Monitor hemodynamic status
- hypotension
 Provide patient w/ water to drink
 Monitor results of serum & urine
osmolality
 Management
 Administration of ADH or its
derivative
( desmopressin , vasopressin)
 It could be administered, intranasally
and intramuscularly
 Have a vasoconstrictive effect, thus
watch out for cardiac ischemia
 Diabetes insipidus is a possible
complication following pituitary
surgery. For which symptoms
should the nurse observe to aid
detection of diabetes insipidus?..
3. Urine specific gravity greater than 1.030
4. Urine output between 5 & 10Li/day
5. Blood glucose level above 300 mg/100
ml
6. Urine negative for glucose & ketones
Syndrome of Inappropriate ADH
(SIADH)
- oversecretion of ADH results in
excessive
water conservation

Etiology :
- CNS disorders
- Ectopic ADH production of some
cancer
Manifestations:
- decreased urine output, water retention
- weight gain, hypertension
- pulmonary edema
- altered mental status due to severe
hyponatremia
( headache, lethargy, seizures and coma)
aboratory :
- plasma osmolality and serum sodium level
are decreased
- urine osmolality and sodium levels
are elevated
- ADH level is elevated

ursing Management :
- diuretics , restrict fluid
- regular assess mental status for signs
of hyponatremia
- skin care and prevent further injuries
 Which of the following would be a
priority goal of care for the client
diagnosed w/ syndrome of
inappropriate secretion of ADH
(SIADH)?..
3. Maintain normal blood glucose level
4. Maintain electrolyte and fluid
balance
5. Promote a regular sleep pattern
6. Prevent fluid volume deficit
Thyroid Disorders Gland

1. HYPOTHYROIDISM
2. HYPERTHYROIDISM
3. GOITER
 Hypothyroidism
 This is a condition that arises from inadequate
amounts of thyroid hormone in the bloodstream

 Myxedema (adult ) – a complication of

hypothyroidism characterized by

hypometabolic state
 Cretinism (children) – short stature and
coarse features
 Clinical Manifestations
 Fatigue & lethargy, weight gain
 Bradycardia, cold hands & feet
 Temperature & pulse become
subnormal; patient cannot tolerate
cold
 Reduced attention span; impaired
short-term memory; slow muscular
movement
 Constipation, decrease urine output
 Goiter (primary hypothyroidism)
 Myxedema - generalized appearance
of thick,puffy dry skin; subcutaneous
swelling in hands, feet & eyelids due
to accumulation of proteoglycans in
the interstitial space
 Myxedema Coma
- major complication of hypothyroidism

usually triggered by stressful condition

- Hypotension
- Hypoventilation
- Hypothermia
- Stupor, progressing to coma
 DIAGNOSTIC TESTS
- decrease serum T3 (triiodothyronine
decrease serum T4 (thyroxine)
(withhold iodine containing foods before
the test)

- increase TSH (primary hypothyroidism)

decrease TSH (secondary
hypothyroidism)
- decrease in radio iodine uptake
 Nursing Management
 Low caloric, high fiber diet (constipation)
 Provide warm environment during cold climate
 Increase iodine in the diet
 Avoid dietary goitregens such as turnips,
soybeans, carrots, peanuts
 Supportive measures(O2, fluids, rest, skin care)
 Pharmacotherapy : caution with CAD

- Proloid (thryroglobulin )
- Synthroid (levothyroxine)
- Cytomel ( liothyronine)
* taken in the morning and for life
A patient who is suspected having
hypothyroidism should be expected to
have which of these symptoms ?….

a. tachycardia
b. weight loss
c. hyperthermia
d. facial edema
 Hyperthyroidism
 Hypermetabolic condition is characterized
by excessive amounts of thyroid hormone
in the bloodstream
 Thyrotoxicosis refers to clinical
manifestations
that occurs when the body tissue is
stimulated
Etiology :
1. autoimmune (Grave’s disease)
2. toxic nodular goiter, toxic adenoma
 Clinical Manifestations
 Difficulty in sitting quietly
 Nervousness, irritability, insomnia
 Tachycardia, hypertension, palpitation
 Heat intolerance
 Fine tremor of hands and arrhythmias
 Increased appetite & progressive weight
loss; diarrhea
 Ophthalmopathy and goiter
 menstrual irregularities, decrease in
libido
 Thyroid storm
 Thyroid storm or crisis, an extreme
form of hyperthyroidism, is
characterized by:
- hyperpyrexia, diarrhea,
dehydration,
tachycardia, arrhythmias, extreme
irritation, delirium, coma
 Thyroid storm may be precipitated
by stress (surgery, infection)
 Nursing Management
 Rest (non-stimulating cool environment)
 Loose clothing
 High caloric, low fiber diet (diarrhea)
 Protect eyes from corneal ulcerations by using
artificial tears or wearing dark glasses
 Replace fluids and electrolytes loses (diarrhea)
 Avoid stimulants such as coffee and tea
 Pharmacotherapy
 Drugs that inhibit hormone synthesis and
action:
- propylthiouracil (PTU) - act by
depressing
the synthesis of thyroid
hormone
- methimazole (Tapazole) – block the
action of the TH in the body as
well as synthesis
side effects : agranulocytosis
 Drugs to control peripheral
manifestations
Propanolol (Inderal)
- acts as a B-adrenergic blocking agent
- abolishes tachycardia, tremor, excess
 sweating,
Drugs nervousness
that inhibit release of thyroid
hormone
and reduce
Iodine the vascularity
: potassium Iodideof(SSKI)
the thyroid
gland Lugol’s solution
 Radiation therapy

 Radioactive Iodine (131i)

 Action limits secretion of thyroid
hormone by destroying thyroid tissue
 Not used for pregnant and major
complication is hypothyroidism
 Subtotal Thyroidectomy
 Used for those with large goiters, or
for those for whom the use of
radioiodine or thionamides is
contraindicated
 Watch out for :
- bleeding
- hypocalcemia
- recurrent laryngeal nerve damage
 Measures to prevent eye damage
from exopthalmos, in which the
eyelids do not close completely
during sleep include?...
3. Massaging the eyes at regular intervals
4. Instilling an ophthalmic anesthetic as
ordered
5. Taping the eyelids closed w/ non-
irritating tape
6. Covering both eyes w/ moistened gauze
pads
 Disorder of the
Parathyroid Gland
PARATHYROID HORMONE
- increases serum calcium by :
1. decreasing elimination of calcium ions in the
urine by the kidney
2. increasing absorption of calcium ions from
the gut
3. increasing bone contribution of calcium ions
to the
plasma
- Decrease serum phosphorus by
 Hypoparathyroidism
 Characterized by :
hypocalcemia, hyperphosphatemia,
neuromuscular hyper excitability due to
hyposecretion of parathormone

Pathophysiology and Etiology :

1. accidental removal or destruction of
parathyroid tissue or its blood supply during

thyroidectomy (most common)

2. necrosis of parathyroid gland due to
infarction of
blood supply
Clinical Manifestations
 Tetany – general muscular hypertonia;
attempts at voluntary movement result in
tremors and spasmodic or uncoordinated
movements
a. tingling sensation of fingers &
circumoral area
b. increase DTR’s
c. Chvostek’s sign
d. Trousseau’s sign – carpopedal spasm
within 3 minutes cuff is inflated
20mmHg above the patient’s SBP
Nursing interventions
 Assess neuromuscular status frequently
due to hypocalcemia, be alert of
laryngospasm
(tracheostomy at bed side)
 Minimize environmental stimuli
 Promote high Ca diet with Vitamin D
(lifelong)
- dairy products, green, leafy vegetables
 Low phosphate diet and Aluminum
Hydroxide
 HYPERPARATHYROIDISM
- innate hyperfunctioning of parathyroid tissue
1. parathyroid adenoma
2. parathyroid hyperplasia
Characterized by :
- increased PTH levels
- persistently elevated serum calcium
- decreased serum phosphorus
- bone lesions
 Clinical Manifestations
 Decalcification of bones
 Skeletal pain, backache, pain on weight-
bearing, pathologic fractures
 Formation of bone tumors

 Calcium-containing kidney stones

Depression of neuromuscular function

 The patient may trip, drop objects, show
general fatigue
 Nausea, anorexia and constipation

 Cardiac arrhythmias and hypertension

 Nursing Interventions
Achieving Fluid & Electrolyte Balance
 Monitor fluid intake & output
 Provide adequate hydration and acidify
urine by giving prune juice and cranberry
 avoid dietary sources of calcium - dairy
products, broccoli, calcium containing
antacids
 Avoid thiazide and vitamin D , instead use
furosemide
 Assess renal function through serum
 Increasing Physical Mobility

 Protect the patient from falls or injury

that may cause fractures
 Administer analgesia as prescribed
 Instruct & demonstrate correct body
mechanics to reduce strain, backache, &
injury
 Disorders of the Adrenal
Glands
 Adrenal Cortical Disorders
1. Hyperfunction: a. Cushing’s Disease
b. Cushing Syndrome
2. Hypofunction : a. Addison’s Disease

 Adrenal medullary Disorders

1. Hyperfunction : a. Pheochromocytoma
 Cushing’s Syndrome
 Is a manifestation of an increase in
cortisol,
mineral corticoids as well androgens
in the
body

Etiology :
1. Pituitary tumor – Cushing’s
disease
2. Adrenal tumors
Manifestations caused by excess
glucocorticoids
 Weight gain/obesity

 Thin extremities, easy bruising

(gluconeogenesis)
 Buffalo hump, moon face, truncal obesity,
striae
 Osteoporosis – kyphosis, backache

 Prone to infection – immunosuppressant

effect
Manifestations caused by
excess Mineralocorticoids
 Hypertension

 Hypernatremia, hypokalemia

 Weight gain

 Edema
Manifestations caused by excess
Androgens
1. Women experience virilism
(masculinization)
 Hirsutism
 Breasts atrophy
 Clitoris enlargement
 Voice masculine
 Menstrual irregularities
Diagnostic Evaluation
 Elevated urinary cortisol
 Loss of diurnal variation of cortisol secretion

(8:00 AM levels typically double that of 8:00 PM

levels)
 Dexamethasone Suppression Test

A. Administer Dexamethasone 1 mg
orally at 11:00 PM
B. Draw Cortisol level at 8:00 AM
before patient rises
C. Expect suppressed Cortisol levels
(less than 5ug/dl)
D. Persistent elevated cortisol level
Nursing interventions
 Encourage foods low in sodium and high in
potassium
 Use meticulous skin care to reduce injury
and breakdown
 Encourage gradual resumption of
activities as the patient gains strength
 Instruct the patient in correct body
mechanics to avoid pain or injury during
activities
 Be alert for evidence of depression; in
some instances, this has progressed to
 Surgical Management
1. Transsphenoidal hypophysectomy
for Cushing’s Disease
2. Bilateral adrenalectomy – hyperplasia
of adrenal glands
 Adrenocortical Insufficiency
 Inadequate secretion of the hormones of
the adrenal cortex, primarily the
glucocorticoids and mineralocorticoids as
well as sex hormones

Pathophysiology and Etiology

1. destruction of the adrenal cortex,
usually
caused by autoimmune process
(Addison’s Disease)
2. adrenelectomy
Manifestations
 Hyponatremia and hyperkalemia
 Water loss
 Muscular weakness due to hypoglycemia
 Mental changes – depression
 Addisonian crisis – acute adrenal
insufficiency
triggered by stress
hypotension, rapid weak pulse, pallor,
shock,
extreme weakness and tachypnea
Nursing interventions
 Achieve normal F/E balance to prevent
shock
 Minimize stressful situations
 Provide for periods of rest and activity
 High-caloric, high-protein , high sodium,
low potassium diet
 Observe/report signs of Addisonian crisis
 Medications : dose is increased during
stress
- IV/IM hydrocortisones in emergency
cases
 In a client with Addison’s disease,
the nurse should anticipate the
need for increased glucocorticoid
supplementation in which of the
following situations?...
3. On rest periods
4. Going on vacation
5. Having surgery performed
6. Having a routine medical checkup
 Pheochromocytoma
 A catecholamine-secreting neoplasm
 Excess secretion of norepinephrine and
epinephrine

 Clinical manifestations:
- Hypertension (cardinal sign),
hypermetabolism & hyperglycemia
- excessive perspiration, tremor, pallor,
face
Diagnostic evaluation

 VMA are elevated in 24-hour urine

sample
 Elevated serum catecholamine level
 CT scan and MRI of the adrenal
glands identify medullary tumor
Nursing interventions
 Remain with the patient during acute
episodes of hypertension
 Instruct the patient about the use of
relaxation exercises
 Reduce environmental stressors
 Eliminate stimulants (coffee, tea,
cola)
Management
 Medical control of BP and preparation for
surgery
 Alpha-adrenergic blockers (clonidine)
inhibit the effect of catecholamine
 Surgery – unilateral or bilateral
adrenalectomy
Maintaining Tissue Perfusion Postoperatively
Maintain adequate hydration w/ infusion to
prevent
hypotension. Because reduction of
catecholamines
immediately postoperatively causes
vasodilatation &
 The nurse is caring for a client with
acute episode of hypertension
secondary to pheochromocytoma. The
nurse should refrain from doing?..
2. Remain with the patient during acute
episodes of hypertension
3. Turn on the television
4. Ensure bed rest and elevate head of
the bed 45 degrees
5. Carry out tasks and procedures in
calm, unhurried manner
DIABETES
MELLITUS
 Diabetes Mellitus
 A metabolic disorder results from
defective insulin production,
secretion, or utilization.
 Characterized by hyperglycemia and
associated abnormal metabolism of
carbohydrates, protein and fats.
 These abnormalities leads to specific
complications affecting different
systems in our body
 Classification of Diabetes
 Type 1 diabetes mellitus
 Absolute lack of insulin
(insulin-dependent)
 Usually young (<30 y.o.;Juvenile
diabetes)
 Thin, ketosis-prone (Ketoacidosis)

 Etiology: - genetic component

-autoimmunity (Islet cells

antibodies)
 Type 2 Diabetes Mellitus
 Relative decrease in insulin or
increased in insulin resistance
(Non-insulin dependent)
 Usually adult (> 30 y.o.; Adult-onset
DM)
 Obese, Ketosis resistant ( HHONKS)

 Etiology: - strong hereditary component

- associated with obesity

causing
 Diagnostic studies
 RBS and FBS
 2 hour post –prandial test
 HbA1c
 Urine ketones (diabetic ketoacidosis)
 Serum electrolytes – hyperkalemia
 Diagnostics for Blood
Glucose
 Random glucose -
- drawn at any time; no fasting.
NV = 60-140 mg/dl
 Fasting blood sugar (FBS) -
- drawn after at least an 8-hour fast
NV = 60-110 mg/dl
 Postprandial test, drawn usually 2 hours

- after a well-balanced meal (75 g)

- to evaluate the efficiency of insulin-
mediated
Manifestations and Complications Of
Diabetes Mellitus
 Acute
- Hyperglycemia (polyuria, polydipsia, polyphagia)
- Dehydrations; weight loss and weight gain
- Diabetic ketoacidosis (DKA)
- Hyperglycemic Hyper-osmolar
Non-ketotic Syndrome (HHONKS)
 Chronic
- microangiopathy and macroangiopathy
(poor wound healing)
- retinopathy (blurring of vision)
- neuropathy (paresthesia and numbness)
- nephropathy (anemia and renal failure)
 Management
Overall goals :
1. regulation of blood glucose
2. prevent complications
Diet
 Caloric restriction and weight reduction
increase insulin sensitivity
- reduction of 250 – 500 calories/ day
- 50% CHO, 30% fats, 20% CHON, 20-25 gms of
fiber
Exercise
 To promote the utilization of carbohydrates,
assist w/ weight control, enhance insulin
sensitivity, & improve cardiovascular circulation
Medications
 Oral hypoglycemic agents (OHA)
- effective only for type II DM
- contraindicated to pregnant and breastfeeding
women as well as allergic to sulfa
 Sulfonylureas – stimulate insulin secretions
and
(Euglucon) increase tissue sensitivity to
insulin
 Biguanides – decrease intestinal uptake and

(Glucophage) hepatic production of glucose

 alpha-glucosidase inhibitors – slow CHO

(Glucobay) absorption
 Thiazolinidine – increase tissue sensitivity
 Insulin Therapy

 Involves the subcutaneous or

intravenous (regular insulin) injection
of short, intermediate, or long-acting
insulin at various times to achieve
the desired effect
 Insulin Onset, Peak, &
Duration
Insulin Onset Peak
Duration
Immediate-acting 0.25 h 0.5-1 h 5
h
(lispro)
Short-acting 0.5-1 h 2-4 h 5-7h
(regular, semilente)
Intermediate-acting 1-3 h 6-12 h
18-24 h
(NPH, lente)
Long-acting 4-6 h 10-30 h
 Insulin Administration :
- usually given before meals
- wash hands, cleanse site with soap & and
H2O or70% alcohol.
- wipe top of insulin bottle with 70% alcohol
- roll the bottle in palm of hands, don’t shake
- inject amount of air that is equal
to each dose into the bottle – short acting
last.
- aspirate short acting first, then long or
intermediate
A client with D.M. is taught to take
NPH insulin at 8:00 AM each day. At
which time would the client be at
greatest risk for hypoglycemia?…

a. About 11 AM, shortly before lunch

b. About 1 PM, shortly after lunch
c. About 5 PM, shortly before dinner
d. About 11 PM, shortly before bed
time
- pinch skin, avoid I.M, don’t aspirate
- rotate the injection site an inch a part
- prefilled syringes are stored vertically,
needle-up
- may increase dose during illnesses
 A nurse is admitting a client
suspected of having D.M. Which of
the following characteristics would
the nurse expect to observe?....
3. Shallow, labored respirations
4. Increased blood pressure
associated with slight peri-orbital
edema
5. Period of altered pulse-rate
6. Increased urinary output
 GOOD
LUCK
AND
GOD BLESS